In Japan, for example, in addition to a rise in measles cases this year, they are seeing big outbreaks of rubella, with weekly totals exceeding 100 cases! These are numbers that are close to what they saw during outbreaks in 2013, a year that ended with 14,344 cases of rubella and 32 cases of congenital rubella syndrome.
And they are already reporting at least one case of congenital rubella syndrome, a 4 week old, which is not surprising, considering that they had nearly 3,000 cases of rubella last year.
Is that what we want to happen here too? Are folks looking forward to having to worry about babies being born with congenital rubella syndrome, a vaccine-preventable disease?
While you likely aren’t too surprised about the flu deaths and the cases of meningococcal disease, did you know that kids still get Hib, babies still get hepatitis B, and that there were three cases of human rabies and a case of diphtheria in the United States last year?
When Was the Last Case of Diphtheria?
That’s despite the fact that the diphtheria vaccine has been around for over 100 years, long before it was combined with the first whole cell pertussis vaccine and the tetanus vaccine to form the DPT vaccine.
A vaccine that helped control respiratory diphtheria, which could lead to the formation of a pseudomembrane in a child’s airway, giving diphtheria the nickname of the “strangling angel.”
The last big outbreaks of diphtheria in the United States occurred in the 1970s, although sporadic cases had continued since, albeit at lower and lower levels each year. Eventually, endemic respiratory diphtheria was declared eliminated in 2009.
Still, we know that there have been some recent cases of diphtheria in the United States.
In April of 2014, a teen from Montgomery County, Ohio developed diphtheria.
And again in April of 2018, someone in Oklahoma developed diphtheria.
Why do we care about a few isolated cases?
Because we know how quickly diphtheria can come back if we stop vaccinating our kids!
Just look at what is happening in many other countries that once had these diseases under good control:
a 22-year-old unvaccinated women who died in Australia (2011)
an unvaccinated 3-year-old who died in Belgium (2016)
a family that became infected in South Africa in which at least one child died (August 2017)
Sandra Roush and Trudy Murphy provided us with pre-vaccine baselines for 13 vaccine-preventable diseases in their article, Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States.
“A greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 were shown for diphtheria, mumps, pertussis, and tetanus. Endemic transmission of poliovirus and measles and rubella viruses has been eliminated in the United States; smallpox has been eradicated worldwide. Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively.”
Roush et al on Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States.
Their study, which came out in 2007, used morbidity (2006) and mortality (2004) data that was recent at the time. The data has held up very well since then, looking at 2018 statistics in the National Notifiable Infectious Diseases Weekly Tables (see below), even with talk of waning immunity for some vaccines.
“…for those trained in pediatrics in the 1970s, Hib (Haemophilus influenzae type b) was a horror.”
Walter Orenstein, MD
The pre-vaccine era for Hib was just before 1988, when the first Hib vaccine came out. We had good hygiene, sanitation, and nutrition in the 1980s and yet, a lot of kids died from Hib meningitis and epiglottitis. At least they did until he got a vaccine to prevent it.
And if it was better hygiene and sanitation, etc., why did it affect every disease at a different time? And why hasn’t better hygiene and sanitation stopped RSV, HIV, norovirus, Zika, and all of the other non-vaccine-preventable diseases?
Shouldn’t measles be on the list with all of the other eradicated diseases, like smallpox and, well smallpox…
Why Haven’t We Eradicated Measles Already?
Eradicating a disease is not as simple as developing a vaccine.
If it were, a lot of diseases would have been eradicated already.
Hopefully, we will add more to the list of eradicated diseases, but there are some that will never be eradicated. Tetanus, for example, is ubiquitous in soil, so would be nearly impossible to eradicate. Other diseases, like rabies and yellow fever, would be hard to eradicate because they can infect animals or insects.
“Recent successes in interrupting indigenous transmission of measles virus in the Americas and in the United Kingdom prompted the World Health Organization (WHO), Pan American Health Organization (PAHO), and CDC to convene a meeting in July, 1996 to consider the feasibility of global measles eradication.”
Measles Eradication: Recommendations from a Meeting Cosponsored by the World HealthOrganization, the Pan American Health Organization, and CDC
Folks started talking about measles eradication in 1996.
Before that though, there had been a goal to eliminate measles in the United States.
“An effort is underway to eliminate indigenous measles from the United States; a target date of October 1, 1982 has been set.”
Although we missed that initial target date, we weren’t too far off.
“In 1978, the US Public Health Service initiated a Measles Elimination Program with the goal of eliminating measles from the United States by 1982. The goals of this program included (1) maintenance of high levels of immunity,(2) careful surveillance of disease, and (3) aggressive control of outbreaks. Unfortunately, the program failed, predominantly because of the failure to implement the recommended vaccination strategy and because of vaccine failure. An increase in measles cases was sustained from 1983 through 1991 and was particularly dramatic from 1989 through 1991.”
