Results tagged “measles” from Pathophilia

Lack of funds may stall the Measles Initiative, a multi-organization program designed to reduce the worldwide mortality of measles. Despite the fact that all regions, except for Southeast Asia, have achieved the United Nations goal of reducing measles mortality by 90% from 2000 to 2010 (and have, thereby, prevented 12.7 million measles deaths), the reduction in measles mortality has leveled off since 2007, and the Initiative is facing a funding gap of $59 million, reports the World Health Organization. (WHO's complementary report on the progress toward reducing measles-related deaths can be found in the latest issue of the MMWR.)

Lack of financial resources could suspend the Initiative's pivotal vaccination efforts next year in densely populated regions like China, Indonesia, Pakistan, Bangladesh, Vietnam, Nigeria, and Ethiopia. And because measles is highly contagious, the disease can flourish rapidly if immunity is lacking, report WHO officials.

Although measles-related deaths fell 78% globally, from 733,000 in 2000 to 164,000 in 2008, 77% of last year's deaths (126,000) occurred in Southeast Asia. Experts fear that there could be a significant uptick in measles-related deaths, to an estimated 1.7 million between 2010 and 2013, if vaccination efforts do not continue.

Estimated No. Measles Deaths, 2000-2008, and Projected Deaths, 2009-2013

^§ 95% uncertainty intervals.

Measles is unlikely to be eradicated in Europe anytime soon, according to the Euvac.net group, a surveillance network for vaccine-preventable diseases. The group's conclusion is based on the relatively high incidence of measles and the prevalence of unvaccinated or incompletely vaccinated children throughout the continent. The group's study of the persistence of measles in Europe, despite the fact that the measles vaccine became a part of routine vaccination more than 20 years ago, was published in the latest issue of The Lancet.

Recent 2-year surveillance data (2006-2007) from 32 European countries revealed a total of 12,132 measles cases; 85% occurred in 5 countries: Romania, Germany, the United Kingdom, Switzerland, and Italy. Most of those affected were either unvaccinated or incompletely vaccinated children; however, nearly 20% were adults. Measles caused the deaths of 7 children.

Age of Deceased	Country	Cause of Death	Vaccination Status
9 months	Romania	Pneumonia	Unvaccinated (below recommended age)
20 months	Romania	Pneumonia	1 vaccine dose
23 months	Romania	Pneumonia	Unvaccinated
13 years	UK	Pneumonia	Unvaccinated (immunosuppressed)
2 years	Germany	Acute encephalitis	Not reported
"Infant"	Germany	Acute encephalitis	Not reported
10 years	Italy	Pneumonia	Not reported (immunosuppressed)

In 2006, 10 cases of acute measles encephalitis* (including the 2 deaths) were reported. Six of those affected had not been vaccinated; one had received a single vaccine dose; and the vaccination status was not known for the remainder. In 2007, 7 individuals, none of whom had been vaccinated, acquired acute measles encephalitis.

On the basis of these data, the group expresses "serious doubts" that measles will be eliminated from Europe by 2010, the current goal of the World Health Organisation. According to WHO, the elimination of measles requires the achievement and maintenance of a minimum 95% vaccination coverage with 2 doses of the measles vaccine. In European countries where there were no measles cases during 2006 and 2007 (Finland, Iceland, Slovenia, Slovakia, and Hungary), vaccination coverage (2 measles vaccine doses) has been historically and consistently high.

* As opposed to subacute sclerosing panencephalitis (SSPE), a rare, fatal complication of measles, which can develop years after the incident infection.

Photo of child with measles rash from the CDC.

 ...before looking forward.

Pathophilia's Top 10 Medical Stories of 2008: A Recap

10. Gunvalson v. PTC Therapeutics

9. California v. Roozrokh and Cardiac-Death Organ Donation

8. Hand, Foot, and Mouth Disease in China

7. Continuing Backlash Against Pharma

6. Media Obsession With Delayed Results of ENHANCE Trial

5. Investigational Drugs for Alzheimer's Disease Disappoint

4. Milder Rotavirus Season Coincides With Vaccine Uptake

3. USAMRIID Scientist Identified as Sole Perpetrator of "Anthrax Letter Attacks"

2. Resurgence of Measles

1. Intentional Drug and Food Tampering in China

Other notable stories of 2008 that didn't make Pathophilia's totally arbitrary list:

• More cases of progressive multifocal leukoencephalopathy (PML) with Tysabri (natalizumab) use
• Pig-slaughter neuropathy
• US government compensates Poling family for vaccine-related autism
• Ted Kennedy diagnosed with glioblastoma multiforme

In 2008, the United States experienced the largest measles outbreak in more than 10 years, due to pockets of imported or importation-associated disease in unvaccinated individuals.* An August report in the MMWR indicated that more than 80% of these 131 cases were related to 7 outbreaks (≥3 cases). Fifteen individuals, including 4 children younger than 15 months of age, were hospitalized for disease. 

