By Emily Dunn, Clinical Features Writer for Australian Doctor Group.
It’s the most infectious vaccine-preventable disease and it’s sweeping the world.
Measles transmission has quadrupled in a year, according to the WHO, with 170 countries reporting 112,163 cases in the first three months of 2019.
Not only is measles exploding in traditional hotspots — Africa is up by 700% — but Western countries are seeing the most widespread outbreaks in decades.
Australia, despite a declaration of measles elimination in 2014, is experiencing its biggest outbreak since 2012, with 113 notifications in the first four months of this year and an unprecedented number of public health alerts.
Many outbreaks in Europe and the US have been fuelled by vaccine-refusers in a climate of disruption in politics and distrust of mainstream medicine.
An imported disease
In Australia, most cases have been in undervaccinated adults and adolescents, of whom there is a cohort born between 1966 and 1992 who received only a single dose. Among the cases this year, almost half have been in young people aged 15-30.
Professor Raina MacIntyre, head of the biosecurity research program at the Kirby Institute, UNSW Sydney, warns that measles is “an imported disease but one that can easily set off an epidemic”.
“The typical case is someone who is from overseas or who has travelled and brought it back. Then they go and sit in the emergency department, and wait for hours and hours.”
A person with measles returning to a community with low vaccination rates can be the match that sparks a fire. In the US, most cases have been imported from Israel, triggering outbreaks with hundreds of cases in ultra-Orthodox Jewish communities in New York.
In Australia, the majority of cases have arrived from Asia, including from the Philippines, which is experiencing one of the worst outbreaks in the world, with 34,000 cases and 466 deaths, mostly in children, since January.
Immunisation researcher Professor Julie Leask, from Susan Wakil School of Nursing and Midwifery at the University of Sydney, says there are concerns about the potential for outbreaks in areas of Australia.
This is particularly true in the NSW Northern Rivers and Byron Bay regions, where vaccination rates in some towns are below 75% and there are clusters of unvaccinated children in informal childcare arrangements in response to recent federal and state government policies (see box below: ‘No jab, no pay’ — is it effective?)
|No jab, no pay — is it effective?|
Refusal to vaccinate children now carries financial and other penalties for parents, but these laws are yet to be fully evaluated.
In 2016, the Federal Government introduced ‘no jab, no pay’ legislation that linked receipt of family assistance payments, including rebates for childcare, to vaccination status.
Since then, the NSW and Victorian governments have introduced ‘no jab, no play’ legislation that tightened the requirements for vaccination for enrolment in preschool and childcare services. SA and WA are considering similar laws; while in Queensland, whether enrolment is dependent on vaccination status is at the discretion of the childcare provider.
Professor Julie Leask, from Susan Wakil School of Nursing and Midwifery at the University of Sydney, says it’s important to evaluate the impact of such policies on children.
She has NHMRC funding for research into the factors that influence the decisions of vaccine refusers in low vaccinating communities.
“There have been some parents who vaccinated because of the policies but the question is, is that group big enough to justify the negative effects of the policies.
“The concern here is that … it is making the children pay twice and punishing the children for the decisions of parents.”
Although immunisation rates for children under five have increased by 1.41% since the introduction of ‘no jab, no pay’, Professor Leask says it would be a leap to say it’s because of the policy as there were other coinciding initiatives.
“Now there is no possibility of exemption, there is no reason to visit a healthcare professional,” she points out.
Dr Margie Danchin, from the Murdoch Children’s Research Institute, is currently working on a project with the Royal Children’s Hospital in Melbourne to evaluate the impact of the Victorian Government’s ‘no jab, no play’ policy on vaccine uptake and the rate of medical exemptions.
While the results are yet to be published, Dr Danchin says the data so far suggests the policy has done little to change the minds of vaccine refusers.
“We also need to evaluate what the impact is on these children who are being prevented from attending preschool,” she adds.
Professor Leask agrees that while public anger around the public health risks posed by vaccine refusal is justifiable, it is wrong for that anger to inform public policy.
“The parents that you are not seeing are the ones who didn’t get there to start with because of poverty or the failure of services to be convenient; that group is really significant.”
However, Professor Leask stresses that adolescents and adults who have not had the recommended two doses of vaccine pose a more significant public health risk.
“If you are a GP faced with vaccine refusers, it will be a big part of what you are doing, but globally it is not the largest cause of low vaccination. The solutions are travel vaccinations and increasing access to primary healthcare.”
This year, the WHO included ‘vaccine hesitancy’ in its top 10 threats to public health.
Professor Leask notes that it also included ‘weak primary healthcare’ and people living in ‘fragile and vulnerable settings’.
“These are more of an enemy of immunisations than hesitancy. Hesitancy is not behaviour, it is a state of mind and the behaviour is refusal — so hesitancy is a misnomer we are trying to get away from.”
Anti-vaccination sentiment cuts across political and social lines, Professor Leask says.
In Australia, television chef Pete Evans and One Nation leader Pauline Hanson are among those who have spouted anti-vaccination views.
