Issue
Number 452
March 26, 2004
UNPROTECTED PEOPLE: Reports of
people who have suffered or died
from vaccine-preventable diseases
Report #66:
SOCIETY PAYS A HIGH PRICE
FOR
NONMEDICAL VACCINATION EXEMPTION
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March 26, 2004
UNPROTECTED PEOPLE #66: SOCIETY PAYS A HIGH PRICE FOR NONMEDICAL VACCINATION
EXEMPTION
The Immunization Action Coalition (IAC) publishes articles about people who
have suffered or died from vaccine-preventable diseases and periodically
devotes an "IAC EXPRESS" issue to such an article. This is the 66th in our
series.
On March 19, 2004, CDC published "Brief Report: Imported Measles Case
Associated with Nonmedical Vaccine Exemption--Iowa, March 2004" in its
electronic publication "MMWR Dispatch." The article recounts the prodigious
effort required to notify hundreds, perhaps thousands, of contacts of an
unvaccinated 19-year-old man who returned to Iowa from New Delhi while
contagious with measles.
The article underscores the societal consequences of a parent's decision to
withhold vaccination from a child because of religious reasons or personal
beliefs. In this instance, the index patient, who had received a nonmedical
exemption from measles vaccination, had the potential to infect susceptible
people in four airports and on three airline flights across three
continents.
Because of high vaccination levels, measles
is uncommon in the United States, with fewer than 200 cases reported
annually since 1997. Such rosy statistics may lead some parents to assume
measles has been "wiped out," calling into question the need for
vaccination. In much of the developing world, however, measles is endemic.
In 2002 alone, it infected 30 million susceptible people worldwide and
claimed the lives of 614,000 children.
With every passing year, the world grows smaller, as more people travel
internationally, coming into contact with people--and diseases--uncommon in
their home communities. A parent who insists on vaccine exemption because of
religious reasons or personal beliefs makes a decision to deny this reality.
More importantly, such parents make a decision to abdicate individual
responsibility for the health of communities their children live in, visit,
or travel through. It is the quintessential example of a "bad neighbor"
policy.
Reported by CDC and local and state public health departments in Iowa and
Michigan, the "MMWR Dispatch" article is reprinted below in its entirety,
excluding references.
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On March 13, 2004, the Iowa Department of Public Health (IDPH) reported to
CDC that a male student aged 19 years with measles in the infectious stage
had flown from New Delhi, India, to Cedar Rapids, Iowa, on March 12. Because
of a nonmedical exemption, the student had not received measles-containing
vaccine (MCV). This report describes the measles case, the public health
response to prevent secondary cases, and the impact on the public health
system. Health-care providers and state and local public health departments
should be alert to possible cases of measles in persons who traveled with
this student or their contacts. Parents considering nonmedical exemptions
for their children should be aware of the potential risk for disease both
for their children and the public.
Measles is a highly infectious acute viral illness that can cause severe
pneumonia, diarrhea, encephalitis, and death. Measles is not endemic in the
United States because of high levels of vaccine coverage (>90% by age 3
years) and the requirement that school-aged children receive 2 doses of MCV.
However, an estimated 745,000 measles deaths occur annually worldwide,
making measles a major vaccine-preventable disease.
The index patient was a member of a group of approximately 28 students and
two supervisors from college A in Iowa who had traveled to India, where
approximately 52,000 cases of measles were reported in 2002. A high
percentage of students from college A are reported to be unvaccinated
because of nonmedical exemptions. Six measles cases occurred among the
students while they were in India. The group had been scheduled to return to
the United States on March 7. To avoid potential spread during the prolonged
airline flights, IDPH recommended that these six students stay in India for
at least 4 days after rash onset (i.e., the period of infectivity). Contacts
of these infectious students who lacked immunity for measles were asked to
stay in India for 18 days after the last possible exposure. Despite these
recommendations, the index patient, who was an unvaccinated contact,
returned to the United States early, flying on March 12 from New Delhi
through Amsterdam and the Detroit Metro Airport to Cedar Rapids, Iowa.
During his travel, he had a cough and conjunctivitis, and within 24 hours of
his arrival in Iowa on March 13, he had a rash. A local physician reported
the case to IDPH. Subsequently, measles was confirmed serologically, and
throat swab and urine specimens were collected for viral isolation.
On March 13, IDPH and the Michigan Department of Community Health (MDCH)
issued press releases to alert air passengers, visitors, and employees who
had been in the involved airports about their risk for measles exposure and
state health advisories to alert physicians and enhance surveillance. On
March 18, CDC issued a health advisory recommending that every person who
had been on the plane with the student or who had been in one of the
involved airports at the same time be evaluated and, if determined to be
susceptible, receive MCV or immune globulin according to the recommendations
of the Advisory Committee on Immunization Practices (ACIP). Measles
vaccination clinics were held on March 14 at the office of Linn County
Public Health (LCPH) in Iowa and on March 15 in Michigan. Passenger lists
were subpoenaed from the airline, and LCPH, IDPH, and MDCH attempted to
contact all passengers on flights with the index patient. Other states in
which exposed passengers reside also are taking public health measures to
control the potential spread of measles.
State and local public health departments should be alert to possible cases
of measles in persons who traveled with this student or their contacts.
Diagnosis can be confirmed by serologic testing. In addition to serologic (IgM)
specimens, throat swabs or urine specimens should be collected for viral
isolation.
The occurrence of six cases in this group of students who traveled abroad
demonstrates the high transmissibility of measles when susceptible persons
are exposed. The majority of states require 2 doses of MCV for children
attending school and post-high school educational institutions; however,
nonmedical exemptions are permitted in certain states. Persons who have
chosen a nonmedical exemption from vaccination are >22 times more likely to
acquire measles than persons who are vaccinated. In addition, increases in
the number of persons who have chosen to be exempt increase the risk of
disease in nonexempt persons. To reduce the risk of infection among
travelers, ACIP recommends that all international travelers be immune to
measles because the disease is endemic or epidemic in many parts of the
world.
This case demonstrates the importance of following the ACIP recommendations
and underscores the impact of nonmedical exemptions on the public health
system. Physicians, public health authorities, and school personnel who
counsel parents considering nonmedical exemptions for their children should
ensure that parents understand the risk that opting out of vaccination
places upon their children and the public.
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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d319a1.htm
To access a ready-to-copy (PDF) version of this issue of "MMWR Dispatch," go
to:
http://www.cdc.gov/mmwr/pdf/wk/mm53d319.pdf
Unprotected People editorial note: For additional information on
measles--including journal articles, recommendations, state vaccination
mandates, case histories, disease photos, and other resources--please visit
IAC's measles web section at
http://www.immunize.org/measles
To read more IAC Unprotected People Reports, go to:
http://www.immunize.org/stories
DISCLAIMER: The Immunization Action Coalition (IAC) publishes
Unprotected People Reports for the purpose of making them available
for our readers' review. We have not verified this report's
content, for which the author(s) are solely responsible.
DO YOU KNOW OF PUBLISHED ARTICLES ABOUT UNPROTECTED PEOPLE? Please
let us know if you find articles or case reports about people who
have suffered or died from vaccine-preventable diseases that have
appeared in the general or scientific media. Send information about
articles or case reports to "IAC EXPRESS" by email to
admin@immunize.org or by fax to (651) 647-9131.
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