History Of The anti-Vaccination Movement

The following history of the anti-vaccination movement is reprinted from Wikipedia:

Religious arguments against inoculation were advanced even before the work of Edward Jenner (pioneer of the smallpox vaccine); for example, in a 1722 sermon entitled "The Dangerous and Sinful Practice of Inoculation" the English theologian Rev. Edward Massey argued that diseases are sent by God to punish sin and that any attempt to prevent smallpox via inoculation is a "diabolical operation". Some anti-vaccinationists still base their stance against vaccination with reference to their religious beliefs.

After Jenner's work, vaccination became widespread in the United Kingdom in the early 1800s.  Variolation, which had preceded vaccination, was banned in 1840 because of its greater risks. Public policy and successive Vaccination Acts first encouraged vaccination and then made it mandatory for all infants in 1853, with the highest penalty for refusal being a prison sentence. This was a significant change in the relationship between the British state and its citizens, and there was a public backlash. After an 1867 law extended the requirement to age 14 years, its opponents focused concern on infringement of individual freedom, and eventually a 1898 law allowed for conscientious objection to compulsory vaccination.

In the 19th century, the city of Leicester in the UK achieved a high level of isolation of smallpox cases and great reduction in spread compared to other areas. The mainstay of Leicester's approach to conquering smallpox was to decline vaccination and put their public funds into sanitary improvements. Bigg's account of the public health procedures in Leicester, presented as evidence to the Royal Commission, refers to erysipelas, an infection of the superficial tissues which was a complication of any surgical procedure.

In the U.S., President Thomas Jefferson took a close interest in vaccination, alongside Dr. Waterhouse, chief physician at Boston. Jefferson encouraged the development of ways to transport vaccine material through the Southern states, which included measures to avoid damage by heat, a leading cause of ineffective batches. Smallpox outbreaks were contained by the latter half of the 19th century, a development widely attributed to vaccination of a large portion of the population.  Vaccination rates fell after this decline in smallpox cases, and the disease again became epidemic in the 1870s (see smallpox).

Anti-vaccination activity increased again in the U.S. in the late 19th century. After a visit to New York in 1879 by William Tebb, a prominent British anti-vaccinationist, the Anti-Vaccination Society of America was founded. The New England Anti-Compulsory Vaccination League was formed in 1882, and the Anti-Vaccination League of New York City in 1885.

John Pitcairn, the wealthy founder of the Pittsburgh Plate Glass Company (now PPG Industries) emerged as a major financer and leader of the American anti-vaccination movement. On March 5, 1907, in Harrisburg, Pennsylvania, he delivered an address to the Committee on Public Health and Sanitation of the Pennsylvania General Assembly criticizing vaccination. He later sponsored the National Anti-Vaccination Conference, which, held in Philadelphia on October, 1908, led to the creation of The Anti-Vaccination League of America. When the League was organized later that month, Pitcairn was chosen to be its first president. On December 1, 1911, he was appointed by Pennsylvania Governor John K. Tener to the Pennsylvania State Vaccination Commission, and subsequently authored a detailed report strongly opposing the Commission's conclusions. He continued to be a staunch opponent of vaccination until his death in 1916.

In November 1904, in response to years of inadequate sanitation and disease, followed by a poorly-explained public health campaign led by the renowned Brazilian public health official Oswaldo Cruz, citizens and military cadets in Rio de Janeiro arose in a Revolta da Vacina or Vaccine Revolt. Riots broke out on the day a vaccination law took effect; vaccination symbolized the most feared and most tangible aspect of a public health plan that included other features such as urban renewal that many had opposed for years.

In the early 19th century, the anti-vaccination movement drew members from across a wide range of society; more recently, it has been reduced to a predominantly middle-class phenomenon.  Arguments against vaccines in the 21st century are often similar to those of 19th-century anti-vaccinationists.

The idea that vaccines, and specifically the Measles/Mumps/Rubella vaccine, causes autism was first proposed by Andrew Wakefield. He was the lead author of a controversial 1998 research study, published in The Lancet, which reported bowel symptoms in a prospective case series of twelve consecutive vaccinated children diagnosed with autism spectrum disorders and other disabilities, and alleged a possible connection with the MMR vaccination. Citing safety concerns, in a press conference held in conjunction with the release of the report, Wakefield recommended separating the components of the injections by at least a year. Given the widespread media coverage of Wakefield's claims, his recommendation was deemed responsible for a decrease in immunization rates in the UK. The section of the paper setting out its conclusions was subsequently retracted by ten of the paper's thirteen authors.

