Back in the day, I used to write posts with titles like When the outbreaks occur, they’ll start in California. I even wrote a followup, When the outbreaks occur, they’ll start in California, 2014 edition. The reason, of course, was that California was one of the epicenters of vaccine hesitancy as well as the home to some high profile antivaccine-sympathetic physicians, such as Dr. Bob Sears (who’s known for making Holocaust analogies about bills tightening school vaccine mandate requirements) and Dr. Jay Gordon (who’s known for continuing to claim, against all evidence, that vaccines cause autism). Of course, it was true. The outbreaks did happen in California, culminating with a large outbreak after Christmas 2014 known as the Disneyland measles outbreak.

Then a funny thing happened in 2015. California passed a bill, SB 277, eliminating non-medical exemptions to school vaccine mandates. The law took effect this school year, and antivaccine activists are, of course, not pleased, assembling a motley crew to oppose the law. Time will tell whether SB 277 has its intended effect of increasing vaccine uptake and maintaining herd immunity, but early indications are that it will.

Now, apparently, we have to turn our attention to another big, populous state where public health is potentially being endangered. Now, most people would probably assume I’m referring to another coastal state with a lot of liberal politics and crunchy New Age-y types, like California, but I’m not. I’m referring to Texas. Yesterday, I saw an article in Science by Kai Kupferschmidt entitled Why Texas is becoming a major antivaccine battlefield:

Peter Hotez used to worry mostly about vaccines for children in far-away places. An infectious diseases researcher at Baylor College of Medicine in Houston, Texas, Hotez is developing shots against diseases in poorer countries such as hookworm and schistosomiasis. But now, Hotez is anxious about children much closer to home. The number of schoolchildren not vaccinated against childhood diseases in Texas is growing rapidly, which means that the state may see its first measles outbreaks in the winter or spring of 2018, Hotez predicted in a recent article in PLOS Medicine. Disgraced antivaccine physician Andrew Wakefield has set up shop in the Texan capital, Austin, and a political action committee (PAC) is putting pressure on legislators facing a slew of vaccine-related bills. "Texas is now the center of the antivaxxer movement,” Hotez says. “There is a big fight coming,” adds Anna Dragsbaek of The Immunization Partnership, a nonprofit organization in Houston that advocates for vaccinations.

Now, in fairness, the article notes that currently Texas still has one of the highest rates of vaccine uptake overall, but as I try to pound home time and time again, it’s not just statewide uptake rates that matter. It’s local pockets of low vaccine uptake that lead to declining herd immunity or community immunity. Whatever you want to call the phenomenon of high vaccine uptake protecting even those who can’t be vaccinated or won’t vaccinate, we’re starting to see a situation in Texas that is worrisome and possibly outright alarming: skyrocketing rates of personal belief exemptions, from 2,300 in 2003 to nearly 45,000 so far this year, more than a 19-fold increase. A graph from the PLoS Medicine article tells the tale:

Looking at that graph, I see little sign that it’s starting to plateau, and public health officials agree. The trend looks as though it will continue. If I were a public health official in Texas, I’d be alarmed, and they are. Of course, at the risk of being repetitive—but when did that ever stop me?—I have to emphasize that it’s not just raw numbers. After all, Texas is a big state. If those numbers were spread out, the trend would still be of concern, but not quite so alarming as it is. From the PLoS article by Peter Hotez:

Measles vaccination coverage in certain Texas counties is dangerously close to dropping below the 95% coverage rate necessary to ensure herd immunity and prevent measles outbreaks. For instance, in Gaines County in West Texas, the percentage of exemptions is now 4.83%, while in Briscoe County in the Texas Panhandle, the percentage is 3.55% (Table 1) [5]. In the very large Austin Independent School District (Travis County), the exemption rate is at 2.02% [5]. Especially troubling are many of the private schools, mostly in Travis County—the Austin, Texas area—where exemption rates often exceed 20%, including more than 40% of the Austin Waldorf School [6]. The rising numbers of nonmedical immunization exemptions across the state in combination with pockets of very low coverage in vulnerable populations is extremely troubling.

Now, I know what antivaccine apologists will say here. They’ll say that those rates are still high. Yes, that is true, but the trend is in the wrong direction. As noted by Hotez, in some counties MMR uptake is falling close to the range where herd immunity will start to waver. It’s not there yet, but it’s trending that way, which is why Hotez is concerned that by next winter there could be outbreaks. Then, of course, there are the private schools, such as the Waldorf Schools (schools I like to refer to as disease vectors because of the Waldorf philosophy that discourages vaccination), much like the case in California. These schools almost always have very high personal belief exemption rates and low vaccine uptake rates.

