May 30 2014

Measles Coming Back

There are some topics I just have to revisit from time to time. I consider this a public service announcement. So far this year there have been 288 confirmed cases of measles. This is the largest number of cases since endemic measles was declared eliminated from the US. The previous worse year was 2011, which saw 220 cases total. 

There is no question that this is tied to vaccine non-compliance. The anti-vaccine movement is scaring people with misinformation and pseudoscience into not vaccinating their children, and as a result we are seeing the return of vaccine-preventable diseases.

When a disease is endemic that means there is a self-sustaining infection – there is always someone infected somewhere and it keeps getting passed around. The MMR vaccine (especially after the second dose was added) resulted in herd immunity, which is a high enough immunity rate so that the infectious disease cannot be passed around indefinitely. High vaccination rates in the US resulted in eliminated measles as an endemic disease by 2000.

Measles cases, and even outbreaks, can still occur, however, by being imported from other countries. Worldwide there are still an estimated 20 million cases per year. In 2012, 122,000 children died from measles. This number is decreasing, due to efforts at worldwide vaccination (now estimated to be at about 84% – good, but not high enough for herd immunity).

Measles cases imported to the US can still lead to outbreaks, especially in populations with low vaccination rates. The CDC reports:

Fifteen outbreaks accounted for 79% of cases reported, including the largest outbreak reported in the United States since elimination (138 cases and ongoing).

Now here comes the important information:

Most of the 288 measles cases reported this year have been in persons who were unvaccinated (200 [69%]) or who had an unknown vaccination status (58 [20%]); 30 (10%) were in persons who were vaccinated. Among the 195 U.S. residents who had measles and were unvaccinated, 165 (85%) declined vaccination because of religious, philosophical, or personal objections, 11 (6%) were missed opportunities for vaccination, and 10 (5%) were too young to receive vaccination.

Most of the measles cases are in people who were not vaccinated, and most of the unvaccinated were those who refused vaccination – and some of those were children whose parents refused on their behalf.

Overall vaccination rates in the US remain high, but there are pockets of low compliance. These occur in communities where anti-vaccine sentiments are common, or even in schools that are friendly to families who do not vaccinate. These low-vaccination pockets can lose their herd immunity, allowing for isolated imported cases to turn into outbreaks.

The conclusion is clear – antivaccine fearmongering is dangerous to the public health. Those who spread such fears should be held accountable, at least in the court of public opinion. I am not talking about honestly raising questions or engaging in discourse, but rather actively advocating against vaccines, fueled by misinformation that can be corrected by honest due-diligence, or even in the face of being corrected by experts.

Such individuals, in my opinion, are guilty of malfeasance and they should be actively marginalized. Meanwhile, the CDC, WHO, and other health organizations, as well as science educators, need to do extra work in order to mitigate the spread of misinformation.

22 responses so far

22 thoughts on “Measles Coming Back”

  1. SteveA says:

    To my shame, my own daughter can be added to the roll-call of measles victims.

    She was due to be vaccinated at the height of the scare and, although I was determined she was going to be vaccinated, my wife insisted that she not be give the MMR vaccine and instead have separate shots. She was concerned about ‘vaccine overload’ and found a doctor willing and able to give my daughter individual injections spread over a period of time (there’s a history of autism in my wife’s family which helps to explain her concern).

    The mumps and rubella shots were delivered on time, but the measles shot was delayed for various reasons, and a week before my daughter was due to get her jab – she came down with the measles.

    Our doctor was both appalled and fascinated when he saw her. He’d never seen a case of measles in real life.

    Ultimately my daughter was fine, but she now has three measles scars on her torso that she’s not going to thank us for when she’s a teenager.

  2. sowellfan says:

    I’m all for active marginalization, but what about civil financial liability for those who spread measles through their own choices? Especially when they infect people who were vaccinated, or were merely too young to get vaccinated.

