Something Worse Than Swine Flu Is Gaining On Us

Maryland health officials said at least four people had been diagnosed with measles in including an 8-month-old infant who contracted the disease in a hospital waiting room. Virginia officials were also warning that an infected man may have exposed hundreds of people to the disease as he visited grocery stores and restaurants.

Last year, 131 cases of measles were reported nationally, the most since 1996, according to the U.S. Centers for Disease Control and Prevention in contrast to the first seven years of the decade, when only 63 cases were reported.

Experts say measles may be reestablishing itself in US. according the Washington Times (5/6/09, Goff) which reports, "While the uproar continues over a potential swine flu pandemic, there is a quiet controversy brewing about the return of an old disease that had once been nearly eradicated in the United States.”

Many people have the impression it is not a serious disease, but Measles kills three out of 1,000 people who develop it.

We should remember that 50 years ago - more than 100,000 children were hospitalized and 500 died annually. While in the decade before the U.S. measles vaccine program began in 1963, an estimated 3 million to 4 million people in this country were infected annually. Between 400 and 500 people died, 48,000 were hospitalized and another 1,000 developed a chronic disability from measles-related encephalitis, according to the CDC.

This is a brief review of Measles to remind us of what we may be facing if, as stated by a noted pediatrician, "this uptick in measles could be the sign of something bigger."

Many physicians have forgotten or have never experienced how dangerous measles could be.

Measles virus infection can cause a variety of clinical syndromes including:
• Severe measles,
• giant cell pneumonia, and
• measles inclusion body encephalitis in immunocompromised patients.

The incubation period of measles is generally asymptomatic and lasts from 10 to 14 days. The appearance of symptoms typically include fever, malaise, and anorexia, followed by conjunctivitis, coryza, and cough. Patients may develop an exanthem known as Koplik's spots. These hich are 1 to 3 mm whitish, grayish, or bluish elevations with an erythematous base, seen on the buccal mucosa typically opposite the molar teeth. The characteristic skin rash is maculopapular and blanches, beginning on the face and spreading centrifugally to involve the neck, upper trunk, lower trunk and extremities. The lesions may become confluent, especially in areas such as the face where the rash develops first.

This cranial-to-caudal progression of the rash is considered characteristic of measles.

Complications of Measles include

• Pneumonia — Patients with measles can develop secondary bacterial or viral pneumonia. In addition

• Coinfection with other viruses can occur especially with para influenza, and adenovirus, but also with cytomegalovirus, enterovirus, influenza, and respiratory syncytial virus.Measles has also been associated with the subsequent development of bronchiectasis, which can predispose to recurrent respiratory infections

• Acute disseminated encephalomyelitis — (ADEM, also known as post infectious or postvaccination encephalomyelitis); Post infectious encephalomyelitis presents soon after the initial clinical manifestations of measles have resolved. Past experience with measles epidemics identified a 10 to 20 percent mortality associated with ADEM. Furthermore, many survivors have residual neurologic abnormalities including behavior disorders, mental retardation, and epilepsy.

• Tracheobronchitis — Measles virus can involve the upper respiratory tract and cause laryngotracheobronchitis (ie, croup), with its attendant complications.

• Otitis media — When patients with measles develop otitis media, it is usually due to bacterial superinfection caused by the same bacterial pathogens that normally cause this infection.

• Since measles is a disseminated infection, involvement of other organ systems can occur, including corneal ulceration, myocarditis, pericarditis, hepatitis, mesenteric lymphadenitis, diarrhea, and appendicitis.

• Subacute sclerosing panencephalitis whereas subacute sclerosing panencephalitis (SSPE) presents seven to ten years after initial infection. It is a progressively fatal degenerative disease of the central nervous system. Its pathogenesis is not well understood, but persistent infection of the central nervous system with a genetic variant of measles virus may be involved. The typical patient with SSPE is under 20 years of age and develops SSPE seven to ten years after measles infection.

Why Is This Increased Frequency Of Measles Happening Now?

• A study in the United States in 1982 found a progressive fall in the number of cases of SSPE from 0.61 cases per million population in 1970 to 0.06 in 1980. The decline in SSPE cases paralleled the decline of measles cases, but with a lag time of several years.

• The estimated incidence of SSPE was 8.5 cases per one million cases of measles that occurred during 1960-1974.

• However, a follow-up study of cases of biopsy-proven SSPE identified from 1992 to 2003, suggests that the risk of this disease may now be 10-fold higher.

There was a resurgence of measles infection in the United States in 1989 to 1991 due to low overall vaccination rates.

• In 2008, CDC data indicate that "131 cases of measles were reported nationally, the most since 1996," with 63 of those incidences occurring in the "first seven years of the decade."