Most important, however, is the fact that a whopping 91% of cases occurred in individuals who had not received vaccination or whose vaccination status was unknown. Among these 112 patients, 85% were eligible to receive vaccination, but 66% had declined because of "philosophical or religious beliefs." In many cases, elected exemptions are based on parents' disproven fears of the risk of autism.

In England, measles was declared endemic this year for the first time since the mid-1990s, because a critical number of parents declined vaccinations for their children. Gibraltar also experienced an unprecedented measles outbreak, which affected 1% of the population. The outbreak was blamed on the poor uptake of measles vaccination and a subsequent shortage of the vaccine.

Those most affected by the deferral of measles vaccination are immunocompromised children and children younger than 12 months of age, who rely on adequate herd immunity. It appears to be a matter of time before a measles outbreak will cause a known, severe complication of the disease, like encephalitis or death, in the United States. Such an event occurred in April in the United Kingdom.

By way of contrast, worldwide deaths due to measles dropped dramatically, according to the World Health Organisation. The plunge in measles-related deaths, from 750,000 in the year 2000 to 197,000 last year, is due to a massive, coordinated vaccination effort, the Measles Initiative. In Africa and countries of the Eastern Mediterranean region specifically, the effort resulted in a fall in measles deaths by approximately 90% during the same time period. The goal of the Measles Initiative—which is led by the American Red Cross, the CDC, the UN Foundation, UNICEF, and WHO—is to reduce the number of measles deaths worldwide by at least 90% by the year 2010.

Because the majority of measles-related deaths no longer occur in Africa, vaccination efforts are now being intensified in other regions—particularly India, where 8.5 million children do not receive their first dose of measles vaccine by 1 year of age. According to a spokesperson for the UN Foundation, the success of the campaign depends on urgently needed funds for the next 2 years.

More details can be found at the following Pathophilia links (and at links through these links):

• And the Air-Travel Risks Just Keep on Comin': This Time, Measles
• Looming Large: The Cost of Not Vaccinating
• Measles Outbreak in DuPage County, IL
• Biggest US Measles Outbreak in 10 Years
• Boo, Boo, Boo: US Measles Cases Increase
• Most US Parents Remain Sane, Vaccinate Children
• Measles Hits Gibraltar, Hard
• Global Measles Initiative a Success, but Funding Needed

* The percentage of US toddlers who received at least 1 dose of MMR vaccine (from 91.5% to 93.0%) has remained stable since 2004. Still nearly 8% of American toddlers did not receive vaccination for the disease in 2007, and geographic clusters of unimmunized children appear to account for this year's record number of cases of the highly contagious disease.

Photo of child with measles rash from the CDC.

Despite the return of measles to the United Kingdom, the United States, and Gibraltar, worldwide deaths from the highly contagious, viral disease have dropped dramatically, according to the World Health Organisation. The plunge in measles-related deaths, from 750,000 in the year 2000 to 197,000 last year, is due to a massive, coordinated vaccination effort, the Measles Initiative. In Africa and countries of the Eastern Mediterranean region* specifically, the effort has resulted in a fall in measles deaths by approximately 90% during the same time period. The goal of the Measles Initiative—which is led by the American Red Cross, the CDC, the UN Foundation, UNICEF, and WHO—is to reduce the number of measles deaths worldwide by at least 90% by the year 2010.

Area	2000	2007	Drop, %
World, measles deaths	750,000	197,000	74
World, measles cases	852,937	279,006	67
Africa, deaths	395,000	45,000	89
Eastern Mediterranean, deaths	96,000	10,000	90

Because the majority of measles-related deaths no longer occur in Africa, vaccination efforts are now being intensified in other regions—particularly India, where 8.5 million children do not receive their first dose of measles vaccine by 1 year of age. According to a spokesperson for the UN Foundation, the success of the campaign depends on urgently needed funds for the next 2 years.

* Includes Afghanistan, Pakistan, Somalia, and Sudan.

