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Annual Review of Virology

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The MMR Vaccine and Autism

Frank DeStefano and Tom T. Shimabukuro
Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for
Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention,
Atlanta, Georgia 30329, USA; email: [email protected]

Annu. Rev. Virol. 2019. 6:585–600 Keywords

First published as a Review in Advance on
measles, mumps, and rubella vaccine, MMR vaccine, autism, autism
April 15, 2019
spectrum disorder, ASD, vaccination, immunization, vaccine safety
The Annual Review of Virology is online at
virology.annualreviews.org Abstract
https://doi.org/10.1146/annurev-virology-092818-
Autism is a developmental disability that can cause significant social, com-
015515
munication, and behavioral challenges. A report published in 1998, but
This is a work of the US Government and is not
subsequently retracted by the journal, suggested that measles, mumps, and
subject to copyright protection in the United States
rubella (MMR) vaccine causes autism. However, autism is a neurodevelop-
mental condition that has a strong genetic component with genesis before
one year of age, when MMR vaccine is typically administered. Several epi-
demiologic studies have not found an association between MMR vaccina-
tion and autism, including a study that found that MMR vaccine was not
associated with an increased risk of autism even among high-risk children
whose older siblings had autism. Despite strong evidence of its safety, some
parents are still hesitant to accept MMR vaccination of their children. De-
creasing acceptance of MMR vaccination has led to outbreaks or resurgence
of measles. Health-care providers have a vital role in maintaining confidence
in vaccination and preventing suffering, disability, and death from measles
and other vaccine-preventable diseases.

585
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1. INTRODUCTION AND BACKGROUND

The most damaging vaccine safety controversy of recent years began as an exploration of the possi-
IBD: inflammatory ble role of measles and measles vaccines in the pathogenesis of inflammatory bowel disease (IBD).
bowel disease That work eventually evolved into a speculative hypothesis that the combined measles, mumps,
MMR vaccine: and rubella (MMR) vaccine may be a cause of autism. Although numerous scientific studies have
refuted a connection between MMR vaccine and autism, some parents are still hesitant to accept
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measles, mumps, and

rubella vaccine MMR vaccination of their children because they are uncertain about the safety of the vaccine. In
ASD: autism spectrum this review, we summarize the genesis of the controversy, review the scientific evidence against a
disorder causal association, describe the effect of the controversy on MMR vaccine acceptance and resur-
gence of measles outbreaks, and discuss what can be done to bolster vaccine confidence, including
PDD: pervasive
developmental the central role of scientists and health-care providers.
disorder
1.1. Autism
Autism, or autism spectrum disorder (ASD) as it is currently defined, is a developmental disability
that can cause significant social, communication, and behavioral challenges. A diagnosis of ASD
now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive
developmental disorder (PDD) not otherwise specified, and Asperger syndrome. ASD with regres-
sion represents a subset of children with ASD who have lost previously acquired developmental
skills, usually language. The causes of ASD are not known, although genetics plays a strong role
(1). ASD develops before birth or early in life, and parents of children with ASD usually notice a
developmental problem before their child’s first birthday (2). The prevalence of ASD has increased
in recent years and is estimated to affect 1 in 59 children in the United States (3).

1.2. Measles, Mumps, and Rubella

Measles is a highly contagious, acute viral infectious disease caused by a paramyxovirus of the
genus Morbillivirus and spread by the respiratory route (4, 5). The disease is characterized by a
prodrome starting about 10–12 days after exposure consisting of fever (often high) and malaise
followed by cough, coryza, and conjunctivitis. The characteristic measles rash, generally occurring
around 14 days after exposure, starts as a maculopapular eruption on the head and spreads to the
trunk and extremities over the course of 3–4 days (Figure 1a). The rash usually lasts 5–6 days and

a b

Figure 1
(a) Child with characteristic red, blotchy rash on third day of the measles rash. (b) Koplik spots on the soft palate and oropharynx due to
pre-eruptive measles on day 3 of the illness.