  3. elmer mccurdy says:

    Wait, civil liability? Sowell fan? Make up your mind. :>D

  4. steve12 says:

    It’s easy to look at those recent threads re: materialism and think that these anti-science views are harmless, but this post really underscores that this isn’t the case.

    The whole “What The BLeep Do we Know?” attitude re: science that has infected our culture has consequences and this is certainly one of them.

  5. Sagan’s words from 2 decades ago ringing true: “We’ve arranged a global civilization in which the most crucial elements — transportation, communications, and all other industries; agriculture, medicine, education, entertainment, protecting the environment; and even the key democratic institution of voting, profoundly depend on science and technology. We have also arranged things so that almost no one understands science and technology. This is a prescription for disaster. We might get away with it for a while, but sooner or later this combustible mixture of ignorance and power is going to blow up in our faces.”

  6. tmac57 says:

    SteveA- So glad to hear that your daughter is OK. Seems that even rational and informed parents can get snared by the misinformation campaign.Surely your wife meant well,and had the utmost concern about something that she read/heard,and it was just enough to push her toward what she perceived as a precautionary principle.
    Most of the time that would have gone without consequences,but your experience shows that the odds can,and does sometimes catch up with people,despite their good intentions.
    Thanks for sharing your experience.

  7. Daina McGee says:

    Carl Sagan knew what he was talking about, for sure.

    I stand strongly for the case of vaccination – how the heck else can society protect itself?
    Enough said. I don’t want someone else’s uniformed and reprehensible decision not to protect themselves and society to make me ill or dead.

    When I was at primary school and high school, choice didn’t come ito it. We lined up, got our jab ad moved on. More often than not the first thing anyinone knew was on that day at class notices.

    A simple as that.

    Nowadays you get some blasted do-gooder on their soapbox waying flagging their flag and flapping their jaws saying we’re all doomed, we need to fill these forms out in triplicate and noo I want my child to die of the next seroius germ that passes into its body from their unvaccinated offspring.

    Now, if we could only engineer these illnesses to wipe these idiots from the face of the earth, that would work….

  8. NorEastern says:

    I would like to complement you on your blog. I am highly educated and view myself as quite adept in critical and sometimes skeptical thinking, but I read some of your articles in awe. Not this one though. But that is due to the topics limited scope.

    Unfortunately a large percentage of the US population is “faith” based. Faith in religion, faith in dogma, faith in purported “Google” experts who happen to sport a pretty face.

    I will admit as the years roll on I am more and more tempted to move to a country that demonstrates sanity in its masses. We will see if I move first, or if demographic change alleviates the problem.

  9. eean says:

    What country would that be NorEastern? I think it’s telling that Mississippi is the state with highest vaccine compliance. Mississippi is usually at the bottom of any state comparison. Education appears to be a bad thing when it comes to vaccine compliance. It really is a cultural problem, which never has trite solutions.

  10. Mlema says:

    It seems that, by and large, this most recent increase in measles can be traced to international travel, especially an Ohio Amish missions trip to the Philippines.

    288 cases
    (the median outbreak size was 5 cases)
    195 were unvaccinated US citizens
    165 of those had declined vaccination because of religious, philosophical, or personal objections
    138 in Ohio Amish country

    “So far all of the cases in the U.S. have been connected to foreign travel.”

    The CDC article is unclear as to why the Amish were not vaccinated. Although they probably comprise most of the group of “religious, philosophical, or personal objections”, it doesn’t seem to be the case that they “declined”. Since over 8000 have been vaccinated since the outbreak, it doesn’t seem to be due to unwillingness. But i don’t know. Some Amish are against vaccination, but most aren’t it seems. Ignorance? Fear? How much do anti-vaccination groups have to do with this, since the Amish tend to self-marginalize socially. If the Amish went to help the Filipinos overseas in the wake of the typhoon last year, they should have known they’d be exposed to all kinds of infectious diseases. How did the mission group manage to travel to the Philippines, where there’s a massive outbreak, without being vaccinated? Is this complacency in the community, or a failure on the part of public health outreach? Complicated.

