tag:theconversation.com,2011:/africa/topics/measles-4021/articlesMeasles – The Conversation2024-03-21T20:24:31Ztag:theconversation.com,2011:article/2262052024-03-21T20:24:31Z2024-03-21T20:24:31ZMeasles is highly contagious, but vaccine-preventable: A primer on recent outbreaks, transmission, symptoms and complications, including ‘immune amnesia’<figure><img src="https://images.theconversation.com/files/583049/original/file-20240320-16-lkngkh.jpg?ixlib=rb-1.1.0&rect=0%2C135%2C3962%2C2913&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A measles virus particle. Measles is one of the most contagious pathogens known.</span> <span class="attribution"><span class="source">(CDC and NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Canada is seeing a resurgence of measles, with cases in the first quarter of 2024 already far surpassing the total for all of 2023. There were <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/measles-rubella-surveillance/2023/week-52.html">12 cases last year</a>, and more than three times that number so far in 2024, with 38 reported as of March 19. </p>
<p>Most of these cases (28) <a href="https://www.quebec.ca/en/health/health-issues/a-z/measles/measles-outbreak">are in Québec</a>, and <a href="https://www.publichealthontario.ca/-/media/Documents/M/24/measles-ontario-epi-summary.pdf?rev=c082f5ae0c6c446f9624d47b7e3c8535&sc_lang=en">eight are in Ontario</a>, while <a href="https://www.saskhealthauthority.ca/news-events/news/measles-exposure-risk-saskatoon">Saskatchewan</a> and <a href="https://news.gov.bc.ca/releases/2024HLTH0026-000274">British Columbia</a> have each reported one case. </p>
<p>As an immunologist with a focus on host-microbe interactions and antiviral immunity, I have been following recent measles outbreaks. </p>
<h2>Symptoms and complications</h2>
<p>Measles (also known as rubeola) is a serious but vaccine-preventable disease caused by an RNA virus of the family <a href="https://www.britannica.com/science/paramyxovirus-virus-family">Paramyxoviridae</a>. </p>
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<a href="https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A child seen from behind with a red rash all over his skin" src="https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=720&fit=crop&dpr=1 600w, https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=720&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=720&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=905&fit=crop&dpr=1 754w, https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=905&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/583046/original/file-20240320-24-qx59sq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=905&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Measles rash appears on the face before spreading downward to other areas of the body.</span>
<span class="attribution"><span class="source">(U.S. Centers for Disease Control)</span></span>
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<p>Measles usually begins with fever, runny nose, conjunctivitis (red watery eyes), sore throat and coughing. These can be initially mistaken for common cold or flu.</p>
<p>However, these non-specific signs and symptoms are typically followed by clinical manifestations that are characteristic of measles. These include Koplik spots (tiny white specks with bluish-white centres in the inner lining of the cheeks), and subsequently a <a href="https://www.cdc.gov/measles/symptoms/signs-symptoms.html">measles rash</a> appearing on the face before spreading downward to other areas of the body.</p>
<p>In most cases, measles resolves on its own. However, <a href="https://www.mayoclinic.org/diseases-conditions/measles/symptoms-causes/syc-20374857">severe complications</a> may arise, especially in immunocompromised individuals. <a href="https://www.cdc.gov/globalhealth/measles/about/index.html">Complications</a> can include pneumonia, encephalitis (brain inflammation and swelling), blindness, deafness and permanent neurological consequences. When measles occurs during pregnancy, it can result in miscarriage, premature labour, stillbirth, birth defects or even fetal death. The most severe cases of measles can be fatal. </p>
<p>Also of note, infection with the measles virus can weaken the immune system for months or years, increasing the risk of infections with a wide range of microbes. While measles-associated immunosuppression has been documented for decades, we are only beginning to decipher its underlying mechanisms. For example, a phenomenon called “<a href="https://doi.org/10.1038/s41467-018-07515-0">immune amnesia</a>” is thought to contribute, at least partially, to unrelated infections in the aftermath of measles.</p>
<h2>What is immune amnesia?</h2>
<p>The naturally occurring (wild-type) strains of measles virus can target, infect and kill memory B and T lymphocytes, which are instrumental to antimicrobial defence. This is because one of the three measles virus receptors, called CD150, happens to be abundantly present on the surface of these lymphocytes.</p>
<p>Long-lived memory cells, which accumulate as a result of immunizations and infections over time, remain in a poised state to mount rapid and rigorous recall responses when we re-encounter microbes. B cells orchestrate the production of antibodies that neutralize extracellular microbes, and T cells work to destroy infected cells. Therefore, when people lose their precious memory cells to measles, the immune system is set back to a default mode, as if it has never seen any microbes or vaccines in the past.</p>
<p>To add insult to injury, <a href="https://doi.org/10.1093/infdis/jiaa407">measles virus may also eliminate “memory-like” innate T cells</a>, which also express CD150, thus removing yet another potent weapon from our antimicrobial arsenal. Therefore, collectively, the ability of measles virus to find and kill memory and memory-like lymphocytes can lead to adaptive and <a href="https://doi.org/10.1371/journal.ppat.1009071">innate immune amnesia</a>, rendering a measles patient or survivor prone to many opportunistic infections.</p>
<h2>How does measles spread and how contagious is it?</h2>
<figure class="align-right ">
<img alt="microscopic image of a virus" src="https://images.theconversation.com/files/583047/original/file-20240320-20-nv4olv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/583047/original/file-20240320-20-nv4olv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=459&fit=crop&dpr=1 600w, https://images.theconversation.com/files/583047/original/file-20240320-20-nv4olv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=459&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/583047/original/file-20240320-20-nv4olv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=459&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/583047/original/file-20240320-20-nv4olv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=577&fit=crop&dpr=1 754w, https://images.theconversation.com/files/583047/original/file-20240320-20-nv4olv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=577&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/583047/original/file-20240320-20-nv4olv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=577&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Microscopic view of a measles virus particle (red).</span>
<span class="attribution"><span class="source">(CDC and NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Measles virus spreads easily through airborne droplets released by infected people when they breathe, talk, laugh, cough or sneeze. In addition, measles virus infectious particles can remain active in the air and on contaminated surfaces for up to two hours.</p>
<p>Measles virus is one of the most contagious respiratory pathogens known, with <a href="https://doi.org/10.1016/S1473-3099(17)30307-9">each person with measles passing on their infection to 12 to 18 other people</a> in a susceptible population. Measles virus is more transmissible than influenza viruses and SARS-CoV-2 variants.</p>
<h2>How effective are measles vaccines?</h2>
<p>Measles vaccines are safe, affordable and extremely effective. According to the World Health Organization (WHO), <a href="https://www.who.int/news-room/fact-sheets/detail/measles">measles claimed 2.6 million lives each year before 1963</a> when a measles vaccine became available. Since then, widespread immunization programs have saved millions of lives, including an estimated 56 million just between 2000 and 2021.</p>
<p>Measles vaccines contain a live measles virus strain that has been attenuated so that it does not inflict harm; yet, it is sufficient to generate protective immune responses. </p>
<p>The measles-mumps-rubella (MMR) vaccine or the measles-mumps-rubella-varicella (MMRV) vaccine is routinely administered to children in <a href="https://www.canada.ca/en/public-health/services/diseases/measles/health-professionals-measles.html">two doses</a>, with a first dose being given after the first birthday, typically between 12-15 months of age, followed by a booster dose recommended after 18 months of age and before attending school. This should afford lifelong protection against measles in most people. </p>
<p>According to the United States Centers for Disease Control and Prevention (CDC), one and two doses of the MMR vaccine are <a href="https://www.cdc.gov/vaccines/vpd/mmr/public/index.html">93 per cent and 97 per cent effective</a> in preventing measles, respectively. </p>
<p>Teens and adults should also <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-12-measles-vaccine.html#">remain up to date with regard to measles immunization</a> since measles can affect anyone. There are blood tests that can be ordered by health-care providers to determine immunity to measles. </p>
<p>The MMR vaccine can be <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-12-measles-vaccine.html#">given at any time</a> during one’s lifespan, but the MMRV vaccine is authorized in Canada only between one and 13 years of age.</p>
<h2>Why are measles cases returning?</h2>
<p>Recent years have witnessed a rise in measles outbreaks within and outside Canada. This is primarily due to an alarming decline in measles vaccination caused by <a href="https://theconversation.com/measles-global-increase-in-cases-likely-driven-by-covid-pandemic-182250">delayed childhood immunizations amid COVID-19</a> lockdowns, vaccine hesitancy <a href="https://theconversation.com/measles-outbreak-why-are-anti-vaxxers-risking-a-public-health-crisis-116334">creating vulnerable societal pockets</a>, anti-vaccine sentiments and <a href="https://time.com/6564694/measles-antivaccine-misinformation/">digital misinformation</a> spread through online social media, and the resumption of global travel post-COVID.</p>
<p>Measles outbreaks occur soon after <a href="https://doi.org/10.1001/jama.2020.20895">herd immunity</a> is compromised. Herd immunity is achieved when an adequately large proportion of a population becomes immune to a specific pathogen through prior infections or vaccination. As a result, the probability of an infectious case encountering a susceptible person drops dramatically. </p>
<p>For measles, the necessary <a href="https://www.who.int/news/item/23-11-2022-nearly-40-million-children-are-dangerously-susceptible-to-growing-measles-threat">threshold for herd immunity is 95 per cent</a>. This means when 95 per cent of people in a population are immune, the remaining five per cent (including newborns, unvaccinated or undervaccinated children and immunodeficient people who cannot receive a measles vaccine) are also indirectly protected since the risk of measles virus transmission is significantly minimized.</p>
<p>By receiving two doses of a measles vaccine, one protects not only themselves but also the vulnerable members of their community. The only way to avoid measles and its serious complications, including proneness to a broad spectrum of unrelated infections, is to vaccinate widely, to engage those who are hesitant to have their children immunized in a respectful dialogue, and to educate the public regarding the unparalleled benefits of measles vaccines.</p>
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Read more:
<a href="https://theconversation.com/how-better-conversations-can-help-reduce-vaccine-hesitancy-for-covid-19-and-other-shots-159321">How better conversations can help reduce vaccine hesitancy for COVID-19 and other shots</a>
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<p>It is also crucial to isolate infected individuals for four days after the appearance of a measles rash to prevent measles virus transmission to others.</p>
<p>In Canada, measles has been <a href="https://www.canada.ca/en/public-health/services/diseases/measles/surveillance-measles.html">a nationally notifiable disease</a> since 1924 (except between 1959 and 1968), and the Canadian Measles and Rubella Surveillance System (CMRSS) ensures the weekly collection of measles data from every province and territory, including zero report submissions.</p><img src="https://counter.theconversation.com/content/226205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mansour Haeryfar does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Canada is seeing a surge in measles cases. Find out what measles is, why it’s returning to Canada, and how people can protect themselves and others.Mansour Haeryfar, Professor of Immunology, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2244932024-03-01T13:33:21Z2024-03-01T13:33:21ZMeasles is one of the deadliest and most contagious infectious diseases – and one of the most easily preventable<figure><img src="https://images.theconversation.com/files/578746/original/file-20240228-16-96qj3k.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Young children, pregnant people and the immunocompromised are among the most vulnerable to measles.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/measles-royalty-free-image/534079149">CHBD/E+ via Getty Images</a></span></figcaption></figure><p>“You don’t count your children until the measles has passed.” <a href="https://www.nytimes.com/2022/11/05/health/samuel-katz-dead.html">Dr. Samuel Katz</a>, one of the pioneers of the first measles vaccine in the late 1950s to early 1960s, regularly heard this tragic statement from parents in countries where the measles vaccine was not yet available, because they were so accustomed to losing their children to measles.</p>
<p>I am a <a href="https://som.cuanschutz.edu/Profiles/Faculty/Profile/25677">pediatrician and preventive medicine physician</a>, and I have anxiously watched measles cases rise worldwide while <a href="https://www.cdc.gov/media/releases/2023/p1116-global-measles.html">vaccination rates have dropped</a> since the early days of the COVID-19 pandemic due to disruptions in vaccine access and the spread of vaccine misinformation.</p>
<p>In 2022 alone, there were <a href="http://dx.doi.org/10.15585/mmwr.mm7246a3">over 9 million measles cases and 136,000 deaths worldwide</a>, an 18% and 43% increase from the year before, respectively. The World Health Organization warned that <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/more-than-half-world-faces-high-measles-risk-who-says-2024-02-20/">over half the world’s countries</a> are at high risk of measles outbreaks this year.</p>
<p>The U.S. is no exception. The country is on track to have one of the worst measles years since 2019, when Americans experienced the <a href="https://www.cdc.gov/measles/cases-outbreaks.html">largest measles outbreak</a> in 30 years. As of mid-February 2024, <a href="https://www.cdc.gov/measles/cases-outbreaks.html">at least 15 states</a> have reported measles cases and multiple ongoing, uncontained outbreaks.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/QUFqJwcKlh0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Measles is on the rise across the U.S. once again, despite being eliminated in 2000.</span></figcaption>
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<p>While this measles crisis unfolds, U.S. measles vaccination rates are at the <a href="http://dx.doi.org/10.15585/mmwr.mm7245a2">lowest levels in 10 years</a>. Prominent figures like the <a href="https://www.washingtonpost.com/health/2024/02/22/florida-measles-outbreak-ladapo/">Florida surgeon general</a> are responding to local outbreaks in ways that run counter to science and public health recommendations. The spread of <a href="https://www.nbcnews.com/health/health-news/measles-outbreaks-anti-vaccine-misinformation-rcna136994">misinformation and disinformation</a> from anti-vaccine activists online further promotes misguided ideas that measles is not a serious health threat and measles vaccination is not essential. </p>
<p>However, the evidence is clear: Measles is <a href="https://www.cdc.gov/measles/symptoms/complications.html">extremely dangerous</a> for everyone, and especially for young children, pregnant people and people with compromised immune systems. But simple and effective tools are available to prevent it.</p>
<h2>Measles is a serious illness</h2>
<p>Measles is one of the most deadly infectious diseases in human history. Before a vaccine became available in 1963, around 30 million people were infected with measles and <a href="https://doi.org/10.1016/j.eclinm.2024.102502">2.6 million people died from the disease</a> every year worldwide. In the U.S., measles was responsible for an estimated 3 million to 4 million infections. Among reported cases, there were 48,000 hospitalizations, 1,000 cases of encephalitis, or brain swelling, and 500 deaths <a href="https://www.cdc.gov/measles/about/history.html">every year</a>. </p>
<p>Measles is also one of the most contagious infectious diseases. According to the Centers for Disease Control and Prevention, <a href="https://www.cdc.gov/measles/about/parents-top4.html">up to 9 out of 10 people</a> exposed to an infected person will become infected if they don’t have protection from vaccines. The measles virus can stay in the air and infect others for up to two hours after a contagious person has left the room. Measles can also hide in an unknowing victim for <a href="https://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html">one to two weeks and sometimes up to 21 days</a> before symptoms begin. Infected people can <a href="https://www.cdc.gov/measles/transmission.html">spread measles</a> for up to four days before they develop its characteristic rash, and up to four days after. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of abdomen with red measles rash" src="https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578749/original/file-20240228-20-nsp7wf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">One characteristic measles symptom is a rash that spreads from the face to the rest of the body.</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/details.aspx?pid=3168">CDC/Heinz F. Eichenwald, MD</a></span>
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<p>The <a href="https://www.cdc.gov/measles/symptoms/signs-symptoms.html">initial symptoms</a> of measles are similar to those of many other common viral illnesses in the U.S.: fever, cough, runny nose and red eyes. Several days after symptoms begin, characteristic tiny white spots develop inside the mouth, and a facial rash spreads to the rest of the body. </p>
<p>While most people’s symptoms improve, 1 in 5 unvaccinated children will be hospitalized, 1 out of every 1,000 will develop brain swelling that can lead to brain damage, and up to <a href="https://www.cdc.gov/measles/symptoms/complications.html#">3 of every 1,000 will die</a>. For unvaccinated people who are pregnant, measles infection can lead to miscarriage, stillbirth, premature birth and low birth weight.</p>
<p>The risk of severe complications from measles persists even after a person appears to be fully recovered. In rare cases, people can experience a brain disease called <a href="https://www.ninds.nih.gov/health-information/disorders/subacute-sclerosing-panencephalitis#">subacute sclerosing panencephalitis</a> that develops seven to 10 years after infection and leads to memory loss, involuntary movements, seizures, blindness and eventually death.</p>
<p>Beyond these individual health effects, the <a href="https://www.idsociety.org/science-speaks-blog/2022/estimating-the-impact-how-much-does-a-measles-outbreak-cost/#/+/0/publishedDate_na_dt/desc/">financial cost</a> to society for containing measles outbreaks is significant. For example, a 2019 measles outbreak in Washington state is estimated to have cost <a href="https://doi.org/10.1542/peds.2020-027037">US$3.4 million</a>. Necessary efforts to control measles outbreaks pull millions of dollars’ worth of critical resources away from other essential public health functions such as ensuring food safety, preventing injuries and chronic diseases, and responding to disasters.</p>
<h2>Vaccines protect against measles</h2>
<p>Why put communities at risk and allow these societal costs from measles when effective and safe tools are available to protect everyone?</p>
<p>Measles vaccines have been so effective, providing lifelong protection to <a href="https://www.cdc.gov/measles/vaccination.html">over 97% of people</a> who receive two vaccine doses, that they are victims of their own success. Initial widespread measles vaccination had reduced measles cases by 99% compared to before the vaccine was available, and consequently, most people in the U.S. are unaware of the seriousness of this disease.</p>
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<a href="https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person looking at Florida Health measles and MMR shot information sheet" src="https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=570&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=570&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578753/original/file-20240228-7861-io367m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=570&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Measles is a highly preventable disease.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/measles-information-sheet-is-seen-posted-at-the-orange-news-photo/1141724959">Paul Hennessy/NurPhoto via Getty Images</a></span>
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<p>Despite the success of highly effective vaccination programs in the U.S., anyone can still come into contact with measles in their community. Measles is most often brought into the U.S. by <a href="https://www.cdc.gov/measles/about/parents-top4.html">unvaccinated American travelers</a> returning home and sometimes from foreign visitors. For people traveling out of the country, the threat of measles exposure is even greater, with widespread outbreaks occurring in <a href="https://wwwnc.cdc.gov/travel/notices/level1/measles-globe">many travel destinations</a>.</p>
<p>Public health leaders who embrace and promote vaccination and follow simple, proven infectious disease containment measures can help prevent measles disease spread. Every single preventable illness, complication, hospitalization or death from measles is one too many.</p><img src="https://counter.theconversation.com/content/224493/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Higgins is affiliated with Immunize Colorado, a nonprofit that works to protect Colorado families, schools and communities from vaccine-preventable diseases (volunteer non-paid board of directors member) and American Academy of Pediatrics (volunteer non-paid chapter immunization representative for the Colorado chapter).</span></em></p>A pediatrician and preventive medicine physician explains how measles vaccines became victims of their own success and the risk that rising outbreaks pose to everyone.David Higgins, Research Fellow and Instructor in Pediatrics, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2240472024-02-26T19:30:04Z2024-02-26T19:30:04ZA pandemic that won’t go away – as COVID enters its 5th year, NZ needs a realistic strategy<p>February 28 marks four years since COVID-19 was <a href="https://www.linkedin.com/posts/michael-baker-73b18710_rampant-covid-poses-new-challenges-in-the-activity-7166926211187765248-pt32?utm_source=share&utm_medium=member_desktop">first reported</a> in Aotearoa New Zealand. Many of us are probably surprised this virus is still causing a pandemic. </p>
<p>The World Health Organization refers to COVID-19 as a <a href="https://www.scientificamerican.com/article/rampant-covid-poses-new-challenges-in-the-fifth-year-of-the-pandemic/">continuing pandemic</a>. As Scientific American put it recently, it “has been the elephant in every room — sometimes confronted and sometimes ignored but always present”. </p>
<p>It wasn’t meant to be like this. The main wave of the 1918 influenza pandemic <a href="https://wwwnc.cdc.gov/eid/article/29/9/22-1265_article">swept through New Zealand</a> in eight weeks, killing 9,000 people – almost 1% of the population. Then it was largely gone, returning as a new seasonal flu virus. </p>
<p>In doing so, it defined how pandemics were expected to behave. This model was written into pandemic plans and collective thinking across the globe.</p>
<p>But COVID is <a href="https://tewhatuora.shinyapps.io/covid19/">still circulating</a> four years after New Zealand reported its first case, and more than two years after the Omicron variant arrived and infection became widespread. </p>
<p>Constantly present, it is also occurring in waves. Unexpectedly, the current <a href="https://www.phcc.org.nz/briefing/covid-19-finishing-year-high-we-need-vigorous-coordinated-response">fifth wave</a> was larger than the <a href="https://www.phcc.org.nz/briefing/aotearoa-new-zealands-fourth-wave-covid-19-and-why-we-should-care">fourth</a>, suggesting we can’t rely on the comforting assumption that COVID will get less severe over time. </p>
<h2>Unpredictable evolutionary shifts</h2>
<p>These waves are driven by the interaction of the organism (SARS CoV-2 virus), the host (human characteristics such as immunity and behaviour), and environmental factors (such as indoor ventilation). </p>
<p>Continuing viral evolution is a major contributor to the changing dynamic. The virus has demonstrated an ability for large, unpredictable evolutionary shifts that dramatically alter its genome and spike protein. </p>
<p>The result is an enhanced ability to evade prior immunity and infect more people. This jump was seen with the highly mutated <a href="https://www.nature.com/articles/s41467-023-43703-3">BA.2.86 subvariant</a> in mid-2023. </p>
<p>Its offspring, JN.1, has acquired additional changes and is causing such a wave of new infections it could potentially be the <a href="https://theconversation.com/the-emergence-of-jn-1-is-an-evolutionary-step-change-in-the-covid-pandemic-why-is-this-significant-220285">next variant of concern</a>, with its own Greek letter. It is now driving epidemic increases across the globe, <a href="https://esr-cri.shinyapps.io/wastewater/#region=Wellington&log_or_linear=linear&period=twelveMonthsButton">including in New Zealand</a>. This dominance by a single subvariant takes us back to the first year of Omicron in 2022.</p>
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<a href="https://theconversation.com/i-have-covid-how-likely-am-i-to-get-long-covid-218808">I have COVID. How likely am I to get long COVID?</a>
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<h2>Under-counting the pandemic impact</h2>
<p>The pandemic continues to have a large, visible health impact. It is a leading cause of serious illness and death, mainly in older populations and those with existing long-term health conditions. </p>
<p>In 2023, it caused more than <a href="https://www.phcc.org.nz/briefing/covid-19-finishing-year-high-we-need-vigorous-coordinated-response">12,000 hospitalisations and 1,000 deaths</a> in New Zealand.</p>
<p>But COVID-19 also has an important and largely unmeasured <a href="https://www.science.org/doi/10.1126/science.adl0867">burden of disease</a> as the cause of long COVID, which may become its biggest health impact. A growing number of studies are describing an estimated incidence of long COVID of 5% to 15% of all infections.</p>
<p>For example, a recent <a href="https://www.nature.com/articles/s41467-023-43661-w">large study</a> of almost 200,000 Scottish adults reported that, after adjustment for factors that might confuse the results, long COVID prevalence following an infection was 6.6% at six months, 6.5% at 12 months, and 10.4% at 18 months. </p>
<p>These findings illustrate an important feature of long COVID: recovery can take <a href="https://theconversation.com/long-covid-symptoms-can-improve-but-their-resolution-is-slow-and-imperfect-212015">two years or more</a>, with <a href="https://gh.bmj.com/content/6/9/e007004">symptoms that fluctuate</a> over time.</p>
<h2>An integrated respiratory disease strategy</h2>
<p>New Zealand now needs a strong, integrated response to COVID-19 and other respiratory infections.</p>
<p>The major pandemic interventions have not changed: vaccination, public health and social measures to prevent infection, and antivirals for more vulnerable groups. The evidence has firmed up that long COVID risk is <a href="https://www.cambridge.org/core/journals/antimicrobial-stewardship-and-healthcare-epidemiology/article/effectiveness-of-covid19-vaccine-in-the-prevention-of-postcovid-conditions-a-systematic-literature-review-and-metaanalysis-of-the-latest-research/A0B115B5D3AA60846799857B801D116E">reduced by vaccination</a>, but research is less certain for antivirals.</p>
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Read more:
<a href="https://theconversation.com/vaccination-testing-clean-air-covid-hasnt-gone-away-heres-where-australia-needs-to-do-better-222889">Vaccination, testing, clean air: COVID hasn't gone away – here's where Australia needs to do better</a>
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<p>But growing pandemic complacency from political leaders and the public has changed things. Some of this apparent indifference can be put down to understandable fatigue with response measures. But it remains dangerous in the face of a continuing pandemic.</p>
<p>One way to keep a focus on prevention and control would be to include these measures in an <a href="https://nzmj.org.nz/journal/vol-136-no-1583/continued-mitigation-needed-to-minimise-the-high-health-burden-from-covid-19-in-aotearoa-new-zealand">integrated respiratory infectious disease strategy</a>. This would combine COVID-19 control measures with those used to protect against influenza, respiratory syncytial virus (RSV), and other respiratory infections. </p>
<p>Measles could be added to the list, given the rising <a href="https://www.phcc.org.nz/briefing/urgent-action-needed-prevent-measles-epidemic-aotearoa-new-zealand">threat to New Zealand</a> from a global resurgence of the disease. </p>
<p>This <a href="https://ojs.victoria.ac.nz/pq/article/view/7500">integrated strategy</a> would include vaccination, promoting testing and self-isolation when sick, and measures to reduce transmission in critical indoor environments such as healthcare, public transport and education settings. </p>
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Read more:
<a href="https://theconversation.com/long-covid-stemmed-from-mild-cases-of-covid-19-in-most-people-according-to-a-new-multicountry-study-195707">Long COVID stemmed from mild cases of COVID-19 in most people, according to a new multicountry study</a>
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<p>Such a programme would need to be supported with community engagement, education, surveillance and research.</p>
<p>Structural inequalities mean Māori, Pacific peoples, and those living in relative deprivation, are less vaccinated, less protected from infection, less tested and less likely to have antivirals. </p>
<p>Consequently, they are more likely to be hospitalised and <a href="https://www.health.govt.nz/publication/covid-19-mortality-aotearoa-new-zealand-inequities-risk#:%7E:text=Ethnicity%20and%20age,with%20European%20and%20Other%20groups.">die from COVID-19</a>. These inequities are currently not being systematically tracked and acted on.</p>
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Read more:
<a href="https://theconversation.com/covid-theres-a-strong-current-of-pandemic-revisionism-in-the-mainstream-media-and-its-dangerous-222934">COVID: there's a strong current of pandemic revisionism in the mainstream media, and it's dangerous</a>
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<h2>Ignoring it won’t make it go away</h2>
