Undermining the importance of measles control measures is reckless endangerment
Can we stop trying to make measles happen?
Measles is one of the most highly contagious human diseases.
At this very moment on March 1, 2024, SIXTY ONE years after the first measles vaccine was approved, we are still dealing with entirely avoidable outbreaks of this communicable and potentially deadly illness. Did this phrase give you some deja vu? It might have, because I wrote the same opener a little over a month ago on another measles newsletter, here.
The common thread? Low vaccination rates and import of the disease by unvaccinated travelers.
Currently there are 15 states in the US that have reported 35 confirmed measles cases in this year alone, with several states having sustained outbreaks and local spread.
An outbreak in the Philadelphia metro area (DE, NJ, PA) that led to 9 cases from local spread (just concluded to be over this week by the Dept of Health).
One in the DC metro area
another in Washington state.
A new outbreak in Georgia
A case report in Missouri, another travel import.
A case report in Ohio from a traveler at the Cincinnati airport - the first case of measles in this area since 2005.
2 cases in California, one in LA and one in San Diego, both in unvaccinated people traveling back from international locations.
Another case in Maryland reported on February 1st from international travel.
And now, a sustained localized outbreak with community spread in Florida. There are 9 currently confirmed cases in Broward County, with 7 of them directly linked to Manatee Bay Elementary School. Separately, Orlando County has reported 4 measles cases this year, but state that they are independent of each other and aren’t a result of local transmission.
CDC released a national alert for physicians last month to keep an eye out for symptoms as a result of this continued spread. Most of the cases occurring in the US are a result of direct importations of unvaccinated US residents (primarily children and adolescents) following international travel. 3 of the outbreaks have more than 5 cases each. But this Florida outbreak is more concerning, because while other jurisdictions have worked quickly to identify the originating case, implement vaccination, education, and isolation protocols, that is not happening in Florida.
Florida Surgeon General Joseph Ladapo is flagrantly defying all scientific and medical guidance and enabling this to spread.
Not only did he not implement evidence-based guidance for containment and control, he sent a letter on behalf of the health department where he is “deferring to parents or guardians to make decisions about school attendance” during the outbreak.
Measles is one of the most contagious human diseases, caused by infection with the measles morbillivirus (MeV). In a non-immune population, someone infected with MeV will infect, on average, 12 to 18 people. Put another way: someone with measles can infect up to 90% of susceptible individuals they come in contact with.
MeV is transmitted primarily through airborne routes: the virus is released into respiratory droplets when someone sneezes, coughs, or breathes. The smaller droplets can remain suspended and travel in the air for several hours, which contributes to the high transmissibility of MeV. Merely entering a room up to 2 hours after an infected person was there can lead to infection.
In addition, it has a long incubation period, on average of 12 days (range 7-14 days). Initial symptoms are fever (which can be as high as 105F), cough, runny nose, and conjunctivitis. Koplik spots (whitish-blue spots inside the lips and cheeks) also appear. The measles rash appears 2-4 days after: a flat red rash that starts at the hairline, spreads down the face, neck, torso, and extremities.
This is compounded by the fact that you are contagious before the measles rash appears, up to 4 days prior (often when only early symptoms present). This means people may expose others before they know they have measles, further contributing to viral spread.
These factors dictate the specific guidance implemented and adhered to by state health departments to contain measles:
Anyone with measles rash much be in isolation for 4 days after the rash presents.
Anyone with potential exposure to measles that is not vaccinated (or considered non-immune) must be in airborne quarantine beginning 5 days after the first potential exposure and last for 21 days.
Post-exposure prophylaxis should be administered to any susceptible individuals: either the MMR vaccine within 72 hours of initial measles exposure OR therapeutic immunoglobulin (IG) within six days of exposure.
Joseph Ladapo is doing none of these things. That constitutes reckless endangerment.
The legal definition of reckless endangerment is a [criminal offense of recklessly engaging in conduct that creates a substantial risk of serious physical injury or death to another person.]
Pretty sure what he’s doing fits the bill, don't you?
In my last piece about measles I discuss why we need 95% of the population vaccinated to contain outbreaks of this virus once it is in a community. These counties in Florida are not there. In the 2021-2022 school year, only 87.4% of kindergartners in Sarasota county and 91.6% of kindergartners in Manatee county reported proof of MMR vaccination. While FL Dept of Health hasn’t released this year’s numbers, investigative reporting suggests that rate in Manatee county is now down to 89.31%.
