Andrew Schroeder reports that measles, once a common and deadly childhood illness which had been declared “eliminated” from many parts of the world including the United States, Canada and Europe nearly two decades ago, is back on the global health agenda. Measles cases globally rose nearly 300 percent in the first quarter of
2019 as compared with the first quarter of 2018, according to surveillance data covering 190 countries released last week from the World Health Organization. Over 112,000 cases were reported to start this year, as opposed to just over 28,000 from the beginning of 2018. That year likewise saw a significant gain as compared to 2017.
Although still not close to the shocking levels of the mid-20th century, when tens of millions of children were infected and millions died, the trend for new measles infections seems to be inexorably and frustratingly on the rise. This trend places children under the age of 10, particularly in poor and conflict affected parts of the world, at increasing levels of entirely avoidable risk.
THE GLOBAL MEASLES RESURGENCE
One of the most common explanations in the media for the measles resurgence has to do with a set of beliefs promoting reluctance to follow through with childhood
vaccinations. The WHO earlier this year labeled this emerging reluctance one of the world’s “top ten” threats to global health. The spread of misinformation about childhood vaccination is leading to a wave of what the World Health Organization calls “vaccine hesitancy.” Over time, declining tendencies to follow through on evidence-based public health recommendations may threaten long-established successful practices, which have improved the health of children since the mid-20th century.
In parts of California, New York and Washington State, for instance, there is evidence that relatively small outbreaks have been correlated with reduced vaccination rates due to anti-vaccine misinformation combined with novel introduction of the virus, often through travelers.
Globally, however, how can the disease’s resurgence be explained? Without question, the world needs to remain vigilant to any possibilities that the consensus around childhood vaccination may be undermined over time by rising “vaccine hesitancy.” However, large numbers of people around the world are still not able to access the vaccinations they both want and need.
MEASLES, CONFLICT AND HEALTH SYSTEMS
In addition to the effect of vaccine hesitancy, we need look no further than the WHO’s own country-level data on the locations and growth trends of measles cases. Almost all the enormous jump in measles cases from 2017 until the beginning of this year is attributable to a handful of places. This year, almost two-thirds of the entire reported global measles caseload is attributable to just two countries: Ukraine and Madagascar. These two countries are highly instructive as to the true reasons why we should pay attention to measles as something like a “canary in the coalmine” for the underlying weaknesses of public health systems.
Let’s start with Ukraine, which may appear, at first glance, to be the most puzzling. Why should a middle-income country on the edge of Europe, with a historically reliable, near-universal public health system, suddenly become a kind of poster child for the rampant spread of infectious childhood illnesses for which immunization
exists? The answer is pretty simple: conflict. Prior to 2014, Ukraine maintained a measles vaccination rate of 95 percent, generally considered the gold standard level for herd immunity. Then, conflict broke out between Ukraine and Russia. As a result, the Ukrainian Ministry of Health budget was frozen and measles vaccination procurement largely ceased until late 2015. By 2016, Ukraine’s vaccination rate had plunged to just 41 percent, one of the lowest rates on the planet. In subsequent years, the vaccination rate in Ukraine crept back up close to its pre-conflict levels, with about 91 percent coverage achieved last year. But the damage had been done. A multi-year cohort of Ukrainian children had lost their immunity to the disease. Combined with widespread disruption of the primary health care system, and the physical effects of conflict on large numbers of communities, measles took root again quickly and began to spread.
Some of the migration of measles from the Ukraine epidemic has apparently gone international, with cases in New York, Israel and elsewhere traced directly to index
cases of travelers from Ukraine. Elsewhere, in places from Yemen to Nigeria, one can also detect the sharply negative impact of conflict on basic health system capacities and measles infection rates. The lessons of the Ukrainian measles epidemic, as is also the case with these other countries, are not only that it doesn’t take much to fundamentally disrupt a well functioning health system and produce an otherwise preventable outbreak. Disruptions to health systems in one country, given high levels of global mobility through air travel, can quickly be felt in many places throughout the world.
THE PERIL OF UNDER-FUNDING HEALTH CARE
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