I’ve often joked about where the next measles outbreaks (or other outbreaks of vaccine-preventable diseases) would occur. Thanks to a new study by a group from the Baylor College of Medicine including Peter Hotez, I know, and I’m not happy. Why? Because, along with Texas and other places, southeast Michigan is one of the places where “make American great again” (MAGA) should really be “make measles great again” (MMGA). I’ll explain, but first a little background.
As I’ve documented many times before, my particular state (Michigan) is a hotbed of antivaccine political activity. Indeed, spurred on by antivaccine political groups (and perhaps an earlier pitch by the makers of the antivaccine propaganda movie VAXXED), my very own state senator (Patrick Colbeck) and state representative (Jeff Noble) teamed up last year to make measles great again in Michigan by co-sponsoring the senate and house versions, respectively, of a truly brain dead bill. The bill, if passed, would have eliminated a regulatory requirement introduced by the Michigan Department of Health and Human Services that parents seeking personal belief exemptions (PBEs) to school vaccine mandates attend an educational session at their county health office and sign a waiver form in which they admit that they are putting their child and others at higher risk for disease. The MDHHS took this action because our state’s PBE rate and vaccine uptake rate sucked at the time. The MDHHS policy worked almost immediately, too, to increase vaccine uptake and decrease PBE rates, just as SB 277 did in California.
The bill didn’t pass, fortunately, but it was yet another of a long line of efforts to chip away at Michigan’s vaccine mandates for school entry, including previous attempts to get a similar bill pasted. The most recent occurred just last week, when Michigan Right to Life managed to get its lackeys in the Michigan Senate, including Sen. Colbeck, to introduce a bill that would require “informed consent” telling parents about vaccines for which human fetal cells are used during the manufacturing process to grow up virus stock necessary for the vaccines. It was nothing more than antivaccine fear mongering designed to frighten parents into not vaccinating, and, amusingly, Michigan Right to Life was not in the least bit amused when it was pointed out on Twitter, to the point of getting in an extensive and hilariously off-base Twitter discussion:
Here's the underlying fear of Dr. Gorski in this: when people find out that several vaccines are manufactured using tissue from aborted babies, they will not get vaccines. So informing people of these medical facts frightens him. But it shouldn't… https://t.co/5HC4J89kBI
— Right to Life of MI (@Right_to_Life) June 12, 2018
The entire Twitter exchange, both in response to Michigan Right to Life and the Tweet that provoked it (below) is epic and worth reading.
Here we go again, antivaxers trying to hijack antiabortionists (or is it the other way around?) to frighten parents into not vaccinating by portraying vaccines as somehow hopelessly "contaminated" by "fetal tissue." 1/ https://t.co/VcA8prjhJ1
— David Gorski, MD, PhD (@gorskon) June 12, 2018
I note that in the exchange, Michigan Right to Life explicitly admitted to having worked with “vaccine freedom” groups like Michigans for Vaccine Choice, although whoever runs its Twitter feed insists that it was only on this issue. When the antiabortion movement met the antivaccine movement indeed.
I’ve also documented how antivaxers have cunningly taken advantage of the political mood in the country and allied themselves with right wing groups opposed to pretty much all government regulation, something that is happening in a major way in Texas, to the point where Texas antivaccine groups offered help to victims of Hurricane Harvey forced to temporarily relocate and enroll their children in different schools in maintaining their vaccine PBEs. Basically, in the middle of a natural disaster, these groups were far more concerned about lowering vaccine rates than actually helping the displaced.
What endangers us all is that politicizing what should be a nonpartisan issue, namely school vaccine mandates to protect our children, is becoming increasingly politicized, with potentially deadly consequences. Here in Michigan, over the last decade we’ve already had a number of outbreaks, mostly of pertussis, one of which led to a distraught parent of a child who died in Michigan’s 2012 pertussis outbreak to form a pro-vaccine advocacy group.
