Tag: eradicated diseases

Vaccine Schedules from the 1940s to 2019

To scare parents away from vaccinating and protecting their kids, anti-vaccine folks continue to push the idea the kids get too many vaccines at too early an age.

They don’t.

When did we have a vaccine schedule when we gave just two vaccines?

They try to reinforce the idea by comparing things to the “good ol’ days,” when they think kids only got one dose of one or two vaccines.

Did they?

Vaccine Schedules from the 1940s to 2019

Let’s take a look at how the vaccine schedule has evolved over time to see how many vaccines kids used to get. Looking at the old vaccine schedules can also help you understand how we got to our current schedule.

Although not a formal schedule, the first vaccine recommendations were published in the AAP’s Special Committee on Prophylactic Procedures Against Communicable Diseases 1938 pamphlet, Routine measures for the prophylaxis of communicable diseases.

It included vaccines against diphtheria, pertussis, rabies, tetanus, tuberculosis, typhoid fever, and smallpox.

A schedule of immunizations from a 1948 AAP Round Table Discussion on the Practical and Immunological Aspects of Pediatric Immunizations

That’s the schedule from 1948!

Surprised?

Many of you were led to believe that kids only got 2 vaccines back in the day. Instead, they got more vaccines and multiple doses of those vaccines.

Multiple doses with formaldehyde inactivated vaccines which contained aluminum. And thimerosal. And far more antigens than kids are exposed to today, even though they now get many more vaccines.

My uncle got polio around the time this vaccine schedule was released in 1951, but before the first polio vaccines were being routinely used.

By the early 1950s, the DPT vaccine became routine. Other vaccines were also available for special situations, including rabies, typhoid, parathyphoid, and the BCG vaccine.

And of course, we got the polio shot in 1955!

Kids got multiple doses of DPT, DT, polio, and smallpox vaccines in 1960.

Although few people remember, the original polio vaccines were monovalent and only included one polio strain in each shot. So you had to get multiple shots to get protected from all three strains!

The polio shot, was used until 1962, when we switched to the oral polio vaccine. Trivalent OPV wasn’t licensed until 1963 though. Before that, kids got multiple doses of monovalent OPV, types 1, 2, and 3.

The ACIP committee came up with four different dosage schedules for measles vaccines in 1964.

And for a few years, we had both inactivated and live measles vaccines…

The recommended immunization schedule by the AAP in the 1966 Red Book. The first measles vaccine was approved in 1963.

Next came the individual mumps (1967) and rubella (1969) vaccines and the combination MMR vaccine (1971).

And the end of routine vaccination with the smallpox vaccine (1972).

Eleven doses of four vaccines protected kids against seven vaccine-preventable diseases in 1983.

The Hib vaccine was added in 1985.

Twelve doses of five vaccines protected kids against eight vaccine-preventable diseases in 1989.

Next came the hepatitis B vaccine and expanded age ranges for the Hib vaccine.

Seventeen doses of five vaccines protected kids against eight vaccine-preventable diseases in 1989 (plus the later Td booster). — Nineteen doses of six vaccines protected kids against nine vaccine-preventable diseases in 1995.

What’s still missing?

Vaccines and protection against rotavirus, hepatitis A, chicken pox, flu, pneumococcal bacteria, meningococcal bacteria, and HPV. And no, they weren’t all added right after the National Childhood Vaccine Injury Act of 1986, another anti-vaccine myth!

Those vaccines were added to the schedule much later:

Varivax – a chickenpox vaccine (1995)
the polio shot – we began to switch back in 1996
VAQTA – the first hepatitis A vaccine was approved for high risk kids in 1996, but wasn’t actually added to the routine vaccine schedule until 2006

This is the immunization we used when I finished residency... — This is the immunization we used when I finished residency…

RotaShield, the first rotavirus vaccine was approved in 1998 but was quickly withdrawn in 1999 because of an increased risk of intussusception

What’s next?

Prevnar, with protection against pneumococcal bacteria (2000)
FluMist – the nasal spray flu vaccine (2004)
new flu shots recommendations for all healthy infants (2004)

Is the vaccine schedule starting to look familiar?

RotaTeq and Gardasil were added to the vaccine schedule the next year, in 2007.

Since then, Prevnar was updated to include protection against 13 strains of pneumococcal bacteria. And we got a new vaccine that covers the B strain of meningococcal disease, but otherwise there haven’t been any major changes to the vaccine schedule in a while.

Do you see 72 vaccines on the schedule?

Kids today routinely get 13 vaccines that protect them 16 vaccine-preventable diseases.

Do you see 72 doses of vaccines on the schedule?

Guess what? These folks are deliberately misleading you.

Kids don’t get 72 doses of vaccines today.

That’s an inflated number that’s used to scare parents. That it is a propaganda technique should be obvious, as the folks who use it don’t use the same anti-vaccine math to inflate the number of doses from the historical schedules.

When is Measles Season?

For a while, especially once we eliminated the endemic spread of measles, we weren’t thinking about measles seasons anymore.

In addition to the recent rise in measles cases, this slide shows the patterns of measles seasons in different parts of the world.

Unfortunately, with ongoing outbreaks and rising cases, many people are asking again – just when is measles season?

When is Measles Season?

Traditionally, the time when measles case counts are the highest occurs:

during the late winter and early spring (temperate climates, like the United States)
after the rainy season (tropical climates)
when kids are in school

So just like flu season, it’s always measles season somewhere…

And in areas of the world where measles is still highly endemic, you can expect cycles of larger measles epidemics every 1 to 4 years.

Can you guess why?

“As higher uniform population immunity is achieved the scale of epidemics, both their duration and absolute number of cases, progressively decreases. Epidemic frequency simultaneously decreases with increasing time intervals between epidemics. Another uniform feature as elimination is approached is the loss of epidemic seasonality.”
Durrheim et al on Measles – The epidemiology of elimination

I’ll give you a hint – there is nothing different about the measles virus during those years.

Eventually though, as the number of people susceptible to measles builds up, there is the opportunity for bigger outbreaks. Of course, that doesn’t happen if most people are vaccinated and protected.

When is Measles Season in the United States?

What about in the United States in the post-vaccine era?

Visiting a place with a lot of measles, especially if you aren't vaccinated and protected, increases the risk that you will bring measles home with you and start an outbreak. — Visiting a place with a lot of measles, especially if you aren’t vaccinated and protected, increases the risk that you will bring measles home with you and start an outbreak.

We don’t really have a measles season, as all of our cases are now imported from other parts of the world.

Where and when are folks traveling?
Where is measles on the rise?

That’s when we will see more measles cases here.

“Source countries included Philippines (14 cases), Ukraine (8), Israel (5), Thailand (3), Vietnam (2), Germany (2), and one importation each from Algeria, France, India, Lithuania, Russia, and the United Kingdom.”
Increase in Measles Cases — United States, January 1–April 26, 2019

In the early part of 2019, we saw a lot of cases because unvaccinated travelers were returning from Philippines, Ukraine, and Israel, countries in peak measles season.

Are Europe's measles outbreaks slowing down yet? — Are Europe’s measles outbreaks slowing down yet?

As cases in those countries hopefully slow down over the summer, unfortunately, we might see a rise in other parts of the world.

Of course, there is an easy way to end our measles seasons once and for all.

Two doses of MMR is your best protection against measles.

Get vaccinated and protected, especially before traveling out of the country.

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? 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.

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.

VAXOPEDIA

Vaccine Schedules from the 1940s to 2019

Vaccine Schedules from the 1940s to 2019

More on Vaccine Schedules from the 1940s to 2019

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