Category: Vaxopedia

Is Measles Still Eliminated in the United States?

Do you remember when measles was eliminated in the United States?

You probably should.

Remember when we eliminated measles and we used to only have about 100 cases of measles in the United States each year?
Remember when we eliminated measles and we used to only have about 100 cases of measles in the United States each year? Pensacola News Journal July 2000

It wasn’t that long ago…

When Measles Was Eliminated in the United States

After several years of declining numbers of measles outbreaks in the United States, the endemic spread of measles was declared eliminated in March 2000.

“The data indicated that, during 1997–1999, measles incidence has remained low (<0.5 cases per 1,000,000 population) and that most states and 99% of counties reported no measles cases. In addition, measles surveillance was sensitive enough to consistently detect imported cases, isolated cases, and small outbreaks. Evidence of high population immunity included coverage of >90% with the first dose of measles vaccine in children aged 19–35 months since 1996 and 98% coverage among children entering school. In 48 states and the District of Columbia, a second dose of measles vaccine is required for school entry. A national serosurvey indicated that 93% of persons aged >6 years have antibody to measles.”

Measles — United States, 1999

What did that mean?

It is easy to understand when you note that we still had 86 cases of measles in the United States that year.

So, measles wasn’t gone yet. It was just that most cases were imported from outside the country. Only imported strains of the measles virus were causing outbreaks.

“The end of endemic measles transmission in the United States has both domestic and international importance. Domestically, the absence of endemic exposure to measles means few persons in the United States will be infected and risk complications of measles. This decreased risk of exposure provides protection to groups not protected directly by vaccination: children too young for routine vaccination; the few persons who, although vaccinated, are not protected, primarily from failure to mount an adequate response to vaccine; persons for whom vaccine is contraindicated (e.g., those with immunodeficiency); and persons who choose not to be vaccinated.”

Wharton on Measles Elimination in the United States

Unfortunately, the “choose not to be vaccinated” group might be endagering our claim to have eliminated measles.

Is Measles Still Eliminated in the United States?

As we break more and more measles records this year, it would be easy to just say that the endemic spread of measles is no longer eliminated in the United States.

“Endemic measles transmission is the existence of any continuous indigenous chain of transmission of measles virus that persists for >1 year in any defined geographic area (e.g., the United States).”

Orenstein on Defining and Assessing Measles Elimination Goals

Still, when you look at the numbers, technically, measles isn’t yet spreading endemically in the United States.

Although we are seeing measles cases in 27 states, about 70% of them are in just two outbreaks in one state - New York.
Although we are seeing measles cases in 27 states, about 70% of them are in just two outbreaks in one state – New York.

We are getting close though.

The outbreaks in Rockland County and Brooklyn started in September and October 2018. If they aren’t stopped soon, will it be easier to make a case that measles is no longer eliminated in the United States?

“Outbreaks in New York City and Rockland County, New York have continued for nearly 8 months. If these outbreaks continue through summer and fall, the United States may lose its measles elimination status.”

U.S. measles cases in first five months of 2019 surpass total cases per year for past 25 years

It sounds like it.

One thing to consider though, after an unvaccinated visitor introduced measles to Brooklyn from Israel back in October, measles has been reintroduced into the community at least seven other times! This includes travelers from Israel, UK, and Ukraine.

So the outbreak isn’t necessarily a “continuous indigenous chain of transmission of measles virus.”

It is multiple chains in the same community.

“There have been additional cases of measles from international travelers to Rockland, exposing more people to measles.”

2018 – 2019 Measles Outbreak in Rockland County

The same thing has happened in Rockland County after the initial importation from Israel in September.

Measles Elimination Criteria

Does that matter?

It likely should, but let’s also look at how we do with other criteria that are often used to assess the absence of the endemic spread of measles:

  • Few measles cases/low measles incidence – we will have the most cases in 2019 since 1992, but most cases are clustered in just a few big outbreaks
  • The duration of outbreaks is short – outbreaks are getting longer and harder to contain, but part of the problem is the global rise in measles and the reintroduction of measles into existing outbreaks
  • Most cases are associated with international importation – still very true
  • No endemic measles virus strain – outbreaks this year have been associated with strains that are commonly seen in Ukraine, the Philippines, and a few other areas
  • Long periods with no unknown-source cases – most cases are linked to international travel
  • High population immunity – except for pockets of susceptibles, folks who intentionally don’t vaccinate their kids or get themselves vaccinated, we do have high population immunity
  • Low levels of transmission from reported cases – in most outbreaks, that it is still true, unfortunately, there are more outbreaks this year
  • Adequate measles surveillance system – definitely true

What is the best argument that the endemic spread of measles has still been eliminated in the United States?

