Bernard Dixon

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Measles, Polio, and Conscience

The first nationwide outbreak of measles in Britain since mass vaccination began 30 years ago raises acute questions regarding the rights of parents who reject immunization on ethical grounds

Bernard Dixon

In 1913, building on ideas going back to the 17th century, the Austrian mystic Rudolf Steiner promulgated his own brand of "anthroposophy," whose tenets ranged from the rejection of chemicals in agriculture to the alleged therapeutic benefits of music and colored lights. His worldview has endured, and today there are communities throughout the world based on Steiner's pantheistic speculations.

So why should this be of concern to readers of ASM News? Answer: because of the impact of these strange notions on health. Like many other belief systems, anthroposophy has had mixed consequences. Its schools and clinics, not only in Europe but also in North and South America, have acquired a reputation for helping mentally handicapped children and others with special needs. On the other hand, Steinerian communities tend to reject vaccination against infectious diseases.

As expounded in Physiology and Therapeutics (Mercury Press, New York, 1920), Rudolf Steiner believed that febrile illnesses such as measles and scarlet fever were related to a child's spiritual development. Following this line of thinking, present-day communities founded upon his approach do not object to immunization simply as part of a wider antipathy towards conventional medicine. Adherents also believe that the use of vaccines (particularly measles vaccine) deprives infants of the opportunity to benefit from the experience of having those diseases.

Against this background, it is no surprise (though still a shock) to find that the first nationwide outbreak of measles in Great Britain since the implementation of mass vaccination over three decades ago has occurred within nonimmune anthroposophic communities. It came to light shortly after a five-year-old boy from a Camphill community in Yorkshire, in northern England, developed measles following a visit to a similar community in north London. Although measles had not been confirmed there by laboratory tests, about 30 of the children showed the typical rash and fever of the disease.

More cases soon began to appear in the Yorkshire community, which meanwhile was visited by an unimmunized family from another anthroposophic group in Gloucestershire. The children in this family too developed symptoms of measles after returning home, triggering more new infections. Eventually, nearly 300 individuals were affected.

Of 46 salivary samples which investigators were able to obtain from the Yorkshire cluster, plus 99 samples from Gloucestershire, 117 were positive for measles. There were also a further 26 linked cases in other Steinerian communities. Overall, only two of the victims had been vaccinated against the disease.

Fortunately, this outbreak did not spread beyond the anthroposophical communities where it began. As the investigators point out (B. Hanratty et al., Epidemiol. Infect. 125-377, 2000), this was undoubtedly a consequence of the high level of measles immunization in Britain over many years. Following the initial introduction of a single-antigen measles antigen vaccine in 1968, combined measles/mumps/rubella vaccine has been widely used. At the time when the outbreak in the Steinerian communities erupted, coverage in the general population among children aged two had been over 90% for six years.

In unimmunized societies, however, the disease typically occurs in epidemics every 2-3 years. It can cause devastating encephalitis and other complications, and indeed remains a killer in many parts of the world. Every year, measles virus kills about a million children, mainly in developing countries.

Principled objections to immunization are, of course, not unique to Britain or any other country. Daniel Feikin and colleagues pointed out recently (JAMA 284:3145, 2000) that 48 U.S. states permit "religious," and 15 states "philosophical," exemptions from mandatory vaccination. That is one solution to the dilemma faced by authorities who wish to both enforce immunization laws and yet respect the concerns of citizens opposed to their enforcement.

Yet the practical consequences of parents declining protection for their children are all too apparent. Feikin et al. cite evidence that the risk of measles infection during 1985 in the United States was on average 35 times higher in children with personal exemptions than in vaccinated children. Likewise, countries where there are more active antivaccine movements have higher rates of pertussis than those where the majority of youngsters are immunized.

The other vaccination scandal in Europe, particularly in the Netherlands, concerns poliomyelitis. Between September 1992 and February 1993, 71 individuals in the Netherlands contracted the disease. Two died and 59 were paralyzed. All but one belonged to an extreme Protestant sect that rejects immunization. The World Health Organization, which in 1988 had proclaimed its hope of ridding the world of polio by 2000, was so appalled by the incident that it issued a press release pointing out the dangers posed by small pockets of unprotected individuals. While praising the Dutch authorities for containing the outbreak, the WHO warned that such incidents were obstacles on the road to global eradication.

The 1993 outbreak was simply part of a continuing pattern in Holland since the inception of immunization in 1957. Although not compulsory, the vaccine was soon widely accepted, with coverage rising to about 97%. Nevertheless, the 1960s and 70s saw several outbreaks. A particularly large one affected 110 patients in 1978. All of these epidemics were confined to people, living in sectarian communities, who belonged to orthodox reformed churches whose members declined protection for themselves and their children. An intriguing aspect of the Dutch situation concerns that country's choice of polio vaccine. In the United States and many other countries, the Sabin (live attenuated) version had gradually but completely replaced Salk (inactivated killed) vaccine by the late 1960s. In contrast, the Netherlands has continued to use Salk vaccine. This decision was based on the tiny but nevertheless real possibility that the attenuated virus can revert to virulence.

One of the merits of attenuated virus is that vaccinated chldren shed it in their feces, and inevitably pass it on to others in nurseries and elsewhere. There is, in consequence, a good chance that some infants who have not been formally immunized will acquire the organism passively and thereby become immune. This does not, of course, happen when inactivated killed virus is administered instead.

It is at least possible, therefore, that if the Dutch government had adopted Sabin polio vaccine, some children may well have been unwittingly protected against the disease regardless of parental desires. Whatever the parents' religious or philosophical objections, their offspring would have been vaccinated just as effectively as if they had received attenuated poliovirus from a health professional during a routine immunization program. And if that scenario poses a difficult question for medical ethics, so too does its logical sequel--that vaccine organisms could be genetically modified specifically to achieve greater dissemination. One laudable aim of such a project might be the need for lower percentage take-up, as compared with a killed vaccine, to achieve an effective level of immunity in the population. But what of the associated possibility of overriding, by biological imperative, conscientious objections to the protection of children against killing diseases?