Why Is Measles a First World Problem?

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:

1. 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.

2. 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.

3. 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.

The Sick Child by Gabriel Metsu.

---

[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.

Comments

[Percysowner]

I had measles and rubella around 1960-63. My doctor had to come to the house, although that was still something doctors did at that time. I was lucky and it wasn't bad. But one of my schoolmates was horribly ill with "regular" measles. He was out of school for 2 weeks and had to be kept in a totally dark room so that his eyesight would not be affected. I can not believe the damage the anti-vaxers have done. These diseases are really dangerous. On another note, my best friends mother ended up suffering from shingles because she had chickenpox as a child and she got it before the shingles vaccine. I turn 60 this month and the first thing I'm doing is getting vaccinated for it. Sadly, my daughter got chickenpox a year or two before the vaccine for it had been approved, so she will have to get the shingles vaccine as well. I can't imagine leaving my child unvaccinated, except in the rare case where there are actual reasons (allergies, compromised immune system) that make it inadvisable.

[liberal japonicus]

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.

I believe that what happened is a bit more complicated. There were a number of deaths due to meningitis among children who were administered the MMR and when the vaccine was first introduced in 1989, I read that one out of every 900 children was experiencing problems. A different variety was tried in 1991, but it came with similar problems. The problems seem to have been with the Urabe mumps strain. This suggests to me that there were licensing issues, and because Japan often protects its domestic health products industry, that may have been a major cause for Japan's particular path.

The other might be a general mistrust of the Health Ministry. In regards to the vaccine, the ministry, which surveyed each prefecture for these kinds of problems, found that in some prefectures, side effects were 1 out of 600 or worse, but they reported the results for the lowest prefecture, saying it was 1 out of 28,000, and dismissed the problems if meningitis. Unfortunately for the government, this was right at the advent of the new information laws, and lawyers representing the families of children who had died won several court cases against the government. (link)

This was roughly concurrent with another Health Ministry scandal, where they imported AIDS tainted blood from overseas which was used with hemophiliacs, so there was (and I think continues to be) a suspicion of Health Ministry directives.

Of course, this is nothing particularly new, the Minamata case of industrial mercury poisoning which was first noted in the late 50's, is still having court cases litigated, so for the government to be the initiator of an action, it runs into a culture of mistrust. I think this overrides any sort of historical memory of epidemics from overseas.

[Brett Bellmore]

I had a similar experience with strep as a child. Remarkable how fast that ice water bath give you the clarity to realize you're freezing, isn't it? But certainly preferable to brain damage from a high fever.

[Doctor Science]

LJ, thank you for your insights.

In the US, a major factor in health scandals like the ones in Japan is regulatory capture, where agencies such as the FDA are doing the bidding of the pharma industry. What you're describing in Japan sounds like regulatory capture with no countervailing forces from other companies, lawyers, scientists, or even regulators trying to do their actual job.

Look at Vioxx, for instance. It was a really messy business, but the messiness is maybe part of why the system kind-of worked.

[wj]

Part of the problem is, I suspect, that most of the country is too young to remember those childhood diseases. So you have a large part of the voting-age population which simply doesn't have the experience that would tell them, first hand, why eradication is a very good idea.

That means, unfortunately, that what it will take to "kick measles to the curb" is a round or two of epidemics. We will have to see lots and lots of children getting very sick, and probably a fair number dying, before the urge to "do something" overcomes the reluctance to "waste tax money" on a threat that just doesn't seem real.

[Brett Bellmore]

I suspect that what will "kick measles to the curb" is not a traditional eradication program, though it would be good to pursue one. As our understanding of the immune system deepens, we're starting to grasp why some people don't get diseases like measles in the first place. I think soon we'll be able to engineer improvements to the human immune system. Starting with bringing the average person up to the level of the exceptional, and later improvements nobody enjoys today.

[Hartmut]

But the microbes will always find new ways too, that's nature.

[Roger Moore]

@Brett Bellmore:

Count me as skeptical of immune reprogramming of the kind you're describing. I'm not an immunologist, but I do work with immunologists in a Department of Immunology, and it makes me very suspicious of suggestions that we can easily eliminate disease by figuring out why some people are immune in the first place. For things where we know how to produce vaccines, that's the easiest and most sensible approach to giving people immunity. We may have to figure out how to give people innate immunity to HIV, but that's a very special case.

And remember that the main limit to measles eradication is social, not technological. We could eradicate measles in relatively short order if we could convince everyone to get vaccinated. If people come up with all kinds of crazy scare stories about vaccines, which have been used for decades with an excellent safety record, why should we expect them to adopt a new, more invasive approach with no substantial safety record?

[jake the snake]

My experience was with Pertussis, though I was too young to remember. My mother said that I could not keep anything down and coughed until I was too exhausted to cough any more. This was in about 1953 when I was around 18 months old. She always claimed that it changed my personality from happy and outgoing to quiet and introverted.
I can't speak for before, but the after description is accurate.