Measles Outbreaks and School Exclusions: Public Health’s Authority to Protect Children and Stop the Spread of Disease

February 07, 2019|1:12 p.m.| ASTHO Staff

As they work to improve the health of tomorrow, today’s public health officials are increasingly occupied with the diseases of yesterday. For example, cases of measles, a highly contagious disease that was once a constant presence in the United States, have increased over the past several years, despite the ready availability of a highly effective vaccine (i.e., the MMR vaccine).

While no longer endemic to the United States, the measles outbreaks we see today are caused by unvaccinated people, both American and foreign visitors, who become infected with measles in other countries and return or travel to the United States. Too often viewed as a benign childhood illness, the dangers of measles, including pneumonia, brain damage, deafness, and death, are clearly recounted by Roald Dahl, author of Charlie and the Chocolate Factory and many other favorites, in his remembrance of his own daughter’s illness and death from measles. As public health responds to the latest measles outbreaks in New York, New Jersey, and Washington state, Dahl’s account is a stark reminder of the importance of vaccinating children against measles and the harmful result that occur when we don’t.

To help prevent the spread of measles, every state requires children enrolled in public school to be vaccinated against a series of diseases, including measles. Most states also require children in private schools to be vaccinated. States allow an exemption to the required vaccines when it is medically necessary, and all but three states (California, Mississippi, and West Virginia) also allow non-medical exemptions based on religious or personal beliefs.

When enough people are vaccinated against measles, those who cannot be vaccinated will also have a higher chance of protection, since there are not enough people through which measles can spread. This is known as herd immunity. Due to its high level of contagiousness, measles requires a high rate of vaccination, between 93-95 percent by some estimates. While CDC estimates that as a nation our kindergarteners are within this range, there are pockets across the country where the rates are much lower. For example, in Clark County, Washington, where the most recent measles outbreak originated, the percentage of kindergarteners who received a vaccine for measles fell from 96.4 percent in 2004 to 84.5 percent in 2017.

When a measles outbreak does occur, those who are unvaccinated and who live in communities with low vaccination rates are at a higher risk of becoming infected. In order to stop the spread of measles, children who are not vaccinated are often required to stay home from school and school-related functions until the outbreak ends or they get vaccinated. Many states have laws expressly allowing state and local health officials or school administrators to temporarily exclude children from school during the outbreak.

For example, in Arizona, students “who lack documentary proof of immunization shall not attend school during outbreak periods of communicable immunization-preventable diseases” (Ariz. Rev. Stat. Ann. § 15-873(C)). Another example includes Maine, where in the event of an actual or threatened outbreak of a communicable disease, students may be excluded from school until the threat no longer exists (22 M.R.S. § 806). Even if a health official does not have express authority to exclude children from school during an outbreak, doing so would be allowable under the official’s general authority to protect the public’s health and well-being, or under quarantine and isolation laws.

Over the years, the exclusion of unvaccinated children from school during disease outbreaks has been challenged by parents and upheld as a valid exercise of public health authority by the courts. In 1992, the Supreme Court of Nebraska determined that the statute used to exclude two unvaccinated students from school during a measles outbreak was valid and that the exclusion did not violate their equal protection rights (Maack v. School Dist. of Lincoln, 491 N.W.2d 341 (1992)).

More recently, in Phillips v. City of New York, 775 F.3d 538 (2015), the Second Circuit Court of Appeals affirmed a lower court’s ruling that the state’s regulation permitting the exclusion of unvaccinated children from school during a disease outbreak is constitutional and did not violate the rights to substantive due process, free exercise of religion, and equal protection. In making its decision, the court concluded that since the state could, if it chose, bar all unvaccinated children from attending public school, then the state’s “more limited exclusion during an outbreak of a vaccine‐preventable disease is clearly constitutional.” Some states now provide notice of the school exclusion authority to parents who claim an exemption to the school vaccination requirements. For example, in Arkansas, parents who seek a vaccination exemption must sign a statement expressing their understanding that unvaccinated children may be excluded from school during a disease outbreak, without the ability to return until the outbreak ends (Ark. Code Ann. § 6-18-702(d)(4)(C)(iv)).

In responding to today’s measles outbreaks, state and local health officials are providing awareness and education around the dangers posed by measles and offering access to the effective vaccine that protects children. These officials may also seek to stop the spread of measles by excluding unvaccinated children from school during the outbreaks. While some may see school exclusion as a drastic course of action, the power to exclude has repeatedly been deemed valid by courts across the country, and it remains a way of protecting the public from measles and other serious diseases.

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