White Coat, Black Art

Are mandatory vaccination orders the best way to fight measles outbreaks?

New York City Mayor Bill de Blasio issued a mandatory vaccination policy in parts of Brooklyn this week, after nearly 300 measles infections were confirmed last fall. New York Times reporter Donald G. McNeil Jr says enforcing such an order will prove challenging.

Mandatory vaccination order issued in New York City after nearly 300 cases of measles confirmed

Steve Sierzega receives a measles, mumps and rubella vaccine at the Rockland County Health Department in Pomona, N.Y., on March 27, 2019. (Seth Wenig/Associated Press)
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New York health officials will face "numerous challenges" figuring out how to enforce a mandatory vaccination order in the wake of a months-long measles outbreak, says New York Times science reporter Donald G. McNeil Jr.

"Trying to do forcible vaccinations is very rare. It's not something we do routinely in the United States," he told White Coat, Black Art host Dr. Brian Goldman.

"It's not like they're going to be running around the streets grabbing kids out of people's arms … and vaccinating them."

New York City Mayor Bill de Blasio declared a public health emergency Tuesday in parts of Brooklyn, after nearly 300 measles infections were confirmed last fall, mostly concentrated in the city's Orthodox Jewish communities in Brooklyn and nearby Rockland County.

Citizens who refuse the order to get vaccinated, or allow their children to do the same, could be fined $1,000 US.

Donald G. McNeil Jr. is a New York Times science reporter who covers global health, plagues and pestilences. (New York Times )

If or when new measles infections are confirmed, city officials will check to see if their families vaccinated up to 48 hours after the order was issued.

A more restrictive policy, he said, could spur vaccine-hesitant parents to lie about their kids' vaccination records, making things worse down the line.

"If you're hiding your child and not taking it to the doctor until you realize, 'Oh my God, my child is really, really, really sick,' by the time that child gets to the doctor, it may be too late," he said.

De Blasio's order comes in the midst of a wave of measles infections in the U.S., Canada and abroad. Hundreds of cases have been reported in the U.S. this year, including in New York City and the Pacific Midwest.

In Canada, there have been 33 confirmed cases of measles.

It's just a blip on the radar compared to much larger outbreaks: Ukraine, the Philippines and Brazil alone have reported more than 62,000 infected and 338 deaths since the beginning of the year.

Do conditional incentives work?

Dr. Allison McGeer, physician and former director of infection control at Mount Sinai Hospital in Toronto, said that the prospect of mandatory vaccinations often "trigger irrationality" when brought to the table.

"I don't think we as a society will ever make any vaccination mandatory all the time for everybody," she said.

"It's a reflection of our desire as a society to leave people's personal choice about things they feel strongly about."

In lieu of mandatory orders, she explained, provincial bodies in Canada often rely instead on conditional requirements.

New York City Mayor Bill de Blasio speaks during a news conference on April 9 declaring a public health emergency in parts of Brooklyn in response to a measles outbreak, requiring unvaccinated people living in the affected areas to get the vaccine or face fines. (Shannon Stapleton/Reuters)

"In Ontario … the mandatory public school vaccination program is very helpful. It doesn't say that a six-year-old has to be vaccinated. What it says is a six-year-old has to be vaccinated to go to public school," she explained.

Similar initiatives exist in New Brunswick and Manitoba, according to a 2011 report in the Canadian Medical Association Journal. All of these cases, however, include a clause allowing parents of children to opt out of vaccination on medical or religious grounds, "or simply out of conscience."

In the event of an outbreak at school, "unvaccinated children can be excluded from entering a school," says the report.

Other incentives — some more aggressive than others — also exist abroad.

McGeer said many hospitals in the U.S. require employees to get the influenza vaccine to prevent transmitting it to patients.

And in Australia, the "no jab, no pay" policy penalizes parents who forgo vaccinating their children by potentially reducing their family tax benefit, child-care rebate and welfare payments.

Dr. Allison McGeer is a physician and former director of infection control at Mount Sinai Hospital in Toronto. (Mount Sinai Hospital)

McGeer says these kinds of conditional requirements, which "both incentivize people to be vaccinated or de-incentivize people who aren't vaccinated," can be more effective given the general public's strong aversion to mandatory vaccination orders.

International travel, anti-vaxxers

Health Canada has issued travel advisories related to measles for the U.S. and multiple countries in Europe, Africa, Asia and South America.

The advisories are currently Level 1, the lowest of four levels, recommending travellers keep their vaccinations up to date, monitor their health as normal and regularly wash their hands.

International travel may have played a part in New York's current outbreak, according to McNeil Jr.

In an extensive report for the Times, he explained that some Orthodox Jewish families travelled to Israel in the fall.

Jayda Kelsall of Ottawa contracted measles despite being vaccinated. She's expressing her anger at people who have deliberately decided not to protect themselves against the highly contagious disease. (Submitted by Jayda Kelsall)
Around the same time, tens of thousands of mostly Hasidic Jews travelled to Ukraine as part of an annual pilgrimage sometimes described as the "Hasidic Burning Man."

When they returned to Israel, they brought back the measles with them. Infections exploded there, reaching a peak of 949 in October, according to WHO.

"It was during that period that some Orthodox Jewish kids from Brooklyn and from Rockland County visited Israel and presumably picked up the measles there and went back home," he said.

Travel may have also been a factor in the case of Jayda Kelsall, an Ottawa woman who contracted the virus after returning from a trip to the U.K. — even though as a cancer patient, she's been vaccinated herself.

She's angry that the anti-vaccination movement — people who choose not to vaccinate themselves or their children — may have put her at a greater risk of infection against her will.

"We rely on people who can be vaccinated to vaccinate to protect the people who are more vulnerable," she said.

"It's baffling to me that people would choose to leave themselves or their children at risk to something that's so preventable."


Written by Jonathan Ore with files from Ruby Buiza. Produced by Sujata Berry and Dawna Dingwall.

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