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resolves in the same order in which it appeared. Individuals are infectious from about 4 days before
the rash onset to 4 days after the rash onset. Koplik spots, which are blue-white plaques on the
mucous membranes of the mouth, are pathognomonic for measles (Figure 1b). Complications of
CRS: congenital
measles include diarrhea, otitis media, pneumonia (viral or bacterial), vision loss, acute encephali- rubella syndrome
tis, seizures, and death. Infection with measles and subsequent recovery confer lifelong immunity
(4, 5). Measles remains a significant cause of death and disability in low-income countries (6).
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Mumps is an acute viral illness caused by a paramyxovirus of the genus Rubulavirus and spread
by the respiratory route (7, 8). In young children, mumps tends to be a mild illness with nonspe-
cific symptoms occurring about 12–25 days after exposure. The characteristic parotitis (when it
does occur) develops around 16–18 days after exposure. Up to a quarter of those infected with
mumps virus are asymptomatic. Orchitis, or inflammation of the testes, is more common in post-
pubertal males, occurring in 12% to 66% of these individuals. Other complications of mumps,
which include aseptic meningitis, encephalitis, pancreatitis, and deafness, are relatively rare but
occur more commonly in older children and adults. Infection with mumps virus generally confers
lifelong immunity (7, 8).
Rubella, commonly known as German measles, is also an acute viral illness that is spread by the
respiratory route (9, 10). It is caused by a togavirus of the genus Rubivirus. Signs and symptoms of
rubella, which occur about 14 days after exposure, are generally mild and include fever, malaise,
upper respiratory symptoms, and a maculopapular rash. Subclinical infection occurs in up to half
of all those infected and is especially common in young children. Complications of rubella are
uncommon and occur more often in older children and adults. The main concern with rubella is
infection during pregnancy and the subsequent risk of congenital rubella syndrome (CRS). CRS
can affect all organ systems in the developing fetus and is more severe when infection occurs early
in pregnancy. Fetal demise, premature delivery, deafness, blindness, other severe birth defects, and
intellectual disability are some of the health problems associated with CRS, which can be delayed
in onset and progress as affected children age. Infection with rubella virus generally confers life-
long immunity (9, 10).

1.3. MMR Vaccine

MMR vaccine is part of the recommended US childhood immunization schedule, which is avail-
able online from the Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/
vaccines/schedules/index.html). It is recommended as a two-dose series with the first dose at
12–15 months of age and the second dose at 4–6 years of age. Combination MMR vaccines are
live virus vaccines indicated for prevention of measles (rubeola), mumps, and rubella. MMR vac-
cines contain attenuated strains of these three viruses, and various forms of the vaccine have been
available since the 1970s (5). MMR vaccine is highly efficacious against measles and rubella, with
vaccine effectiveness of around 97% or higher following two doses (4, 9). The two-dose vaccine
effectiveness (with Jeryl Lynn strain vaccines) against mumps is lower, around 88% (8). Waning
immunity to the mumps component of MMR vaccine has been observed and likely contributes to
mumps outbreaks in some types of highly vaccinated populations, such as college students living
in dorm settings, necessitating a third MMR dose to help contain outbreaks (11). The combina-
tion trivalent MMR vaccine has been the predominant measles-containing vaccine in the United
States and other high-income countries for decades. In the United States, MMR and combination
measles, mumps, rubella, and varicella (MMRV) vaccines are the only measles-containing vac-
cines available (4). MMR vaccine has advantages over monovalent vaccines for measles, mumps,
and rubella or bivalent measles and rubella vaccines. MMR vaccine requires fewer injections (two
shots for two doses of each antigen versus four to six separate shots with bivalent or monovalent

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vaccines) and reduces the chance for delays in protection that can result from spacing out vaccines
over time.
MMR vaccine is well tolerated. Common adverse reactions include injection site reactions,
fever (5–15%), and mild rash (5%). MMR vaccine is associated with febrile seizures, which occur
at a rate of about 1 in 3,000–4,000 vaccinated children with the first dose. Thrombocytopenia, or
low platelet count, is a rare adverse reaction that occurs at a rate of about 1 case per 30,000–40,000
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doses. Arthralgia following MMR vaccination has been observed but primarily in adult women
(4, 12).