  11. Mlema says:

    I suspect some of the large number of cases in California may also be due to travel to the Philippines. Filipinos are the largest Asian minority group in California, and California is home to the largest population of Filipino Americans.,_Filipinos_in_the_United_States.png

    My thoughts are: outreach and education. I wouldn’t want to increase divisiveness in certain situations. But anti-vaccinations groups need to be brought to task. It’s irresponsible to encourage people to forego vaccination. The pro-vaccination voices need to be as loud as the anti-. But not in a hateful way. Maybe people who end up with measles because they didn’t get vaccinated could do public service messages. Hopefully insurance expansion will bring people in who avoided care due to expense. It’s notable that the Amish tend to avoid health insurance too.

    I suspect that the outbreak in the Philippines is directly related to the US outbreak. Travel after the typhoon being largely responsible? I noted also that 30 cases were in already vaccinated people – which also deserves attention. i think this is a global problem and the US needs to get back on track with its public health programs.. We’ve really been failing for a number of years now imo.

  12. Mlema says:

    I meant outbreak in the US is probably related to the outbreak in the Philippines – not the other way around.

  13. BillyJoe7 says:


    “I noted also that 30 cases were in already vaccinated people – which also deserves attention”

    I’m not sure what you mean by “deserves attention”.
    This is the whole reason for the drive towards achieving herd immunity – to protect those who do not seroconvert (as well as those who are unable to be vaccinated because of immunodeficiency or becasue they are too young to be vaccinated).

  14. Bruce says:

    I would also add that drawing attention to something like that obfuscates the real issue. Vaccines are not 100% effective, we know this, and as BJ mentioned, it is the reason why we need the drive towards herd immunity.

    Statistically you should be drawing attention to how many of those who were exposed who were immunised got it compared to how many of those who weren’t immunised who got it. Merely stating that 30 of the people who got it were immunised will very likely send out the incorrect message as most people will not be able to do the basic statistics.

  15. SquirrelElite says:


    I don’t have time to dig out the article, but I saw a discussion of the outbreak among the Amish in Ohio.
    One of the travelers to the Philippines stated that they asked about vaccinations needed for the travel and were advised about certain diseases, but measles was not mentioned.
    So they got some vaccinations prior to the trip, but not the MMR.

    Now that they have returned and discovered the danger the hard way, there is a big move among the Amish to get vaccinated to prevent measles and limit its spread.

  16. Mlema says:

    BJ, Bruce, Hi
    I felt that 30 cases being in vaccinated individuals was a high percentage of the total (10%). I feel it deserves investigation. Maybe I’m wrong. I think you’d have to know how many vaccinated people were exposed to those with measles in order to decide whether or not this is a high number. It seems high to me, especially since the Amish probably don’t have that much interaction with non-vaccinated people outside their community. But the Amish in Ohio probably have more such contact because they’ve moved into non-Amish industries outside their communities. If you can re-cast the number of infected who’d already been vaccinated in a different light to show me how it’s not so notable, I’ll certainly reconsider my opinion on that. I think you’d have to consider the other areas visited by infected travelers too – like CA. Thanks.

    Thanks. If what you’re saying is so, it shows that the Amish did not refuse the vaccine based on religious or personal preference. And if that’s so, then the conclusion that 138 people (the largest subgroup – 85%) who were included in the category of “religious, philosophical, or personal objections” probably should not be. And then, that would reflect on the idea that this isn’t a problem with the Amish community being ignorant or fearful, but instead the possibility that we’re not doing enough to prevent transmission as a member of the global community.
    From the study:
    “Of the 288 cases, 280 (97%) were associated with importations from at least 18 countries.”
    Of course, it points up that we have to do better at getting everyone vaccinated. But it also points up that the number of people who were infected due to not getting vaccinated due to “religious, philosophical, or personal objections” is actually very small (what would it be if the Amish weren’t placed in that category?) I shouldn’t speculate too much without verification that they did indeed ask for appropriate vaccinations before travel.

