Tag: pockets of susceptibles

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

The Puget Sound Measles Outbreak

Breaking News – there is a new case in King County (see below)

Everyone is likely familiar with the large outbreaks that we have been seeing this year in New York (Brooklyn and Rockland County), Michigan, and the Pacific Northwest.

There have already been 79 cases of measles in Washington so far this year.
There have already been 79 cases of measles in Washington so far this year.

After all, those outbreaks make up the majority of measles cases that have occured so far this year.

The Puget Sound Measles Outbreak

Have you heard of the latest outbreak?

This one, also centered in the Pacific Northwest, began with exposures to a traveler with measles at Seattle-Tacoma International Airport on April 25.

“A Canadian resident from British Columbia who traveled to the Seattle area in late April 2019 has been diagnosed with measles. The traveler, a man in his 40s, has since recovered from his illness.

Prior to arriving in King County, he spent time in Japan and New York during the period that he was infected, two places that currently have measles outbreaks. This case has no connection to the recently-ended measles outbreak based in Clark County, Washington state.

While he was infectious with measles, he spent time in the Seattle area at several locations, including popular tourist attractions and Sea-Tac Airport. Anyone who does not have immunity to measles through vaccination or from previously having measles is at risk for infection if they were at a location of measles exposure.”

Measles case in traveler to King County

Those exposures have led to cases in:

  • King County – 6
  • Pierce County – 2
  • Snohomish County – 1

The latest case is a six-month old infant in King County, with exposures at the Seattle Children’s Hospital Emergency Dept on May 24.

“This case was a household contact of a person diagnosed with measles earlier this month, and was not exposed to measles in the community.”

A new case of measles diagnosed in a King County resident

With exposures in Bothell, Lynnwood, Mill Creek, Orting, Bonney Lake, Puyallup, Renton, Auburn, Issaquah, Woodinville, Kent, and Seattle.

And that’s what has led to the name Puget Sound outbreak. The Puget Sound is an inlet of the Pacific Ocean along the northwest coast of Washington, near Everett, Olympia, Seattle, and Tacoma.

How big will this outbreak get?

Immunization rates in the Puget Sound area are a bit better than in Clark County, where the last Pacific Northwest outbreak was centered.
Immunization rates in the Puget Sound area are a bit better than in Clark County, where the last Pacific Northwest outbreak was centered.

It’s anyone’s guess at this point, keeping in mind that all it would take is for one of these exposures to be in a “pocket of susceptibles” with low immunization rates to start a big outbreak.

And all it would take to stop the outbreaks is for folks to get vaccinated and protected, understanding that vaccines are safe and necessary.

More on the Puget Sound Measles Outbreak

Fact Checking the Truth About Vaccination Rates in California

In general, higher immunization rates should translate into lower rates of disease.

And it is true that in most states, including California, overall immunization rates are up.

So what’s happening?

Fact Checking the Truth About Vaccination Rates in California

Everyone knows what’s happening!

Clusters of unvaccinated kids and adults.

Pockets of susceptibles.

Abuse and overuse of vaccine exemptions.

And folks who continue to scare parents away from vaccinating and protecting their kids.

There are measles outbreaks in this part of northern California...
There are measles outbreaks in this part of northern California…

What’s the truth about California’s immunization rates and the reason they are still having outbreaks of measles and other vaccine-preventable diseases?

“Oh, but wait! What do you mean we have higher vaccination coverage NOW than we did back then? How can that be? I thought rates have been declining steadily for two decades putting us in a terrible position of falling wayyyy below herd immunity levels!?

I thought the reason we are now “in danger of disease outbreaks” is because of the increasing number of children being exempted from vaccines? Hold on, wait. You’re telling me there are LESS kids exempted now than there were in the year 2000 when we were free of outbreaks because of “high vaccination rates”? That can’t be right…can it?”

Melissa Floyd

You aren’t going to get it from anti-vaccine folks

73% is actually pretty good for a Waldorf school!
73% is actually pretty good for a Waldorf school!

But it’s not surprising that you get misinformation about herd immunity from folks who think vaccines don’t actually create herd immunity.

And it shouldn’t be surprising that you can’t hide in the herd when your herd is a cluster of unvaccinated kids at a Waldorf school.

Vaccines are safe, with few risks, and are obviously necessary. Vaccinate your kids and help stop the outbreaks.

More on Fact Checking the Truth About Vaccination Rates in California

Fact Checking Brian Hooker’s Statement to WA Legislators

Anti-vaccine folks brought out a lot of their big guns to a Washington State House Health Committee meeting about personal belief exemptions.

Brian Hooker makes a lot of statements about measles that mirror anti-vaccine talking points.

What was the meeting about?

A bill was introduced in the Washington Legislature that would limit non-medical vaccine exemptions by removing a philosophical or personal objection for the MMR vaccine.

Fact Checking Brian Hooker’s Statement to WA Legislators

Showing up to oppose the bill were Robert F. Kennedy Jr., Toni Bark, and Brian Hooker, none of which helped their side.

Why not?

Let’s see what Hooker said?

“There is a problem with measles in Washington State, but it’s not low vaccination rates, it’s actually high vaccination rates with a vaccine product unable to provide lifetime immunity or vigorous passive maternal protection to infants during the first year of life.”

Brian Hooker

Of course!