1.4. Impact of MMR Vaccination

Live attenuated measles vaccines became available from the early to mid-1960s (5). Their intro-
duction in the United States coincided with a dramatic decline in measles cases by the end of the
decade (Figure 2). Combination vaccines that contained live attenuated MMR viruses (MMR vac-
cine) became available in the United States in 1971 (5). Although there was a resurgence of measles
in 1989–1991 in the United States and elsewhere (13), cases continued to decline, and, in 2000,
measles was declared eliminated from the United States (14) (Figure 2), meaning that the disease
is no longer continuously transmitted. When measles cases occur in the United States, it is because
they are brought in (i.e., imported) from other countries still experiencing measles. Measles was
declared eliminated from the Americas in 2016 (15). Global measles vaccination, in the form of
MMR vaccine or combination measles-rubella vaccination (used mainly in low-income countries),
has resulted in substantial reduction of measles cases and measles deaths (16), a testament to the
success of measles vaccination programs worldwide.

600,000 1989 –1991

1963 30,000 Resurgence
Vaccine
25,000
500,000 licensed
20,000

15,000
Number of cases

400,000 1993
10,000 Vaccines for
Children Program
5,000
300,000
0
1985 1990 1995 2000 2005 2010 2015

200,000

1989 2000
100,000 Second dose Elimination
recommended declared

0
1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

Year
Figure 2
Measles cases in the United States, 1962–2016. Data taken from the National Notifiable Diseases Surveillance System (https://wwwn.
cdc.gov/nndss/).

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Mumps cases also have declined substantially since the introduction of MMR vaccine, although
mumps outbreaks continue to occur in the United States, mostly in older children and college-age
individuals, even in situations with highly vaccinated populations (11). Likewise, rubella and CRS
cases have declined dramatically in the United States since the introduction of MMR vaccine;
rubella and CRS were declared eliminated from the United States in 2004 (14) and from the
Americas in 2015 (17).
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2. MMR VACCINE AND INFLAMMATORY BOWEL DISEASE

The possibility that MMR vaccine may cause autism was first raised by Andrew Wakefield and
colleagues in 1998. Wakefield had earlier conducted studies of the possible role of measles in
IBD, and it was this work in bowel disease that led to a hypothesis about how MMR vaccine
could cause a gut pathology that could predispose children to central nervous system toxicity and
possibly autism. Although the hypothesis rested on an MMR vaccine–induced bowel disorder,
a possible link between the vaccine and bowel pathology was never established and ultimately
disproved.
Wakefield’s initial study suggesting a possible link between measles vaccine and IBD was an
epidemiologic investigation that suggested that measles-containing vaccines increased the risk of
Crohn disease and ulcerative colitis (18). However, a subsequent study by some of the same au-
thors did not find an association between measles vaccination and IBD (19). Other studies also did
not find evidence that measles-containing vaccines are associated with an increased risk of IBD
(20–23). However, these studies involved a monovalent measles vaccine, and Wakefield would later
argue that it is the combination MMR vaccine that is the real culprit in enabling the measles vac-
cine virus to infect the bowel and cause pathology. The most comprehensive study of a possible
association between measles vaccines, including MMR vaccine, and IBD was a population-based
study conducted in four large health-care organizations in the United States (24). The study sub-
jects were born between 1959 and 1989, with follow-up as long as 25 years or more. The study
identified 155 cases of IBD, and each was matched to up to five controls. No increased risk was
found for Crohn disease, ulcerative colitis, or any IBD following MMR vaccine specifically or any
measles-containing vaccine in general.
Laboratory studies also played into the debate about possible gastrointestinal pathology related
to the measles virus or vaccines. Again, one of these was a study by Wakefield that reported finding
measles virus nucleocapsid protein in 13 of 15 patients with Crohn disease (25). However, he and
other investigators were unable to replicate these initial findings (26–28).

3. AUTISTIC ENTEROCOLITIS
Wakefield’s research on measles virus and IBD evolved into a hypothesis that measles vaccination,
specifically with MMR vaccine, could lead to a new syndrome of gastrointestinal pathology and
neurodevelopmental regression. Wakefield first proposed this idea in a report in The Lancet in
1998 (29). The article was a descriptive report of the clinical features of 12 children who had a
history of pervasive developmental disorder (nine had autism) and intestinal abnormalities. The
only suggested link with MMR vaccination was that for eight of the children, a parent or physi-
cian reported worsening of the child’s behavioral problems shortly after receipt of MMR vaccine.
Despite the limitations of the article (30), it generated intense media and public attention result-
ing in decreased MMR vaccination coverage, particularly in the United Kingdom, with resultant
re-emergence of measles disease and deaths. Although the article was retracted by the journal be-
cause of improprieties in subject recruitment and financial conflicts of interest (31–33), the doubts
it raised have lingered.