<p>As we enter the fifth pandemic year, we need a change in thinking about COVID-19. This infection has <a href="https://doi.org/10.3390/ijms242317039">pathological features</a> in common with the other severe coronaviruses (SARS and MERS). </p>
<p>It is wishful thinking to imagine it will suddenly transform into a common cold coronavirus. As a recent <a href="https://www.nature.com/articles/s41579-023-00878-2#Abs1">review article</a> concluded: </p>
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<p>Transition from a pandemic to future endemic existence of SARS-CoV-2 is likely to be long and erratic […] endemic SARS-CoV-2 is by far not a synonym for safe infections, mild COVID-19 or a low population mortality and morbidity burden. </p>
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<p>In the face of this continuing pandemic threat, we need a response that is evidence-informed rather than evidence-ignored.</p><img src="https://counter.theconversation.com/content/224047/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Baker is a member of the Ministry of Health's COVID-19 Technical Advisory Group (TAG). The University of Otago receives funding from the Health Research Council of New Zealand and the New Zealand Ministry of Health for his research on COVID-19 and other infectious diseases.</span></em></p><p class="fine-print"><em><span>The University of Otago receives funding from the Health Research Council of New Zealand and the New Zealand Ministry of Health for research on COVID-19 and other infectious diseases.</span></em></p><p class="fine-print"><em><span>Matire Harwood was a member of the Ministry of Health COVID-19 TAG. She receives research funding from Health Research Council, National Heart Foundation and National Science Challenge-Healthier Lives. She also works at Papakura Marae which received funding for COVID-19 testing, vaccination and management.</span></em></p>On the fourth anniversary of New Zealand’s first COVID case it’s clear this is not a normal pandemic. Despite fatigue and indifference, New Zealand must heed the evidence and improve its response.Michael Baker, Professor of Public Health, University of OtagoAmanda Kvalsvig, Associate Professor, Department of Public Health, University of OtagoMatire Harwood, Associate Professor, Department of General Practice and Primary Care, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2221442024-01-31T04:43:32Z2024-01-31T04:43:32ZMeasles is on the rise around the world – we can’t let vaccination rates falter<figure><img src="https://images.theconversation.com/files/572324/original/file-20240131-29-6uve5g.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5176%2C3445&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/viral-disease-measles-rash-concept-doctor-1323694607">fotohay/Shutterstock</a></span></figcaption></figure><p>In recent weeks a series of measles alerts have been issued <a href="https://www.news.com.au/lifestyle/health/health-problems/sydney-canberra-melbourne-put-on-alert-after-airport-measles-cases/news-story/6f2c44209c20ad319fe1ff4036070be0">around Australia</a>, including in <a href="https://www.health.nsw.gov.au/news/Pages/20240124_01.aspx">New South Wales</a>, <a href="https://www.health.vic.gov.au/health-alerts/new-measles-cases-in-victoria">Victoria</a> and <a href="https://metrosouth.health.qld.gov.au/news/measles-alert-for-brisbane-south-0">Queensland</a>, after the identification of a small number of cases in travellers returning from overseas. </p>
<p>Meanwhile, places such as the <a href="https://emergency.cdc.gov/newsletters/coca/2024/012524.html">United States</a> and the <a href="https://www.dailymail.co.uk/health/article-12982153/Measles-resurgence-fears-spark-national-call-action-health-chief-warns-UK-forgotten-illness-like-HALF-children-areas-not-jabbed-rates-slump-10-year-low-wake-Covid-anti-vax-movement.html">United Kingdom</a> have been contending with larger measles outbreaks.</p>
<p>In fact, the World Health Organization reported a <a href="https://www.bbc.com/news/health-68068226">45-fold increase</a> in measles cases in Europe last year, with 42,200 cases recorded in 2023 compared to 941 in 2022.</p>
<p>In South Asia, <a href="https://www.who.int/india/health-topics/measles">India</a> and <a href="https://www.cdc.gov/globalhealth/measles/data/global-measles-outbreaks.html">Pakistan</a> have also recently reported outbreaks.</p>
<p>So what’s the risk of a larger outbreak in Australia? Fortunately it’s likely to be quite low – but ensuring we continue to have high rates of vaccination coverage is crucial.</p>
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<h2>Remind me – what is measles?</h2>
<p>Measles is a <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Measles/">highly infectious</a> viral disease. It spreads through tiny droplets when an infected person coughs or sneezes. Measles is so contagious that if one infected person comes into contact with ten unvaccinated people, they can infect <a href="https://www.theguardian.com/world/2024/jan/23/first-edition-measles-outbreak">nine of them</a>.</p>
<p>It can take around ten to 12 days for symptoms to appear after a person has been exposed to the virus. Although measles is characterised by a rash, symptoms are generally cold-like to begin with, including a fever, runny nose, fatigue, and sore or red eyes. The rash, which is not itchy, emerges two or three days later and spreads from the face down the body. </p>
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Read more:
<a href="https://theconversation.com/measles-in-samoa-how-a-small-island-nation-found-itself-in-the-grips-of-an-outbreak-disaster-128467">Measles in Samoa: how a small island nation found itself in the grips of an outbreak disaster</a>
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<p>Sometimes measles can lead to secondary infections such as an ear infection, diarrhoea or pneumonia. In rare cases measles can cause encephalitis (inflammation of the brain). </p>
<p>In severe cases measles can lead to hospitalisation and death. We saw this in 2019 in the Pacific Island nation of Samoa. Out of <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30044-X/fulltext">5,667 infections</a> in a four-month period, 81 died, mostly young children.</p>
<h2>Vaccination works</h2>
<p>Vaccination is the most effective strategy to protect against measles. Two doses of the MMR vaccine (given to children at <a href="https://www.healthywa.wa.gov.au/Articles/J_M/Measles-mumps-rubella-MMR-vaccine">12 months and 18 months</a> in Australia) provide protection against measles, mumps and rubella.</p>
<p>Babies under one year have natural protection from their mums that wears off gradually. Infants six to 11 months <a href="https://www.health.nsw.gov.au/Infectious/measles/Pages/measles-vax-qanda.aspx">can be vaccinated</a> if they will be travelling internationally, but will still need to take a further two doses.</p>
<p>Once vaccinated, the chance of getting measles is <a href="https://www.mayoclinic.org/diseases-conditions/measles/expert-answers/getting-measles-after-vaccination/faq-20125397">very low</a> and you are considered protected for life. </p>
<p>However, <a href="https://www.health.nsw.gov.au/Infectious/measles/Pages/measles-vax-qanda.aspx#howeff">about one in 100 people</a> who are vaccinated may still contract measles if they’re exposed to the virus. Although it’s not entirely clear why this happens, the infection in a vaccinated person is generally mild.</p>
<h2>Vaccination rates are faltering</h2>
<p>Globally, there has been <a href="https://www.dailymail.co.uk/health/article-12982153/Measles-resurgence-fears-spark-national-call-action-health-chief-warns-UK-forgotten-illness-like-HALF-children-areas-not-jabbed-rates-slump-10-year-low-wake-Covid-anti-vax-movement.html">a drop in childhood vaccinations</a> over the course of the COVID pandemic. This is likely due to a <a href="https://jamanetwork.com/journals/jama/fullarticle/2813910?guestAccessKey=417a7c3d-66ff-4692-9312-0eaf0256d5ca&utm_source=silverchair&utm_campaign=jama_network&utm_content=healthpolicy_highlights&u">range of factors</a> including declining trust in vaccines, misinformation and disruptions to access.</p>
<p>In Europe, the <a href="https://www.bbc.com/news/health-68068226">proportion of children</a> who received a first dose of the MMR vaccine dropped from 96% in 2019 to 93% in 2022, and from 93% to 91% for the second dose. This is important because about <a href="https://www.who.int/news-room/questions-and-answers/item/herd-immunity-lockdowns-and-covid-19#:%7E:text=The%20percentage%20of%20people%20who,among%20those%20who%20are%20vaccinated.">95% vaccination coverage</a> is needed to achieve herd immunity against measles. Under this scenario, those who are not vaccinated will be protected because the virus won’t spread.</p>
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Read more:
<a href="https://theconversation.com/measles-has-been-identified-in-nsw-qld-and-sa-5-things-to-know-about-the-virus-202945">Measles has been identified in NSW, Qld and SA. 5 things to know about the virus</a>
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<p>In the UK, health authorities <a href="https://www.dailymail.co.uk/health/article-12982153/Measles-resurgence-fears-spark-national-call-action-health-chief-warns-UK-forgotten-illness-like-HALF-children-areas-not-jabbed-rates-slump-10-year-low-wake-Covid-anti-vax-movement.html">have expressed alarm</a> at the number of children who have not been vaccinated, with reports up to almost half of children in parts of London have not received both shots.</p>
<p>As of September 2023, the <a href="https://www.health.gov.au/topics/immunisation/immunisation-data/childhood-immunisation-coverage/immunisation-coverage-rates-for-all-children">Australian government</a> reported immunisation rates across all childhood vaccinations of 93.26% for one-year-olds, 91.22% for two-year-olds, and 94.04% for five-year-olds. There are slight disparities between different states and territories and among some population groups. </p>
<h2>Boosting vaccination coverage</h2>
<p>While we appear to be quite close to the herd immunity threshold for measles and not in immediate danger of an outbreak, we still need to be vigilant. </p>
<p>Australia has an excellent outbreak surveillance in place in all states for infectious diseases including measles. But outbreaks are <a href="https://www.cdc.gov/globalhealth/measles/data/global-measles-outbreaks.html">occurring globally</a>, and are liable to take hold when people are unvaccinated or under-vaccinated. So we need to be alert in all states, increase surveillance at international transit points, and continue to increase immunisation coverage, especially among young children. Educating parents and the wider community about the importance of MMR vaccines is key.</p>
<p>It’s never too late to be vaccinated against measles if you missed out as a child, or are unsure if you’ve had two doses. As a single infected traveller can cause an outbreak, vaccination is particularly important if you travel frequently. If you’re unsure of your vaccination status, you can ask your GP or check your own or your children’s record through the <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/How-to-find-your-immunisation-records">Australian Immunisation Register</a>. </p>
<p>If you suspect you or someone in your family is infected it’s important to stay isolated and contact your doctor. They will confirm the infection by <a href="https://www.health.vic.gov.au/health-alerts/new-measles-cases-in-victoria">referring you</a> for a blood test and possibly a RT-PCR test.</p>
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Read more:
<a href="https://theconversation.com/why-people-born-between-1966-and-1994-are-at-greater-risk-of-measles-and-what-to-do-about-it-110167">Why people born between 1966 and 1994 are at greater risk of measles – and what to do about it</a>
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<p><em>The Australian department of health in collaboration with the Australian Academy of Science has developed a set of <a href="https://www.science.org.au/curious/people-medicine/measles-everything-you-need-know">useful resources</a> on measles which can assist travellers, the general public and health professionals.</em></p><img src="https://counter.theconversation.com/content/222144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaya Dantas is Professor of International Health in the Curtin School of Population Health and leads a program of research in refugee and migrant health. She is currently lead CI on grants funded by Healthway and Lotterwest and CI on a DISER grant. Jaya is the International Health SIG Convenor of the Public Health Association of Australia, has been appointed to the Committee of Women in Global Health, Australia and is on the Editorial Advisory Group of the Medical Journal of Australia. She has lived experience of infectious disease in India and Africa.</span></em></p>Though the outbreaks overseas are bigger, a number of cases have also been detected in Australia so far this year.Jaya Dantas, Deputy Chair, Academic Board; Dean International, Faculty of Health Sciences and Professor of International Health, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2212912024-01-19T07:24:56Z2024-01-19T07:24:56ZMeasles is the most infectious disease known to science – adults should consider getting another MMR vaccine<figure><img src="https://images.theconversation.com/files/569842/original/file-20240117-23-b5my4a.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2053%2C2996&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Adult MMR jabs could play an important role in preventing measles outbreaks</span> <span class="attribution"><a class="source" href="https://www.gettyimages.co.uk/detail/news-photo/syringes-containing-the-mumps-measles-and-rubella-vaccine-news-photo/57470629?adppopup=true">Mark Kegans/Getty Images</a></span></figcaption></figure><p>Imagine a disease more infectious than any other known to medical science, that would kill <a href="https://www.who.int/news-room/fact-sheets/detail/measles">2.6 million young children every year</a> and leave millions more with deafness and even brain damage. It sounds like something from pandemic horror fiction, but such a disease does exist – measles. </p>
<p>Yet even measles was tamed across the world, at least for a while. In the aftermath of the successful eradication of smallpox in the 1970s, a similar global vaccination effort crushed measles mortality from 2.6 million in 1980 down to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388903/">73,000 by 2014</a>.</p>
<p>Measles’ R number (the average number of people someone with the virus will go on to infect) of 15 or more puts even the most rampant variants of SARS-CoV-2 in the shade. Because of this infectiousness, it’s never been quite possible to achieve eradication, but many countries have been declared <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5069432/">measles-free</a> by the World Health Organization.</p>
<p>This achievement isn’t necessarily permanent, however. The UK was deemed measles-free in 2016 but lost its status just two years later. And now there are rising case numbers across England, with <a href="https://www.bbc.co.uk/news/uk-england-birmingham-68007804">significant outbreaks</a> in London and the west Midlands.</p>
<p>The principal weapon in the war against measles has been the MMR vaccine, rolled out from 1971, which also provides immunity against <a href="https://www.nhs.uk/conditions/mumps/">mumps</a> and <a href="https://www.who.int/news-room/fact-sheets/detail/rubella">rubella</a> – two other viruses with potentially nasty long-term effects. </p>
<p>MMR’s global deployment was perhaps the greatest public health triumph of the last quarter of the 20th century, saving at least 56 million lives <a href="https://www.who.int/news-room/fact-sheets/detail/measles">by WHO estimates</a>. </p>
<p>Until, in 1998, a spanner was thrown in the works when spurious claims were made in The Lancet about a connection between the MMR vaccine and autism. In 2010, <a href="https://www.bmj.com/content/340/bmj.c696">the paper was retracted</a> by the journal and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136032/">its lead author, Andrew Wakefield, struck off</a> from practising medicine in the UK. But by then, the damage had been done. </p>
<p>Despite <a href="https://www.cdc.gov/vaccinesafety/vaccines/mmr/mmr-studies.html">numerous studies</a> confirming both the efficacy and safety of MMR, and failing to find any connection whatsoever with autism, many people began to have second thoughts about bringing their children in for vaccination. Vaccine hesitancy had set in, and measles began its insidious return, with global deaths climbing to <a href="https://www.bmj.com/content/383/bmj.p2733">136,000 in 2022</a>.</p>
<h2>Vaccine hesitancy and misinformation</h2>
<p>Vaccine hesitancy, <a href="https://theconversation.com/victorian-britain-had-its-own-anti-vaxxers-and-they-helped-bring-down-a-government-218671">although nothing new</a>, has become such a problem for public health services that it is the subject of intense research interest. </p>
<p>And it isn’t just scare stories about autism. <a href="https://pubmed.ncbi.nlm.nih.gov/33684019/">Studies have revealed</a> the full complexity of the problem – that there is no single factor which vaccine-hesitant people share, and therefore no obvious, easy public educational strategy to solve the problem. </p>
<p>Those who are <a href="https://pubmed.ncbi.nlm.nih.gov/30476112/">less educated</a> have a tendency to hesitancy – but so do those who are <a href="https://pubmed.ncbi.nlm.nih.gov/28757057/">highly educationally qualified</a>. Likewise, those who <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5103-8">hold deep religious convictions</a> but also those who are <a href="https://pubmed.ncbi.nlm.nih.gov/31262584/">militantly anti-religious</a>, those who <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191728">distrust the nanny state</a>, those who distrust capitalism and particularly <a href="https://pubmed.ncbi.nlm.nih.gov/31431420/">the pharmaceuticals industry</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/30639802/">the poorest in society and the richest</a> – all these groups show elevated levels of vaccine hesitancy, yet often have little else in common at all. </p>
<p>In contrast, a middle-of-the-road, middle-income, reasonably educated person with weakly held religious beliefs is the most likely to be found in the queue at the vaccination station. We still do not really know why.</p>
<p>Vaccine hesitancy is now a problem for all vaccination programmes but particularly measles, since its R of 15 or more means that any drop in vaccine coverage will result in a rapid increase in cases. </p>
<p>Where vaccine coverage becomes locally low, there can be <a href="https://theconversation.com/over-3-000-killed-by-deadly-virus-in-democratic-republic-of-the-congo-this-year-and-its-not-ebola-123220">local epidemics of considerable severity</a>. Many countries have now <a href="https://www.bbc.co.uk/news/health-49507253">lost their hard-earned measles-free status</a>, in Europe including Albania, the Czech Republic and Greece, as well as the UK.</p>
<p>But there is one thing we can all do to help – and if you live in the UK, <a href="https://www.nhs.uk/conditions/vaccinations/nhs-vaccinations-and-when-to-have-them/">the NHS can help you do it</a>. </p>
<h2>MMR is not just for kids</h2>
<p>Even if an adult has received MMR as a child or survived an attack of measles in the pre-vaccination days, their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189124/">immunity can wane</a>. Although the risk of a second attack bad enough to produce the symptoms seen in unprotected children is very small, adult MMR is still worthwhile as it goes beyond just protecting the person who receives the vaccination.</p>
<p>By bolstering the immunity of adults against these three viruses, it decreases the likelihood of an <a href="https://pubmed.ncbi.nlm.nih.gov/10443793/">asymptomatic infection</a> and prevents an adult becoming an unwitting carrier. Adult MMR can help to restore some of the herd immunity that has been lost due to vaccine hesitancy.</p>
<figure class="align-center ">
<img alt="Two women and baby are in a medical office with yellow walls. One of the women holds a baby, who's dressed in pink and looks unhappy, while the other woman, dressed in a nurse's uniform administers a vaccine to the baby." src="https://images.theconversation.com/files/569840/original/file-20240117-23-52meji.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569840/original/file-20240117-23-52meji.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569840/original/file-20240117-23-52meji.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569840/original/file-20240117-23-52meji.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569840/original/file-20240117-23-52meji.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569840/original/file-20240117-23-52meji.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569840/original/file-20240117-23-52meji.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Measles vaccines aren’t only for children.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.co.uk/detail/news-photo/month-old-amelia-down-sits-on-the-lap-of-her-mother-helen-news-photo/167095249?adppopup=true">Geoff Caddick/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Babies under a year of age cannot receive MMR, so they are the most vulnerable. Opting for adult MMR helps protect those babies from measles, and it helps prevent rubella in pregnant women and their babies. </p>
<p>And if you’re a man of a certain age, opting for adult MMR also protects you personally against orchitis – the dreaded <a href="https://www.nhs.uk/conditions/mumps/complications/">inflammation of the testicles</a> that is a symptom of mature men’s mumps.</p>
<p>It would be a tragedy for the world to return to the days of uncontrolled measles epidemics due to sustained vaccine hesitancy over MMR. Let’s get herd immunity against measles back up to where it should be by choosing adult MMR.</p><img src="https://counter.theconversation.com/content/221291/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Derek Gatherer receives funding from the UK Economic & Social Research Council for work on vaccine hesitancy.</span></em></p>Herd immunity to measles is waning due to vaccine hesitancy over MMR. Adult MMR is one way to help get it back up again.Derek Gatherer, Lecturer, Biomedical and Life Sciences, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2102332023-07-27T14:46:30Z2023-07-27T14:46:30ZMeasles: it’s not just London that’s at risk of an outbreak – it’s all of the UK<p>Since the start of 2023, measles has been reported in a third of countries in the World Health Organization (WHO) European region. And in the first five months of the year, there were <a href="https://www.who.int/europe/news/item/19-07-2023-european-region-achieves-high-routine-immunization-coverage--but-falls-short-of-pre-pandemic-levels">5,699 cases reported there</a> – nearly seven times as many as in the whole of 2022. </p>
<p>The UK lost its measles-free status in 2019, indicating that the measles virus was circulating and there was inadequate vaccination to prevent its spread. If exposed to the measles virus, <a href="https://www.who.int/news-room/fact-sheets/detail/measles#:%7E:text=Transmission,of%20their%20unvaccinated%20close%20contacts.">90% of unvaccinated people will get infected</a>. The virus spreads like wildfire among the unvaccinated, as demonstrated recently when seven unvaccinated children at a nursery school in <a href="https://www.bbc.co.uk/news/uk-england-stoke-staffordshire-66297202">Stoke-on-Trent nursery</a> caught the bug.</p>
<p>With the <a href="https://www.gov.uk/government/publications/health-protection-report-volume-17-2023/hpr-volume-17-issue-7-news-14-july-2023">latest data</a> from the UK Health Security Agency (UKHSA) showing at least one measles case in each region in England this year, and warnings of the potential for outbreaks in London, where else in the UK are children at risk? The short answer is probably “everywhere”. </p>
<p>Schools in all four devolved nations have now broken up for the summer holidays and people are travelling both in the UK and abroad and may encounter the measles virus on their travels. Eighty-one per cent of the 128 confirmed cases of measles in England so far in 2023 have been as a result of in-country community transmission.</p>
<p>There are no specific drugs for measles, so treatment is to help relieve symptoms and address complications, such as bacterial infections. <a href="https://www.cdc.gov/globalhealth/newsroom/topics/measles/index.html">For every 1,000 people infected</a>, between one and three of them will die (deaths are highest in children under the age of five and those with weakened immune systems). </p>
<p>Deaths are commonly due to secondary bacterial infections. Pneumonia accounts for 60% of measles-associated deaths.</p>
<p>Other complications such as deafness, fits and encephalitis (brain inflammation) are relatively common. Around 25% of people who develop measles need hospital care.</p>
<p>But measles is a highly preventable disease, with two doses of the measles, mumps and rubella (MMR) vaccine <a href="https://www.nhs.uk/conditions/vaccinations/mmr-vaccine/">protecting around 97%</a> of people. In the UK, MMR is given as part of the <a href="https://www.nhs.uk/conditions/vaccinations/nhs-vaccinations-and-when-to-have-them/">routine childhood immunisation schedule</a>, with dose one (MMR1) given around the age of 12 months, and MMR2 given as part of the pre-school boosters at age three years and four months. </p>
<p>Yet MMR levels across many parts of the UK fall far short of the 95% coverage needed for <a href="https://theconversation.com/measles-how-declining-vaccination-levels-in-london-are-threatening-herd-immunity-209827">“herd immunity” against measles</a> – where enough people are vaccinated that the virus is unable to spread. In the first quarter of 2023, UK-wide coverage for <a href="https://www.gov.uk/government/statistics/cover-of-vaccination-evaluated-rapidly-cover-programme-2022-to-2023-quarterly-data">MMR2 by the age of five</a> (that is, more than 18 months after it’s due) was just below 86% and no devolved nation had coverage above 90%. </p>
<p>While London has the lowest coverage for the same metric (at around 75%), only one of the other six NHS England regions had coverage above 90% (and even then, only just, at 90.5%).</p>
<p>There have always been pockets of populations with much lower-than-average levels of MMR coverage, but this has become much more complicated during the pandemic when disruptions to services in early waves meant that certain age groups may also have missed out on routine childhood immunisations. </p>
<p>For example, of the children attending a large paediatric emergency department in Greater Manchester, it was found that <a href="https://bmjopen.bmj.com/content/13/6/e072053">just 20%</a> of four-year-olds had received both the required doses of MMR. This pattern is seen globally, with many countries yet to attain the levels of routine immunisation coverage they had pre-pandemic. During 2022, <a href="https://www.who.int/news-room/fact-sheets/detail/immunization-coverage">21.9 million children missed</a> their first dose of a measles vaccine – nearly 3 million more than in 2019.</p>
<p>Mumps and rubella – viruses also covered by the MMR vaccine – are also highly infectious diseases and can make children extremely ill. Complications include deafness and fits. But it’s never too late to catch up on a missed dose of the MMR vaccine. </p>
<p>In the UK, you can check your vaccinations with your GP surgery. There are <a href="https://www.nhs.uk/conditions/vaccinations/mmr-vaccine/">some situations</a> where older children and adults need to check they are up to date with their vaccinations, for example, if they are about to start university or travel abroad. </p>
<p>Adults in different age groups might also not be fully protected – for example, those who have been immunised according to the NHS schedule and were born between 1970 and 1979 may only be vaccinated against measles. And those born between 1980 and 1990 may not be protected against mumps.</p>
<p>But measles isn’t the only vaccine-preventable disease on the rise. Last year’s discovery of type 2 <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01804-9/fulltext">polio virus</a> in London wastewater and reports of increased cases of <a href="https://www.gov.uk/government/publications/diphtheria-cases-among-asylum-seekers-in-england-2022/diphtheria-cases-among-asylum-seekers-in-england-2022">diphtheria</a> among a vulnerable population in England means that improving routine childhood vaccination coverage should be a priority. </p>
<p>For MMR, a national catch-up campaign is underway, and many regions have set up measles-elimination groups. If this work is successful, hopefully the UK will be able to regain its measles-free status.</p><img src="https://counter.theconversation.com/content/210233/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Professor Rachel Isba receives funding from Action Medical Research (AMR) and the National Institute for Health and Care Research (NIHR) and has previously received funding from the Children's Hospital Alliance (CHA), Health Education England (HEE), the Sir Halley Stewart Trust, and the Dowager Countess Eleanor Peel Trust. She is a Trustee of the Royal Society for Public Health. </span></em></p>Seven children at a nursery in Stoke-on-Trent have caught measles. But other parts of the UK are at risk too.Rachel Isba, Professor of Medicine, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2098272023-07-18T16:10:33Z2023-07-18T16:10:33ZMeasles: how declining vaccination levels in London are threatening herd immunity<figure><img src="https://images.theconversation.com/files/538068/original/file-20230718-23-6nl8w9.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5176%2C3445&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/viral-disease-rash-measles-concept-doctor-1297395328">fotohay/Shutterstock</a></span></figcaption></figure><p>The UK Health Security Agency (UKHSA) <a href="https://www.gov.uk/government/publications/health-protection-report-volume-17-2023/hpr-volume-17-issue-7-news-14-july-2023">has warned</a> of an increased risk of measles outbreaks, particularly in London. </p>
<p>Although the probability of a large epidemic is still considered to be low elsewhere in the UK, the UKHSA’s projections suggest the capital could see <a href="https://www.gov.uk/government/publications/measles-risk-assessment-for-resurgence-in-the-uk">40,000 to 160,000 cases</a>, with hospitalisation rates of 20%-40%.</p>
<p>For 60 years, measles has been preventable by a <a href="https://www.nhs.uk/conditions/vaccinations/mmr-vaccine/">widely available vaccine</a>, so why is London facing a potential disaster now? </p>
<p>The answer lies in faltering vaccine coverage, particularly since the late 1990s, but <a href="https://theconversation.com/measles-global-increase-in-cases-likely-driven-by-covid-pandemic-182250">exacerbated</a> by COVID pandemic. </p>
<p>Measles is a viral infection that primarily affects children but can also occur in adults. It can cause <a href="https://academic.oup.com/jid/article/189/Supplement_1/S4/823958">serious complications</a>, particularly in people with weakened immune systems. </p>
<p>The measles virus <a href="https://www.who.int/news-room/fact-sheets/detail/measles">spreads</a> through respiratory droplets from an infected person, making it easily transmissible in close quarters such as schools, hospitals, and public transport. It’s known to be one of the most infectious pathogens affecting humans. </p>
<p>The <a href="https://theconversation.com/coronavirus-is-the-r-number-still-useful-138542">basic reproduction number</a>, R, for measles, is estimated to be <a href="https://pubmed.ncbi.nlm.nih.gov/28757186/">between 12 and 18</a>. This means one infected child can pass on the disease to 12 to 18 other children in a completely susceptible population. </p>
<p>The effective reproduction number, Re, takes into account the proportion of contacts who are not susceptible, either because they have already had measles or have been vaccinated. If the Re is larger than one, the disease spreads. </p>
