When it comes to the measles, antivaxers love to repeat a series of talking points. One is that measles is not a dangerous disease and was considered a normal part of childhood 50 or 60 years ago. This is what I like to refer to as the "Brady Bunch" gambit, mainly because antivaxers who try to make this argument often invoke an episode of The Brady Bunch from 1969, Is There a Doctor in the House?, in which all six kids contract the measles within a day of each other. Their illness is played for laughs, with the kids shown playing board games and enjoying having a few days off from school, while their concurrent illness provokes a conflict over whether the girls' pediatrician or the boys' pediatrician would be the family doctor. They also like to point to an episode of The Donna Reed Show from 1959 and an old episode of The Flintstones from around the same period, both of which portrayed measles as no big deal. It's a ridiculous and dangerous argument that relies primarily on nostalgia and cherry-picked bits of mid-century Americana, rather than the actual risk of severe complications due to the measles. Other common antivax tropes about the measles include the claim that "vaccines didn't save us" against it (they did) and that herd immunity is a myth or that "natural" immunity is better (it isn't, especially against a disease as contagious as the measles).

Unfortunately, one of the topics I missed blogging about last week due to the travel and power outages that kept me away from the blog more than I've been away in a long time put the lie to all three of those common antivaccine tropes in a highly compelling way. I'm referring, unfortunately, to the ongoing measles outbreak in Romania, which hit the news again last week. This outbreak shows not only that measles is serious, but that vaccines can save and herd immunity is real. More importantly, it shows what could be a glimpse of our future if we allow vaccination rates to fall, thanks to antivaccine activists, perhaps aided by not-so-benign neglect on the part of the Trump administration.

Behold the horror:

National public health officials said an ongoing measles outbreak in Romania has infected more than 3,400 people and killed at least 17 despite an aggressive nationwide vaccination campaign. Meanwhile, the European Center for Disease Prevention and Control (ECDC) warned of a greater regional outbreak of measles as a result of below-target vaccination coverage numbers in Romania. “This poses a risk of potential repeated exportation to other [European] countries and possible continuous transmission in some where vaccination coverage is suboptimal,” the ECDC said in a recent rapid risk assessment report on the Romanian outbreak. As of March 10, Romania’s National Institute of Public Health said 3,446 cases of measles have been confirmed since the outbreak began last year. The country is one of six in the European Union or European Economic Area judged by WHO to still have endemic transmission of the vaccine-preventable disease, along with Belgium, France, Germany, Italy and Poland.

I'm sure that any antivaccinationists who read this will point immediately to the phrase "despite an aggressive nationwide vaccination campaign," as though the outbreak isn't being stopped by increased vaccination. Of course, this line of argument fails to take into account that, once there are outbreaks, authorities are going to be playing catch-up, and it will take a while for increased vaccination rates to slow and stop the fury of the outbreak.

More importantly, children are dying, and they're dying at roughly the rate we know from history to expect in developed countries. Normally, according to the CDC, the mortality rate from measles is typically quoted as 0.2% in the US but can be as high as 10% in areas with high levels of malnutrition. When measles is rare, as it fortunately still is in the US (for now, anyway), deaths are unlikely or likely only to be one, because you have to have thousands of cases before significant numbers of children die of the disease. Unfortunately, Romania has reached that level. So, right there, the case of Romania puts the lie to the claim that measles isn't a dangerous disease.

Indeed, what we're seeing in Romania is a mortality rate of around 0.5%. Worse, the deaths nearly all occurred among those who need herd immunity the most, as this report from the European Centre for Disease Prevention and Control found:

As of 17 February 2017 [2], 3 071 cases had been reported to the National Institute of Public Health, with 2 341 since October 2016 (Figure 2). These cases are either laboratory-confirmed, or have an epidemiological link to a laboratory-confirmed case. Cases have been reported in 36 districts with the districts of Caras Severin (n=703), Arad (n=617) and Timis (n=566) having reported the highest number of cases (Figure 3). To date, 16 deaths have been reported, all of which occurred in persons who were immunocompromised or had other co-morbidities. Infants <1 year old (n=549) and children 1–4 years old (n=1,247) made up the majority of cases. Ninety-six percent of cases were unvaccinated (n=2 958), 80 cases had received one dose of MCV and 33 had received two doses.

So right away we see two things. First, the vast majority of the cases of measles occurred in unvaccinated children, 96%! This is basically as close to a natural experiment as there is to see what happens when vaccine coverage falls below the rate necessary to maintain herd immunity. Second, it's exactly the children who most rely on herd immunity who are dying. Again, this is what happens when vaccine coverage falls.