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Wakefield has continued to develop and promote his hypothesis. He has claimed that the com-
bination of developmental regression and gastrointestinal disorders following MMR vaccination
is a new syndrome that he has called autistic enterocolitis (34). Studies that have attempted to
evaluate the emergence of a new syndrome consistent with autistic enterocolitis, including devel-
opmental regression and gastrointestinal disorders, have not found links with MMR vaccination.
An analysis using a large database of general medical practices in the United Kingdom found
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that children with autism were no more likely than children without autism to have gastroin-
testinal disorders requiring medical evaluation before their diagnosis of autism (35). One of the
original authors of the autistic enterocolitis hypothesis subsequently reported seeing similar in-
testinal changes in children without developmental regression and in unvaccinated children (36).
Two separate studies found that the proportion of autistic children with regression or with bowel
symptoms was not different between time periods before and after the introduction of MMR
vaccine (37, 38).
A study that detected persistent measles virus infection in the intestines of children with autism
and bowel problems (39) also was promoted to support the autistic enterocolitis hypothesis. The
study found that 75 of 91 children with developmental disorders and ileal lymphonodular hy-
perplasia and enterocolitis had evidence of persistent infection compared with 5 of 70 controls.
Limitations of the study included uncertainty about the specific developmental disorders of the
study participants (e.g., the proportion with autism) and unknown temporal relationships between
measles virus infection and onset of gastrointestinal and developmental disorders. Furthermore,
the study did not distinguish whether the virus particles were from vaccine or wild-type measles
viruses. A replication study that attempted to overcome the limitations of the preceding study
provided strong evidence that autism is not associated with persistent measles virus RNA in the
gastrointestinal tract or with MMR vaccine exposure (40). The study examined ileal and cecal
tissue specimens from 25 children with autism and gastrointestinal disturbances and 13 children
with gastrointestinal disturbances alone using real-time reverse transcription-polymerase chain
reaction to detect measles virus RNA. Assays were conducted in three laboratories blinded to di-
agnosis, including the laboratory that made the original findings of a possible link between measles
virus and ASD. All three laboratories found no differences between the two groups in the presence
of measles virus RNA in the bowel biopsy samples.

4. EPIDEMIOLOGIC STUDIES OF MMR VACCINE AND AUTISM

Beginning soon after publication of the Wakefield paper in 1998, several epidemiologic studies
were conducted to evaluate the suggested association between MMR vaccine and autism. The
studies used different designs and were conducted in different populations; each found no in-
creased risk of autism following MMR vaccination. The first studies to be reported were ecologic
studies in which population-level trends in MMR vaccination were compared with trends in autism
(Table 1). The first study was conducted in a district of London and published in 1999 in The
Lancet (41). This study included an analysis of whether the introduction of MMR vaccine in the
United Kingdom in 1988 influenced the incidence of autism. The study found no sudden change
in the incidence of autism after introduction of MMR vaccine and no association between receipt
of the vaccine and development of autism. In addition, at two years of age, the MMR vaccination
coverage among the autism cases was nearly identical to coverage in children in the same birth co-
horts in the whole district of London. Other ecological studies comparing trends in measles vacci-
nation coverage with corresponding trends in autism were conducted in the United Kingdom, the
United States, Japan, and Canada (42–45). None of these studies found a correlation between in-
creasing trends in autism and measles vaccination coverage (Table 1). However, ecological studies

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Table 1 Epidemiologic studies of MMR vaccines and ASD

Study Design Years Population Comparison Outcome(s) Finding(s)
VI06CH28_DeStefano

41 Ecological and 1979–1998 Children in eight UK health Trends in incidence before Annual trends in autism No sudden increase in autism
case series districts born during and after introduction of cases cases after introduction of
1979–1992, including 498 MMR vaccination to the Temporal clustering of MMR vaccination
cases of autism United Kingdom in autism onset or No temporal clustering after
1988 developmental vaccination
regression
ARjats.cls

