• Vaccine hesitancy is a growing risk to health in Michigan and globally.
• Michigan is one of a minority of states that grant parents vaccine waivers for philosophical reasons.
• Health education can be an effective strategy. Public health professionals need to craft their education messages in many forms to address the many reasons parents choose not to vaccinate.

Early this year, the World Health Organization (WHO) began a new 5-year strategic plan and highlighted 10 major threats to global health. Many are familiar and relevant to Michigan, including air pollution and climate change, noncommunicable diseases (e.g., heart disease, diabetes, and cancer), antimicrobial (e.g., antibiotic or antimycotic) resistant pathogens driven by overuse/misuse in humans and farm animals, and the potential for an influenza pandemic.

One threat, however, stands out for its novelty and social origin: vaccine hesitancy.

Vaccine hesitancy — defined as the reluctance or refusal to vaccinate despite the availability of vaccines — covers a spectrum, from those who question specific vaccines or their timing, to others who flatly reject them (known colloquially as anti-vaxxers). Many diverse, inter-related factors may contribute to vaccine hesitancy, including risk/benefit concerns, politicization, religion, perception of the pharmaceutical and healthcare industries, social pressure, and lack of knowledge/awareness.

The MMR (Measles, Mumps, and Rubella) vaccine frequently comes under scrutiny by the vaccine hesitant. Some have erroneously believed that this vaccine causes autism—it doesn’t. The fear of vaccine-induced autism, however, has largely given way to a litany of criticisms and dismissals that are often low in biological plausibility and light in high-quality evidence.

While fallacious anti-vaccine messages can spread quickly among people across social media like, well, measles, high quality evidence, studies, and arguments take time and resources to conduct and publicize. Moreover, investing time, talent, and money into debunking unsubstantiated anti-vaxx theories diverts resources away from other important health problems.

Before the measles vaccine was introduced in 1963, an estimated 2.6 million deaths occurred globally each year from the disease. An increase in the availability of vaccination led to an 80 percent drop in measles deaths worldwide from 2000 to 2017. Yet, the disease appears to be surging back: In 2019, there have already been 228 confirmed cases of measles in the United States across 12 states – and it’s only March. A travel-related case of measles was just confirmed in Oakland County, underscoring the global scope of the problem, and, perhaps the limits of state-level policy to fully protect public health.

Deaths from measles declined in the United States before the vaccine was introduced due to improved nutrition, housing, social conditions, and health education, as well as health care access and the ability to treat secondary infections. These improvements arose from 20^th Century developments in public health and the advent of local health departments, but they didn’t completely solve the problem, and that’s why vaccines continue to be an essential component of preserving the public’s health.

Measles can kill, but it can also harm and disable. Focusing only on deaths from measles misses the fact that it can lead to pneumonia blindness, deafness, and lifelong brain damage (to say nothing of general unpleasantness, hospitalization, and other costs of care). Ignoring these non-fatal harms and further discounting a child’s potential death from measles because access to safe food, housing, and health care services have improved survival is folly (particularly as measles cases spike globally and threaten the most vulnerable here at home and abroad as the leading cause of vaccine-preventable death). Vaccines are a cost-effective way to prevent diseases that create both human costs for the afflicted and economic and social costs for the rest of society.

A prime example of the costs associated with vaccine hesitancy occurred in 2017 in Oregon. An unvaccinated six-year-old child cut his forehead while playing outside; the cut was cleaned and patched at home. Six days later, the child was taken to the hospital due to breathing difficulties, muscle spasms, jaw clenching, and severe pain, and received a diagnosis of tetanus. Fifty-seven days of inpatient care were required (including forty-seven in an intensive care unit) during which the boy was placed on mechanical ventilation, suffered immense pain, elevated blood pressure and temperature, and extreme distress. The costs—beyond the unnecessary suffering experienced by this child—exceeded $800,000 before including air transportation, outpatient follow-up, or rehabilitation costs. These extreme costs associated with a vaccine-preventable disease like tetanus serve to illustrate why vaccines are not only safe and beneficial, but also highly cost-effective. The occurrence of preventable diseases (particularly if they grow in incidence) will further inflate our bloated, untenable health care spending in the U.S.

Our 2018 public health report found that the U.S. in general—and Michigan specifically—have been investing relatively little in public health. Rising social inequities in the U.S. are, at the same time, contributing to unsanitary living conditions and a resurgence of “medieval diseases” like typhus and vaccine-preventable hepatitis A (of which Michigan is suffering an ongoing outbreak that has led to 732 hospitalizations and 28 deaths).

Michigan’s childhood immunization rate has been among the lowest in the U.S. At the county-level, Houghton (12.4), Lapeer (10.9), and Livingston (7.9) have a notably high percent of school children that have obtained vaccination waivers. Vaccine hesitancy tends to spread as a social contagion, clustering in specific communities or neighborhoods and resulting in rates of vaccine refusal that are far in excess of state or county rates.

States require children to be immunized in order to attend schools, but students who cannot receive vaccines (due to a weakened immune system, for instance) are typically granted medical waiver. Michigan is one of 17 states that allow parents to obtain vaccine waivers for non-medical, philosophical reasons. These policies have become a political battleground as states like Washington that are experiencing large outbreaks of measles seek to tighten waiver requirements. Policies that liberally grant immunization waivers certainly increase public health risks; however, it should be recognized that waiver policies are ultimately about school attendance, not immunization. Eliminating non-medical waivers may seem like a clear choice, however state policies seeking to force vaccination may also risk a variety of unintended, counterproductive consequences, such as politicizing the issue into discussions of personal liberty rather than public health or pushing anti-vaxx parents to remove their children from school (thereby denying the child the benefits of educational resources beyond the already denied benefits of vaccines).

State officials likely will be forced to decide whether to maintain or strengthen current waiver policies, but denying parents the opportunity to waive vaccine requirements for school attendance is not the only option for states to increase the proportion of children being immunized. Some evidence suggests that health education can be an effective strategy, particularly if it recognizes the diverse sources of and reasons for vaccine hesitancy and targets interventions accordingly. Failure to identify these differences may lead to ineffective communication (e.g., making utilitarian arguments about the good of the many may not be the best strategy to persuade a vaccine hesitant parent concerned principally for the good of his or her own child). Given past successes of public health campaigns targeting tobacco use, perhaps campaigns like Michigan’s I Vaccinate offer hope for increasing childhood immunization; the reach and impact of such programs is necessarily subject to the availability of resources and state investment.

The relative ease of obtaining vaccine waivers in states like Michigan puts everyone’s health at risk. Vaccine-preventable diseases also create costs that the whole of society must bear. Unfortunately, whether we expend resources to provide health care treatment for avoidable diseases (like measles) or to conduct research and provide education to counteract misinformation about vaccines, it appears that some degree of increased cost due to vaccine hesitancy is likely inevitable.

Ultimately, parents who refuse vaccines generally believe they are doing what is in the best interests of their child. This refusal affects each of us, however, and it is essential to make the public policy and program changes needed to address the ongoing anti-vaxx trend. The public has a collective interest in sharing the message that vaccines are safe, beneficial, cost-effective, and necessary.