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Measles outbreaks, 2011

We frequently write about the consequences and costs of not vaccinating and how the anti-vaccine movement is causing real harm to real people through its assaults on public health. For example, through his fear mongering in the U.K., Andrew Wakefield, aided and abetted by a credulous and sensationalistic British media, managed to reverse decades of progress that had resulted in measles having come under control; as a result of plummeting vaccination rates in the wake of his 1998 Lancet case series, measles came roaring back in the U.K. Now it appears to be roaring back in Europe as well.

It’s bitterly ironic that news of measles outbreaks in the U.S. and Europe have come to the fore even as, over the long Memorial Day weekend, promoters of the scientifically discredited notion that vaccines cause autism gathered in a suburb of Chicago to sell “biomedical” treatments for autism and promote an anti-vaccine world view as part and parcel of the yearly autism quackfest known as Autism One. Adding to the grim irony is that last Thursday Nature published an issue with a special section devoted specifically to vaccines. The timing seemed just too deliciously appropriate to ignore. Think of it. In the Chicago area, there was a collection of anti-vaccine crackpots meeting to present fallacious “science” claiming that vaccines cause autism and all manner of chronic health problems. In contrast, one of the oldest and most distinguished scientific journals in existence publishes several articles in a single issue about vaccines. The karma was even stronger, given that the week before the CDC published a new Morbidity and Mortality Weekly Report (MMWR) last week discussing the status of measles in the U.S.

The Nature vaccine issue has a number of articles on the topic of vaccines, ranging from an editorial, to news items, to scientific articles. For my purposes, three articles caught my attention:

The article discussing the case of measles is particularly relevant today, as we are in the middle of a resurgence of measles cases, both here in the U.S. and a much worse outbreak in Europe. In the U.S. we have had thus far this year 118 cases of confirmed measles, the most cases since 1996. Of these cases, 47 resulted in hospitalization and 9 in pneumonia. Fortunately, none had encephalitis, and none died, but that’s only because the risk of encephalitis is between 1:1,000 and 1:5,000. In an outbreak of 118, there’s only around a 10% chance (at the most) of having a case of measles encephalitis among the children. However, the more children there are who are infected, the greater the chance of complications such as encephalitis, and let’s not forget that we already have an 8% pneumonia rate.

Fortunately, MMR vaccine uptake in the U.S. remains generally high, although there are increasingly pockets of low uptake susceptible to outbreaks. Indeed, that’s what appears to be happening. As reported in Nature and the MMWR report cited above, measles was in essence eliminated from the U.S. in 2000. This was not easy to do; measles is one of the most contagious viruses that exist. Indeed, it’s the contagiousness of the measles virus that has allowed it to find its way back into the U.S. from other countries, as described in the MMWR report:

Among the 118 cases, 105 (89%) were import-associated, of which 46 (44%) were importations from at least 15 countries (Table), 49 (47%) were import-linked, and 10 (10%) were imported virus cases. The source of 13 cases not import-associated could not be determined. Among the 46 imported cases, most were among persons who acquired the disease in the WHO European Region (20) or South-East Asia Region (20), and 34 (74%) occurred in U.S. residents traveling abroad.

More worrisome, of the 47 hospitalized patients, all but one were unvaccinated, and the statistics were:

Unvaccinated persons accounted for 105 (89%) of the 118 cases. Among the 45 U.S. residents aged 12 months−19 years who acquired measles, 39 (87%) were unvaccinated, including 24 whose parents claimed a religious or personal exemption and eight who missed opportunities for vaccination. Among the 42 U.S. residents aged ≥20 years who acquired measles, 35 (83%) were unvaccinated, including six who declined vaccination because of philosophical objections to vaccination. Of the 33 U.S. residents who were vaccine-eligible and had traveled abroad, 30 were unvaccinated and one had received only 1 of the 2 recommended doses.

Do you see the pattern here?

Leaving a child unvaccinated leaves that child at a greatly increased susceptibility to measles and therefore a highly elevated risk of catching the virus when exposed. This is particularly true when enough people refuse vaccines to compromise herd immunity, so that the unvaccinated can no longer rely on the herd, which they’ve gotten away with doing in the past. Nowhere is this more evident than in Europe, where more than 6,500 cases were reported in 2010, and we have Andrew Wakefield to thank for decreased vaccination rates that are only now starting to recover, as this story in–of all places–The Huffington Post describes:

To prevent measles outbreaks, officials need to vaccinate about 90 percent of the population. But vaccination rates across Europe have been patchy in recent years and have never fully recovered from a discredited 1998 British study linking the vaccine for measles, mumps and rubella to autism. Parents abandoned the vaccine in droves and vaccination rates for parts of the U.K. dropped to about 50 percent.

The disease has become so widespread in Europe in recent years that travelers have occasionally exported the disease to the U.S. and Africa.

Although overall vaccine uptake rates are high, thanks to Andrew Wakefield, there are pockets of children whose parents fear the vaccine more than measles and have therefore not vaccinated. These pockets have been enough to allow measles not just to come roaring back in Europe, but to allow Europe to export its measles to the U.S.

Perhaps the most interesting perspective this week on the issue of vaccine rejectionism is the second article I cited above, Vaccines: The real issues in vaccine safety by Roberta Kwok, who notes in the beginning of her article that “hysteria about false vaccine risks often overshadows the challenges of detecting the real ones.” She begins by citing the case of John Salamone. We’ve met him before in the context of my review of Paul Offit’s most recent book, Deadly Choices: How the Anti-vaccine Movement Threatens Us All. Salamone’s son is an example of a real adverse reaction to a vaccine. Basically, his son got polio from the live oral polio vaccine, a known complication. His son got that vaccine, even though an inactivated polio virus vaccine known to be safer was available at the time, because the oral polio vaccine was cheaper and more easily administered. As a result, Salamone became a real vaccine safety activist, in contrast to the anti-vaccine activists at Generation Rescue masquerading as “vaccine safety” activists. He and other parents worked together to effect change, and the U.S. shifted to the safer vaccine in the late 1990s.

