Four days ago José, a happy 8-month-old baby boy who loved to laugh and bounce on his father’s knee developed a fever of 103°F. Then a rash appeared on his face and torso, and he became lethargic and wouldn't feed. Jose’s family had visited just two weeks ago with a recently emigrated family. One of their children had also developed a rash, cough, red eyes, and fever. That family told José’s parents the rash would go away and he would be feeling better in a couple of weeks. Unfortunately for José, his rash worsened, and he developed a cough, difficulty breathing, diarrhea, and increased lethargy, so his parents rushed him to the emergency department. He was admitted to pediatrics and diagnosed with measles and pneumonia. José’s brain began to swell and he developed encephalopathy, dying 3 days later. It was determined that measles was the precipitating factor.
- What could have been done to avoid this needless loss of life?
- What do you know about measles that you could have taught this family?
- What is the role of healthcare professionals in helping children avoid measles?
- What tests are done to diagnose measles? What is its cause? How is it transmitted?
- What is the nurse’s role in the measles epidemic?
- What prevention and treatment strategies are available?
We thought that measles had been eradicated in the United States, but these questions have become relevant in the last decade due to an alarming increase in cases of measles. What happened? Why are we still hearing about measles when we have a proven vaccine available? It’s a new chapter in the history of measles, and America is back in the story.
Measles outbreaks hit a record high in 2019 despite the CDC’s 2000 declaration of its elimination due to an effective vaccine. Measles remains a common contagious disease of children in undeveloped countries because it is easily transmitted. In developed countries with easy access to the vaccine, it should have remained eradicated. So why are we seeing a changing tide in the development of new cases?
Although the Centers of Disease Control and Prevention (CDC) recommends it, many attitudinal arguments against the vaccine have arisen. The resistance to vaccines in the United States is very different from those worldwide. Global cases of measles are seen where the barriers are lack of access to medical services, financial constraints, or lack of adequately trained medical personnel to administer vaccines. Let’s take a look at the arguments in our country and then explore the barriers internationally.
Arguments FOR the Measles Vaccine
The first dose of the MMR* vaccine is generally given to children 9 to 15 months of age, with a second dose at 15 months to 6 years of age, with at least 4 weeks between the doses. The case in favor of this vaccine has been established by the scientific community. The scientific evidence is plentiful that the MMR protects the entire community from measles if 97% of the population is vaccinated.
*MMR. Measles, mumps, and rubella—childhood diseases that have largely been eliminated in recent years. Older Americans can recall have had one or all of them in childhood before the vaccines became available.
In addition to its effectiveness, another argument in favor of the measles vaccine is the simplicity of administration. Two visits to the doctor or a clinic provides lifelong immunity. The effectiveness of the vaccine is 93% from the single dose, and increases to 97% after the second dose, making the risk of contracting the highly contagious disease extremely small.
One vaccination of MMR costs $1 per child, so protection can be had for the cost of a couple of dollars. The cost of treating the symptoms and possible complications can reach into the tens of thousands. Common complications of measles are diarrhea and ear infection. More serious complications, however, include hearing loss, pneumonia, and swelling of the brain. Ultimately, having contracted measles, between 1 and 2 children per 1,000 will die. That is a cost that no parent wants to contemplate.
Statistically, dropping from a herd immunity of 97% down to 93% of those vaccinated increases the rate of cases two-fold, from 13% to 28%. With each increase in number of measles cases, the probability of developing more severe measles also increases. Only a few percentage points below the herd immunity goal of 97% decreases the protection for the general population. This is discussed further in a later section. *Herd immunity. The resistance to the spread of a contagious disease within a population that results if a sufficiently high proportion of individuals are immune to the disease, especially through vaccination.
[Unless otherwise cited, the material in this section is from UN News, 2019.]
In the United States, the lack of vaccination is attributed to fear as well as to claims of personal freedoms and/or religious values, whereas global barriers against measles vaccination have been attributed to lack to access. Proponents of worldwide vaccination programs have recognized many barriers to adequate vaccination.
The global Measles and Rubella Initiative is a collaborative effort between the American Red Cross, CDC, WHO, the United Nations Foundation, and UNICEF. (See Resources for ways to support their efforts.)
