The World Health Organization (WHO) recently published a document titled Ten threats to public health in 2019. The list includes factors such as air pollution, climate change, the global influenza pandemic, Ebola and other high-threat pathogens, weak primary healthcare, and vaccine hesitancy. The number of American parents who do not vaccinate their children is on the rise, and not coincidentally, the number of measles cases in the United States is spiking in 2019.

Looking at the past 10 years of nationwide data, so far this year there have been more than five times the average annual number of measles cases in the nation with nearly half the year remaining. Data from the US Centers for Disease Control – graph – Nevada Capital News

Heidi Parker is the executive director of Immunize Nevada and said that the WHO listing of vaccine hesitancy and the rapid resurgence of measles, especially in nearby northern California, fosters concern among Nevada immunization stakeholders.

“I think that (the WHO listing) was a wake-up call for a lot of us that have seen that (hesitancy) increasing and so that coupled with maybe some access challenges that maybe are more unique to Nevada. We are struggling with those provider shortages, being able to get into primary care, and while that has effects all across healthcare, it absolutely affects getting vaccinated,” Parker said. “When you put all that together it gives us obviously a lot of cause for concern and definitely the need for us to still be out there. We’ve been doing this for almost 25 years and we still have this high level of measles cases nationally, and you have hep A in Las Vegas. These diseases are still there. We still need to be educating people.”

Immunize Nevada is not an immunization provider. They are a coalition of groups and agencies.  Parker said a large part of the coalition’s mission is educational outreach.

“We have partners from what I would consider across the immunization spectrum, our health plans, our school nurses, our public health partners, our health districts, community health nurses in our rural counties, our community health centers like our FQHC (Federally Qualified Health Center). We really bring in all of those people that might have a role in immunization.

“And then our job is to make sure that our communities know why immunizations are important, when you know what that schedule looks like in terms of birth-to-seniors, and then how to access them and how to pay for them. That tends to be a concern for a lot of people. That’s the kind of information we help with as well.”

Vaccine Hesitancy

State immunization laws vary widely, but every state provides a medical exemption that enables parents to not have their children vaccinated if the vaccine can be proven to present a health threat. Most states have either a religious or philosophical exemption to include Nevada, but in recent years a rollback of religious exemptions is gaining steam. California stopped granting personal belief exemptions in 2014. Officials followed the law change with an educational campaign, and a recent study released in the Journal of the American Medical Association shows California has decreased the number of unvaccinated kids by nearly 5 percent.

New York ended both religious and philosophical exemptions in June of this year. Washington State will drop the personal belief exemption effective July 28 of this year. Maine will stop granting philosophical exemptions on September 1, 2021.

Centers for Disease Control data and the most recent Nevada Immunization Report Card from Immunize Nevada shows 00.1 percent of vaccine exemptions in Nevada are for medical reasons, and 3.1 percent of are for religious reasons.

The reasons for parents not wanting their children to be vaccinated are many and varied. Some initially act on bad information discovered and further made viral through social media. A famous piece of misinformation connects vaccinations with Autism. Many parents who object to vaccinations do so for ingrained religious or philosophical reasons. Nevada Capital News asked Parker if such deeply held opposition to vaccinations presents an insurmountable ideological divide.

“I think hesitancy comes from a lot of different places for parents. I think sometimes maybe that’s why it can feel insurmountable because you’re not always sure what information parents have received or where they’re coming from in their questions. A lot of times when they have an opportunity to just sit down and have those conversations with a health care professional, or even when we’re out in the community, they get those questions answered.”

If you’re seeking political drama, attend a committee hearing at the Nevada State Legislature when a bill regarding vaccinations is being heard. Bills that would variously affect immunization law often become proxy battles over the issues of personal freedom, privacy and government authority. During Nevada’s 2019 legislative session a bill that would have helped aggregate and manage immunization data was amended out of existence and garnered passionate testimony from those concerned with privacy rights and government overreach.

For instance, in northern California attitudes behind efforts to form the State of Jefferson and secede from the Union are also incubators for anti-vaccine sentiment. Significant numbers of parents in parts of northern California are flaunting state law and opting not to have their children vaccinated. Not surprisingly, northern California is a measles hot spot. Parker has noted an uptick in the number of Nevada parents who seek personal belief exemptions from having their children take the required courses of vaccines from birth to 18.

“Some of the other areas that I think have grown that we’re seeing even on a national level and in California as well is some of that freedom of choice, medical freedom … it’s coated in different ways, but really the bottom line is, it’s parents feeling like they are the ones that should be making these decisions and no one should be telling them what to do. There shouldn’t be mandates. The government shouldn’t be involved in anything. That is definitely a more challenging situation, because we can help people with facts, and we can give them personal stories of vaccine preventable diseases like polio and things, but the other part is harder.”

Parker said the decision not to vaccinate children could have serious impacts on public health, especially in a school.

“That’s a piece that we want everybody to really understand that the choices you’re making, especially in the context of vaccination, can absolutely impact someone else adversely. Someone that’s fighting cancer, they can die from measles if they contract it while they’re sick. And for some of those that’s not a choice, that’s the choice they’re not making for themselves because someone else has made that choice for them. I think that’s where that choice part gets kind of complicated, because in other things, yeah, that choice you make just affects you and your family, maybe, but in the case of public health and vaccination, it really does affect our whole community.”

Why is it important to know who is and who is not immunized?

