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Of Mouse and Measles

“Mickey Mouse Gets the Measles,” reported one website. “Space Mountain with a Side of Measles,” proclaimed a news blog, which could not resist adding that Measles was “not the name of an eighth ‘Snow White’ dwarf.”

Joshua M. Sharfstein, MD

That a major measles outbreak began at the home of beloved cartoon characters is certainly attention-grabbing news. Most of the reporting and commentary, in turn, has focused on the role of declining vaccination rates. This concern is especially acute in specific communities, including Orange County, California, where the theme park is located, and where some private schools have immunization rates as low as 60%. A recent Kaiser study in Pediatrics found clusters of underimmunization in 5 areas of northern California.

Beyond the setting, there has not been much discussion of the significance of Disneyland to the story. “Don’t expect a ‘Disneyland effect’” improving immunization rates, wrote one health economist. Parental attitudes on vaccines are too fixed, and our attention spans too short, she wrote, to think that anything will change.

I disagree. My intuition is in line with that of some practicing pediatricians: Mickey, Minnie, Goofy, and friends can help change the terms of the discussion on vaccines.

The traditional framing of a vaccine controversy sets the evidence and judgment of scientists and clinicians against the skepticism of a small minority about the risks and benefits of specific immunizations. The playing field is science, and points are won with data.

On one side are the vast majority of pediatricians, myself included, who fully support the recommended vaccine schedule. Our perspective on the evidence indicates that the benefits of vaccines to children in our practices and to all children are far greater than the risks. (I was the dad who ran out to purchase pneumococcal vaccination with my own money during the narrow window after US Food and Drug Administration approval but before the recommendation for universal vaccination was implemented.)

On the other side are increasing numbers of parents who are concluding that the risk of vaccination to their children is greater than the potential benefit. They are willing to take the risk of illness and skip vaccination. As one California pediatrician close to many parents who refuse vaccination stated on his Facebook page, “Most anti-vaxers do believe vaccines work. They aren’t willing to risk the side effects.”

Pediatricians tend to respond to vaccine resistance by flooding parents with evidence of vaccine effectiveness and safety. The problem is that while information is important, overdoing it may backfire.

A recent Michigan study found that presenting facts to vaccine-refusing parents may actually have the effect of making them more reluctant to vaccinate. As Julie-Anne Leask, PhD, MPH, of the University of Sydney’s School of Public Health in Australia, has written, “there is little empirical support for the hope that decision making about vaccination is based on ‘facts’ alone.” She also warns clinicians to be careful of deluging parents with information that have the “opposite effect of polarising people into existing positions where … those opposed become more entrenched....” Her recommendation is for a more deliberate approach, reinforced by trusted leaders in a community, which emphasizes the benefits of “protecting children from threatening diseases.”

And what better way to convey those benefits than to imagine a Disneyland where children and parents do not have to fear measles?

After many years of decline, measles is back, and outbreaks are just one sign of trouble. School systems are sending children who are not vaccinated home for weeks at a time. Parents of children with cancer and other conditions that preclude vaccination are becoming increasingly angry about the risk that nonvaccinating parents are causing.

As measles continues to spread, these skirmishes can be expected to extend past schools. It is reasonable to ask whether children with cancer and other underlying disorders should risk their health at Disneyland, at the movies, and in sports stadiums simply because other parents have rejected vaccination. Should a child in such a situation become seriously injured or die, pressure will grow for political leaders to protect the most vulnerable—and businesses will react to avoid liability. The Internet headline might one day read: No MMR, No Mickey Mouse.

“What … do non-vaxers want?” asked the California pediatrician close to many parents hesitant to accept pediatric recommendations. “They don’t want to be discriminated against. They want to be able to attend school if they want (if not sick, of course)…. They don't want it to even be an issue that affects social and family life.”

Carefully and clearly, clinicians and community leaders together can respond to this sentiment: Not possible.

When it comes to life-threatening diseases, there is no having your cake and eating it too. There is no refusing to vaccinate but getting to do everything else just the same. When parents reject recommended vaccines, then a community can impose restrictions to protect the lives and health of other children.

States already make this decision with respect to schools. In 30 states, with rare exceptions, state law requires parents to immunize their children or agree not to send them to school. Twenty states have decided otherwise and permit broader exception language for parents. There are signs pressure is already growing for these laws to be strengthened.

The Disneyland outbreak illustrates beautifully that more is at stake for children than rare adverse effects. That’s because vaccines do more than protect from disease. They provide a zone of safety around our children everywhere they go. They protect all children in case of illness with cancer or other disorders. Vaccines allow families to live in communities that are safer, more livable, and more fun.

Where doctors have tried and failed, they should consider calling in some reinforcements. I understand Donald Duck is available for consults.

About the author: Joshua M. Sharfstein, MD, is Associate Dean for Public Health Practice and Training at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. A pediatrician, he lives with his family in Baltimore.
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