Measles vaccines save lives. Why aren’t parents getting their kids vaccinated?
The TL;DR? Anti-vaccine disinformation and survivorship bias. People don’t remember the public health burden of measles because our vaccination campaigns in the 1970s were so effective to reduce measles here. So much so that the US was declared free of endemic measles in 2000. However, that is likely to be no longer the case in the near future if we continue down this path.
Globally, measles vaccines are estimated to have prevented 56 MILLION deaths between 2000 and 2021.
The World Health Organization (WHO) has raised alarm about the dramatic increase in measles morbidity and mortality. There were substantial outbreaks in 37 countries in 2022 (compared to 22 in 2021), and cases increased by 18%. There was a 43% increase in deaths due to measles compared to 2021, with the majority of them among children.
While the United States was declared free of endemic measles in 2000, increased anti-vaccine sentiment and dropping vaccine rates jeopardizes that status. The Pan American Health Organization alerted alliance countries to update plans to prevent the re-establishment of endemic measles.
It is heartbreaking that this is the state of affairs with a widely available vaccine with 97-99% effectiveness. Today, it takes conscious effort to avoid measles vaccination and this rejection is eroding our collective health and well-being.
Last year, the CDC reported the highest level of vaccine exemptions for kindergarteners ever recorded; nearly all were listed as ‘non-medical’. The average vaccine rates nationwide dropped to 93.1% for measles, mumps, and rubella and polio. The exemption rate increased 0.4 percentage points to 3.0%. Exemptions increased in 41 states, exceeding 5% in 10 states.
On top of that, there are even people like the midwife on Long Island who administered fake ‘vaccines’ to thousands of children so parents could falsify school vaccine records. Is it really any wonder that we are seeing spread of this disease we thought we had under control?
Measles is a very serious illness that people need to stop making light of.
Prior to 1963, measles led to serious epidemics every couple of years and caused on average 2.6 million deaths annually (when the global population was much lower; for context, it was 3 billion in 1960, compared to 8.1 billion today).
Mortality rates vary based on access to supportive care, but range from 0.1% to up to 10% in areas with lower access to care. 30% of measles cases lead to serious and potentially permanent complications, including pneumonia, blindness, hearing loss and deafness, severe diarrhea and dehydration, and encephalitis (brain infection and swelling). Encephalitis occurs in about 0.3% of measles cases, and can be potentially fatal as is.
But another complication of measles is Subacute Sclerosing Panencephalitis (SSPE), a progressive, disabling, and deadly brain disorder that occurs following primary measles. It occurs in up to 18 of every 100,000 measles cases, with the highest risk among children under 5. There is no cure or treatment for SSPE, and it is fatal within 1-3 years of diagnosis. SSPE, along with measles itself and other associated complications, is entirely preventable now.
Anti-MMR vaccine sentiment began with Andrew Wakefield and his 1998 falsified “study” in the Lancet.
In 1998, Andrew Wakefield, a discredited former British gastroenterologist, published a fraudulent case study in the Lancet, falsely linking MMR vaccines to autism. His ‘study’ included 12 pre-selected children & relied heavily on parental anecdotes (unverified stories told by parents). It also included falsified data that supported the claims Wakefield wanted to make. Wakefield had several serious financial conflicts of interest: he wanted to sell his own MMR vaccine, he was hired by a legal team to find ‘evidence’ of harm of the existing MMR vaccine, and he was trying to create and sell a fraudulent “autism” diagnosis test.
While the “study” was retracted, the harm was done. Copious data have been put forth since the Wakefield paper, and to date, there is ZERO evidence linking MMR (or any other vaccine) to autism. And that’s not for lack of trying. In 2002, Wakefield also tried to make claims related to the Varicella vaccine.
Key studies:
1999 Epidemiological Study: An epidemiological analysis of 498 children with autism or autism-like disorder for individuals prior to MMR introduction and after in North Thames region of UK. The prevalence of autism was the same between vaccinated and unvaccinated populations. Age of diagnosis did not differ, and onset of symptoms of autism were not temporally linked to receipt of MMR vaccination.