Unvaccinated kids are getting measles because we are vaccinating too many people. Why haven’t we noticed this before?

“When the measles vaccine was first introduced, most people over the age of 15 who had wild measles had lifetime immunity. In developed nations, like other communicable infections, measles was no longer dangerous except in rare circumstances because of inadequate nutrition, poor sanitation, and / or lack of healthcare.”

Brian Hooker

It is scary that Hooker makes statements like this, considering that he is an Associate Professor of Biology at Simpson University in Redding, California, where he specializes in chemistry and biology coursework.

When measles was killing kids in the 1950s in the United States, we had good nutrition, sanitation, and access to healthcare.

What was missing?

A measles vaccine!

“Because having the measles was a routine part of childhood, teens, adults, parents, and grandparents were immune. And because of maternal passive immunity, infants were protected.”

Brian Hooker

Yes, measles was once considered a rite of passage, but only because it had to be endured, as there was no way to avoid it. And you had to get sick and survive having measles to earn your lifetime immunity.

Tragically, not everyone did.

“But in fact, if the mothers of the children had wild measles when they were children and they are nursing, the babies may be protected. If the mothers were vaccinated, even if they are nursing, they may not be. Additionally, maternal antibodies transported across the placenta can provide vital immunity against measles for infants.”

Brian Hooker

While it is true that passive immunity from a mother who had a natural infection likely lasts longer than one who had vaccine induced immunity, it isn’t that much longer. At 6 months, few infants still have antibodies against measles, whether their mothers were vaccinated or had naturally acquired immunity. And it has nothing to do with nursing.

“As the editor of the journal Vaccine Dr. Gregory Poland of The Mayo Clinic stated in 1994, “…as measles immunization rates rise to high levels in a population, measles becomes a disease of immunized persons.”

Brian Hooker

Quoting Gregory Poland didn’t go so well for Toni Bark when she tried it at a Minnesota Senate hearing.

“But he also said that sometimes people who oppose the vaccines will pick out one sentence in the scientific study and extrapolate it to mean things that it does not mean… He said that measles is the most contagious disease that we know, and yet we found that fear and ignorance is more so.”

Senator Carla Nelson on The Anti-vaxxers Might Wish that What was Lost had not been Found

It makes you wonder why these folks are still quoting Poland.

“It was reported in the news and provided to legislators that in Clark County, WA there is a 22% exemption rate, but this is based on the voluntary Immunization Information Survey (IIS) which does not accurately reflect the vaccination status of all children enrolled in Washington schools. When compared to the more accurate CDC statistics for the state of Washington for MMR coverage among 19 to 35 month olds, it is 95.3% +/- 2.6%. The IIS erroneously reports this number at 81.8% and cannot be relied upon.”

Brian Hooker

These folks realize that the outbreaks aren’t occurring in the entire state of Washington, right? They are in very specific schools and communities where we do find very high levels of non-medical vaccine exemptions. These are the clusters of intentionally unvaccinated children experts have been warning about, the pockets of susceptibles.

“As I have already remarked, vaccination does not guarantee immunization and infectious diseases routinely break out in highly vaccinated communities. An example of this is pertussis outbreaks, which occur due to problems with the acellular pertussis portion of the DTaP and Tdap vaccine, creating asymptomatic carriers.”

Brian Hooker

Vaccination does not guarantee immunization?

I guess that is a way to say that vaccines aren’t 100% effective, but that is hardly an effective argument against getting vaccinated. Being intentionally unvaccinated often guarantees that you will get sick in an outbreak. Remember, even in outbreaks of pertussis and mumps, when waning immunity can be a concern, that attack rate is much higher in those who are unvaccinated.

“Over the past ten years in the U.S., there has been one reported death from the measles, and it is unclear based on the medical history of the patient whether and how measles played a role in their death. During the same time period (based on Vaccine Adverse Event Reporting System (VAERS) reports), there have been 105 reported deaths associated with the MMR or MMRV vaccinations.”

Brian Hooker

There have actually been seven measles deaths in the United States in the past 10 years, although only one was verified by the CDC.

Still, if Hooker is going to push unverified vaccine deaths in VAERS, why wouldn’t he also look at the reports of deaths from measles in the CDC Wonder database? And the 9 additional SSPE deaths?

And to doubt that measles actually killed a woman who got caught up in the 2015 measles outbreaks in Washington? What’s wrong with the modern anti-vaccine movement?!?

“You must not only protect those who are susceptible to poor infection outcome, but protect those who are susceptible to poor vaccination outcome, and to consider the unintended consequences of a fully vaccinated population that does not have lifetime immunity.”

Brian Hooker

It is becoming ever more clear that we must protect ourselves from these folks who push anti-vaccine propaganda and scare parents away from vaccinating and protecting their kids.

What does Hooker intend to do to “protect those who are susceptible to poor infection outcome?” How does he propose that everyone get lifetime immunity if they don’t get vaccinated?

“I also warn them not to share their fears with their neighbors, because if too many people avoid the MMR, we’ll likely see the diseases increase significantly.”

Dr. Bob Sears in The Vaccine Book

Anti-vaccine folks have already done such a good job scaring parents that too many of them are abusing vaccine exemptions. That’s why we are having more outbreaks, especially with the global rise in measles, and why states are having to tighten their vaccine laws.

More on Fact Checking Brian Hooker’s Statement to WA Legislators