Alan Melnick is frustrated and open to new ideas. The Clark County health officer and his staff are on the fourth week of a public health crisis that Washington hasn’t seen before and he suspects that the measles outbreak that has already claimed 23 people at that point will only grow larger for the foreseeable future.

But what has him so frustrated he is seeking input is that the rapid-fire spread of the sometimes-fatal disease is preventable. For years the vaccination rates in Clark County have remained well below the threshold to stop a highly contagious disease like measles from ravaging a community.

“The bottom line is, there’s no surprise we’re seeing this right now,” Melnick said. “If we don’t get our immunization rates up, we’re going to see more of it in the future.”

The misinformation that has fueled the decline in vaccination rates, largely born from a debunked assertion that vaccines cause autism, seems to be as contagious as measles itself. Clark County, like other health agencies and news organizations, is bombarded on social media with myths and “junk science” about the dangers of vaccination. Melnick sees the links pop up on Facebook and spread because the articles seem well sourced and the websites look professional.

“That’s garbage, but it’s out there, and they’re making it look good,” Melnick said in an interview Wednesday.

By Saturday, the number of Clark County’s confirmed measles cases would jump to 31 since Jan. 1. The list of locations where people with measles might have spread it to others included nine health care facilities, nine schools, three churches, the Portland International Airport and a Portland Trail Blazers game.

Infected people shopped at Costco and high-end grocery store Chuck’s Produce. They went out to eat and met with their financial planners.

If the Vancouver area met what is called “herd immunity,” the number of people who need to be vaccinated to stop a contagious disease, those would be fine activities. But you need a vaccination rate of 93 percent to achieve herd immunity, and as of 2017, the Vancouver area's was at only 66. That means that people who have never received a vaccine, people who have weak immune systems, children too young to receive a vaccine or people who cannot for a medical reason are in danger of the air itself when they leave the house.

Melnick has a store of immune globulin that can help stave off the disease, but he's rationing it out for the most dire cases, such as pregnant women, who run a much higher chance of miscarriage or stillbirth if infected with measles.

Measles outbreaks generally go in 21-day cycles. The virus radiates out from the original carriers to their personal community first, then to the broader community through central locations, then from people who were infected second-hand and then spread it to their own communities.

And it’s doing just that -- one man in King County with measles visited southwest Washington before he was diagnosed, and then Friday night, Multnomah County officials announced an Oregonian had been diagnosed with measles.

Before the measles vaccine was widely available, between 400 and 500 people died every year, according to the U.S. Centers for Disease Control and Prevention. About 1,000 people every year dealt with one of the most serious consequences -- swelling of the brain, which can cause lifelong problems.

Nearly every child under 15 in the U.S. got measles before 1963. But after vaccination became widespread, that number dropped so low that the 30 people diagnosed in Clark County is one of the largest outbreaks nationally.

At the same time, New York has more than 160 cases of measles in an outbreak that took hold in a orthodox Jewish community, where many people are unvaccinated and spend most days working, socializing and worshipping together.

Melnick said that the Vancouver outbreak is not confined to any one religion or demographic population. But it still has the potential to be as large and dangerous as New York’s.

“It is is what keeps me up at night,” Melnick said. “This could be exponential. It’s like taking gasoline and throwing a match into it.”

TWO STATES AT RISK

Clark County and state health officials say they don’t know yet how the outbreak started. Usually, measles is brought back by someone who traveled abroad and then unknowingly introduces it into the U.S.

New York’s outbreak has been linked to a measles outbreak in Israel, where members of the New York Jewish community visited or hosted guests.

Health officials in Washington have not pinpointed a source and say that they are too busy right now trying to mitigate the reach of the outbreak to dedicate more resources to the investigation.

And officials say they need more resources. Friday, Gov. Jay Inslee declared a state of emergency to access medical help from other states and deploy all available Washington state agencies to assist the response to the outbreak.

State data and national research does show that there trends in who is vaccinated and who is not. The demographics are varied and make it hard to point to who might be a likely culprit.

