by Doctor Science
In my previous post, I said that I'd been surprised to find that
vaccine-controllable diseases are one of the few areas where the US health system does a better job than other "First World" countries -- because we have stricter and more intrusive government regulations.
I already knew that measles had become very rare in the US, but there was a bad outbreak in Wales (in the UK) this spring, which was pretty much a direct consequence of
Andrew Wakefield's fraudulent work which claimed that the
MMR vaccine causes autism.
I guessed that the non-Anglophone First World countries would have been less infected with this deadly meme, and so would have very low rates of measles, mumps, and rubella (German measles). I was surprised and appalled to learn I was wrong.
For instance, 2011 was the worst year in decades for measles in the US, with 222 cases. That same year, France -- the land of Louis Pasteur! -- had 15,000 cases of measles. In 2008, Japan had 11,000 cases of measles. In 2011, in the entire United States there were only 4 cases of rubella. In the first half of 2013, Japan has already had 8500 cases of rubella, and there have been more than 26,000 cases in Poland. The CDC has issued travel alerts for Japan and Poland, recommending that all US travelers make sure their MMR vaccine is up to date, and urging unvaccinated pregnant women to avoid those countries. This is the sort of warning I expect them to make about travelling to places like Haiti or the Democratic Republic of the Congo, but Japan?!?!? What the hell is going on?!?
I've made some charts, comparing measles incidence over the last few years in the G8 countries, all of which are large and wealthy. The Data are visible on Google Drive.
Measles cases per 100,000 population, normal scale.
Measles cases per 100,000 population, logarithmic scale. This makes it easier to see that the US' measles rate is not just lower than France's and Japan's, it's usually about an order of magnitude lower than any of its fellow G8 nations.
With further research, I found that the low US measles rate isn't just us. Since 2002, there has been no "native" measles in the whole Western Hemisphere, it's no longer "going around".[1] The measles cases the Americas get are all imports, which then spread a little among the few unvaccinated people.
This is a pretty damn epochal change. Here's a graph I used in the last post, showing the number of measles cases/year since before the MMR vaccine came out.
As you see, I (age 9) and my brother (age 7) were part of the very last major measles epidemic in the US, in the winter of 1965-66.
And I have to tell you younger folks, don't believe people who say measles is "just a childhood disease, like a cold or the flu". I have *never* been sicker in my life: I was so sick, an American doctor made a house call! I still remember the indescribably vile medicines I had to take, three kinds in different colors: red, bluefish, and horror-movie yellow, and the fact that I threw up everything, for days, including Christmas dinner. I also remember my fever, so high that I was hallucinating and crying with fear, only to "wake up" in the bathtub, where my parents had put me to bring the fever down.
Right now in the US, about 20-25% of people who get measles spend some time in the hospital. This wasn't what happened back before the vaccine, but it wasn't because we didn't get as sick: hospitals can do more, and the standards about when you go there have changed. If one of my children had been as sick with anything, ever, as I was with measles, it's fairly likely she'd have been hospitalized, for dehydration if nothing else. Our standards for "normal childhood illness" have changed, IMO for the better.
From my youthful perspective, the worst thing of all about measles was that I got sick the day before the Christmas party on the last school day of 1965, was horribly sick for 2 weeks, straight through Christmas vacation, and got well just in time to go back to school after the break. Whereas my "lucky" brother only became ill just as school was starting up again. But he was a good deal sicker than me when the mumps came around that spring.
Anyway, I cannot figure out why the other rich countries tolerate keeping these diseases around, when so much better than the US in general at promoting their general health. Three things seem to be going on:
- Japan is the oddest case, because it's an island nation. That *should* give the Japanese people a long historical memory of horrible epidemics coming from overseas, and make it easier to have a "get disease out of Japan and keep it out!" policy.
Instead, MMR vaccination in Japan has gone in its own, highly inefficient direction. Japan was using a distinctive MMR vaccine in the early 90s, and there were problems with side-effects, even deaths. So instead of switching to the MMR vaccine everyone else was using, they stopped using MMR at all in 1994. They have separate measles, mumps, and rubella vaccines, and they're given just before elementary school starts, instead of to toddlers. This means that the most dangerously susceptible people, very young children, aren't being vaccinated.
As the US CDC says, this culture-wide laxity has made Japan a major exporter of measles (and mumps and rubella) for several decades.
- In Europe and the Americas, there are some communities that resist vaccination, for political and/or religious reasons: Roma (aka gypsies aka travellers), haredi (aka ulta-orthodox aka fundamentalist) Jews, some fundamentalist-evangelical Christian groups, anthropsophists [pdf], etc.
Schools associated with such groups are like petri dishes: all it takes is one germ getting in from the outside, and BOOM everyone in the community is exposed. Even as I write, there's a measles outbreak in Brooklyn in the haredi Jewish community.
The leaders of such groups are often deeply suspicious of governmental intervention of any kind -- a suspicion which is not without basis (in both directions), and so easily slides into paranoia. Sensitive, gentle persuasion can help such leaders and their communities change their minds, but I think it's unrealistic not to expect that there will always be some vaccination-refusing communities.
I have no idea if anti-vaccination religious or ethnics groups are an issue in Japan.
- And then there's a low-level doubt about the benefits of vaccination throughout society, which scum like Wakefield and Jenny McCarthy exploit. Their efforts ensure that there are enough unvaccinated people in the general population that when a virus gets out of a "petri-dish population" it can spread widely.
This theory (WIM) is based on a CDC study of the 2008-2011 outbreak in France.
several measles clusters were identified among students at private schools operated by a traditionalist religious group; secondary household clusters also occurred. Ministry of Health (MOH) representatives contacted the group’s leaders, but these discussions were unsuccessful in mitigating parents’ reluctance to have their children vaccinated.
There were a couple of years where most cases were inside this "traditionalist religious group" (I don't know of what religion), then it gradually spread to the whole country. The regions of France where most of the cases ended up occurring were those where the general population was less-vaccinated, not necessarily those where the first outbreaks occurred.
I don't know what it's going to take to actually kick measles to the curb with smallpox. Polio
is well on track to get there, but nothing similar is in prospect for measles. The barriers are cultural, not medical, and are present in even the wealthiest and best-educated nations.
[1] I assume the US paid most of the money to eradicate measles and rubella in this hemisphere, and it was definitely money well spent. It *should* have come out of the "national security" budget, because there's no doubt that it makes the people of the US more secure. I don't think it would be possible to get the US measles rate so low if the disease were still present in Latin America, given that LA is basically the capital of Central America and Miami is the capital of the Caribbean.
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