In 2017, the UK achieved World Health Organization (WHO) measles-elimination status based on the number of confirmed cases in 2014––2016. However, a dramatic rise in the number of outbreaks in 2018 (specifically, 991 confirmed cases in England compared with 284 cases in 2017) has led to that status being withdrawn.
The increase in measles prevalence is not a problem solely restricted to the UK. WHO suggests that there are major measles outbreaks currently occurring in Angola, Cameroon, Chad, Kazakhstan, Nigeria, Philippines, South Sudan and Thailand. In the WHO European region, there were approximately 90,000 cases reported in the first six months of 2019 – a figure that surpasses the number of cases reported for the entirety of 2018 (86,462).
What is measles?
Measles is a highly contagious negative strand RNA virusthat is transmitted via the respiratory system. It is characterized by a fever and skin rash, typically accompanied by a cough, coryza and conjunctivitis. Whilst the infection typically clears within 7–10 days, measles can lead to more serious complications, such as pneumonia, acute disseminated encephalomyelitis, measles inclusion body encephalitis or subacute sclerosing panencephalitis. Measles infection also results in a transient immune suppression that can last over two years post infection, increasing susceptibility to other infections and illnesses.1
The rise of the anti-vaxxers?
Measles is almost completely preventable with two doses of the MMR vaccine, a combined vaccine that is administered subcutaneously. The first dose is given when a child is around 13 months old, and a second dose is given at 3 years and 4 months.
Recent WHO and UNICEF coverage data suggests that 86% of children globally have received their first dose of the MMR vaccine and 69% have received the second. Therefore, over 20 million children in 2018 did not receive a measles vaccine through routine vaccination programs. Despite global health authorities placing emphasis on the importance of vaccinating children against measles, in recent years an anti-vaccination movement has risen in which parents are consciously choosing to not vaccinate their children. Subsequently, the WHO has placed vaccination hesitancy as one of the top ten threats to global health in 2019. Whilst vaccine hesitancy isn't the only reason for the increasing number of measles cases, it is one of the more complex contributing issues. A global expert group, "Measuring Behavioural and Social Drivers of Vaccination" (BeSD) was established by the WHO in 2018. The group aims to support the assessment of factors that affect vaccine uptake, and to develop a set of tools to support programs and partners to quantify and address them. Several issues identified thus far include complacency, inconvenience in accessing vaccines and a lack of confidence as key issues underpinning hesitancy.
Finding the right approach – and the resources – to tackle the problem
In the United Kingdom, prime minister Boris Johnson has insisted that the NHS will meet the target of 95% of children receiving both doses of the MMR vaccine. “After a period of progress where we were once able to declare Britain measles-free, we’ve now seen hundreds of cases of measles in the UK this year. One case of this horrible disease is too many, and I am determined to step up our efforts to tackle its spread," he said.
Johnson has called upon social media platforms to help him in this cause. He intends to create a discussion with social media companies to address how only accurate information regarding vaccinations is disseminated to the public. Currently, anti-vaxx "propaganda" is rife online and can provide inaccurate information regarding vaccinations that confuses parents.
Some experts are concerned however that the government's intentions will be limited by a lack of resources due to the "stretched" NHS.
Helen Bedford, Professor of Child Public Health, Institute of Child Health, UCL, says: “It is very good that the government is taking the issue of protecting our children from infectious diseases so seriously. The strategies they suggest echo those of Public Health England’s earlier this year."
She continues: "What is needed to show real commitment though, are resources. With General Practices closing and the numbers of health visitors fallen by a quarter in four years, this is a system under pressure. We need to put resources into increasing numbers of practice nurses, the skilled workforce who day in and day out, vaccinate children and adults to protect them against serious diseases.”
Her concerns are echoed by Dr Doug Brown, Chief Executive, British Society for Immunology, who says: “Improving vaccine uptake is a complex issue and it requires many stakeholders, including the Government, NHS, local authorities and local communities, to work together to prioritize immunization services and learn lessons from regions that are performing well."
Johnson's announcement for the UK's strategy might be deemed somewhat "tame" when compared to recent tactics adopted by other countries.
In June of this year, New York Governor Andrew Cuomo signed a legislation (S.2994A/A.2371) that removed nonmedical exemptions from school vaccination requirements. Nonmedical exemptions (such as religious beliefs) have led to "unacceptably" low rates of vaccination in New York, Cuomo the official statement declares.
New York is currently facing its worst outbreak of measles in 25 years, and the Governor believes that that the new law will help protect the public amid the outbreak: "The science is crystal clear: Vaccines are safe, effective and the best way to keep our children safe. This administration has taken aggressive action to contain the measles outbreak, but given its scale, additional steps are needed to end this public health crisis." He adds, "While I understand and respect freedom of religion, our first job is to protect the public health and by signing this measure into law, we will help prevent further transmissions and stop this outbreak right in its tracks."
The legislation means that New York joins other states that do not accept nonmedical exemptions to vaccination, including California, Mississippi, West Virginia and Maine.
Meanwhile, in 2017, Italy made six vaccines mandatory after a large outbreak of measles. A recently published study found that in 2016, 87% of 2-year-olds were vaccinated against measles. By mid-2018 that figure had risen to 94% among 30-month-old children.2
The dilemma of unvaccinated children in the doctor's office
It seems that healthcare providers may also face a challenge in the form of how they are able to treat unvaccinated children in the community. Today, the C.S. Mott Children’s Hospital National Poll on Children’s Health released a report detailing the findings of their 2019 national survey, in which they asked a national sample of parents (N=2,032) of children 0–18 years old about how primary care offices should manage children whose parents refuse all vaccines. The study findings show that four in 10 parents are very or somewhat likely to move their child to a different provider if there are children in the practice whose parents refuse all vaccines. Twenty seven percent said that they believed unvaccinated children should be required to wear a mask in the doctor's office waiting room, and 17% suggest that unvaccinated children should be banned from the waiting room completely.
The findings bring to light the dilemma of whether parents should be notified if there are children in the practice whose parents have refused all vaccines. As 43% of parents in the poll believed they should be informed, further pressure is placed on healthcare providers. The report emphasizes: "Primary care providers need to think carefully about whether to institute policies to prevent their patients from being exposed to vaccine-preventable diseases, and then communicate those policies to all patients in their practice."
1. Laksono et al. 2019. Measles Virus Host Invasion and Pathogenesis. Viruses. DOI: 10.3390/v8080210.
2. D'Ancona et al. 2019. The law on compulsory vaccination in Italy: an update 2 years after the introduction. Eurosurveillance. https://doi.org/10.2807/1560-7917.ES.2019.24.26.1900371.