Measles and the hesitancy to vaccinate

By Dr Bruce Lubotsky Levin, Dr Ardis Hanson, and Dr Peter D. Hurd

Image Credit: HPV Vaccination by PAHO. CC BY-ND 2.0 via Flikr.

Around the world, measles affects more than 20 million people each year causing blindness, encephalitis, severe diarrhea, dehydration, and severe respiratory infections (e.g., pneumonia). Further, measles is one of the leading causes of death in children under five, especially in developing countries.

Measles and childhood vaccination can provide a very important example of prevalence, incidence, and the role of social factors in preventing disease in populations (read this freely available chapter). Measles vaccinations can prevent millions of deaths around the world, and the incidence of measles has declined significantly since 2000. However, the fight against measles also shows how important social forces are in disease prevention.

A discredited study that linked the measles vaccine to autism in 1998 had a devastating impact on vaccination rates, which dropped from 90% to 54% after the article was published. The controversy, generated by the 1998 Wakefield study, became a major public health issue in the United Kingdom (UK). In some areas of the UK, population immunity dropped significantly below herd immunity, which is the threshold above which sustained transmission is unlikely.

The measles vaccination, approved in the United States in 1963, virtually eliminated measles in the country by 2000. However, a recent outbreak in the state of California, linked to attendance at Disneyland, was attributed again to the lack of vaccinations.

Why the hesitancy to vaccinate? One explanation could be the public perception of risk, which is connected to two factors: hazard and outrage. Hazard is the scientific risk of morbidity or mortality; outrage is attributed to the factors surrounding an event that frighten, worry, or upset the public. The controversy surrounding the measles, mumps, and rubella (MMR) vaccine and autism is very similar to other scares, such as the pertussis vaccine controversy during the 1970s and 1980s that also occurred in Great Britain. The pertussis vaccine scare also resulted in a series of epidemics (whooping cough) across Britain, Europe, Japan, the United States, Russia, and Australia.

 Media exploitation exaggerated the vaccine’s potential for harm and soft-pedaled the dangers of whooping cough itself. Parents became convinced that neurological damage would occur if their children were vaccinated. Prior to the routine vaccinations in the 1950s, an estimated 60% to 70% of British children had whooping cough, and over 9,000 infants and children died (Baker, 2003). Hence, between the public and the media, it took a significant amount of time and health education to address the safety of the pertussis and MMR vaccines and to bring the level of population immunity to previous levels.

Other reasons for the hesitancy to vaccinate may be religious or cultural beliefs that lead to exemptions from immunizations, lack of a national immunization program that reaches to all areas of a country, or failure to receive booster vaccinations. Any of these may be a factor when visiting a foreign country and/or entering into one’s home country. It is important to consider the balance between individual freedoms and the health of a population. Determining such a balance at a national or global level can present difficult choices.



Baker, J. P. (2003). The pertussis vaccine controversy in Great Britain, 1974–1986. Vaccine, 21(25–26), 4003–4010.


Bruce Lubotsky Levin, DrPH, MPH, is Associate Professor and Head of the Behavioral Health Concentration in the College of Public Health at the University of South Florida. He also is Adjunct Associate Professor at The University of Texas Health Science Center at Houston, School of Public Health. He currently serves as Editor-in-Chief of the Journal of Behavioral Health Services & Research, a peer-reviewed scholarly journal, and is Co-PI of the USF Institute for Translational Research Education in Adolescent Drug Abuse funded by NIH (NIDA).

Ardis Hanson, PhD, is Assistant Director for Research and Education at the Hinks and Elaine Shimberg Health Sciences Library, USF Health, at the University of South Florida. She serves as liaison to the College of Medicine as part of her role as Assistant Director. Her research interests include the intersection of health practice and policy with a focus on health and organizational communication.

Peter D. Hurd, PhD, is Professor and Department Chair of Pharmaceutical and Administrative Sciences at St. Louis College of Pharmacy. Dr. Hurd's research interests include public health, leadership/management, health literacy, and psychosocial aspects of medication use. His recent teaching includes courses in public health, the healthcare system, and research methods. He has published over 50 peer-reviewed articles and book chapters

They are co-authors of Introduction to Public Health in Pharmacy available in print and online.


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