Kwok’s overall point is that these fake vaccine safety scares, such as the widespread belief that vaccines cause autism, have made it more difficult to identify real vaccine safety issues:

Vaccines face a tougher safety standard than most pharmaceutical products because they are given to healthy people, often children. What they stave off is unseen, and many of the diseases are now rare, with their effects forgotten. So only the risks of vaccines, low as they may be, loom in the public imagination. A backlash against vaccination, spurred by the likes of Andrew Wakefield — a UK surgeon who was struck off the medical register after making unfounded claims about the safety of the measles, mumps and rubella (MMR) vaccine — and a litany of celebrities and activists, has sometimes overshadowed scientific work to uncover real vaccine side effects. Many false links have been dispelled, including theories that the MMR vaccine and the vaccine preservative thimerosal cause autism. But vaccines do carry risks, ranging from rashes or tenderness at the site of injection to fever-associated seizures called febrile convulsions and dangerous infections in those with compromised immune systems.

Serious problems are rare, so it is hard to prove that a vaccine causes them. Studies to confirm or debunk vaccine-associated risks can take a long time and, in the meantime, public-health officials must make difficult decisions on what to do and how to communicate with the public.

It’s true, too. So much time and effort of legitimate researchers, not to mention scarce research funds, have been wasted demonstrating again and again that there is no detectable link between vaccines and autism suggestive of a causative relationship. None of it is enough to convince the believers. Whenever yet another in a long line of studies is published that fail to find any detectable link between vaccines and autism or vaccines and other chronic conditions or diseases, the anti-vaccine believers brush it away and demand “more research.” Either that, or they demonize the researchers and those who point to those studies as being “pharma shills” or somehow possessing of nefarious motives of some sort or another. And so it goes.

The article then goes on to describe how public health officials have become increasingly vigilant about vaccine side effects, setting up intensive surveillance systems, most recently and famously for the 2009 H1N1 pandemic. Specifically, scientists were looking above all for evidence of a link between the H1N1 vaccine and Guillain-Barré syndrome, based on studies that suggested a link between the 1976 swine flu vaccine and this debilitating neurological syndrome. Studies thus far have not shown a link between the latest H1N1 vaccine and Guillain-Barré, which is good, but vigilance continues, not just for H1N1 vaccines but for every vaccine. The result of this surveillance has been to find a link between a rotavirus vaccine and intestinal intussusception, as well as a link between the measles, mumps, rubella and varicella (MMRV) vaccine and febrile convulsions. As a result, the MMRV was no longer recommended as a preferred choice.

Unfortunately, links are often not clear, and during the period of uncertainty between the first report of a possible vaccine complication and studies that either confirm or refute the link, public health officials are forced to make decisions on incomplete evidence. One current example is the possible link between the H1N1 vaccine Pandemrix and narcolepsy in young people. It is not yet clear whether this association is spurious or likely to indicate causation. Another aspect of this issue is whether there are genetic susceptibilities to adverse reactions due to vaccines. Contrary to what the anti-vaccine movement claims, scientists have never denied that there might be genetic factors resulting in increased susceptibility to vaccine injury. However, in science actual evidence is required, rather than speculation, and what we have now on this issue is, for the most part, speculation. It’s also not at all a straightforward issue to determine genetic determinants of increased risk for adverse reactions. Just as finding a genetic cause of autism has been difficult and full of dead ends, despite clear evidence of a strong heritable component, finding evidence of a genetic predisposition to vaccine injury is anything but a trivial task. Moreover, even in children who might have such a hypothetical predisoposition to vaccine injury, when the risk-benefit calculation is done it may well end up that the benefits of vaccines still outweigh the risks. Such would seem to be the case for children with mitochondrial disorders.

So how do we convince parents that the fear mongering by the anti-vaccine movement about vaccines and autism (or vaccines and all the other the movement tries to link with them, for that matter) is without basis in evidence and science and that it is safe to vaccinate? I agree with Julie Leask is at the National Centre for Immunisation Research and Surveillance, Discipline of Paediatrics and Child Health, School of Public Health, University of Sydney, New South Wales 2006, Australia, who wrote the last article that caught my interest, Target the fence-sitters. This is the way to go; the hard core anti-vaccine believers are not going to change their minds, no matter how much evidence you throw at them. We’ve seen this time and time again right here on this very blog, right here in the comments, stretching back over six years.

That’s why it’s a waste of time and effort to try to change the mind of the likes of J.B. Handley, Jenny McCarthy, Barbara Loe Fisher, Ginger Taylor, and others. There was a time when I thought that I could, but six and a half years of beating my head against the wall has taught me that I’m about as likely to succeed in changing their minds as I am to convince the Pope to become an atheist. It’s just not going to happen. What does happen is that I (and others) are attacked for our efforts. The bottom line is that I no longer care about changing, for example, J.B. Handley’s mind; I only care about countering his influence whenever possible. The fence-sitters can still be reached. They haven’t (yet) fallen down the rabbit hole of pseudoscience, autism “biomed,” and conspiracy mongering. There’s still hope to reach them, and reach them I try to do, using a variety of techniques ranging from pure sarcasm and full frontal assault to humor to dispassionate discussions of scientific papers. What works the best? I really don’t know, because I have no way of measuring. I do, however, keep trying. So do several other members of the SBM blog, who all have different styles, different levels of—shall we say?—aggressiveness in attacking pseudoscientific and unscientific claims about vaccines.

