[Skip to Content]
[Skip to Content Landing]
Original Investigation
September 2017

Public Health and Economic Consequences of Vaccine Hesitancy for Measles in the United States

Author Affiliations
  • 1MD/PhD Candidate, Division of Epidemiology, Stanford University School of Medicine, Stanford, California
  • 2Texas Children’s Hospital Center for Vaccine Development, National School of Tropical Medicine, Baylor College of Medicine, Houston
  • 3Department of Biology, Baylor University, Waco, Texas
  • 4James A. Baker III Institute for Public Policy, Rice University, Houston, Texas
  • 5Scowcroft Institute of International Affairs, The Bush School of Government and Public Service, Texas A&M University, College Station
JAMA Pediatr. 2017;171(9):887-892. doi:10.1001/jamapediatrics.2017.1695
Key Points

Question  How does vaccine hesitancy affect annual measles cases and economic costs in the United States?

Findings  In this modeling study of children (age 2-11 years), a 5% reduction in measles, mumps, and rubella vaccination coverage resulted in a 3-fold increase in annual measles cases with an additional US$2.1 million in public sector costs.

Meaning  Even small declines in vaccination coverage in children owing to vaccine hesitancy may have substantial public health and economic consequences that will be larger when considering unvaccinated infants, adolescents, and adults.


Importance  Routine childhood vaccination is declining in some regions of the United States due to vaccine hesitancy, which risks the resurgence of many infectious diseases with public health and economic consequences. There are ongoing policy debates on the state and national level, including legislation around nonmedical (personal-belief) exemptions for childhood vaccination and possibly a special government commission on vaccine safety, which may affect vaccine coverage.

Objective  To estimate the number of measles cases in US children and the associated economic costs under scenarios of different levels of vaccine hesitancy, using the case example of measles, mumps, and rubella (MMR) vaccination and measles.

Design, Setting, and Participants  Publicly available data from the US Centers for Disease Control and Prevention were used to simulate county-level MMR vaccination coverage in children (age 2-11 years) in the United States. A stochastic mathematical model was adapted for infectious disease transmission that estimated a distribution for outbreak size as it relates to vaccine coverage. Economic costs per measles case were obtained from the literature. The predicted effects of increasing the prevalence of vaccine hesitancy as well as the removal of nonmedical exemptions were estimated. The model was calibrated to annual measles cases in US children over recent years, and the model prediction was validated using an independent data set from England and Wales.

Main Outcomes and Measures  Annual measles cases in the United States and the associated public sector costs.

Results  A 5% decline in MMR vaccine coverage in the United States would result in an estimated 3-fold increase in measles cases for children aged 2 to 11 years nationally every year, with an additional $2.1 million in public sector costs. The numbers would be substantially higher if unvaccinated infants, adolescents, and adult populations were also considered. There was variation around these estimates due to the stochastic elements of measles importation and sensitivity of some model inputs, although the trend was robust.

Conclusions and Relevance  This analysis predicts that even minor reductions in childhood vaccination, driven by vaccine hesitancy (nonmedical and personal belief exemptions), will have substantial public health and economic consequences. The results support an urgent need to address vaccine hesitancy in policy dialogues at the state and national level, with consideration of removing personal belief exemptions of childhood vaccination.