Measles Madness: An inevitable outbreak and what we can learn from it
Clark County, Washington, just north of Portland and the community where I practice as a pediatrician, has made national news over the past few months. We’ve had a major measles outbreak since early January, which was just declared officially over on April 29. There were a total of 71 confirmed cases, with the vast majority being unvaccinated children. The governor has declared a state of emergency, and the outbreak spread to Portland and Seattle as well. The list of exposed locations has been nightmarish, including the Portland airport, an NBA basketball game, and IKEA among many others. According to the Clark County Public Health Department, responders logged a tireless 19,000 hours in dealing with the outbreak.
A Washington Post article from January 23 called my community an anti-vaccination ‘hotspot’. Dr. Peter Hotez, a professor of pediatrics at Baylor University, was blunt in his assessment of the situation: “Portland is a total train wreck when it comes to vaccine rates.” (1) Ouch.
My community has been on edge. During the early days of the outbreak my clinic was taking taking nearly 2000 calls a day, many from concerned parents worried about the risk for their kids. We were basically operating a drive-thru measles clinic, putting on gowns, gloves, and masks and seeing possible cases in their cars. Parents of healthy kids cancelled checkups, not wanting to risk an exposure. Schools were disrupted and nervous families stopped leaving the house.
How did this happen? Measles is something my grandparents might have gotten, like cholera or smallpox. An archaic sounding scourge that we supposedly triumphed over. So why did this completely preventable disease tear through my community in 2019?
It’s worth a little reflection to know how we got here, why this outbreak (and the others spreading through our country) was inevitable, and to understand that we’re on a collision course for even more outbreaks in the future.
Most people don’t realize how common measles used to be. In the U.S. alone, an estimated 3-4 million cases occurred each year before the vaccine was licensed in 1963. The vaccine was shockingly effective and rates plummeted after that. It still proved difficult to deliver measles vaccine to the parts of the world that needed it most, and even in 1980 there were about 2.6 million deaths from measles worldwide according to the World Health Organization. Most of these were children. A second vaccine dose was added to the recommended schedule in 1989, and by 2000 the CDC declared that measles had been eliminated from the United States. This was one of the most stunning victories in the history of American medicine.
“Elimination” doesn’t mean there are no cases – there were an average of 56 per year in the U.S. from 2001-2008 imported from other countries – but it means that no more cases originated from the U.S. As vaccination rates fell, however, the average number of cases more than doubled over the next 5 years, peaking at a whopping 667 cases in 2014. (2) (We’re poised to shatter that number in 2019, with over 700 cases identified by the end of April.)
There were a few high-profile outbreaks in 2014, including 383 cases that spread through a largely unimmunized Amish population in Ohio, as well as an outbreak at Disneyland that eventually affected 147 people across 8 states.
Why is measles so scary? First, it’s super contagious. Most viruses spread when kids touch surfaces that another snotty kid touched or when someone coughs directly in their face. But measles particles float in the air for a long time – you can get measles if you walk into a room and simply breathe the air two hours after an infected person has left!
Those who are old enough to have gotten measles as a kid know that it was almost a “rite of passage” thing, kind of like chicken pox. It’s true that the vast majority of those affected by measles will recover just fine. But it’s still a scary illness. Kids with measles are miserable, with a fever up to 105 degrees, malaise, cough, red eyes, and an impressive rash. And the complications are even scarier. Infected kids can get pneumonia or encephalitis (inflammation of the brain). About 2 out of 1000 will die, and some can develop a brain complication called subacute sclerosing panencephalitis 7-10 years after their infection. While rare, this condition is fatal.
The economic burden of measles takes a backseat to the health risks, but it’s still impressive. Outbreaks can cost up to $114,286 per case to control according to a 2014 study. (3) Schools and businesses close, and families tend to avoid going to public places and spending their money.
Our recent measles outbreak in Clark County was predictable because of sharply decreasing vaccination rates, and it should be a cautionary for the rest of the country which is heading in the same direction, albeit more slowly.
According to Clark County public health statistics, the percentage of kindergartners who are fully vaccinated dropped from 91% in 2005 to 76.5% today. For measles vaccine in particular, the rate fell from 96.4 to 84.5% over the same period.
That percentage is crucial because of the concept of herd immunity. That means that a certain percentage of individuals being vaccinated against a disease prevent it from taking a toehold in a community and spreading. Kids who are unable to be vaccinated due to their age or other restrictions depend on herd immunity to stay healthy. It’s also the only reason that those who are not vaccinated by parental choice can usually avoid the illness.
Because measles is so contagious, the percentage of the population that needs to vaccinated to maintain herd immunity is about 95%. (4) So we’re seeing the predictable results of my county’s kindergartners falling to 84.5%, and we should all be concerned that the percentage for the nation as a whole is teetering at 94.3% and falling according to the CDC.
This is terrifying and our kids are at risk. Most people don’t know that 136,000 people throughout the world (mostly kids under five years old) still died of measles in 2018 according to the World Health Organization. That number has risen for two straight years. That’s because public health officials trying to deliver vaccines struggle every day to overcome obstacles such as poverty, war, and lack of funding in many places across the globe. And here in my wealthy community anyone can get the vaccine today with a phone call – and our rates are plummeting. That’s a tragedy.