In the meantime, as the MMWR report on the 2011 measles outbreak in the U.S. and the articles in Nature demonstrate, the anti-vaccine movement is doing real damage as it reverses hard-won gains made against measles over the last four decades.

Posted in: Public Health, Vaccines

Leave a Comment (51) ↓

51 thoughts on “Measles outbreaks, 2011

  1. isles says:

    Small correction – MMRV wasn’t withdrawn. The link to febrile seizures was sort of wishy-washy (only showed up after certain doses, iirc) but the numbers were there. OTOH febrile seizures don’t do lasting harm and combination vaccines reduce missed doses. So ACIP withdrew its *preference* for MMRV over MMR and then varicella separately, but MMRV remains a valid choice. If you can get it, anyway; I don’t think Merck has had any to sell in a while.

  2. hat_eater says:

    I strongly encourage all other readers who maintain blogs to write from time to time about vaccines, especially if you have children. My post on the MMR scare is often found in searches and it was linked to in many discussions about the vaccine safety. I always check out the reaction and tt seems to me that the voice of another parent is more likely to be considered by the fence-sitters because they are themselves in my situation.
    And of course don’t forget to link to relevant research articles!

  3. Thank you for recapping all of the recent events in the news regarding vaccinations. Indeed, vaccines and vaccination have been at the forefront of the medical news headlines these days. An additional irony is that the World Health Assembly was recently debating whether to destroy the world’s last known stockpiles of smallpox. Smallpox is a disease that mankind was able to eradicate from the world due to vaccination. Measles was well on it’s way to being eradicated in the world and had reached that status in the US as of 2000. But unfortantely, due to the fraudulent autism-MMR link we have taken several steps back. Of note, UNICEF has recently published the prices that it pays for vaccines in order to spure competition among it’s suppliers. In this way, UNICEF will be able to obtain cheaper vaccines and be able to vaccinate more children throughout the world. The fight is not over, we shall more forward.

    Dr Sam Girgis
    http://drsamgirgis.com

  4. David Gorski says:

    So ACIP withdrew its *preference* for MMRV over MMR and then varicella separately, but MMRV remains a valid choice.

    Noted and wording changed slightly.

  5. TsuDhoNimh says:

    Fortunately, none had encephalitis, and none died, but that’s only because the risk of encephalitis is between 1:1,000 and 1:5,000. In an outbreak of 118, there’s only around a 10% chance (at the most) of having a case of measles encephalitis among the children

    Europe is right on target, with about 1 death or encephalitis case for every thousand or so cases.

    http://www.guardian.co.uk/news/datablog/2011/may/28/measles-europe-cases-map

  6. Sid Offit says:

    http://kidshealth.org/teen/infections/bacterial_viral/encephalitis.html
    Encephalitis is an inflammation (swelling) of the brain. Encephalitis is usually caused by a virus, but other things, including bacteria, may cause it as well. Although encephalitis sounds scary, most cases aren’t serious.

  7. Sid Offit says:

    Tsu

    I see 3 deaths in 7,300 cases, making for 1 death per 2,438 cases. I didn’t see how you came up with the 1 – 1,000 number until seeing you were lumping encephalitis in with death. I think death is a worse outcome. And you don’t seem to realize these are only reported cases. Many go unreported. Finally, in the propaganda materials Dr. Gorski mentions, we’re told of 3 deaths per 1,000 measles cases – a number wildly inconsistent with reality. I guess you can win those fence sitters over to your side…if you lie to them.

  8. Harriet Hall says:

    @ Sid Offit,
    “Although encephalitis sounds scary, most cases aren’t serious.”

    The mortality rate for measles encephalitis is 15%, and 20-40% are left with neurologic sequelae. Sounds pretty serious to me.

    “3 deaths per 1,000 measles cases – a number wildly inconsistent with reality”

    Whose reality? In developed countries, the overall death rate is as low as 1 in 1000, but is higher in infants and in the immunocompromised. In 3rd world countries the death rate is as high as 30%.

  9. tmac57 says:

    Sid Offit-”Measles Still Has a Devastating Impact in Unvaccinated Populations”

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1712354/

  10. Mark Crislip says:

    “Although encephalitis sounds scary, most cases aren’t serious.”
    What a maroon, as B. Bunny might say

    But after the wow shes pretty comment, I expect nothing less.

    Clin Microbiol Infect. 2011 Apr;17(4):621-6. doi: 10.1111/j.1469-0691.2010.03276.x.
    Long-term outcome of acute encephalitis of unknown aetiology in adults.
    Schmidt A, Bühler R, Mühlemann K, Hess CW, Täuber MG.
    Source

    Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
    Abstract

    Encephalitis is caused by a variety of conditions, including infections of the brain by a wide range of pathogens. A substantial number of cases of encephalitis defy all attempts at identifying a specific cause. Little is known about the long-term prognosis in patients with encephalitis of unknown aetiology, which complicates their management during the acute illness. To learn more about the prognosis of patients with encephalitis of unknown aetiology, patients in whom no aetiology could be identified were examined in a large, single-centre encephalitis cohort. In addition to analysing the clinical data of the acute illness, surviving patients were assessed by telephone interview a minimum of 2 years after the acute illness by applying a standardized test battery. Of the patients with encephalitis who qualified for inclusion (n = 203), 39 patients (19.2%) had encephalitis of unknown aetiology. The case fatality in these patients was 12.8%. Among the survivors, 53% suffered from various neurological sequelae, most often attention and sensory deficits. Among the features at presentation that were associated with adverse outcome were older age, increased C-reactive protein, coma and a high percentage of polymorphonuclear cells in the cerebrospinal fluid. In conclusion, the outcome in an unselected cohort of patients with encephalitis of unknown aetiology was marked by substantial case fatality and by long-term neurological deficits in approximately one-half of the surviving patients. Certain features on admission predicted an unfavourable outcome.