Photo of measles vaccination in Bangladesh by Daniel Cima/American Red Cross.

12/05/08 update: This week's MMWR provides additional tabulated and graphic data. In Southeast Asia, the number of measles deaths dropped from 235,000 to 136,000 (42%) during the period from 2000 to 2007. In the Western Pacific, measles deaths fell from 25,000 to 7000 (73%). The estimated number of measles deaths in the Americas or Europe is less than 1000 for all years, with vaccination coverage rates of 93% and 94%, respectively.  

What's the difference between getting measles and getting married? You can do both in Gibraltar. No wait, that's what's the same. Okay, one results in an uncomfortable, highly contagious condition with the risk of long-term complications, and the other...Oh, forget it.

Nearly 1% of Gibraltar's population has been affected by an intense measles outbreak during the last 3 months, reports the NYT. Specifically 276 cases of the disease, among a population of 28,000, are being reported by the British territory's health director. A Gibraltar news source indicates that the actual number of those infected is probably greater, given that residents with mild disease may not report their illness.

Those with measles range in age from 4 months to 58 years; however, most are children. Cases have been generally mild, but some infected individuals—including infants—have needed intensive hospital care. Gene analysis suggests that the responsible virus came from an outbreak in nearby Algeciras, Spain, a port city across the Bay of Gibraltar, writes the NYT.

The recent number of measles cases in Gibraltar stands in sharp contrast to reported cases of the disease in the territory during the previous 10 years: zero. The outbreak is believed to be due to inadequate immunization, despite assumptions that vaccination rates among Gibraltar's children were high. All infected persons had not been vaccinated or were only partly vaccinated (ie, with 1 dose of MMR vaccine) reports a Gibraltar news source. During the beginning of the outbreak, a vaccination campaign faltered twice because of vaccine shortages in Britain, according to the NYT.

Earlier this year, measles was declared endemic in the United Kingdom, after 14 years of eradication. The UK's Health Protection Agency reports a total of 956 measles cases from January to September of this year. At last count, the number of measles cases in the United States for the year was 131.

Photo of child with measles rash from the CDC.

Epi Wonk outs himself in the Atlanta Journal-Constitution by recounting his childhood experience with measles, which included hospitalization and treatment with an oxygen tent. Like many of a certain age, I also acquired measles as a youngster (despite having been vaccinated) and missed 2 weeks (2 weeks!) of junior high. And I didn't stay home because of contagiousness; I stayed home because I felt absolutely terrible.

Epi Wonk is right to chastise Washington for not initiating a progressive public-service campaign (where is our acting Surgeon General anyway?) to urge morbidity-reducing and life-saving vaccination and to counter the spurious claims of an increasingly vocal and attention-hungry antivax crowd.

Photo of child with measles rash from the CDC.

The overwhelming majority of American toddlers (age, 19-35 months) received at least 1 recommended vaccine last year, according to data from the National Immunization Survey (NIS), and coverage for at least 1 dose of varicella reached 90% for the first time. Detailed data from the survey were reported in this week's MMWR.

The coverage rate in 2007 for the recommended 4:3:1:3:3:1 series* of vaccinations was 77.4%, which was comparable to rates of previous years. However, the NIS report noted "substantial variability" of coverage among states (Maryland, 91.3%; Nevada, 63.1%) and urban areas (Philadelphia, 82.2%; San Bernardino, 69.6%). Nevertheless, very few children in the examined age group (0.6%) received no vaccinations whatsoever.

Coverage rates for the 4:3:1:3:3:1 series were not significantly different among racial or ethnic groups after adjusting for poverty status, but certain vaccines (ie, 4th dose of DTaP and 4th dose of PCV7) were less likely to be received by children living at or below the poverty level, according to the report. The ethnic group composed of American Indians and Alaska Natives had the highest coverage rates for the vaccination series and specifically for MMR (96.2%), HepB (96.7%), and varicella (94.9%). 

Despite the record number of measles cases reported this year in the United States, the percentage of toddlers who received at least 1 dose of MMR vaccine has remained stable since 2004 (Table). Still nearly 8% of American toddlers did not receive vaccination for the disease in 2007, and small geographic clusters of unimmunized children appear to account for this year's record number of cases of the highly contagious disease. (For those parents who remain wary of MMR vaccination owing to unsubstantiated fears of autism, yet another study published in this week's PLoS One dispels the connection. Orac provides the necessary background and details, sparing others the trouble of posting on the subject. Hosanna.)