43 Ecological 1980–1994 birth cohorts California kindergartners MMR coverage and autism Annual trends in autism No correlation between level
occurrence cases MMR coverage and large
increase in autism cases
44 Ecological 1988–1996 birth cohorts Yokohama, Japan, children up ASD incidence before and Annual trends in ASD ASD incidence continued to
to age 7 years after termination of incidence increase after withdrawal
MMR vaccination of MMR vaccination
program
42 Ecological 1988–1999 UK general practice patients Time trend analysis of First recorded diagnosis of Autism incidence increased
12 years and younger, with a MMR vaccination autism fourfold while MMR
August 31, 2019

focus on boys 2–5 years of coverage and autism vaccination was steady at
age incidence >95% in boys 2–5 years
45 Ecological 1987–1998 birth cohorts Schoolchildren in Montreal, PDD time trends relative PDD (n = 180), including PDD rates increased while
Canada (N = 27,749) to trends in MMR autism MMR vaccination
14:21

vaccination coverage decreased

46 Case control 1987–2001 UK general practice patients MMR vaccinated versus First recorded diagnosis of MMR vaccine was not
born in 1973 or later unvaccinated PDD, with subgroup associated with an
Cases (n = 1,294) analysis of first diagnosis increased risk of autism or
Controls (n = 4,469) of autism (n = 991) other PDDs
47 Case control 1986–1993 birth years Atlanta, Georgia, Age at first MMR Autism and autism The distribution of ages at
schoolchildren 3–10 years vaccination subgroups MMR vaccination was
old in 1996 similar in the cases and
Autism cases (n = 624) controls

www.annualreviews.org
School-matched controls

•
(n = 1,824)
48 Case control Not stated (includes Children 2–15 years old in a Vaccinated versus Diagnosis of autism No increased risk of autism
years before and after region of Poland unvaccinated with First symptoms of autism found in any of the
2004 when MMR was Autism cases (n = 96) MMR or single antigen comparisons including
included in the Polish Controls (n = 192) measles vaccine after single antigen or
vaccination schedule) MMR vaccines
49 Case control 1984–1992 birth years Yokohama, Japan MMR vaccination ASD No increased risk of ASD
Cases diagnosed with ASD by associated with MMR
1997 vaccination
ASD cases (n = 189)
Matched controls (n = 224)

The MMR Vaccine and Autism

50 Retrospective 1991–1998 birth cohorts Children in Denmark Vaccinated versus Autistic disorder (n = 316) Risk of autistic disorder or
cohort (N = 537,303) unvaccinated Other ASD (n = 422) other ASD was not
increased by MMR
vaccination

591
51 Retrospective 2001–2012 Privately insured US children ASD diagnosis according ASD diagnosis up to age MMR not associated with
cohort who had older siblings with to MMR vaccination 5 years (n = 994) increased risk of ASD,
or without ASD status and sibling ASD even among high-risk
(N = 95,727) status infants with an older
sibling with ASD