Following the controversy, in March, 2004, the British General Medical Council (GMC) announced it was launching an inquiry into allegations of serious professional misconduct against Wakefield and two former colleagues. It centered on claims, brought forth by journalist Brian Deer, that autistic and neurotypical children may have been subjected to unnecessary lumbar punctures and colon biopsies, including one colonoscopy that caused the child life-threatening perforations of the bowel. Additionally, Wakefield is accused by the GMC of suppressing and falsifying data based on the testimony of Dr. Stephen Bustin and Dr. Nicholas Chadwick during the Autism Omnibus vaccine hearing in June, 2007.

In February 2009, The Sunday Times reported that a further investigation by the newspaper had revealed that Wakefield "changed and misreported results in his research, creating the appearance of a possible link with autism", citing evidence obtained by the newspaper from medical records and interviews with witnesses, and supported by evidence presented to the GMC. The newspaper went on to state that the rates of inoculation fell from 92% (very slightly below measles herd immunity) to below 80% after the publication of Wakefield's study, and that confirmed cases of measles in England and Wales have risen from 56 in 1998 to 1348 in 2008, with two child fatalities.

In February 2010, The Lancet formally retracted Andrew Wakefield’s 1998 paper.

In May 2010, the British General Medical Council investigation concluded that Wakefield and his two colleagues, Professor Walker-Smith and Professor Murch, had engaged in serious medical misconduct concerning the 1998 study and Wakefield’s license to practice medicine in the UK was revoked.

In January 2011, the British Medical Journal found that Andrew Wakefield had participated in intentional fraud concerning his work which led to the 1998 paper that linked the MMR Vaccine to Autism. The BMJ published three articles by journalist Brian Deer that detailed how the fraud was conducted entitled “Secrets of the MMR Scare” Part 1, Part 2 and Part 3. In November 2011, the BMJ published another article entitled “More Secrets of the MMR Scare”.

Links To Disease Outbreaks Due To Anti-Vaccination Beliefs:

CDC Preventable Measles Among U.S. Residents, 2001--2004: “her parents had declined to have her vaccinated for religious beliefs.”

CDC Import-Associated Measles Outbreak --- Indiana, May--June 2005: “Persons choosing a nonmedical exemption from vaccination are approximately 22 times more likely to acquire measles than persons who are vaccinated. Parents and persons who opt out of vaccination should be aware of the risk that this practice places upon their children and their community. Communities of persons who have not been vaccinated can make intensive measles-containment activities necessary.”

CDC Measles --- United States, 2004: “One case of secondary spread was identified in a California resident aged 19 years with a nonmedical exemption for measles vaccination who had had close contact with one of the adoptees. In the second outbreak, a U.S. student aged 19 years with a nonmedical exemption for measles vaccination was infected in India and returned to Iowa, where two secondary cases occurred.”

CDC Varicella Outbreak Among Vaccinated Children --- Nebraska, 2004: “No parents of susceptible students agreed to administration of varicella vaccine to their children during the outbreak, likely because of a widespread belief among the parents that the vaccine was ineffective; the outbreak coincided with introduction of the varicella vaccination requirement, and some vaccinated students were contracting varicella. This report refutes the misconception that vaccination was ineffective and underscores the importance of investigating such outbreaks and educating parents about the value of varicella vaccination.”

CDC Measles --- United States, 2005: “28 (88%) patients aged 1--19 years had not been vaccinated, primarily because their parents were concerned about potential adverse events associated with vaccination. The outbreak occurred because measles was imported into a population of children whose parents had chosen not to vaccinate their children because of safety concerns, despite evidence that that measles-containing vaccine is safe and effective. A major epidemic was averted because of high vaccination levels and a low rate of vaccine failure in the surrounding community. The cost of containing this outbreak was estimated at $167,685. This outbreak and other cases reported during 2005 likely could have been prevented had existing ACIP vaccination recommendations been followed. The index case traveler should have been vaccinated with 2 doses of measles-containing vaccine before departure; exposed school-age children and personnel working in health-care facilities also should have had the recommended 2 doses before exposure.”

