Tag: measles eradication

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

What’s Your Chance of Getting Measles Right Now?

It shouldn’t be a surprise that a lot of folks are thinking about their risk of getting measles right now.

But with record levels of measles cases this year, some of us are thinking about our level of risk much differently than others.

rIf you are unvaccinated and exposed to someone with measles, you risk is actually 1,000,000 times higher…

While most of us simply want to make sure we are vaccinated and protected, anti-vaccine folks are taking every opportunity to downplay their risks.

What’s Your Chance of Getting Measles Right Now?

So what’s your chance of getting measles?

“Measles is one of the world’s most contagious diseases. It is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretions. The virus remains active and contagious in the air or on infected surfaces for up to 2 hours. It can be transmitted by an infected person from 4 days prior to the onset of the rash to 4 days after the rash erupts.”

WHO on Measles

That’s actually not that simple to figure out, but depends on:

Those who have had two doses, with no plans to travel, and who live in an area with no reported cases, are at extremely low risk to get measles – the risk won’t be zero until measles is eradicated.

In this kind of low risk situation, kids don’t need early doses of MMR vaccines and most adults can probably get away with just having one dose of MMR.

“Measles is highly contagious and spreads through the air when an infected person coughs or sneezes. It is so contagious that if one person has it, 9 out of 10 people of all ages around him or her will also become infected if they are not protected.”

CDC on Measles is Highly Contagious

On the other hand, if you are unvaccinated and were at the AMC Theater on Lemon Street in Fullerton, between 11 p.m. and 4 a.m. on April 25, then your chance of getting measles is about 90%!

Wait! That’s a little more than the 0.000092% chance that anti-vaccine folks are throwing around…

The odds of being hit by lightning are low because we practice storm safety and don’t run around outside when we see lightning!

To think of it another way, if you knew that your chances of getting hit by lightning were a little over 1 in a million, would that make you think it is okay to go outside and play golf during a severe thunderstorm?

Would you think the risk is so low that you could let your kids play outside if you heard thunder and saw lightning flashes nearby, or would you all rush inside?

That’s right! The risk of getting hit by lightning is low because most of us don’t take chances when we hear thunder or see lightning.

It’s the same with measles and other vaccine-preventable diseases.

The overall risk is low because most people are vaccinated and protected!

If you aren’t vaccinated and protected, as we see more and more cases, your risk of getting sick, and getting others sick, is going to continue to get higher and will always be much higher than someone who is fully vaccinated, no matter how much you want to believe in shedding, mild measles, or whatever myths help you justify keeping your kids unvaccinated and unprotected during an outbreak.

Remember, you can’t hide in the herd if you are scaring away too much the herd

Vaccines are safe, with few risks, and are obviously necessary.

You can avoid getting measles.
You can greatly reduce your family’s risk of getting measles.

Make sure your family is protected so they don’t get caught up in a measles outbreak

More on Your Chance of Getting Measles


Why Do We Include SSPE When Counting Measles Deaths?

Anti-vaccine folks often like to push the idea that parents shouldn’t worry about measles and that it is just a rash with a little fever.

They leave out the part that it is a week of having a high fever, irritability, and other symptoms too.

In addition to downplaying the symptoms of measles, they never talk about the possible complications, such as encephalitis, seizures, and death.

Why Do We Include SSPE When Counting Measles Deaths?

They certainly never talk about SSPE or subacute sclerosing panencephalitis.

“Subacute sclerosing panencephalitis (SSPE) is a progressive neurological disorder of children and young adults that affects the central nervous system (CNS). It is a slow, but persistent, viral infection caused by defective measles virus.”

Subacute Sclerosing Panencephalitis Information Page

SSPE is a late complication of having a natural measles infection.

That’s why it should be included when counting measles deaths.

“Available epidemiological data, in line with virus genotyping data, do not suggest that measles vaccine virus can cause SSPE. Furthermore, epidemiological data do not suggest that the administration of measles vaccine can accelerate the course of SSPE or trigger SSPE in an individual who would have developed the disease at a later time without immunization. Neither can the vaccine lead to the development of SSPE where it would not otherwise have occurred in a person who has already a benign persistent wild measles infection at the time of vaccination.”

Subacute sclerosing panencephalitis and measles vaccination

It is not a complication of having a measles containing vaccine. If it were, then why didn’t we see more cases of SSPE as more and more people got vaccinated, instead of a drop in SSPE cases and deaths, corresponding to a drop in measles cases?

But SSPE isn’t gone yet, just like measles hasn’t yet been eradicated.

32 of these SSPE deaths have been since 2000. Source is the CDC Wonder database.
32 of these SSPE deaths have been since 2000. Source is the CDC Wonder database.

Since 2000, when the endemic spread of measles was eliminated in the United States, there have been at least 37 SSPE deaths.

“Investigators learned that, in 2012, at age 11 years, the boy, who was previously healthy and developmentally normal, had been admitted to a tertiary care children’s hospital in Oregon with severe, progressive encephalopathy. Before the onset of his neurologic illness, the patient had been a straight-A, fifth-grade student who played soccer and basketball. The symptoms began approximately 4 months before the hospital admission, when the patient began to struggle with homework, drop utensils, and doze off during meals, eventually progressing to falling asleep while walking.”

Notes from the Field: Subacute Sclerosing Panencephalitis Death — Oregon, 2015

I say at least, because the CDC Wonder database doesn’t list the 2015 SSPE death of a boy in Oregon.

Anti-vaccine folks like to ignore the fact that yes, people have died of measles recently. And measles puts you at risk for SSPE, which is always fatal.
Anti-vaccine folks like to ignore the fact that yes, people have died of measles recently. And measles puts you at risk for SSPE, which is always fatal.

We are fortunate that no one has died since 2015, but as we get more and more measles cases, tragically, in addition of the risk of someone dying of measles directly, it increases the risk that someone will eventually develop SSPE.

“Decreasing rates of vaccination in the United States, particularly among preschool-aged children (children <5 years of age) living in inner-city areas, resulted in a resurgence in the number of cases of measles reported during 1989–1991; during this period, 55,622 cases of measles and 123 measles-associated deaths were reported.”

Bellini et al on Subacute Sclerosing Panencephalitis: More Cases of This Fatal Disease Are Prevented by Measles Immunization than Was Previously Recognized

Remember, there were at least 12 extra SSPE deaths following the large measles outbreaks of the late 1980s.

Will we see any after the rise in the cases the last few years?

Vaccines are safe, with few risks, and obviously necessary.

Don’t risk a complication of measles. Don’t risk getting SSPE.

More on SSPE Deaths

Why Haven’t We Eradicated Measles Already?

The first measles vaccine was developed in 1963.

So why do we still have measles?

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.

What about measles?

Anti-vaccine folks do not understand herd immunity.

While there was never a goal to eradicate measles by 1967, we have missed several deadlines to get measles under better control.

What was the first deadline?

“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.

There is still some work to be done though, especially with the uptick in cases and deaths in the last few years.

“Eradication of both measles and rubella is considered to be feasible, beneficial, and more cost-effective than high-level control.”

Orenstein et al on Measles and Rubella Global Strategic Plan 2012–2020 midterm review report: Background and summary

Work that we can still do if everyone makes the commitment to implement their elimination plans.

And folks vaccinate and protect their kids!

What’s the alternative?

To go back to when even more kids got sick and died with measles?

More on Eradicating Measles