I’m Sarah Kliff, filling in this week for Sean Rameswaram while he’s on vacation.



CLIP: An historic victory over a dread disease has dramatically unfolded at the University of Michigan. Here scientists usher in a new medical age with the monumental reports that prove the Salk vaccine against crippling polio to be a sensational success...

CLIP: Good news from Geneva, the World Health Organization has made it official--smallpox throughout the world has been virtually eliminated  

CLIP: The CDC reports that measles practically wiped out tonight in the United States.


SARAH KLIFF (Guest Host): All of these huge victories? They’re the result of vaccines.

JULIA BELLUZ (Reporter): They’re one of the greatest gifts of public health of the last 100 years.


SARAH: But some people believe vaccines are a threat to public health.

CLIP <Alex Jones>: I’ve had hundreds of guests and scientists on. I’ve read all the source documents. I’ve played clips of the father of the polio vaccine admitting it had cancer viruses in it and more and AIDS, HIV. I’ve proven it, they’re killing you why do you want to die?! Why do you wanna believe their lies? What is your problem?

CLIP <Trump>: Just the other day two years old, two-and-half-year old, a child, a beautiful child went to have the vaccine and came back and a week later had a tremendous fever, got very, very sick, now is autistic.

SARAH: All of this helps explain why measles -- a disease the US officially eliminated nearly two decades ago --  is making a comeback.

JULIA: So there are a bunch of outbreaks happening in the US at the moment.

SARAH: Julia Belluz is a senior correspondent here at Vox.


CLIP <news>: From January 1st to February 21st, 159 cases of measles have been confirmed in 10 states.

JULIA: But most notably in Washington there are more than 60 cases there which is really big for a measles outbreak. And it's mostly involving children who haven't been vaccinated. And on January 25th the governor declared a public health emergency.

CLIP <Governor Inslee>: We're having our children stay home for a number of days. We're asking people actually to be diagnosed in their homes not actually to go to the doctor's office because that can infect people in the office.

JULIA: And it started in early January. There was a child there was traveling and picked up measles brought it back to Clark County,  a place in Washington that has a pretty high proportion of children who aren't vaccinated and it just sparked this big outbreak.

CLIP <news>: Experts here warn the public might have been exposed at a recent Portland Trail Blazers game, at Portland’s airport, at area schools, a local Costco, and IKEA. Washington state has been called a hotspot because of its anti-vaccine movement. It has one of the lowest vaccine rates in the country.   But it’s not just in the northwest.

JULIA: There are outbreaks in several states now. So Texas, Oregon, in New York State, we know that travelers to Israel brought the virus back to unvaccinated Orthodox Jewish communities and spread it there. So it's not just Washington and it's not just the U.S.

Globally we're seeing measles return. So Europe has had these massive outbreaks more than 40,000 cases in the first six months of last year. Japan is battling one of its worst measles outbreaks in years with more than 160 cases. And the WHO just recently called the vaccine hesitancy one of the biggest health threats of 2019.


SARAH: And are these places where you have a lot of kids not getting vaccinated? Is it because they can't afford the vaccines or don't know about them? Like what's driving this?

JULIA: So in Washington state, the health department there said that what they've seen is a lot of misinformation being spread in places like Facebook and through social media and that parents are concerned about safety of the vaccines, about this thoroughly discredited idea that vaccines cause autism. It originated with a study of 12 children that has since been deemed fraudulent.

CLIP <Dr. Anthony Fauci of NIH>: When it was investigated it became clear that the data upon which those statements were made were false and the person who made them had his medical license revoked in England.

JULIA: And sometimes it's this concern for individual liberty and freedom and the right to choose what you want to do with your own child.

CLIP <Parent 1>: Cause they’re our children, and we’ll decide what goes into their bodies.

CLIP <Parent 2>: I don’t vaccinate my children because health doesn’t come from injecting poisons into your bloodstream, and I protect my children from disease and from illness by building their immune systems with good solid nutrition, with fresh air, clean water, and rest.