• The "CDC said that as of 2006, the most recent year numbers are available, 93 percent of American children had received the measles vaccine."

Yet, infectious disease experts say a vaccination rate of 95 percent is necessary to keep highly contagious diseases, such as measles, from becoming re-established in the US.

Moreover, because vaccine rates are much lower in many countries, even developed European countries," people's globe-trotting habits mean that Americans are far from protected.

This led the chief of infectious disease at the Children's Hospital of Philadelphia to opine that the U.S. may be seeing the crest of the vocal anti-vaccine movement, which has gained momentum over the past decade. The movement has been spurred by a feared link between vaccines and autism—which affects one in 150 children in the United States.

In 1998, a study by British researcher Andrew Wakefield looked at 12 children with autism and suggested that the onset of their symptoms was linked to receiving the MMR vaccine. Though it was later discovered that Dr. Wakefield misrepresented some of the data, his findings had a major impact.

As an example of what mis-information can do-Measles vaccination rates in the United Kingdom dropped almost immediately. In 1998, the year Dr. Wakefield's research was published in the Lancet medical journal, there were only 56 measles cases. The current rate of full MMR vaccine coverage for British children is only 77 percent. This resulted in 1,348 cases of measles in the U.K. last year, up 36 percent from 2007.

In the past decade, at least 20 studies have shown no link between the MMR vaccine and autism. And February 2009, a special federal court after a thorough review ruled in three test cases that there was no link between the vaccine and autism.

Despite the above factual evidence that measles vaccine does not cause autism and court rulings corroborating these facts, this growing anti-vaccine movement has not been dissuaded. In California, as in other states there are clusters of unvaccinated children, most of who are from upper-middle-class neighborhoods with supposedly educated parents. They have opted not to protect their children from measles.

“Vaccine refusal,” says the May 7, 2009 NEJM, “ not only increases the individual risk of disease but also increases the risk for the whole community. As a result of substantial gains in reducing vaccine-preventable diseases, the memory of several infectious diseases has faded from the public consciousness and the risk–benefit calculus seems to have shifted in favor of the perceived risks of vaccination in some parents' minds. If the enormous benefits to society from vaccination are to be maintained, increased efforts will be needed to educate the public.

SUMMARY & OPINION

In summary, vaccines are one of the greatest advances in medical history and in just the past 50 years, polio, measles, rubella, mumps, and Haemophilus influenzae type B disease have nearly disappeared in the U.S. Parents, however, are increasingly choosing to refuse vaccination of their children because of the fear of autism caused by vaccination, despite no credible evidence of an association.

• In the early 1980s, all 50 states required immunization.

• Rates of exemptions, however, for required school immunizations began to increase from about 1% in 1991 to 1.5% to 2.5% in 2004 despite the fact that unvaccinated children are significantly more likely to contract measles and pertussis than vaccinated children.

• Unvaccinated children are more likely to be white, live in higher-income households, and have a married mother with a college education.

• The Pediatric Committee on Bioethics advises against discontinuing care for families that refuse vaccines, 40% of pediatricians report that they will no longer provide care to families who refuse all vaccines.

• In view of the shift in perception about the safety of vaccines, we must remind our patients — and ourselves — that immunizations are responsible for saving more lives than virtually any other medical advance.

• Parental doubts about the safety of childhood vaccinations therefore are leading to outbreaks of largely eradicated diseases like measles and whooping cough.

A U.S. measles outbreak last year -- almost exclusively among unvaccinated people -- has sparked concern about places where many parents opt out of having their children vaccinated.
Too many abstainers can put a town at risk. Parents must realize that if children live in a community that has a cluster of refusers, their risk of getting a vaccine-preventable disease goes up, just by virtue of who they play with.
Eradicating a disease requires vaccinating a large percentage of the nearby population to stop infections from spreading -- what's called "herd immunity." Parents must understand that schools with many abstainers have been linked to outbreaks.
As an example in Colorado, schools with an outbreak of whooping cough in the 1990s had an average of 4.3% of students who had opted out of vaccination, compared with 1.5% at schools without an outbreak.
So stay alert for the post-Swine flu pandemics-the used to be common and very dangerous—Measles, Whooping Cough and all the rest of the killer diseases of the pre-vaccination era.

REFERENCES:
Recommended Immunization Schedules
http://www.cispimmunize.org/IZSchedule_Childhood.pdf
http://www.cispimmunize.org/IZSchedule_Adolescent.pdf
http://www.cispimmunize.org/IZSchedule_Catchup.pdf

JW Pediatr Adolesc Med Jan 28 2009


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