It’s not as though Texas hasn’t had outbreaks yet, either. For instance, in 2013 there was a measles outbreak centered at a Texas megachurch. The outbreak started when a person who contracted measles overseas visited Eagle Mountain International Church in Newark, located about 20 miles north of Fort Worth, Texas. This particular church is part of Kenneth Copeland Ministries. (Terri Pearsons is Kenneth Copeland’s daughter.) Kenneth Copeland and Terri Pearson promote all sorts of “natural healing” woo that you could easily find at Joe Mercola’s website, and, as is so common with believers in “natural healing,” they are (or at least were) antivaccine. In the wake of the outbreak, Terri Pearsons actually encouraged those who haven't been vaccinated to do so, adding that the Old Testament is "full of precautionary measures." Sadly, this is a common theme. Antivaccine warriors remain stubbornly antivaccine until the consequences of not vaccinating hit home.

Of course, I have no idea whether this sermon represented a true change of heart. Googling “Terri Pearsons” and “vaccines” brought up scads and scads of hits about the Eagle Mountain measles outbreak, but I didn’t have time to keep searching for more recent statements by Pearsons on vaccines. I do know that, even at the time, Pearsons’ statements were contradictory in that she still expressed concerns for “very young children with a family history of autism.” In any case, fundamentalist religious communities have become a new center for vaccine resistance and disease outbreaks, and Texas has those in abundance, which is another reason for concern in the face of rising personal belief exemption rates. They represent a fertile ground for antivaccine pseudoscience to take root.

There’s another thing Texas has that contributes to measles outbreaks, unfortunately, and that’s Andrew Wakefield:

But Hotez believes the situation in the Lone Star State is more perilous. One factor is the arrival of Wakefield, widely seen as the father of the modern antivaccine movement. Wakefield published a paper in The Lancet in 1998 that alleged a link between the MMR vaccine (which combines shots against measles, mumps, and rubella) and autism. Several large studies have failed to find the link, Wakefield's paper was retracted in 2010, and he was disbarred as a physician after the U.K. General Medical Council found him guilty of dishonesty and endangering children. Wakefield has appeared at screenings of his film Vaxxed, released in April, all over Texas and has testified at many city councils, Dragsbaek says. “He is definitely a major influencer.”

I’d be somewhat cautious about this assessment, though. Andrew Wakefield has lived in Texas for well over a decade, basically having fled his home in England after having sparked an antivaccine panic there. I have no doubt that Wakefield is a major influencer. Also, in 2016 he’s been more active than ever, having released an antivaccine propaganda film, VAXXED, that peddles the conspiracy theory that is the “CDC whistleblower” and promotes pretty much every common antivaccine lie known to the antivaccine fringe. His partners in woo, Del Bigtree and Polly Tommey, have been traveling the country to show up at screenings and promote the movie. Sometimes they’re even joined by Wakefield himself, who is a rock star among antivaccine activists. Sometimes they meet with federal legislators; sometimes they meet with state legislators; sometimes they meet with Donald Trump. (OK, Wakefield and his fellow travelers only met with Trump once, but once is bad enough.)

I just want to emphasize, though, that this goes way beyond just Wakefield:

Meanwhile, a PAC named Texans for Vaccine Choice has sprung up after state Representative Jason Villalba, a Republican lawyer from Dallas, proposed scrapping nonmedical exemptions last year. (The Texas House of Representatives voted down the bill.) “While they do not have a whole lot of money, they have a lot of people that they can deploy to interfere in primary campaigns,” Dragsbaek says. “They made Villalba's primary campaign very, very difficult.” Rebecca Hardy, director of state policies at Texans for Vaccine Choice, says the group is not trying to convince parents that vaccines are dangerous, but fighting for their right not to immunize their children. (It's also helping them apply for exemptions.)

We have our own version of this PAC in Michigan, but fortunately it seems not to have anywhere near the influence. The Texas PAC is more active, including its online presence. It peddles the usual antivaccine myths, with articles resenting being called out for pseudoscientific beliefs that endanger children and instead trying to peddle the risible narrative that these parents have made a “thoughtful decision to selectively, delay, or decline vaccines in the state of Texas.” I like to call such decisions pseudo-thoughtful. They appear thoughtful to parents because the parents actually do think a lot about their decisions, but they aren’t really thoughtful in that the parents’ thought is wasted because it’s based on misinformation, pseudoscience, and conspiracy theories. Particularly hilarious is an article that tries to make a virtue of being a crackpot—excuse me, a cracked pot. Of course, yet another of my irony meters exploded when I read a post on an antivaccine site complaining about trolls.

It’s a common misconception that antivaccine views and vaccine-hesitancy are primarily the provenance of crunchy coastal liberals. They’re not. As I point out frequently, antivaccine views are the pseudoscience that transcends political views. Unfortunately, we very well might be seeing evidence of that in Texas when the next measles outbreaks happen there.