And that's what happened in Romania:

MMR vaccination rates have fallen in recent years in Romania to below the 95% threshold recommended to interrupt transmission. According to the ECDC, coverage for one dose was just 86% in 2015 in Romania compared with 97% in 2007. In 2013, the last year when data were reported for two doses, 88% had received two doses compared with 96% in 2007. According to the CDC, two doses of the MMR vaccine are about 97% effective at preventing measles, and one dose is 93% effective. In response to the outbreak, Romania lowered the age of the first MMR vaccine dose from 12 months to 9 months as part of an effort to fully vaccinate children between the ages of 9 months and 9 years. According to the ECDC, family doctors are registering unvaccinated children for vaccination — with the goal of giving one dose of the MMR vaccine to those under age 5 years and two doses to those between the ages of 5 years and 9 years — while community nurses are mobilizing children mainly in vulnerable population groups.

So that's all it took, a decline in vaccine coverage from 96% of children having received two doses of the MMR to 88%. Herd immunity is a function of how contagious a disease is and how effective the vaccine is. Measles is, unfortunately, very contagious, meaning that high rates of vaccination are required to provide herd immunity. Fortunately, the MMR is highly effective, but no vaccine is 100% effective. Even with 100% vaccine coverage, there would still be roughly 3% of the population who would not be immune. Obviously, with lower levels of vaccine coverage, more are vulnerable. Basically, to block the transmission of measles requires 90-95% coverage, the higher the better. What Romania shows is just how tenuous the situation can be with respect to keeping measles under control, even in developed countries. It doesn't take much. The measles virus is out there, and it will take advantage when there is an opening. The most effective way to give the virus the chance it needs is to let vaccination uptake fall, and it doesn't have to fall much.

But why has the uptake of MMR fallen in Romania? One story tells us:

But Bodog said only 80 percent of Romanians receive the first vaccination dose and just 50 percent receive the second. In Romania, poverty, the lack of access to health services, and the percentage of parents who refuse to vaccinate their children are at the heart of the recent epidemic. Religious organisations and public figures have led recent anti-vaccination campaigns.

It's not clear where the antivaccine sentiment came from or why it is so strong in Romania, but one study from UNICEF of antivaccine sentiment found on Eastern European social media sites found that fear of toxins in vaccines was the predominant, with fear of side effects and conspiracy theories as the other main reasons. It noted that in Romania school nurses perform mandatory vaccination during class, which is "seen as a human rights violation and a safety issue." Parents are also skeptical about the skills of the school nurses and "feel surpassed by authorities in its decision to have children vaccinated." Oddly enough, contrary to the case in the US and Western Europe, fear of autism or other developmental disorders is not nearly as major a driver of antivaccine sentiment, although there are a number of common conspiracy theories.

Here's one example:

Romanian discussions directly blame the U.S. for purposefully infecting people with HIV using polio vaccines. Users create a direct link between vaccines and widespread HIV in Romanian orphanages. In the same sense, users claim that vaccines are being used against the Romanian populations. According to members of the anti-vaccination sentiment, vaccines against polio and chickenpox are used in Romania, which are not used in the U.S. anymore.

Clearly, Romanians have been listening too much to Dr. Leonard Horowitz. I will say one thing about this UNICEF report that makes me question its validity is the fact that in a table entitled Common arguments by influencers: Romanian speaking, UNICEF described Left Brain/Right Brain as "Autism news science & opinion, Anti-Vax leaning. Um, no. Left Brain/Right Brain is an ally in the campaign to refute antivaccine misinformation. It is not in any way, shape, or form and antivaccine blog, or the least bit sympathetic to the antivaccine viewpoint.

In any case, whatever the cause of the decline in MMR uptake, poverty and neglect, antivaccine sentiments, or some unholy combination of the two, Romania is a cautionary tale of just how easy it is to lose hard won ground in the fight against infectious disease. It's also an example that worries me, because if you think it can't happen here you are deluded, especially with Tom Price in charge of the Department of Health and Human Services saying things like this:

HHS Secretary Tom Price says it should be up to states to regulate whether immunizations are required https://t.co/soyH0YpO5E — CNN Politics (@CNNPolitics) March 16, 2017

Basically, Price is signaling that he doesn't think immunizations are a federal responsibility. Given his membership in the Association of American Physicians and Surgeons (AAPS), an organization that is basically an Ayn Rand-worshiping John Birch Society disguised as a medical professional society that routinely publishes antivaccine misinformation in its journal, as well HIV/AIDS denialism and other pseudoscience, it's not at all surprising that Price would think that way.

While it's true that states set the laws setting school vaccine mandates, but they rely on the work of the CDC to know what the latest science-based recommendations are for vaccine coverage upon which they base their mandates. Also, Price's view ignores the fact that viruses and bacteria do not respect arbitrary lines on a map that separate states. The federal government, although not primarily responsible for vaccine requirements, nonetheless plays a critical role in vaccine policy. Given that Donald Trump has consistently expressed antivaccine sentiments over the last decade and Tom Price seems to think that the federal government has little role in vaccine policy, I fear that Romania is a warning to us. It's a warning that, I fear, we will not heed.