So let’s get to the study, The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties, which was published in PLoS Medicine just this week. At the beginning of the article, the authors note some important background points. First, since 2009, the number of “philosophical-belief” vaccine nonmedical exemptions (NMEs) has risen in 12 of the 18 states that currently allow this policy: Arkansas (AR), Arizona (AZ), Idaho (ID), Maine (ME), Minnesota (MN), North Dakota (ND), Ohio (OH), Oklahoma (OK), Oregon (OR), Pennsylvania (PA), Texas (TX), and Utah (UT). Based on this observation, the authors analyzed the relationship between NME/PBE rates and actual vaccine coverage. Interestingly, if you look at the graph, Michigan was one of the states where NME/PBE rates were rising, but took a big drop in the 2015-2016 school year. Not coincidentally, that was the school year in which the new requirement that parents seeking PBEs must attend an educational session at their county health department and sign only a state-approved form that admits that withholding vaccination could endanger their children and others.
Next, the authors looked at NME/PBE rates by county for the states using data from either the 2015-16 or 2016-17 school years to produce this map:
Here is a list of the ten US counties with the highest NME/PBE rates:
The rates of NME/PBEs in some of these counties is truly staggering, as high as nearly 27%. Also alarming is that eight out of the top ten counties are in Idaho. Truly, when the next outbreaks happen, they’ll probably happen in Idaho. I’m guessing that the only thing that’s stopped them so far is the relatively sparse population density of the state.
Finally, the authors looked at kindergarten populations:
Furthermore, we examined total numbers of kindergarteners with NMEs per county to identify focal areas with large numbers of potentially vulnerable pediatric populations. County NME totals were also provided by state health departments. The exception is MO, whose private kindergarten (2015–2016) and public kindergarten (2014–2015) enrollment numbers were taken together from the National Center for Education Statistics (nces.ed.gov) to derive NME raw counts. Shown in Fig 3 and Table 2 are the counties—associated with large metropolitan areas—where more than 400 kindergarteners have received NMEs. They include Phoenix, AZ (Maricopa County); Salt Lake City, UT and Provo, UT (Salt Lake and Utah Counties, respectively); Seattle, WA and Spokane, WA (King and Spokane Counties, respectively); Portland, OR (Multnomah County); Troy, MI, Warren, MI, and Detroit, MI (Oakland, Macomb, and Wayne Counties, respectively); Houston, TX, Fort Worth, TX, Plano, TX, and Austin, TX (Harris, Tarrant, Collin, and Travis Counties, respectively); Pittsburgh, PA (Allegheny County); and Kansas City, MO (Jackson County). The high numbers of NMEs in these densely populated urban centers suggest that outbreaks of vaccine-preventable diseases could either originate from or spread rapidly throughout these populations of unimmunized, unprotected children. The fact that the largest count of vaccine-exempt pediatric populations originate in large cities with busy international airports may further contribute to this risk.
Here’s the map:
Lovely. Detroit. It had to be Detroit in the list, along with the others. Of course, I note that in reality what we are looking at is the Detroit metropolitan area, which generally includes the Wayne, Oakland, and Macomb Tricounty area:
I can’t help but note that Oakland and Macomb Counties encompass nearly all the northern suburbs and exurbs of Detroit, which include just the sort of affluent, largely white, communities where one would expect to find large numbers of antivaxers. Indeed, these are the places where the VAXXED crew focused their efforts the last time they were in the state. (Indeed, Troy in Oakland County is the home to our largest antivaccine group, Michigan for Vaccine Choice.) Wayne County does include Detroit, but it also includes the Grosse Pointes and several other affluent suburbs, which is why I really wish for an analysis using even more granular data. As for the rest of the rollcall of dishonor, Maricopa County in Arizona is not unexpected given the concentration of woo in Arizona, nor is it surprising that there are three counties in Texas.