Together these entities are working to address the barriers of funding, education, administration, and transportation of the measles vaccine. For example, the American Red Cross and international Red Crescent organizations have vaccinated over 2 billion children through their measles and rubella campaigns since 2001 and the efforts of 17 million volunteers worldwide (American Red Cross, 2018). Unfortunately, these efforts are thwarted during a natural disaster, or times of economic and political upheaval, when their workers cannot deliver services to communities in need (eg, refugee camps).
"More than 1 in 10 children—almost 20 million worldwide—failed to receive potentially lifesaving vaccines in 2018," the UN has said, citing obstacles including conflict, cost, and complacency.
According to a joint study by WHO and UNICEF, ten countries accounted for 11.7 of the 19.4 million under- and non-vaccinated youngsters in the world. At the same time, global protection against four diseases that are regarded as a gauge of overall coverage—diphtheria, tetanus, pertussis, and measles—has "stalled" at around 86% since 2010, the study found. A 95% coverage rate still eludes many countries.
The United Nations has stated that measles outbreaks reveal "entrenched gaps" in coverage. Citing major gaps in measles vaccine coverage across countries at all income levels, the UN report showed that the number of cases of the highly infectious disease doubled from 2017 to 2018, to more than 340,000.
"Measles is a real-time indicator of where we have more work to do to fight preventable diseases," said UNICEF's Executive Director, Henrietta Fore, in 2019. "Because measles is so contagious, an outbreak points to communities that are missing out on vaccines due to access, costs, or, in some places, complacency. We have to exhaust every effort to immunize every child."
A far higher level of coverage is needed to protect against vaccine-preventable disease outbreaks, UN health experts insist, noting that 118 countries achieved a 90% coverage threshold last year. Ideally, it should be 95% across countries and communities globally, they maintain.
American children are at risk not only from their non-vaccinated compatriots but also from others globally. Because the current delivery of the measles vaccine is via injection, it requires administration by skilled personnel. Further, vaccines must be kept both sterile and cold, and the storage, transport, and delivery steps of vaccination are challenging for developing countries that have unstable electricity and refrigeration. Because of international travel, these countries and their non-vaccination affect the entire world.
New vaccine patches are being explored that could simplify the delivery of the vaccine but communication and education for the need for vaccines must be equal in effort. Funding for such projects is still a great challenge for many developing nations.
Political issues that impact the availability of medical services and vaccines for the public were a major cause for measles outbreaks in the Middle East. While politicians argued about power, policies, and finances, public health facilities were closed and thousands went unvaccinated. In the remote villages of Central and South America and Africa, where measles outbreaks occur the most, vaccines are often not available because of lower socioeconomic status.
Instead of improving delivery of systems to provide the vaccines and surveys of families who have received them, the governments of these vulnerable people merely track the cases of measles. There have been valiant efforts to deliver vaccines but Third World and developing countries often do not have the resources to reach all of their populations.
As a healthcare professional, becoming an advocate for vaccination is powerful. People rely on the recommendations of educated healthcare professionals and anyone who is hesitant or resistant themselves can be a negative influence on many people.
The necessary first step is understanding the disease itself, the history of measles and its vaccine development, its clinical symptoms and treatments and, most important, overcoming vaccine resistance.
Alarming Costs of Non-vaccination
As early as 2010 the CDC was warning that the costs of not receiving the vaccine are alarming, saying vaccines are one of the most successful and cost-effective public health tools for prevention of disease and death (CDC, 2010). Following the CDC recommendations for seven childhood vaccinations (DTaP, Td, Hib, polio, MMR, hepatitis B, and varicella) results in an annual cost savings of $9.9 billion in direct medical costs for treating the disease and an additional $33.4 billion indirect costs to families and communities (CDC PB, 2018).
Costs to society from declining vaccination rates (in U.S. dollars) were estimated by AOL's Daily Finance in 2011:
- A 2002–2003 outbreak of measles in Italy, "which led to the hospitalizations of more than 5,000 people, had a combined estimated cost between 17.6 million euros and 22.0 million euros."
- A 2004 outbreak of measles from "an unvaccinated student return[ing] from India to Iowa was $142,452."
- A 2006 outbreak of mumps in Chicago, "caused by poorly immunized employees, cost the institution $262,788, or $29,199 per mumps case."
- A 2007 outbreak of mumps in Nova Scotia cost $3,511 per case.