Abbreviations: ASD, autism spectrum disorder; MMR, measles, mumps, and rubella; PDD, pervasive developmental disorder.
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are limited by their reliance on population-level data in which trends in a certain condition could
be affected by changes in several other factors in addition to the exposure of interest.
The association between measles vaccination and autism has been evaluated in other studies
that used stronger epidemiologic designs, including case-control and cohort studies, that obtain
individual-level data and are able to control for confounding factors that could bias the results.
Case-control studies assessed the association between measles vaccination and autism by compar-
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ing the measles vaccination histories of children with autism with the measles vaccination histo-
ries of control children who did not have autism. Case-control studies have been conducted in the
United Kingdom, the United States, Poland, and Japan (46–49). None of these studies found an
increased risk of autism following measles vaccination with either MMR vaccine or monovalent
measles vaccine (Table 1). The largest of the case-control studies, which included 1,294 cases
of pervasive developmental disorder and 4,469 controls from the UK General Practice Research
Database, found a relative risk of 0.86 [95% confidence interval (CI): 0.68–1.09] for the associa-
tion between MMR vaccine and pervasive developmental disorder (46), and no increased risk was
found for autism specifically.
Two cohort studies have been conducted of MMR vaccination and autism. In the cohort stud-
ies, populations of children were identified from birth or early childhood and grouped according
to whether they had received MMR vaccine. Computerized record systems were used to deter-
mine which children were subsequently diagnosed with autism, and the rates of autism were com-
pared between vaccinated and unvaccinated children. One of the cohort studies was conducted
in Denmark. Using national population and health-care registries, the authors of a retrospective
review of all children (>500,000) born in Denmark between 1991 and 1998, including nearly
100,000 who had not been vaccinated with MMR, found no association between MMR vaccina-
tion and the development of autism or ASDs (50). The relative risk associated with MMR was
0.92 (95% CI: 0.68–1.24) for autistic disorder and 0.83 (95% CI: 0.65–1.07) for other ASDs. A
more recent study addressed the possibility that MMR vaccination is a risk factor only in cer-
tain high-risk children (51). The study included about 100,000 younger siblings of children who
had been diagnosed with ASD. The study found that receipt of MMR vaccine was not associ-
ated with increased risk of ASD even among the higher risk children whose older siblings had
ASD.
A meta-analysis of the published epidemiologic studies concluded that MMR vaccine is not
associated with an increased risk of autism (52). The evidence for a possible association between
MMR vaccine and autism also has been extensively reviewed by three committees of the National
Academy of Medicine (53–55), and all have concluded that MMR vaccine does not cause autism.

5. IMPACT OF THE MMR VACCINE AND AUTISM CONTROVERSY

In the United Kingdom, the 1998 Wakefield article had a profound impact, with subsequent de-
creases in MMR vaccination coverage and a dramatic increase in measles cases (56–58). Public
confidence in the safety of MMR vaccine showed substantial declines in the early 2000s, possibly
influenced by increasing negative media coverage of the MMR vaccine–autism controversy (58).
MMR vaccination coverage, which had consistently been above 90% for the first dose in young
children in the mid-1990s, sharply declined, dropping to just below 80% by the mid-2000s (58).
At the same time, annual measles cases increased from <100 in the late 1990s to a peak of just over
2,000 in 2012 (59). With the retraction of the Wakefield article in 2010 (31) and the accumulat-
ing evidence that MMR vaccine does not cause autism, MMR vaccine acceptance and vaccination
coverage recovered and stabilized in the United Kingdom (60). By 2010–2011, first-dose MMR
vaccination coverage by age 24 months climbed to above 90% and has stayed at >90% through

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2017, although coverage has fallen slightly in recent years. Measles case counts have decreased,
and, in 2016, measles was declared eliminated from the United Kingdom (61).
The United States also experienced increased antivaccine sentiment and vaccine hesitancy fol-
lowing the publication of the Wakefield article on the alleged MMR vaccine–autism association,
but the effect on coverage appeared less obvious than in the United Kingdom, at least at the na-
tional level. First-dose MMR vaccination coverage in children 19–35 months old remained ≥90%
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throughout the 2000s and up to the present (62). However, substantial numbers of parents (up to
one-quarter or more) express vaccine hesitancy, with intention to delay or space out vaccinations
or not vaccinate at all, or express concerns about the risks and benefits of MMR vaccination and
childhood immunizations in general (63, 64). Parents of young children—those with children in
the age range for routine MMR vaccination—express the strongest concerns (64). While national
coverage with MMR vaccination remains high, vaccine hesitancy tends to cluster geographically,
leaving selected communities vulnerable to introduction and spread of vaccine-preventable dis-
eases (63, 65, 66). In the early to mid-2000s, measles cases in the United States reached record
lows with <100 annual cases during most years of the first decade of the twenty-first century (67).
However, in the second decade (2011 to 2018), measles outbreaks appeared to be increasing in
frequency, resulting in increased case counts (67). Several large outbreaks pushed up case counts
in 2013–2015, with 667 cases in 2014 alone (68). These outbreaks originated from imported cases,
and most people who developed measles were unvaccinated or had unknown MMR vaccination
status (68–71). Fortunately, high levels of MMR vaccination coverage in the population and cor-
responding population immunity along with targeted isolation and vaccination efforts have con-
tained and controlled these outbreaks. Nevertheless, the threat of continued sporadic outbreaks
from imported cases in the United States and in other countries where measles has been eliminated
underscores the importance of maintaining a high level of MMR vaccination coverage.

