VANCOUVER, Wash. — The Thanksgiving holiday, for some, may be conjuring up bleak memories of the COVID-19 pandemic. Not only was it harder to see loved ones during the thick of the outbreak, but it made us aware — perhaps for the first time — that gatherings of families and friends carried the risk of spreading potentially deadly disease to more vulnerable people.
COVID-19 is still with us, but vaccines are at least widely available. At the same time, dissent that came to a head during the pandemic concerning perceptions of vaccine safety is being felt more keenly now than ever.
Pertussis, more commonly known as whooping cough, is a respiratory infection that spreads easily. It starts with symptoms that seem like a cold: sneezing, runny nose, low-grade fever and a mild cough. But within two weeks it can cause fits of coughing so severe as to make it hard to catch your breath — accompanied by the characteristic "whooping" sound that earned the bacterial infection its nickname.
As of Nov. 2 of this year, the state of Washington had reported 1,193 cases of whooping cough for the season, compared to just 51 by the same time the year before. Likewise, in Oregon, the state had 850 reported cases as of Nov. 19, compared to just 33 the year before.
Many of those cases, according to health officials, were among adults or children who were not vaccinated — despite the modern DTaP vaccine, which protects against pertussis, being available since at least the 1990s. Throughout the U.S., vaccination rates among young children have been waning, with vaccine exemptions reaching "the highest percentage ever reported" this school year, according to a study shared in a recent CDC report.
It's been a similar story with measles. Between the late 1990s and the 2000s, vaccines had all but eradicated measles in the U.S. But since the 2010s, localized outbreaks have started to crop up again every few years.
This year, the Oregon Health Authority tracked a measles outbreak centered on Marion County that grew to 31 cases, hospitalizing two people. Cases were overwhelmingly among young people, nearly half of them under the age of 10.
This was a larger measles outbreak than in 2019, then considered an outlier, when Oregon saw 28 cases linked to an even more widespread outbreak in Clark County.
These trends have local public health officials, like Clark County Public Health Director Alan Melnick, sounding the alarm.
"As a physician in general, it's really frustrating to see people get sick, have their lives disrupted, potentially die — and you know, we're talking about children here as well — from something that is very preventable," Melnick said. "There's no reason why we should be seeing these outbreaks and illnesses from something that is preventable with something that is so safe and effective and inexpensive as a vaccine."
Someone who has been vaccinated against whooping cough can still contract it, but Melnick's department said that it's not nearly as severe in those cases.
The reason why families choose not to vaccinate their kids can range. For some, there are barriers to accessing health care, or there may be religious reasons. But in many cases it's a matter of vaccine hesitancy, or perhaps resistance, among families who could otherwise seek vaccination but don't — and those numbers seem to be growing.
According to the OHA, only about 1% of kindergartners before the year 2000 had a non-medical vaccine exception. By this school year, that share had grown to 8.8%.
How to reach the vaccine hesitant
Dr. Ben Hoffman is a pediatrician with Doernbecher Children's Hospital at OHSU and the director of two hospital programs focused on children. He's currently the national president of the American Academy of Pediatrics. We asked him why those numbers had been growing, and in Oregon especially.
"I think there are a lot of reasons," Hoffman began. "So first of all, there has always been an undercurrent of vaccine hesitancy in Oregon that's different than in a lot of other places. I practiced in New Mexico for 15 years before I moved to Oregon in 2011, and the concerns about vaccines and some of the beliefs about vaccines, they're very different in Oregon. I think some of it comes from the history of libertarian ideals; what I've learned to appreciate as the Oregon frontier spirit."
And then there are concerns that continue to percolate about a link between the MMR (measles, mumps and rubella) vaccine and autism, Hoffman added, stemming from a single long-discredited study published in 1998. Despite the fact that the study's conclusions were never replicated or supported by other works, its influence is still being felt today.
"And so I think those two factors — the concern about the impact of vaccines and then the desire for personal freedom and even parental rights — sort of meld here in a unique way that we're seeing now, I think, a little bit more nationally, but has been a consistent issue here in Oregon for decades," Hoffman said.
As a pediatrician, Hoffman said that he knows vaccines are among the most effective ways to protect kids, families and communities from potentially deadly disease. But in Oregon, something like 10% of parents disagree.
In 2019, a bunch of those parents rallied at the Oregon Capitol, protesting a bill in the legislature that would have tightened the state's opt-out rules for kids in school, which grant exceptions for any self-proclaimed religious or philosophical belief. The bill died as part of a deal to end a Republican walkout.
The people who protested that bill said that they were not necessarily against vaccines, but they did not want the government forcing their kids to get shots. But at least some of those parents believed that they were protecting their children by not getting them vaccinated.
Reaching those people, Hoffman said, comes down to establishing trust.
"When we're talking about vaccines, really what we're dealing with is settled science, and the fact that fear gets interjected through rumors and social media and other issues makes it really complicated ... it can instill fear in families," Hoffman said. "I think that's why having a trusting, you know, long-term trusting relationship with somebody makes it a little bit ... it makes it easier to have trust.