- A 2008 outbreak of measles in San Diego, California cost $177,000, or $10,376 per case. (Alazraki, 2011)
Responding to Vaccine Resistance
We will look at some of the reasons given by people who are anti-vaccination and evaluate them in terms of the common good.
Hoax of Connection with Autism
A supposedly scientific journal article connecting the MMR vaccine with autism was declared a hoax—but its damage was done. Andrew Wakefield, a British gastroenterologist, falsely stated in 1995 his "finding" that aluminum and metal used in the MMR vaccine builds up in the brains of some children, causing autism spectrum disorders and colitis (Alazraki, 2011).
Wakefield's study involved only 12 children and he later lost his medical license for falsifying the study. His original claim was printed in the Lancet in 1998 and was later called "perhaps the most damaging medical hoax of the last 100 years" (Flaherty, 2011). After other scientists identified misconduct in his research methods—and even fraudulent work—his paper was partly retracted in 2004 and then completely in 2010, but it continues to be cited by anti-vaccination activists (Dyer, 2010). Wakefield was also found guilty by Britain's General Medical Council of serious professional misconduct and his license was revoked so that he can no longer practice medicine in the United Kingdom, his home country (Triggle, 2010).
Wakefield's claim was that the traces of mercury and aluminum that were to be found in the original MMR vaccine were causing autism and colitis. Early studies involved 537,303 children and an additional study with a much larger population of 657,461 children examined any possible truth to Wakefield's claims, however none found any evidence of a link between vaccines and autism (Edwards, 2001).
It is now the scientific conclusion that there is no link between MMR vaccine and either autism or colitis. The World Health Organization has expressed fear that the damage done in the minds of cautious parents has creating a generation of protective parents refusing to vaccinate their children. Time magazine in 2011 cited Wakefield's fake study as "that paper [that] killed children" and declared that he had been responsible for millions of childhood deaths (Park, 2011).
Against Religious Values
Some religious groups follow scriptures that state adherents should never allow a foreign substance in the body. In this thinking, a vaccine is a foreign substance and therefore proscribed. One example of such a group is Orthodox Jews, who believes the Torah clearly forbids vaccines because they intrude on the sacred body.
The debate continues over religious freedom versus protection of society from a preventable disease. A concern is that those who choose not to vaccinate put others at risk, generally children under age 1.
A recent outbreak occurred in the City of New York among ethnic minorities. Measles has spread to 4 out of the 5 major boroughs (New York Times, 2019). Health officials confirmed at least 626 (and counting) cases of measles in 2019 in New York City alone. New York Major Bill de Blasio has mandated vaccinations in four city zip codes. He has also declared a state of emergency in public health.
While the CDC makes vaccine recommendations, compliance has been left to the common sense of families for the protection of their children; now, however, in NYC vaccinating children according to the CDC recommendations is mandatory and 123 summonses have been issued for noncompliance. The majority of those summons are within an Orthodox Jewish community. The fine is up to $2,000.
Because of the nature of international flights and people moving into and out of New York, the city remains an area of potential transmission through travel; one person can have droplet contact with thousands of travelers in airports as well as train and bus terminals. New York City still has the highest proportion of the 940 cases identified in the United states in 2019.
When several Jewish parents filed a lawsuit claiming that to mandate a vaccine is against their constitutional rights to freedom of religion, a Brooklyn judge upheld the vaccine order, based on the higher principle of protection for the greater good (New York Times, 2019).
Threat to Individual Freedom
In the United States, childhood diseases continue to be seen because of parents who refuse to have their children vaccinated; they express fear of the safety of the vaccines and assert their freedom to choose how to care for their own family. The debate between individual freedoms and protection of the society continues to grow. In the language of philosophy, when a choice is made for the greater good as opposed to the individual right it is called utilitarianism. Societies differ in the degree to which they value utilitarianism. For example, North Americans value individuality based on personal freedoms and rights, whereas many Asian societies value what is best for the family (for example, protecting a family's name and honor).
The American attitude has impacted the number of children being vaccinated; unfortunately, it is the innocent children who suffer. Ironically, those who resist vaccinating their children infringe on the rights of others. The unvaccinated child may expose other people's children. It is estimated that 90% of people exposed to the measles virus who are not vaccinated will acquire the disease—and the majority of these are very young children.
