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.
