The Costs of Anti-Vaccine Rhetoric

The Example of Ukraine 2018

This past weekend, a spat erupted across Twitter over concerns of anti-vaccine rhetoric when Joe Rogan challenged Dr. Peter Hotez, a noted vaccine advocate, to debate vaccine safety with presidential candidate and vaccine skeptic Robert F. Kennedy Jr on Rogan’s podcast.  Battle lines were drawn as vaccine advocates and vaccine skeptics took to Twitter for a battle of words and, for some, insults. With the topic near many people’s minds, I think it a good time to provide a quick example of the damage that social media rumors and misinformed anti-vaccine rhetoric impose on society.

In 2008 a seventeen-year-old boy died in Ukraine shortly after receiving a measles, mumps, and rubella (MMR) vaccine. Despite medical authorities finding that his death was unrelated to the vaccine, rumors that blamed the vaccine quickly spread across social media. This anti-vaccine rhetoric within the country began effecting vaccine uptake almost immediately. Prior to this incident, for over a decade, Ukraine had consistent rates of MMR vaccine coverage for young children above 95-percent. Just one year later, vaccine coverage of children aged 12-23 months, the youngest age group eligible to be vaccinated, dropped to 75-percent. By 2016 it was down to 42-percent. The only country in the world with worse coverage than Ukraine at this time was Chad.

Figure 1. Data provided by World Bank.

The next step was predictable. Eight years of low vaccination rates accumulated to a significant total of unvaccinated children. The country sat on the precipice of danger and measles cases began to surge within the country. In 2017 there were just under 5,000 cases of measles in Ukraine. In 2018 and 2019 there were 53,000 and 57,000 cases before falling back to under 500 in 2020 after measles vaccination rates returned to levels near those of the early 2000s.These measles outbreaks in 2018 and 2019 were the largest within Europe in over two decades. For comparison, there were only 5,000 cases of measles across all of Europe in 2016.  

One may think that parents who choose not to vaccinate their children impose risks only on their own family. However, the highest rates of measles infection in recent outbreaks have occurred in children under one-year of age; these are children too young to receive the vaccine. Parents who choose not to vaccinate their own children are putting other children at risk.  

The first measles vaccine was developed by Dr. John Enders and colleagues in 1963 and improved by Dr. Maurice Hilleman and colleagues in 1968.  Within the United States the vaccines nearly eliminated a disease that previously caused 10s of thousands of hospitalizations and hundreds of deaths each year.  

Figure 2. Data smoothed using a 5-year moving average. Data acquired at Our World in Data website.

In part, the success of the MMR vaccine has fueled its naysayers. When cases are so low the risk of an unvaccinated child being infected is small and it is easy for a parent to decide “I’m not going to vaccinate my child against measles.” However, the risk is so small only because most other people follow the advice of doctors and other health experts and vaccinate their children. Other children being vaccinated limits the exposure of children who are not vaccinated. Because most people do their part, the anti-vaccine community is able to free-ride on the safety provided by others in their neighborhoods, schools, and towns. If multitudes of parents rejected the MMR vaccine for their children and vaccination rates fell significantly, the United States would soon look like Ukraine in 2018 and 2019.

Risks are increasing within the United States. In 2020, for the first time since 1992, the United States recorded over 1,000 cases of measles. While vaccination rates in the United States have not plummeted as they did in Ukraine, pockets of geography with low vaccination rates are growing. For instance, Myong-Hun Chang and I examined MMR vaccine coverage and the use of personal belief and medical exemptions in California schools in recent years (prior to a change in California law in 2016).  In the year 2000, 25 percent of schools in California had rates of MMR vaccination for kindergarteners below 95-percent - a common estimate of the level of vaccinations needed to produce herd immunity for measles. 12-percent of schools were below 90-percent. By the year 2015 these percentages had increased to 32 and 15-percent of California schools. In 2015 nearly one-third of California schools lacked rates of vaccination among kindergarteners needed to produce herd immunity for measles.

Private schools had even worse levels of coverage. In 2015 45-percent of private schools in California had MMR vaccine coverage less than 95-percent among kindergarteners and 28-percent of private schools had rates of MMR vaccine coverage less than 90-percent among kindergarteners. These schools sat then, and still sit today, as a tinderbox of risk waiting for one spark to set a fire. Growing anti-vaccine rhetoric is likely to make the problem worse and the risk even greater in coming years.

This is part of the message that Dr. Hotez and other vaccine advocates wish that people understood. As many say, you don’t see the positive effects of public health until it isn’t there. Only when public health disappears do you see the costs that it has prevented. In this case, as vaccine misinformation continues to erode confidence in safe and effective vaccines, we are losing a portion of our public health protection. Each vaccine rejected inches us closer to the outcomes that plagued Ukraine just a few short years ago.

Troy Tassier is an economist at Fordham University in New York and the author of the forthcoming book, The Rich Flee and the Poor Take the Bus: How our unequal society fails us during outbreaks, available from Johns Hopkins University Press in 2024.