CDC Outbreak of Measles --- San Diego, California, January--February 2008: “Measles transmission in schools was common in the era before interruption of endemic-disease transmission, and school requirements for vaccination have been a successful strategy for achieving high vaccination coverage levels in this age group and decreasing transmission in school settings. In the United States, all states require children to be vaccinated in accordance with Advisory Committee on Immunization Practices recommendations before attending school. However, medical exemptions to immunization requirements for day care and school attendance are available in all states; in addition, 48 states offer nonmedical religious exemptions, and 21 states (including California) offer nonmedical personal belief exemptions (PBEs). These exemptions are defined differently by each state. The PBE allowed by California requires only a parental affidavit. Compared with vaccinated persons, those exempt from vaccination are 22 to 224 times more likely to contract measles.

CDC Measles --- United States, January 1--April 25, 2008: “Many of the measles cases in children in 2008 have occurred among children whose parents claimed exemption from vaccination because of religious or personal beliefs and in infants too young to be vaccinated. Forty-eight states currently allow religious exemptions to school vaccination requirements, and 21 states allow exemptions based on personal beliefs. During 2002 and 2003, nonmedical exemption rates were higher in states that easily granted exemptions than states with medium or difficult exemption processes; in such states, the process of claiming a nonmedical exemption might require less effort than fulfilling vaccination requirements. Although national vaccination levels are high, unvaccinated children tend to be clustered geographically or socially, increasing their risk for outbreaks. An upward trend in the mean proportion of school children who were not vaccinated because of personal belief exemptions was observed from 1991 to 2004. Increases in the proportion of persons declining vaccination for themselves or their children might lead to large-scale outbreaks in the United States, such as those that have occurred in other countries (e.g., United Kingdom and Netherlands).”

CDC Update: Measles --- United States, January--July 2008: “Washington, April 2008: Because of their parents' philosophical or religious beliefs, none of the 16 children had received measles-containing vaccine. Illinois, May 2008: Because of their parents' beliefs against vaccination, none of the 25 had received measles-containing vaccine.”

Mumps Outbreak --- New York, New Jersey, Quebec, 2009: “The index patient was a boy aged 11 years who had returned on June 17 from the United Kingdom, where a mumps outbreak is ongoing with approximately 4,000 cases, primarily in unvaccinated young adults in the general population.”

Hospital-Associated Measles Outbreak — Pennsylvania, March–April 2009: “None of the three secondarily infected children had been vaccinated for measles; the child aged 11 months was too young for routine vaccination, and the index patient and his brother were unvaccinated by parental choice.”

Notes from the Field: Measles Transmission Associated with International Air Travel --- Massachusetts and New York, July--August 2010: “On July 8, 2010, the Massachusetts Department of Public Health (MDPH) notified CDC of a case of laboratory-confirmed measles in an unvaccinated airline passenger aged 23 months.”

Measles Imported by Returning U.S. Travelers Aged 6--23 Months, January to February 2011: “In the first 2 months of 2011, CDC received reports of seven imported measles cases among returning U.S. travelers aged 6--23 months; four required hospitalization. Young children are at greater risk for severe measles, death, or sequelae such as subacute sclerosing panencephalitis. Although all seven children had been eligible for vaccination before travel, none had received measles, mumps, and rubella (MMR) vaccine.”

Notes from the Field: Measles Outbreak --- Hennepin County, Minnesota, February--March 2011: “The patients included children aged 4 months--4 years and one adult aged 51 years; seven of the 13 were of Somali decent. Eight patients were hospitalized. Vaccination status was known for 11 patients: five were too young to have been vaccinated, and six (all of Somali descent) had not been vaccinated because of parental concerns about the safety of the measles, mumps, and rubella (MMR) vaccine.”

Measles --- United States, January--May 20, 2011: “During 2001--2008, a median of 56 (range: 37--140) measles cases were reported to CDC annually; during the first 19 weeks of 2011, 118 cases of measles were reported, the highest number reported for this period since 1996. Of the 118 cases, 47 (40%) resulted in hospitalization. Nine patients had pneumonia, but none had encephalitis and none died. All but one hospitalized patient were unvaccinated.”

