The Resurgence of Measles in Children and Adults

What is Measles?

Measles, also call rubeola, is a highly contagious and deadly acute viral infection. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family and is closely related to the rinderpest and canine distemper viruses.

Measles was originally described by a Persian physician Muhammad ibn Zakariya ar-Razi (860-932), in the 10th century A.D. as a disease that is “more dreaded than smallpox”. In 1757, a Scottish physician (Francis Home) proved that measles is produced by an infectious agent in blood (CDC, 2019). During a measles outbreak in 1954, John F. Enders and Dr. Thomas C. Peebles collected blood samples from several ill children to isolate their blood; and successfully, they create the measles vaccine.

Transmission, Symptoms and Complications

Measles normally lives in the mucus membrane of the respiratory tract of an infected person and can spread through coughing and sneezing. It can live up to two hours in the air when the infected person coughed or sneezed. Additionally, measles is inactivated by heat, sunlight, acidic pH, ether, and trypsin. Measles cannot spread to other species.

The symptoms of measles include a high fever (as high as 105°F) and malaise, cough, respiratory tract infection and conjunctivitis, and a rash. The rash usually appears about 14 days after exposure and the infected person is contagious 4 days before to 4 days after the rash appears.

The Centers for Disease Control and Prevention (CDC) reports that there are several groups that may suffer from complications due to measles, which include:

• Children under 5 years of age;
• Adults older than 20 years of age;
• Pregnant women; and
• People with compromised immune systems

Common complications as a result of measles are ear infections and diarrhea. However, more sever complications include, pneumonia, encephalitis, convulsions, intellectual disability, respiratory and neurologic, premature birth or low-birth weight, and death. In rare case, a complication called subacute sclerosing panencephalitis (fatal disease of the central nervous system) may result from contracting measles at a young age.

Vaccinations

The opposition to vaccinate began long before the Measle vaccine was discovered. Vaccines have been a source of uncertainty, hesitancy and availability for centuries. In the 1700’s, an English Reverend, Edmund Massey, gave a sermon against the “dangerous and sinful practice of inoculation” where he referred to vaccines as a punishment for sins and diabolical operations. Some of Reverend Massey’s views and the general hesitancy of vaccination have continued until today and it is seen in the antivaccine movement. However, in low and lower middle-income countries (LMIC), the lack of vaccine is defined by the country’s inability to afford or provide the vaccine to its population. However, in non-LMIC, the antivaccine movement has threatened the course of measles elimination that by creating worry and hesitancy in parents with young and susceptible children. This has reversed many countries achievement of measles elimination. Dr. Soumya Swaminathan, Deputy Director General Programmes at World Health Organization (WHO) said, “The resurgence of measles is of serious concern, with extended outbreaks occurring across regions, and particularly in countries that had achieved, or were close to achieving measles elimination.” “Without urgent efforts to increase vaccination coverage and identify populations with unacceptable levels of under-, or unimmunized children, we risk losing decades of progress in protecting children and communities against this devastating, but entirely preventable disease.”

A study conducted in China provided supplementary immunization activities against measles between 2003 and 2009. The results of this study confirmed that the practice of supplemented measles vaccination activity can significantly decrease the incidence of measles (HU, 2018). Because of the resurgence of measles, it may be important to begin targeting susceptible populations where the incidence of measles is on the rise.

In the US, the CDC recommends that children get two doses of the combined Measles, Mumps and Rubella vaccine, with the first dose between 12 - 15 months of age, and the second dose should be given between 4 - 6 years of age. In the US, there are at least 47 states that allow parents to opt out of vaccinations because of religious beliefs, and 17 states that allow philosophical exemptions for personal or moral reasons. Because of the vaccination exemptions, these populations are at a greater risk for contracting measles. In 2019, there were more than 1,200 cases of measles reported and was the highest outbreak since 1992.

The WHO has reported that since 2000, more than 21 million lives have been saved because of the measles vaccination. Only Two doses of the measles vaccine provide a safe and effective regimen for measles protection. The CDC reports that one dose is 93% effective, while two does is 97% effective. However, according to the WHO, ninety-five percent coverage is necessary to prevent outbreak. However, globally, the first dose has an 85 percent protection rate and the second dose has stalled at 67 percent. Because of the rate of this coverage, the death toll continues to rise in susceptible and unvaccinated populations. Since 2017, the Americas, the Eastern Mediterranean Region and Europe have suffered the greatest surges in measles cases, while the incidence of measles fell in the Western Pacific Region.

However, after the outbreak, immunizing at-risk populations help to reduce the number of infected people and deaths. Doctors Without Borders is an agency that responds to these types of epidemics and conducts mass vaccination operations for vulnerable children, which account for at least 80 percent of their measle vaccinations and provide supportive care for infected children so they don’t become fatalities.