JULIA: What's common is this mistrust of vaccine safety and of the pharmaceutical and medical communities and I think that mistrust sometimes outweighs their fear or concern about the diseases that they're preventing. And sometimes these are diseases that parents today have never seen. So there are those concerns.

Even more common than parents who are just opting out of vaccines are parents who want to delay them and create their own vaccine schedule. So a few years back one of the most popular children's health books was The Vaccine Book by a Dr. Sears who's based in California. And he was advocating for parents just to create their own vaccine schedules and to think about spacing out their child's immunizations.

CLIP <Dr. Sears>: And I encourage parents to keep looking for a doctor that will provide you with an alternative vaccine schedule if you feel that it's the best thing for your baby.

SARAH: Is there a legitimate reason to do that?

JULIA: No, there isn’t. It's not at all based on science and just is completely unfounded.

SARAH: And this was a pediatrician giving this advice? Or still gives this advice?  

JULIA: He was a pediatrician and he was recently admonished by the state for signing off on medical exemptions, dubious medical exemptions for kids.


SARAH: So I am lucky I have never actually seen a case of measles in person. What is measles? What does it look like? What does it feel like?

JULIA: Measles is one of the most infectious viruses known to man basically. So the thing that makes it really unusual is that a person with measles can walk into a room, cough, and leave. And then hours later if you're not vaccinated you can catch the virus from droplets in the air that that person left behind and no other virus that we know about can do that.


CLIP: Measles has an infection rate of 90% for anyone exposed and not immunized, with no visible symptoms for weeks.

JULIA: And so basically it's really really easy to get measles if you're not vaccinated. And one measles case in an unvaccinated population can lead to 12 to 18 others. And so basically these little aerosols can stay suspended in the air for really long periods of time after a person has left a room or they can live on surfaces. So if you aren't vaccinated and you touch a service with a virus and put your hand in your mouth then you can get measles.

SARAH: And what are these symptoms that would tell you that you had measles?


JULIA: So first the virus will incubate in the body for like 10 to 12 days and then you'll start getting symptoms that are sort of like a really bad cold. So a fever, cough, stuffy nose, bloodshot watery eyes. And then after that this really uncomfortable spotty rash starts to spread through the body. So it usually starts on the head, the face, and neck, and then moves its way downward.  And in uncomplicated cases people will start to feel better in a couple of weeks.

But the concerning thing is that about 30% of patients have complications from the virus and these usually occur in like really young people like under five or in people who are immunocompromised such as cancer patients or you know people with other diseases that have compromised their immune system.

And you can develop pneumonia which accounts for the most measles-related deaths. So that's the most likely way that people will get really sick and die from measles. Some people develop blindness, ear infections, really severe diarrhea.  

CLIP <Minnesota doctor>: One in a thousand children who get measles will have encephalitis or infection in their brain. They can have permanent brain damage. And so we wouldn’t vaccinate if this was just a rashy illness, this is a very serious disease.   

JULIA: And so it's children under five who have the highest probability of death and the CDC has some really awful statistics about that. They talk about how one in every 20 children with measles gets pneumonia, one in a thousand will experience brain swelling and then it's one or two in a thousand children who will die.


SARAH: Could someone be contagious before they know they have measles?

JULIA: So that's another scary thing about the virus. You can start spreading it when you just have these cold like symptoms before you have the rash. And so it might not be clear that you even have measles at that point. You could be in a movie theater or like we saw in the Washington outbreak in an IKEA or a dollar store coughing and spreading the virus to others and you have no idea you're infected.

        SCORING <Basically Barbara>

Coming up, how frightening things were before they invented the measles vaccine. I’m Sarah Kliff, host of The Impact, filling in for Sean Rameswaram this week while he’s on vacation.


SCORING: 1950s-style music

CLIP <l958 health PSA>: Betty doesn’t feel well today. There’s a school nurse in Betty’s school. The nurse looks at Betty very carefully. She sees some red spots. Could it be the measles?  

SARAH KLIFF (Guest Host): What did the world look like before there was a measles vaccine?

JULIA (Reporter): For children and adults who were around before the early 1960s there's a very good chance they suffered through measles or they had friends who did it was just an extremely widespread and common childhood illness.