Notes from the Field: Measles Outbreak --- Indiana, June--July 2011: “Of the 14 patients, 13 were unvaccinated persons in the same extended family. The nonfamily member was a child aged 23 months who had received 1 dose of measles, mumps, and rubella vaccine 4 months before illness onset. Four of the 14 patients were males; median age was 11.5 years (range: 15 months--27 years). One patient was a woman in week 32 of pregnancy who was hospitalized for acute pneumonitis. The index patient was an unvaccinated U.S. resident aged 24 years who noted a rash on June 3 during a return flight from Indonesia, where measles is endemic.“

Influenza-Associated Pediatric Deaths --- United States, September 2010--August 2011: “These findings underscore the importance of vaccinating children to prevent influenza virus infection and its potentially severe complications. Health-care providers should develop a comprehensive strategy to increase vaccination coverage among children.”

Outbreak of Meningococcal Disease Associated with an Elementary School — Oklahoma, March 2010: “During March 10–31, 2010, the Oklahoma State Department of Health (OSDH) investigated an outbreak of meningococcal (Neisseria meningitidis) disease involving a consolidated school district of 1,850 students in rural northeastern Oklahoma. Five cases of meningococcal disease (including one probable case) were identified among four elementary school students and one high school student. Two students died; two recovered fully, and one survivor required amputation of all four limbs and facial reconstruction. None of the five patients had received a meningococcal vaccination previously.”

Measles — United States, 2011: “In 2000, the United States achieved measles elimination (defined as interruption of year-round endemic measles transmission). However, importations of measles into the United States continue to occur, posing risks for measles outbreaks and sustained measles transmission. During 2011, a total of 222 measles cases (incidence rate: 0.7 per 1 million population) and 17 measles outbreaks (defined as three or more cases linked in time or place) were reported to CDC, compared with a median of 60 (range: 37–140) cases and four (range: 2–10) outbreaks reported annually during 2001–2010. Most patients (86%) were unvaccinated or had unknown vaccination status. The increased numbers of outbreaks and measles importations into the United States underscore the ongoing risk for measles among unvaccinated persons and the importance of vaccination against measles.”

Severe Varicella in an Immunocompromised Child Exposed to an Unvaccinated Sibling with Varicella — Minnesota, 2011: “On December 13, 2011, the Minnesota Department of Health was notified of varicella in a girl, aged 3 years, admitted to a hospital after a 2-day history of fever of 102.7°F (39.3°C) and an extensive maculopapulovesicular rash (>500 skin lesions) with vesicles in the mouth and throat. The child received weekly immunosuppressive therapy with methotrexate (12.5 mg) for juvenile rheumatoid arthritis diagnosed at age 18 months. Neither she nor her younger sibling, aged 21 months, had received a first dose of varicella vaccine (routinely recommended at age 12–15 months). Their parents refused vaccination because of personal beliefs.”

Pertussis Epidemic — Washington, 2012: “Since mid-2011, a substantial rise in pertussis cases has been reported in the state of Washington. In response to this increase, the Washington State Secretary of Health declared a pertussis epidemic on April 3, 2012. By June 16, the reported number of cases in Washington in 2012 had reached 2,520 (37.5 cases per 100,000 residents), a 1,300% increase compared with the same period in 2011 and the highest number of cases reported in any year since 1942.”

Vaccination Coverage Among Children in Kindergarten — United States, 2011–12 School Year: “In 2011, CDC reported 17 outbreaks of measles and 222 measles cases, most of which were imported cases in unvaccinated persons. This was the highest number of measles cases in any year in the United States since 1996 and highlights the importance of monitoring measles vaccination coverage at the local level.”

Mumps Outbreak on a University Campus — California, 2011: “On September 29, 2011, the California Department of Public Health confirmed three cases of mumps among students recently evaluated at their university's student health services with symptoms suggestive of mumps. An investigation by CDPH, student health services, and the local health department identified 29 mumps cases. The presumed source patient was an unvaccinated student with a history of recent travel to Western Europe, where mumps is circulating. The student had mumps symptoms >28 days before the onset of symptoms among the patients confirmed on September 29. Recognizing that at least two generations of transmission had occurred before public health authorities were alerted, measles, mumps, and rubella (MMR) vaccine was provided as a control measure. This outbreak demonstrates the potential value of requiring MMR vaccination (including documentation of immunization or other evidence of immunity) before college enrollment, heightened clinical awareness, and timely reporting of suspected mumps patients to public health authorities.”

