What can the lessons of measles teach us about the importance of vaccines?

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What can the lessons of measles teach us about the importance of vaccines?

In 1713, Cotton Mather, a prominent Boston minister who would bring the practice of smallpox variolation to the colonies, watched helplessly as measles devastated his family. On October 18 of that year he wrote in his diary, “The Measles coming into the Town, it is likely to be a Time of Sickness, and much Trouble in the Families of the Neighbourhood.” That day his eldest son became ill. Two daughters developed measles over the next few days. However, in the midst of this “heavy Calamity,” there was joy: his wife gave birth to twins Eleazar and Martha.

But in quick succession Mather’s wife, three more daughters, another son, and the maid contracted measles. On November 8 he wrote that his wife has “surprising Symptomes of Death upon her.” She died the next day while one of the daughters was worsening. On November 14, the maid died, and the newborns were noted to be ill with measles and “languishing in the Arms of Death.” Tiny Eleazar died on November 18 and his twin, Martha, died soon after. Finally, last to be struck down, was the “lovely Jerusha,” aged 2 years, 7 months, who had been a particular delight to Mather. In just a few weeks, measles had claimed four members of his family.

Terrible narratives like this would become less frequent as time passed because of changing epidemiological dynamics, generally improved health, and better medical care, but measles was never seen as an entirely benign disease. As Alexander Monro (secundus) (1733-1817) wrote, “[I]t is well known how liable this disease is to infest the lungs, and how great destruction it causes there.” Success with smallpox variolation at preventing disease led 18th-century doctors to try a similar approach with measles. During a 1758 measles epidemic in Edinburgh, Francis Home (1719-1813) inoculated subjects with measles. He tried a variety of inocula (blood as well as material scraped from the rash) and methods (intranasal inoculation as well as inoculation of skin) over the year. Most inoculated children became ill with what seemed to be a mild form of measles; the outcome Home hoped to prevent, pulmonary complications, did not develop in any of the subjects.

Several other physicians attempted measles inoculation into the 20th century, when tissue culture techniques finally provided a way to grow the vaccine virus in the lab. At last the great burden of disease could be reliably relieved. Mather’s dreadful calamity would not be repeated in countries with strong immunization programs. But his words unfortunately still resonate today across developing countries, where measles deaths in children under five devastate families and communities because of lack of access to measles vaccine.

For more on measles and measles vaccine history, see the timeline at HistoryofVaccines.org, an education project of The College of Physicians of Philadelphia. 


Sources

Jugelen C. The long prehistory of modern measles vaccination. In Plokin SA, ed. History of Vaccine Development. New York: Springer; 2011:189-198.
Matter C. The Diary of Cotton Mather. Boston: The Massachusetts Historical Society; 1911. Retrieved from https://openlibrary.org/books/OL25527894M/Diary_of_Cotton_Mather_...

Karie Youngdahl
Director, The History of Vaccines

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Karie Youngdahl
Director, The History of Vaccines

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Karie Youngdahl is the director of the award-wining History of Vaccines project, found online at www.historyofvaccines.org. The site offers historical and contemporary information about vaccines and vaccine-preventable diseases with the aim of exploring the impact vaccines have had on human health. The History of Vaccines is a project of The College of Physicians of Philadelphia, the oldest professional medical society in the United States. 

Youngdahl is a graduate of Stanford University. Before launching HistoryofVaccines.org in 2010, she worked as a writer and editor in educational and biomedical publishing. 

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What can the lessons of measles teach us about the importance of vaccines?

The scientific evidence is strong--vaccines save lives and prevent dangerous diseases like measles.  But perhaps the most poignant lesson is that good science alone is not always enough. Laws and policies matter a lot. As the US experiences a significant measles outbreak, one lesson is clear: science and policy go hand-in-hand. In order to fully realize the power of vaccines, we also need strong laws and policies to support high immunization rates. 

The current measles outbreak is reigniting the discussion about mandatory immunizations versus freedom to choose and is playing out differently in each state.   California, where the outbreak originated, has a moderately difficult vaccine exemption policy. Parents can opt out of vaccines based on their beliefs. As one of only 20 states that allow non-medical or ‘philosophical’ exemptions, California is now rethinking that policy.

In contrast, Mississippi is only one of 2 states (West Virginia being the other) that only accept a medical reason for not vaccinating. As such, Mississippi boasts the highest measles vaccination rate in the country. However, Mississippi recently faced a critical situation. A legislative proposal was filed which would allow non-medical exemptions. Fortunately the existing legislation was upheld and no changes were made to their exemptions’ policy.

Many times we propose policies in their perfect form and must then find a compromise that allows for the political realities. This was the case in Colorado in 2014, which had high non-medical exemption rates. The Colorado Children’s Coalition along with other stakeholders proposed doing away with non-medical exemptions. The policy, in the end, required compromise and was modified. While it was not perfect, the amended policy resulted in certain limitations with respect to non-medical exemptions. Schools must publish exemption rates and parents must go through vaccine education. The real accomplishment was finding middle ground to limit exemptions and balance political realities- all buttressed by the expert opinions of the local and national medical community.

