Senate Panel Tackles US Measles Outbreaks, Vaccine Exemptions

Kerry Dooley Young

March 06, 2019

Researchers on Tuesday offered a Senate panel suggestions for increasing use of vaccines, including addressing the worthiness of vaccine exemptions and paying physicians for time spent counseling parents on the benefits of these shots for their children and for society as a whole.

The Senate Health, Education, Labor and Pensions (HELP) Committee is looking for ways to help combat measles outbreaks, which have been linked to the refusal of some parents to have their children vaccinated.

At least 159 cases of measles have been confirmed this year in the United States. That marks an unwelcome resurgence of a viral infection that had been declared eliminated in 2000, said Senate HELP Committee Chairman Lamar Alexander (R-TN) at the hearing.

"Charlatans and Internet fraudsters who claim that vaccines aren't safe are preying on the unfounded fears and daily struggles of parents, and they are creating a public health hazard that is entirely preventable," Alexander said.

Measles is particularly worrisome, given its ability to spread, said Sen. Patty Murray of Washington, the ranking Democrat on the HELP Committee.

"It's easily transmitted through coughing and sneezing. It can linger in the air and on infected surfaces for 2 hours," Murray said. She noted that people can be contagious well before developing measles' telltale rash.

Physicians on Front Line

Witnesses at the HELP hearing emphasized the role of physicians in serving as the front line in efforts to contain measles. Among them was Ethan Lindenberger of Norwalk, Ohio, a high school senior who has gained attention for his decision to be vaccinated despite his mother's objections. He'd earlier missed his vaccinations for measles, chickenpox, and polio, he told the committee.

Lindenberger said his decision to catch up on the childhood vaccines he missed was due in part to the encouragement of his family physician.

Medical professionals need to make a convincing case for parents who may be spooked about vaccines by tales spread on social media, researchers told the HELP Committee. Much of this work relies on presenting the scientific evidence that supports the safety and effectiveness of the measles vaccine.

Physicians and researchers also must try to weave a personal angle into this outreach, Lindenberger said. Misinformation about vaccines spreads among parents "on a very anecdotal level," fueled by people "sharing stories and experiences," he told the committee. He urged an adoption of this approach for efforts to win over reluctant parents.

"People don't resonate well with information in data and numbers. They resonate better with stories," Lindenberger told the committee.

Physicians and researchers should work to ensure that parents hear about people who have suffered from measles and other infections that could have been prevented with vaccines, Lindenberger suggested. They should also emphasize the risks from these illnesses for the parents' own children, he said.

"There's a huge, misinformed belief that measles isn't a dangerous disease that spreads around the antivaccine community," Lindenberger said. "When you convince parents not that the information is incorrect but that their children are at risk, that's a much more substantial way to cause people to change their minds."

About 1 in 1000 people who are infected with measles develop encephalitis, 1 in 1000 develop severe pneumonia, and about half of patients with these severe complications die, according to testimony from Jonathan A. McCullers, MD, chairman of pediatrics at the University of Tennessee Health Science Center, Memphis.

Witnesses and senators at the hearing stressed the idea that the measles vaccine is a victim of its own success.

Because measles is now relatively rare, people have less appreciation of the vaccine and have more questions about the potential for complications. These concerns have persisted despite a widely cited 2004 Institute of Medicine report that refuted what McCullers in his written testimony called the Wakefield Hoax. This was a reference to a British physician's now discredited claim of a link between the measles, mumps, and rubella (MMR) vaccine and autism.

"Successive cohorts of parents hear about real or perceived adverse events and not the disease," another witness, Saad B. Omer, MBBS, MPH, PhD, professor of epidemiology and pediatrics at Emory University, Atlanta, Georgia, told the HELP Committee. "The mental calculus changes."

Physicians are the most trusted sources of information on vaccines for parents, yet physicians often struggle to find the time to fully address the concerns a parent may have about vaccines, Omer said.

In his written testimony, his first recommendation to the HELP Committee was to examine ways to make vaccine counseling reimbursable.

"Part of the reason, not all of the reason, is that this is not reimbursable," Omer said. "So physicians lose money on this kind of important public health education."