6. WHAT CAN BE DONE TO MAINTAIN CONFIDENCE IN VACCINES

AND VACCINE COVERAGE?
6.1. Robust Postlicensure Vaccine Safety Monitoring Systems
and Research Programs
Public confidence in vaccines is boosted by the existence of comprehensive and robust systems
to evaluate the safety of vaccines and rapidly detect potential safety problems. The foundation of
vaccine safety rests on evaluations that are conducted before a vaccine is ever licensed. Vaccines are
extensively tested for safety and efficacy before licensure. Prelicensure clinical trials are effective
at identifying and characterizing the most common adverse reactions (72). However, such trials
are often not large enough to detect and characterize rare adverse events (73). Furthermore, the
generalizability of safety results from clinical trials can be constrained by exclusion criteria that
often omit individuals with chronic medical conditions.
Robust postlicensure safety monitoring and research are required to detect and assess new or
unexpected safety concerns after vaccines have been licensed (73). These monitoring and research
activities provide important data to regulators and public health officials to guide development and
implementation of vaccination policies, to reassure health-care professionals and the public on the
safety of vaccines, and to take action if vaccine safety problems are detected and confirmed (74).
Vaccine safety monitoring primarily involves spontaneous reporting systems and active surveil-
lance. In spontaneous reporting systems, reports of adverse events following immunization are vol-
untarily submitted to regulatory or public health authorities or to vaccine manufacturers. Most
countries have a spontaneous reporting system, which may be specific for vaccines or used for

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both vaccines and drugs. The United States has a jointly managed CDC and US Food and Drug
Administration (FDA) program called the Vaccine Adverse Event Reporting System (75). Sponta-
neous reporting systems are intended for early detection of possible vaccine safety problems and
are not designed to assess causality. Safety signals (76) detected in spontaneous reporting systems
often need to be assessed further in more robust data systems.
Active surveillance for vaccine safety in the United States relies on near real-time sequential
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monitoring of vaccine safety using large-linked electronic health record databases that have in-
formation on vaccinations, medical encounters, and demographics for a covered population (77).
Because population-based information (numerator and denominator) is available in active surveil-
lance systems, it is possible to estimate the risk of adverse events. In the United States, the CDC
conducts active surveillance through its Vaccine Safety Datalink project (78), and the FDA uses
the Post-Licensure Rapid Immunization Safety Monitoring program (79).
Comprehensive vaccine safety monitoring and research programs are essential to providing
timely safety data, but just as important is the forum through which the information is communi-
cated. National advisory committees, such as the CDC’s Advisory Committee on Immunization
Practices (ACIP), are composed of individuals outside of government and convene regularly at
public meetings to hear and discuss data on vaccine safety, effectiveness, and benefit-risk balance
(74). The open and transparent deliberation process of the ACIP, which includes input from the
public in the form of spoken or written comments, can enhance the credibility of vaccination
policy recommendations and increase confidence in public health organizations advocating for
vaccination programs.

6.2. Communication and the Role of the Health-Care Provider

Scientific data are essential in the monitoring and evaluation of vaccine safety, but scientific
evidence alone often is not sufficient to provide reassurance about vaccine safety. Although
most parents support immunizations, many have concerns or misconceptions that could erode
their confidence in vaccines (80–83). Fortunately, immunization coverage in US children is
high. Nonetheless, a sizable fraction of parents do not have their children fully immunized, and
concern about vaccine safety is a leading reason for underimmunization. These concerns persist
despite the scientific evidence that vaccines do not cause autism or a host of other conditions that
have been alleged to be caused by vaccines. It is therefore critically important that public health
agencies, medical organizations, and other influential authorities continue to focus on the safety
of vaccines and assure public confidence by (a) providing clear, consistent messages about vaccine
safety concerns; (b) supporting effective and transparent vaccine safety monitoring systems and
research activities; (c) providing reviews and recommendations by respected independent expert
groups on vaccine safety controversies; and (d) engaging advocacy groups in constructive and
open dialogue about their vaccine safety concerns.
Parents regard primary health-care providers as their most trusted source for information on
immunizations (80, 84, 85). Thus, health-care providers who administer vaccines must be able to
effectively communicate the benefits and risks of vaccines. Such communication includes listen-
ing with empathy and addressing concerns of parents and patients with honest and direct infor-
mation to allow informed decisions to be made. The American Academy of Pediatrics does not
advise pediatricians to remove nonvaccinating families from their practices. Instead, pediatricians
should listen carefully and respectfully to parents’ immunization concerns, factually communi-
cate the benefits and risks of vaccines, and work with parents who may be concerned about hav-
ing their child vaccinated (86). In the United States, Vaccine Information Statements (VISs) are
the cornerstone of provider-patient vaccine benefit-risk communication. VISs are required to be