Mistrust of Western Medicine
[Material in this section is from WHO, 2019.]
Many of the cases of measles in the United States have been seen in immigrant and ethnic minority communities. Culturally, they may be accustomed to another type of medical care, and that leads them to distrust Western medicine and fail to comply with government recommendations.
Physicians agree that vaccinations are crucial to public health and wellness. The American Medical Association highly endorses compliance with available CDC recommendations for all vaccines, including measles vaccine for children beginning at age 12 months. Proponents of the vaccine also include the World Health Organization, which firmly stated that measles vaccinations reduced global fatalities by 75% between the years 2000 and 2013.
By 2017 the global push to improve vaccine coverage resulted in an 80% reduction in deaths. During 2000–2017, with support from the Measles & Rubella Initiative and Gavi, the Vaccine Alliance, measles vaccination prevented an estimated 1.1 million deaths; most of the deaths averted were in Africa and in countries supported by the Gavi Alliance.
But without sustained attention, hard fought gains can easily be lost. Where children are unvaccinated, outbreaks occur. Because of low coverage nationally or in pockets, multiple regions were hit with large measles outbreaks in 2017, causing many deaths. Based on current trends of measles vaccination coverage and incidence, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) concluded that measles elimination is greatly under threat, and the disease has resurged in a number of countries that had achieved, or were close to achieving, elimination.
Four in five children receive the MMR vaccine that protects them from unnecessary bouts of measles, mumps, or rubella. The other 20% are left vulnerable to sickness that can become life-threatening. The lowest immunization compliance is among the poor, who may have insufficient healthcare; they are also the ones who are likely to have complications. When they are compromised, it threatens the gains we may be making in other areas of maternal and child health.
Fear of Negative Effects on the Body
Like anything introduced into the body, there are potential side effects. The immune system provides surveillance, building and destroying cells and activating signals. When a foreign agent, or antigen, is introduced into the body, surveillance cells, known as dendritic cells, recognize it as foreign and communicate with specialized white blood cells, known as macrophages and neutrophils, to attack. B-Cells signal which cells are to be attacked and create specialized antibodies within the blood that carry memories of the attack.
The body responds first with a general inflammatory response of vasodilation to help move killer cells more quickly to the offending pathogen. The clinical manifestations of heat and swelling come from vasodilation. Vasodilation pushes on nerve endings, causing pain; the side effects of vaccines reflect this natural immune response and indicate the body is responding correctly. When an arm or leg muscle hurts from the injection site, it is a demonstration of the vasodilation stage.
The more advanced stage of antibodies that develop immunity through memory cells takes several days. These memory cells remain in our system for years, but can degenerate over time, which is why a booster vaccine may be needed. Babies and young children don't yet have the memory cells, which is why they seem to get ill so often. Their body hasn't responded to the plethora of pathogens yet, so their immune system is immature.
Vaccines are a way of helping the body quickly develop the needed and protective antibodies against diseases. Inactivated vaccines transport to the body, through an injection or oral liquid, the shell or dead pieces of a pathogen. The body recognizes it as an enemy and quickly goes into action through the creation of antibodies. Think of the skin of a snake—it may elicit screams as if it were the live snake, however there is no venom within the snake skin to bite or hurt us. Live vaccines are synthetically altered real germs that initiate a strong response but cannot cause the actual disease.
Side effects from vaccines are real but generally not serious. A comparison of effects from the vaccine versus the actual measles disease is shown on the table below. Figures are based on a projection of 10,000,000 children; that is, if that number were in the study, these would be the results based on actual scientific evidence.
Side Effects of Measles Compared with the MMR Vaccine
980,000 with fever (10%)
9,800,000 with fever (98%)
490,000 with mild rash (5%)
9,800,000 with rash (98%)
1000 allergic reaction (0.0001%)
800,000 with severe diarrhea (0.08%)
1000 inflammation of genitalia (0.0001%)
700,000 ear infection (7%) may cause permanent hearing loss
600,000 pneumonia (6%)
10,000 develop encephalitis (0.1%)
2,500 progressive brain inflammation—SSPE (0.0025%)
2,500 progressive brain inflammation—SSPE (0.0025%)
2.5 million children will suffer from side effects from measles
1 child may die
20,000 children will die