Vaccine Exemptions

Senators at the hearing did not strongly pursue this suggestion, but they did dig into the topic of state policies for vaccine exemptions.

There's variation in the rules by which a child can gain admission to schools without having received the normally required vaccinations. States offer exemptions to students who have certain medical conditions. Thirty states also allow religious exemptions. Seventeen states allow both religious and so-called personal exemptions, McCullers of the University of Tennessee told the committee. He called California "an illustrative case" about what happens when there's a fairly liberal approach to exemptions.

California once allowed religious and personal exemptions. As a result, the overall level of vaccination fell below the level needed for herd immunity, and in 2014-2015, the state experienced a measles outbreak linked to visits to Disneyland. California has since eliminated nonmedical exemptions, and the vaccination rate has risen to 97%, McCullers said in his testimony.

Another witness at the hearing, John Wiesman, DrPH, MPH, the secretary of health for Washington state, spoke in favor of making it more difficult for people to receive exemptions. The state legislature has bills pending to remove personal exemptions for admission to school and childcare, he said.

Three measles outbreaks have occurred in Washington state in the past decade, one of which resulted in the death of an immunocompromised person who was exposed to measles in a clinic waiting room, according to Wiesman's testimony.

"The current outbreak is larger and infecting people faster than those in recent history," he said. He noted that 69 cases were reported from the end of December 2018 to March 1, 2019.

Sen. Rand Paul, MD (R-KY), who serves on the HELP Committee, took a different tack from that of colleagues and witnesses. He spoke of his concerns about cases in which "vaccine mandates have run amok," and cited the withdrawal of a rotavirus vaccine as a warning. This product was withdrawn for causing intestinal blockage in children, he said.

"I'm not a fan of government coercion, yet, given the choice, I do believe that the benefits of most vaccines vastly outweigh the risks," Paul said.

"Yet, it is wrong to say that there are no risks to vaccines," Paul said, noting the existence of the National Vaccine Injury Compensation Program.

In concluding his remarks, Paul stressed that he objected to compelling people to be vaccinated, not to the shots themselves.

"I'm not here to say, 'Don't vaccinate your kids.' If this hearing is for persuasion, I'm all for the persuasion," Paul said. He noted that his family has been vaccinated.

"For myself and my children, I believe that the benefits of vaccines greatly outweigh the risks, but I still do not favor giving up on liberty for a false sense of security," Paul said.

Paul's statement drew a burst of applause from the audience at the hearing. Later at the hearing, a fellow Republican physician emphasized a need to consider the broad societal effects of decisions about vaccinations. An infected person can put others at risk.

"It is not just the individual who is affected, but it is the individual with whom the person goes to school with," Sen. Bill Cassidy (R-LA) said in an exchange with Lindenberger.

The young man agreed.

"My school viewed me as a health threat, and that for me, that also pushed me to look further into getting my vaccines despite my mother's beliefs, because I saw the threat that was being imposed," he told Cassidy.

"Hearts and Minds"

During the hearing, Omer and Wiesman told the committee of a need for robust funding of efforts to boost vaccination rates, to better track students' medical records to spot missed shots, and to address sporadic shortages of vaccines in general.

Such funding would lie largely outside of the scope of the work of the HELP Committee. Sens. Murray and Alexander are senior members of the Senate Appropriations Committee, which sets the operating budgets of federal health agencies, including the Centers for Disease Control and Prevention (CDC).

In his testimony, Wiesman noted that CDC Director Robert Redfield, MD, has emphasized a need to persuade Americans to use vaccines.

"We need to change the hearts and minds of people in this country to not leave science on the shelf," Redfield recently told the Seattle Times.

Wiesman recalled a recent stumble in this effort by his own agency. On Valentine's Day, the Washington State Department of Health posted a cartoon on its Facebook page showing a schoolboy asking a schoolgirl if she will be his valentine. She asks if he has been vaccinated.

"While this social media post had one of our most shares ever and most likes, laughing faces, and angry faces, I have come to understand how this post just furthers the divide," Wiesman said in testimony. "I can do better, we all can do better. In fact, we must do better to focus on our mutual interest of keeping kids healthy."

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