Finally, the authors asked the question: Is there a correlation between the rate of NME/PBE and MMR coverage? Their findings were striking:
As shown in Fig 4 and Table 3, there was a significant inverse association between state NME rate and MMR vaccination rate by Spearman correlation (P = 0.03; Fig 4) and beta regression (P = 0.007). Similarly, we calculated Spearman correlation between state NME rate and MMR rate for all 50 US states and the District of Columbia. States with no information for either NME rate or MMR vaccination rate were excluded (CO, IL, MN, MO, OK, and WY). From this analysis, we found a significant inverse association between state NME rate and MMR vaccination rate (P = 0.04) as compared to states allowing NMEs. Overall, states with more NME students exhibited lower MMR vaccination rates. In contrast, states that have banned NMEs—MS, CA, and WV—exhibit the highest MMR vaccine uptake and lowest incidence of vaccine-preventable diseases.
None of this, of course, is in the least bit surprising. Moreover, I’ve written about this as long as 12 years ago, when I noted that states with lax requirements for NME/PBEs had lower rates of vaccine uptake and greater chances of outbreaks. It’s also been shown that relatively small decreases in vaccine uptake can lead to outbreaks.
One interesting aspect of this study is the aforementioned observation that eight of the ten counties with the highest NME/PBE rates are in Idaho, in counties with fewer than 50,000 people, leading Dr. Hotez to comment in a news story about the study:
Hotez said he did not know what factors were behind the high exemption rates in some of the rural places; researchers are hoping to conduct a follow-up study on social and demographic factors. But the findings, he said, should prompt federal health agencies such as the Centers for Disease Control and Prevention to undertake investigations.
The high numbers of exemptions in those densely populated urban centers “suggest that outbreaks of vaccine-preventable diseases could either originate from or spread rapidly throughout these populations of unimmunized, unprotected children,” the authors conclude in the report. Many communities are in cities with busy international airports, further increasing the risk of disease spread.
As I said, what’s probably been protecting Idaho is the very sparseness of its population. I do have some ideas why Idaho might be such a hotbed of antivaccine sentiments. For one thing, as I said above, antivaxers are very much courting conservative groups, and Idaho has been a Republican stronghold for decades. Indeed, in 2016, Donald Trump garnered more than twice as many votes as Hillary Clinton. Idaho is also a hotbed of antigovernment militia activity. In particular, Idaho’s panhandle has a long history of major radical right wing groups beginning in the 1980s when Aryan Nation’s leader Richard Butler encouraged whites to retreat to Idaho to form an all-white state. In other words, there is fertile ground there for a message of resisting government mandates, including school vaccine mandates. More recently, there has been a wave of Californians moving to Idaho, some explicitly to avoid SB 277, the California law that has banned NMEs.
Be that as it may, you can bet that I’m not happy that the metro Detroit area includes three of the top fifteen metropolitan areas with the highest rates of NME/PBE. I don’t want to be at ground zero for the next wave of outbreaks of vaccine preventable diseases. More importantly, I don’t want my young relatives to be endangered. Also, I can’t help but echo this lyric, given the Disneyland measles outbreak a mere three and a half years ago, “It’s a small world, after all.” The authors agree:
The results reported here for the US have potential relevance internationally. While NMEs continue to rise in most of the 18 US states that allow them, several European countries, including France and Italy, as well as Australia, have taken measures to either make vaccines compulsory or even fine parents who refuse to vaccinate their children [15–17]. Romania has experienced serious and large measles outbreaks and may also tighten vaccine legislation . Our concern is that the rising NMEs linked to the antivaccine movement in the US will stimulate other countries to follow a similar path. It would be especially worrisome if the very large low- and middle-income countries—such as Brazil, Russia, India, and China (the BRIC nations), or Bangladesh, Indonesia, Nigeria, and Pakistan—reduce their vaccine coverage. In such a case, we could experience massive epidemics of childhood infections that may threaten achievement of United Nations global goals .
It really is a small world after all, and we risk making measles great again not just in the US, but everywhere.