So what can we do as a vaccine community to ensure vaccine policies matter and make a difference? The scientific community needs to engage with policy makers to ensure that evidence-based science is the foundation of all laws and policies pertaining to vaccines.   Likewise policy makers need to reach out to the scientific experts to design policies that are based in science. A multidisciplinary approach to crafting sound laws and policies for vaccines is needed to ensure that science is reflected in the laws and policies.  The lesson learned from the measles outbreak is simple--science and policy must align in order to prevent outbreaks.

Anna Dragsbaek
President & CEO, Immunization Partnership

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Anna Dragsbaek
President & CEO, Immunization Partnership

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Anna C. Dragsbaek became aware of the critical role that vaccines play in the health of communities when working in a rural hospital as a Peace Corps volunteer in Sierra Leone, West Africa.  She later pursued and completed her law degree, specializing in Public Health Law, at the University of Houston while working as Manager of the Immunization Project at Texas Children's Hospital. 

In 2008, Anna became President and CEO of The Immunization Partnership, a nonprofit which promotes the importance of immunization through advocacy and education to individuals, community partners and healthcare providers. 

Anna is very committed to the local and international community, holding past and present board positions on the American Immunization Registry Association, The Confederation of Meningitis Organization, American Leadership Forum, and the Texas Lyceum.  She has been published in several peer reviewed journals,  and has received numerous awards, including the CDC Childhood Immunization Champion Award for promoting and fostering childhood immunizations. She was also the recipient of the 2013 Episcopal Health Foundation award for Community Health Leadership. 

Anna is the proud parent of two boys, who are both fully immunized.  

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What can the lessons of measles teach us about the importance of vaccines?

It comes to no surprise that the recent outbreak of more than 100 cases (at this writing) of measles in the nation opened up contentious debate over vaccinations, which in turn , has a profound impact on public health. Though measles were declared no longer endemic in the United States more than a decade ago, it has not been eradicated. As long as measles exist around the globe, still common in some countries in Europe, Asia, the Pacific, and Africa, the threat of its introduction by people outside of the country will continue to remain. The outbreak brings to light that immunization is in itself a public health issue, and vaccines play a significant role to increase the wellbeing of our Americans by elevating preventability and sustainability within the healthcare ecosystem.

An essential part of public health, in the practice of serving and honoring all the men and women who are American veterans, is to consistently address healthcare initiatives applicable to them. Our military and the Veterans Health Administration has long been in touch with the public health issues surrounding our veterans, working to reach the 21.8 million American veterans currently in the U.S., to provide a comprehensive system of healthcare assistance. The Veterans Health Council’s ongoing expansive efforts to educate and inform veterans of health benefits to ensure proper and prompt medical care, extends to raising awareness on necessary immunizations. For example, in October 2014, the Department of Veterans Affairs announced partnership with community pharmacies to expand access to vaccinations recommended by the Centers for Disease Control and Prevention (CDC) for veterans across the country.

Not just our veterans, but every American has a public health commitment to each other and to our communities. And vaccines allow that commitment to be exercised to the fullest extent, to protect and to sustain the healthy communities that exist. Despite the recent outbreak, the track record for today’s measles vaccine, making the disease rare, regards it as one of the most impressive accomplishments of modern science and medicine, according to the CDC. In fact, not only measles, but the elimination of many other preventable diseases have been successful because of available vaccinations.

Recognizing the importance of vaccines also identifies room for improvement, to make it easier for Americans to have access to their healthcare providers and to develop a healthy relationship with doctors for example, to raise any questions or concerns with regards to vaccination. A stronger patient-doctor-provider relationship will carve out a system that accurately captures the perception of health from individuals to enhance understanding of how we can continue to ensure Americans have access to vaccines, the best defense to infectious diseases.

To ensure best systems in enhancing the leverage of achieving better health, effective vaccination puts the nation’s healthcare delivery and practice on a much more viable path. The measles outbreak is an invaluable opportunity to remember that we absolutely depend on the continued success of vaccinations, and they represent one of the most important health investments to securing our nation’s health.

Thomas J. Berger, PH.D.
Executive Director, Veterans Health Council

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Thomas J. Berger, PH.D.
Executive Director, Veterans Health Council

Dr. Tom Berger is a Life Member of Vietnam Veterans of America (VVA) and founding member of VVA Chapter 317 in Kansas City, Missouri. Dr. Berger served as a Navy Corpsman with the 3rd Marine Corps Division in Vietnam, 1966-68. Following his military service and upon the subsequent completion of his postdoctoral studies, he held faculty, research and administrative appointments at the University of Kansas in Lawrence, the State University System of Florida in Tallahassee, and the University of Missouri-Columbia, as well as program administrator positions with the Illinois Easter Seal Society and United Cerebral Palsy.

After serving as chair of VVA's national PTSD and Substance Abuse Committee for almost a decade, he joined the staff of the VVA national office as "Senior Policy Analyst for Veterans' Benefits & Mental Health Issues" in 2008. Then in June 2009, he was appointed as "Executive Director of the VVA Veterans Health Council", a 501c3, whose primary mission is to improve the healthcare of America's veterans through education and information.