Two Measles Outbreaks After Importation — Utah, March–June 2011: “Outbreak 1. On April 5, 2011, a health-care provider notified the Salt Lake Valley Health Department (SLVHD) of an unvaccinated Salt Lake County resident aged 16 years with generalized rash (onset April 4) and a 3-day history of sore throat and fever (101.7°F [38.7°C]). On April 8, a health-care provider notified SLVHD that an unvaccinated Salt Lake County patient aged 15 years had sought care in late March with generalized rash (onset March 21), fever (103.7°F [39.8°C]), cough, coryza, and conjunctivitis. This patient had attended a school class on March 21 with the patient reported previously. Five additional Salt Lake County residents were confirmed to have measles, with the last rash onset on April 17, 2011. Outbreak 2. On May 24, 2011, a Cache County resident notified the Bear River Health Department that her unvaccinated child aged 7 years had signs and symptoms compatible with measles, including generalized rash (onset May 23) and fever (101.5°F [38.6°C]). Two unvaccinated siblings of the patient, for whom the parents declined postexposure vaccination, were home-quarantined and developed measles, with rash onsets June 1 and 2, respectively. Additionally, two Cache County residents and one Millard County resident, all family members of the two siblings, were identified as having measles; the last reported rash onset was June 16, 2011. In the two outbreaks, separated by 36 days, 13 persons were confirmed to have measles; nine (69%) were unvaccinated and had personal belief exemptions.”

Three Cases of Congenital Rubella Syndrome in the Postelimination Era — Maryland, Alabama, and Illinois, 2012: “Infant A. In February 2012, an infant born in Maryland at 36 weeks' gestation and weighing 4.2 lbs (1,910 g) was noted at birth to have congenital heart defects, hyperpigmented skin lesions, cataracts, cerebral edema, and pericardial effusion. Hearing impairment was suspected after the infant failed a hearing screening test before hospital discharge in February, and bilateral profound hearing impairment was diagnosed by an audiologist in June. The mother, in her late 20s, was from urban Tanzania. She reported having a rash around the time of her first missed menstrual period in June 2011 while in Tanzania. At the time, she did not know that she was likely a few weeks pregnant. She reported having received all of her childhood vaccinations in Tanzania, but rubella-containing vaccine had not been part of the routine vaccination schedule. Infant B. In March 2012, an infant was born in Alabama by cesarean delivery at 33 weeks' gestational age. At birth, the infant had generalized hemorrhagic purpura (a blueberry muffin rash) over the entire body, patent ductus arteriosus, cardiomegaly, thrombocytopenia, pneumonitis, anemia, and liver dysfunction. Approximately 1 month later, the infant was transferred to a pediatric hospital, where the infant died in April 2012. The mother was a woman in her late 20s from Nigeria. Receipt of a rubella-containing vaccine, which is not part of the routine vaccination schedule in Nigeria, was not recorded at any time. Infant C. In September 2012, an infant was born in Illinois by cesarean delivery at approximately 32.5 weeks' gestational age, weighing 1.4 lbs (650 g). Conditions noted after birth included cataracts, Dandy-Walker syndrome (discovered on antenatal ultrasound), intrauterine growth retardation, thrombocytopenia, chorioretinitis, coarctation of the aorta (which was repaired), mild liver dysfunction, mildly elevated transaminases, mild direct hyperbilirubinemia, and persistent elevation of C reactive protein. The child was discharged in February 2013. The mother was an immigrant from Sudan in her late 20s. Her rubella vaccination status was unknown; however, rubella vaccine is not part of the routine vaccination schedule in Sudan.”

Varicella Death of an Unvaccinated, Previously Healthy Adolescent — Ohio, 2009: “In April 2012, as part of the routine review of vital statistics records, the Ohio Department of Health identified a 2009 death with the International Classification of Diseases, 10th Revision code for varicella as the underlying cause. Because varicella deaths are nationally reportable, the Ohio Department of Health conducted an investigation to validate that the coding was accurate. Investigators learned that, on March 12, 2009, the adolescent girl was admitted to a hospital with a 3-day history of a rash consistent with varicella and a 1-day history of fever and shortness of breath. The patient was started on intravenous acyclovir (on day 4 of illness) and broad-spectrum antibiotics and antifungals, but she died 3 weeks later. The case underscores the importance of varicella vaccination, including catch-up vaccination of older children and adolescents, to prevent varicella and its serious complications.”