    Let’s not let our focus on people who refuse vaccination due to ill-conceived pseudoscientific ideas detract from the focus on international efforts and preventative pre-travel vaccinations. (or screening non-citizen travelers to the US, who were obviously a very large part of the outbreak as well – almost half apparently, with the other half accounted for by the unprotected Amish travelers)


  17. BillyJoe7 says:


    Using rough figures:

    Coverage for measles = 90%
    Seroconversion rate = 95%

    200 people
    20 unvaccinated
    10 vaccinated but not seroconverted

    Therefore, in an outbreak, you would expect 1/3 to be in vaccinated individuals.
    1/10 is actually a low figure.
    (Perhaps accounted for by the Amish being a relatively isolated population)

  18. BillyJoe7 says:

    ..make that:
    9 vaccinated but not seroconverted.

    (the reason I used 200 people instead of 100 people)

  19. Mlema says:

    BillyJoe, but we don’t know how many people who were vaccinated were exposed without getting the measles.

    If we have 90% coverage, and 95% seroconversion, then about 86% of the population should be protected. The only way to know if the 30 vaccinated but sick is a high number to be infected is to know how many people were exposed to measles. There’s no way to know this. But if 750 people were exposed, we should expect 30 people who were vaccinated to get sick. I don’t think it’s unreasonable to conjecture that at least 750 people were exposed. The Amish situation is unique, and I think that’s why the 30 seemed high to me. But there were other areas of outbreak, and in the end, as I said, there’s not a good way to put the 30 in context so i shouldn’t have made it remarkable. Thanks for talking back. The problem with these kinds of calculations is: the percentages of vaccinated, vaccinated and not seroconverted, and not vaccinated are never evenly distributed throughout the population.

    Mostly I just wanted to call into question the way the CDC grouped those who weren’t vaccinated. It sounds like the biggest group of those who weren’t vaccinated simply were ill-served by vaccination programs. Partly their fault, but, if the story from SquirrelElite is true, largely not their own fault. One article said that the Amish self-quarantined. Anyway, this is a global issue. I’d like to see everyone who can be vaccinated, vaccinated. It makes sense to put the screws to people who refuse for reasons of pseudoscience. But let’s make sure that we’re putting the screws to the right people for the right reasons. What do you think about my idea of public service messages? Are they already out there? i haven’t seen any myself. They should include photos like the one on this page, with testimonies. People who use their celebrity to discourage vaccination should be sanctioned in some way. This part gets tough. Again, i think the pro-vaccination voices have to be louder than the anti.
    thanks again

  20. BillyJoe7 says:


    “The only way to know if the 30 vaccinated but sick is a high number to be infected is to know how many people were exposed to measles”

    It’s irrelevant.
    If my figures are correct:
    1/3 of those who contracted measles would be those who were vaccinated but did not seroconvert.
    2/3 of those who contracted meases would be those who were unvaccinated.
    The number of exposed individuals is irrelevant.

    “The Amish situation is unique, and I think that’s why the 30 seemed high to me”

    Well the actual proportion was not 1/3 but much lower at 1/10.
    Do you mean that you would have expected it to be even lower than 1/10?
    I suppose it would depend on how isolated the Amish are and how typical was the population with which they came into contact in relation to percentages of vaccinated and unvaccinated.

  21. Mlema says:

    “I suppose it would depend on how isolated the Amish are and how typical was the population with which they came into contact in relation to percentages of vaccinated and unvaccinated.”

    That’s all I’m saying. There’s no way to know whether 30 is high or low, so i shouldn’t have said it “deserves attention”.

  22. BillyJoe7 says:

    All I’m saying is that 30, being only 10% of the total doesn’t seem too high at all, especially when you expected it to be 30% of the total.

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