2002 Population-Level Cohort Study: This retrospective cohort study included 537,303 children representing 2,129,864 person-years of study and spanned 1991 and 1998. 82% of the children had received MMR vaccination, and autism outcomes were compared among groups. The risk of autism in the group of vaccinated children was the same as that in unvaccinated children. Similar to the study above, there was no association between the age at the time of vaccination, the time since vaccination, or the date of vaccination and the development of autism.
2019 Population-Level Cohort Study: A large-scale population-wide cohort study involving over 650,000 children. A total of 657,461 children were included, born from 1999 to 2010 who were followed up between 2000 and 2013 to an average of 8.6 years of age. In Denmark, children receive dose 1 at 15 months, and dose 2 at age 4 (prior to 2008, age 12). Of the entire cohort, about 1% of the children were diagnosed with autism at 6-7 years of age. When comparing vaccinated vs unvaccinated, there was NO link between MMR and autism. There was a genetic link to autism, though.
2014 Systematic Review: A comprehensive systematic review of 338 studies, inclusive of millions of subjects. The review revealed no increased risk of autism following the MMR vaccine.
Subsequent studies and meta-analysis have corroborated these findings that the MMR vaccine does not cause autism.
Parents, please get your kids vaccinated.
All children need two doses of the MMR (measles-mumps-rubella) vaccine, starting with dose 1 at 12 through 15 months old, and dose 2 at 4 through 6 years of age. Yes, your kids can receive the second dose earlier as long as it is at least 28 days after dose 1.
If it were me, and I had kids in this interim window, maybe aged 2 or 3? Currently, I’d probably opt to get their second dose a bit early. While the first dose is already quite effective, there are some people who don’t seroconvert after one dose. With measles rates concerningly high and spreading, I would not chance my child’s health.
There are some legitimate medical contraindications, but these are rare compared to the rates of vaccine exemptions.
The MMR and MMRV vaccines are live attenuated viral vaccines. As such, the medical contraindications apply for specific individuals who may be immunocompromised:
If you have a weakened immune system due to disease (cancer, HIV/AIDS (if unmanaged, HIV-positivity alone does not preclude vaccination), tuberculosis) or medical treatments (such as radiation, immunotherapy, steroids, or chemotherapy), or you live with people who have the same. If you have blood conditions such as bruising or bleeding disorders you may also be precluded.
There are some reasons why people may need to delay MMR (although people should be vaccinated as kids!):
If you’re pregnant or thinks you might be pregnant. You should wait to get MMR vaccine until after pregnancy has ended. You can get the MMR vaccine if you’re nursing though - and those antibodies will be passively transferred through breast milk.
If you’ve gotten a blood transfusion or received blood products, you should delay vaccination by 3 months.
If you received other vaccines in the previous 4 weeks. You can receive the MMR vaccine at the same time as others, but if your immune system is already working to develop protection against a recent vaccine not co-administered, the robustness of the MMR protection may be reduced.
If you’re moderately or severely ill, you should delay until you’re feeling better (that’s true with all vaccines).
Even if someone has severe, life-threatening allergies to specific ingredients, the MMR vaccine usually can be administered safely under clinical care of an allergist.
But these contraindications aren’t the reason for people avoiding MMR vaccinations. These exemptions are predominantly “personal belief” exemptions.
If the vaccine is so effective and I’m vaccinated, then why should I care if measles is spreading?
Aside from the fact that it is a wholly selfish attitude toward something that impacts collective society (see, I told you there would be some snark), there are people who don’t have immunity that we ALSO care about protecting.
First: kids are not protected, and they are at the greatest risk for severe outcomes. The current vaccine for measles is either the combination MMR (measles, mumps, rubella) or MMRV (measles, mumps, rubella, and varicella). It is a 2-dose regimen, with dose 1 administered at 1 year old, and the second dose between 4-6 years old. As such, kids aren’t fully protected until that age.
There is also a small proportion of people who, even after vaccination, do not develop robust immunity.
There are also people who are immunocompromised, older adults, and those with underlying medical issues who may be at high risk for severe outcomes.
Immune amnesia: measles damages immune memory
Remember where I mentioned that MeV likes to infect immune cells? Well, after they hitch a ride in the innate immune cells to those lymphoid organs, MeV then infects adaptive immune cells: the B cells and T cells (lymphocytes). These are the cells that establish memory immunity, and not just memory immunity to measles, but to any previous infections and vaccinations. When MeV infects these B and T cells and replicates within them, the virus ultimately damages and destroys the cells themselves plus the ability of the B cells to produce protective antibodies. This leads to immune amnesia: broad impairment to memory immunity as a result of the damage MeV infection causes.