The resistance to vaccination often falls across political divides. Christian and Waldorf schools in Oregon report some of the lowest vaccination rates, though the parents who send their kids to each might vote for opposing political parties. Among the Vancouver-area churches with infected parishioners, many are evangelical.

People resistant to vaccines also span the socioeconomic spectrum. While some outbreaks have been linked to more wealthy enclaves, rural parts of Washington show some of the lowest immunization rates.

Washington Health agency spokeswoman Danielle Koenig said that is partly due to access. Some counties in Washington have so few places that can administer these vaccines that parents go without.

But despite knowing which schools and regions of Oregon and Washington have low immunization rates, there is a growing sense that public health agencies are losing the battle to “anti-vaxxers” -- the label attached to those most fervently against vaccines.

Koenig pointed out that Washington’s vaccination rates have held relatively stable for the past decade -- but that level is below what health officials want it to be.

Oregon, too, suffers from chronically low vaccination rates.

The Washington State Department of Health provides education and messaging about the benefits of vaccines. Officials remind parents that most do choose to vaccinate their children.

Throughout the state, seven out of 10 people are fully vaccinated.

“While it does seem like a loud argument online, it really is just a small percent of people who are not choosing vaccinations,” Koenig said.

But a statewide average does not necessarily help Clark County, where just 77.4 percent of all public students have completed their vaccinations.

EXEMPTIONS ARE EASY

Washington and Oregon laws require public school students to be vaccinated in order to receive an education -- mostly.

Both states allow significant leeway for parents to obtain an exemption.

Oregon and Washington, among many states, allow parents to enroll their children in school without vaccines by claiming a philosophical objection, as well as religious and medical ones.

To balance that leniency, a parent must meet with a health care provider first. The intent was that perhaps a doctor could explain the serious risks in the choice not to vaccinate.

But in Washington, parents can also opt out of that meeting if they claim they have a religious objection to any form of health care intervention. In Oregon, they can choose to watch a state-produced video instead.

The trade-off is that children who lack required vaccinations can be barred from school, as they have been in the Evergreen School District during the measles outbreak.

More than 100 students do not have necessary vaccinations, according to district spokeswoman Gail Spolar. Of those, the vast majority have philosophical or religious exemptions.

The school district tries to send work home for the students to keep up with school while they must stay home, Spolar said, but cannot ensure they will stay on track. Once they are allowed back at school, staff try to help them catch up.

Spolar said that school officials share the same harried problems as anyone trying to control the measles outbreak, but that pro-vaccination messaging is not the school district’s job.

Parents and guardians file the immunization paperwork when they enroll kids in school, and it would be impossible to try to convince each one of the cost of not vaccinating, Spolar said.

“That isn’t something that we’re going to do,” she said.

Instead, they are focused on handling the current outbreak. Not even the 20-year veterans of the district can remember an outbreak like this one, Spolar said, so they have had to learn how to manage it on the fly.

The school district is sending letters and emails in several languages, posting signs at schools, locking doors against unannounced visitors. The learning curve is steep, so any conversation about whether this situation will be commonplace in the future is left for later, Spolar said.

“IT IS A BIG DEAL”

But at the county health office, Melnick is ready.

“We need a cultural shift here and broad community consensus on this before this changes.”

He expects outbreaks to get worse before they get beter. The last confirmed measles case in Clark County was 2011 -- two children had the disease. In 2015, the first person to die of measles in 12 years was in Washington.

Multnomah County had a measles case last summer, and Clark County had a suspected case that could not be confirmed.

Meanwhile, mumps and chickenpox -- which children often get vaccinated for at the same time as measles -- have become more regular occurrences.

Vaccination opponents point to the low number of people hospitalized or dying of measles as a sign that the risk is overblown. Only one person has been hospitalized so far in the current outbreak. But Melnick argues that one out of 30 is higher than it should be.

Especially when the hospitalization comes from a disease that was declared eliminated from the U.S. in 2000 and is expected to affect no people every year.

“If the airline industry was crashing two jumbo jets each year, I think people would be afraid to fly,” Melnick said.

“It is a big deal.”

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