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Read more:
<a href="https://theconversation.com/vaccine-hesitancy-is-one-of-the-greatest-threats-to-global-health-and-the-pandemic-has-made-it-worse-208227">Vaccine hesitancy is one of the greatest threats to global health – and the pandemic has made it worse</a>
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<p>Before measles vaccines became available, almost everybody over five would have had the disease, which for most meant lifelong immunity. But <a href="https://academic.oup.com/jid/article/189/Supplement_1/S4/823958?login=false">complications</a> like encephalitis or pneumonia caused many <a href="https://en.wikipedia.org/wiki/Olivia_Dahl">deaths</a>. Even today, thousands die <a href="https://www.who.int/news-room/fact-sheets/detail/measles">from measles</a> globally every year – mostly unvaccinated young children.</p>
<p>Vaccination campaigns have been <a href="https://ourworldindata.org/vaccination#how-vaccines-work-herd-immunity">remarkably successful</a> in reducing the number of measles cases. Mass vaccination programmes started in the 1960s and quickly suppressed the spread in most developed countries. The measles shot is a “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9595357/">sterilising</a>” vaccine, which means it not only prevents illness, but also transmission.</p>
<p><strong>Measles cases in the US, 1938–2019</strong></p>
<figure class="align-center ">
<img alt="A graph showing how vaccinations in the US affected measles cases." src="https://images.theconversation.com/files/538009/original/file-20230718-25-c5oh3a.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538009/original/file-20230718-25-c5oh3a.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=356&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538009/original/file-20230718-25-c5oh3a.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=356&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538009/original/file-20230718-25-c5oh3a.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=356&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538009/original/file-20230718-25-c5oh3a.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=448&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538009/original/file-20230718-25-c5oh3a.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=448&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538009/original/file-20230718-25-c5oh3a.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=448&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/3/3f/Measles_US_1938-2019.png">Julius Senegal</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>We don’t actually need to vaccinate every single person against measles for everybody to be protected. By vaccinating a large enough proportion of the population, we can lower the Re below one, effectively “starving” the pathogen of new hosts. The population then reaches “<a href="https://theconversation.com/herd-immunity-why-the-figure-is-always-a-bit-vague-141839">herd immunity</a>”.</p>
<p>Mathematical modelling, taking in the virus’ reproduction number and other factors, allows us <a href="https://theconversation.com/what-is-herd-immunity-and-how-many-people-need-to-be-vaccinated-to-protect-a-community-116355">to estimate</a> the level of vaccination needed to reach and maintain herd immunity. </p>
<p>For measles to be eliminated, <a href="https://www.nhs.uk/conditions/vaccinations/why-vaccination-is-safe-and-important/">between 90% and 95%</a> of the population <a href="https://www.who.int/news/item/10-11-2021-global-progress-against-measles-threatened-amidst-covid-19-pandemic">should be immune</a> (either from vaccination or infection).</p>
<p>Herd immunity could be lost if we don’t keep vaccinating children who are born susceptible to measles. Two doses of the measles, mumps and rubella (MMR) vaccine are <a href="https://www.cdc.gov/vaccines/vpd/measles/index.html">needed</a> – the first at 12 months and the second at age five – for effective protection.</p>
<p>The current levels of MMR coverage in England, particularly in London, are <a href="https://www.gov.uk/government/news/london-at-risk-of-measles-outbreaks-with-modelling-estimating-tens-of-thousands-of-cases">well below</a> the 95% threshold. </p>
<p><strong>Vaccination levels needed to maintain herd immunity</strong></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/537912/original/file-20230717-27-pnlijj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537912/original/file-20230717-27-pnlijj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=496&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537912/original/file-20230717-27-pnlijj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=496&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537912/original/file-20230717-27-pnlijj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=496&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537912/original/file-20230717-27-pnlijj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=623&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537912/original/file-20230717-27-pnlijj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=623&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537912/original/file-20230717-27-pnlijj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=623&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This graph shows vaccination levels needed for herd immunity for diseases with different R values, and how this applies to measles.</span>
<span class="attribution"><a class="source" href="https://www.gov.uk/government/publications/measles-risk-assessment-for-resurgence-in-the-uk">UKHSA; Adam Kleczkowski</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p><strong>MMR vaccination levels across different age groups in London</strong></p>
<figure class="align-center ">
<img alt="This graph shows vaccination levels for MMR 1 and MMR 2 across different age groups in London for children born between 1985 and 2016." src="https://images.theconversation.com/files/538040/original/file-20230718-26248-b0ibpg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538040/original/file-20230718-26248-b0ibpg.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=583&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538040/original/file-20230718-26248-b0ibpg.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=583&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538040/original/file-20230718-26248-b0ibpg.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=583&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538040/original/file-20230718-26248-b0ibpg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=733&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538040/original/file-20230718-26248-b0ibpg.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=733&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538040/original/file-20230718-26248-b0ibpg.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=733&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.gov.uk/government/publications/measles-risk-assessment-for-resurgence-in-the-uk">UKHSA; Adam Kleczkowski</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The UK has never reached the 95% level of MMR coverage recommended by the World Health Organization (WHO) to eliminate measles, although it has come close enough to prevent a repeat of the large outbreaks that regularly occurred before the 1960s. </p>
<p>However, a drop in vaccination rates in the late 1990s meant <a href="https://theconversation.com/measles-epidemic-parents-reluctant-to-vaccinate-their-children-need-to-hear-of-the-horrors-of-forgotten-diseases-122688">repeated revivals</a> of the virus. This drop is often <a href="https://www.bbc.co.uk/programmes/w3cswjk9">linked</a> to the publication of Andrew Wakefield’s Lancet paper linking the MMR vaccine to autism, which has since been debunked.</p>
<p>Then, in 2017, the WHO declared that the UK had <a href="https://ukhsa.blog.gov.uk/2019/08/19/measles-in-england/">eliminated measles</a>, but this was not maintained. Cases subsequently started occurring more frequently in areas with particularly low vaccination coverage. An <a href="https://www.gov.uk/government/news/measles-outbreaks-across-england">outbreak in England</a> between 2017 and 2018 saw a nearly fourfold increase in confirmed cases. Other <a href="https://www.bbc.com/news/health-45246049">European countries</a> had similar problems.</p>
<p>The COVID pandemic has seen vaccination levels drop further, creating a <a href="https://www.who.int/news/item/27-04-2022-unicef-and-who-warn-of--perfect-storm--of-conditions-for-measles-outbreaks--affecting-children">perfect storm</a> of <a href="https://www.gov.uk/government/publications/measles-risk-assessment-for-resurgence-in-the-uk">low immunity levels</a>. </p>
<p>Some children born since 2015 who were going to be given their second MMR shot during the COVID pandemic missed it. These groups of children are at particular risk, as they are now at school, where they can easily catch the virus. </p>
<p>As well as COVID lockdowns limiting access to routine healthcare, vaccine hesitancy and <a href="https://bylinetimes.com/2021/10/01/inside-the-radicalised-anti-vaxxer-network-influencing-government-vaccine-advisory-panel/?s=09">outright anti-vaxxer attitudes</a> have likely been magnified by COVID <a href="https://www.bbc.com/news/54893437">vaccine misinformation</a>. </p>
<p><strong>Estimated immunity levels for different age groups, London and England</strong></p>
<figure class="align-center ">
<img alt="This graph shows the estimated immunity levels for different age groups in London and England for children born between 1985 and 2016." src="https://images.theconversation.com/files/538031/original/file-20230718-21-vbdwkp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538031/original/file-20230718-21-vbdwkp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=599&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538031/original/file-20230718-21-vbdwkp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=599&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538031/original/file-20230718-21-vbdwkp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=599&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538031/original/file-20230718-21-vbdwkp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=752&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538031/original/file-20230718-21-vbdwkp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=752&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538031/original/file-20230718-21-vbdwkp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=752&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.gov.uk/government/publications/measles-risk-assessment-for-resurgence-in-the-uk">UKHSA; Adam Kleczkowski</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>While only <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1170146/risk-assessment-for-measles-resurgence-in-the-UK-2023.pdf">three-quarters</a> of eligible five-year-olds in London have received their second MMR dose, immunity levels are not the same across all age groups. The UKHSA has sought to work out immunity levels in different age groups to better understand the risk of outbreaks. </p>
<p>The UKHSA <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/769970/UK_measles_and_rubella_elimination_strategy.pdf">combined</a> the proportion of vaccinated people in different age groups with vaccine <a href="https://www.cdc.gov/vaccines/vpd/measles/index.html">efficacy</a> (93% after the first dose and 97% after two). It also accounted for the misclassification of unvaccinated and under-vaccinated people. </p>
<p>The resulting immunity levels are unevenly distributed across ages, as seen in the graph above. Most adults 55 or over are likely to have had measles when they were young. Children born between the start of the vaccination programme and the late 1980s were given a catch-up in 1994 and 1996 and are relatively safe. But children born in the late 1990s and early 2000s are potentially at high risk, as is the most recent, post-2015 cohort. </p>
<p>With its consistently low vaccination levels, London is more likely to face an outbreak than the rest of the UK. Counting how many people would need to become infected to fill in the “immunity gap” gives the worst-case estimate of 160,000 cases for the capital.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/measles-outbreaks-and-political-crises-go-hand-in-hand-122968">Measles outbreaks and political crises go hand in hand</a>
</strong>
</em>
</p>
<hr>
<p>Some <a href="https://www.gov.uk/government/collections/notifications-of-infectious-diseases-noids">1,053 cases</a> of measles were reported in England and Wales over the past year, and we could see more. Most of the new disease outbreaks can <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/849538/PHE_Measles_Guidelines.pdf">be controlled</a> by emergency vaccination and management of contacts. But loss of immunity makes the virus escape more likely and could lead to large, uncontrollable outbreaks.</p><img src="https://counter.theconversation.com/content/209827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Kleczkowski receives funding from the UKRI and from the Scottish Government. He is a trustee of the Scottish Forestry Trust.</span></em></p>Projections from the UKHSA suggest London could see a measles outbreak totalling 40,000 to 160,000 cases at current vaccination levels.Adam Kleczkowski, Professor of Mathematics and Statistics, University of Strathclyde Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2015692023-04-18T20:01:07Z2023-04-18T20:01:07ZDiseases gave us the rise of Christianity, the end of the Aztecs and public sanitation. How might future plagues change human history?<figure><img src="https://images.theconversation.com/files/517613/original/file-20230327-27-ualse4.jpg?ixlib=rb-1.1.0&rect=0%2C6%2C4439%2C3183&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Elena Mozhvilo/Unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>“Every once in a while a book lands on your desk that changes the way you perceive the world you live in, a book that fundamentally challenges your understanding of human history.” So began the blurb that came with this book. Aha! I thought. The usual advertising hyperbole, a gross exaggeration. </p>
<p>Yet <a href="https://www.penguin.com.au/books/pathogenesis-9781911709053">Pathogenesis</a> <em>did</em> challenge much of my understanding of world history. Who knew that if it wasn’t for an Ebola-like pandemic in the 2nd century CE, Christianity would never have become a world religion? Or that if it weren’t for retroviruses, women would be laying eggs rather than having live births? (According to the book’s author, a retrovirus inserted DNA into our ancestor’s genome that caused the placenta to develop.)</p>
<hr>
<p><em>Book review: Pathogenesis: How germs made history – by Jonathan Kennedy (Torva)</em></p>
<hr>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=923&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=923&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=923&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1160&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1160&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1160&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>However, this is not another book of Amazing Facts: it is a work of scholarship, with nearly 700 references and notes. At the same time, it is very readable, and even amusing at times. </p>
<p>Many books have been written about the impact of disease on civilisation. I have even written my own modest <a href="https://medium.com/@adrian.esterman/infectious-diseases-and-their-impact-on-civilisation-4eb8ac72cc5b">essay</a> on the topic. However,
Pathogenesis delves deeply into the social history of the world. </p>
<p>Jonathan Kennedy has a PhD in sociology from the University of Cambridge, and his sociological bent comes through strongly. In eight chapters, and some 350 pages, Kennedy takes us on a whirlwind tour of social history, describing how infectious diseases have shaped humanity at every stage. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/viruses-are-both-the-villains-and-heroes-of-life-as-we-know-it-169131">Viruses are both the villains and heroes of life as we know it</a>
</strong>
</em>
</p>
<hr>
<h2>‘It’s a bacterial world’</h2>
<p>Kennedy starts by describing the three great branches of living organisms, <a href="https://theconversation.com/from-peaceful-coexistence-to-potential-peril-the-bacteria-that-live-in-and-on-us-104110">bacteria</a>, <a href="https://microbiologysociety.org/why-microbiology-matters/what-is-microbiology/archaea.html">archaea</a>, and <a href="https://www.britannica.com/science/eukaryote">eukaryotes</a> – it is the latter that contains all complex life forms, including humans. However, fewer than 0.001% of all species are eukaryotes. </p>
<p>Bacteria, on the other hand, are the dominant life form on this planet. As Kennedy puts it, “it’s a bacterial world, and we’re just squatting here”. </p>
<p>Our own species, <em><a href="https://theconversation.com/rethinking-homo-sapiens-the-story-of-our-origins-gets-dizzyingly-complicated-99760">Homo sapiens</a></em>, arose some 315,000 years ago, living for the most part in Africa. At the same time, human species such as Neanderthals and <a href="https://theconversation.com/dna-from-elusive-human-relatives-the-denisovans-has-left-a-curious-mark-on-modern-people-in-new-guinea-196113">Denisovans</a> spread out into Europe. However, about 50,000 years ago, <em>Homo sapiens</em> burst out of Africa and spread across the world, while all other human species simply vanished. There are many <a href="https://www.scientificamerican.com/article/how-homo-sapiens-became-the-ultimate-invasive-species/">theories</a> as to why and how this occurred – for example, perhaps <em>Homo sapiens</em> were just smarter. </p>
<p>However, Kennedy proposes his own theory. Because <em>Homo sapiens</em> lived primarily in Africa, they were exposed to many pathogens, and eventually acquired genetic changes that gave them some protection. The exodus out of Africa exposed other species to these pathogens, causing their demise. </p>
<p>He describes the <a href="https://theconversation.com/who-were-the-mysterious-neolithic-people-that-enabled-the-rise-of-ancient-egypt-heres-what-weve-learned-on-our-digs-121070">Neolithic</a> revolution, which took place about 12,000 years ago and which saw the change from hunter-gatherers to farmers. Because of their nomadic existence in small groups, hunter-gatherers tended to be relatively healthy, with an average lifespan of 72 - better than the average lifespan in some countries today! </p>
<p>It has always been assumed that this revolution was a good thing, bringing better nutrition and more leisure time. However, in Kennedy’s view, the Neolithic revolution led to the emergence of despotism, inequality, poverty and backbreaking work. He describes how settlement and the farming of domestic animals led to the emergence of zoonotic diseases – that is, <a href="https://theconversation.com/preventing-future-pandemics-starts-with-recognizing-links-between-human-and-animal-health-167617">diseases spread by animals</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Settlement and the farming of domestic animals led to the emergence of diseases spread by animals.</span>
<span class="attribution"><span class="source">kallerna/Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/disease-evolution-our-long-history-of-fighting-viruses-54569">Disease evolution: our long history of fighting viruses</a>
</strong>
</em>
</p>
<hr>
<h2>Plagues and social upheavals</h2>
<p>In a chapter on ancient plagues, Kennedy quotes from Monty Python’s <a href="https://theconversation.com/life-of-brian-at-40-an-assertion-of-individual-freedom-that-still-resonates-114743">The Life of Brian</a>: </p>
<blockquote>
<p>All right, but apart from the sanitation, the medicine, education, wine, public order, irrigation, roads, a fresh water system, and public health, what have the Romans ever done for us?</p>
</blockquote>
<p>He points out that Roman cities were, in fact, “filthy, stinking and disease-ridden”, and goes on to describe the great plagues <a href="https://theconversation.com/how-3-prior-pandemics-triggered-massive-societal-shifts-146467">that weakened the Roman Empire</a>. The first was the Antonine Plague, possibly caused by smallpox. This was followed some 70 years later by the Plague of Cyprian from AD 249-262, which led to the splitting of the Roman Empire and the rise of Christianity. </p>
<p>Kennedy completes this chapter with a description of the Plague of Justinian, caused by bubonic plague. The massive deaths caused by this epidemic led to the demise of the Roman Empire, and the Muslim conquest of the Middle East. </p>
<p>In the period 1346–53, the <a href="https://theconversation.com/did-the-black-death-give-birth-to-modern-plagues-3820">Black Death</a> tore through North Africa and Europe, killing an <a href="https://en.wikipedia.org/wiki/Black_Death">estimated</a> 75 million to 200 million people. Kennedy describes the devastation and huge social upheavals that resulted from this pandemic. Until then, the Roman Catholic Church dominated society. But:</p>
<blockquote>
<p>During the Black Death and subsequent plague outbreaks, people looked to the Church for comfort. All too often they didn’t find it. </p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=486&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=486&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=486&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=611&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=611&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=611&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Black Death killed an estimated 75–200 million people in Europe and North Africa. Hugo Simberg Black Death.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This led to the rise of Protestantism, aided by the invention of the printing press - a shortage of labour encouraged the development of such labour-saving devices. Over the next 200 years, waves of plague repeatedly hit Europe. A quarantine system was developed in Venice, and <em>cordon sanitaires</em> established, to prevent movement of people between cities - ring any bells? </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/did-the-black-death-give-birth-to-modern-plagues-3820">Did the Black Death give birth to modern plagues?</a>
</strong>
</em>
</p>
<hr>
<h2>Pathogens as New World killers</h2>
<p>In the period from 1500 onwards, white colonialists nearly wiped out indigenous people by infecting them. Kennedy starts with the early 16th century, when Spanish conquistador Hernán Cortés led an expedition to Mexico. His arrival <a href="https://theconversation.com/how-smallpox-devastated-the-aztecs-and-helped-spain-conquer-an-american-civilization-500-years-ago-111579">introduced smallpox</a>, which resulted in the total destruction of the Aztec Empire within just two years. However, this was just the start. </p>
<p>In the early 1530s, Mexico was hit by an epidemic of <a href="https://theconversation.com/measles-new-efforts-needed-to-stop-an-old-disease-13706">measles</a> that killed 80% of its population, making it the deadliest epidemic in recorded history. Over the following decades, across the whole of the Americas, the introduction of infectious diseases from Europe resulted in a 90% fall in the population. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hernán Cortés brought smallpox to Mexico, resulting in the total destruction of the Aztec Empire within two years, as illustrated in this 16th-century drawing of Aztec smallpox victims.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>However, during this period, it wasn’t just the New World that was profoundly affected by pathogens. On the west coast of Africa, explorers and would-be colonialists died in droves from <a href="https://theconversation.com/worlds-first-mass-malaria-vaccine-rollout-could-prevent-thousands-of-children-dying-169457">malaria</a> and <a href="https://theconversation.com/zika-dengue-yellow-fever-what-are-flaviviruses-53969">yellow fever</a>. </p>
<p>Interestingly, Kennedy starts his chapter on revolutionary plagues with the murder of <a href="https://theconversation.com/george-floyd-deserved-a-better-life-a-new-book-charts-his-trajectory-from-poverty-to-the-us-prison-industrial-complex-and-the-impact-of-his-death-182947">George Floyd</a> and the <a href="https://theconversation.com/the-black-lives-matter-movement-has-provoked-a-cultural-reckoning-about-how-black-stories-are-told-149544">Black Lives Matter</a> movement, before delving deep into the history of slavery. He describes slavery in Greek and Roman times, and the booming trade in slaves in the medieval Mediterranean. </p>
<p>The association between black Africans and <a href="https://theconversation.com/slavery-is-not-a-crime-in-almost-half-the-countries-of-the-world-new-research-115596">slavery</a> only began in the 15th century. In fact, only 3% of the 12.5 million humans trafficked across the Atlantic ended up in the United States. The most common destinations of the slave ships were the European colonies in the Caribbean, where African slave labour was first used more than a century before their shipment to North America. </p>
<p>Meanwhile, in the Caribbean, slave labour from tropical West Africa toiled on sugar plantations owned by the English, Spanish, French and Dutch. Yellow fever carried by mosquitoes wiped out many of the Europeans, including military garrisons, leading to slave revolts.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-a-slave-state-how-blackbirding-in-colonial-australia-created-a-legacy-of-racism-187782">Friday essay: a slave state - how blackbirding in colonial Australia created a legacy of racism</a>
</strong>
</em>
</p>
<hr>
<h2>Diseases ‘thrived’ in Dickensian habitats</h2>
<p>When Kennedy switches his focus to Britain, and the industrial revolution, he describes it as the change from a Thomas Hardy novel to one by <a href="https://theconversation.com/great-expectations-by-charles-dickens-class-prejudices-the-convict-stain-and-a-corpse-bride-159816">Charles Dickens</a>. The crowded and unsanitary conditions in working-class urban districts created new habitats, in which pathogens thrived. </p>
<p>Kennedy again evokes Monty Python to invoke the scenery of those days, reminding readers of the famous four Yorkshiremen sketch. The scene made me think of a different quote from the same sketch:</p>
<blockquote>
<p>You were lucky to have a house! We used to live in one room, all hundred and twenty-six of us, no furniture. Half the floor was missing; we were all huddled together in one corner for fear of falling!</p>
</blockquote>
<p>Every Epidemiology 101 course covers the story of <a href="https://www.newscientist.com/people/john-snow/">John Snow</a> (no – not the “Winter is coming” one!). <a href="https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section2.html">Two decades</a> before the development of the microscope, Snow examined cholera outbreaks to discover the cause of disease and how to prevent it. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=619&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=619&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=619&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=778&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=778&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=778&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">John Snow proved in 1854 that cholera is a waterborne disease: a London pub is named for him.</span>
<span class="attribution"><a class="source" href="https://www.geograph.org.uk/profile/6699">ceridwen/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>During the third UK cholera outbreak in 1854, Snow famously removed London’s Broad Street water pump, to demonstrate that cholera was a waterborne disease. For those interested, there is a <a href="https://londonspubswherehistoryreallyhappened.wordpress.com/2019/03/05/john-snow/">John Snow</a> pub in London. Kennedy, of course, includes this story in his book.</p>
<p>Kennedy points out that 3.5 billion people – half of the world’s population – have no access to proper toilets, while a billion don’t have clean drinking water and 1.5 million people, mainly children, die every year from waterborne diarrhoeal diseases. </p>
<p>We still have massive <a href="https://theconversation.com/explainer-why-cholera-remains-a-public-health-threat-74444">cholera outbreaks</a>, especially in areas where normal life has been disrupted by war or natural disasters. <a href="https://theconversation.com/tuberculosis-kills-as-many-people-each-year-as-covid-19-its-time-we-found-a-better-vaccine-151590">Tuberculosis</a> still kills 1.2 million people a year, despite the availability of antibiotics. Malaria kills another 600,000. </p>
<p>Finally in this section, he briefly covers <a href="https://theconversation.com/covid-hospitalisations-and-deaths-are-rising-faster-than-cases-but-that-doesnt-mean-more-severe-disease-187163">COVID</a>. He points out that not everyone in the world benefited from the medical advances that came about because of COVID, and the self-interested actions of high-income countries have deprived the poorer countries. As he puts it, “pathogens thrive on inequality and injustice”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fleas-to-flu-to-coronavirus-how-death-ships-spread-disease-through-the-ages-137061">Fleas to flu to coronavirus: how 'death ships' spread disease through the ages</a>
</strong>
</em>
</p>
<hr>
<h2>Future plagues</h2>
<p>Kennedy concludes by looking at future plagues. He points out humanity’s precarious position: we live on a planet dominated by bacteria and viruses. He believes our best chance of surviving the threat posed by pathogens will come from working collaboratively and reducing inequality both within and between countries. </p>
<p>Based on its title, I assumed this book would be about the role of pathogens in shaping civilisation. Instead, I found a social history of the world, with the odd foray into diseases and their influence on society. Nonetheless, I thoroughly enjoyed the book, and can highly recommend it to those with an interest in history, sociology and epidemiology.</p><img src="https://counter.theconversation.com/content/201569/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adrian Esterman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This whirlwind tour of social history describes how infectious diseases have shaped humanity at every stage. It suggests reducing inequality will give us our best chance of surviving future plagues.Adrian Esterman, Professor of Biostatistics and Epidemiology, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2029452023-03-30T07:08:42Z2023-03-30T07:08:42ZMeasles has been identified in NSW, Qld and SA. 5 things to know about the virus<figure><img src="https://images.theconversation.com/files/518957/original/file-20230403-20-itefrs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>New South Wales health authorities have issued a <a href="https://twitter.com/NSWHealth/status/1640875391685656576/photo/1">measles alert</a> after a baby who recently returned from overseas, and subsequently visited several sites in Western Sydney, tested positive to the virus. </p>
<p>This follows <a href="https://www.sunshinecoast.health.qld.gov.au/about-us/news/public-health-alert-measles-venue-of-concern">two cases of measles</a> in a family on Queensland’s Sunshine Coast who returned from overseas on March 13, and a case in South Australia which was also <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/public+health/alerts/health+alerts/measles+case+in+south+australia">acquired overseas</a>.</p>
<p>Measles is an extremely contagious disease but, thanks to immunisation, is now rare in Australia. Here are five things you need to know about the virus – and why it’s important to get vaccinated. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1640875391685656576"}"></div></p>
<h2>1. Measles can cause severe illness and death</h2>
<p>Measles is a viral infection that can cause a variety of complications, including encephalitis, or inflammation of the brain. </p>