Year	≥1 MMR Dose, %
2003	93.0
2004	93.0
2005	91.5
2006	92.3
2007	92.3

Data for the NIS were collected by means of telephone survey for more than 17,000 children (household response rate, 64.9%). The report acknowledges a possible underestimate of vaccine coverage owing to the exclusive use of provider-verified histories. In addition, clusters of unimmunized children were not likely to be detected, given the survey methods.

* Vaccine doses: 4 DTP/DTaP/DT, 3 polio, 1 MMR, 3 Hib, 3 Hep B, and 1 varicella.

Photo of toddler receiving pneumococcal vaccine from the CDC.

At last count, the number of Americans who had contracted measles this year was 127. Now add 4 more cases.

This week, the CDC's MMWR reports a total of 131 cases of the highly contagious infection in 15 US states and the District of Columbia from January 1 to July 31 (Table). The overwhelming majority of these cases were imported* (13%) or linked to imported disease (76%). (It is important to note that the number of imported measles cases in the United States has not changed appreciably over the years, but that the number of importation-associated cases accounts for this year's dubious record.) A large percentage (81%) of measles cases were related to 7 outbreaks (≥3 cases). Fifteen individuals, including 4 children younger than 15 months, were hospitalized for disease; however, there have been no deaths—yet. 

Most important, however, is the fact that a whopping 91% of cases occurred in individuals who had not received vaccination or whose vaccination status was unknown. Among these 112 patients, 85% were eligible to receive vaccination, but 66% had declined because of "philosophical or religious beliefs." 

Location	Measles Cases
Illinois	32
New York	27
Washington state	19
Arizona	14
California	14
Wisconsin	7
Hawaii	5
Michigan	4
Arkansas	2
DC	1
Georgia	1
Louisiana	1
Missouri	1
New Mexico	1
Pennsylvania	1
Virginia	1

The MMWR highlights outbreaks in 2 locations, Washington state and Illinois, in which affected children had not been vaccinated on the basis of personal-belief exemptions. A sizable portion of these children were home schooled, which obviates the vaccination requirement for traditional-school enrollment.

In an editorial note, the CDC advises that the current national vaccination rate for measles is adequate to prevent the "sustained spread of measles," but that importation-associated outbreaks are likely to continue as long as there are geographic clusters of unvaccinated individuals. Unfortunately this information will probably be used by parents who forego vaccination to maintain their behavior.

Most affected by the deferral of measles vaccination are immunocompromised children and children younger than 12 months of age, who rely on adequate herd immunity. It appears to be a mere matter of time before a measles outbreak will cause a known, severe complication of the disease, like encephalitis or death, in the United States. Such an event has already occurred in the United Kingdom.

* Genetically or epidemiologically linked to cases in Italy, Switzerland, Belgium, India, Israel, China, Germany, Pakistan, the Philippines, and Russia.

Photo of child with measles rash from the CDC.

So far this year, 127 Americans have contracted measles (rubeola), say Federal health officials, creating the largest measles outbreak in the United States since 1997. The current outbreak is believed to be the result of unvaccinated Americans acquiring the viral disease during overseas travel.

States with measles cases now include Arizona, Arkansas, California, Georgia, Hawaii, Illinois, Louisiana, Michigan, Missouri, New York, New Mexico, Pennsylvania, Virginia, Wisconsin, and Washington. The disease has also been reported in Washington, DC. Measles was acquired in Belgium, China, Germany, India, Israel, Italy, Pakistan, the Philippines, Russia, and Switzerland, according to the CDC.

The lack of vaccination among some American children is due to the increasing use of personal or religious exemptions by parents, owing to their unsubstantiated fears of the risk of autism. Reuters reports that, last month, measles was declared endemic in England for the first time since the mid-1990s, because parents declined vaccinations for their children.

Photo of child with measles rash from the CDC.

Seven school-age children have contracted measles (rubeola) in DuPage County, IL, approximately 30 miles west of Chicago, according to the Illinois Department of Public Health. Investigation is pending, and the source of the infection remains unknown; however, inadequate immunization appears to be the cause of the outbreak.

In early May, the MMWR reported 64 cases of measles from January 1 to April 25 in the United States. A case of measles imported from Switzerland occurred April 17 in Chicago. As of May 23, the CDC has confirmed 103 US cases this year, the highest number for this time period since 2001.