    Ann Neurol. 2007 Sep;62(3):235-42.
    Long-term neurological and functional outcome in Nipah virus infection.
    Sejvar JJ, Hossain J, Saha SK, Gurley ES, Banu S, Hamadani JD, Faiz MA, Siddiqui FM, Mohammad QD, Mollah AH, Uddin R, Alam R, Rahman R, Tan CT, Bellini W, Rota P, Breiman RF, Luby SP.
    Source

    Divisions of Viral and Rickettsial Diseases and Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, Centers for Disease Control and Prevention, Atlanta GA 30333, USA. zea3@cdc.gov
    Abstract
    OBJECTIVE:

    Nipah virus (NiV) is an emerging zoonosis. Central nervous system disease frequently results in high case-fatality. Long-term neurological assessments of survivors are limited. We assessed long-term neurologic and functional outcomes of 22 patients surviving NiV illness in Bangladesh.
    METHODS:

    During August 2005 and May 2006, we administered a questionnaire on persistent symptoms and functional difficulties to 22 previously identified NiV infection survivors. We performed neurologic evaluations and brain magnetic resonance imaging (MRI).
    RESULTS:

    Twelve (55%) subjects were male; median age was 14.5 years (range 6-50). Seventeen (77%) survived encephalitis, and 5 survived febrile illness. All but 1 subject had disabling fatigue, with a median duration of 5 months (range, 8 days-8 months). Seven encephalitis patients (32% overall), but none with febrile illness had persistent neurologic dysfunction, including static encephalopathy (n = 4), ocular motor palsies (2), cervical dystonia (2), focal weakness (2), and facial paralysis (1). Four cases had delayed-onset neurologic abnormalities months after acute illness. Behavioral abnormalities were reported by caregivers of over 50% of subjects under age 16. MRI abnormalities were present in 15, and included multifocal hyperintensities, cerebral atrophy, and confluent cortical and subcortical signal changes.
    INTERPRETATION:

    Although delayed progression to neurologic illness following Nipah fever was not observed, persistent fatigue and functional impairment was frequent. Neurologic sequelae were frequent following Nipah encephalitis. Neurologic dysfunction may persist for years after acute infection, and new neurologic dysfunction may develop after acute illness. Survivors of NiV infection may experience substantial long-term neurologic and functional morbidity.

    J Neuropsychol. 2008 Sep;2(Pt 2):477-99.
    Neurocognitive and functional outcomes in persons recovering from West Nile virus illness.
    Sejvar JJ, Curns AT, Welburg L, Jones JF, Lundgren LM, Capuron L, Pape J, Reeves WC, Campbel GL.
    Source

    Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA. zea3@cdc.gov
    Abstract

    Long-term neurocognitive and functional impairments following West Nile virus (WNV) disease are poorly understood. We assessed quality-of-life indices and neurocognitive performance in a cohort of 54 persons recovering from one of three WNV disease syndromes (fever [WNF], meningitis [WNM], or encephalitis [WNE]) approximately 1.5 years following acute illness. We compared findings between the three syndromic groups; the study cohort and a demographically similar group of 55 controls from a study of chronic fatigue syndrome (CFS); and the study cohort and a ‘normative’ control population based on cognitive test data. Persistent symptoms, diminished quality of life, and functional impairment were reported by 50% of WNF patients, and 75% each of WNM and WNE patients. Overall, objective neurocognitive performance did not differ significantly between the three syndromic groups, or between the study cohort and the CFS controls or the normative controls. In some neurocognitive subtests, the study cohort scored below the 15th percentile when compared with normative control data. Most persons who returned to independent living following hospitalization for WNV illness had persistent subjective complaints, but had normal cognitive function. However, a minority displayed subtle neurocognitive deficits more than 18 months following acute disease.
    J Child Neurol. 2006 Oct;21(10):910-2.
    Childhood encephalitis in Crete, Greece.
    Ilias A, Galanakis E, Raissaki M, Kalmanti M.
    Source

    Department of Pediatrics, University of Crete, Heraklion, Crete, Greece.
    Abstract

    This study included all 18 cases of children hospitalized for encephalitis in the referral university hospital of Heraklion, Crete, Greece, during the 5-year period from 2000 to 2004. Encephalitis was attributed to viral infection (echovirus, herpes simplex virus 1, varicella-zoster virus, cytomegalovirus, and influenza A) in eight children and to bacteria (Mycoplasma pneumoniae, group A beta-hemolytic streptococcus, and Rickettsia typhi) in a further five cases. Multiple hyperintense brain lesions on magnetic resonance imaging (MRI) were associated with a severe clinical presentation but not with a guarded long-term outcome. Five children still presented with mild to moderate sequelae after 1.5 to 5.3 (median 4.0) years. Our findings confirm the elimination of measles, mumps, and rubella-associated encephalitis in the postvaccine era. MRI appeared to be of great diagnostic value. Although no fatalities were observed, deficits did persist in several patients.

  11. Sid Offit says:

    @Harriet
    the overall death rate is as low as 1 in 1000, but is higher in infants and in the immunocompromised

    No, it’s much lower. Just look at the data from France. Yes, the measles is more dangerous in the groups you mention, but those targeting “fence sitters” are not making that disinction, rather they state deaths in 3 out of 1,000

    @Mark

    Nipah and West Nile? You must realize encephalitis severity varies with the infectious agent.