<p>Before the development of effective vaccines, children’s author Roald Dahl gave a harrowing <a href="https://theconversation.com/how-roald-dahl-became-a-passionate-vaccine-advocate-155725">account</a> of the death of his daughter Olivia from measles encephalitis. </p>
<p>A feared complication is a type of progressive encephalitis that can occur many years after infection called <a href="https://www.ninds.nih.gov/health-information/disorders/subacute-sclerosing-panencephalitis">subacute sclerosing encephalitis</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-roald-dahl-became-a-passionate-vaccine-advocate-155725">How Roald Dahl became a passionate vaccine advocate</a>
</strong>
</em>
</p>
<hr>
<p>Deaths from measles are much more <a href="https://academic.oup.com/ije/article/38/1/192/696766">common</a> in developing countries, where up to one in six infants with measles die from the infection. However, deaths are <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/8FA6078276359430CA257BF0001A4C42/$File/australian_vaccine_preventable_disease_epidemiological_review_series_measles_2012_2019.pdf">still reported</a> in Australia. </p>
<p>Although deaths due to measles globally have fallen sharply since 2000, in 2018 the World Health Organization <a href="https://www.who.int/news-room/fact-sheets/detail/measles">estimated</a> there were more than 140,000 deaths due to measles, mostly in children aged under five. </p>
<p>Measles can also have <a href="https://pubmed.ncbi.nlm.nih.gov/28646947/">indirect impacts</a> on the immune system, with children being more susceptible to other bacterial and viral infections following measles. </p>
<h2>2. Measles is highly infectious</h2>
<p>Measles can spread quickly though susceptible populations. In unvaccinated people, a single case <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30307-9/fulltext">can result in</a> more than 12 to 18 secondary cases. </p>
<p>After exposure, around <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html">nine out of ten</a> people who are not protected by vaccination or past infection will become infected. </p>
<figure class="align-center ">
<img alt="Doctor puts a stethoscope on the chest of a child with measles" src="https://images.theconversation.com/files/518325/original/file-20230330-28-xpnj00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/518325/original/file-20230330-28-xpnj00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518325/original/file-20230330-28-xpnj00.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518325/original/file-20230330-28-xpnj00.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518325/original/file-20230330-28-xpnj00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518325/original/file-20230330-28-xpnj00.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518325/original/file-20230330-28-xpnj00.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Measles spreads quickly in unvaccinated populations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/viral-disease-measles-rash-concept-doctor-1323694004">Shutterstock</a></span>
</figcaption>
</figure>
<p>A person with measles is infectious even before symptoms develop – from <a href="https://www.who.int/news-room/fact-sheets/detail/measles">four days before</a> the appearance of a rash to four days after.</p>
<p>The measles virus remains infectious in air or on surfaces for <a href="https://www.ecdc.europa.eu/en/measles/facts#:%7E:text=Virus%2Dcontaining%20droplets%20can%20remain,rash%20to%20four%20days%20afterwards.">up to two hours</a>. This means transmission can occur in a hospital waiting room even after the person with measles has left.</p>
<h2>3. The measles vaccine is very effective (though not perfect)</h2>
<p>The measles vaccine has been <a href="https://www.who.int/news-room/fact-sheets/detail/measles">estimated</a> to have averted more than 23 million deaths between 2000 and 2018. </p>
<p>At a <a href="https://www.unicef.org/supply/documents/measles-vaccine-price-data">cost</a> of less than US$2 per dose, it is thought to be one of the most cost-effective health interventions available. </p>
<p>It is highly effective. An Australian <a href="https://pubmed.ncbi.nlm.nih.gov/26668766/">study</a> estimated one dose of vaccine reduced the risk of measles by 96.7%, and two doses by 99.7%. </p>
<p>However, there are some limitations. The vaccine is less effective if given under the age of 12 months due to the baby’s immature immune system. (In outbreak situations, or when an infant is travelling to a country where measles is common, it is sometimes given from <a href="https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/measles#recommendations">six months of age</a>).</p>
<p>Another limitation is the measles vaccine is “live” (meaning it contains a very small amount of <a href="https://www.health.gov.au/are-vaccines-safe">live – but weakened – virus</a>), so pregnant women and some people with weakened immune systems cannot receive it.</p>
<p>In Australia, anyone born during or after 1966 <a href="https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/measles#recommendations">should check</a> they have had two doses of measles-containing vaccine, and if not, see their doctor to discuss vaccination. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-virus-families-that-could-cause-the-next-pandemic-according-to-the-experts-189622">5 virus families that could cause the next pandemic, according to the experts</a>
</strong>
</em>
</p>
<hr>
<h2>4. Vaccinating children can also protect those who aren’t vaccinated</h2>
<p>“Herd immunity” occurs where high vaccination coverage stops a disease from spreading far in a population.</p>
<p>Because measles is so infectious, the vaccination threshold for herd immunity is high, and is the rationale for Australia’s <a href="https://www.health.gov.au/topics/immunisation/immunisation-data/childhood-immunisation-coverage">target to vaccinate</a> 95% of children against measles and other vaccine-preventable diseases.</p>
<p>Encouragingly, in 2022, <a href="https://www.health.gov.au/topics/immunisation/immunisation-data/childhood-immunisation-coverage/current-coverage-data-tables-for-all-children">93% of two-year-old Australian children</a> had received their first dose of the measles-mumps-rubella vaccine. </p>
<p>This high vaccination rate led to Australia being declared <a href="https://www.lowyinstitute.org/the-interpreter/measles-outbreaks-are-rising-across-world-what-can-australia-do#:%7E:text=Australia%20was%20declared%20free%20of,resurgence%20in%20the%20developed%20world.">free from measles</a> in 2014, reflecting an absence of ongoing local transmission of measles. </p>
<p>Maintaining Australia’s measles elimination status requires ongoing high vaccination rates, an effective surveillance system to detect imported and locally acquired cases, and a rapid public health response to cases. </p>
<p>The World Health Organization can withdraw the <a href="https://www1.racgp.org.au/ajgp/2020/march/measles-elimination-in-australia">measles elimination</a> status of a country or region if local transmission is re-established, as happened to the United Kingdom in 2019.</p>
<figure class="align-center ">
<img alt="Health worker puts bandaid on child's arm after vaccination" src="https://images.theconversation.com/files/518324/original/file-20230329-23-wu22mb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/518324/original/file-20230329-23-wu22mb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518324/original/file-20230329-23-wu22mb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518324/original/file-20230329-23-wu22mb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518324/original/file-20230329-23-wu22mb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518324/original/file-20230329-23-wu22mb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518324/original/file-20230329-23-wu22mb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Countries must maintain high rates of vaccination to hold their elimination status.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/people-vaccination-concept-immunity-health-covid19-2011400480">Shutterstock</a></span>
</figcaption>
</figure>
<p>However, even where herd immunity is not achieved, high vaccine coverage tends to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2596463/pdf/yjbm00110-0184.pdf">increase</a> the average age that unvaccinated children get infected. This is important, as the chance of a baby being exposed to measles virus before they have an opportunity to be vaccinated is reduced. </p>
<h2>5. COVID led to a resurgence of infection in many countries</h2>
<p>The COVID pandemic has disrupted many health services, including immunisation programs. This has disproportionately affected countries where systems were under strain prior to the pandemic. One <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9403570/">systematic review</a> identified several countries where the number of vaccines given fell by more than 50%. </p>
<p>Before the COVID pandemic, global coverage of measles-containing vaccines was increasing. The <a href="https://www.who.int/news-room/fact-sheets/detail/measles">proportion</a> of children who received one dose of measles vaccine by their first birthday went from 72% in 2000 to 86% in 2018. </p>
<p>While these previous gains in coverage have provided some ongoing protection, as the number of unvaccinated younger children accumulate globally, the risk of measles outbreaks increases. </p>
<p>Many countries are now <a href="https://www.cdc.gov/globalhealth/measles/data/global-measles-outbreaks.html">reporting</a> outbreaks, including India, Yemen, Somalia, Ethiopia, Indonesia, Zimbabwe and Pakistan. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/measles-global-increase-in-cases-likely-driven-by-covid-pandemic-182250">Measles: global increase in cases likely driven by COVID pandemic</a>
</strong>
</em>
</p>
<hr>
<p>In theory, measles could be a candidate for eradication, like was achieved for <a href="https://www.who.int/news-room/spotlight/history-of-vaccination/history-of-smallpox-vaccination#:%7E:text=Thanks%20to%20the%20combined%20efforts,1975%20and%20Africa%20in%201977.">smallpox</a> in the 1970s. </p>
<p>In addition to the benefits of eliminating deaths from measles, there is a <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30052-9/fulltext">compelling</a> economic argument to eradicate measles, as vaccination would no longer be required. However, this goal seems to be slipping out of reach, and the longer we leave it the harder it will be.</p>
<p><em>Rob Hall, former senior lecturer of public health at Monash University, co-authored this article. Rob previously received research funding from the World Health Organization. He was previously a member of the Technical Advisory Group on Immunization and Vaccine-Preventable Diseases for the Western Pacific Region of the World Health Organization.</em></p><img src="https://counter.theconversation.com/content/202945/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine Gibney receives funding from the Medical Research Future Foundation and the National Health and Medical Research Council. She is a member of the Australian Technical Advisory Group on Immunisation.</span></em></p><p class="fine-print"><em><span>Allen Cheng receives funding from the Australian Department of Health and the National Health and Medical Research Council. He is a member of the Australian Technical Advisory Group on Immunisation and the Communicable Diseases Network of Australia, advising governments on communicable diseases control </span></em></p>Measles is an extremely contagious disease but, thanks to immunisation, is now rare in Australia.Katherine Gibney, Senior research fellow, The Peter Doherty Institute for Infection and ImmunityAllen Cheng, Professor in Infectious Diseases Epidemiology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1954992022-12-06T12:57:15Z2022-12-06T12:57:15ZMeasles: why the World Health Organization has declared it an ‘imminent global threat’<p>One consequence of the pandemic was <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1">reduced access</a> to routine healthcare and lower uptake of immunisations. As a result, in November 2022, the World Health Organization <a href="https://www.who.int/news/item/23-11-2022-nearly-40-million-children-are-dangerously-susceptible-to-growing-measles-threat">declared</a> measles to be an “imminent threat in every region of the world”. They described how a record number of nearly 40 million children had missed at least one measles vaccine dose in 2021.</p>
<p>Measles is a viral respiratory illness. <a href="https://www.cdc.gov/measles/hcp/index.html">Transmission</a> is similar to COVID, with the spread between people being driven by respiratory droplets and aerosols (airborne transmission). The infection produces a rash and fever in mild cases. </p>
<p>But <a href="https://www.nhs.uk/conditions/measles/">severe cases</a> can include encephalitis (brain swelling), blindness and pneumonia. There are approximately <a href="https://www.who.int/news/item/23-11-2022-nearly-40-million-children-are-dangerously-susceptible-to-growing-measles-threat">9 million cases a year and 128,000 deaths</a>.</p>
<p>The measles vaccine, which can be administered by itself or in combination with other vaccinations such as mumps and rubella to make up the MMR immunisation, is very effective. Most countries have a two-dose schedule, with the first jab usually given at 12 months of age and the second dose when the child is four years old.</p>
<p>The vaccine provides very high and long-lasting protection, and really is a model example of the term “vaccine-preventable disease”. The two-dose schedule <a href="https://vk.ovg.ox.ac.uk/vk/mmr-vaccine#:%7E:text=After%20two%20doses%20of%20MMR,will%20be%20protected%20against%20rubella.">gives</a> about 99% protection against measles infection. </p>
<p>In developing countries where vaccine uptake is low, as many as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1712354/">one in ten</a> who get measles, die from it. In developed countries, deaths are overwhelmingly in unvaccinated people at a <a href="https://vk.ovg.ox.ac.uk/vk/measles#:%7E:text=In%20high%20income%20regions%20of,children%20in%20resource%2Dpoor%20countries.">rate</a> of around one in 1,000 to 5,000 measles cases. </p>
<p>The potential for new outbreaks of vaccine-preventable diseases in areas such as <a href="https://gh.bmj.com/content/5/9/e003515">conflict zones</a> and among <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9383728/">refugee populations</a> is high. Problems such as <a href="https://www.msf.org/measles-poses-deadly-risk-malnourished-children-afghanistan">malnutrition</a> greatly raise the risks of severe illness, and respiratory infectious diseases are a <a href="https://theconversation.com/ukraine-disease-control-is-a-casualty-of-war-so-a-surge-in-covid-cases-is-likely-179218">huge concern</a> for humanitarian groups supporting vulnerable groups such as Ukrainian refugees.</p>
<p>Measles is incredibly infectious. Its <a href="https://www.news-medical.net/health/What-is-R0.aspx">basic reproduction number</a> (R0) – that is, how many people on average an infected person will go on to infect in a susceptible population – is <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30307-9/fulltext">estimated</a> to be between 12 and 18. For comparison, the R0 of the omicron COVID variant is <a href="https://pubmed.ncbi.nlm.nih.gov/35262737/">thought to be</a> around 8.2. </p>
<p>The proportion of a population that needs to be vaccinated to keep outbreaks under control and to minimise onward transmission around a community is known as the herd immunity threshold (HIT). For measles, vaccine <a href="https://www.yalemedicine.org/news/herd-immunity#:%7E:text=Measles%2C%20for%20example%2C%20spreads%20so,the%20threshold%20is%20about%2080%25.">coverage</a> of 95% is typically considered to be the HIT magic number. </p>
<p>Most of the world is some way below that threshold, with <a href="https://www.who.int/news/item/23-11-2022-nearly-40-million-children-are-dangerously-susceptible-to-growing-measles-threat">global coverage</a> of around 71% for two doses, and 81% for one dose coverage. In the UK, 2021-22 <a href="https://www.bmj.com/content/378/bmj.o2353">data</a> shows that 89% of children had received one measles vaccine dose.</p>
<p>Globally, there has been significant progress in <a href="https://www.who.int/news-room/fact-sheets/detail/children-reducing-mortality">reducing</a> deaths from all causes in children under the age of five. Annual deaths declined from 12.5 million in 1990 to 5.2 million in 2019. However, low vaccine coverage could reverse those gains.</p>
<p>Even if children survive measles, there is a possibility of long-term damage to their immune system, <a href="https://www.cidrap.umn.edu/news-perspective/2019/11/measles-does-long-term-damage-immune-system-studies-show">described</a> as a “form of immune amnesia”. In unvaccinated populations, a severe case of measles resulted in an average loss of 40% of antibodies that would normally recognise germs. </p>
<p>After a mild case of measles, unvaccinated children lost 33% of those antibodies. By comparison, measurements in healthy control populations indicated an antibody loss of 10% over similar or longer durations.</p>
<h2>Misinformation is rife</h2>
<p>Anti-vaccine advocacy has driven false rumours and scare stories, such as the <a href="http://www.bmj.com/content/342/bmj.c7452">fake claims</a> by former physician and anti-vaccine activist Andrew Wakefield that the MMR vaccine causes autism. This belief persists. For example, a <a href="https://misinforeview.hks.harvard.edu/article/users-of-social-media-more-likely-to-be-misinformed-about-vaccines/">US population survey</a> in 2020 found: “18% of our respondents mistakenly state that it is very or somewhat accurate to say that vaccines cause autism.”</p>
<p>Misinformation since the start of the COVID pandemic has <a href="https://www.who.int/health-topics/infodemic/the-covid-19-infodemic">been extensive</a>. And there is a risk of this misinformation further translating into greater levels of hesitancy and vaccine refusal for <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0001012">routine immunisation</a>.</p>
<p>Measles spreads easily and is a severe infection in the short- and long-term in unvaccinated populations. There is a great need for immunisation campaigns to increasingly protect against vaccine-preventable diseases, across the globe. The need is particularly urgent in developing countries and among other vulnerable populations such as refugees and areas of conflict.</p><img src="https://counter.theconversation.com/content/195499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Head has previously received funding from the Bill & Melinda Gates Foundation and the UK Department for International Development.</span></em></p>Many children have missed a measles vaccine dose since the start of the COVID pandemic.Michael Head, Senior Research Fellow in Global Health, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1905652022-09-21T13:11:00Z2022-09-21T13:11:00ZCOVID pandemic created immunisation gaps in Africa. Over half a million children are at risk<figure><img src="https://images.theconversation.com/files/485537/original/file-20220920-18-c12wfn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Routine immunisation has resulted in diseases like measles being drastically reduced.</span> <span class="attribution"><span class="source">Laszlo Mates/shutterstock</span></span></figcaption></figure><p>The COVID pandemic exposed the fault lines in health systems and national routine immunisation programmes around the world. </p>
<p>A <a href="https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades">recent</a> World Health Organization (WHO) report showed that the pandemic fuelled the largest sustained decline in childhood vaccine coverage rates. </p>
<p>These declines threaten to undo the exceptional efforts made in preventing and controlling the devastating burden of vaccine preventable diseases globally. Routine immunisation has prevented <a href="https://ourworldindata.org/vaccination#global-decline-in-vaccine-preventable-diseases">two to three million deaths</a> yearly. Of the lives saved, <a href="https://www.afro.who.int/health-topics/immunization#:%7E:text=Immunization%20currently%20prevents%20over%204,every%20year%20because%20of%20vaccines.">800,000</a> were in the Africa region. Routine immunisation has led to a drastic reduction in diseases like neonatal tetanus and measles. And bacterial meningitis (type A) and polio have virtually been eliminated across the continent. </p>
<p>The repercussions of the pandemic on routine immunisation programmes in the African region are yet to be fully realised. What we do know so far is that the pandemic has resulted in substantial disruptions to national routine immunisation programmes. As a result, the continent is seeing an increased number of outbreaks of vaccine preventable diseases. </p>
<p>African countries had nearly eliminated the deadly form of meningitis type A. But a four-month-long meningitis outbreak was reported in the <a href="https://www.afro.who.int/news/meningitis-outbreak-democratic-republic-congo-declared-over#:%7E:text=Meningitis%20outbreak%20in%20Democratic%20Republic%20of%20the%20Congo%20declared%20over,-24%20December%202021&text=Brazzaville%2FKinshasa%20%E2%80%93%20The%20Democratic%20Republic,and%20205%20deaths%20were%20recorded.">Democratic Republic of Congo</a> in 2021. It accounted for 2,665 cases, claiming 205 lives. This resurgence has been <a href="https://www.voanews.com/a/covid-threatening-resurgence-of-deadly-meningitis-in-africa/6736714.html?s=09">linked</a> with the suspension of meningitis vaccination campaigns at the height of the COVID pandemic. In February 2022, <a href="https://www.afro.who.int/news/malawi-declares-polio-outbreak">Malawi</a> reported its first wild case of poliovirus type 1 in 30 years. A second case followed in <a href="https://www.afro.who.int/countries/mozambique/news/mozambique-confirms-wild-poliovirus-case">Mozambique</a> three months later. The outbreaks sparked <a href="https://doi.org/10.1016/s1473-3099(22)00269-9">mass polio vaccination campaigns</a> across southern Africa. </p>
<p>UNICEF and the WHO have <a href="https://www.who.int/news/item/27-04-2022-unicef-and-who-warn-of--perfect-storm--of-conditions-for-measles-outbreaks--affecting-children">warned</a> of the heightened risk for measles outbreaks, given widening immunisation gaps. </p>
<p>Currently, Zimbabwe is contending with a devastating measles outbreak. Within five months, there have been <a href="https://twitter.com/MoHCCZim/status/1567416772512415744?s=20&t=JslCu5Tki9SCpNLaJXclwg">6,551 confirmed measles cases</a> and <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/zimbabwe-measles-outbreak-death-toll-rises-685-health-ministry-2022-09-03/">704 related deaths</a>. </p>
<p>These emerging outbreaks are a matter of great concern. They call for urgent and sustained public health interventions. Unless these are put in place, the compounding effects of the pandemic could derail regional progress towards the global <a href="https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030">immunisation targets</a> that secure the health and wellbeing of infants and children.</p>
<p>The resurgence of deadly vaccine preventable diseases underscores the importance of maintaining high vaccination coverage rates. Children everywhere must have access to all the recommended lifesaving vaccines they need. The disruptions observed during the COVID pandemic also highlight the importance of establishing resilient health systems. Systems must be able to withstand acute and prolonged shocks while delivering essential health services like immunisation programmes. </p>
<h2>Immunisation before COVID</h2>
<p>It is important to contextualise the performance of routine immunisation programmes within the African region. Even before the pandemic, the African region was already contending with a precarious situation. </p>
<p>For one, an <a href="https://www.afro.who.int/publications/investment-case-vaccine-preventable-diseases-surveillance-african-region-2020-2030">estimated</a> 30.7 million children under five continue to suffer from vaccine preventable diseases. These include rotavirus diarrhoea, pneumonia, pertussis and measles. Of these children, more than 520,000 die each year because of poor access to essential immunisation services. </p>
<p>The continent’s health systems have to manage on average <a href="https://www.afro.who.int/health-topics/disease-outbreaks/outbreaks-and-other-emergencies-updates">150 cases of disease outbreaks and other public health emergencies</a> every year. These range from armed conflicts to climate-related disasters (including flooding, drought, and famine) and disease outbreaks. National routine immunisation programmes have had to function in this context. </p>
<h2>The pandemic widened immunisation gaps</h2>
<p>On the continent the pandemic has substantially disrupted national routine immunisation programmes. In many countries health systems were forced to divert limited resources to combat the pandemic. This often left immunisation services vulnerable. </p>
<p>At the height of the pandemic, <a href="https://doi.org/10.1016/S2214-109X(21)00512-X">several countries reported</a> having to suspend vaccination services. There were disruptions to vaccine supply chains which led to stockouts. The number of people taking up immunisation services declined due to restrictions on public gathering. Many people also feared being exposed to the virus at health facilities. </p>
<p>A good measure of the COVID-related disruptions to immunisation programmes is the coverage of the three doses of the diphtheria-tetanus-pertussis (DTP3) vaccine. The <a href="https://www.who.int/data/gho/data/indicators/indicator-details/GHO/diphtheria-tetanus-toxoid-and-pertussis-(dtp3)-immunization-coverage-among-1-year-olds-(-)">WHO</a> uses the coverage of DTP3 to monitor access to immunisation services and measure the performance of broader health systems. </p>
<p>The <a href="https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades">WHO report</a> shows that the COVID-19 pandemic contributed to a general decline in DTP3 coverage globally – irrespective of economic power or income level. </p>
<p>In Africa, national immunisation programmes in several countries maintained optimal performance, achieving <a href="https://immunizationdata.who.int/index.html">DTP3 coverage rates above 90%</a>. These included Algeria, Botswana, Burkina Faso, Burundi, Ghana, Kenya, Malawi, Mauritius, Namibia, Sierra Leone, Uganda and Zambia. </p>
<p>Of concern, however, are the 29 countries that recorded coverage of less than 90%, creating substantial immunisation gaps.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=293&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=293&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=293&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=368&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=368&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=368&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">DTP vaccine coverage in many African countries was below the WHO’s 90% threshold.</span>
<span class="attribution"><span class="source">Data Source: WHO, https://immunizationdata.who.int/index.html</span></span>
</figcaption>
</figure>
<p>The increased misinformation and disinformation during the pandemic also led to some decline in public trust and confidence in immunisation services. This has significantly affected vaccine demand. </p>
<h2>Charting a way forward</h2>
<p>The pandemic provides useful lessons on the importance of continuously strengthening health systems and “crisis-proofing” national routine immunisation programmes. </p>
<p>COVID-19 has been a catalyst for renewed political interest in immunisation programmes. But this must be followed up with regional solidarity to re-prioritise routine immunisation in the national and regional public health agendas. </p>
<p>National governments will have the responsibility to secure and sustain donor funding while increasing domestic financial commitments that will fill the funding gaps for national immunisation programmes. This is in line with the <a href="https://www.afro.who.int/health-topics/immunization/the-addis-declaration-immunization">declarations they have endorsed</a>. </p>
<p>But most importantly, there’s a need to intensify demand for vaccines and immunisation programmes. This is critical to build back public confidence and trust in vaccines and immunisation services in a post-COVID world.</p><img src="https://counter.theconversation.com/content/190565/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edina Amponsah-Dacosta does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The pandemic has disrupted national immunisation programmes. As a result, the African continent is seeing more outbreaks of vaccine preventable diseases.Edina Amponsah-Dacosta, Postdoctoral Research Fellow, Vaccines for Africa Initiative, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1896222022-09-05T20:04:33Z2022-09-05T20:04:33Z5 virus families that could cause the next pandemic, according to the experts<p>The CSIRO has delivered a comprehensive <a href="https://www.csiro.au/pandemic">report</a> on how we should prepare for future pandemics. </p>
<p>The report identifies six key science and technology areas such as faster development of vaccines and onshore vaccine manufacturing to ensure supply, new antivirals and ways of using the medicines we already have, better ways of diagnosing cases early, genome analysis, and data sharing. </p>
<p>It also recommends we learn more about viruses and their hosts across the five most concerning virus families. These causes of disease could fuel the next pandemic. </p>
<p>We asked leading experts about the diseases they can cause and why authorities should prepare well:</p>
<h2>1. Coronaviridae</h2>
<p><strong><em>COVID-19, Middle East respiratory syndrome (MERS), severe acquired respiratory syndrome (SARS)</em></strong></p>
<p>The first human <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204879/">Coronaviruses</a> (229E and OC43) were found in 1965 and 1967 respectively. They were low-grade pathogens causing only mild cold-like symptoms and gastroenteritis. Initial understanding of this family came from study of related strains that commonly infect livestock or laboratory mice that also caused non-fatal disease. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3358201/">HKU-1 strain in 1995</a> again did not demonstrate an ability to generate high levels of disease. As such, coronaviridae were not considered a major concern until severe acquired respiratory syndrome (<a href="https://www.who.int/health-topics/severe-acute-respiratory-syndrome#tab=tab_1">SARS-1</a>) first appeared in 2002 in China.</p>
<p>Coronaviridae have a <a href="https://www.nature.com/articles/s41467-021-22785-x">very long RNA genome</a>, coding up to 30 viral proteins. Only four or five genes make infectious virus particles, but many others support diseases from this family by modifying immune responses. The viruses in this family mutate at a steady low rate, selecting changes in the outer spike to allow virus entry into new host cells.</p>
<p>Coronaviridae viruses are widespread in many ecological niches and common in bat species that make up <a href="https://www.si.edu/spotlight/bats/batfacts">20% of all mammals</a>. Mutations spread in their roosts can spillover into other mammals, such as the <a href="https://link.springer.com/article/10.1007/s11259-020-09781-0">civet cat</a>, then into humans. </p>
<p>Coronaviridae <a href="https://www.cdc.gov/coronavirus/2019-ncov/variants/genomic-surveillance.html">genome surveillance</a> shows an array of previously unknown virus strains circulating in different ecological niches. Climate change threatens intersections of these viral transmission networks. Furthermore, pandemic human spread of SARS-CoV-2 (the virus that causes COVID) has now seeded new transmissions back into other species, such as mink, cats, dogs and white-tailed deer. </p>
<p>Ongoing viral evolution in new animal hosts and also in immune-compromised <a href="https://www.bmj.com/content/376/bmj-2021-069807">HIV patients in under-resourced settings</a>, presents an ongoing source of new variants of concern.</p>
<p><strong>– Damian Purcell</strong></p>
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Read more:
<a href="https://theconversation.com/long-covid-how-researchers-are-zeroing-in-on-the-self-targeted-immune-attacks-that-may-lurk-behind-it-169911">Long COVID: How researchers are zeroing in on the self-targeted immune attacks that may lurk behind it</a>
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<h2>2. Flaviviridae</h2>
<p><strong><em>Dengue fever, Japanese encephalitis, Zika, West Nile fever</em></strong></p>
<p>The flaviviridae family causes several diseases, including dengue, Japanese encephalitis, Zika, West Nile disease and others. These diseases are often not life-threatening, causing fever, sometimes with rash or painful joints. A small proportion of those infected get severe or complicated infection. Japanese encephalitis can cause inflammation of the brain, and Zika virus can cause birth defects.</p>
<p>While all these viruses may be spread by mosquito bites, when it comes to each individual virus, not all mosquitoes bring equal risk. There are <a href="https://www.cdc.gov/zika/prevention/transmission-methods.html#:%7E:text=Zika%20virus%20is%20transmitted%20to,spread%20dengue%20and%20chikungunya%20viruses.">key mosquito species</a> involved in transmission cycles of dengue and Zika virus, such as <em>Aedes aegypti</em> and <em>Aedes albopictus</em>, that may be found in close to where people live. These mosquitoes are found in water-holding containers (such as potted plant saucers, rainwater tanks), water-filled plants, and tree holes. They also like to bite people.</p>
<p>The mosquitoes that spread these viruses are not currently widespread in Australia; they’re generally limited to central and far north Queensland. They are routinely detected through biosecurity surveillance at Australia’s major <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005993/">airports and seaports</a>. With a rapid return to international travel, movement of people and their belongings may become an ever-increasing pathway of introduction of the diseases and mosquitoes back into Australia.</p>
<p>Different mosquitoes are involved in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000427/">transmission</a> of West Nile virus and Japanese encephalitis. These mosquitoes are more likely to be found in wetlands and bushland areas than backyards. They bite people but they also like to <a href="https://theconversation.com/how-australian-wildlife-spread-and-suppress-ross-river-virus-107267">bite the animals</a> most likely to be carrying these viruses. </p>
<p>The <a href="https://theconversation.com/japanese-encephalitis-virus-has-been-detected-in-australian-pigs-can-mozzies-now-spread-it-to-humans-178017">emergence of Japanese encephalitis</a>, a virus spread by mosquitoes between waterbirds, pigs, and people, is a perfect example. Extensive rains and flooding that provide idea conditions for mosquitoes and these animals create a “perfect storm” for disease emergence. </p>
<p><strong>– Cameron Webb & Andrew van den Hurk</strong></p>
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Read more:
<a href="https://theconversation.com/japanese-encephalitis-virus-has-been-detected-in-australian-pigs-can-mozzies-now-spread-it-to-humans-178017">Japanese encephalitis virus has been detected in Australian pigs. Can mozzies now spread it to humans?</a>
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<h2>3. Orthomyxoviridae</h2>
<p><strong><em>Influenza</em></strong></p>
<p>Before COVID-19, influenza was the infection most <a href="https://www.health.gov.au/resources/publications/australian-health-management-plan-for-pandemic-influenza-ahmppi">well-known</a> for causing pandemics.</p>
<p>Influenza virus is subdivided into types (A, B, and rarely C and D). Influenza A is further classified into subtypes based on haemagglutinin (H) and neuraminidase (N) protein variants on the surface of the virus. Currently, the most common influenza strains in humans are A/H1N1 and A/H3N2.</p>
<p><a href="https://www.who.int/news-room/spotlight/influenza-are-we-ready/zoonotic-influenza">Zoonotic infection</a> occurs when influenza strains that primarily affect animals “spill over” to humans. </p>
<p>Major changes in the influenza virus usually result from <a href="https://www.nejm.org/doi/full/10.1056/NEJMp0904572">new combinations</a> of influenza viruses that affect birds, pigs and humans. New strains have the potential to cause pandemics as there is little pre-existing immunity.</p>
<p>Since the beginning of the 20th century, there have been four influenza <a href="https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html">pandemics</a>, in 1918, 1957, 1968, and 2009. In between pandemics, seasonal influenza circulates throughout the world. </p>
<p>Although influenza is not as infectious as many other respiratory infections, the very short incubation period of around 1.4 days means outbreaks can spread quickly.</p>
<p>Vaccines are available to prevent influenza, but are only <a href="https://pubmed.ncbi.nlm.nih.gov/31903487/">partially</a> protective. Antiviral treatments are available, including oseltamivir, zanamivir, peramivir and baloxavir. Oseltamivir <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62449-1/fulltext">decreases</a> the duration of illness by around 24 hours if started early, but whether it reduces the risk of severe influenza and its complications is <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600%2814%2970041-4/fulltext">controversial</a>.</p>
<p><strong>– Allen Cheng</strong> </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/my-year-as-victorias-deputy-chief-health-officer-on-the-pandemic-press-conferences-and-our-covid-future-166164">My year as Victoria's deputy chief health officer: on the pandemic, press conferences and our COVID future</a>
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<h2>4. Paramyxoviridae</h2>
<p><strong><em>Nipah virus, Hendra virus</em></strong></p>
<p>Paramyxoviridae are a large group of viruses that affect humans and animals. The most well known are measles and mumps, as well as parainfluenza virus (a common cause of <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Croup/">croup</a> in children). </p>
<p>Globally, <a href="https://www.who.int/news-room/fact-sheets/detail/measles">measles</a> is a dangerous disease for young children, particularly those who are malnourished. Vaccines are highly effective with the measles vaccine alone <a href="https://www.who.int/news/item/12-11-2015-measles-vaccination-has-saved-an-estimated-17-1-million-lives-since-2000">estimated</a> to have saved 17 million lives between 2000 and 2014.</p>
<p>One group of paramyxoviruses is of particular importance for pandemic planning – henipaviruses. This includes Hendra virus, Nipah virus and the new <a href="https://theconversation.com/what-is-this-new-langya-virus-do-we-need-to-be-worried-188577">Langya virus</a> (as well as the fictional MEV-1 in the film <a href="https://www.reuters.com/article/idUS57323549020110913">Contagion</a>). These are all zoonoses (diseases that spill over from animals to humans)</p>
<p>Hendra virus was first <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.1995.tb126050.x">discovered</a> in Queensland in 1994, when it caused the deaths of 14 horses and their horse trainer. Infected flying foxes have since spread the virus to horses in Queensland and northern New South Wales. There have been seven <a href="https://www.outbreak.gov.au/for-vets-and-scientists/hendra-virus">reported</a> human cases of Hendra virus in Australia, including four deaths.</p>
<p>Nipah virus is more <a href="https://www.who.int/news-room/fact-sheets/detail/nipah-virus">significant</a> globally. Infection may be mild, but some people develop encephalitis (inflammation of the brain). Outbreaks frequently occur in Bangladesh, where the first <a href="https://pubmed.ncbi.nlm.nih.gov/10781618/">outbreak</a> was reported in 1998. Significantly, Nipah virus appears to be able to be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547369/">transmitted</a> from person-to-person though close contact.</p>
<p><strong>– Allen Cheng</strong></p>
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<strong>
Read more:
<a href="https://theconversation.com/what-is-this-new-langya-virus-do-we-need-to-be-worried-188577">What is this new Langya virus? Do we need to be worried?</a>
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<h2>5. Togaviridae (alphaviruses)</h2>
<p><strong><em>Chikungunya fever, Ross River fever, Eastern equine encephalitis, Western equine encephalitis, Venezuelan equine encephalitis</em></strong></p>
<p>The most common disease symptoms caused by infection with alphaviruses like chikungunya and Ross River viruses are fever, rash and painful joints.</p>
<p>Like some flaviviruses, <a href="https://www.who.int/news-room/fact-sheets/detail/chikungunya">chikungunya virus</a> is thought to be only spread by <em>Aedes aegypti</em> mosquitoes in Australia. This limits risks, for now, to central and far north Queensland. </p>
<p>Many different mosquitoes play a role in transmission of alphaviruses, including dozens of mosquito species suspected as playing a role in the spread of <a href="http://conditions.health.qld.gov.au/HealthCondition/condition/14/217/120/ross-river-virus">Ross River fever</a>. Many of these mosquitoes <a href="https://theconversation.com/how-can-the-bite-of-a-backyard-mozzie-in-australia-make-you-sick-171601">are commonly found across Australia</a>. </p>
<p>But what role may these local mosquitoes play should diseases such as eastern equine encephalitis or western equine encephalitis make their way to Australia? Given the capacity of our home-grown mosquitoes to spread other alphaviruses, it is reasonable to assume they would be effective at transmitting these as well. That’s why the CSIRO report <a href="https://www.csiro.au/pandemic">notes</a> future pandemic preparation should work alongside Australia’s established biosecurity measures. </p>
<p><strong>– Cameron Webb & Andrew van den Hurk</strong></p>
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<strong>
Read more:
<a href="https://theconversation.com/how-can-the-bite-of-a-backyard-mozzie-in-australia-make-you-sick-171601">How can the bite of a backyard mozzie in Australia make you sick?</a>
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<img src="https://counter.theconversation.com/content/189622/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allen Cheng receives funding from the Australian National Health and Medical Research Council and the Australian government for research, including in influenza. He is Chair of the Advisory Committee for Vaccines and a member of the Australian Technical Advisory Group on Immunisation. </span></em></p><p class="fine-print"><em><span>Andrew van den Hurk has received funding from local, state and federal agencies to study the ecology of mosquito-borne pathogens, and their surveillance and control. He is an employee of the Department of Health, Queensland Government.</span></em></p><p class="fine-print"><em><span>Cameron Webb and the Department of Medical Entomology, NSW Health Pathology, have been engaged by a wide range of insect repellent and insecticide manufacturers to provide testing of products and provide expert advice on mosquito biology. Cameron has also received funding from local, state and federal agencies to undertake research into mosquito-borne disease surveillance and management.</span></em></p><p class="fine-print"><em><span>Damian Purcell consults for Moderna on mRNA vaccine education and receives funding from the National Health and Medical Research Council, and the Victorian Government grants. He is Past Presidents' advisor for the Australasian Virology Society, and Committee member of the RNA Network of Australia.</span></em></p>Authorities have been warned about five virus families that could cause future pandemics. Here are snapshots of the diseases each can cause and why we should be worried.Allen Cheng, Professor in Infectious Diseases Epidemiology, Monash UniversityAndrew van den Hurk, Medical Entomologist, The University of QueenslandCameron Webb, Clinical Associate Professor and Principal Hospital Scientist, University of SydneyDamian Purcell, Professor of virology and theme leader for viral infectious diseases, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1881572022-08-09T18:52:00Z2022-08-09T18:52:00ZNZ children face a ‘perfect storm’ of dangerous diseases as immunisation rates fall<figure><img src="https://images.theconversation.com/files/478217/original/file-20220809-18-orxjcu.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C5226%2C3473&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Routine childhood immunisations have dropped so dramatically globally during the COVID-19 pandemic that the World Health Organization and <a href="https://www.unicef.org/press-releases/WUENIC2022release">UNICEF</a> are raising the alarm. </p>
<p>Internationally, <a href="https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades">25 million children</a> in 2021 alone have missed out on life-saving vaccinations. This is the <a href="https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades">largest sustained drop</a> in childhood immunisation in a generation. </p>
<p>In Aotearoa New Zealand, we are seeing a similarly concerning trend. The decline in childhood immunisation resulting in low overall coverage is now putting our tamariki (children) at real risk of preventable disease, especially with national borders open again.</p>
<p>The country is not alone in suffering collateral damage to normal childhood immunisation programmes due to the COVID-19 pandemic. But while the decline may be worrying, all is not lost. </p>
<h2>Risk of disease outbreaks</h2>
<p>Immunisation coverage at six months of age <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/immunisation-coverage/national-and-dhb-immunisation-data">has fallen</a> in New Zealand from a high of around 80% in early 2020 to 67% by June 2022, and as low as 45% for Māori. </p>
<p>This is important because immunisation coverage at six months is used as a marker for timely receipt of lifesaving <a href="https://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/new-zealand-immunisation-schedule">government-funded vaccines</a>, including for whooping cough (pertussis), diphtheria, polio, pneumococcal disease and rotavirus.</p>
<p>For example, <a href="https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/whooping-cough">whooping cough</a> (pertussis), a particularly serious illness for babies, is a very real concern. Aotearoa has seen a <a href="https://surv.esr.cri.nz/PDF_surveillance/PertussisRpt/2019/PertussisReportMay2019.pdf">pertussis resurgence</a> every three to four years, meaning we are due an increase in cases at a time when we also have low vaccine coverage.</p>
<p>Additionally, these declines in immunisation coverage and subsequent risk of infection are especially important to consider now, as international travel picks up.</p>
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<img alt="" src="https://images.theconversation.com/files/478239/original/file-20220809-16-8awc3f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478239/original/file-20220809-16-8awc3f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=572&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478239/original/file-20220809-16-8awc3f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=572&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478239/original/file-20220809-16-8awc3f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=572&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478239/original/file-20220809-16-8awc3f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=719&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478239/original/file-20220809-16-8awc3f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=719&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478239/original/file-20220809-16-8awc3f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=719&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">NZ Ministry of Health</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<h2>The return of ‘old’ diseases</h2>
<p>Polio, a viral disease that can cause paralysis, disappeared from Aotearoa thanks to immunisation, with the Western Pacific region declared <a href="https://www.scielosp.org/pdf/bwho/2000.v78n12/1375-1375/en">polio free</a> in 2000. As some parts of the world have yet to eradicate it, however, we still vaccinate children against polio. </p>
<p>A <a href="https://www.statnews.com/2022/07/29/u-s-polio-case-tied-to-viruses-detected-in-u-k-israel-suggesting-silent-spread">recent case</a> in an unvaccinated young man in New York shows how the virus can travel and re-emerge – even in developed, polio-free countries.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/diphtheria-is-back-in-australia-heres-why-and-how-vaccines-can-prevent-its-spread-186348">Diphtheria is back in Australia, here's why – and how vaccines can prevent its spread</a>
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<p>Likewise, <a href="https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/diphtheria">diphtheria</a> is a rare but serious disease that causes breathing problems and can also lead to nerve paralysis and heart failure, with 5% to 10% of people with the disease dying. </p>
<p>Until widespread immunisation after the 1940s, diphtheria was a common cause of childhood death, and we haven’t seen it in Aotearoa for decades. But diphtheria has recently been detected in Australia in two unvaccinated children. </p>
<p>With New Zealand’s <a href="https://covid19.govt.nz/international-travel/who-can-enter-new-zealand/">borders fully open</a> since July 31, we run the risk of both these “old” diseases being imported and causing problems for our under-immunised tamariki and their whānau.</p>
<h2>A perfect measles storm</h2>
<p>The significant measles outbreak of 2019 serves as a warning. More than 2,000 <a href="https://www.health.govt.nz/system/files/documents/pages/health-report-measles-review-2020.pdf">people were infected and 700 hospitalised</a>, with the largest case numbers in Auckland.</p>
<p>Fiji, Tonga and Samoa also saw outbreaks, with Samoa <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30053-0/fulltext">particularly devastated</a> by more than 5,000 cases and more than 80 deaths, mostly in young children. </p>
<p>The severity of this outbreak <a href="https://www.health.govt.nz/system/files/documents/pages/health-report-measles-review-2020.pdf">could have been prevented</a> because the combined measles, mumps and rubella (MMR) vaccine is highly effective. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-most-challenging-phase-of-the-omicron-outbreak-is-yet-to-come-but-new-zealand-may-be-better-prepared-than-other-countries-175819">The most challenging phase of the Omicron outbreak is yet to come, but New Zealand may be better prepared than other countries</a>
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<p>But childhood coverage of MMR was not high enough at the time (nor has it been historically), leaving a <a href="https://journal.nzma.org.nz/journal-articles/a-measles-epidemic-in-new-zealand-why-did-this-occur-and-how-can-we-prevent-it-occurring-again">known immunity gap</a> of susceptible teens and young adults. </p>
<p>Significant efforts have since been made to <a href="https://www.health.govt.nz/your-health/healthy-living/immunisation/measles-vaccination">close this gap</a> in MMR coverage, although these have been dwarfed by the COVID-19 vaccination campaign. </p>
<p>The upshot is a potential perfect storm for another measles outbreak, with low MMR coverage worldwide and locally. Measles could “walk” through New Zealand airports and meet under-immunised tamariki and rangatahi (youth). </p>
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<h2>Prevention as cure</h2>
<p>There is some good news, however. This year we’ve seen the introduction of new initiatives to help manage surges of winter ills, including the government funding influenza vaccines for children aged three to 12. </p>
<p>This is welcome, as influenza crosses our border every year (with the <a href="https://doi.org/10.1038/s41467-021-21157-9">exception of 2020</a> when COVID-19 public health measures, including quarantine and mask wearing, were in force). Because children are often <a href="https://www.influenza.org.nz/children/influenza-disease-vaccination-and-children">considered super-spreaders</a>, vaccination of children can reduce influenza-like illness and related costs in both tamariki and their whānau. </p>
<p>But the message from World Health Organization Director-General Tedros Adhanom Ghebreyesus remains urgent:</p>
<blockquote>
<p>Planning and tackling COVID-19 should also go hand-in-hand with vaccinating for killer diseases like measles, pneumonia and diarrhoea. </p>
</blockquote>
<p>In Aotearoa New Zealand, the COVID-19 vaccination experience has also shown how Māori and Pacific community health providers can help reach high vaccination targets – especially when combined with good outreach services, increasing vaccination providers beyond GP clinics, and building the vaccination workforce.</p>
<p>But right now the statistics paint a concerning picture. Low childhood immunisation coverage puts tamariki at risk of <em>many</em> preventable and serious diseases and adds a major burden to the <a href="https://theconversation.com/resurgent-covid-19-flu-and-other-viruses-are-pushing-new-zealands-health-system-to-the-limit-and-now-winter-is-coming-183536">already strained healthcare system</a>. </p>
<p>Prevention must be our top priority. It is better than the best cure, and will protect the health system from overload so it is available for those who need urgent care.</p><img src="https://counter.theconversation.com/content/188157/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Howe receives funding from the Health Research Council. While not the principal investigator she has been involved in research projects funded by GSK and was the first KPS Research Fellow. She works with the Immunisation Advisory Centre as their Research and Policy Analyst.</span></em></p><p class="fine-print"><em><span>Emma Best is as a member of anti-infectives Subcommittee of PHARMAC and holds research grants Health and Research Council. She works as a medical advisor for the Immunisation Advisory Centre </span></em></p><p class="fine-print"><em><span>Dr. Matthew Hobbs receives funding from the New Zealand Health Research Council, Cure Kids/A Better Start National Science Challenge and IStar. He was also previously funded as a researcher by the New Zealand Ministry of Health. </span></em></p>The risk of serious disease outbreaks among NZ children is now very real. Some childhood immunisation rates have dropped from about 80% in early 2020 to 67% by June 2022, and as low as 45% for Māori.Anna Howe, Research Fellow, University of Auckland, Waipapa Taumata RauEmma Best, Senior Lecturer, Department of Child and Youth Health, University of Auckland, Waipapa Taumata RauMatthew Hobbs, Senior Lecturer (Above the Bar) in Public Health and Co-Director of the GeoHealth Laboratory, University of CanterburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1822502022-05-04T13:03:13Z2022-05-04T13:03:13ZMeasles: global increase in cases likely driven by COVID pandemic<figure><img src="https://images.theconversation.com/files/461275/original/file-20220504-13-c76318.jpg?ixlib=rb-1.1.0&rect=46%2C0%2C5184%2C3453&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In the first two months of 2022, 17,000 cases were already reported worldwide.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/viral-diseases-hand-infected-foot-mouth-693857683">fotohay/ Shutterstock</a></span></figcaption></figure><p>A report by the World Health Organization (WHO) and Unicef warns that there could be a significant increase in the number of measles cases around the world. More than 17,000 cases have already been reported globally in January and February, an increase of nearly 80% from the 9,665 cases reported in the <a href="https://www.who.int/news/item/27-04-2022-unicef-and-who-warn-of--perfect-storm--of-conditions-for-measles-outbreaks--affecting-children">same period last year</a>. The report cites low global vaccination rates in the past few years as the main driver of this increase. Given measles is a preventable disease, it’s worrying to see cases rising.</p>
<p>Measles is a disease caused by infection by the <a href="https://www.nature.com/articles/nrdp201649">measles virus</a>, which is spread through respiratory droplets when a person with the virus coughs or sneezes. Symptoms can include fever, cough, red eyes and a rash. Measles is extremely contagious, and is one of the <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30307-9/fulltext">most easily spread viruses</a> that infect humans. It is particularly dangerous for children, who may develop severe complications (such as pneumonia or brain swelling) as a result of measles.</p>
<p>But measles is easily prevented with a double vaccine dose which is usually administered by the time a child is four years old. This vaccine provides lifelong protection against measles. In places where measles vaccination is high, there are <a href="https://www.sciencedirect.com/science/article/pii/S0264410X14001571">low numbers of infections and deaths</a>. Despite this, cases of measles are still seen in nearly every country in the world. </p>
<p>According to the report, cases are rising most quickly in countries where vaccination rates are the lowest in the world. The countries that experienced the most significant increases in case numbers last year were Somalia, Yemen, Afghanistan, Nigeria and Ethiopia. In these countries, only 46-68% of the population is vaccinated against measles. Typically, it’s recommended that 95% of the population needs to be vaccinated to protect children.</p>
<p>The low vaccination rates in many of these countries are likely caused by a number of factors – including low investment in healthcare systems as well as conflicts and natural disasters that disrupt vaccination programmes. But the pandemic has only worsened measles vaccine rollout, due to such health programmes being halted and greater funding and effort being diverted to COVID-19 vaccination programmes. This means many children didn’t receive their first or second doses of the measles vaccine during the pandemic – making it even more difficult to reduce outbreaks and stop the spread of this virus.</p>
<p>Other reasons – such as ongoing conflicts and refugee migrations – also make it difficult to track patients and administer double doses on time. With a contagious disease like measles, these can spread rapidly in crowded camps and houses, making immunisation even more important. </p>
<h2>Global cases rising</h2>
<p>The WHO reports also show that case numbers are rising in almost all countries around the world – the UK included. </p>
<p>In 2019, 119 of the 194 WHO member states had over 90% first dose vaccination coverage. In 2020, this dropped to <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7045a1.htm?s_cid=mm7045a1_w">only 75 countries</a> with the largest decreases seen in the <a href="https://www.frontiersin.org/articles/10.3389/fmed.2021.798031/full">Netherlands, Armenia and Romania</a>. In the UK alone, only <a href="https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-how-do-mmr-vaccination-rates-vary-across-england">around 87%</a> of people are fully vaccinated against measles – though this number varies depending on the region, with some areas such as London only having a vaccination rate of around 75%. It’s a similar story in the US, where case numbers are increasing despite measles being <a href="https://www.nature.com/articles/s41598-020-80214-3">declared eliminated in 2000</a>.</p>
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<img alt="A doctor or nurse administers a vaccine to a child." src="https://images.theconversation.com/files/461276/original/file-20220504-15-hl0x06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461276/original/file-20220504-15-hl0x06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461276/original/file-20220504-15-hl0x06.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461276/original/file-20220504-15-hl0x06.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461276/original/file-20220504-15-hl0x06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461276/original/file-20220504-15-hl0x06.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461276/original/file-20220504-15-hl0x06.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The measles vaccine can offer lifelong protection against the virus.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pediatrician-makes-vaccination-small-boy-542046412">adriaticfoto/ Shutterstock</a></span>
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<p>Again, it’s likely that the rise in cases many countries have seen is because fewer vaccines are being administered. While the pandemic is one reason for this, vaccine hesitancy is another factor. A <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002578">direct relationship</a> has been observed between increased hesitancy and increased cases of measles. </p>
<p>Children and pregnant people are at greatest risk from these increases in measles cases. This is because they’re more likely to suffer severe side effects as a <a href="https://www.who.int/news-room/fact-sheets/detail/measles">result of measles</a>. But anyone who isn’t vaccinated is at risk of contracting the disease – and more importantly, they’re more likely to pass it on to any other unvaccinated people they come into contact with. </p>
<p>Mass vaccination programmes are still the best way to combat the rise in measles cases globally – especially given 95% of the population needs to be vaccinated with both doses to achieve herd immunity. While ensuring these programmes have the funding needed to provide these vaccines is important, it may also be important to put efforts into educating people on the importance of measles vaccination and that the vaccine is safe.</p>
<p>Global support must also be given to countries experiencing low vaccination rates – especially if this is due to natural disasters or refugee crises. This is especially important given that measles is highly contagious and local outbreaks can quickly spread globally.</p>
<p>Given the increase in case numbers seen at the beginning of this year, it’s likely numbers will only continue to rise throughout 2022. This resurgence is just one example of the knock-on effect that the COVID-19 pandemic has had on other diseases – and the importance of getting regular vaccination programmes back on track to prevent further spread of harmful viruses.</p><img src="https://counter.theconversation.com/content/182250/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Conor Meehan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The latest report from the WHO and Unicef found cases have increased nearly 80% worldwide.Conor Meehan, Senior Lecturer in Microbiology, Nottingham Trent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1688992021-10-22T12:39:13Z2021-10-22T12:39:13ZParents were fine with sweeping school vaccination mandates five decades ago – but COVID-19 may be a different story<figure><img src="https://images.theconversation.com/files/427788/original/file-20211021-14-cn140n.jpg?ixlib=rb-1.1.0&rect=197%2C8%2C2645%2C1814&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children and parents lined up for polio vaccines outside a Syracuse, New York school in 1961.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/LinedUpForPolioVaccine1961/4da7b3b42ecd4a68a089a5985f951f32/photo?Query=school%20vaccine&mediaType=photo&sortBy=arrivaldatetime:asc&dateRange=Anytime&totalCount=1077&currentItemNo=9">AP Photo</a></span></figcaption></figure><p>The ongoing battles over COVID-19 vaccination in the U.S. are likely to get more heated when the Food and Drug Administration authorizes emergency use of a vaccine for children ages 5 to 11, expected later this fall.</p>
<p>California <a href="https://www.gov.ca.gov/2021/10/01/california-becomes-first-state-in-nation-to-announce-covid-19-vaccine-requirements-for-schools/">has announced</a> it will require the vaccine for elementary school attendance once it receives full FDA approval after emergency use authorization, and other states may follow suit. COVID-19 vaccination mandates in workplaces and colleges have sparked controversy, and the possibility that a mandate might extend to younger children is <a href="https://www.kff.org/coronavirus-covid-19/press-release/most-parents-dont-want-their-schools-to-require-covid-19-vaccination-but-most-favor-requiring-masks-for-unvaccinated-children-and-staff/">even more contentious</a>.</p>
