The Measles Ward at the University Teaching Hospital in Lusaka, Zambia (2003)
Bill Moss, MD, MPH
Dr. Bill Moss is a Professor at the Johns Hopkins Bloomberg School of Public Health and Director of Epidemiology at IVAC. He is a pediatrician and global health expert in childhood infectious diseases and has worked extensively in the areas of measles control and eradication, malaria control, and HIV treatment.
The Measles Ward was empty. The Measles Ward at the University Teaching Hospital in Lusaka, Zambia was always full of children, particularly now at the start of the measles season. But several months after the Government of Zambia conducted their first national mass measles vaccination campaign in 2003, the ward was empty. I was astounded. I took a photograph of the empty ward. It is difficult to see the absence of something, but this was a striking image of the absence of measles – an empty hospital ward – and an image that captured the power of vaccines. A successful mass vaccination campaign can provide sufficient protection to vaccinated children and herd immunity to those few who are not immunized, demonstrating that measles virus transmission can be stopped and a measles ward emptied. Approximately 5% of the hundreds of children admitted to that ward died of measles every year, with more dying who never made it to the hospital, others dying after leaving the hospital, and children weakened by measles. These deaths were stopped. It was invisible, but real.
Measles is a viral infection caused by measles virus and characterized by fever, cough, runny nose, red eyes and a distinctive rash. Well-nourished children with good access to health care rarely die of measles, but about 1 in 1000 can get a severe neurological disease as a result of an immune reaction to measles virus. Undernourished children, however, are at high risk of death from measles. In the most extreme circumstances, such as refugee camps, as many as one quarter of children with measles can die. In the absence of vaccination, almost all children will get measles because of its high contagiousness. Today, it is difficult to imagine that prior to the introduction of measles vaccine fifty years ago, measles killed millions of children each year, with some estimates as high as six to eight million deaths per year due to measles. This is far higher than the number of deaths due to AIDS, tuberculosis, and malaria.
Remarkably, a measles virus strain isolated in the mid-1950s, which formed the basis for most of the commonly used measles vaccines around the world today, continues to provide protection against measles five decades later. We do not need to develop new measles vaccines each year as we do for influenza virus. The vaccine is safe and inexpensive, and two doses are sufficient to provide protection to nearly everyone.
So why does measles still kill tens of thousands of children each year? Why is it still occurring in some of the richest countries of the Americas and Europe? Why, in 2014, do we have more measles cases in the United States during the first quarter of the year than we have had since 1996?
The problem is invisibility, as successful public health programs undermine themselves. The disease goes away, political and public attention are directed elsewhere, rumors and misinformation spread, and risks of the vaccine are perceived to be higher than the risk of disease. Along with the high contagiousness of measles virus, a small drop in the number of vaccinated children can lead to outbreaks.
Photo Credit: Dr. James Chipeta (2010)
Sadly, the empty Measles Ward in Lusaka was full again in 2010, overflowing with children in the hallways, as a result of a large measles outbreak that swept through much of sub-Saharan Africa that year. Routine immunization coverage was not sustained at sufficient levels, vaccination campaigns were postponed, and susceptible people accumulated. Once this tinder was ignited by the introduction of measles virus, a massive epidemic had exploded. In the Americas and Europe, misconceptions about the safety of measles vaccine continues to result in low measles vaccine coverage in some communities, which have led to recent measles outbreaks in California, New York, and Washington state and have put children unable of receiving measles vaccine due to serious medical conditions at high risk.
We have the tools to defeat measles, even the tools to eradicate measles. The global public health community now faces a stark choice: to continue to make progress in measles reduction with the ultimate goal of measles eradication, or have recent successes in measles control lead to a loss in public interest, donor support, and political motivation. This year, World Immunization Week’s challenge to everyone, no matter where you live, is to know which vaccines you need, check that you are up-to-date on your vaccinations, and continue to protect yourself by getting timely vaccinations.. Meeting this challenge will be necessary to ensure that future generations of children do not die of measles and that all measles wards are emptied.