Measles Update – November 2018

November 19, 2018 Rene F. Najera

Measles was declared eliminated in the United States in 2000 as part of a lengthy public health campaign to eliminate it in the entire continent, a campaign that reached its goal in 2016. Before the measles vaccine was developed, it is estimated by the World Health Organization that there were about 2.6 million deaths worldwide, most of them in young children. After the vaccine, the number of cases of measles and deaths from measles dropped precipitously.

Lately, it seems that measles is trying to make a comeback, especially in populations where there are enough unvaccinated (and, thus, susceptible) individuals to trigger an outbreak. This is currently the case in places like Rockland County, New York. There, a measles outbreak has reached 75 confirmed cases:

Most of the cases in Rockland County are in an Orthodox Jewish community. In turn, it is believed that the index case (the first confirmed case) brought measles to the New York area via Israel. In Israel, the legislature is voting on a bill that would prevent unvaccinated/non-immune children from attending public school when an outbreak was declared. This is in response to a sizeable outbreak of measles in the country.

The Centers for Disease Control and Prevention (CDC) are reporting measles outbreaks in "Arkansas, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington," and the District of Columbia. Together, these outbreaks account for over 200 cases. Like with most outbreaks of vaccine-preventable diseases, "the majority of people who got measles were unvaccinated," according to CDC.

It's not just the United States and Israel that are dealing with a re-emergence of measles. In Italy, the recently-elected, populist government has reversed its course on vaccine requirements for school-age children amid a large outbreak of measles in the whole of Europe. Whereas the Italian government officials campaigned on anti-vaccine promises, the current epidemic has reached thousands of cases and, sadly, some reported deaths from measles. Several European countries have less than the necessary 95% measles vaccine coverage to prevent outbreaks.

Map of Europe showing measles rates per million residents

In Venezuela, a completely different set of circumstances than those of Europe and the United States are at play. There, a political crisis that has been going on for years has collapsed many primary services, including healthcare. As a result, immunization campaigns have not occurred like they used to. So children are not being immunized, allowing for the re-emergence of several vaccine-preventable diseases, including measles. From The Washington Post:

"The PAHO said in a statement that Venezuela’s health-care system — including disease-prevention programs — had been continually deteriorating because of economic and political problems. “This has led to an increase in the number of outbreaks of infectious diseases, particularly of measles, diphtheria and malaria. The situation is being aggravated by population movements both within the country and to neighboring countries,” it said."

In the latest epidemiological update, the World Health Organization (WHO) is reporting thousands of cases and dozens of deaths in Venezuela and Brazil, primarily at their border:

"In 2018, as of 23 October, a total of 8,091 confirmed measles cases, including 85 deaths, have been reported in 11 countries of the Region of the Americas: Antigua and Barbuda (1 case), Argentina (14 cases), Brazil (2,192 cases, including 12 deaths), Canada (25 cases), Colombia (129 cases), Ecuador (19 cases), Guatemala (1 case), Mexico (5 cases), Peru (38 cases), the United States of America (142 cases), and the Bolivarian Republic of Venezuela (5,525 cases, including 73 deaths).

Since the 21 September 2018 Epidemiological Update on Measles, an additional 1,462 confirmed measles cases were reported, including 13 deaths, in 7 countries of the Region (3 cases in Argentina, 457 cases and 2 deaths in Brazil, 3 cases in Canada, 44 cases in Colombia, 17 cases in Peru, 18 cases in the United States, and 920 cases and 11 deaths in Venezuela)."

Finally, in places like Thailand, confusion over religious concerns and political strife has led to an avoidance of measles vaccine by residents there. In turn, this has translated to thousands of cases of measles and at least 13 reported deaths. (The true number of cases is difficult to ascertain because of the remoteness of the country and the difficulty of reporting cases by public health officials.)

As you can see, measles is far from being eradicated like smallpox was in the 1970s, or like polio is so close to becoming. If anything, it is making a strong comeback in places currently categorized as being free from endemic transmission. (By endemic, we mean a continuous level of transmission, without the disease really going away.) The causes for this re-emergence are varied. In the United States and Europe, it seems that anti-vaccine sentiment tied together with political views are lowering the level of immunity in different communities (i.e. herd immunity). In Venezuela, continued political strife has collapsed the systems and institutions responsible for vaccination. And, in Thailand, confusion over religious edicts and political strife are at play. Whatever the reason, this worldwide situation is something that public health authorities seem to be taking very seriously, and something we will continue to update you about in the foreseeable future.

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