And in the US, its proponents range from environment lawyer Robert Kennedy Jr, who has campaigned for Barack Obama, to Texan Republican Jonathan Stickland, who infamously branded immunisation as “sorcery”.
In a recent Twitter argument with vaccinologist Professor Peter Hotez, from Baylor College of Medicine in Houston, Mr Stickland summed up a growing sentiment in the West when he wrote to Professor Hotez that “parental rights mean more to us than your self-enriching ‘science’”.
Prof Peter Hotez MD PhD@PeterHotez
You are bought and paid for by the biggest special interest in politics. Do our state a favor and mind your own business. Parental rights mean more to us than your self enriching “science.” #txlege
|A perfect storm: populism, science scepticism and Facebook|
The forces propelling a tide of vaccine refusal in Western countries range from populist politicians to alternative lifestylers and even Russian internet trolls.
Twenty years after Andrew Wakefield’s discredited publication linking MMR vaccination to autism, anti-immunisation sentiment is being amplified by social media and is stripping back public health gains, researchers warn.
In 2018, an Ipsos MORI poll conducted in conjunction with Kings College London in 38 countries, including Australia and New Zealand, found six out of 10 people either believed that some vaccines caused autism or said they were unsure whether or not that was true.
Distrust of Big Pharma and officialdom has been fanned by far-right politicians in Europe, including Marine LePen in France, where measles cases have risen six-fold, and the leaders of the ruling anti-establishment Five Star Movement in Italy, according to an investigation by the Guardian newspaper.
In Italy, MMR vaccination dropped to 85% between 2010 and 2015, fuelled partly by a successful vaccination injury case, later overturned, that had relied on Wakefield’s Lancet study.
Last year, faced with hundreds of cases, the government somersaulted, declaring a ‘measles emergency’ and making vaccination compulsory for attending Italian public schools, sparking widespread protests.
European researchers have found a “highly significant positive association” between the percentage of people in a country who voted for populist parties and those who believe that vaccines are not important nor effective.
“Vaccine hesitancy and political populism are driven by similar dynamics: a profound distrust in elites and experts,” they wrote.
Deterioration in public trust of vaccines has also arisen because of the sheer volume of ‘fake news’ and incorrect information disseminated via the internet, researchers say, pointing to the US-based website Natural News as a prime offender.
Such websites promote natural therapies and sell supplements alongside articles feeding conspiracy theories about aluminium in vaccines “destroying children’s brains” and toxic “chemtrails”.
These stories are amplified on social networking platforms like Facebook. However, the tech giants this year took steps to curb anti-vaccination activity, including pledges by Google-owned YouTube to ban monetisation of anti-vaccination videos and by Instagram to axe anti-vaccination hashtags.
Video: Watch a CBS news report on Facebook’s plans to crack down on anti-vaccination messages.
But the horse has bolted. According to a study by a US expert on decision-making, Assistant Professor David Broniatowski from the George Washington University, health information-seekers are being manipulated by trolls and tweeting computer programs, or ‘bots’.
Drawing on 1.8 million tweets collected over three years, his team showed that so-called vaccination ‘debate’ on Twitter was largely driven by bots and distributors of malware who were notable for tweeting much more often than average Twitter users.
In addition, Russian trolls have used vaccination as a political wedge, with provocative tweets referring to racial, socioeconomic and religious divisions designed to fan tensions within the US.
Professor Broniatowski describes it as the ‘weaponisation’ of health communications.
— Rada Rouse
Celebrity criticism of vaccination has also been influential in the US where discredited former UK doctor Andrew Wakefield, author of a since-retracted 1998 Lancet study linking MMR vaccine to autism, courted Donald Trump during the presidential race.
Some political commentators have noted that an anti-vaccination stance has become increasingly common among Republican officials.
“When Donald Trump came out in favour of measles vaccination [in April], it was a good thing for tipping the ideological gradient back,” Professor Leask says.
“There will be ways of thinking along the Left and the Right that justify a vaccine refusal position. The Right will say that ‘the government shouldn’t be interfering in my liberties’, while the Left will say ‘this is not organic and natural and I don’t want Big Pharma saying what will go into my child’.”
Dr Margie Danchin, a paediatrician at the Murdoch Children’s Research Institute and Royal Children’s Hospital in Melbourne with a special interest in vaccination, says despite media coverage highlighting affluent areas where vaccine coverage is low, it is an issue that affects both the very top and the very bottom of the socioeconomic spectrum.
“There is a cognitive dissonance among those people who are well educated and who may well have a science background who are choosing not to vaccinate or only partially vaccinate,” she says.
“But for those in very low socioeconomic groups, vaccine coverage is also low. For these people, it is more practical barriers such as family size or difficulty getting time off work. They are also disproportionately affected by policies that restrict family payments or childcare access.”
Dr Danchin warns that while it is mostly young travellers bringing the disease back to Australia, it is young children, especially the under-fives, who develop the most serious illness and are at the highest risk of complications such as pneumonia and encephalitis.
For every 10 unvaccinated people exposed to measles, nine will contract the disease. One primary case causes up to 18 secondary cases, she says.
In children, however, 99.9% of those who are exposed and unimmunised will contract the disease.