CLIP <l958 PSA>: Dr. Fuller comes to see Betty at home.  And sure enough, he says that she does have the measles. Dr. Fuller explains to Betty that she will have to stay in bed until she gets well.

JULIA: And at that time there were about 4 million measles cases a year which is huge. Nearly 50,000 hospitalizations and about 500 deaths.

SARAH: Every year.

JULIA: Every year. And it was a leading killer of children globally.


JULIA: And in 1963 in the U.S., the vaccine was introduced. It was just incredibly effective. <HAPPY MUSIC SCORING UNDERNEATH> It was a big public health success story. So again if you think about 4 million cases when it's introduced.  And in 2000 measles was actually eliminated here,  meaning there are no homegrown outbreaks.  So every outbreak we have is usually sparked by a traveler who’s in a place where measles is still circulating like Israel or the Philippines and they bring the virus back to the U.S. So yeah it's an incredibly effective vaccine.  



SARAH: What are vaccination rates for measles here in the U.S. right now?

JULIA: So the national average now is 91 percent but that hides these clusters of vaccine refusal where the average is much lower. So there are parts of the U.S. where nearly 30%of kids are getting some type of exemptions from vaccines. And again in Clark County this epicenter of the Washington outbreak it's one in four kindergartners who weren't vaccinated. And measles is just so remarkably contagious that you need nearly everyone to be vaccinated to achieve what's called herd immunity. Right. And it changes with every vaccine but you need a certain percentage of the population to be immunized so that if you know a sick person with the disease enters a community it's not going to spread and you everywhere. So the herd is protected. And with measles you need about like it's something like 93 to 95 percent.

CLIP <Dr. Fauci>: We vaccinate children first time at 11-12 months, and then the booster at 4-6 years. Those infants are vulnerable to measles if they get exposed. So it’s our responsibility to protect them. And the only way you can protect those who are not old enough to yet get vaccinated or who are immunosuppressed is to be part of that herd immunity. 

JULIA: And if you have two doses it's something like 95 to 97 percent won't get measles. They'll be protected from the virus.  


SARAH: What about side effects are there any kind of key measles vaccine side effects to worry about?

JULIA:  People can have serious allergic reactions to the vaccine. But that's happening in fewer than one in a million cases. And then you have these even more severe side effects like seizure or deafness, they're so rare that researchers don't even know if they're actually caused by the vaccine.

CLIP: <CDC’s Dr. Nancy Messonnier at Congressional hearing>

We have a host of experience with it, the vaccine has been used for a really long time. We in the United States enjoy one of the most robust systems to monitor vaccines, and that’s why we can say with confidence that this is safe vaccine. The most common side effects are a sore arm, which goes away pretty quickly.

SARAH: So we have this vaccine that is super effective. Very few side effects. Is this I kind of considered the gold standard of vaccines, like one of the best we know how to make?

JULIA: Absolutely, it's one of the most effective vaccines we have and it's so effective that if more people were vaccinated we could eradicate the disease.



SARAH: You've been reporting on this for a while. When was the first time you saw measles making this comeback in the U.S.?

JULIA: So I think it was really around 2015 when people started to note that the outbreaks seemed to be getting larger. So there was this outbreak in Disneyland in California that happened,  affecting more than 140 people in multiple states.  

CLIP <news>: What started at the Orange County theme parks has spread to Colorado, Washington, Utah and now Mexico.

So it ended up being this big outbreak that originated at the happiest place on earth.


JULIA: One that got less attention but was even bigger was an outbreak in 2014 among the Amish in Ohio. A missionary picked up the virus in the Philippines returned to his unvaccinated community and spread the virus there and nearly 300 people got sick in that outbreak.


JULIA: In 2017 there was a big outbreak in the Somali American community in Minnesota.

CLIP: The state’s health commissioner says the community has been targeted with misinformation about vaccine risk.

CLIP: 46 of the 48 confirmed cases are in children 10 years old or younger.  

CLIP: I just finished doing rounds on these children and they are miserable. They’re in the hospital, they have IV’s, they’re not drinking, they have terrible coughs, some have pneumonia.