Measles is spread by respiratory droplets or fomites, and infection occurs in 90% of those who are not vaccinated. The incubation period of the virus is 10-12 days, which is followed by mild-moderate fever, persistent cough, rhinitis, conjunctivitis, and pharyngitis. Approximately 3 days later, high fever, Koplik's spots (view image), and the characteristic skin rash (view image) appear. The measles rash—typically erythematous, blotchy, and slightly pruritic—begins on the face, hairline, and behind the ears and progresses to the chest, back, thighs, and feet. After approximately 2 weeks, the rash fades in reverse order.

Complications of measles include otitis (1/10), pneumonia, (1/15), encephalitis (1/1000), and thrombocytopenia. Pregnant women should avoid exposure to measles, owing to associated risks of miscarriage, premature labor, and low-birth-weight infants.

Measles cases are highly contagious, beginning 4 days before the rash appears and lasting until 4 days after the rash disappears. Vaccination confers approximately 98% immunity. The CDC recommends that all children should receive 2 doses of MMR vaccine (at 12-15 months and at 4-6 years). Adults without documented immunity should receive at least 1 MMR dose. International travelers should undergo age-dependent vaccination. Illinois reports an immunization coverage level among school-age children of 98%; however, the state does offer personal and religious exemptions.

Map of DuPage County from Wikipedia Commons.

Photos of Koplik's spots and measles rash from CDC.

2008 is becoming the year of reckoning, thanks in part to the anti-vax movement. Today's MMWR reveals that 64 cases of measles—a disease declared eliminated in the United States in 2000—have occurred so far this year in the country.* Compare that number with the average 62 cases annually during the last 8 years, and you've got the expectation for a dubious record in 2008.

According to the MMWR, most reported measles cases (84%) this year were due to imported disease from other countries (59 patients were US residents), and the overwhelming majority occurred in persons who were unvaccinated or whose vaccination status was unknown. Exactly half of the patients were younger than 5 years; 14 were younger than 1 year and therefore not eligible for immunization. Among the 21 US residents aged 16 months to 19 years, two thirds claimed exemption from vaccination because of religious or personal beliefs. Twenty-one measles patients were adults (including 1 US resident born before 1957). 

Although 14 (22%) of those affected were hospitalized, there were no fatalities. Possibly the most shocking revelation is that 1 patient was an unvaccinated health care worker who acquired the disease in hospital. Another 17 individuals were infected while visiting a health care facility, including a 12-month-old child who, ironically, was exposed to the virus in the physician's office while receiving a routine MMR vaccine.

Details of the 2008 measles cases are tabulated below, and the MMWR provides a very nice annotated map:

Location	No. Cases	Date of Cases/ Outbreak	Source
San Diego, CA	11	01/25-02/16	Switzerland; genotype D5 (Index pt = unvaccinated child who traveled to Switzerland)
Honolulu, HI	3	02/05-02/25	California outbreak (1), Italy (2)
NY, NY	22	02/07-04/20	Israel (2), Belgium (2), Unknown (8); genotype D4
Pima Co, AZ	15	02/13-04/23	Switzerland; genotype D5 (Index pt = unvaccinated adult from Switzerland)
Missaukee Co, MI	4	02/19-04/08	Unknown; genotype D5 (Index pt = unvaccinated 13-year-old)
Fairfax, VA	1	02/25	India
Milwaukee Co, WI	4	03/19-04/09	China (likely); genotype H1 (Index pt = 37-year-old with unknown vaccination status; likely exposed to Chinese visitor with disease)
Los Angeles, CA	1	03/23	Unknown
Pittsburgh, PA	1	04/12	Unknown
Nassau Co, NY	1	04/12	Unknown
Chicago, IL	1	04/17	Switzerland

Although US vaccination levels are high, reports the MMWR, unvaccinated children tend to be clustered geographically or socially, which increases the risk of outbreaks. The article undermines the belief of some vaccine rejectionists that they can coast on the vaccine-provided immunity of other US residents. Cases to date show that the risk of imported disease remains high, and that unvaccinated individuals can propagate the spread of foreign-born infection. It is notable that a substantial measles outbreak occurred earlier this year in San Diego, CA, home of 3 vaccine-rejecting moms who were recently profiled by the NYT. The index patient in the San Diego outbreak was an unvaccinated child, who brought the infection back from Switzerland.

And California receives more negative attention today because of a pertussis outbreak that has closed a private school near San Francisco.  

*Up until April 25.