The measles virus was down and out. Now it’s primed for a comeback

Back near the start of this century, before the full damage of Andrew Wakefield’s debunked study linking measles vaccine and autism became clear and social networking sites turbo-charged the disruptive power of vaccine opponents, some experts believed the world was ready to rid itself of measles once and for all.

These days, with massive outbreaks in the Philippines and Ukraine, more than 80,000 cases in the past year in Europe, and ongoing epidemics in New York, Washington, Texas, Illinois, and California, measles does not feel like an endangered virus.

There’s less talk about measles eradication in 2019. In fact, projections about the future of measles are much more somber now than they were in the early aughts. More measles, not less, appear to be on the horizon, at least in the near term, experts glumly admit.

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“I think that’s almost a certainty,” said Dr. Art Reingold, a professor of infectious diseases epidemiology in the school of public health at the University of California, Berkeley.

Reingold spent more than a decade on scientific bodies that advise the World Health Organization and the Centers for Disease Control and Prevention on vaccine policy, and has a deep understanding of the effectiveness and safety profiles of vaccines. To see the effort against measles moving in the wrong direction is frustrating as hell, he acknowledged. “But I’m not smart enough to know what the answer is,” he told STAT.

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Dr. Nancy Messonnier, director of the CDC’s center for immunization and respiratory diseases, said she believes recent increases in measles cases — after years of very low numbers in the United States — mark a “new normal.”

Messonnier isn’t worried that the U.S. is heading back to a time with hundreds of thousands of cases each year and 500 or so deaths from complications. Despite the attention the vociferous anti-vaccination movement manages to generate for itself, the conditions here are not ripe for that kind of backsliding.

“In general, nationally, most Americans are vaccinated and it is the pockets of individuals that are unvaccinated,” she said.

Still, Messonnier and others anticipate more regular outbreaks in those clusters of susceptible children.

The tragedy is it doesn’t have to be that way.

Measles could be eradicated. Future generations of children could be spared both measles infections and eventually measles vaccination, after the viruses were certified as gone.

The measles vaccine is effective enough to do the job, experts believe. The measles component of the MMR vaccine — it also protects against mumps and rubella — prevents infection in 97 out of every 100 kids who get the recommended two doses. If enough children were vaccinated with MMR around the globe, measles would follow smallpox into the history books.

The problem is that outbreaks keep happening. Like the current epidemic in New York involving Orthodox Jewish families. Or the massive one that sickened more than 66,000 people in Madagascar over the past six months or so, killing as many as 900 children.

In some parts of the world — poorer countries plagued by political strife — immunization programs aren’t effective enough to vaccinate all or even most children.

In affluent countries, the problem is a different one — parents choosing, for religious or philosophical reasons, not to get their children vaccinated against measles.

Whatever the reason, the outcome is the same. Measles is the viral equivalent of a heat-seeking missile. If it is circulating in or introduced into an area where there are susceptible kids, it will find and infect them.

A combination of factors makes this virus a veritable infecting machine. Here’s how it works. Alex Hogan/STAT

Parents who steadfastly refuse to vaccinate their children because they believe vaccines trigger autism or other harms and others who delay vaccination because of these discredited concerns are creating clusters of susceptible kids. Those clusters drill holes into the wall of herd immunity public health relies on to keep diseases like measles at bay.

These pockets of unprotected children are like kindling. An American who gets infected abroad and returns home sick can effectively put a match to that kindling. The more kindling, the bigger the resulting fire.

That is exactly what happened in the ongoing New York outbreak, triggered when an unvaccinated child from Orthodox Jewish community traveled to and was infected in Israel. To date, there have been 181 cases in this outbreak. Israel’s outbreak traces back to the explosive spread of measles in the Ukraine.

It’s also likely what happened in 2015 when 147 children from a number of states were infected when the virus spread at Disneyland in California. A child from the Canadian province of Quebec was infected at the park, too. He or she was a member of a religious community that doesn’t vaccinate; the outbreak ignited in Quebec engulfed 159 people.

This is what the measles virus does.

“Outbreaks that happen in Europe or South America or whatever, they’re all a plane ride away,” said John Wiesman, health secretary for Washington state, which is battling an outbreak that likely originated somewhere in Eastern Europe. “And with global travel today, in terms of our health security, we’ve got to in our own communities make sure that we don’t have pockets of unimmunized kids.”

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To date, 74 cases have been reported in the Washington outbreak. Efforts to control it have cost the state over $1 million.

It has been difficult for public health officials to prioritize measles eradication — in part because of how hard it has been to get rid of other diseases. Nearly 40 years after it was declared eradicated, smallpox remains the only human disease wiped out by human actions.

The repeated and unexpected setbacks that have dragged out the polio eradication program, now 19 years past its original target, have for years made some wary of trumpeting a new eradication target.

Back in the early 2000s when people hoped polio eradication was in sight, talk about tackling measles next was gaining ground. There was never an official launch of a measles eradication program, like the ones that are trying to end polio or Guinea worm. Still, some groundwork was laid.

All six regions of the WHO declared measles elimination a goal. Only one, the Americas, was declared free of endemic measles in 2016.

Dr. William Moss, who spent seven years on a measles and rubella working group that advises the World Health Organizations’s Strategic Advisory Group of Experts on Immunization, is on a committee that is preparing a discussion paper on measles eradication for the 2020 meeting of the World Health Assembly, the annual meeting of WHO member countries.

He wouldn’t say what direction it is taking, but admitted he personally doesn’t think a push to eradicate measles is in the cards at the moment.

“To be honest, I don’t see a goal being set in the next five years,” said Moss, a professor of infectious diseases epidemiology at Johns Hopkins University and executive director of the International Vaccine Access Center. “What I see actually happening is some more interim milestones being set. And then at some future date, the issue being raised again. Maybe that’s 2025. I’m not sure.”