Measles Running Rampant in Pakistan and Wales

Whenever I hear someone say that vaccine-preventable diseases are harmless or that they are just a right of passage for children, I can't help but shake my head a bit. Part of the reason behind this mindset is a lack of experience with these diseases. Many young parents have never seen them in action. The most they know is their own childhood experiences with them; they clearly survived and, with death being thankfully uncommon, probably don't know or remember anyone who died of one of these illnesses, especially if anyone contracted a disease at a young age. And then there's the rarity of the diseases thanks to the success of vaccinations. I have to admit that before I developed an interest in vaccines and the manufactroversy surrounding them, I probably would have held a similarly flippant opinion of childhood diseases.

But I learned more about them. I read about their typical presentation, what some of the more serious complications are and how commonly they occur, and how long a person is contagious (often starting before any symptoms appear). I learned that while one needn't panic and run for the hills when there's an outbreak, a healthy respect for the seriousness of vaccine preventable diseases doesn't go amiss. Above all, I've learned that they are worth preventing, if not for one's own health, then for the health of those around them. While I might be healthy and think I might fare well if infected, the same may not be true for others I infect.

To this end, vaccinations are one of the best public health measures in modern medicine. When people avoid or reject them in sufficient numbers, we invariably see outbreaks of disease sooner or later. Outbreaks like the current measles outbreaks in Pakistan and Wales.

Epidemic in Pakistan

Punjab

As I wrote in January, Pakistan is in the grips of a major measles epidemic. Already this year, the province of Punjab has seen 7,794 cases of measles, including six children who have died of the disease. This is in the expected range of 1-2 deaths per 1,000 cases. Difficulties with vaccine distribution and uptake, as well as attacks on health care workers, have been significant blocks to containing the epidemic. According to reports, efforts are under way to engage international organizations like UNICEF, the Global Alliance for Vaccines and Immunization, the WHO, the United States Centers for Disease Control and Prevention and others for aid in procuring and administering measles vaccines to 3 million children in Punjab alone. This effort is part of a country-wide push to protect the nation's children and, hopefully, bring the measles crisis under control.

The magnitude of the outbreak is staggering, particularly to someone where measles is nearly unheard of. However, exposure is just a plane ride away. Thanks to vaccine scares, the disease has come roaring back to places that once had it under control. Within the last several years, Europe has seen measles go from sporadic activity to widespread outbreaks, with France one of the hardest hit. The latest region in Europe that's been popping up in my news feed is Wales.

Achosion o'r Frech Goch

The first I learned of the Welsh measles outbreak was on February 28, 2013, when the BBC reported that the Swansea and Neath Port Talbot areas had recorded 189 cases. This comes after England and Wales had seen their highest number of measles cases in 18 years. Since then, the number of measles cases has passed 800, with 77 people hospitalized since the outbreak began last November. In fact, the number of cases is approaching the area where we would start expecting to see deaths.

That may, in fact, be the case. A 25-year-old man, Gareth Williams, may be the first death in this outbreak. Preliminary lab tests have shown that he was infected with measles when he died. Williams had been treated in hospital for his asthma and discharged. After a few days, he fell ill and developed a rash. On April 17, he visited a general practitioner, and on the 18th, he was found dead in his flat. Although measles likely contributed to his death, the cause of death is still under investigation. My thoughts go out to Mr. Williams' wife, young daughter, his parents and his sister.

What gets to me about all this is that it never should have happened. Back in 1998, Andrew Wakefield published a now-retracted small case series study in The Lancet, claiming to link the MMR three-in-one vaccine with a new disorder of the gut. Following publication, Wakefield held a press conference and made other media appearances where he suggested that the MMR caused a gut disorder that then led to autism, despite there being no data to support such a claim in the study itself. As a result, MMR uptake rates in the United Kingdom plummeted, falling far below the 95% uptake rate required to establish herd immunity. And before anyone claims that Wakefield never said MMR causes autism, he certainly is making that claim now.

Now, Wakefield is not solely responsible for the current outbreak. The editor of The Lancet, Richard Horton, should never have published the study, even if Wakefield had never committed research fraud by manipulating data. And the U.K. media also deserves well-placed blame for latching onto Wakefield's claims and widely publicizing them. Remember, this was a case-series of only 12 patients. The design only allowed for preliminary findings that would have required further research by others to validate. Other researchers did try to replicate Wakefield's findings, but, no surprise since he fudged the data, they failed.

Wakefield recently came out swinging at the U.K. government, trying to shift blame for the outbreak from himself to the government. He brazenly claims that because the government removed approval for a single measles vaccine, that they are responsible for the outbreak, because people that he scared away from the MMR had no other option. Wakefield does not even acknowledge that he caused a scare or that he did anything inappropriate by making media appearances suggesting that the MMR was dangerous or that it led to autism, both claims of which are false.

Wales has not had adequate MMR uptake for 1 dose of MMR for many, many years. It is still under 95% for the whole country, and uptake of the second dose is even lower. It is no surprise that we have been seeing growing outbreaks of disease in the United Kingdom. Since Wakefield's fraudulent research, there have been waves of outbreaks, each larger than the last.

And at least one Swansea-area health provider is not doing much to help. The Children's Immunisation Clinic parrots Wakefield's bogus claim that the MMR three-in-one jab is dangerous and can cause autism. As evidence, they provide links to articles in the Daily Mail, a newspaper in the U.K. that is frequently criticized for publishing dubious articles.

Pakistan and Wales both serve as strong reminders of just how important measles immunization is. Despite the mistaken notion that measles is a "mild" disease, the experiences seen in regions where the disease is endemic shows just how serious a disease it is. In the U.S., if anti-vaccination groups continue to have any influence on uptake, leading to pockets where protection has fallen below 95%, these countries, as well as many others, show us out future. Measles is not a mild disease.