“A small number of cases have occurred outside of these neighborhoods but have, to date, not resulted in sustained transmission of measles.”

Measles Cases Rise to 466 Including in Two Unvaccinated Children Spending Time in Areas with Measles Activity

Even where there are big outbreaks, measles isn’t spreading outside of very specific communities of intentionally unvaccinated children and adults.

And that’s because most people are vaccinated and protected and aren’t letting measles spread endemically!

Losing Measles Elimination Status

If we did lose our status of having eliminated measles, we wouldn’t be the first.

“As of 30 June 2018, measles transmission in Venezuela has been ongoing for over one year. Therefore, endemic transmission of measles is considered to have been reestablished in Venezuela.”

Fourth ad hoc Meeting of the Technical Advisory Group (TAG) on Vaccine-preventable Diseases

Tragically, since their outbreaks began a few years ago, there have been nearly 10,000 cases and at least 78 deaths. Cases have also spread to many other countries in South America.

Venezuela isn’t the only country where we have seen the return of measles though.

In 2017, the European regional verification commission verified the reestablishment of the endemic spread of measles in the Russian Federation and in Germany.

“Countries in all six WHO regions have adopted goals for measles elimination by 2020.”

Progress Toward Regional Measles Elimination — Worldwide, 2000–2017

Surprisingly, some other countries in Europe, like Belgium, France, and Italy, never eliminated measles.

What’s next?

Hopefully, instead of a new normal, the rise in cases gets us back on track to eliminating and one day eradicating measles.

More on When Measles Was Eliminated in the United States

When Do You Get the Measles Vaccine?

With the rise in measles cases this year, folks are asking when they routinely get the measles vaccine to help make sure they are vaccinated and protected.

Do you know when you routinely get your measles vaccine?
Adults who aren’t high risk might be able to get away with simply having one dose of MMR or a measles containing vaccine since 1967.

Unfortunately, there isn’t an easy answer.

When Do You Get the Measles Vaccine?

Well, there kind of is.

Today, we routinely give:

  • the first dose of the measles vaccine (MMR) when toddlers are 12 to 15 months old, and
  • the second dose of MMR when they are 4 to 6 years old

However, if you are at high risk to get measles, especially if you are planning to travel out of the country or to specific areas with active outbreaks, you should get those doses early.

Early Doses of MMR

How early?

As early as age six months.

In fact, high-risk infants 6 through 11 months of age should receive one early dose of MMR vaccine, a dose that will have to be repeated when they are 12 months old. This early dose is mostly about international travel though and not travel within the United States, unless there is a specific recommendation in a local area.

“For outbreaks with sustained, community-wide transmission affecting infants <12 months of age and with ongoing risk of exposures to infants, health departments may consider vaccination of infants aged 6-11 months in these affected areas (including visitors) with 1 dose of MMR vaccine. This recommendation should be made following careful assessment of the benefit of early protection against measles during a period of increased transmission and exposure, and risk of decreased immune response following subsequent MMR doses in infants vaccinated at <12 months of age compared with infants vaccinated at ≥12 months of age.”

Manual for the Surveillance of Vaccine-Preventable Diseases

And children 1 to 3 years of age who are high-risk should receive two doses of MMR vaccine (instead of waiting to get the second dose when they are 4-6 years old), separated by at least 28 days.

This second dose doesn’t have to be repeated though.

When Did We Use to Give the Measles Vaccine?

Still, more than a review of the current immunization schedule, most folks want to know when we used to get vaccinated against measles. That’s what might help you figure out if you are vaccinated and protected.

Hopefully, you can just check your shot records too.

It might also help to know that we began:

  • giving the first measles vaccine in 1963. This doesn’t count as a dose of measles vaccine though, as it didn’t provide long-lasting protection.
  • giving the first improved, live measles vaccine in 1967.
  • using the combined MMR in 1971.
  • offering a second dose of MMR to kids in 1990.

So, how many doses have you had?

What to Know About Getting an MMR Vaccine

If you haven’t had two doses and are at high risk to get measles, get caught up and protected. Keep in mind that you don’t need to check your titers first and you won’t need a third dose of MMR. Titers might be a good idea if you were born before 1957 and aren’t sure if you had a natural case of measles.