  12. Sid Offit says:

    @Mark

    Are those at the Mayo Clinic and National Institute of Neurological Disorders and Stroke “maroons” as well?

    http://www.mayoclinic.com/health/encephalitis/DS00226
    Encephalitis can cause flu-like symptoms, such as a fever or severe headache, as well as confused thinking, seizures, or problems with senses or movement. Many cases of encephalitis may go unnoticed because they result in only mild flu-like symptoms or even no symptoms. Severe cases of encephalitis, while relatively rare, can be life-threatening

    http://www.ninds.nih.gov/disorders/encephalitis_meningitis/detail_encephalitis_meningitis.htm
    Encephalitis can be caused by bacterial infection and, most often, viral infections. Several thousand cases of encephalitis are reported each year, but many more may actually occur since the symptoms may be mild to non-existent in most patients.

  13. David Gorski says:

    Sid, I’m never ceased at how casually you dismiss a 1 in 1000 death rate among children as being of no consequence and therefore not worth vaccinating to prevent.

    Still, watching you argue with a real infectious disease doctor will be entertaining, I predict. I’m going to get out the popcorn as I sit back and watch Dr. Crislip school you.

  14. Sid Offit says:

    @David

    It’s not about dismissing any number. It’s about pointing out when a number is incorrect, unsubstantiated or misleading. Again going back to what’s happening in France, were seeing a death, depending on how recent the numbers are, in 1 out of 2,300 (as per the link above) or 1 out of 1,600 (based on a more recent report of 10,000 cases). And as I must repeat, these are reported cases which represent a fraction of actual ones.

    As it relates to vaccination, parents have to decide if that number is going to tilt the risk reward calculation in favor of vaccination. Along with that they have to consider that, regardless of the reason, there were only 150 cases in the entire nation.

    Additionally, those suffering the worst effects of the measles are those in unique circumstances. If those circumstance don’t apply to my child, it’s almost certain he or she won’t suffer a dangerous complication.

    So we’re left to decide between an illness that’s unlikely to be problematic in a healthy child and a procedure that, like all medical procedures, has risks both known and unknown

    As far as being “schooled” a fact is a fact. I did not make up the Mayo Clinic’s assessment of encephalitis nor did I invent the measles mortality data.

  15. Harriet Hall says:

    @Sid Offit,

    The data from from France indicate a 1 in 2400 death rate for the 1st quarter of 2011. Based on only 3 deaths, I don’t think this is necessarily representative of the true death rate in developed countries. Other estimates are not “much lower” than 1 in 1000. Anyway, it’s still a significant death rate, especially when you consider the death rate from measles vaccine is zero.

    You didn’t acknowledge that the mortality rate for measles encephalitis is 15%, and 20-40% are left with neurologic sequelae. Sounds pretty serious to me. Encephalitis is 1 in 1000 for measles but only 1 in a million for the vaccine.

    Since all it takes to expose your child is one kid on a plane from France, it seems to me the vaccine is reasonable insurance

  16. Harriet Hall says:

    @Sid Offit, ” there were only 150 cases in the entire nation.” Yes, duh, because enough people got vaccinated.

  17. Kat says:

    Of course, as rational human beings understand, death and encephalitis are not the only negative outcomes of having the measles. Focussing on those two things ignores the more common outcomes, which also come at a cost to society and the individuals.

    Even a relatively mild case of measles is not very pleasant (a few weeks of feeling ridiculously ill and lying in a dark room). Not to mention the time off work/school, and the time and effort of others to look after you.

    The more extreme side effects of the disease just make for even more compelling reasons to avoid it (by vaccination) where possible.

  18. passionlessDrone says:

    Hello friends –

    I have a question. I don’t understand why a single carrier coming back internationally hasn’t been able to start mini outbreaks for a long time now.

    I sort of thought that the vaccine only worked ~ 95% of the time; i.e., some individuals, for whatever reason, just didn’t get immunity. While we usually tallk about children, this also means that there are tons of adults walking around out there that have no protection.

    Now, some adult or child goes to foreign country X, picks up measles, and sneezes ten times in Laguardia or JFK while getting their luggage or waiting for a transfer. Given the highly contagious nature of measles, and the fact that one in twenty adults who were born in the vaccine era don’t have protection, and thousands of people walking through airport terminals. Shouldn’t we be seeing cases more often than this?

    - pD

  19. Sid Offit says:

    @Harriet

    there were only 150 cases in the entire nation.” Yes, duh, because enough people got vaccinated.

    True, but how does the reason for the risk reward ratio being as it is change the risk reward ratio? I mean regardless of the reason the risk of the measles is close to zero. Don’t I have to take into account the world that is?

    As to encephalitis, I

    Even if there were a 15% fatality rare it wouldn’t change the fact that most cases of viral encephalitis (according not to me but the sources to which I linked) are mild. That doesn’t mean one would want encephalitis, just that it isn’t the danger it’s portrayed to be. And I’m not sure about that 15% number. The textbook Vaccines reports 4,000 cases of encephalitis in the pre-vaccine era and 400-500 deaths. But at a 15% mortality rate we’d see 600 measles deaths from encephalitis alone, yet pneumonia is said to have accounted for 60% of those 400-500 deaths. And if many cases are mild or asymptomatic aren’t we back to reported cases vs cases?

  20. Chris says:

    pD:

    I have a question. I don’t understand why a single carrier coming back internationally hasn’t been able to start mini outbreaks for a long time now.

    Because there is high enough herd immunity in most places, and those of us born before 1957 actually had measles. Also the second MMR vaccine has been recommended for about twenty years, that confers about 99% immunity for measles. Here is a graphical way to see how this works, play around with it:
    http://www.software3d.com/Home/Vax/Immunity.php

    You will notice that the outbreaks do occur in places where like minded people tend to not vaccinate. Just recently a Waldorf School in Virginia has asked all those children who are not vaccinated to stay home for the last two weeks of school (the students had been exposed):
    http://www2.dailyprogress.com/news/2011/may/27/more-area-measles-cases-likely-ar-1070013/

  21. weing says:

    “True, but how does the reason for the risk reward ratio being as it is change the risk reward ratio? I mean regardless of the reason the risk of the measles is close to zero.”