<p>Kids are already required to get a host of other vaccines to attend school. School vaccination mandates have been around since the 19th century, and they became a fixture in all 50 states in the 1970s. Vaccine requirements are among the <a href="https://pubmed.ncbi.nlm.nih.gov/12508514/">most effective means of controlling infectious diseases</a>, but they’re currently under attack by small but vocal minorities of parents who consider them unacceptable intrusions on parental rights.</p>
<p>As a public health historian who studies the <a href="https://www.ucpress.edu/book/9780520247499/state-of-immunity">evolution of vaccination policies</a>, I see stark differences between the current debates over COVID-19 vaccination and the public response to previous mandates.</p>
<h2>Compulsory vaccination in the past</h2>
<p>The <a href="https://doi.org/10.1353/bhm.2004.0062">first legal requirements for vaccination</a> date to the early 1800s, when gruesome and deadly diseases routinely terrorized communities. A loose patchwork of local and state laws were enacted to stop epidemics of smallpox, the era’s only vaccine-preventable disease. </p>
<p>Vaccine mandates initially applied to the general population. But in the 1850s, as universal public education became more common, people recognized that schoolhouses were likely sites for the spread of disease. Some states and localities began enacting <a href="https://doi.org/10.1093/jhmas/XXXIII.3.344">laws tying school attendance to vaccination</a>. The smallpox vaccine was crude by today’s standards, and concerns about its safety led to numerous lawsuits over mandates.</p>
<p>The U.S. Supreme Court upheld compulsory vaccination in two decisions. The first, in 1905, <a href="https://supreme.justia.com/cases/federal/us/197/11/">affirmed that mandates are constitutional</a>. The second, in 1922, <a href="https://supreme.justia.com/cases/federal/us/260/174/">specifically upheld school-based requirements</a>. In spite of these rulings, many states lacked a smallpox vaccination law, and some states that did have one failed to enforce it consistently. Few states updated their laws as new vaccines became available.</p>
<p>School vaccination laws underwent a major overhaul beginning in the 1960s, when health officials grew frustrated that <a href="https://doi.org/10.1177/0033354919826558">outbreaks of measles were continuing to occur in schools</a> even though a safe and effective vaccine had recently been licensed.</p>
<p>Many parents mistakenly believed that measles was an annoying but mild disease from which most kids quickly recovered. In fact, it often caused <a href="https://www.cdc.gov/measles/symptoms/complications.html">serious complications</a>, including potentially fatal pneumonia and swelling of the brain.</p>
<p>With encouragement from the Centers for Disease Control and Prevention, all states updated old laws or enacted new ones, which generally covered all seven childhood vaccines that had been developed by that time: diphtheria, pertussis, tetanus, polio, measles, mumps and rubella. In 1968, just half the states <a href="https://www.ucpress.edu/book/9780520247499/state-of-immunity">had school vaccination requirements; by 1981, all states did</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Smiling boy rolls up his sleeve to get a shot from a nurse" src="https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427792/original/file-20211021-27-psl61q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sometimes, students even received vaccinations from nurses at school.</span>
<span class="attribution"><a class="source" href="http://resource.nlm.nih.gov/101447463">NIH U.S. National Library of Medicine</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Expanding requirements, mid-20th century</h2>
<p>What is most surprising about this major expansion of vaccination mandates is how little controversy it provoked.</p>
<p>The laws did draw scattered court challenges, usually over the question of exemptions – which children, if any, should be allowed to opt out. These lawsuits were often brought by chiropractors and other adherents of alternative medicine. <a href="https://pubmed.ncbi.nlm.nih.gov/15868682/">In most instances, courts turned away these challenges</a>.</p>
<p>There was scant public protest. In contrast to today’s vocal and well-networked anti-vaccination activists, organized resistance to vaccination remained on the fringes in the 1970s, the period when these school vaccine mandates were largely passed. Unlike today, when <a href="https://www.cdc.gov/vaccinesafety/concerns/index.html">fraudulent theories of vaccine-related harm</a> – such as the discredited notion that vaccines cause autism – <a href="https://theconversation.com/anti-vaccination-mothers-have-outsized-voice-on-social-media-pro-vaccination-parents-could-make-a-difference-120572">circulate endlessly on social media</a>, public discussion of the alleged or actual risks of vaccines was largely absent.</p>
<p>Through most of the 20th century, <a href="https://doi.org/10.1353/bhm.2013.0047">parents were less likely to question</a> pediatricians’ recommendations than they are today. In contrast to the empowered “patient/consumer” of today, an attitude of “doctor knows best” prevailed. All these factors contributed to overwhelmingly positive views of vaccination, with more than 90% of parents in a 1978 poll reporting that <a href="https://www.ucpress.edu/book/9780520247499/state-of-immunity">they would vaccinate their children even if</a> there were no law requiring them to do so.</p>
<p>Widespread public support for vaccination enabled the laws to be passed easily – but it took more than placing a law on the books to control disease. Vaccination rates <a href="https://doi.org/10.1177/0033354919826558">continued to lag in the 1970s</a>, not because of opposition, but because of complacency.</p>
<p>Thanks to the success of earlier vaccination programs, most parents of young children lacked firsthand experience with the suffering and death that diseases like polio or whooping cough had caused in previous eras. But public health officials recognized that those diseases were far from eradicated and would continue to threaten children unless higher rates of vaccination were reached. Vaccines were already becoming a victim of their success. The better they worked, the more people thought they were no longer needed.</p>
<p>In response to this lack of urgency, <a href="https://press.uchicago.edu/ucp/books/book/chicago/V/bo14237741.html">the CDC launched a nationwide push in 1977</a> to help states enforce the laws they had recently enacted. Around the country, health officials partnered with school districts to audit student records and provide on-site vaccination programs. When push came to shove, they would exclude unvaccinated children from school until they completed the necessary shots.</p>
<p>The lesson learned was that making a law successful requires ongoing effort and commitment – and continually reminding parents about the value of vaccines in keeping schools and entire communities healthy.</p>
<h2>Add COVID-19 to vaccine list for school?</h2>
<p>Five decades after school mandates became universal in the U.S., <a href="https://www.pewresearch.org/science/2017/02/02/vast-majority-of-americans-say-benefits-of-childhood-vaccines-outweigh-risks/">support for them remains strong overall</a>. But misinformation spread over the internet and social media has weakened the public consensus about the value of vaccination that allowed these laws to be enacted.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="adults and kids with signs protesting COVID-19 vaccines" src="https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427942/original/file-20211022-39064-z486w0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some anti-vaccination activists are vocal opponents of vaccine mandates for kids.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/with-her-daughter-ella-baindourov-nara-varderesyan-leads-news-photo/1235967787?adppopup=true">Sarah Reingewirtz/MediaNews Group/Los Angeles Daily News via Getty Images</a></span>
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<p>COVID-19 vaccination has become politicized in a way that is unprecedented, with sharp partisan divides over whether <a href="https://www.pewresearch.org/fact-tank/2020/07/22/republicans-remain-far-less-likely-than-democrats-to-view-covid-19-as-a-major-threat-to-public-health/">COVID-19 is really a threat</a>, and whether the <a href="https://news.gallup.com/poll/352397/democratic-republican-confidence-science-diverges.aspx">guidance of scientific experts can be trusted</a>. The attention focused on COVID-19 vaccines has given new opportunities for anti-vaccination conspiracy theories to reach wide audiences. </p>
<p>[<em>Over 115,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.] </p>
<p>Fierce opposition to COVID-19 vaccination, powered by <a href="https://www.npr.org/2021/10/17/1046598351/the-political-fight-over-vaccine-mandates-deepens-despite-their-effectiveness">anti-government sentiment and misguided notions of freedom</a>, could undermine support for time-tested school requirements that have protected communities for decades. Although vaccinating school-aged children will be critical to controlling COVID-19, lawmakers will need to proceed with caution.</p><img src="https://counter.theconversation.com/content/168899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Colgrove has received funding from the National Library of Medicine, the Greenwall Foundation, the Milbank Memorial Fund, and the William T. Grant Foundation. </span></em></p>Public health experts know that schools are likely sites for the spread of disease, and laws tying school attendance to vaccination go back to the 1800s.James Colgrove, Professor of Sociomedical Sciences, Mailman School of Public Health; Dean of the Postbaccalaureate Premedical Program, Columbia School of General Studies, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1663932021-09-28T11:56:22Z2021-09-28T11:56:22ZCan healthy people who eat right and exercise skip the COVID-19 vaccine? A research scientist and fitness enthusiast explains why the answer is no<figure><img src="https://images.theconversation.com/files/422695/original/file-20210922-25-11lek97.jpg?ixlib=rb-1.1.0&rect=16%2C24%2C5439%2C3612&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Several thousand protestors opposed to the COVID-19 vaccine march through the streets of midtown Manhattan in New York on Sept. 18, 2021. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/several-thousand-protestors-opposed-to-the-covid-19-vaccine-news-photo/1341164693?adppopup=true">Andrew Lichtenstein/Corbis News via Getty Images</a></span></figcaption></figure><p>I’m a fitness enthusiast. I also adhere to a nutrient-dense, “clean” eating program, which means I minimize my sugar intake and eat a lot of whole foods for the purpose of optimizing my health. </p>
<p>You might wonder how effective such a diet and exercise plan would be in the fight against COVID-19, since some <a href="https://www.washingtonpost.com/technology/2021/09/12/wellness-influencers-vaccine-misinformation/">have suggested</a> – without supporting evidence – that vaccination may be unnecessary if a detailed wellness lifestyle is closely followed. </p>
<p>As a <a href="https://scholar.google.com/scholar?hl=en&as_sdt=0%2C43&q=Bloomer+and+memphis&btnG=">research scientist</a> who has studied nutrition for close to 20 years, I have watched the wellness community’s response to the COVID-19 vaccines with great interest. While eating right can <a href="https://doi.org/10.3390/nu12061562">favorably impact the immune system</a>, it is not reasonable to expect that nutrition alone will defend against a potentially life-threatening virus. </p>
<h2>My experience with nutrition science</h2>
<p>My lab group at the <a href="https://www.memphis.edu/healthsciences/">University of Memphis</a> studies the effect of food and isolated nutrients on human health. In January 2009, we conducted an initial study of a stringent vegan diet. We enrolled 43 men and women who were allowed to eat as much plant-based food as desired, but drank only water, for 21 days. </p>
<p>The results demonstrated improvements <a href="https://doi.org/10.1186/1476-511X-9-94">in many variables</a> related to cardio-metabolic health, such as blood cholesterol, blood pressure, insulin and C-reactive protein – a protein that increases in response to inflammation. We have <a href="https://pubmed.ncbi.nlm.nih.gov/?term=bloomer+and+daniel+fast">since completed</a> multiple human and animal nutrition studies using this dietary program. </p>
<figure class="align-center ">
<img alt="A woman eating a healthy salad." src="https://images.theconversation.com/files/422240/original/file-20210920-19-log1mt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422240/original/file-20210920-19-log1mt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422240/original/file-20210920-19-log1mt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422240/original/file-20210920-19-log1mt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422240/original/file-20210920-19-log1mt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422240/original/file-20210920-19-log1mt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422240/original/file-20210920-19-log1mt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Diet improvements may reduce or eliminate the need for some medications, but a clean diet cannot completely protect you from COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-eating-salad-royalty-free-image/912617718?adppopup=true">Tara Moore via Getty Images</a></span>
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<p>My lab’s research has resulted in some 200 peer-reviewed scientific manuscripts and book chapters specific to <a href="https://umwa.memphis.edu/fcv/viewprofile.php?uuid=rbloomer">nutrients and exercise</a>, and the interaction between these two variables. The results of our work, as well as that of other scientists, clearly demonstrate the power of food to favorably impact health.</p>
<p>For many individuals, a positive change in eating habits results in such an improvement in clinically relevant measures like <a href="https://doi.org/10.1186/1476-511X-9-94">blood cholesterol</a> <a href="https://doi.org/10.3390/ijerph17072557">and glucose</a> that doctors can sometimes reduce or eliminate certain medications used to treat high cholesterol and diabetes. In other cases, these measures improve but the patient still requires the use of medications to control their disease. This tells us that in some situations, a great nutrition program is simply not enough to overcome the body’s challenges.</p>
<h2>Nutrition and other wellness approaches do matter</h2>
<p>Although certain <a href="https://doi.org/10.3389/fphar.2020.01189">natural products</a> have been discussed as treatments for COVID-19, little emphasis has been placed on whole food nutrition as a protective measure. I think this is unfortunate, and I believe strengthening our immune system with the goal of battling COVID-19 and other viral infections is of great importance. And the <a href="https://theconversation.com/good-nutrition-can-contribute-to-keeping-covid-19-and-other-diseases-away-145086">evidence tells us</a> that a <a href="https://doi.org/10.3390/nu12061562">nutrient dense diet</a>, <a href="http://dx.doi.org/10.1136/bjsports-2021-104080">regular exercise</a> and <a href="https://doi.org/10.1007/s00424-011-1044-0">adequate sleep</a> can all contribute to optimal immune function. </p>
<p>Regarding nutritional intake, a <a href="https://doi.org/10.1136/bmjnph-2021-000272">recently published study</a> using a sample of health care workers who contracted COVID-19 noted that those who followed a plant-based or pescatarian diet had 73% and 59% lower odds of moderate to severe COVID-19, respectively, compared to those who did not follow those diets. Although interesting, it’s important to remember that these findings represent an association rather than a causal effect. </p>
<p>While people can use nutrition to help shore up their immune system against COVID-19, diet is only one important consideration. Other <a href="https://doi.org/10.3945/an.115.010207">variables matter</a> a great deal too, including <a href="https://pubmed.ncbi.nlm.nih.gov/29306937/">stress management</a>, <a href="https://doi.org/10.3389/fimmu.2020.570122">nutritional supplements</a> and <a href="https://doi.org/10.1016/S0140-6736(20)31142-9">physical distancing and mask-wearing</a>.</p>
<p>But to be clear, all of those elements should be considered tools in the toolbox to help combat COVID-19 – not a replacement for potentially life-saving vaccines. </p>
<figure class="align-center ">
<img alt="A teenage boy at a clinic getting a COVID-19 shot." src="https://images.theconversation.com/files/422243/original/file-20210920-25-4sj241.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422243/original/file-20210920-25-4sj241.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422243/original/file-20210920-25-4sj241.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422243/original/file-20210920-25-4sj241.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422243/original/file-20210920-25-4sj241.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422243/original/file-20210920-25-4sj241.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422243/original/file-20210920-25-4sj241.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Charles Muro, age 13, receives a COVID-19 shot at a mass vaccination center in Hartford, Connecticut. Without the vaccine, even young people in good health are not fully protected from the virus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/charles-muro-age-13-is-inoculated-by-nurse-karen-pagliaro-news-photo/1232871480?adppopup=true">Joseph Prezioso/AFP via Getty Images</a></span>
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<h2>Vaccines are not perfect, but they save lives</h2>
<p>I find it interesting that nearly all parents understand the importance of having their kids <a href="https://abcnews.go.com/US/vaccine-mandates-place-attend-school-us/story?id=80046650">vaccinated against serious illnesses</a> like mumps, measles and varicella. They do not expect that certain foods, or a nurturing environment, will do the job of a vaccine. </p>
<p>Yet, when it comes to COVID-19, this thought process is abandoned by <a href="https://www.washingtonpost.com/technology/2021/09/12/wellness-influencers-vaccine-misinformation/">some who believe</a> that a healthy lifestyle will substitute for the vaccine, without seriously considering <a href="https://theconversation.com/what-happens-when-the-covid-19-vaccines-enter-the-body-a-road-map-for-kids-and-grown-ups-164624">what the vaccine actually does to provide protection</a> against the virus – something that a healthy lifestyle alone simply cannot do. </p>
<p>When contemplating whether to receive the COVID-19 vaccine, consider the following: All medications have risks, including things as <a href="https://www.huffingtonpost.co.uk/entry/daily-aspirin-causes-more-than-3000-deaths-per-year-scientists-warn_uk_593fb481e4b0b13f2c6daa10">seemingly benign as aspirin</a>. <a href="https://doi.org/10.1177/0024363918816683">Hormonal contraception</a> – something used by millions of women every month – is thought to cause an estimated 300-400 deaths annually in the U.S. The same is true for <a href="https://www.huffpost.com/entry/what-would-wendy-davis-do_b_3672484">cosmetic surgery</a>, <a href="https://doi.org/10.1007/s00266-020-02027-z">Botox injections</a> and other elective procedures. </p>
<p>Many people are willing to accept the low risks in those cases, but not with those involving <a href="https://theconversation.com/what-does-full-fda-approval-of-a-vaccine-do-if-its-already-authorized-for-emergency-use-165654">the COVID-19 vaccines</a> – despite the fact that the risk of <a href="https://www.theguardian.com/world/2021/aug/27/blood-clot-risk-greater-after-covid-infection-than-after-vaccination">serious complications or death from COVID-19</a> far outweighs the low risk of serious <a href="https://theconversation.com/new-covid-19-vaccine-warnings-dont-mean-its-unsafe-they-mean-the-system-to-report-side-effects-is-working-164455">adverse events</a> from the vaccines. </p>
<p>No lifestyle approach, including strict adherence to a holistic, nutrient-dense diet – vegan, plant-forward or otherwise – will confer total protection against COVID-19. The vaccines <a href="https://theconversation.com/medicine-is-an-imperfect-science-but-you-can-still-trust-its-process-166811">aren’t perfect</a> either; <a href="https://theconversation.com/what-is-a-breakthrough-infection-6-questions-answered-about-catching-covid-19-after-vaccination-164909">breakthrough infections</a> do occur in some cases, though the vaccines <a href="https://www.wsj.com/articles/breakthrough-cases-covid-19-delta-variant-11627596643">continue to provide robust protection</a> against <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7037e1.htm?s_cid=mm7037e1_w#T1_down">severe illness and death</a>. </p>
<p>I encourage people to do all they can to improve the health and functioning of their immune system, naturally. Then, seriously consider what additional protection would be gained from vaccination against COVID-19. When people make decisions based on the latest science – which is always evolving – rather than on emotions and misinformation, the decision should become much clearer.</p><img src="https://counter.theconversation.com/content/166393/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard J. Bloomer has received research support and has served as a consultant to a variety of dietary ingredient and supplement companies over the past 20 years. </span></em></p>A growing body of research shows that nutrition, sleep, exercise and a host of other lifestyle choices can help optimize the immune system. But they are no substitute for life-saving vaccines.Richard Bloomer, Dean of the College of Health Sciences, University of MemphisLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1668112021-09-07T12:52:18Z2021-09-07T12:52:18ZMedicine is an imperfect science – but you can still trust its process<figure><img src="https://images.theconversation.com/files/418963/original/file-20210901-25-big4r.jpg?ixlib=rb-1.1.0&rect=0%2C72%2C2039%2C1085&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intensive care physicians are yet again facing ICU bed and staff shortages as severe COVID-19 cases rise.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hospital-coronavirus-emergency-department-ward-royalty-free-image/1321692378?adppopup=true">gorodenkoff/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>The Conversation is running a series of dispatches from clinicians and researchers operating on the front lines of the coronavirus pandemic. You can <a href="https://theconversation.com/us/topics/covid-19-front-lines-84846">find all of the stories here</a>.</em> </p>
<p>As an intensive care physician in Southern California who endured the onslaught of COVID-19 in 2020, it has been deeply disheartening to experience chillingly familiar scenes all over again. The ICUs in the University of California San Diego Health hospital network where <a href="https://profiles.ucsd.edu/venktesh.ramnath">I work</a> are again overflowing – especially with patients who need ventilators. Families peer through tinted hospital windows for glimpses of loved ones. And <a href="https://www.washingtonpost.com/health/staff-shortages-hospitals-covid/2021/08/12/85f636b4-fa97-11eb-8a67-f14cd1d28e47_story.html">hospital administrators scramble</a> to keep up with necessary staffing and beds to accommodate the influx of patients.</p>
<p>What is so vexing is that COVID-19 is still the culprit, despite the availability of <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7034e2.htm">highly effective vaccines</a> that <a href="https://doi.org/10.1038/d41586-021-02054-z">slashed U.S. COVID-19 daily case numbers and hospitalizations</a> within months. The vaccines also allowed economies to <a href="https://budgetmodel.wharton.upenn.edu/issues/2021/3/1/epidemiological-and-economic-effects-of-covid-19-vaccine">begin to recover</a> and provided a way for people to experience some sense of normalcy again. </p>
<p>In early spring, the efficacy of the vaccine engendered hope that herd immunity – in which infectious viral spread is prevented through a high proportion of the population’s being immune to the disease – <a href="https://www.wsj.com/articles/well-have-herd-immunity-by-april-11613669731">could be within reach</a> in months. Instead, pandemic panic is again suffocating us, largely because a large part of the public <a href="https://www.nytimes.com/2021/07/31/us/virus-unvaccinated-americans.html">still shuns vaccination</a> – with only 62% of the eligible U.S. population <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total">fully vaccinated</a> as of early September 2021.</p>
<p>I wanted an answer to the obvious question: Why?</p>
<h2>Straight from the source</h2>
<p>So I turned to my patients for answers. At the bedside in their hospital rooms, I first asked about how they were feeling and performed detailed exams before addressing the elephant in the room. “Did you receive the COVID-19 vaccine?” And if not, I gently asked, “Did you have a specific reason you could share with me, so I can understand better?”</p>
<p>Somewhat surprisingly, patients candidly told me their reasons for avoiding the vaccine.</p>
<p>A common response I heard was that it was simply inconvenient. “I was too lazy and I didn’t get around to it,” some admitted, looking away sheepishly as they did so. Curiously, they did not consider the myriad “inconveniences” of becoming infected, such as medical complications – including death – and associated costs for treatment, lost work, dependence on others for basic necessities such as child care, the risk of infecting family members, the potential for developing <a href="https://theconversation.com/deciphering-the-symptoms-of-long-covid-19-is-slow-and-painstaking-for-both-sufferers-and-their-physicians-164754">long-haul COVID-19</a> and more.</p>
<p>Others expressed a fervid distrust of vaccine-testing methods, stating that people had been “guinea pigs in past vaccine experiments that later caused autism.” Yet more than 25 studies in the past 20-odd years have disproved any <a href="https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Studies-Examine-the-Evidence.aspx">causal link between vaccines and autism</a>. </p>
<p>Some felt that the forceful public messaging to get vaccinated belied true motivations of the authorities, adding: “I mean, why are they pushing this so hard? Something must be wrong with it.” Yet few question the strong public health stance on healthy eating practices and exercise, or wearing seat belts while driving. </p>
<p>Still others feared the possibility of life-threatening side effects: “Thousands had heart attacks from the vaccine – it’s all on the CDC website,” they told me. So I took <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html?s_cid=11374:covid%20vaccine%20heart%20problems:sem.ga:p:RG:GM:gen:PTN:FY21">a close look</a> at the CDC website to understand their claims better. </p>
<p>Reports of heart inflammation occurred in 699 cases out of 177 million vaccinated people, or 0.0004%, with causal links to the vaccines still being investigated. Development of blood clots causally associated with the Johnson & Johnson vaccine are <a href="https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-05-12/07-COVID-Shimabukuro-508.pdf">also extremely rare</a>, occurring in 28 cases out of 8.73 million doses given as of May 7, 2021 – a rate of 0.0003%. This extremely low risk of blood clots is still significantly lower than the <a href="https://doi.org/10.1136/bmj.n1931">risk of blood clots</a> from an <a href="https://www.nytimes.com/2021/08/27/health/blood-clots-coronavirus.html">actual COVID-19</a> infection.</p>
<h2>Medicine as art and imperfect science</h2>
<p>In some cases, political affiliation can <a href="https://www.economist.com/united-states/2021/07/27/americas-vaccination-woes-cannot-be-blamed-only-on-politics">partially explain</a> vaccine antipathy. But my patients’ responses highlighted two other themes to me.</p>
<p>First, people often forget that medicine is an art <a href="http://dx.doi.org/10.1136/mh.26.1.18">based on applied science</a>, not a deductive science based on irrefutable forces in nature like gravity. Patients and families often ask me in the ICU to predict what will happen to loved ones unequivocally, only to be disappointed when I avoid speaking in certainties.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An ICU doctor hugs and comforts a patient in a COVID-19 ICU" src="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Having to deliver devastating news and uncertainties about patient outcomes has taken a heavy toll on ICU physicians during the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/dr-joseph-varon-hugs-and-comforts-a-patient-in-the-covid-19-news-photo/1229807339?adppopup=true">Go Nakamura/Getty Images News</a></span>
</figcaption>
</figure>
<p>Once viewed as <a href="https://doi.org/10.1136/bmj.317.7174.1729">omniscient authorities</a>, doctors now openly acknowledge that limitations of medical data require scrutiny and careful application to particular circumstances. COVID-19 has reinforced our appreciation that there are no perfect cures or 100% guarantees of success. Rather, medicine is governed by what is probable. What are the chances I still may have cancer if the test result returns negative? Am I more or less likely to survive pneumonia by taking this specific antibiotic?</p>
<p>Doctors must then engage in <a href="https://doi.org/10.1016/j.chest.2020.05.548">thoughtful analysis</a> of the strengths and weaknesses of scientific methods and data to optimize and tailor our recommendations for individual patients – without the luxury of perfect or even complete datasets to rely on. The vaccine has clearly been shown – its rare side effects notwithstanding – to provide an overwhelmingly high likelihood of benefit over potential risks to almost all individuals. This <a href="https://doi.org/10.1001/jama.2021.11717">includes people</a> who have been <a href="https://apnews.com/article/science-health-coronavirus-pandemic-ad52011f4ca1853fad6eee41a7310c2e">previously infected with COVID-19</a>. Yet the unvaccinated continue to fixate on rare side effects to justify skipping the shot.</p>
<h2>Vaccines are medicines too</h2>
<p>Many of my patients also seem to view vaccines and other public health-based recommendations like offers to buy a used car – with skepticism and independence, threatening to walk away at any moment. Doing one’s part to stop the spread of disease is a culturally nuanced civic virtue, like <a href="https://doi.org/10.1016/j.trf.2014.01.004">safe driving</a>, which transcends absolute autonomy. In the U.S., most drivers willingly do not drive while intoxicated, cross lanes without warning or block other cars that are trying to merge. These are norms that make driving in the U.S. relatively efficient, safe and even pleasant compared with some other countries. </p>
<p>The path to herd immunity, like highway safety, requires majority participation without immediate guarantees of complete personal freedom. Vaccines succeed not because they are 100% risk-free to the individual but because collective efforts focus on achieving the common good.</p>
<p>Oddly, at the same time that my patients rejected the vaccine, they showed strong interest in receiving other types of medicine “shots” like monoclonal antibodies – which mimic natural antibodies – or anti-inflammatory medications. While <a href="https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/">some of these treatments</a> have demonstrated benefits in certain situations – <a href="https://doi.org/10.1001/jama.2021.2747">others</a> <a href="https://doi.org/10.1056/NEJMoa2028700">have not</a>. And some present the risk of <a href="https://www.fox19.com/2021/08/21/seriously-yall-stop-it-fda-dispels-myth-about-ivermectin-covid-cure/">very serious harm</a>. </p>