Poland et al on Failure to Reach the Goal of Measles Elimination
There is also the fact that measles is just so dang contagious!
Improving vaccination rates and a two-dose MMR schedule helped decrease measles rates even further and finally eliminate the endemic spread of measles in the United States in 2000.
What were some other deadlines and goals?
In 1989, the World Health Assembly resolved to reduce measles morbidity and mortality by 90% and 95%, respectively, by 1995, compared with disease burden during the prevaccine era.
In 1990, the World Summit for Children adopted a goal of vaccinating 90% of children against measles by 2000.
Regional measles-elimination goals have been established in the American Region (AMR) by 2000, the European Region (EUR) by 2007, and the Eastern Mediterranean Region (EMR) by 2010.
A regional measles-elimination goals have been established in the Western Pacific (WPR) by 2012.
In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan with the objective to eliminate measles in four World Health Organization (WHO) regions by 2015 – the Region of the Americas, EUR, EMR, and WPR.
Countries in all six WHO regions have adopted goals for measles elimination by 2020.
Obviously, we haven’t hit all of the goals and deadlines on time.
What have we done?
We have tremendously reduced the number of children who get measles and who die with measles. For example, instead of meeting the 2010 goals of decreasing global measles mortality by 90% over 2000 levels, we have decreased it by 74%. The world has gone from an estimated 100 million cases and 5.8 million deaths in 1980 and an estimated 44 million cases and 1.1 million deaths in 1995 to “just” 7 million cases and 89,780 deaths in 2016.
Either way, it is important to understand something he leaves out. There are few deaths from measles these days because most folks are vaccinated!
Whatever his motivation, let’s take a look at what Dr. Bob is saying about measles…
“Measles hysteria is everywhere. And it’s clear the hysteria is a result of media fear around this disease, a disease every child used to get (and handle virtually without complication) not that long ago.”
Dr. Bob Sears
Not that long ago?
I’ve been a pediatrician for 22 years and I have never seen a child with measles. Neither did I have measles, as I was fortunate enough to grow up in the post-vaccine era for measles – a vaccine that has been available for since the 1960s.
Anti-vaccine folks try to hide the risks of measles in mortality rates, but the reality of it is that about 500 people died each year up until the early 1960s when the first measles vaccine was developed.
“There is another side to this measles conversation: how we’ve unintentionally shifted the burden of disease to babies and adults, both groups who are more likely to experience complications, by vaccinating all schoolchildren and losing natural immunity.”
After all, the MMR vaccine provides life-long immunity to most people. That’s not the problem.
If we went back to the pre-vaccine era, when everyone got measles naturally, as Dr. Bob seems to be advocating for, not only would those kids have to earn their immunity, but many babies (those who hadn’t had measles yet) and adults (those with immune system problems) would still be at great risk.
And while measles was cyclical in the pre-vaccine era, it shouldn’t be when folks are vaccinated and protected. What happened to the cycles between 1997 and 2007?
“Unlike natural immunity, the measles vaccine does NOT offer lifelong protection. Estimates of its protection average around 15 years, and describe a phenomenon in the vaccine world known as “waning immunity.”
“The other trend we’ve seen over the past 10 years is an increase in adult measles cases. “
Dr. Bob’s sidekick neglects to mention that in addition to unvaccinated kis with measles, the trend is an increase in measles cases in unvaccinated adults! After all, most folks who get measles in these outbreaks are unvaccinated.
“To recap: by losing natural immunity for measles for children 5-19 years old, we’ve exposed babies, pregnant women, and adults to measles—all vulnerable groups who are more likely to experience serious complications from the disease.”
Perhaps the only true statement that they make – “we’ve exposed babies, pregnant women, and adults to measles—all vulnerable groups who are more likely to experience serious complications from the disease.”
And no, vitamin A is not a proven therapy or measles in developed countries. It mainly helps prevent complications in kids who have a vitamin A deficiency.
Anti-vaccine folks, in addition to trying to argue that vaccines are full of poison, typically try to make a case that vaccines aren’t even necessary.
Because, they claim, vaccines don’t even work. They claim that it was better hygiene and sanitation, not vaccines that helped get rid of smallpox, polio, and measles.
Did Better Hygiene and Sanitation Get Rid of Vaccine-Preventable Diseases?
On the surface, the idea that better hygiene and sanitation helped get rid disease makes a lot of sense.
“The 19th century shift in population from country to city that accompanied industrialization and immigration led to overcrowding in poor housing served by inadequate or nonexistent public water supplies and waste-disposal systems. These conditions resulted in repeated outbreaks of cholera, dysentery, TB, typhoid fever, influenza, yellow fever, and malaria.