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provided to a patient or a patient’s parent or legal representative (in the case of a child) before ev-
ery dose of vaccines that are covered under the National Childhood Vaccine Injury Act of 1986. In
practice, the CDC makes VISs available for nearly all US-licensed vaccines regardless of covered
status. An increasing number of resources that address vaccine safety concerns, including miscon-
ceptions and unsubstantiated allegations, are available, including websites, brochures, resource
kits, and videos. More information on vaccine risk communication resources can be obtained at
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http://www.cdc.gov.

6.3. School Attendance Requirements and Stricter Vaccine Exemptions

Vaccination requirements for attendance at childcare facilities and schools are tools to incen-
tivize parents to vaccinate children with MMR and other routinely recommended childhood im-
munizations (87). However, these types of requirements, or mandates, and the inevitable objec-
tions to them underscore the tension between societal interests and individual interests in matters
of public health (88). The rationale for school vaccination mandates is that the interests of the
group—members of a classroom, a school, a school system, and those who have contact with
schoolchildren—take precedent over the rights of any one individual. Although vaccines are not
risk-free, the benefits of vaccination in preventing the spread of infectious diseases in a school
setting and beyond outweigh the risks of adverse events in an individual child, especially in a situ-
ation where that child is benefiting from a common good or community resource, such as a public
school.
In the United States, all states have vaccination requirements for attendance at public schools,
as do most private schools and childcare facilities. However, the nature and types of vaccination
exemptions vary widely, with religious, philosophical, or personal belief exemptions available in
most states, and all states allow medical exemptions. Furthermore, requirements for receiving and
maintaining medical and nonmedical exemptions also vary (89). Three states—California, Missis-
sippi, and West Virginia—–allow only medical exemptions. California’s current strict exemption
law went into effect in 2015; the following year the state saw a substantial increase in medical
exemptions, indicating that parents opposed to vaccination might have searched out physicians
willing to provide medical exemptions liberally within the context of the law (90). The availability
and ease of obtaining nonmedical exemptions are associated with the likelihood that parents will
request such exemptions (91–93). The relationship between the availability and ease (or strictness)
of obtaining nonmedical exemptions on early childhood vaccination coverage and the incidence
of vaccine-preventable diseases is mixed (91, 94, 95). However, states that allow only medical ex-
emptions have relatively high coverage of required vaccines for enrolled kindergartners (96). Since
nonmedical exemptions tend to cluster geographically (65, 66), isolated pockets of low MMR vac-
cination coverage (and susceptibility to measles spread) can exist in communities despite high
overall state and national coverage.

6.4. Resurgence of Vaccine-Preventable Diseases

Lack of acceptance of vaccination with consequent decreases in vaccination coverage leads to
resurgence of vaccine-preventable diseases, as was demonstrated with pertussis vaccination in sev-
eral countries in the 1970s and 1980s (97) and MMR vaccination in the United Kingdom and the
United States more recently. The resurgence of disease is then followed by increased acceptance of
vaccination. It would be tragic if this were to be the path to restoring confidence in MMR vaccina-
tion. Everything should be done to avoid a scenario where widespread resurgence of measles, with
its attendant suffering, disability, and death, becomes the motivating force for renewed acceptance
of MMR vaccination.

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DISCLOSURE STATEMENT
The findings and conclusions in this article are those of the authors and do not necessarily repre-
sent the official position of the Centers for Disease Control and Prevention. Use of any product
trade names is for identification purposes only.
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