“The best way to protect yourself and your loved ones from measles is by getting vaccinated. You should plan to be fully vaccinated at least 2 weeks before you depart. If your trip is less than 2 weeks away and you’re not protected against measles, you should still get a dose of MMR vaccine.”

Before international travel: Make sure you’re protected against measles

Lastly, if possible, try to get your second dose of MMR at least two weeks before your trip.

More on When We Give the Measles Vaccine

If Measles Was Eliminated, Why Do We Still Have Measles?

Measles has been declared eliminated in the United States.

Unfortunately, that doesn’t mean that we totatly got rid of measles.

When Was Measles Eliminated in the United States?

That becomes clear when you realize that there were 86 cases of measles in the United States when measles was eliminated.

When was that?

Back in March 2000.

What Does Measles Elimination Really Mean?

So why do we still have measles if it was eliminated already?

It’s because elimination is not eradication.

Measles is much more contagious than smallpox, which is part of the reason we are stuck in the measles elimination phase.
Measles is much more contagious than smallpox, which is part of the reason we are stuck in the elimination phase.

And even then, technically measles itself hasn’t been eliminated in the United States.

The Endemic Spread of Measles

Only the endemic spread of measles has been eliminated.

“Endemic measles transmission is the existence of any continuous indigenous chain of transmission of measles virus that persists for >1 year in any defined geographic area (e.g., the United States).”

Orenstein on Defining and Assessing Measles Elimination Goals

That’s why we still have measles. All of the cases we do now have are either imported or linked to a case that was imported.

Unfortunately, as our measles outbreaks get longer and harder to control, it could be that we soon lose our designation of having eliminated measles and all of the progress that went with it.

More on Measles Elimination in the United States

Ask 8 Questions Before You Skip a Vaccine

As anti-vaccine folks get more attention because of the rise in outbreaks of vaccine-preventable disease, in addition to more folks getting vaccinated, we are seeing some of the leaders of the anti-vaccine movement get more vocal.

Are measles outbreaks a sign that the anti-vaccine movement is “winning?”

Meetings, dinners, rallies…

They are doing everything they can to get their misinformation and propaganda out so that you don’t vaccinate and protect your kids.

Ask 8 Questions Before You Skip a Vaccine

If you see any of these folks, ask them a few questions…

  1. If Andrew Wakefield was right, and the MMR vaccine is associated with autism, then why are you worried about thimerosal? The MMR vaccine never contained thimerosal…
  2. If Robert F. Kennedy, Jr is right, and it is all about thimerosal, then why are you worried about the MMR vaccine? The MMR vaccine never contained thimerosal…
  3. If you are worried about thimerosal and aluminum, then why are you worried about the MMR vaccine? Not only has it never contained thimerosal, as a live vaccine, but it has also never contained aluminum.
  4. If vaccines are associated with autism, then why don’t the counties with the highest immunization rates have the highest rates of autism?
  5. If better hygiene and sanitation got rid of vaccine-preventable diseases, then why didn’t it do it for all diseases at the same time? And why hasn’t it gotten rid of RSV, Ebola, Zika, HIV, Norovirus, and all of the diseases that we don’t have vaccines for?
  6. If measles is so mild, then during the measles epidemics from 1989 to 1991 in the United States, why were 11,000 people hospitalized and why did 123 people die?
  7. If you are concerned about vaccines that have a distant association with abortion, then why don’t you vaccinate your kids with all of the vaccines that don’t use WI-38 and MRC-5 cells lines?
  8. If your arguments are so solid, then why do you need to keep moving the goalposts (it’s autoimmune diseases they are worried about now, not autism) and why are they so easy to refute (vaccines aren’t associated with autoimmune diseases either)?

The answers will be predictable.

They will revolve around three basic core beliefs of the anti-vaccine movement.

  • The belief that vaccines are toxic, full of poison, and always cause damage and injuries.
  • The belief that vaccine-preventable diseases are mild and you are better off getting natural immunity.
  • The belief that vaccines don’t even work.

Is that what you believe?

Will you let those kinds of beliefs scare you away from vaccinating and protecting your kids?

Are you going to put our kids at risk because you believe those things?

Are you really making an informed choice to skip or delay a vaccine when all of the scary things that people are telling you about vaccines aren’t even true?

More on Questions to Ask Before You Skip a Vaccine