By 1900, however, the incidence of many of these diseases had begun to decline because of public health improvements, implementation of which continued into the 20th century. Local, state, and federal efforts to improve sanitation and hygiene reinforced the concept of collective “public health” action (e.g., to prevent infection by providing clean drinking water).”
Achievements in Public Health, 1900-1999: Control of Infectious Diseases
It makes a lot of sense because better hygiene and sanitation did actually help control and eliminate many infectious diseases, including cholera, dysentery, and typhoid fever.
Others, like yellow fever and malaria, decreased because the mosquitoes that spread them were brought under control.
“Strategic vaccination campaigns have virtually eliminated diseases that previously were common in the United States, including diphtheria, tetanus, poliomyelitis, smallpox, measles, mumps, rubella, and Haemophilus influenzae type b meningitis.”
Achievements in Public Health, 1900-1999: Control of Infectious Diseases
That still left a lot of work for vaccines.
After all, we had good hygiene and sanitation in the United States when kids were routinely dying of polio, measles, Hib meningitis, pneumococcal meningitis, and rotavirus, etc.
Any way, if better hygiene and sanitation can get rid of so many diseases, why has each vaccine-preventable disease been controlled at a different time – yellow fever (1905), polio (1979), smallpox (1980), measles (2000), neonatal tetanus (2000), congenital rubella syndrome (2004), respiratory diphtheria (2009)?
What about the infectious diseases which don’t have vaccines? Why hasn’t better hygiene and sanitation helped control those diseases yet, like RSV, norovirus, Ebola, and Zika, etc.?
“Perhaps the best evidence that vaccines, and not hygiene and nutrition, are responsible for the sharp drop in disease and death rates is chickenpox. If hygiene and nutrition alone were enough to prevent infectious diseases, chickenpox rates would have dropped long before the introduction of the varicella vaccine, which was not available until the mid-1990s. Instead, the number of chickenpox cases in the United States in the early 1990s, before the vaccine was introduced in 1995, was about four million a year. By 2004, the disease incidence had dropped by about 85%.”
Misconceptions about Vaccines
And why does better hygiene and sanitation only work for chicken pox in countries that routinely use the chicken pox vaccine?
As most folks know, neither the DPT nor OPV vaccines are used in the United States.
That they are still used in other countries likely raises some questions for those folks that get them.
Why Are the DPT and OPV Vaccines Still Used in Some Countries?
As I am sure you have guessed, there is no conspiracy about the continued use of these vaccines in other parts of the world. We aren’t getting rid of old stocks of vaccines or using cheaper vaccines in poorer parts of the world.
So what’s the reason?
To understand why they are still used in other countries, it helps to understand why they aren’t used here.
Remember that the DPT vaccine, which protects folks against diphtheria, pertussis, and tetanus, came under attack in the 1970s and 80s as some folks blamed the vaccine for causing vaccine injuries, including seizures and encephalopathy. It didn’t, but we still got a new vaccine, DTaP, which doesn’t seem to work as well.
“Although concerns about possible adverse events following their administration have led to the adoption of acellular pertussis vaccines in some countries, whole-cell pertussis vaccines are still widely produced and used globally in both developed and developing countries. Whole-cell pertussis vaccines that comply with WHO requirements, administered according to an optimal schedule have a long and successful record in the control of whooping cough. Furthermore, the excellent efficacy of some currently available whole-cell pertussis vaccine has also been shown, not only in recent clinical trials, but also on the basis of the resurgence of disease where vaccination has been interrupted or when coverage has markedly decreased. Therefore, WHO continues to recommend whole-cell pertussis vaccines for use in national immunization programmes.”
WHO on Recommendations for whole-cell pertussis vaccine
The WHO now recommends that if countries do switch to DTaP, the acellular pertussis vaccine, they should be prepared to add additional periodic booster doses and immunizations during pregnancy, which may still “may not be sufficient to prevent resurgence of pertussis.”
The OPV vaccine, on the other hand, was replaced because it can rarely cause vaccine-associated paralytic polio (VAPP) and circulating vaccine-derived polio virus (cVDPV). Of course, it does it at much lower rates than wild polio virus, so until polio is well controlled, the benefit of using OPV outweighs the risk. In addition to being less expensive and easier to use, OPV has the benefit over IPV of providing better herd immunity.
At some point, as we did in the United States in 2000, countries make a switch to the IPV vaccine.
In 2016, remaining countries that use OPV switched from trivalent OPV to bivalent OPV, because wild polio virus type 2 was eradicated in 1999. Once the remaining two types are eradicated, we can stop using the OPV vaccine altogether.
Until then, countries either use:
OPV plus one dose of IPV
sequential IPV-OPV schedules – high vaccine coverage and low risk of wild polio importation
IPV only schedules – sustained high vaccine coverage and very low risk of wild polio importation
So there is no conspiracy. These vaccines are safe and they work.