Deaths from measles have risen to new heights in Europe in the past year. The rapid spread of the measles virus has led to more than 3,300 cases and 35 deaths in Romania, Italy, Germany and Portugal. The most recent death was that of a six-year-old boy in Italy who died on June 22.
Nearly all of the recorded deaths have been in unvaccinated individuals, despite there being a safe and effective vaccine against measles, routinely used in the UK since 1968 and, as part of a triple measles, mumps and rubella (MMR) vaccine, since 1988.
Successful implementation of the MMR vaccine was interrupted in the early 2000s following publications by Andrew Wakefield linking it to autism. These claims have since proven unfounded in large epidemiological studies – but, for a period between 1998 and 2004, MMR coverage fell dramatically enabling measles epidemic outbreaks such as the one in Swansea, UK in 2012-13 (1,219 people infected), and the 2015 Disneyland outbreak in California (147 people infected).
The recent European outbreaks have been recorded in areas with low vaccination rates, linked to highly vocal anti-vaccination groups and their supporters (for example the Five Star Movement, a populist Italian party). This has been compounded by continuing problems in the supply of vaccines and access to vaccination services.
Ten years ago, immunisation rates in Romania were as high as 97%. Several events prompted a downward trend. Around 2013 a former TV presenter and media celebrity fronted an anti-vaccination campaign in Romania, supported by an ultra-conservative religious pro-life movement. A shortage of vaccine supplies made the problem worse, as did difficulties in vaccination services reaching more rural parts of the country and minority groups, such as Romanian Roma. Within three years the immunisation rates dropped from 92% to below 80%.
Even if a country has high vaccination rates, there can be pockets of low vaccination. Portugal has very high vaccination rates (98% in 2015) but still experienced an outbreak in which nearly half of the cases were healthcare workers. And Germany has high national rates but large regional variation.
Migration can also bring new cases to countries with high immunisation coverage: Slovakia experienced an “imported case” of measles in 2015 in a 25-year-old, unvaccinated Italian student. Vaccination coverage in Hungary has been over 95% for a few decades, yet in 2017 there were 54 cases of measles in the regions bordering Romania.
Far from being a benign childhood illness, measles is highly infectious and dangerous. It spreads rapidly in unvaccinated populations, through direct contact but also through the air by coughs and sneezes. Just visiting a room where an infected person has been within a couple of hours, such as a GP’s surgery, can be sufficient for a susceptible person to catch the disease. It can cause a number of complications (such as ear infections, pneumonia, meningitis, gastroenteritis or brain damage from encephalitis). Measles can also cause a rare but devastating condition called SSPE which leads to a progressive destruction of the central nervous system.
Measles vaccination coverage of at least 95% of the population has been recommended by the WHO. This significantly reduces the chances of the virus spreading, and creates a protective barrier known as herd protection or immunity.
Certainly there are many reasons for the causes of outbreaks in Europe, so what could this mean specifically for the UK? Should we be concerned? The UK is keeping up rates of MMR immunisation at the moment, achieving the WHO target of 95% in 2016 for the first dose of MMR, and maintaining rates of over 90% for two of the recommended three doses.
But it would not take much to send this off course. Immunisation rates only need to drop slightly below 95% for measles to start circulating more widely in the population, leading to serious illness and deaths. As this has already been happening across Europe, governments of Germany, France and Italy are bringing in urgent measures in order to prevent further cases.
Most people are too young to remember a time when deaths from measles were commonplace. The author Roald Dahl painfully recalled how his seven-year-old daughter died of measles encephalitis. Olivia died in 1962, six years before a measles vaccine was available in the UK. Two decades years later, he wrote a moving account of her death. Unfortunately, his pleas to vaccinate are still echoed by parents who have experienced the heartbreak of losing their child from the same vaccine-preventable complication.
As British GP Eleanor Draeger told her colleagues at the recent British Medical Association annual meeting: measles is a disease that should by now be consigned to history.