    You still don’t know the reason the risk of measles is close to zero? What are you, an idiot?

    “Don’t I have to take into account the world that is?”
    And the world that is is….?

  22. Mark Crislip says:

    I regret my entry as 1) I had no idea that different pathogens have different results and made a total fool of myself. And
    2) Why discuss with someone who finds smallpox victims pretty?

  23. weing says:

    “Additionally, those suffering the worst effects of the measles are those in unique circumstances. If those circumstance don’t apply to my child, it’s almost certain he or she won’t suffer a dangerous complication.”
    Very brave of you, bwana. You know what they say about fools rushing in?

  24. HF says:

    Here’s the EUVAC report that the data in the Guardian article linked above is from.

    http://www.euvac.net/graphics/euvac/pdf/2011_first.pdf

    I’m not sure I’m reading it right, but it looks like for the 1st quarter of 2011, there were 3 deaths in Europe out of a total of 9,349 reported cases.

    From the report:

    “The deaths occurred in three females aged
    18 years, 29 years and 30 years as a consequence
    of acute pneumonia complicating measles. All cases
    were laboratory-confirmed cases of measles. The
    18-year old case was unvaccinated while in the
    other cases the vaccination status was unknown.
    Moreover, there were 11 cases that suffered acute
    encephalitis as a complication of measles: nine from
    France, one from Austria and the other from Belgium
    The cases from France were reported in four males
    and five females, all previously unvaccinated against
    measles. Two cases were in 5-year old children, five
    cases were in teenagers between the ages of 11
    years and 16 years, and two cases were 20 years of
    age.”

  25. Chris says:

    Dr. Crislip:

    2) Why discuss with someone who finds smallpox victims pretty?

    Exactly! This why I ignore the person is not a well respected author, and for some reason thinks that being a real estate investor makes him smarter than epidemiologists, scientists and infectious disease doctors. I will buy you a beer at the Del Mar in July.

  26. Harriet Hall says:

    @pD, “I have a question. I don’t understand why a single carrier coming back internationally hasn’t been able to start mini outbreaks for a long time now.”

    There have been many such outbreaks. In one recent case, a 7 year old unvaccinated child returning from a trip to France brought back measles to San Diego: he exposed a total of 839 people. 11 unvaccinated children developed the disease, including 3 infants too young to have received the vaccine. One baby was hospitalized for 3 days with a fever of 106.

    In addition to factors mentioned by other commenters, even without any immunity not everyone who is exposed gets the disease. Contagion depends on the dose of virus received and many other factors. And people can have asymptomatic infections that are not recognized.

  27. Harriet Hall says:

    @Sid Offit, “Don’t I have to take into account the world that is?”

    If most people agreed with your stance on vaccines, the world would not be the way it is. Measles would still be endemic in the US. You are willing to benefit from the actions of others while refusing to contribute to them. If more people do as you do, measles will soon come back and you will have to make decisions based on a different world.

    “Even if there were a 15% fatality rare it wouldn’t change the fact that most cases of viral encephalitis are mild.”

    What are you saying? 20-40 percent of the survivors are left with neurologic sequelae. 15% dead, 20-40 percent permanently damaged, and 45-65% who might possibly be considered to have “mild” disease? If you believe this means that most cases of measles encephalitis are mild, your thinking is warped.

  28. Th1Th2 says:

    Of these cases, 47 resulted in hospitalization and 9 in pneumonia. Fortunately, none had encephalitis, and none died, but that’s only because the risk of encephalitis is between 1:1,000 and 1:5,000.

    I find this really embarrassing for the medical community if someone would die of a benign, self-limiting and uncomplicated measles. So no one died, none had encephalitis so what the heck? That’s not surprising. These patients shouldn’t even be in the hospital. These incompetent doctors are the ones who are putting these patients at risks of complication and death. FUD. Tsk tsk

  29. lilady says:

    @ Passionless Drone: The reason why major outbreaks are often prevented is that the United States has an excellent reporting and surveillance system

    Whenever there is an exposure aboard a plane, the CDC is notified, which in turn notifies each State’s Health Department. The CDC epidemiologists begin the process by contacting the airline for the passenger manifest (listing of names and addresses of every passenger aboard the flight). Within hours the CDC notifies the home countries of foreign passengers that there was an exposure aboard a flight.

    The State Health Department in turn notifies each county health department via telephone, providing the name, address and telephone number of the county resident(s) who were exposed to a measles case.

    Oftentimes, it is a local hospital’s Emergency Room physician/ infection control nurse or a private physician who notifies a county health department about suspicious rashes along with other early symptoms such as choryza or Koplik’s spots indicating measles infection. Measles is a Reportable Disease requiring an immediate telephone report to the county health department. The physician or the infection control nurse will do some preliminary investigating about history of immunization, exposure, recent travel, etc. and that information is relayed to county epidemiologists to begin the rather extensive investigation.

    Appropriate lab specimens will be obtained from the patient for proper diagnosis in a county lab or hospital lab specializing in virology technology. Very often the process of notifying the State Health Department, the CDC, the airline and foreign passengers, starts at the County health department.

    New York State Department of Health has some printed guidelines for the epidemiology, case surveillance and outbreak containment of measles available on the web:

    NYS Department of Health-Measles Outbreak Control Guidelines-January, 2011.

    You will see in those guidelines, how special measles immunization clinics and the providing of immune globulin can contain a measles outbreak.

    Children who are not immunized against measles because of a medical or philosophical exemption are not permitted to attend school and a quarantined in the home.