Measles — United States, January 1–August 24, 2013: “To update measles data, CDC evaluated cases reported by 16 states during January 1–August 24, 2013. A total of 159 cases of measles were reported during this period. Most cases were in persons who were unvaccinated (131 [82%]) or had unknown vaccination status (15 [9%]). Forty-two importations were reported, and 21(50%) were importations from the World Health Organization (WHO) European Region. Eight outbreaks accounted for 77% of the cases reported in 2013, including the largest outbreak reported in the United States since 1996 (58 cases). These outbreaks demonstrate that unvaccinated persons place themselves and their communities at risk for measles and that high vaccination coverage is important to prevent the spread of measles after importation.”

Notes from the Field: Measles Outbreak Among Members of a Religious Community — Brooklyn, New York, March–June 2013: “On March 13, 2013, an intentionally unvaccinated adolescent aged 17 years returned to New York City from London, United Kingdom, while infectious with measles. This importation led to the largest outbreak of measles in the United States since 1996. A total of 58 cases were identified, including six generations of measles infection in two neighborhoods of the borough of Brooklyn. All cases were in members of the orthodox Jewish community. No case was identified in a person who had documented measles vaccination at the time of exposure; 12 (21%) of the cases were in infants too young (aged <12 months) for routine immunization with measles, mumps, and rubella (MMR) vaccine.”

Notes from the Field: Measles Outbreak Associated with a Traveler Returning from India — North Carolina, April–May 2013: “On April 14, 2013, public health officials in North Carolina were notified of suspected measles infections in two unvaccinated members of a family. Measles was confirmed by laboratory testing at the State Laboratory of Public Health on April 16, 2013. Investigators learned that a third unvaccinated member of the household had developed fever and rash 11 days earlier, after returning to the United States from a 3-month visit to India, but measles had not been suspected until household contacts sought evaluation for similar symptoms. During April and May, direct and indirect transmission from the returning traveler resulted in 22 identified cases of measles (including the two cases first reported), for a total of 23 cases overall. Most cases were among residents of a largely unvaccinated religious community in rural North Carolina. Eighteen (78%) of the 23 patients were unvaccinated, three (13%) had been fully vaccinated with 2 doses of measles vaccine, and two (9%) had unknown vaccination status.”

Measles Outbreak Associated with Adopted Children from China — Missouri, Minnesota, and Washington, July 2013: “A boy and a girl, both aged 2 years and with cerebral palsy, were in the process of being adopted by families in the United States, but became ill in China before traveling to the United States. The boy (child A) developed rhinorrhea and cough on June 24. At the time of his immigration medical examination by a panel physician on June 29, the boy was found to have a rash on his neck. Because he was afebrile and had no other symptoms or signs, the rash was diagnosed as contact dermatitis. By the next day, the rash began on his head and spread to his trunk and extremities, and he developed a fever. The girl (child B) was noted to be febrile on June 29 during her immigration medical examination, but no other symptoms or signs were present. Two days later, the panel physician was told by her adoptive parents that the girl was afebrile and doing well. However, investigators later learned that on June 29 the girl had developed cough, fever, and conjunctivitis, and on July 1 she had developed a rash on her face and neck. On July 4, both ill children traveled on different flights to the United States. They were hospitalized shortly after arrival in Washington and Missouri, respectively. Measles was confirmed in both children by positive immunoglobulin M (IgM) serology and polymerase chain reaction (PCR), and both were placed on isolation precautions. Neither child had documented measles vaccination, and their adoptive parents had executed affidavits, consistent with current policy, for exemption from the vaccine requirements for immigration until after their arrival in the United States.”

Notes from the Field: Measles — California, January 1–April 18, 2014: “During January 1–April 18, 2014, the California Department of Public Health received reports of 58 confirmed measles cases, the highest number reported for that period since 1995. Patients ranged in age from 5 months to 60 years. Most of the 58 patients were either unvaccinated (25 [43%]) or had no vaccination documentation available (18 [31%]). Of the 25 patients who were known to be unvaccinated, 19 (76%) had philosophical objections to vaccination, three (12%) were too young (aged ≤12 months) for routine vaccination, and three (12%) were unvaccinated for unknown reasons.”