There are a lot of terrible illnesses in the world that we can’t do much about. Even against influenza, our vaccines are imperfect and we do the best we can. But it’s different with measles. One dose of the vaccine provides 93% protection against the virus, and two takes that up to 98%. Most public health officials think that we can eliminate measles from the earth someday, just like smallpox.
So why are these vaccination rates headed in the wrong direction? The modern anti-vaccine movement, of which the MMR vaccine has often been the focal point, has complicated origins. But if you had to point to one person as the biggest cause, it would be Dr. Andrew Wakefield, a British gastroenterologist. No one has been a bigger threat to children’s health over the past quarter of a century.
In 1998, Wakefield published a paper in the Lancet, one of the most prestigious medical journals, claiming to show a link between MMR and autism. This was huge. The science was later discovered to be completely fraudulent, and an investigation revealed that some of his patients were recruited by a UK lawyer preparing a lawsuit against MMR vaccine manufacturers. On top of that, Wakefield was in the process of developing a testing kit for “autistic enterocolitis” (an unproven condition he made up), from which he estimated he could make $43 million per year. (5) The Lancet retracted the article and Wakefield was shunned by the medical community, but the damage was done. Vaccination rates plummeted in Great Britain after his “study” and also fell here in the United States. He continues to rant against vaccines to whoever will listen. The anti-vaccine movement has run with his original “findings” and never looked back.
I see parents everyday who choose to not to give their kids some or all of the recommended vaccines. It can be easy to demonize them, but the reality is that these are good parents who are trying to do what’s best for their kids. They are usually thoughtful and try to “do their homework” on vaccines. They tend to care deeply about what their kids eat, limit screen time, and make sure their kids are active. These parents span the entire spectrum of wealth, race, and educational level. They include nurses, teachers, cooks, and financial planners.
They have a variety of reasons for their beliefs. Most common is the fear of being responsible for hurting their child with the vaccines or causing autism. Some are suspicious of vaccine manufacturers, the government, and doctors being in cahoots and profiting off something that is harmful to kids. They assume there is a raging debate even in the medical community and often even ask if I vaccinate my kids (there’s not and of course I do).
I can talk about how vaccines have been proven not to cause autism or how there is a far greater risk of severe side effects from amoxicillin than a vaccine, but that doesn’t work. This isn’t a scientific debate, but an emotional one. Hearing about a friend of a friend whose child immediately became autistic after getting vaccines leaves a far bigger emotional impression than any cold hard data I could recite.
When science and expertise have lost much of their currency, what can we do? How do we change their minds? Well, like most pediatricians I try to listen to them, be respectful, and develop some trust so that they’ll be more comfortable with vaccines in the future. But perhaps this outbreak can help as well. None of my patients or parents has ever seen measles, so it’s been theoretical and less scary. Now they’re seeing it in their neighborhoods, churches, and schools. It’s become a story, and our brains are wired to connect with stories. It’s left quite an impression in my community and now even across the country. This is a good thing! It’s created emotion - whether that’s anger or fear – and emotion can change beliefs.
Since stories are so powerful I’ll close with one more. “Suzy” is an impossibly cute young patient in my practice who was born with an immune system that doesn’t work quite right. Suzy’s body doesn’t make much of the immunoglobulin that she needs to fight off diseases, so she has to go to the hospital every few weeks to get some immunoglobulin injected into her body. Suzy is also not able to get the measles vaccine because her body can’t create a response to it, and she would likely be hospitalized if she got the measles. During the outbreak Suzy was in a store where there was a measles exposure. She left ten minutes before the infected person arrived. These are scary times for Suzy and her family as a completely preventable disease spreads through her community.
For the moment, let’s all just forget the pro- and anti-vaccine facebook hype. We finally have something real to focus on. This outbreak is happening, it’s clear why it’s happening, and it’s clear that we’re on track for more outbreaks in the future. Let’s learn from it and work towards decisions that keep Suzy and all of our kids safe.
1. Stanley-Becker, Isaac. “Officials in anti-vaccination ‘hotspot’ near Portland declare an emergency over measles outbreak.” Washington Post article. January 23. https://www.washingtonpost.com/nation/2019/01/23/an-anti-vaccination-hotspot-near-portland-suffers-public-health-emergency-over-measles
2. CDC Manual for the surveillance of vaccine-preventable disease. Chapter 7: Measles. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html#f21
3. Ortega-Sanchez IR, Vijayaraghavan M, Barskey AE, Wallace GS. The economic burden of sixteen measles outbreaks on United States public health departments in 2011. Vaccine. 2014;32(11):1311–7. doi: 10.1016/j.vaccine.2013.10.012
4. Ludlow M, McQuaid S, Milner D, de Swart RL, Duprex WP. (January 2015). "Pathological consequences of systemic measles virus infection". The Journal of Pathology. 235 (2): 253–65.
5. Deer, B. How the vaccine crisis was meant to make money. BMJ . 2011;342c5258.