A Florida state policy set amid a measles outbreak in Broward County has vaccination proponents aghast, with many saying it leaves unvaccinated children especially vulnerable to the highly contagious disease.
In a letter dated Tuesday about an outbreak at Manatee Bay Elementary School in Weston, located northwest of Miami and west of Fort Lauderdale, the state’s surgeon general, Joseph Ladapo, said that while it is normal policy to tell unvaccinated children to stay home during an outbreak, the state department of health will leave the choice of whether to send susceptible kids to school up to their parents. Six measles cases have been reported at the school in the past week.
Due “to the high immunity rate in the community, as well as the burden on families and educational cost of healthy children missing school, DOH is deferring to parents or guardians to make decisions about school attendance,” Ladapo said.
Typical public health policy in a measles outbreak is to tell unvaccinated children they must stay home until the outbreak is over. That can be a lengthy break from in-person learning because measles has a long incubation period — up to 21 days — and can be transmitted in the four days before an infected person starts to feel ill. Every time a new case is discovered, the countdown clock for that 21-day period is reset. Broward County Public Schools is offering online instruction for students who stay home.
Public health experts were taken aback by seeing a state surgeon general effectively tell parents they can ignore what public health considers to be best practice for containment of a measles outbreak — though they acknowledged that the policy was in keeping with Ladapo’s earlier pronouncements on Covid vaccines. He had repeatedly questioned the safety of the messenger RNA Covid shots made by Moderna and Pfizer, urged parents of healthy kids not to give them Covid vaccinations, and, in early January, announced he was calling for a halt in the use of the mRNA Covid shots.
“This is pretty stunning public health guidance to get from a state health commissioner in 2024. And it would be absolutely baffling to see if it wasn’t frankly so consistent with the kinds of things we’ve seen and heard from … this office over the past few years,” said Jason Schwartz, an associate professor of health policy at the Yale School of Public Health. “It’s the latest in a sort of series of actions and statements that all seem to minimize the risk of vaccine-preventable diseases.”
The Florida Department of Health did not immediately respond to a request for comment.
In an interview with STAT, Katelyn Jetelina, an epidemiologist who writes a popular Substack column called Your Local Epidemiologist, said she was struggling to find the words to describe her reaction to Ladapo’s letter. It does not urge parents of unvaccinated children to get their kids vaccinated against measles, does not mention the safety of measles vaccines, and makes no reference to the health risks measles poses.
Measles is a nasty infection, involving an itchy, total body rash. Most people who contract measles survive, but the Centers for Disease Control and Prevention estimates that about 1 in 5 unvaccinated people who are infected will be hospitalized. One in 20 infected kids — before widespread use of measles vaccine, this was a disease of early childhood — will develop pneumonia, and about 1 in 1,000 will develop encephalitis, or swelling of the brain, which can leave a child deaf or cognitively impaired.
Studies have shown that measles infection induces what’s known as immune amnesia — it destroys a sizable portion of the antibodies to other diseases that infected children have built up through infections and vaccinations, leaving them more vulnerable to illness for several years after having had measles. Deaths from measles are rare, but they do occur; earlier this month, an Irish adult died from complications of measles. And on rare occasions, people who have had measles years before will develop a fatal condition called subacute sclerosing panencephalitis, when viruses that have lingered in their central nervous system reactivate.
“Measles has been rightly feared for generations, and remained at least until recently rightly feared,” Schwartz said. “It’s an unnecessary gamble to play the odds when we have a remarkably effective, remarkably safe vaccine.”
The goal of keeping unvaccinated children out of the path of the virus is to both protect them from infection and to stop transmission. If unvaccinated children continue to attend school and become infected, the outbreak could expand to other schools, other counties, other states.
“It’s really measles management 101,” Jetelina said. “It’s not really supposed to be ‘choose your own adventure.’”
Broward County Public Schools is the sixth largest school system in the country, educating about 250,000 students in 239 public and 87 charter schools. District policy is that children must be vaccinated against measles to attend school, though children with medical or religious exemptions — a loophole often used by parents who oppose vaccinations — are allowed to attend without being vaccinated.
Ladapo’s approach here may have roots in the widespread criticism of the lengthy school closures in the Covid pandemic.
Michael Mina, an epidemiologist and measles expert who formerly taught at the Harvard T.H. Chan School of Public Health, said that while he vehemently disagrees with the policy, he could understand that a health official might conclude that the public would not stomach excluding children from school for the time it could take to stop a measles outbreak.
But the approach Ladapo has laid out will increase the risk of a lengthy outbreak, one that could spread far beyond this single school, Mina said.
“He’s writing this with this Manatee Bay [Elementary School] outbreak in mind. But how many more of these letters does he want to write? I think that the policy that he’s putting forward in this particular letter is just greatly increasing the chances that he’s going to have to write letters for other school systems in Broward County and whatever the county over is,” he said.
“The really important thing here is the best thing you can possibly do at the beginning of a measles outbreak is to stop allowing exposure to any unvaccinated individuals. You need to nip it in the bud.”
Mina and Jetelina both suggested families with unvaccinated children — either by choice or because the children are too young to be vaccinated — might want to rethink spring break plans if they intend to travel to the Miami area. Likewise pregnant people who have no immunity against measles; infection during pregnancy can result in premature delivery or low birth weight babies.
Wendy Parmet, director of the Center for Health Policy and Law at Northeastern University School of Law, said she doesn’t recall seeing a senior state health official tell parents they can ignore a measles control policy before. But she is concerned that while this may be a first, it won’t be the last. She fears the pushback against Covid control measures in the aftermath of the pandemic could well be making health officials gun-shy of using aggressive public health measures.
“Given where the politics are, given where some of the courts have come down, given the way the media has come down, we might well see health officials being more timid about intervening in measles outbreaks and other similar outbreaks,” Parmet said. “It almost defies our understanding of human behavior to think that officials aren’t going to think once, twice, three times before doing the kinds of things that we saw New York do or California do years back.”