World Outbreak Cases

The CDC reports that measles outbreaks have occurred in the US is because of the increase in travelers who contract virus in other countries and/or because of the spread measles in communities with pockets of unvaccinated people. The measles outbreaks have often followed natural disasters (e.g. eruptions of Mt. Pinatubo in 1991), war (e.g. conflict in Syria) and political crisis (e.g. Haiti in the early 1990s). In 2019, the United States reported its highest number of cases in 25 years. Additionally, there have been other countries that lost their measles elimination status after they suffered measles outbreaks - Albania, Czechia, Greece and the United Kingdom. 

Almost half of the global cases reported in 2019 cases, as of September, were documented in Africa. A major measles outbreak occurred in Madagascar in 2019 that resulted in more than 150,000 cases and 1,000 deaths. This outbreak was complicated by nearly 50 percent of the children in Madagascar are malnourished and some parents are resistant to vaccinations because of religious beliefs or the isolation of traditional health practitioners.

In the US, there have been approximately 1,200 people infected with measles this year. The CDC reports that in 2019, there were 300 new cases of measles reported in New York and its Mayor declared it a public health emergency. This outbreak occurred in an Orthodox Jewish community of New York Measles. The CDC also reports that outbreaks are more likely to spread from international travel and communities of unvaccinated people. In 2019, more than 75 percent of the measles cases in the US have been connected to those that occurred in New York (CDC, 2019).

The recent measles outbreak in the Pacific Island of Samoa has infected over 3,800 people and killed 55 people, the majority of them children under 4 years old. The Samoa government closed its offices for two days, officially declared a state of emergency, and began a mass vaccination campaign. This campaign was set to vaccinate at least 190,000 young children and women of childbearing years. Schools have been closed, children are banned from large public gatherings, and parents have been urged to bring their children to a doctor at the first signs of illness. According the WHO, prior to the Samoan measle outbreak, their vaccination rate was at 31 percent, which declined since 2013. Because of the accidental death of two young children, in 2018, after being injected with a contaminated measles-mumps-rubella vaccine in a clinic, many parents have been hesitant to vaccinate their children (Epstein, 2019).

Public Health Impact of Measles

The public health urgency of the current global measles situation has been recognized by technical experts involved in all aspects of measles elimination. In 2001, the CDC partnered with several global organizations and countries to establish the Measles and Rubella Initiative (M&RI), to reduce measles and rubella deaths. This initiative is committed to ensure that children do not die from measles or born with congenital rubella syndrome. The M&RI seeks to reach the measles and rubella elimination goals of the Global Vaccine Action Plan by supporting countries in their coverage of measles, rubella and other vaccines; fund, plan, implement and monitor quality supplemental campaigns; investigate outbreaks and provide technical and financial support and propose and participate in solutions to stronger immunization delivery; and supporting a global laboratory network for measles and rubella.

In 2018, UNICEF warned that global incidents of measles are increasing at alarming levels, with significant outbreaks in Ukraine, Israel and the Philippines. Epidemics of measles are the result of disruptions in the delivery of public health services. The inadequacy of measles surveillance in many countries has further severely hampered progress towards elimination goals . What we observe is the predictable result of the system we have created; interludes of relative tranquility followed by massive measles outbreaks, often affecting older age groups than were historically impacted, which consume huge amounts of public health resources and undermine confidence in immunization.

In a recent call to action, the six chairpersons of Regional Verification Commissions for Measles and Rubella elimination discussed the compelling epidemiological, economic and ethical arguments for setting a global measles eradication goal and strongly advocated that it was urgent that exceptional coordinated efforts were made to ensure a world where no child dies of measles.

Eradication of measles

The factors that increase the problem; could reduce the problem

Thanks to an effective vaccination program, measles was declared eliminated in the United States in 2000. However, the highly contagious virus continues to circulate in many regions of the world and reentered the United States through infected travelers from countries experiencing measles outbreaks. This has resulted in several recent U.S. outbreaks in communities with pockets of unvaccinated people. ANJ. The World Health Organization lists vaccine hesitancy as one of 10 global health threats in 2019. ANJ

However, through a combination of the WHO’s EPI and periodic supplemental immunization campaigns, annual childhood deaths from vaccine preventable diseases have dropped from an estimated 0.9 million in 2000 to 0.4 million in 2010.

Some countries are attempting to address to crack-down on anti-vaxxers amidst the rise in Measles. For example, Germany increased it’s fines to €2,500. Italy prohibits unvaccinated children from attending school. France increased mandatory vaccinations from 3 to 11. And School Directors in Australia can be fined if all students aren’t vaccinated.

The UNICEF announcement that global measles cases had increased by 48.1% between 2017 and 2018, with 98 countries reporting measles cases in 2018 compared to 2017 is profoundly alarming. Thus it is hard to argue that this event is not extraordinarily unusual and unexpected.

Even after the disease has started to spread, immunizing at-risk populations can still reduce the number of infections and deaths. MSF responds to the threat of measles epidemics by conducting mass vaccination campaigns for vulnerable children (about 80 percent of our measles vaccination activity) and providing routine vaccination as part of pediatric care, both in emergency settings and in areas where government immunization systems do not function. During outbreaks we also provide supportive care for infected children, to prevent complications from becoming fatal. 

References

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