<p>I reminded my patients that the COVID-19 vaccine stimulates a person’s own immune system to make <a href="https://theconversation.com/what-happens-when-the-covid-19-vaccines-enter-the-body-a-road-map-for-kids-and-grown-ups-164624">antibodies that can neutralize the virus</a> and that surpass the capabilities of <a href="https://www.webmd.com/vaccines/covid-19-vaccine/news/20210826/monoclonal-antibodies-vs-vaccines-vs-covid-19">commercially created antibody formulations</a>. So the vaccines help prevent infection and development of serious illness from COVID-19 in the first place. People who experience the <a href="https://theconversation.com/what-is-a-breakthrough-infection-6-questions-answered-about-catching-covid-19-after-vaccination-164909">rare breakthrough infections</a> following vaccination generally have a <a href="https://www.wsj.com/articles/breakthrough-cases-covid-19-delta-variant-11627596643">shorter and milder course of COVID-19 infection</a> and are far less likely to <a href="https://doi.org/10.1093/cid/ciab543">end up hospitalized</a> than those who are unvaccinated. Vaccines <a href="https://doi.org/10.1038/s41586-021-03738-2">also confer</a> <a href="https://www.npr.org/sections/goatsandsoda/2021/08/30/1032520934/immunity-to-covid-19-could-last-longer-than-youd-think?ft=nprml&f=1032520934">longer-term protection</a>, whereas the other medications are used reactively – when a serious infection has already begun – and those medications have <a href="https://www.coronaviruspreventionnetwork.org/coronavirus-vaccine-and-antibody-science">shorter-term results</a>.</p>
<h2>How past vaccination efforts succeeded</h2>
<p>In the past, many vaccines that successfully vanquished societal outbreaks of <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">polio</a>, <a href="https://www.historyofvaccines.org/timeline/measles">measles</a> and <a href="https://www.historyofvaccines.org/content/articles/mumps">mumps</a> are now routinely administered in childhood with minimal objection, despite the fact that there is no such thing as <a href="https://www.cdc.gov/vaccines/vac-gen/side-effects.htm">zero risk</a>.</p>
<p>As I continue to have conversations with patients who suffer greatly from COVID-19 illness as a direct consequence of having avoided the vaccine, my own pain – for being an ineffective healer and witness to such loss – is inexorable. Overcoming this fourth wave of COVID-19 still feels out of reach until our vaccination efforts can somehow better emphasize the effectiveness of vaccines, even when scientifically imperfect, and prioritize civic health care responsibilities over pure autonomy. If not, I fear that our battle against COVID-19 will rage on.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/166811/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Venktesh Ramnath does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A critical care doctor brings a frontlines perspective to the frustration of dealing firsthand with vaccine hesitancy and discusses the limitations of science and medicine.Venktesh Ramnath, Associate Clinical Professor of Medicine, University of California, San DiegoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1655642021-08-09T12:28:16Z2021-08-09T12:28:16ZWhy refusing the COVID-19 vaccine isn’t just immoral – it’s ‘un-American’<figure><img src="https://images.theconversation.com/files/414632/original/file-20210804-19-1r8mn23.jpg?ixlib=rb-1.1.0&rect=44%2C88%2C7304%2C4704&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many individuals are rejecting the COVID-19 vaccines for personal reasons.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/anti-vaccine-rally-protesters-hold-signs-outside-of-houston-news-photo/1233672891?adppopup=true">Mark Felix / AFP via Getty Images</a></span></figcaption></figure><p>Decades ago I helped organize a conference that brought together vaccine skeptics and public health officials. The debate centered on what governments can and cannot demand from citizens, and what behaviors one can rightly expect from others.</p>
<p>It took place many years before the current coronavirus pandemic, but many things that happened at that conference remind me of our circumstances today. Not least, <a href="https://theconversation.com/profiles/christopher-beem-222877">as a political theorist who also studies social ethics</a>, it reminds me that arguments grounded in self-interest can often be correct – but still deeply inadequate. </p>
<h2>The rationality of vaccine skepticism</h2>
<p>I recall one participant summarizing her objection to vaccines in the following way: She said that the government demanded that she allow a live biological agent to be injected into her child’s body even though it could not guarantee her child’s safety. For these reasons, she claimed, she had every right to decide that her child would not receive the vaccine.</p>
<p>This woman’s objection was driven by her suspicion that the MMR vaccine, for measles, mumps and rubella, caused autism. <a href="https://www.cdc.gov/vaccinesafety/concerns/autism.htm">This claim has been shown, repeatedly and conclusively, to be without merit</a>. Still, she was not entirely wrong. Many vaccines do contain live agents, though they are in a <a href="https://www.hhs.gov/immunization/basics/types/index.html">weakened or attenuated state</a>. And while adverse and even serious reactions have been known to occur, such a risk is <a href="https://theconversation.com/new-covid-19-vaccine-warnings-dont-mean-its-unsafe-they-mean-the-system-to-report-side-effects-is-working-164455">infinitesimally small</a>. Indeed, the preponderance of evidence shows that the risk of harm or death to the unvaccinated child from infections such as MMR is <a href="https://www.who.int/news/item/05-12-2019-more-than-140-000-die-from-measles-as-cases-surge-worldwide">far greater than any associated with receiving the vaccine</a>. </p>
<p>But more importantly, this parent’s decision to reject the vaccine affected more than just her child. Because so many parents refuse vaccination for their children, outbreaks of measles have taken place throughout the U.S. In fact, in 2019 the United States reported <a href="https://www.unicef.org/stories/measles-explained-whats-behind-recent-outbreaks">its highest number of cases of measles in 25 years</a>. </p>
<h2>COVID and vaccine hesitancy</h2>
<p>Many individuals are rejecting the COVID-19 vaccine for <a href="https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-in-their-own-words-six-months-later/">similar reasons – that is, reasons grounded in self-interest</a>. They say that COVID vaccines are experimental, their long-term effects are unknown and that emergency authorization by the Food and Drug Administration was rushed. </p>
<p>In fact, while the vaccines were <a href="https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization">given emergency authorization</a> to expedite their availability to the general public, they are not experimental but rather the result of <a href="https://doi.org/10.1038/d41586-020-03626-1">years of already existing research</a> on mRNA vaccines and coronaviruses – the family of viruses including SARS-CoV-2 that causes COVID-19. And they received authorization only after <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/safety-of-vaccines.html">conclusive evidence showing they were indeed safe</a>. </p>
<p>Those who reject the COVID vaccine also note that many receiving the vaccine have had an adverse reaction, including <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html">flu-like symptoms</a> that are short-lived but often quite unpleasant. Cases of <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/allergic-reaction.html">anaphylactic shock</a> or blood clots have also happened, but they have <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/safety-of-vaccines.html">been extremely rare</a>, and <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/allergic-reaction.html">safeguards on how to provide immediate care are in place</a> for any such eventuality. </p>
<p>Here again the risks associated with the vaccine are extremely small, but for some people, still real. Therefore these individuals apparently decided that they <a href="https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-june-2021/">would rather take their chances with the disease itself</a>. Many are young and don’t think the disease will affect them, and many more don’t trust the doctors, scientists and politicians who they say are pushing them to take the vaccine.</p>
<p>One could readily dispute these claims, too. In fact, <a href="https://www.cnbc.com/2021/07/30/us-covid-vaccine-rates-delta-variant.html">rising vaccination rates</a> over the past few weeks show that many people have reevaluated the risks of remaining unvaccinated. Whether these people have seen evidence of the virulence of the delta variant or have seen for themselves that millions of people have taken the vaccine and are completely fine, <a href="https://www.kff.org/coronavirus-covid-19/press-release/vaccine-monitor-some-who-were-hesitant-to-get-a-vaccine-in-january-say-they-changed-their-mind-because-of-family-friends-and-their-personal-doctors/">their evaluation of their own self-interest has changed</a>. </p>
<p>Nevertheless, many <a href="https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-in-their-own-words-six-months-later/">others remain adamant</a> that these risks are unacceptable. Like that parent from many years ago, these individuals are not entirely wrong. There are risks associated with getting the vaccine. And knowing these risks, and knowing that they bear the costs of their decision, many Americans believe that they alone have the right to decide. What the government or anyone else wants is beside the point.</p>
<p>But here again, the costs of refusing the vaccine are not borne by the individual alone. <a href="https://theconversation.com/us-is-split-between-the-vaccinated-and-unvaccinated-and-deaths-and-hospitalizations-reflect-this-divide-164460">Rising case numbers and hospitalizations</a>, <a href="https://www.usatoday.com/storytelling/coronavirus-reopening-america-map/">renewed restrictions</a> regarding public events, even the <a href="https://www.usnews.com/news/health-news/articles/2021-08-04/delta-variant-accounts-for-nearly-all-of-coronavirus-cases-in-us">emergence of the delta variant</a> itself are happening largely because many millions of Americans chose not to get the vaccine. And for parents of children under 12 who cannot yet receive the vaccine – some of whom are immune compromised – the thought of <a href="https://doi.org/10.1038/d41586-021-01826-x">returning to school</a> this fall with infection rates again climbing no doubt fills them with dread.</p>
<p>Many would argue that this lack of concern for other people is immoral. The Golden Rule – do unto others as you would have others do unto you — manifests that concern for the well-being of others is at the core of morality. Those who choose not to take the vaccine ignore this concern and therefore act immorally. But, I would argue that their indifference to the welfare of others is not only immoral, it is also un-American.</p>
<h2>Democracy and concern for others</h2>
<p>Americans are a <a href="http://clearlycultural.com/geert-hofstede-cultural-dimensions/individualism/">highly individualistic nation</a>, and the spirit of “rugged individualism,” or the idea of “pulling yourself up by your bootstraps,” runs deep in American culture and history. In fact, from the nation’s very beginning, Americans have accepted the notion that human beings care about themselves and those they love more than they do about other people. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A portrait of James Madison" src="https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=721&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=721&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=721&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=907&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=907&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414636/original/file-20210804-23-7cb44w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=907&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">James Madison, the fourth president of the U.S.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/james-madison-fourth-president-of-the-united-states-of-news-photo/3246309?adppopup=true">Stock Montage/Stock Montage/Getty Images</a></span>
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<p>At the time of America’s founding, <a href="http://dictionnaire-montesquieu.ens-lyon.fr/en/article/1376475883/en/">many contemporaries believed</a> that a democracy is possible only if citizens love their country more than themselves. But America’s founders rejected this idea. Human beings are not angels, <a href="https://billofrightsinstitute.org/primary-sources/federalist-no-51">James Madison said</a>. The founders accepted the reality of human selfishness and developed institutions – especially the checks and balances among the three branches of government – whereby people’s natural selfishness could be directed toward socially useful ends. </p>
<p>But neither Madison nor any of the other founders believed that human beings were merely selfish. Nor did they believe that a democracy could be sustained on selfishness alone. The Federalist Papers were written by James Madison, Alexander Hamilton and John Jay in support of the U.S. Constitution drafted in 1787. <a href="https://www.gutenberg.org/files/1404/1404-h/1404-h.htm#link2H_4_0055">In Federalist 55</a>, Madison presents this summation of human nature: </p>
<p>“As there is a degree of depravity in mankind which requires a certain degree of circumspection and distrust, so there are other qualities in human nature which justify a certain portion of esteem and confidence. Republican government presupposes the existence of these qualities in a higher degree than any other form.” </p>
<p>Yes, Madison says, human beings are selfish, and one must not ignore that reality when one is deciding how to run a society. But people are not merely selfish. We are also capable of acting with honesty and integrity and of thinking for the good of the whole rather than merely ourselves. </p>
<p>More, Madison argued that this other side of human nature, this concern for others, had to be operative if democracy were to survive. In fact, he insisted that, more than any other form of government, a democracy depended on virtuous citizens. Speaking at the ratifying convention for the U.S. Constitution in his home state of Virginia, <a href="https://press-pubs.uchicago.edu/founders/documents/v1ch13s36.html">Madison said</a>: </p>
<p>“Is there no virtue among us? If there be not, we are in a wretched situation. No theoretical checks – no forms of government can render us secure. To suppose that any form of government will secure liberty or happiness without any virtue in the people, is a chimerical idea.” </p>
<h2>Mere selfishness is ‘un-American’</h2>
<p>Madison lived through the yellow fever epidemic of 1793. <a href="https://digitaldoorway.montpelier.org/2020/03/31/executive-power-in-an-epidemic/">He even advised</a> President George Washington about how he might address this health emergency. But there was no vaccine, nor even an understanding of what caused the epidemic.</p>
<p>While we don’t know what Madison would have said about a vaccine, we do know what <a href="https://www.presidency.ucsb.edu/documents/statement-the-president-the-polio-vaccine-situation">President Dwight D. Eisenhower said after the development of the polio vaccine</a>. Eisenhower’s words likewise affirm the idea that our democracy requires that we show concern for one another. </p>
<p>“We all hope that the dread disease of poliomyelitis can be eradicated from our society. With the combined efforts of all, the Salk vaccine will be made available for our children in a manner in keeping with our highest traditions of cooperative national action,” he said.</p>
<p>Because of Madison and the other founders, the United States is a free and democratic society. Within very broad limits, Americans all have the right to make their own decisions. In some cases, Americans may even have the right to ignore the impact of their decision on others. </p>
<p>But a free society demands more of its citizens than mere selfishness. Political institutions can help direct and mitigate the effects of this natural human inclination to selfishness. </p>
<p>Throughout history, America’s leaders have recognized that without concern for others, without the highest tradition of cooperative national action, democracy is in peril. People who decide not to get vaccinated must understand that their actions are not just selfish, they are un-American. </p>
<p>[<em>Understand what’s going on in Washington.</em> <a href="https://theconversation.com/us/newsletters/politics-weekly-74/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=politics-most">Sign up for The Conversation’s Politics Weekly</a>.]</p><img src="https://counter.theconversation.com/content/165564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Beem does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>America’s founders accepted the reality of human selfishness. But, they also said people were capable of thinking for the good of the whole, which is necessary for a free society.Christopher Beem, Managing Director of the McCourtney Institute of Democracy, Co-host of Democracy Works Podcast, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1647462021-08-05T19:25:52Z2021-08-05T19:25:52ZMandatory COVID-19 vaccination in schools this fall? Ontario’s 1982 legislation spurred organized opposition<iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/mandatory-covid-19-vaccination-in-schools-this-fall--ontario-s-1982-legislation-spurred-organized-opposition" width="100%" height="400"></iframe>
<p>As our minds turn to back-to-school, it is urgent <a href="https://www.ctvnews.ca/health/coronavirus/how-can-canada-avoid-a-fourth-wave-of-covid-19-doctors-weigh-in-1.5530730">to increase Canada’s COVID-19 vaccination rates</a> <a href="https://theconversation.com/how-to-increase-covid-19-vaccine-uptake-and-decrease-vaccine-hesitancy-in-young-people-161071">among young people</a>. </p>
<p>Currently <a href="https://covid-19.ontario.ca/data/covid-19-vaccinations-data">eligible children (12-17) and young people (18-29) have the lowest rate of vaccination</a> of any age group in Ontario: 49.2 per cent of 12- to 17-year-olds and 56.2 per cent of 18- to 29-year-olds have received two vaccinations.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://theconversation.com/ca/topics/vaccine-confidence-in-canada-107061">Click here for more articles in our series about vaccine confidence.</a></span>
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<p>Many universities have decided not to make vaccination <a href="https://theconversation.com/mandatory-covid-19-vaccines-on-university-campuses-an-obvious-solution-or-a-problem-164738">mandatory but to encourage it</a>. Ontario’s back-to-school plan for viral safety does not include mandating COVID-19 vaccines for eligible students <a href="https://www.cbc.ca/news/canada/toronto/ontario-back-to-school-covid-19-cases-outbreaks-1.6127752">and staff</a>, <a href="https://globalnews.ca/news/8083611/covid-ontario-school-guidance-reaction/">prompting criticism from some health experts</a>.</p>
<p>The experience with Ontario’s current compulsory school immunization for other diseases shows there are advantages and disadvantages of requiring vaccination. Mandating vaccines for school attendance may not be the best way to increase vaccination rates for COVID-19. </p>
<h2>Ontario’s 1982 legislation</h2>
<p>Ontario is one of only two provinces in Canada that requires students to have up-to-date vaccinations in order to attend school. The other is New Brunswick. </p>
<p><a href="https://www.ontario.ca/laws/statute/90i01">Ontario’s legislation</a> has been <a href="https://digitalcommons.osgoode.yorku.ca/cgi/viewcontent.cgi?article=1045&context=ontario_statutes">in place since 1982</a>, and currently requires that students be inoculated against <a href="https://www.wechu.org/your-health/immunization/immunization-requirements-school">nine diseases including mumps, measles, diphtheria and polio</a>. Children who are not vaccinated can be suspended from school for up to 20 days, and their parents can be forced to pay fines of up to $1,000.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A stop sign reading 'measles alert'." src="https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=604&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=604&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=604&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=759&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=759&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414656/original/file-20210804-13-g7e0u2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=759&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Disease outbreaks can occur where there are clusters of unvaccinated people. Here, a sign at a clinic in Vancouver, Wash., warns visitors of a measles outbreak in January 2019.</span>
<span class="attribution"><span class="source">AP Photo/Gillian Flaccus</span></span>
</figcaption>
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<p>There are exemptions for medical, religious and philosophical reasons. The total <a href="https://doi.org/10.9778/cmajo.20140088">number of exemptions is small</a> (1.8 per cent among seven-year-old students in 2012-13), although the number of exemptions for religious and conscientious reasons is rising. </p>
<p>Of even more concern is the fact that exemptions are <a href="https://www.toronto.ca/city-government/data-research-maps/research-reports/public-health-significant-reports/toronto-schools-immunization-coverage-rates/">geographically concentrated</a>. An epidemic could race through a school where many parents have sought exemptions.</p>
<p>Parents who chose to object for conscientious reasons are now required to attend a vaccine education session. The <em>National Post</em> reports that according to a survey it did of Ontario’s province 35 health units, <a href="https://nationalpost.com/news/ontarios-mandatory-class-for-parents-seeking-vaccine-exemptions-has-zero-conversions">this education is ineffective in changing parents’ minds</a>.</p>
<h2>Measles rates, U.S. example affected legislation</h2>
<p>A vaccine against the measles was <a href="https://doi.org/10.1093/clinids/5.3.445">first used</a> in Canada in 1964, and after that rates of the disease fell substantially. But measles infections fell even faster in the United States, where many states passed laws requiring vaccinations to attend school. </p>
<p><a href="https://www.cmaj.ca/content/126/2/123">By 1980, all U.S. states</a> required immunization for school attendance. In 1979, as rates in the U.S. continued to fall, Canada experienced a significant outbreak with over 20,000 infections across the country. But vaccine mandates were not the only reason why measles rates were falling more rapidly in the U.S. </p>
<p>Vaccination rates in Canada were fairly high. In some provinces, <a href="https://pubmed.ncbi.nlm.nih.gov/7059877">more than 90 per cent of children were immunized by the time they went to school</a>. But not all Canadian children were fully protected against the measles despite having received their shots. </p>
<p>In the early years of the measles vaccination program, a killed virus was often used, but this turned out to be less effective than the live virus. Also, physicians often administered half doses of the live vaccine to conserve the supply. The killed virus vaccine was only used in the U.S. for one year, but it was used in Canada for four years, particularly in Ontario and Alberta. </p>
<p>During the 1979 epidemic in Alberta, <a href="https://www.jstor.org/stable/4453054?seq=1#metadata_info_tab_contents">78 per cent of the students</a> infected with the measles had a documented history of being vaccinated against the disease. Despite this, public health officials in Canada looked at the American success at reducing measles and recommended similar measures be taken here. In 1981, the Canadian Paediatric Society <a href="https://www.upi.com/Archives/1981/09/17/Measles-could-be-stamped-out-in-Canada-if-every/6280369547200/">called for mandatory measles vaccinations</a>. </p>
<p>In 1982, three officials at the Department of National Health and Welfare in Ottawa published an article in the Canadian Medical Association Journal, saying that the U.S. experience showed that “<a href="https://pubmed.ncbi.nlm.nih.gov/7059877/">more can and must be done</a>.” They recommended that provinces enact compulsory measles vaccination programs. </p>
<h2>Did compulsory vaccination work?</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman holding a baby holds a placard reading 'Forced medical procedures equals violence against children.'" src="https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414653/original/file-20210804-13-cvsbbw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Protesters outside the Ontario Legislature in Toronto in 2019 supported a group that announced filing a constitutional challenge against the province’s vaccination law.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chris Young</span></span>
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</figure>
<p>There was a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1346155/?page=1">significant uptick in vaccination rates in Ontario schools</a> in the years following the introduction of the vaccine mandate. From 1983 to 1984, the number of vaccinated children in grades 1-6 increased from 92 per cent to 95 per cent. For high school students, the results were more dramatic. Vaccination rates increased from 53 per cent in 1983 to 87 per cent in 1984.</p>
<p>But vaccine compulsion also hardened opposition to vaccination. While there had been <a href="https://doi.org/10.3138/cbmh.9.2.159">anti-vaccine groups in Ontario</a> in the early decades of the 20th century, these groups had disappeared before the Second World War. </p>
<p>The passage of the 1982 legislation spurred the formation of the Committee Against Compulsory Vaccination, which lobbied for exemptions to be extended to people who objected to vaccination for reasons of conscience, not just religion. The legislation was amended accordingly in 1984. Anti-vaccination advocates have <a href="https://toronto.citynews.ca/2019/10/29/child-vaccination-rally-toronto">continued their fight against the legislation ever since</a>.</p>
<h2>Provincial comparisons</h2>
<p>Nor has the vaccine mandate resulted in elevated rates of vaccination in Ontario compared to provinces without vaccine mandates. According to the 2017 Childhood National Immunization Coverage Survey, <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/2017-vaccine-uptake-canadian-children-survey.html">two-year-old children in Alberta and Newfoundland</a> are significantly more likely to be fully vaccinated than Ontario children. New Brunswick, the other province with a vaccine requirement for school entry, is similar to the countrywide average. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A vial of MMR vaccine next to a box of vials." src="https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=694&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=694&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=694&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=872&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=872&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414660/original/file-20210804-23-8wgjln.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=872&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Ontario vaccination rates against measles, mumps and rubella are similar to national averages, but Ontario children are slightly more likely to be vaccinated against tetanus and pertussis.</span>
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</figure>
<p>The Childhood National Immunization Coverage Survey only provides countrywide data on the vaccination status of seven-year-olds. But data from Public Health Ontario suggests that <a href="https://www.publichealthontario.ca/-/media/documents/i/2020/immunization-coverage-2018-19.pdf?la=en&sc_lang=en&hash=3DA1B035CC80AFC2341F7AE6BD87041F">seven-year-olds in Ontario</a> are slightly more likely to be vaccinated than their peers in other provinces. </p>
<p>Ontario vaccination rates against measles, mumps and rubella are very similar to national averages, but Ontario children are slightly more likely to be vaccinated against tetanus (85.8 per cent compared to 80.5 per cent), and pertussis, popularly known as “whooping cough” (85.7 per cent compared to 80.5 per cent).</p>
<h2>Other ways of improving vaccination rates</h2>
<p><a href="https://www.cdhowe.org/public-policy-research/shot-arm-how-improve-vaccination-policy-canada">A 2015 report</a> by the C.D. Howe Institute argued that relatively few parents are actively opposed to vaccination. Instead, “barriers to access, complacency or procrastination” are more important. </p>
<p>The institute recommended adopting Ontario’s policy of forcing parents to make a deliberate choice about vaccinating their children along with elements of Alberta’s early intervention. Alberta makes extensive use of public health nurses at community health centres. </p>
<p>Public health nurses reach out to parents after their children are born to talk to them about health services, including immunization. If a child is not immunized by the time they reach two months of age, the nurse calls the parents or sends them a letter <a href="https://doi.org/10.1016/j.puhe.2021.02.034">to remind them</a>. Up to three calls are made to ensure vaccination. </p>
<p>While mandating vaccines for children in school holds the promise of increasing vaccination rates, for now, it seems prudent to increase access and education around vaccines to encourage uptake. </p>
<p><em>Do you have a question about COVID-19 vaccines? Email us at <a href="mailto:ca-vaccination@theconversation.com">ca‑vaccination@theconversation.com</a> and vaccine experts will answer questions in upcoming articles.</em></p><img src="https://counter.theconversation.com/content/164746/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Carstairs received funding from AMS Healthcare for this research.</span></em></p><p class="fine-print"><em><span>Curtis Fraser and Kathryn Hughes do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The effects of Ontario’s compulsory school immunization show there are advantages and disadvantages of requiring vaccination.Catherine Carstairs, Professor, Department of History, University of GuelphCurtis Fraser, MA student, History, University of GuelphKathryn Hughes, Research assistant, Department of History, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1621102021-07-06T15:00:16Z2021-07-06T15:00:16ZWhy Africa’s push to make vaccines should look further than COVID-19<figure><img src="https://images.theconversation.com/files/405100/original/file-20210608-130350-1ba9vr4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South African President Cyril Ramaphosa, Deputy president David Mabuza, Health Minister Dr Zweli Mkhize visiting the Aspen Pharmacare sterile manufacturing facility. </span> <span class="attribution"><span class="source">Lulama Zenzile/Die Burger/Gallo Images via Getty Images</span></span></figcaption></figure><p>It’s unlikely that vaccine manufacturing will offer Africa a quick fix for COVID-19. Countries on the continent are grappling with a diverse array of challenges. These include vaccine hesitancy, supply bottlenecks and a lack of operational funding and human resources to administer jabs. </p>
<p>Still, the political will to boost local manufacturing of vaccines is rising across the globe, including in Africa – and has never been this high.</p>
<p>The reason is simple. COVID-19 has shown that regions and countries take care of their own people first when crises hit. Africa wants to be able to do the same. To do so, the continent must seize new opportunities to fast-track the development of vaccine manufacturing capacity and to boost regulatory processes.</p>
<p>In 2020, about 40 African countries participated in a World Health Organisation (WHO) <a href="https://www.who.int/director-general/speeches/detail/director-general-s-opening-remarks-for-panel-is-africa-ready-to-finance-its-own-vaccine">training marathon</a> to build manufacturing capacity.
