KISS 2/27/14 Good and bad measles news

1. PSA: If you work in a cancer center, get your MMRs

A research student at the Hillman Cancer Center infected with measles has exposed 300 co-workers and cancer patients to this highly contagious disease. 15 unvaccinated colleagues have been asked to stay at home until next week, over 100 non immune patients were seen and some have had to be treated with anti-measles immunoglobulins to prevent infection. This is a total nightmare scenario, easily prevented by getting your MMRs. So if you are about to start work in a cancer research center (or hospital, or nursery, or school), or you are planning to travel abroad, check that you have had 2x MMRs. Do not be that index case!

2. Carribean has not seen measles transmission since 2002

Not that I would encourage anyone to travel unvaccinated, but you would be unlikely to bring back measles from the Carribean, as PAHO reports today. Before the establishment of PAHO/WHO’s Expanded Immunization Program in 1977, more than 250,000 measles cases and 12,000 deaths were recorded yearly in the Americas, so this is an amazing, life saving success of measles containing vaccines/MMR.

Dutch measles outbreak: 141 more cases this week, no death reported (whew)

The new measles numbers and map have been released, the past week saw 141 new cases of measles for a total of 921. Luckily no death has been reported, and I hope it stays that way.

Have a look at the map - the new cases are red, the old ones grey. See how the majority of the new cases stays along the Bible Belt and only the odd case escapes herd immunity and pops up in areas of >95% MMR coverage. I hope the Dutch are going to release an animated map at some point, because it just so beautifully illustrates the principles of epidemiology.

Meanwhile, measles break out in the Dutch Bible Belt...

The Netherlands do have a "Bible belt" - an area which has a high density of fundamentalist protestants, characterised by their vaccine refusal (and a generally conservative attitude amongst the very liberal Dutch). This has, over the years, given rise to serious outbreaks of vaccine preventable diseases, extending far beyond the belt region. For example, in 1978, a polio outbreak in the Netherlands, totalling over a 100 cases, of which 80 (all unvaccinated) were paralytic and one was fatal, spread to Canada and the United States leading to 14 cases of paralytic polio in unvaccinated Amish, and a further 2 non-paralytic cases in unvaccinated non Mennonite in the area. Apart from the molecular analysis of the virus, showing that the cases were related, the infection chain was also clear:

During the 1978 outbreak, members of the affected religious group traveled from the Netherlands to Canada, where cases subsequently appeared. An Amish family from an Ontario town 15 miles from the affected area moved in late summer 1978 to the Pennsylvania town where the first U.S. Amish case subsequently occurred, in January 1979.

Another polio outbreak struck the area in 1992/3, most of the 71 cases amongst the unvaccinated Bible belt inhabitants. This outbreak also spread to Canada.

In 1999/2000, a measles epidemic struck the Bible belt and neighbouring regions, totalling just under 3300 cases, of which 94% were entirely unvaccinated, and only one patient had had both MMRs. 16% had complications, over 150 were hospitalised, and 3 patients died. Importantly No association was observed between preexisting illness and either reason for admission (P = 0.5) or residual symptoms at discharge (P = 0.5) contradicting the notion that measles are a generally "harmless" disease in "healthy" children.

More recently, in 2004/5, rubella (the "r" in the MMR) swept through in the Bible belt, also spreading to Canada. The consequences were devastating:

In The Netherlands and Canada, 387 and 309 rubella cases were reported, respectively. Of these, 97% were in unvaccinated individuals of orthodox protestant denomination. Reported consequences of rubella in pregnancy were 2 fetal deaths and 14 infants with congenital infection. Of the latter, 11 had clinical defects including deafness in all but eye defects in none. 

The reason should be crystal clear - low vaccination uptake. The Dutch equivalent of the CDC, the RIVM publishes the numbers in handy maps - see the MMR vaccination coverage in the 1998 cohort (as school children, the baby chart was not available) vs measles cases:

The darker, the bad

Now, 13 years after the last big outbreak (enough time for the next generation of unvaccinated Bible belters), the next outbreak has started, with one protestant primary school boasting an impressive 1 in 5 pupils infected:

the "belt" even more visible in infant vaccination gaps

This is an impressive illustration how vaccine refusal (in religious and quasi-religious groupings) leads to large national and international disease outbreaks, causing significant illness, disability and death. These communities effective provide CPR to diseases that should have long been eradicated by providing a "renewable" population of susceptible individuals. Since it may not be possible to change the attitude of certain groups, it is even more important to uphold vaccination coverage around them, to reduce the potential for spread as much as possible.