We Asked an Expert What Would Happen if No One Got Vaccinated

On January 23, the Centers for Disease Control and Prevention issued a health advisory to address the recent multi-state measles outbreak associated with travel to Disneyland in California.The agency said 52 measles cases were associated with the outbreak, and 28 occurred in unvaccinated persons. This a big deal because measles was supposed to have been eliminated in the United States in 2000 thanks to vaccinations, yet here we are.

There have been split reactions to the disease outbreak. President Obama stressed that the science behind vaccines is "indisputable" and instructed parents to vaccinate their children. But New Jersey Governor (and likely 2016 presidential candidate) Chris Christie made a call for "balance" to allow parents "some measure of choice" to not vaccinate. On the somewhat more bizarre end of the spectrum, CNN gave airtime to Arizona cardiologist Dr. Jack Wolfson, who proudly stated his refusal to vaccinate his two children and claimed that another child's leukemia was "very likely from vaccinations in the first place."

To be very clear, there's no science to support what Dr. Wolfson is claiming. But what would happen if we all stopped vaccinating ourselves and our kids? One of the most vocal vaccine advocates is Dr. Paul Offit. He's the Director of the Vaccine Education Center at the Children's Hospital of Philadelphia, where he's also a professor and an attending physician for the Division of Infectious Diseases. He's written several books documenting the rhetoric of the anti-vaccination movement, and was kind enough to take some time from his busy schedule and talk to me about the what might happen if more Americans stopped vaccinating. Spoiler alert: It's not pretty.

VICE: In the US, what are the current rates of vaccination for things like measles?
Dr. Paul Offit: The rates are in the high 80 percent, low 90 percent range. They're actually very good. The problem is that there are certain districts or regions that are woefully undervaccinated.

The ideal rate would be 100 percent, right?
Well, remember, there are hundreds of thousands of people who can't be vaccinated because they're getting chemotherapy for cancer, or other therapies for chronic diseases. Those people really depend on those around them to be vaccinated.

For highly contagious diseases, you really need vaccines in the 92 to 94 percent rate to prevent outbreaks. Measles, in many ways, is the canary in the coal mine. It's the best indicator of the health of immunization right now, because it's a very effective vaccine and a very contagious virus. So when that herd immunity starts to fray, that's the disease that's going to come back first. You have to have immunization rates drop further to see diseases like polio come back, which are less contagious.

So, once the number of vaccinated people drops below a certain percentage, is there a point at which even the herd immunity won't protect people that are vaccinated?
Sure, sure. Firstly, vaccines aren't 100 percent effective. If you've gotten a dose of the measles vaccine, and let's say it's 95 percent effective, that means that of 100 people, five in an outbreak who have gotten the vaccine will get infected.

There was an outbreak of the measles in the Netherlands between 1999 and 2000. Several thousand people got sick. Obviously, you were in the best position if you were vaccinated and living in a highly vaccinated community; you were in the worst position if you were not vaccinated living in a relatively unvaccinated community. But you were actually better off being unvaccinated living in a highly vaccinated community than being vaccinated and living in a highly unvaccinated community. That's surprising, right? So yeah, the herd is the most important thing.

At what point, with diseases like measles, would we see outbreaks like California's happen more often?
There was a great article written by Gary Baum in the The Hollywood Reporter, where he went to elementary schools in places like Beverly Hills or Santa Monica or Marina Del Rey, and found that the immunization rates in some schools were less than 50 percent. Those places are just waiting for this to happen. But remember, they are part of a much larger herd: The area around them is better vaccinated. But once [an outbreak has] started, it takes off. It would've been much worse if the California State Department of Health didn't react as quickly and effectively as they did. Once kids were infected or known to be exposed, they'd be quarantined for three weeks, which led to fewer secondary or tertiary cases. I give them credit. But that's a lot of money and time that's wasted taking care of this.

Broadly speaking, under current law, could these kind of dangerously low rates conceivably happen elsewhere or are there safeguards in place like what you just described in California?
No, I think there's pop off valves that make it perfectly possible. Obviously, every state has medical exemptions to vaccinations, but 20 states have philosophical exemptions—one of them is California—and you can simply say that "it's not my philosophy" to get vaccinated, which is ridiculous. Forty-eight states have religious exemptions, so in states where there's not a philosophical exemption, people can just say "it's my religion," and nobody really challenges that.

So what would America start to look like if everyone took advantage of these philosophical or religious exemptions and stopped getting vaccinated?
It would look like what it used to look like—which is to say, every year, 48,000 people would be hospitalized with measles and 500 would die. There would be people who would have subacute sclerosing panencephalitis, which is a chronic measles infection of the brain and is essentially a death sentence. Mumps would be a common cause of deafness and sterility. Rubella or German measles would cause as many as 20,000 children to be born with severe permanent birth defects every year, and 5,000 spontaneous abortions. Bacterial meningitis caused by streptococcus pneumoniae caused by haemophilus influenza B or meningococcus, and it would cause tens of thousands of children to die or be left with permanent neurological damage. The rotavirus would cause 70,000 children to be hospitalized with dehydration and 60 to die. The chicken pox would cause 10,000 children to be hospitalized, and 70 to 100 would die. Hepatitis A would cause tens of thousands of cases and about 100 deaths. Hepatitis B would again re-emerge as a silent epidemic; millions of people would be chronically infected, and about 5,000 would die of acute hepatitis B. Tens of thousands would go on to have chronic hepatitis. This would mean infections of the liver, which can cause things like cirrhosis and liver cancer.

This would be every year?
Yes.

Wow. What would you say are the key forces that are leading us down that road?
Our misguided respect for individual choice. I mean, I just don't get it. You have Governor Christie, who says that it should be a parent's choice whether or not their kids get vaccinated. In that state, there is a state law to require car seats for children. Why is that not a parent's choice? Because obviously, car seats prevent your children from dying if you're in an accident. I don't see how this is any different. The only difference that I can see is that if you choose not to get a vaccine, it affects not only your child, but those with whom they come in contact. How is vaccination a personal choice? How is that a matter of conscience? I think these exemptions are misnamed, and I think we shouldn't have them.

I think that people who choose to put themselves and their children at risk should, in some ways, have to pay for it. If we're going to be spending more money—I mean, think of all the money that was spent by the Department of Health in California to quarantine these cases to prevent secondary and tertiary cases—then those who make the choice for that to happen should pay for it. How about that? Almost like a smoking tax.

So what should we do to promote higher rates of vaccination?
Making it much harder to get the exemptions is step one, and then ultimately eliminating those exemptions is step two. The answer to the question "What most likely educates people away from these false beliefs?" is "the disease." We can talk vaccination education, but we can also say that if we let our guard down, this is going to happen. So, we failed. We failed to be compelling. Nothing is as compelling as the virus or the disease itself. Reasonable people are scared of measles. The anti-vaccine people think that measles is no big deal, which shows that they're perfectly capable of denying history.

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