In the event of a preventable disease outbreak in a public school, a rapid response is critical. To act in a timely way, health officials need an accurate record of kids who have not been vaccinated so they can send them home from school. Parker said that Nevada immunization stakeholders are working to keep accurate and timely records.

“I think everybody is doing a great job as best as we can to prepare for that (an outbreak). Some of the schools are just making sure that they have a good up to date list of which children in those schools aren’t vaccinated. That’s also for medical reasons. Those kids are obviously just as much at risk because we are concerned about them contracting measles as well. Those kids that aren’t vaccinated would need to be notified very quickly. Especially with measles, that response needs to be quick to prevent that spread. It is highly contagious.”

In recent history, Nevada has yet to contend with a large-scale measles outbreak. There are lesson to be learned from on-going preventable disease outbreaks in Oregon, New York and elsewhere. Parker said should an outbreak occur in Nevada, schools are prepared to communicate quickly and clearly with parents.

“You can look at some of these other states like Washington and New York, California a little bit ago, couple years ago, but it can grow really fast, and that’s what New York is dealing with,” Parker said. “I think what Nevada is really trying to do is just be proactive. We also want to make sure that parents whose children are not vaccinated understand that their children are excluded from school during those outbreaks, and that’s not something that they always remember that they agreed upon.”

What are Nevada immunization rates?

According to the Nevada Immunization Report Card for 2015 – 2017, roughly 94 percent of the state’s kindergarteners are current on the five essential batteries of shots needed to enter school, MMR, DTaP, Varicella, Polio, and Hepatitis B, but there are  alarmingly low immunization rates in some schools, both urban and rural. Again, according to CDC data 00.1 percent of Nevada vaccine exemptions are for medical reasons, and 3.1 percent of are for religious objections.

Data for Reno area schools shows an immunization average of 96 percent, which may seem high, but many children remain unvaccinated. For instance, the Mount Rose K-8 Academy of Languages has an immunization rate of 94.57 percent. The school has 461 students. Thus, as many as 20 kids have not received the recommended sequences of vaccines for their age.

In rural Nevada the average immunization rate is lower. In Elko’s Grammar #2 school, 66 percent of students are current on their vaccine schedule.  In Wells, the Leopard Cubs Preschool – Wells Family Resource Center shows an immunization rate of 57 percent.

While most schools in the Las Vegas area have immunization percentages in the mid to upper 90s, there are a few statistical outliers where immunization rates are low. Southern Highlands Prepatory School in Las Vegas has an immunization rate of 70 percent.

With more parents seeking exemptions and measles rates soaring, Parker said Immunize Nevada has come full circle in nearly 30 years. A measles outbreak in the late 1980s caused the Immunize Nevada coalition to form, but for Parker, 2019 marks an unfortunate homecoming for her organization.

“Immunization coalitions like Immunize Nevada were founded in the mid ’90s, ironically as a response to the previous large measles outbreak in the late ’80s and early ’90s that the US experienced. At that time there was grave concern about what was happening and the deaths and hospitalizations that occurred. There was a big movement to mobilize support in communities, and that’s how a lot of immunization coalitions were founded. That’s how our founding groups back then came to be as well. Unfortunately, this is one of those things, it’s not a positive that we have come full circle.”

Elimination status

In a May 2019 press release, the US Centers for Disease Control warned the US may lose the Measles elimination status it achieved in 2000. From the release:

“Outbreaks in New York City and Rockland County, New York have continued for nearly 8 months. If these outbreaks continue through summer and fall, the United States may lose its measles elimination status. That loss would be a huge blow for the nation and erase the hard work done by all levels of public health. The measles elimination goal, first announced in 1966 and accomplished in 2000, was a monumental task. Before widespread use of the measles vaccine, an estimated 3 to 4 million people got measles each year in the United States, along with an estimated 400 to 500 deaths and 48,000 hospitalizations.”

As a veteran of the effort to keep measles at bay, Parker is not pleased with backward steps.

“That’s not some place where we want to be. We’ve seen some commentary recently where people are saying measles is kind of that canary in the coal mine. Measles is so highly contagious. It spreads quickly. But that’s the first … then what else are we going to see? There’s a lot of hepatitis A outbreaks right now. The measles vaccine also prevents mumps, so I’m hoping that we don’t see those other diseases start coming back. But everything is just a plane ride away, train, road trip. Just because of that ease of travel, that is how it can spread as well.”

The low-income immunization gap

Looking forward, Parker said the Immunize Nevada coalition will focus on the low-income/immunization gap. Parker said her nonprofit works closely with the state’s health districts, and they have identified a vaccine gap for low income families. There is free vaccine access for low income families through the CDC’s Vaccines for Children Program. Many qualify for assistance yet do not have their children vaccinated. Moving forward, Immunize Nevada and its partners are working to understand why.

“The big question is, if there’s vaccine access, they’re eligible for it, then why is that not happening,” Parker said. “That kind of leads us back to that whole provider shortage. If you can’t get an appointment. If you don’t have a provider that’s contracted with Medicaid … we do have a high Medicaid population … and when that’s not balanced in terms of the access points, then unfortunately, this is where we’re seeing the immunization gap. And it’s fairly large. That’s why it’s alarming because we don’t want to see a gap in a place that we have resources for.”

Nevada has steadily increased vaccination rates over the past few decades, and Parker said she is thankful for those accomplishments, but that the low-income/vaccination gap is hidden.

“We’re like, ‘yeah, childhood immunizations are improving,’ and that’s been such a positive, but then the data underneath shows us that unfortunately, for those below poverty, children, it’s not improving.”