With a brief reminder, Florida Surgeon General Joseph Ladapo upended a public health standard that had long kept measles epidemics under control.
On February 20, as measles spread through an elementary school in Manatee Bay, South Florida, Ladapo sent parents a letter giving them permission to send unvaccinated children to school during the outbreak.
The Department of Health “defers decisions about school attendance to parents or guardians,” wrote Ladapo, appointed to head the agency by Florida Gov. Ron DeSantis, whose name is listed above Ladapo’s on the letterhead.
Ladapo’s move contradicts advice from the Centers for Disease Control and Prevention.
“This is not a parental rights issue,” said Scott Rivkees, a former Florida surgeon general who is now a professor at Brown University. “This is about protecting classmates, teachers and community members from measles, which is a very serious and highly transmissible disease.”
Most people who are not protected by a vaccine will get measles if they are exposed to the virus. This vulnerable group includes children whose parents do not vaccinate them, infants who are too young for the vaccine, those who cannot be vaccinated for medical reasons, and others who do not develop a strong and long-lasting immune response to the vaccine. Rivkees estimates that about a tenth of people in a community fall into the vulnerable category.
The CDC advises unvaccinated students to stay home from school for three weeks after exposure. Because the highly contagious measles virus spreads through tiny droplets in the air and on surfaces, students are considered exposed simply by sitting in the same cafeteria or classroom with someone infected. And a person with measles can spread an infection before developing fever, cough, rash or other signs of the disease. About 1 in 5 people with measles end up in hospital, 1 in 10 develop ear infections that can lead to permanent hearing loss, and about 1 in 1,000 die from respiratory and neurological complications.
“I don’t know why the health department wouldn’t follow the CDC recommendations,” said Thresia Gambon, president of the Florida chapter of the American Academy of Pediatrics and a pediatrician who practices in Miami and Broward, the county hit by the current outbreak measles. “Measles is so contagious. It’s very worrying.”
Considering the dangers of the disease, the vaccine is incredibly safe. A person is about four times more likely to die from lightning during their lifetime in the United States than to have a potentially life-threatening allergic reaction to the measles, mumps, and rubella vaccine.
Nonetheless, last year a record number of parents requested exemption from school vaccination requirements for religious or philosophical reasons across the United States. The CDC reported that childhood immunization rates hit a 10-year low.
In addition to Florida, measles cases have been reported in 11 other states this year, including Arizona, Georgia, Minnesota and Virginia.
According to the most recent data released by the Florida Department of Health in 2022, only about a quarter of Florida counties have reached the 95% threshold above which communities are considered well protected against measles outbreaks. In Broward County, where there have been six cases of measles, about 92 percent of preschool children had received routine vaccinations against measles, chickenpox, polio and other diseases, according to reports last week. The remaining 8% included more than 1,500 children who were granted vaccine exemptions, starting in 2022.
According to the county superintendent of schools, the Broward local health department has offered measles vaccines at Manatee Bay Elementary since the outbreak began. If an unvaccinated person receives a dose within three days of exposure to the virus, he or she is much less likely to contract measles and spread it to others.
For this reason, in the past, government officials have occasionally mandated vaccination in emergencies. For example, in 1991 Philadelphia’s deputy health commissioner ordered children vaccinated against their parents’ wishes during epidemics traced to their faith healing churches. And during a large measles outbreak among Brooklyn’s Orthodox Jewish communities in 2019, New York’s health commissioner mandated that anyone who lived, worked or went to school in hard-hit neighborhoods be vaccinated or face a $1,000 fine. In that order, the commissioner wrote that the presence of anyone without the vaccine in those areas, unless medically contraindicated, “creates an unnecessary and avoidable risk of continuation of the epidemic.”
Ladapo moved in the opposite direction with his letter, deferring to parents because of the “high rate of immunity in the community,” which the data contradicts, and because of the “burden on families and educational costs of healthy children who fail at school”.
However, the burden of an epidemic only increases as measles cases spread, requiring more emergency care, more testing and broader quarantines as illnesses and hospitalizations increase. Containing a 2018 outbreak in Southern Washington with 72 cases cost about $2.3 million, plus $76,000 in medical costs and about $1 million in economic losses from illness, quarantine and care. If the numbers increase, even death becomes a burden. An outbreak among a largely unvaccinated population in Samoa has caused more than 5,700 cases and 83 deaths, mostly among children.
Ladapo’s letter to parents also marks a departure from the norm because local health departments tend to take the lead in containing measles outbreaks, rather than state or federal authorities. In response to questions from KFF Health News, the Broward County Health Department deferred to the Florida State Health Department, which Ladapo oversees.
“The county has no power to disagree with the state health department,” said Rebekah Jones, a data scientist who was removed from her position at the Florida health department in 2020 amid a rift over the data on coronavirus.
DeSantis, a Republican, nominated Ladapo to head the state health department in late 2021, as DeSantis integrated covid vaccine skepticism into his political platform. In the months that followed, Florida’s health department removed information about covid vaccines from its home page and reprimanded a county health director for encouraging his staff to receive the vaccines, leading to his resignation. In January, the health department’s website published Ladapo’s call to completely suspend vaccination with covid mRNA vaccines, based on notions that scientists say are implausible.
Jones wasn’t surprised to see Ladapo move on to measles. “I think this is the predictable result of turning fringe, anti-vaccine rhetoric into a defining characteristic of Florida government,” he said. Although his latest decision goes against the advice of the CDC, the federal agency rarely intervenes in measles epidemics, leaving the task to the states.
In an email to KFF Health News, the Florida health department said it is working with others to identify contacts of people with measles, but that details about cases and exposure locations are confidential. He repeated Ladapo’s decision, adding: “The surgeon general’s recommendation may change as epidemiological investigations continue.”
For Gambon, the epidemic is already disconcerting. “I would like to see the surgeon general promote what is safest for children and school staff,” she said, “as I am sure there are many who may not have as strong immunity as we hope.”