Measles — United States, January 1–May 23, 2014: “Although measles elimination (i.e., interruption of year-round endemic transmission) was declared in the United States in 2000, importations of measles cases from endemic areas of the world continue to occur, leading to secondary measles cases and outbreaks in the United States, primarily among unvaccinated persons. To update national measles data in the United States, CDC evaluated cases reported by states from January 1 through May 23, 2014. A total of 288 confirmed measles cases have been reported to CDC, surpassing the highest reported yearly total of measles cases since elimination. Most of the 288 measles cases reported this year have been in persons who were unvaccinated (200 [69%]) or who had an unknown vaccination status (58 [20%]); 30 (10%) were in persons who were vaccinated. Among the 195 U.S. residents who had measles and were unvaccinated, 165 (85%) declined vaccination because of religious, philosophical, or personal objections, 11 (6%) were missed opportunities for vaccination, and 10 (5%) were too young to receive vaccination. Measles elimination has been maintained in the United States since elimination was declared almost 15 years ago. However, approximately 20 million cases of measles occur each year globally, and importations into the United States continue to pose a risk for measles cases and outbreaks among unvaccinated persons.”

Notes from the Field: Outbreak of Pertussis in a School and Religious Community Averse to Health Care and Vaccinations — Columbia County, Florida, 2013: “On August 30, 2013, the Florida Department of Health in Columbia County was notified of a Bordetella pertussis laboratory-positive unimmunized child attending a local charter school (316 students from pre-K through 8th grade) in a large religious community averse to health care and vaccinations. Kindergarten immunization records showed that only five (15%) of 34 students were fully immunized with pertussis-antigen–containing vaccines. In seventh grade, only one (5%) of 22 students was fully immunized with pertussis-antigen–containing vaccines. Of the children who were not fully immunized in these two grades, 84% had religious exemptions.”

Measles Outbreak in an Unvaccinated Family and a Possibly Associated International Traveler — Orange County, Florida, December 2012–January 2013: “The Florida Department of Health in Orange County was notified by a child care facility on January 11, 2013, that a parent had reported that an attendee and three siblings were ill with measles. All four siblings were unvaccinated for measles and had no travel history outside of Orange County during the periods when they likely had been exposed. A fifth, possibly associated case was later reported in a Brazilian citizen who had become ill while vacationing in Florida. An Orange County unvaccinated resident aged 10 years developed a fever (maximum temperature 104.5°F [40.3°C]) on December 25, 2012. Rash onset was on December 28. Additional symptoms included cough, coryza, and conjunctivitis. The patient was evaluated at a local pediatric urgent care clinic on December 29 and given a presumptive diagnosis of viral rash of unknown etiology. Patient 2 (aged 7 years), patient 3 (aged 13 years), and patient 4 (aged 4 years) are all siblings of patient 1, and their illnesses were secondary cases in this outbreak. All four children in the family were unvaccinated; the parents had claimed a religious exemption to vaccination. On January 25, 2013, the Florida Department of Health in Miami-Dade County was notified by CDC of a report from Brazil of a confirmed measles case in a Brazilian citizen who had visited Florida during his exposure and infectious periods. Patient 5, aged 20 years, sought medical care for same-day onset of rash and a 4-day history of fever, oral lesions, and conjunctival hyperemia at a Miami urgent care facility on December 30, 2012. Public health officials in Brazil reported to CDC that this patient had no documented history of measles vaccination and had also visited Orlando-area theme parks in Orange County during the December 14–21 timeframe; the theme parks were not identified. The genomic sequence from the patient in Brazil was identical to the sequences obtained from patients 2–4 in the United States, suggesting an epidemiologic linkage between these cases.”