Dr. Berger has been involved in veterans' advocacy for over twenty-five years, and he is a member of VVA's national Health Care, Government Affairs, Agent Orange and Toxic Substances, and Women Veterans committees. As such, he is a member and the former Chair of the Veterans Administration's (VA) Consumer Liaison Council for the Committee on Care of Veterans with Serious Mental Illness (SMI Committee) in Washington, D.C.; he is also a member of the VA's Mental Health Quality Enhancement Research Initiative Depression Executive Committee (MHQUERI) based in Little Rock, Arkansas and the South Central Mental Illness Research and Education Clinical Center (SC MIRECC) based in Houston, Texas. Dr. Berger holds the distinction of being the first representative of a national veterans' service organization to hold membership on the VA's Executive Committee of the Substance Use Disorder Quality Enhancement Research Initiative (SUD QUERI) and serves as a national committee member on the National Association of Alcohol and Drug Abuse Counselors (NAADAC) veterans' working group and member of the National Leadership Forum on Behavioral Health-Criminal Justice Services with the CMHS-funded national GAINS Center. He has also served as a reviewer of research proposals for the Department of Defense (DoD) "Congressionally Directed Medical Research Programs" and is a current member of the Education Advisory Committee for the National Center on PTSD.

Dr. Berger has addressed veterans' health care issues on local Washington and national media outlets including CNN, before FDA committees and Justice Department commissions, and on many occasions, has presented on-the-record testimony before both the U.S. House of Representatives and Senate Veterans' Affairs Committees, Subcommittees and Roundtables regarding mental health, substance abuse and related health issues affecting America's veterans.

Dr. Berger's varied academic interests have included published research, books and articles in the biological sciences, wildlife regulatory law, adolescent risk behaviors, domestic violence, substance abuse, suicide, and post-traumatic stress disorder. He currently resides in Silver Spring, Maryland.

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What can the lessons of measles teach us about the importance of vaccines?

We’re all in this together.

People sometimes imagine that whether or not to vaccinate is a personal decision—that it only affects your own children. And other people assume that as long as their own children are vaccinated, they don’t need to worry about what their neighbors do.  These fallacies come from a fundamental misunderstanding of how vaccines work.

Immunizations protect individuals from catching diseases, that’s true. But that’s not really their main purpose. We can’t just rely on immunizations to protect individuals one by one, because of several limitations. Some people can’t be vaccinated—including young babies. The MMR (measles-mumps-rubella) vaccine isn’t given until 12 months of age. Other people cannot be vaccinated because they have health or immune problems, or are undergoing chemotherapy. These cannot-be-vaccinated people, ironically, are at the highest risk of complications from infectious diseases. And, like any other medical interventions, vaccines don’t work 100% of the time. With the MMR vaccine, after completing the series of two doses 99% percent of individuals are fully protected for life. That’s an amazingly effective vaccine. But in a huge country like ours, even if 300 million people are fully vaccinated, 3 million of us (that’s the 1% who don’t respond to the vaccine) will remain unprotected. The Disneyland theme parks in California have about 40,000 visitors a day—even if they all were fully vaccinated, 400 would remain susceptible to measles. Add to that the babies and other people who can’t be vaccinated, and you’ve got a pretty big crowd of people who are at risk.

So how can vaccines best protect everybody? By what’s called “herd immunity.” If almost all of the people in a community are protected with vaccines, that prevents the spread of the disease to everyone—not just the vaccinated people, but to everyone. Once a population has a high rate of people who are immune from vaccines, the disease just dies out. With few people to infect and transmit disease, even if one case appears the germs have no one to spread to.

That’s exactly what happened in the 1990’s in the USA. Widespread use of the MMR vaccine led to measles being eradicated—there was no transmission from person to person. Even when a rare case was imported from someone traveling from overseas, it didn’t lead to an outbreak.

Unfortunately, we’ve let our guard down. Though overall rates of vaccination remains very high, several communities (especially in California, near Disneyland) now have a high proportion of unvaccinated kids. What’s happening now with measles was predictable and preventable.

It’s time to get back to protecting our children and our communities. Vaccinations protect not just your kids, but your neighbor’s kids, and the baby across the street, and the woman upstairs who had a kidney transplant. Not vaccinating puts all of us at risk. We’re all in this together. We can beat measles again, if we all do the right thing.

Roy Benaroch, MD
Adjunct Assistant Professor of Pediatrics, Pediatrician

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Roy Benaroch, MD
Adjunct Assistant Professor of Pediatrics, Pediatrician

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Roy Benaroch, MD is a pediatrician and Adjust Assistant Professor of Pediatrics at Emory University. He writes about health and parenting topics at his blog, The Pediatric Insider, and at many other sites. His lecture series, Medical School for Everyone: Grands Rounds Cases, is now available through Amazon or The Great Courses. You can also follow Dr. Benaroch on Twitter

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