"If you've built trust over time — I mean one one of the ways, in conversations that I have with families, one of the things I assure them is I would never recommend for their child anything that I did not or would not recommend for my own child. And I promise you, all of my children have been vaccinated in accordance with the best practice recommendations."
Simply asserting authority — telling someone that you're the doctor and you know best — doesn't work, Hoffman said.
"That's never been my style. I was taught very differently — as I said, meeting people and families where they are, and that becomes easier over time as you learn to learn to develop mutual trust," he said.
Barriers and breaking them down
One of the things that's complicated the problem of vaccine hesitancy is the U.S. health care system itself. Visits to the doctor are becoming shorter and shorter, and in many cases harder to access, which makes it more difficult for health care professionals to establish a rapport with patients.
"We want a system that supports, that puts kids and families and communities in the center and provides for their needs in a way that is authentic and decreases barriers," Hoffman said. "So that, you know, if the biggest barrier to a family getting their child vaccinated are concerns, that we have an opportunity they can get to see me that we have time to sit down and have the conversation we need to have — meaning that I'm not being forced to move rooms every six minutes — that we can have the conversation in their language so that I can utilize, you know, adequate interpreter services. And then I have the ability to work with them to actually get that vaccine to their child in the most expedient, simple way. And that the system now is set up that there are so many barriers — the payment issues, the access issues and all of that."
The worst-case scenario is that there will be a tragic resurgence in preventable disease before vaccine uptake recovers. That's a new problem for health care professionals, because when many of these vaccines first came out, there was much more awareness of the harm that the diseases themselves could cause.
"If you go back to the '50s around polio," Hoffman said, "you know the '40s and '50s with polio, people lined up in the streets (for vaccines) because everybody knew somebody who had been severely affected by polio and was in an iron lung or was, you know, was going to have lifelong disabilities because of that. We absolutely do not want to get back to that."
With diseases like whooping cough and measles on the rise, that scenario is what Hoffman fears most.
"It terrifies me," he said. "It terrifies me."
Skeptics in high places
While it's too soon to say if he'll be confirmed, President-elect Donald Trump has selected Robert F. Kennedy Jr. to lead the U.S. Department of Health and Human Services — a massive $2 trillion-dollar agency which administers enormous health insurance programs like Medicaid, Medicare and the Affordable Care Act.
Throughout his failed bid for president, Kennedy raised the profile of vaccine skeptics in the U.S. He previously helped co-found one of the country's most prominent anti-vaccine groups, has repeatedly expressed doubt about the research behind vaccine safety and has repeated false claims about the MMR vaccine causing autism.
If you're wondering whether Kennedy could have an impact on the issues highlighted by Dr. Hoffman, critics have linked his 2019 visit to the island nation of Samoa, and his influence on leaders there, to a cascading series of events culminating in a measles outbreak that caused dozens of deaths and almost 2,000 hospitalizations — mostly among babies and young children.
Samoa put a pause on MMR vaccinations in July 2018 after two babies died due to an error in administration. Someone mixed the vaccine with an unrelated drug instead of water, The Guardian reported. By the time the government restarted vaccinations, fighting a rising tide of misinformation about the MMR vaccine that Kennedy helped to amplify, it was too little and too late.
Hoffman said it's not his place as a pediatrician to comment on a specific political nomination. But he did have some thoughts about Kennedy's beliefs and past statements.
"When I think specifically about RFK, we actually have many places where we agree — concerns about nutrition, concerns about the burden of chronic illness for children in this country. We may disagree about how we think about the origins and what some of the mechanisms for addressing those issues might be, but there is some common ground.
"We will always go back — and when I say we, pediatricians and the American Academy of Pediatrics will always go back — to policy and science, and we hope ... we look forward to working with an administration and to public health officials who are willing to acknowledge the settled science and address the needs of kids and families communities in a way that will protect them based on what we know to be true, and not based on fear and innuendo and conjecture and rumor."
Hoffman acknowledged that Kennedy is among the most prominent vaccine skeptics in the U.S., but he's also become something of a figurehead for a group that is louder than it is large.
"The actual community of anti-vaxxers is, you know, the majority of the information, especially on social media, comes from a very small group of people that just have a lot of reach," Hoffman said. "And the fear of that sown there ... it can be difficult for families, for people to shake ... and a lot of that has to do with the the role of social media and the fact that, as I mentioned before, most of that is not fact-checked. And while it's not fair to blame the social media platforms for this, their practices — including algorithms and things like autoplay and the scrolling feed (that keeps) people stuck to that platform — help drag users into the abyss of misinformation and disinformation that can be hard to get out of."
There's a real risk in the noise being turned up even further with a larger platform and more legitimacy, Hoffman said — making it more complicated for physicians to establish trust. But it isn't as if he and his colleagues are going to give up.
"As I said, we're committed to working with whoever we have to work with, whether it's somebody (where) there's fundamental agreement or somebody with whom there might be some disagreement," Hoffman said. "And my hope is that an opportunity for conversation and an honest discussion about what we actually know, as opposed to what people might think or choose to believe and what they fear."