Notes from the Field: Measles in a Micronesian Community — King County, Washington, 2014: “The United States achieved measles elimination (interruption of continuous transmission lasting ≥12 months) in 2000. Despite elimination, 592 measles cases were reported in the United States during January 1‒August 22, 2014, the highest number since 1994, primarily among unvaccinated travelers and their unvaccinated contacts. Measles remains endemic outside the Western Hemisphere, with outbreaks affecting communities in the Philippines, Vietnam, and China. An ongoing measles outbreak with approximately 350 measles cases and one death in the Federated States of Micronesia during January–July 2014 also has been reported. On May 30, 2014, a child in King County, Washington, aged 4 years and unvaccinated against measles, developed a measles rash 4 days after returning home from 2 weeks in the Federated States of Micronesia. During the following 5 weeks, 14 additional measles cases (nine laboratory-confirmed B3 wild-type and five epidemiologically linked) were reported in King and Pierce counties. Patients were aged 5 months‒48 years (median = 3 years). Two patients were too young to have been vaccinated against measles according to U.S. recommendations, nine were aged >12 months and unvaccinated against measles, three had received 1 dose of measles-containing vaccine, and one had received 2 doses. Twelve cases occurred in the local Micronesian community, in which many children and adults have no documentation of measles vaccination; during two community vaccination clinics early in the outbreak, 71% of the 267 community members who came to the clinic had no electronic or written vaccination record nor knowledge of previous measles vaccination.”

Notes from the Field: Measles Transmission at a Domestic Terminal Gate in an International Airport — United States, January 2014: “In March 2014, CDC identified a possible cluster of four laboratory-confirmed measles cases among passengers transiting a domestic terminal in a U.S. international airport. Through epidemiologic assessments conducted by multiple health departments and investigation of flight itineraries by CDC, all four patients were linked to the same terminal gate during a 4-hour period on January 17, 2014. Patient 1, an unvaccinated man aged 21 years with rash onset February 1, traveled on two domestic flights on January 17 and 18 that connected at the international airport. Patient 2, an unvaccinated man aged 49 years with rash onset February 1, traveled from the airport on January 17. Patient 3, an unvaccinated man aged 19 years with rash onset January 30, traveled domestically with at least a 4-hour layover at the airport on January 17. Patient 4, an unvaccinated man aged 63 years with rash onset February 5, traveled on a flight to the airport on January 17.”

Measles Outbreak — California, December 2014–February 2015: “On January 5, 2015, the California Department of Public Health (CDPH) was notified about a suspected measles case. The patient was a hospitalized, unvaccinated child, aged 11 years with rash onset on December 28. The only notable travel history during the exposure period was a visit to one of two adjacent Disney theme parks located in Orange County, California. On the same day, CDPH received reports of four additional suspected measles cases in California residents and two in Utah residents, all of whom reported visiting one or both Disney theme parks during December 17–20. By January 7, seven California measles cases had been confirmed, and CDPH issued a press release and an Epidemic Information Exchange (Epi-X) notification to other states regarding this outbreak. Measles transmission is ongoing.

As of February 11, a total of 125 measles cases with rash occurring during December 28, 2014–February 8, 2015, had been confirmed in U.S. residents connected with this outbreak. Of these, 110 patients were California residents. Thirty-nine (35%) of the California patients visited one or both of the two Disney theme parks during December 17–20, where they are thought to have been exposed to measles, 37 have an unknown exposure source (34%), and 34 (31%) are secondary cases. Among the 34 secondary cases, 26 were household or close contacts, and eight were exposed in a community setting. Five (5%) of the California patients reported being in one or both of the two Disney theme parks during their exposure period outside of December 17–20, but their source of infection is unknown. In addition, 15 cases linked to the two Disney theme parks have been reported in seven other states: Arizona (seven), Colorado (one), Nebraska (one), Oregon (one), Texas (one), Utah (three), and Washington (two), as well as linked cases reported in two neighboring countries, Mexico (one) and Canada (10).

Among the 110 California patients, 49 (45%) were unvaccinated; five (5%) had 1 dose of measles-containing vaccine, seven (6%) had 2 doses, one (1%) had 3 doses, 47 (43%) had unknown or undocumented vaccination status, and one (1%) had immunoglobulin G seropositivity documented, which indicates prior vaccination or measles infection at an undetermined time. Twelve of the unvaccinated patients were infants too young to be vaccinated. Among the 37 remaining vaccine-eligible patients, 28 (76%) were intentionally unvaccinated because of personal beliefs, and one was on an alternative plan for vaccination. Among the 28 intentionally unvaccinated patients, 18 were children (aged <18 years), and 10 were adults. Patients range in age from 6 weeks to 70 years; the median age is 22 years. Among the 84 patients with known hospitalization status, 17 (20%) were hospitalized.”