    Local health departments immediately issue a press release to local media to alert people of possible exposures in shopping malls, or at a physicians office, at a school or any congregate enclosed area. The local health department has around the clock “on call” coverage specifically for measles reports and other highly virulent infectious diseases, in order to facilitate timely notification and quick response to public health emergencies

  30. Jan Willem Nienhuys says:

    I doubt that one can say that many cases go unreported. In the Netherlands (and I don’t doubt the rest of Europe as well) health authorities must report each case of measles, so the source of contagion can be located. It is possible that some parents or people will not call the doctor in case of high fever and a rash, and if they just stay home and not cause any other infection they might go undetected.

    In the Netherlands national immunization against measles was started around 1977. Since then we had two major outbreaks: 1988 (1500 cases) and 1999/2000 (3400 cases, 3 deaths). Since 2000 the numbers have been very low: between 1 and 20 per year, with 209 in 2008. Note the 11 years periodicity.

    In the Netherlands we have roughly three groups who systematically oppose vaccination:
    1. our national Bible Belt (an area with about 1.4 million people and an estimated 20,000 children without BMR, i.e. about 12% of the under-10)
    2. anthroposophs
    3. antivaxers

    Together they produce a slowly growing reservoir of unvaccinated people. One gets an epidemy when every sick person infects at least one other person. So sooner or later there are so many unvaccinated people that a single imported case can start the epidemy.

    In particular it is to be feared that the epidemy in South East France (in the area Rhônes-Alpes 78 cases per 100.000 in this year already) will carry over to the Netherlands.

  31. HF says:

    The whole hospitalization thing is confusing to me. It seems like about 40% of the U.S. cases have been hospitalized this year.

    According to the EUVAC report, the hospitalization rate for all of Europe was 22% in the first quarter of 2011 but the rates ranged from 0% in one country to 100% in others. I don’t get it.

  32. pmoran says:

    The deaths occurred in three females aged
    18 years, 29 years and 30 years as a consequence
    of acute pneumonia complicating measles

    Note the ages. Unless something has changed, these so-called “childhood illnesses” are liable to be much more serious in adults. This could help explain high hospitalization rates.

    A measles epidemic could well be devastating if a weakly immune elderly population is allowed to develop.

  33. Chris says:

    HF:

    According to the EUVAC report, the hospitalization rate for all of Europe was 22% in the first quarter of 2011 but the rates ranged from 0% in one country to 100% in others. I don’t get it.

    Would you believe each country has a different system of public health, medical availability and standards of disease notification? It is eerily like they are all separate countries! For some reason I would believe Germany has different reporting standards than Bulgaria, and France differs from the UK.

    I don’t mean to be glib, but as a person who spent my youth in multiple countries, and has traveled quite a bit: I realize that there are differences between geographic bureaucracies.

  34. Barbara.Anne.Mays says:

    Greetings from Australia. Here, those people campaigning against the anti-vaxxers have developed effective campaign techniques. You can follow them at their Facebook page https://www.facebook.com/stopavn#!/stopavn?sk=info

    One member has made a study of Australia’s leading anti-vax campaigner, (American expatriate Meryl Dorey) and published his findings on her veracity at http://www.ratbags.com/rsoles/history/2011/05may.htm#21dorey

  35. HF says:

    Chris:

    No worries, you didn’t sound glib to me.

    I googled around a bit and figured this out. So, it looks like the 100% hospitalization rate for Bulgaria is likely accurate. I found this article:

    NOSOCOMIAL TRANSMISSION OF MEASLES AMONG HEALTHCARE WORKERS, BULGARIA, 2010

    “Of the 24,047 cases investigated, 89.3% belonged to the Roma ethnic community. The majority (86.8%) were hospitalised, mainly due to epidemiological considerations – patients from overcrowded households with poor living conditions and inadequate access to medical care.”

    http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19842

    I think the Roma are the group who are sometimes known as gypsies. I guess the best way to isolate the Roma who are diagnosed with measles is to hospitalize them.

    Germany, France and the UK all have similar hospitalization rates, around 20%, similar to the European average.

  36. desta says:

    “Additionally, those suffering the worst effects of the measles are those in unique circumstances. If those circumstance don’t apply to my child, it’s almost certain he or she won’t suffer a dangerous complication. ”

    What a great idea. Then your child, with few complications to none, can infect plenty of other kids, who can infect other kids, so that the disease can make its way over to the children who will suffer the worst effects and possibly die. Those kids don’t belong to you, so why should you care?

  37. rork says:

    “Do you see the pattern here?”
    I was actually disappointed that the MMWR did not attempt to estimate the number of non-vaxed people expected under the null hypothesis of no vax effect. We are supposed to be impressed that too many seem non-vaxed, but it’s left to (every!) reader to figure out how impressed we should be. (Perhaps it’s their job to just report the facts, not to do a study – I’m sympathetic there.)

  38. omakii says:

    Dr. Gorski –

    Great post today. I think arguments like this – scientifically sound, but with pathos – are the ones that will help convince the fence sitters.

  39. The Blind Watchmaker says:

    Anyway….

    So the Huffpo must have some new writers.

  40. aeauooo says:

    “The fence-sitters can still be reached. They haven’t (yet) fallen down the rabbit hole of pseudoscience, autism “biomed,” and conspiracy mongering. There’s still hope to reach them, and reach them I try to do, using a variety of techniques ranging from pure sarcasm and full frontal assault to humor to dispassionate discussions of scientific papers.”

    As someone who works in a local health jurisdiction and is tasked with addressing vaccine-hesitancy in this county, you and the other members of the SBM blog continue to be an excellent resource for my work.

    Thanks for calling my attention to the Nature issue.

  41. Calli Arcale says:

    It’s funny (not “ha ha” funny, though) that Sid thinks encephalitis is no big deal. Most cases are mild, he says. Well, over 50% anyway, as long as you define “mild” as “survive with no lasting impairment”.

