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Measles: A New Debate about an Old Nemesis

On January 16th, major news outlets in Denver and along the Front Range reported that a Denver resident had been diagnosed with measles after traveling abroad. Health officials were quoted as saying he was contagious between January 9th and 14th and listed the places he had been during that time such as King Soopers, a health spa, an Urgent Care Center and then St. Joseph’s Hospital. Other media coverage simply stated that health officials were working to track down anyone with whom he might have come into contact.

MMR VaccineMany of the articles led with describing this as the “first” case of measles to be diagnosed in Colorado this year—“first”, as in suggesting other cases were to follow.

Nineteen years ago, the headlines were very different. In 2000, the Center for Disease Control announced that the United States had eliminated measles due, in large part, to a highly effective nationwide vaccination program. To be clear, this announcement did not mean that there would no longer be any active cases diagnosed within US borders. While vaccination programs led to measles being eliminated in the US and a number of other countries in the Americas, the highly contagious virus continued to pose a serious health risk in other parts of the world. Stating the virus had been eliminated in the US meant that those cases that occurred would be the result of someone with the virus coming into the country—or returning to the country after international travel—and infecting others.

To understand the impact an outbreak of measles can have on a person, it’s important to compare the US before 1963—when a measles vaccine (termed MMR because it also vaccinates against the mumps and rubella) was developed—and the years after.

First and foremost, what does measles feel like? Symptoms include a fever that gradually goes up to 103 to 105 degrees, dry cough, sore throat, runny nose, “pink eye”, white spots with a bluish center inside the mouth on the lining of the cheek and a rash that typically begins at the hairline and extends down across the face and rest of the body.

According to data compiled by the CDC, prior to 1963, nearly every child got the measles before they turned 15 years old. Roughly 3 to 4 million people became infected each year. Of those cases that were reported, 48,000 people were hospitalized, and 4,000 developed encephalitis (swelling of the brain). Of those 4,000 cases of encephalitis, 1,000 would develop seizures, deafness and/or intellectual impairment. Measles was also listed as one of the leading causes of infant mortality.

From 2000 to 2014, the threat of a measles outbreak was very low; less than 100 cases were reported in any given year. That changed in 2014 when 644 cases were diagnosed, stemming from roughly two dozen outbreaks that were largely connected to a severe outbreak in the Philippines. The worst outbreak involved 383 unvaccinated people primarily from an Amish community in Ohio.

In 2015, a year later, there were 188 unvaccinated people diagnosed with the virus. The origin wasn’t confirmed, but most of those who became infected had been at Disneyland at the same time.

In 2017, 75 cases were diagnosed in Minnesota among unvaccinated members of a Somali-American community.

In 2018, there were 17 outbreaks in New York City, New York state and New Jersey. Those cases were largely concentrated among unvaccinated people living in Orthodox Jewish communities and was traced to a strain of the virus in Israel where a large outbreak was occurring.

In addition to these situations, the CDC reported 82 cases of measles being brought in to the United States from other countries. That is the largest importation of measles since the virus was eliminated in 2000.

And now, residents of Clark County, Washington are in the midst of an outbreak with 53 confirmed cases and 2 more suspected. Of the 53 people who are confirmed with measles, 51 of are younger than 18 years old. Of those 51 people, 38 are younger than 10 years old. It should be noted that Clark County has one of the worst percentages of vaccination rates in the entire state with 1 out of every 4 children being unvaccinated.

One of the significant challenges of dealing with an outbreak is contacting those who might be infected and don’t know it, possibly leading to the virus being spread even further.

At this point, an extensive investigation by Washington officials has determined that people who were contagious went to, among other places, a local Costco, the airport and a Blazers game. The next step has been to reach out to those who might be infected, most typically with a phone call at a pre-announced scheduled time with a second follow up call later in the day.

Public health officials have declared a medical state of emergency, a decision supported by Washington Health Secretary John Wiesman. “This outbreak is more alarming than anything we’ve experienced in more than two decades,” Wiesman states. “It’s larger and infecting people faster.”

3 Year old with the Measles, who was unvaccinatedSo, let’s talk about the pink elephant in the room.

One thing those who get the measles have in common is not being vaccinated. (Note—MMR requires 2 doses. The CDC states that people who have only had one dose may get infected, but the severity is notably less.) The measles vaccine is known to be extremely effective, so why would parents choose to not vaccinate their child?

No study can capture all situations or feelings, but a number of studies show that people, in general, oppose vaccinations for their children because of specific medical reasons, religious reasons or personal/philosophical reasons.

Those reasons are also reflected in state law. Although all 50 states have legislation requiring specific vaccines for students, all states also allow exemptions for medical reasons. Almost all states also allow exemptions for religious reasons. Currently, 17 states allow exemptions for people who object to immunizations for personal, philosophical or moral reasons. Washington is one such state. Colorado is another.

At their most basic level, vaccines are their own worst public relations enemies, largely because they’re so effective. People who have never seen—let alone, experienced—an outbreak of the measles have a tendency to underestimate just how bad the virus is.

However, other factors have had a major impact, not the least of which was a 1998 study published in the highly prestigious Lancet Medical Journal which suggested a link between vaccines and autism. The study made huge news—huge—and officials began to notice an immediate decline in vaccinations as parents became concerned that vaccines would injure their children.

Following the publication, other scientists began to find problems with how the study was constructed and the results it produced. Not surprisingly, that didn’t get much media attention. Fast forward through multiple other studies followed by investigations to the year 2010 when the Lancet Medical Journal officially retracted the study and the researchers were cited for ethical violations. In a crowning blow, the British Medical Journal published articles that chronicled the scientists being found guilty of fraud (they falsified data) largely for financial gain.

Sadly, news of the follow up—including The Lancet’s retraction and scientists’ fraud—did not make it on the radar of those who were already distrustful of the vaccine. That opposition is only fortified by articles repeating the flawed data from the study that continue to circulate on social media.

Even more unfortunate, the general decay of trust in institutions fed by numerous conspiracy theories and felt by some people in countries—both developed and otherwise—around the world has extended to medicine, as well, potentially causing people who fervently want to protect their families to be hesitant about receiving the very medical care that would provide the protection they seek.

VaccinesEven with all this information about the efficacy of vaccines and the dangers of children not being vaccinated, a number of states in the US have continued to have large numbers of unvaccinated children.

In fact, in 2013, Colorado ranked 45th among states in vaccinating children 19-35 months and 50th in the numbers of kindergarteners who were vaccinated.

Those numbers prompted the state to devote a significant amount of attention to increasing vaccination rates, and last year’s numbers show a marked improvement. As reported in the June 28, 2018 edition of The Denver Post, “New figures from the health department show, for the second school year in a row, that more than 90 percent of students got their required shots.”

Measles InfoKiowa County ranks right up there with the rest of the state. According to figures from Kiowa County Public Health, 93.3% of all school aged children are up to date on their vaccines with 3 families receiving exemptions.

Time will only tell how Clark County will weather this storm. Good news is that, as of this writing, there have been no new cases reported. Bad news: 10 other states are reporting cases of the measles. Oregon, which shares a border with Washington, just reported 4 cases in one county.

For its part, Washington State is talking about introducing legislation to remove personal exemptions as an acceptable reason for not vaccinating students. More than 700 residents—even with the outbreak going on around them—showed up to strongly and loudly voice their opposition. Similar moves are being considered by the other states that allow that exemption. No word on larger public sentiment yet.

Luckily for millions of people, there is the potential for measles to be eventually eradicated in most of the corners of the world. That basically leaves us with two questions: what is the cost of making measles a thing of the past? What is the cost of not doing that?

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