When MeV eliminates these memory immune cells, this weakens your defense against previously encountered pathogens or pathogens you’ve been vaccinated against, rendering you susceptible to other infections and illness, and this can persist for years after measles.
Getting measles can effectively erase the immune memory that someone has developed against other pathogens.
Let’s use a scenario to illustrate this.
Hypothetically, say a child gets measles from an unvaccinated person when they are 3 years old. They are too young to have completed their measles vaccine regimen, but have been vaccinated for Hepatitis B, DTaP (diphtheria, tetanus, and pertussis), Rotavirus, Poliovirus, Influenza, COVID-19, Hepatitis A, Haemophilus influenzae type b (Hib), Pneumococcal bacteria, Varicella (1 dose at least), and maybe RSV.
So this child has measles and hopefully will recover from that without long-term complications, and is now ALSO at risk of losing protection for all of these other illnesses, many which can be very serious at their age.
Let’s be clear: measles is much more than just a transient infection: its capacity to increase susceptibility to other infections due to immune system damage is a long-term risk to individuals and public health, underscoring the importance of vaccination even more.
Should I get an MMR dose if I am an adult and was vaccinated as a kid?
Broadly speaking, if you got vaccinated as a kid, it is unlikely you’ll get infected even if you are exposed. Vaccination with the current 2-dose series is 97% effective. About 5% of people do not develop protection after the first dose (why the second dose was added in the 1980s), but 95% of those (meaning 97% total population) will be fully protected after a second dose.
There are simply some people who don’t develop long-term immunity after vaccination. There was a high-profile instance in 2011 of a vaccinated individual being ‘patient zero’ - Out of 88 close contacts, 4 got infected and had symptoms. Those who got infected had more than 200 contacts, and none got measles. (thankfully, vaccine coverage protected the vast majority of these people), but this is the exception, not the rule. And MMR vaccine rates have been in decline - which means these exposures will lead to continued spread, compared to this instance where transmission was halted pretty rapidly.
You do not need the MMR vaccine if you meet any of these criteria for presumptive evidence of immunity:
You have written documentation of adequate vaccination:
If you’ve gotten at least one dose of an MMR or MMRV vaccine on or after the first birthday for preschool-age children (kids too young to get the second dose) or if you’re now an adult not at high risk for exposure and transmission.
OR (preferably) you’ve gotten 2 doses of an MMR or MMRV vaccine for everyone else, especially during ongoing outbreaks.
You have laboratory confirmation of past infection or had blood tests that show you are immune to measles, mumps, and rubella.
You were born before 1957. If you were born prior to 1957, measles rates were so high that is it presumed everyone either got measles and is immune, or was exposed to measles and developed immunity without becoming symptomatic.
What if I’m not sure if I got the vaccine?
First, try to find your vaccination records. If you do not have written documentation of MMR vaccine, you should get vaccinated. The MMR vaccine is safe, and there is no harm in getting another dose if you may already be immune to measles, mumps, or rubella. Ultimately, it is not necessary to get titers done to verify, unless your insurance requires it to cover the MMR vaccine.
If you received the live attenuated measles vaccine in the 1960s, you don’t need to be revaccinated. If you received the inactivated measles vaccine or you don’t know which vaccine you received prior to 1968, you should get at least one dose of MMR. This is because the inactivated measles vaccine that was available from 1963 to 1967 is intended to protect those who may have received killed measles vaccine, which was available in 1963-1967 and was less effective.
Anti-vaccine disinformation is a top 10 global health threat.
If health agencies around the world don’t rapidly implement coordinated global efforts to increase vaccine rates, we may soon be in a position, once again, where measles outbreaks are the norm, not the rarity.
If you know someone who is hesitant or resistant to the MMR vaccine, please send them my way; I’d be happy to address legitimate concerns.
As always, thanks for joining in the fight for science!
Thank you for supporting evidence-based science communication. With outbreaks of preventable diseases, refusal of evidence-based medical interventions, roadblocks to scientific progress that improve food and crop sustainability, it’s needed now more than ever.
Yours in science,
Andrea