JULIA: We've also seen these recent outbreaks in New York state in New York City among among the Orthodox Jewish community. So it's really just in these last few years that we've seen these larger outbreaks.    


SARAH: And are those outbreaks tied to the anti vaccine movement?

JULIA: Yes so there's definitely a link between people opting out of vaccines so so in the U.S. states set the vaccine policies and they can they decide on who can get exemptions or not. And there's a clear correlation between states that allow more people to opt out of vaccines and vaccine preventable diseases making a comeback.


SARAH: Which states have the most lax vaccination policies?

JULIA: So there are they're actually 17 states in the US that have both the philosophical and the religious exemptions and they’re really diverse politically, geographically--  Arkansas, Colorado, Washington, Oregon, Ohio, Pennsylvania. So yeah, it's a mix for sure.

SARAH: Which states have the strictest vaccine laws?

JULIA: The states that have long had the strictest vaccine laws are Mississippi and West Virginia.


JULIA: And there they only allow medical exemptions so you can't get these religious or personal belief exemptions.

SARAH:  And have we seen any measles outbreaks in Mississippi or West Virginia?

JULIA: Not recently, and they have incredibly high vaccine coverage rates. And then the other states that joined them just in the last few years since the Disneyland outbreak is California. So they also abolished their nonmedical exemption, so those religious and philosophical exemptions. And they've seen an increase  in their vaccine coverage rates.

But they've also seen an increase in their medical exemptions. So there are parents you know going to these I guess dubious pediatricians who are signing off on probably illegitimate medical exemptions.

CLIP: I think goes was down to individual identity of people who for whom it's important to believe they're smarter than doctors. So you see big clusters of unvaccinated children in Northern California close to San Francisco where you have an immensely prosperous highly educated community.

JULIA: But this story in California is a little more nuanced because at the same time that they abolished the nonmedical exemptions they also went after schools that were allowing kids provisional entry on the promise that they would be vaccinated and that a loophole that exists in many states so parents can present a letter to the school saying they will have their child vaccinated. And then the schools don't follow up and then you have unvaccinated children in schools. So when California closed their nonmedical exemption loophole, they also went after these provisional school entries and that helped drive their overall coverage rates.

SARAH: One thing I wonder about is in a way if the measles vaccine has almost been too effective that most of us don't really remember or even know what measles is like and it makes people a little more willing to kind of roll the dice and not get the vaccine. Does that seem to be an element here?


JULIA: I think that's absolutely an element.  So our I think our proximity to these diseases is further and further away. And I have a friend who works in global health in Peru and he always talks about how people there will walk for miles and line up for vaccines and they're so grateful for them and there's still this enthusiasm. And that's something I think we've lost here because of what we don't have this proximity to to these outbreaks anymore.

SARAH: What would you say to someone who refuses to vaccinate his or her children?

JULIA: I would say it's not just your kids health. It's the health of babies. Remember that with measles you can't vaccinate a child who's younger than 12 months. So we're talking about protecting your friend's baby from getting measles or your own newborn. We're talking about the 7 year old kid in your school who is on chemotherapy or the mom who had a bone marrow transplant and you know her immune system is weakened.  So it's really not just about you and it's not just about your kid's health.  And we don't want to return to a pre vaccine world.


SARAH: We actually came across this letter from the pre-vaccine world. It’s written by the children’s book author Roald Dahl. He lost his daughter Olivia to measles in l962, that’s the year before the measles vaccine came out. We were hoping, Julia, that you could read a small section of this letter. It’s pretty heartbreaking and it’s written to parents a few decades later.


JULIA: Yeah. I love Roald Dahl and I love him even more after reading this letter. So in 1986 he wrote:

As the illness took its usual course. I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning when she was well on the road to recovery I was sitting on her bed showing her how to fashion little animals out of colored pipe cleaners. And when it came to her turn to make one herself I noticed that her fingers in her mind were not working together and she couldn't do anything. Are you feeling alright, I asked her. I feel all sleepy, she said.

In an hour she was unconscious.

In twelve hours she was dead.

It really is almost a crime to allow your child to go unimmunized.