May 07 2019

Here’s Why This Year’s Measles Outbreaks Are So Bad

Measles is back with a vengeance. So far this year, more than 700 Americans have become infected, the greatest number of cases reported in the U.S. in more than 25 years.

Columbia Mailman School experts say a variety of factors are behind the recent upsurge, which has spread quickly despite the availability of a safe and effective vaccine. Understanding these factors, they say, could point to a way to stop future outbreaks from taking hold.

“We’re facing a perfect storm of a highly contagious infection introduced into pockets of unvaccinated children,” says Melissa Stockwell, an associate professor of population and family health at Columbia Mailman and of pediatrics at Columbia University Irving Medical Center. “It’s important that everyone is familiar with the risks.”

Measles is many times as infectious as the flu and lingers in the air or on surfaces hours after an infected individual has left a room. “Ninety out of one hundred non-vaccinated people exposed to an infected person will develop the disease,” says Ian Lipkin, director of the Center for Infection and Immunity at Columbia Mailman.

While most cases of the measles are mild, one in twenty infected children in the U.S. is hospitalized with pneumonia, and some infections can cause deafness. In 2017, the illness killed 110,000 people worldwide, nearly all young children in low-income countries.

Alumni on the Front Lines

The biggest of the ongoing measles outbreaks in the U.S. is linked to a traveler from Israel who infected members of an Ultra-Orthodox Jewish community in Brooklyn last year. From there, measles spread to other Ultra-Orthodox communities north of the city in Rockland County. In all, there have been 13 separate outbreaks across 22 states this year.

The Health Commissioner of Rockland County, Patricia Ruppert, MPH ‘15, is leading the effort to stop the outbreak there. On April 16, Ruppert ordered parents to keep any children with measles or children who were exposed to measles away from public places within the county, with exceptions made for medical care. Separately, she required that schools turn away unvaccinated students without a medical or religious exemption. These and other actions have led to a recent uptick in vaccinations in the county. 

In New York City, Health Commissioner Oxiris Barbot ordered that everyone eligible for the MMR vaccine in four Brooklyn zip codes get vaccinated. She also closed several schools that failed to exclude students without vaccination documentation. Nina Rothschild, DrPH ‘00, a research scientist in the City Health Department, set up a measles call center after the department was swamped with questions about measles. Among other responsibilities, call center staff arrange for couriers to transport specimens from the providers’ sites to the department’s public health laboratory.

Rabbis and other Jewish leaders have also been active in the measles response, speaking out to encourage the small group of non-vaccinating parents in their communities to vaccinate their children. While New York and other states allow religious exemptions for the MMR vaccine, Judaism like all the other major religions supports vaccination. “The same holds true of Ultra-Orthodox communities” emphasizes Stephen Morse, professor of epidemiology and an originator of ProMED-mail, an international network for outbreak reporting and disease monitoring. “It’s important that we do what we can to avoid stigmatizing people who have historically been subject to a great deal of stigmatization.”

Countering Misinformation

According to Melissa Stockwell, two strands of misinformation contribute to the recent outbreaks. First, families mistakenly believe that measles is not dangerous; at the same time, they fear the vaccine could harm their child. Of course, the truth is the opposite. “We know that measles is a severe disease, and the vaccine is safe,” she says.

In some ways, the MMR vaccine has been a victim of its own success. The experience of measles is outside the living memory of most people alive today. The vaccine was introduced in the 1960s, and by 2000, measles was eliminated in the U.S., meaning it was no longer endemic. Since then, outbreaks of measles in the U.S. only happen when they are triggered by visitors from other countries where measles is circulating. 

Meanwhile, public confidence in the vaccine has weakened ever since the 1998 publication of a now-discredited paper by Andrew Wakefield which spuriously linked the vaccine to autism. A 2008 paper by Ian Lipkin and colleagues demonstrated conclusively that the MMR vaccine had no link to autism. But in recent years, the spread of falsehoods has accelerated in viral fashion via Twitter and Facebook. “The ease and rate of spread of disinformation related to vaccine safety have increased dramatically with the rise of social media platforms,” says Lipkin.  

Thankfully, technology can also be effective in a positive direction. While it may not be possible to change the minds of the most ardent anti-vaxxers, alumna Rachel Alter, MPH ‘18, found success in engaging with the larger group of parents who are undecidedResearch by Stockwell showed that simple text message reminders can motivate more parents to vaccinate their children.

Forward or backward?

Globally, vaccination efforts have led to enormous progress against measles; according to WHO estimates, improved vaccine coverage prevented more than 20 million measles deaths since 2000. Some public health experts believe measles could eventually be eradicated like smallpox. In the U.S., even a small improvement in vaccination rates could make a huge difference. If just 2 percent more children were vaccinated, herd immunity would stop any imported measles case in its tracks.

Unfortunately, this year’s outbreaks suggest the trend is moving in the wrong direction—a development that presents the unwelcome possibility that measles could regain a foothold in the U.S. “If we can’t stop the outbreaks, there’s a risk measles will become endemic again,” says Stockwell. “It’s crazy to think about. The MMR vaccine was a huge public health achievement. Today we’re facing the prospect of going backward.”

“If enough people decide to refuse [the vaccine], there’s no reason measles couldn’t reestablish itself,” adds Stephen Morse, who had measles as a child at a time when children were routinely infected. “I lived through that time. I would not want to live through it again.”