    I would fall in that category. I had meningitis which progressed to encephalitis when I was four. I survived, and have no lasting sequelae. In fact, I was able to enter kindergarten the following September with the rest of my peers.

    But it was not mild. I spent two weeks in the hospital, most of which I only dimly remember as a series of strange images because I had a temperature of 107 and was hallucinating. I developed a terrible phobia of the smokestack for the local coal-fired power plant, and of clouds illuminated from beneath by city lights, because that was what I could see out the window of my hospital room. I remember one night, terrified of the scene that I could not understand, screaming for the nurses to come close the drapes, utterly terrified . . . .

    I also remember trying to fight the nurses putting in a new IV line. My veins were not holding up well, and they were low on supplies, and in those days they didn’t have flexible catheters — you actually had the needle stay in your vein the whole time, so you had to have the affected arm splinted so you wouldn’t bend it and puncture the vein.

    I came quite close to dying. To this day, the cause is unknown; the hospital was coping with an influenza outbreak and managed to lose both CSF samples that were taken from me. It was treated initially on the assumption of it being Hib — I was put into isolation, and put on intravenous antibiotics. But the etiology ended up looking more viral.

    But hey, that was a mild case! Flu-like symptoms. No lasting sequelae, and of course I lived. God forbid anyone get a severe case, if that’s what a mild one is like.

  42. Paddy says:

    I fear this is a public health battle which is going to rumble on and on. All this disinformation provided by quacks pushing “alternatives” to vaccines and, often, to modern medicine in general reminds me increasingly of the disinformation campaigns conducted by the tobacco industry a few decades ago. We’re up against vested interests here.

  43. lilady says:

    I read the Frugal Dietician link provided by the poster above. It points out the irony of the loonies meeting in Chicago to discuss the now thoroughly debunked theories of the vaccine-autism links, versus this latest report of 118 confirmed cases of measles YTD in the United States.

    I’ve also visited the web site of one of the sponsors of the Autism One Conference, to view today’s latest “revealing” article about aluminum in vaccines and latex ports on vaccine vials which are “contaminants leading to autism” according to them. Simply more of the same drivel and bogus voodoo medicine.

    Calli Arcale mentions her experience with encephalitis which did not progress to encephalopathy. My cousin, long before measles vaccine was licensed, was diagnosed with measles encephalitis which led to encephalopathy and lasting sequelae. I lost my childhood friend to polio before the availability of the Sabin polio vaccine.

    I worked as a public health nurse involved in investigating and reporting of vaccine-preventable diseases and witnessed the dramatic downtown in morbidity and mortality, once the HIB vaccine was licensed.

    We are now facing public health emergencies, due to the activities of the anti-vaccine crowd.

  44. Th1Th2 says:

    Calli Arcale,

    But hey, that was a mild case! Flu-like symptoms. No lasting sequelae, and of course I lived. God forbid anyone get a severe case, if that’s what a mild one is like.

    Despite the interventions, no diagnosis was made?! Glad you made it alive after all those shots in the dark.

  45. lilady says:

    @ Calli Arcali: You survived encephalitis, but so many people don’t…it is a medical emergency, not the mild disease that some posters here have stated.

    It is very traumatic for a youngster…or an adult…to undergo lumbar punctures. Sometimes, when a patient’s brain swells due to viral or bacterial disease, physicians will not perform a lumbar puncture, due to the risk of herniation of the brain stem. They treat with broad spectrum antibiotics and provide ventilator support to these very ill patients.

    I am very disheartened that the means (vaccines) are now available to decrease the incidence of meningitis, encephalitis and septicemia, but the activities of Wakefield and his cohorts have impacted negatively on the rates and timeliness of childhood immunizations.

  46. WilliamLawrenceUtridge says:

    What I find horrifyingly amusing from Sid and Th1Th2 isn’t the numbers bandied about, the hypothetical death rates being lower than expected or higher than expected, the “it’s not that bad” bleating, completely ignoring the parents who have to watch their children’s brains come close to boiling or the children themselves’ suffering. I find it horrifyingly amusing that they are stating one, three, ten, however many completely preventable deaths aren’t that many.

    Every single person who dies from measles and related complications did not have to die. But whatever, that’s not important right? So long as their precious fluids survive.

    The whole point of vaccination is to prevent unnecessary suffering (which is nice) and protect the 0.1% of the population who get a normally “safe” disease and friggin’ die from it. So, Sid, let’s assume only 1% of people with measles gets encephalitis as a complication, and only 0.1% of people with that complication die from it. Congratulations, in the United States, you just killed (300,000,000 * 0.01 * 0.001) three thousand people. If we’re talking China or India, that’s probably around ten thousand. World-wide, 60,000+ deaths from one disease alone.

    Good job. Just let me know how many people are “acceptable losses” before we hazard the “risks” of vaccinating.

  47. Scott says:

    Just let me know how many people are “acceptable losses” before we hazard the “risks” of vaccinating.

    If they were being honest, they’d answer something on the order of 6 billion. More precisely, everyone but themselves and their immediate families.

  48. WilliamLawrenceUtridge says:

    I also like Th1Th2′s response to Calli Arcale. Because apparently he lives in a world that lacks uncertainty, where all questions are due to incompetence and not incomplete knowledge, where all diagnostic issues are easily resolved without any time constraints. Apparently medicine, for Th1Th2, is easy. Would that all medicine be handled by such experts lacking in doubt. It reminds me of the 19th century, when science was disproving earlier theories but hadn’t yet developed effective, evidence-based treatments. The therapeutic nihilism resulted in a number of countries simply dissolving any regulation over doctors and the best interventions consisted of doing nothing.

    Because nothing, apparently, is all medicine has to offer.

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