Measles in 2019, or How Our Success Led to Our Downfall

For decades, in the United States, there has been very little talk about measles – for good reason. Thanks to the effectiveness of the measles vaccine that was initially available in 1963, and improved upon in 1968, rates of measles steadily fell until an outbreak in 1989. After that, the recommendation was updated to require two doses of the vaccine instead of one, and rates again fell. Interestingly, Dr. Thu Tran’s father-in-law, Dr. Samuel Katz, was very instrumental in developing the vaccine.

In 2000, it was declared that measles was successfully eliminated in the United States – there was no sustained transmission for over 12 months. Unfortunately, that victory was short-lived. All the recent concern in the news is believed to have started with a case of measles in a traveler entering the United States. This resurgence is occurring in other countries as well. Europe reported 15 times more cases in 2018 than in 2016. A recent New England Journal article also notes that Venezuela and Madagascar are experiencing concerning increases as well.

If being infected with measles simply meant dealing with a rash, we wouldn’t be so concerned. Most people in fact, do recover uneventfully after a week of rash, fever, fatigue, runny nose, cough and eye symptoms. However, measles can also lead to blindness (especially when the patient is malnourished and/or deficient in vitamin A), severe diarrhea, ear infections, and, uncommonly, death due to pneumonia. Rarely, it also can affect the brain and result in permanent brain damage. The highest risk is for those with cancer, HIV, solid organ transplants, those on high-dose steroids and others with immune compromise, including those on certain medications for rheumatologic disease.

The virus spreads rapidly through under-vaccinated populations, since 90% of susceptible people will become ill after exposure. Droplets of the virus remain active for 2 hours after an infected person leaves a room. The solution is simple. Two doses of the vaccine given in childhood at 12-15 months and at 4-6 years, provides 97% protection to those children. Because it’s a live-attenuated vaccine, people with compromised immune systems due to illness or chemotherapy can have complications from it.

To keep all of us well, including those who cannot take the vaccine, we rely on ‘herd immunity’. By that we mean that if at least 93-95% of the population is vaccinated, spread through the community can be limited, even if the virus is somehow introduced. If only a few people actually become ill from the measles virus, fewer other people will be exposed. In this sense, each one of us has an obligation to be immunized, as limiting spread is a public health issue.

Adults born before 1957 are considered immune, as are those with documented receipt of the measles-mumps-rubella (MMR) vaccine or lab evidence of immunity. If you are uncertain about your status, you can discuss your personal situation with your doctor and decide whether to check an antibody level or receive an MMR vaccine. Pregnant women cannot receive the vaccine until after they give birth. Check the cdc.gov website for general information and travel-related recommendations.

In the past, 2-3 million deaths per year worldwide were attributed to measles, and even now 100,000 occur. So why isn’t every child vaccinated for their own benefit and for the benefit of the general public? As I mentioned, some children can’t receive the vaccine because of their own health issues. But most unvaccinated children have parents who believe misinformation from the 1990s about vaccines leading to autism spectrum disorder.

The alleged connection was described in a Lancet journal article in 1998 related to only 12 children. In 2004, 10 of the 13 authors published a retraction of the findings, and in 2010 the Lancet officially retracted the article. Other reporters showed that besides problems with the procedures of the study, 3 of the 12 children didn’t even have ASD, 5 had developmental concerns prior to the vaccine, and that the subjects were recruited through an anti-vaccination organization that was gathering information for future litigation.

In contrast, in 2014, numerous studies reporting on a combined 550,000 children found no relationship between MMR and ASD. In fact, in some studies, the prevalence of ASD increased despite declines in vaccination rates. So, bottom line – there is no connection between MMR and ASD. As with any vaccine, there are potential side effects, such as rash, febrile seizures or a transient decrease in platelets. Brain infection is very rare, and almost always has occurred in immunocompromised hosts.

Through education programs, healthcare workers are trying to increase the immunization rate. Los Angeles quarantined those exposed to the virus to limit spread. The greatest incidence of recent cases have been in Brooklyn and in Rockland County in New York State. Community influencers, including rabbis for the Orthodox Jewish communities most affected, became involved to encourage vaccination. There is no religious basis for refusal.

Rockland County barred unvaccinated children from school and other public places where more than 10 people could be expected to gather. This was controversial enough, since it included many schools that were not affected by the measles outbreaks. But then in April, the New York City Health Commissioner, generated even more uproar by declaring that every person over 6 months old living in 4 Brooklyn zip codes ‘shall be vaccinated’ or face a $1000 fine.

It seems odd to have a ruling regarding a global issue be directed at 4 zip codes. Clearly the virus can cross zip codes. The need for vaccination is clear. One person’s refusal to vaccinate unfairly affects the health of others. However, that decision is often borne of fear or lack of information. Rapid and concerted efforts to engage more community influencers and healthcare workers to educate people, correct misinformation, enforce current vaccine requirements for school entry, and limit non-medical waivers could potentially be more effective without invoking questions about new impositions on personal liberty. For instance, a state could make a requirement that a family requesting a religious waiver must bring a letter from a religious institution substantiating that claim.

When the vaccine was initially introduced it was readily accepted because adults were familiar with measles as a serious, potentially fatal illness. That part of the picture is unknown to young parents today. In that sense the success of the vaccine is partly responsible for the resurgence of the illness.

Hopefully the measles resurgence of 2019 will result in bringing us closer to 93% vaccination rate and return us to our 2000 status of: MEASLES – ELIMINATED!

REFERENCES:

Paules,C, Marston, H, Fauci, A. NEJM: Measles in 2019 
Cantor, Julie. NEJM: Mandatory Measles Vaccine in NYC 

Uptodate.org

cdc.gov —
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.html
https://www.cdc.gov/features/measles/index.html