All 54 countries on the continent also supported Ethiopia’s recently passed resolution to the <a href="https://healthpolicy-watch.news/us-backs-trips-waiver-to-strip-vaccines-of-patent-protection-as-wha-pushes-local-vaccine-capacity/">74th World Health Assembly</a>, focused on strengthening local production of medicine and health technology. At the recent <a href="https://www.g20.org/the-global-health-summit-ended-with-the-signing-of-the-rome-declaration.html">G20 Global Health Summit</a>, the European Commission also announced a new initiative on manufacturing in Africa, backed by €1 billion. </p>
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Read more:
<a href="https://theconversation.com/trips-waiver-us-support-is-a-major-step-but-no-guarantee-of-covid-19-vaccine-equity-160638">TRIPS waiver: US support is a major step but no guarantee of COVID-19 vaccine equity</a>
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<p>That’s critical because manufacturing vaccine doesn’t come cheap. Success will depend heavily on support – in cash and in kind – from developed countries. It takes hundreds of millions of dollars to produce a <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30346-2/fulltext">new vaccine</a>. </p>
<p>There is hope for relaxation of <a href="https://theconversation.com/trips-waiver-us-support-is-a-major-step-but-no-guarantee-of-covid-19-vaccine-equity-160638">intellectual property rights</a>. These are necessary to open the way to local manufacturing of existing vaccines. </p>
<p>But the production process for new vaccines can take as long as five to 10 years. The typical vaccine roadmap begins with exploratory research, followed by pre-clinical and clinical safety and efficacy testing on animals and humans – and regulatory reviews and approvals for licensing. Only then can the manufacturing process begin.</p>
<p>This requires a significant body of skills. Local expertise in areas such as research and development, regulatory expertise and quality assurance must be strengthened too. </p>
<h2>Local manufacturing</h2>
<p>It will take several more years before countries are fully prepared to manufacture new vaccines to the scale of contributing significantly to global output. Therefore, governments should adopt a longer-term view that prioritises the most urgent health challenges in the region. This vision must be about manufacturing vaccine generally, rather than COVID-19 vaccines specifically.</p>
<p>Africa has <a href="https://www.nature.com/articles/d41586-021-01048-1">54 countries</a> and 1.2 billion people, but produces only 1% of all the vaccines it administers. The continent also faces a heavy burden of disease. Over <a href="https://www.who.int/news-room/fact-sheets/detail/malaria#:%7E:text=Disease%20burden&text=cases%20in%202018.-,The%20estimated%20number%20of%20malaria%20deaths%20stood%20at%20409%20000,all%20malaria%20cases%20and%20deaths">90%</a> of the world’s malaria deaths and <a href="https://www.afro.who.int/health-topics/hivaids">70%</a> of all people living with HIV are in Africa.</p>
<p>So far, the continent has only a few producers of vaccines. Statutes signed between the government of Senegal and the Institut Pasteur in <a href="https://www.avmi-africa.org/manufacturers/#1490181278853-496b3000-e3fc">2009</a> allowed the country to manufacture yellow fever vaccines. There are <a href="https://www.avmi-africa.org/manufacturers/#1490181277540-254a2bb0-9973">six other vaccine manufacturing institutes</a>. One is <a href="https://www.vacsera.com/">VACSERA </a>in Egypt, the oldest vaccine manufacturer in Africa. Egypt is slated to complete the production of <a href="https://egyptindependent.com/egypt-to-produce-40-million-doses-of-sinovac-vaccine-in-2021/">40 million</a> doses of China’s Sinovac COVID-19 vaccine domestically by the end of 2021. In South Africa, the pharmaceutical company<a href="https://www.aspenpharma.com/"> Aspen</a> will be manufacturing doses of the <a href="https://www.reuters.com/article/uk-health-coronavirus-safrica-johnson-jo-idUSKBN2BO5IA">Johnson & Johnson</a> COVID-19 vaccine under licence.</p>
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Read more:
<a href="https://theconversation.com/vaccine-production-in-south-africa-how-an-industry-in-its-infancy-can-be-developed-153204">Vaccine production in South Africa: how an industry in its infancy can be developed</a>
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<p>Most local companies engage only in packaging and labelling, and occasionally fill-and-finish steps. But it’s noteworthy that there are about <a href="https://www.afro.who.int/news/what-africas-vaccine-production-capacity">80 sterile injectables facilities</a> on the continent. These produce a broad range of fill-and-finish sterile solutions and emulsions including anaesthetics, eye drops and multi-drug resistant tuberculosis vaccines. Significant financial commitment would be required to transform them into fully integrated manufacturing facilities. But these operations have built solid track records with partners and suppliers that will benefit expansion plans.</p>
<h2>Integrating policies</h2>
<p>Africa’s segmented markets, and often small economies, are at odds with the fact that vaccines are mostly produced in large quantities to keep prices down. They require large markets for sustainability. Regulatory bodies that meet international standards are also lacking, presenting a further hurdle.</p>
<p>Integrating national and regional policies and strategies would in effect increase the size of the overall market. All countries could then benefit, regardless of the size of their economy.</p>
<p>More integration will drive agreement on the manufacturing of products in high demand in Africa. It will also expand market access, and help avoid costly duplication. But most importantly, it will help ensure sustainability because most African countries’ markets are too small to support their own manufacturing. </p>
<p>African countries must make better use of regional economic integration platforms such as the <a href="https://www.ecowas.int/">Economic Community of West African States</a>, the <a href="https://www.comesa.int/">Common Market for Eastern and Southern Africa</a>, and the new <a href="https://au.int/en/cfta">African Continental Free Trade Agreement</a>, all of which offer great opportunities. </p>
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Read more:
<a href="https://theconversation.com/africas-free-trade-area-offers-great-promise-but-only-if-risks-are-managed-with-resolve-161535">Africa's free trade area offers great promise. But only if risks are managed with resolve</a>
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<p>The <a href="https://www.un.org/africarenewal/magazine/november-december-2020/afcfta-africa-readying-free-trade-come-january-2021">African Continental Free Trade Area</a>, for example, aims to reduce all trade costs – it will eliminate 90% of tariffs – and enable Africa to integrate further into global supply chains. Cutting red tape and simplifying customs procedures will bring significant income gains. </p>
<p>Strong regulatory capacity and oversight is another building block for vaccine production and product safety. Countries must strengthen their regulatory systems to ensure that all medical products are of the highest quality, and that local manufacturers maintain international standards. This is why it’s critical for member states to urgently ratify the treaty to support the creation of the <a href="https://au.int/en/pressreleases/20200205/african-medicine-agency-ama-treaty">African Medicines Agency</a>. To date, <a href="https://au.int/en/pressreleases/20210507/republic-guinea-deposits-instrument-ratification-african-medicines-agency-ama">seven</a> of the required 15 African Union member states have ratified the treaty.</p>
<p>The World Health Organisation, where I am the regional advisor for vaccine research and regulation in the Africa region, works with member states and partners towards local vaccine manufacture.</p>
<p>In Ethiopia, for example, we are working closely with the Ministry of Health. We’re conducting a feasibility study in respect of the potential for high-standard manufacturing of vaccines. We’re also developing cost estimates for a road map to success.</p>
<p>Ethiopia, home to the second biggest population on the continent, had to pay a hefty US$707 million to procure routine vaccines between 2016 to 2020. That’s an enormous financial burden and sends a very clear message about the urgency for local manufacturing.</p>
<h2>Looking forward</h2>
<p>Africa is facing <a href="https://www.dw.com/en/coronavirus-digest-who-says-africa-urgently-needs-20-million-vaccine-doses/a-57695529">delays in accessing life-saving vaccines</a> for COVID-19. The continent may experience similar delays in the future. The continent faces significant and enduring <a href="https://www.hsph.harvard.edu/news/features/africa-cdc-head-is-driving-a-new-public-health-agenda-on-the-continent/#:%7E:text=March%2012%2C%202020%20%E2%80%93%20Africa%20faces,growing%20burden%20of%20chronic%20diseases">public health threats</a>, including measles, rotavirus, yellow fever and Ebola.</p>
<p>To manage these public health threats, Africa needs its own capacity for vaccine development and production so that it can immunise for childhood diseases and help control outbreaks of highly infectious diseases – including COVID-19.</p><img src="https://counter.theconversation.com/content/162110/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bartholomew Dicky Akanmori is Regional Adviser for Vaccine Research and Regulation in the WHO Regional Office for Africa. </span></em></p>Vaccine manufacturing doesn’t come cheap. It depends heavily on support from developed countries. It also requires much more than relaxing intellectual property rights and a desire for vaccine equity.Bartholomew Dicky Akanmori, Professor Emeritus of Immunology, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1616762021-06-01T19:03:45Z2021-06-01T19:03:45ZThe real challenge to COVID-19 vaccination rates isn’t hesitancy — it’s equal access for Māori and Pacific people<figure><img src="https://images.theconversation.com/files/403692/original/file-20210601-23-1a0mhzy.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5447%2C3637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Reports of potentially higher rates of <a href="https://www.rnz.co.nz/national/programmes/morningreport/audio/2018786055/maori-communities-rate-of-vaccine-hesitancy-alarmingly-high-peeni-henare">vaccine hesitancy</a> among <a href="https://www.rnz.co.nz/news/ldr/442341/whanganui-health-providers-grapple-with-covid-19-vaccine-hesitancy">Māori</a> and <a href="https://www.nzherald.co.nz/nz/covid-19-coronavirus-battle-to-spread-truth-about-vaccine-in-pacific-communities/YLTW4PBLYGCA7WIVP7GZH4PZJE/">Pacific</a> populations have seen the government target COVID-19 vaccine and information campaigns at those communities.</p>
<p>And there are excellent reasons for such a targeted approach, designed and delivered by Māori and Pacific leaders for Māori and Pacific people. More so, given <a href="https://www.hhrjournal.org/2020/06/the-waitangi-tribunals-wai-2575-report-implications-for-decolonizing-health-systems/">existing inequities</a> within the <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-019-1057-4">health-care system</a> that have fostered unequal health outcomes and <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.15309">distrust in health institutions</a> themselves.</p>
<p>But it is also important to confront the inference that Māori and Pacific people are more prone to believe COVID-19 vaccine conspiracy theories, and that this might be the most significant barrier to vaccination uptake.</p>
<p>Using data collected from a <a href="https://openaccess.wgtn.ac.nz/articles/journal_contribution/COVID-19_Vaccine_Hesitancy_and_Acceptance_in_a_Cohort_of_Diverse_New_Zealanders/14658885">diverse sample</a> of New Zealanders, we found no basis for this. When modelling accounts for the key factors we know are associated with vaccine hesitancy, such as education and age, ethnic differences are no longer statistically significant.</p>
<p>That is, differences in vaccine hesitancy rates for Māori and Pacific communities are explained by their younger age structure and lower educational attainment. Indeed, across all communities, these are the main factors associated with vaccine hesitancy.</p>
<p>These findings are, of course, fairly intuitive when we look at the <a href="https://www.tandfonline.com/doi/full/10.1080/1177083X.2021.1879181">successful leadership</a> from Māori and Pacific communities during the early pandemic response, including initiatives such as a <a href="https://www.nzherald.co.nz/nz/local-focus-covid-card-experiment-underway-in-ngongotaha/XBL4CSMBIQCNMIJQKNGSD6IKBY/">contact tracing card trial</a> and <a href="https://thespinoff.co.nz/society/10-05-2020/community-checkpoints-an-important-and-lawful-part-of-nzs-covid-response/">community checkpoints</a>.</p>
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<figcaption><span class="caption">A government campaign to encourage New Zealanders to get the Covid-19 vaccine is noticably Māori and Pacific focused.</span></figcaption>
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<h2>The risk of inequitable vaccination rates</h2>
<p>The real risk is that the intention to be vaccinated doesn’t translate into actual uptake. Early data on the COVID-19 vaccine rollout suggests <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-data-and-statistics/covid-19-vaccine-data">fewer Māori and Pacific people are fully immunised</a>. </p>
<p>This matters because these populations have a <a href="https://www.nzma.org.nz/journal-articles/estimated-inequities-in-covid-19-infection-fatality-rates-by-ethnicity-for-aotearoa-new-zealand">greater risk</a> of COVID-19 transmission, severe infection, ICU admission or even death. </p>
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Read more:
<a href="https://theconversation.com/a-year-after-new-zealands-first-covid-19-lockdown-discrimination-and-racism-are-on-the-rise-160858">A year after New Zealand's first COVID-19 lockdown, discrimination and racism are on the rise</a>
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<p>Despite the Ministry of Health’s <a href="https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-vaccines-archived/covid-19-getting-vaccine/covid-19-vaccine-rollout">phased rollout plan</a>, it seems some populations could be protected sooner than others due to the geographic and other barriers faced by Māori and Pacific people.</p>
<p>This mirrors known trends in health-care access in Aotearoa where services are <a href="https://researchcommons.waikato.ac.nz/bitstream/handle/10289/14271/Chapter%206%20Mixed%20methods%20NZPR-46_Whitehead-et-al_final.pdf?sequence=2&isAllowed=y">inequitably distributed</a>. Wealthier, healthier and whiter populations tend to have the best access to facilities and high-quality care. </p>
<h2>Time and distance are the real barriers</h2>
<p>Our analysis shows that offering vaccination at existing health facilities and pop-up sites <a href="https://www.nzma.org.nz/journal-articles/will-access-to-covid-19-vaccine-in-aotearoa-be-equitable-for-priority-populations-open-access">would be inequitable</a>. Māori, older people and poorer communities would be disproportionately affected by distance and travel times from where they live. </p>
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<a href="https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=534&fit=crop&dpr=1 754w, https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=534&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/403243/original/file-20210527-13-ph2i8x.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=534&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Estimated travel times to five types of potential COVID-19 vaccine delivery site.</span>
<span class="attribution"><span class="source">NZ Medical Journal</span>, <span class="license">Author provided</span></span>
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<p>Schools and GP clinics are clearly the most easily accessible sites. However, converting schools into vaccination centres might not be feasible. The best option could be combining effective outreach programs with vaccination centres run from GP clinics, Māori providers and Pacific health services.</p>
<p>While some will find ways to overcome access barriers, others won’t have the time, money or resources. These obstacles become mountains if people are already vaccine-hesitant — regardless of ethnicity. </p>
<p>If they postpone or forgo the vaccine altogether it will make existing inequities worse and challenge the overall COVID-19 elimination strategy, especially when borders open and the risk of community transmission increases. </p>
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Read more:
<a href="https://theconversation.com/vaccination-alone-will-not-provide-full-protection-when-borders-open-nz-will-still-be-managing-covid-19-158414">Vaccination alone will not provide full protection. When borders open, NZ will still be managing COVID-19</a>
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<h2>The threat of other infectious diseases</h2>
<p>We know many people have deferred routine health care during the pandemic, including <a href="https://www.rnz.co.nz/news/national/416113/fears-of-measles-resurgence-as-vaccinations-drop-away-in-lockdown">childhood immunisation</a> against other infectious diseases. This has happened against a backdrop of <a href="https://www.health.govt.nz/system/files/documents/publications/improving-new-zealands-childhood-immunisation-rates-sep19.pdf">already declining immunisation</a> rates among children in general, and among tamariki Māori and Pacific children in particular. </p>
<p>The result has been <a href="https://www.stuff.co.nz/national/health/300200870/just-20-per-cent-of-dhbs-meeting-vaccination-targets-nz-cant-afford-to-slip--expert">worsening coverage rates</a> in some regions with persistently low coverage anyway, as people <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.15551">stayed away</a> from primary health-care providers. </p>
<p>Closing the borders and restricting movement to stop COVID-19 transmission also reduced the spread of <a href="https://www.nature.com/articles/s41467-021-21157-9">other infectious diseases</a>. When these controls are lifted the risk of serious childhood disease outbreaks, such as measles and pertussis, will increase. </p>
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Read more:
<a href="https://theconversation.com/how-to-increase-covid-19-vaccine-uptake-and-decrease-vaccine-hesitancy-in-young-people-161071">How to increase COVID-19 vaccine uptake and decrease vaccine hesitancy in young people</a>
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<p>High childhood vaccination coverage must be prioritised to counter the vulnerability of Māori and Pacific communities to the immediate and long-term burdens of these diseases. </p>
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<h2>Avoiding a perfect storm</h2>
<p>This winter’s influenza immunisation campaign and the MMR (measles, mumps and rubella) catch-up program are particularly focused on young Māori and Pacific adults. The priority is to prevent further devastating <a href="https://www.nzma.org.nz/journal-articles/a-measles-epidemic-in-new-zealand-why-did-this-occur-and-how-can-we-prevent-it-occurring-again">outbreaks of measles</a>.</p>
<p>However, the resources <a href="https://www.stuff.co.nz/national/health/300266885/flu-vaccine-rollout-set-to-start-for-over-65s-rest-of-nz-to-wait-longer-than-usual?rm=a">currently prioritised</a> for the COVID-19 vaccine campaign inevitably affect other immunisation campaigns. </p>
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Read more:
<a href="https://theconversation.com/covid-vaccine-hesitancy-spell-out-the-personal-rather-than-collective-benefits-to-persuade-people-new-research-160824">COVID vaccine hesitancy: spell out the personal rather than collective benefits to persuade people — new research</a>
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<p>Communities across Aotearoa may soon face a perfect storm: fewer resources available to address low childhood immunisation rates, delayed influenza protection and MMR catch-ups, and the potential for the inequitable delivery of COVID-19 vaccines. </p>
<p>These factors, combined with increasing freedom of movement, are likely to result in infectious disease spread, particularly in Māori and Pacific communities. </p>
<p>For the health system to be adequately responsive, it should engage Māori and Pacific leadership in the governance, design and delivery of vaccination campaigns. It will require resourcing, monitoring and accountability to build adaptable solutions that ensure community aspirations are met.</p><img src="https://counter.theconversation.com/content/161676/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Age and education level are the main factors associated with vaccine hesitancy. While this affects Māori and Pacific communities, basic access to health care and information is more important.Jesse Whitehead, Postdoctoral Researcher, University of WaikatoKate C. Prickett, Director of the Roy McKenzie Centre for the Study of Families and Children, Te Herenga Waka — Victoria University of WellingtonPolly Atatoa Carr, Associate Professor, University of WaikatoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1593212021-05-10T20:00:34Z2021-05-10T20:00:34ZHow better conversations can help reduce vaccine hesitancy for COVID-19 and other shots<figure><img src="https://images.theconversation.com/files/399076/original/file-20210505-17-jjtl9o.jpg?ixlib=rb-1.1.0&rect=452%2C331%2C5854%2C4134&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Empathetically exploring the positive motivations of people who are vaccine hesitant may help improve acceptance for COVID-19 vaccines and others.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 250px; border: none; position: relative; z-index: 1;" src="https://narrations.ad-auris.com/widget/the-conversation-canada/final-how-better-conversations-can-help-reduce-vaccine-hesitancy-for-covid-19-and-other-shots" width="100%" height="400"></iframe>
<p>New parents have many decisions to make soon after their baby is born. One of them is about vaccination.</p>
<p>Between the cooing and crying, cards and bouquets, and yet another change of clothes, parents will be asked about inoculating their infant against childhood illnesses. Where once the answer would have been “yes” by default, the past few decades <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/2017-vaccine-uptake-canadian-children-survey.html">have seen more Canadian parents hesitate</a>. </p>
<h2>Vaccine hesitancy</h2>
<p>While vaccination remains the norm, for a range of reasons exhausted mothers and nervous fathers are saying “We’ll wait” or even “No” to vaccinations in maternity wards across the country. </p>
<p>In an era of patient-centrism and individual autonomy, the parents’ right to hesitate is accepted. But health-care professionals are often worried by both the individual risks and societal consequences of the choices that are being made. Life threatening and altering diseases <a href="https://doi.org/10.1503/cmaj.109-4812">like polio</a> <a href="https://www.canada.ca/en/public-health/services/diseases/measles/measles-in-canada.html">or measles</a> — once eradicated or marginalized by vaccines — are creeping back.</p>
<figure class="align-center ">
<img alt="An infant being vaccinated" src="https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">While vaccination remains the norm for babies and children, some parents have become more hesitant about vaccines.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Canadians’ attitudes towards COVID-19 vaccines suggest hesitancy and its societal consequences are not limited to the choices of newly minted parents. Recent surveys <a href="https://angusreid.org/canada-covid-vaccine-january/">in Canada</a>, <a href="https://doi.org/10.1038/s41591-020-1124-9">and globally</a>, show many of us are hesitant about vaccines that have been produced with such herculean effort and enormous cost. So many, in fact, that the immunization thresholds required to tame COVID-19 are under threat. </p>
<p>This hesitancy has been described <a href="https://doi.org/10.1016/j.vaccine.2015.04.036">in detail</a>, and linked to <a href="https://www.cnn.com/2021/02/15/politics/covid-vaccine-hesitant-partisan-split/index.html">people’s politics</a>, past <a href="https://www.thestar.com/opinion/contributors/2021/02/06/vaccine-hesitancy-in-the-black-community-is-deeply-rooted-in-a-history-of-racism-overcoming-that-lack-of-trust-will-be-a-tough-task.html">community traumas</a> and attitudes towards <a href="https://doi.apa.org/doiLanding?doi=10.1037%2Fhea0000586">science and industry</a>.</p>
<p>However, just what to do about it has been less clear. While most Canadians will say yes to COVID-19 vaccines, many of us also know a friend or a family member who is, at least for the moment, saying no. </p>
<p>Most of us know someone who mistrusts some element of the vaccine — from the speed of its production, to the intentions of its manufacturers or deliverers. Indeed, COVID-19 vaccine hesitancy is said to be on the rise, nudged upwards by the various <a href="https://doi.org/10.1136/bmj.n883">pauses, or stops, introduced by governments</a>. How, under these conditions, might we turn a “no” into a “maybe,” or even a “yes?” </p>
<h2>Motivational interviewing</h2>
<p>My research team at the University of Calgary’s School of Public Policy started our most recent work with just this question in mind. It turns out the answer was just a few provinces away in Québec, and took us back to newborns and their parents. </p>
<p>We have been working with Canadian federal and World Health Organization funding to support family doctors as they respond to the pandemic. To support better conversations about vaccine hesitancy, we met with Dr. Arnaud Gagneur, a hospital-based neo-natalogist in Sherbrooke. He and his colleagues are world leaders in improving dialogue around vaccination with new parents. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A family doctor in a face mask talking to a patient" src="https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Family doctors are well positioned to have productive conversations with patients about vaccination, including COVID-19 vaccination.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The technique they’ve been working with for more than a decade is called motivational interviewing and it has shown great success.</p>
<p>Described in <a href="https://doi.org/10.1016/j.vaccine.2019.03.076">academic journals</a> and <a href="https://www.nytimes.com/2021/01/31/opinion/change-someones-mind.html">media coverage</a>, a motivational interview is based on a seemingly simple idea: find a vaccine-hesitant person’s positive motivation. The art of accomplishing this lies in long and empathetic engagement with the person to get to the roots of their hesitancy. </p>
<p>Those roots will often be negatively expressed: “I don’t like the way it was made,” or “It’s a conspiracy, you know.” Under the principles of motivational interviewing, these roots are to be respected and acknowledged, regardless of how gnarled they might appear. Attempting to chop them off with arguments and facts will only encourage the person to <a href="http://doi.org/10.1001/jamapediatrics.2017.2219">sink deeper into their hesitancy</a>. Unless the person’s concerns are acknowledged as valid, facts are more likely to hinder than help. </p>
<p>The aim isn’t to chop off the negative, but rather to have the positive reveal itself. This takes conversation, close listening, empathy and above all, trust. Shifting out of the negative reason and into an expression of a positive aspiration is something that takes time, not argument. This, in motivational interviewing, is the key to moving from “I’m religiously opposed to the vaccine,” to helping someone understand that vaccination may allow them to attend worship again soon.</p>
<h2>Progress in primary care</h2>
<p>Our team was originally dismayed by this. Of course it worked for Dr. Gagneur and his team, but they have huge blocks of time to talk to new parents about their hesitancy. Neither all that time, nor the intensity of a recent birth, are common features of family medicine as practised in Canada. Could the principles of motivational interviewing be distilled into the short encounters of most primary care visits? </p>
<p>We were encouraged to seek an answer because family doctors have <a href="https://www.annfammed.org/content/18/4/349">the expertise</a> and <a href="https://doi.org/10.1136/bmj.m3898">the relationships</a> to deal with COVID-19 and its <a href="https://doi.org/10.1136/bmj.m3026">long-tailed consequences</a>. They have also been identified as <a href="https://www.milbank.org/2021/03/leveraging-trust-in-primary-care-to-promote-behavior-change-during-covid-19/">key players</a> in countering vaccine hesitancy. This is because they have the long-term relationships with patients who trust them, and the space to understand and validate the concerns those patients raise. </p>
<p>Where many people might struggle to find the positive motivation in a friend or family member’s hesitancy, a family doctor is better positioned to do so. With this in mind, our team has been working with doctors from across Canada to develop a pragmatic tool to help them navigate tricky conversations with people considering COVID-19 vaccines, or with parents making decisions about their children. </p>
<p>The tool will be web-based and stocked with helpful examples. Along with the family doctors who have been so generous with their time in developing the tool, we are hoping it will contribute to better conversations about vaccine hesitancy.</p><img src="https://counter.theconversation.com/content/159321/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Myles Leslie receives funding from SSHRC, and the WHO. </span></em></p>From maternity wards to primary care, Canadian researchers are looking to find the positive motivations of vaccine hesitant people, whether they are new parents or other adults.Myles Leslie, Associate Professor, School of Public Policy, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1557252021-02-23T10:15:00Z2021-02-23T10:15:00ZHow Roald Dahl became a passionate vaccine advocate<p><a href="https://www.sky.com/watch/to-olivia">To Olivia</a>, a new film on Sky Cinema, captures the year (1962) that author Roald Dahl’s daughter died of measles encephalitis. The death of seven-year-old Olivia nearly tore the family apart. This terrible story will be new to many people, but it’s not new to me. I first heard it 30 years ago from Dahl himself. </p>
<p>I was a junior doctor in Oxford and 74-year-old Dahl was my patient. He was hospitalised with a rare form of leukaemia, and every third night when I was on call, <a href="https://www.theguardian.com/books/2016/sep/12/roald-dahl-medical-pioneer-stroke-hydrocephalus-measles-vaccination">we would talk</a> late into the night. As the weeks went on and it became clear he was not going to recover, he became more thoughtful about his own life.</p>
<p><a href="https://www.liverpooluniversitypress.co.uk/books/id/40651/">He told me</a> about Olivia one evening as I sat by his bed. She caught measles during an outbreak at her school. Initially, it was just a mild illness.</p>
<p>“We thought she was over the worst of it,” Dahl explained. “One saw, you know, the usual sort of thing, the fever, the tiredness, the spots. We even teased her for her polka dots.” </p>
<p>The next day she deteriorated.</p>
<p>Dahl had a wan smile and his eyes began to well up. </p>
<p>“I was sitting on her bed showing her how to fashion little animals out of coloured pipe cleaners,” Dahl later wrote, “and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.”</p>
<p>Dahl asked Olivia if she was feeling all right.</p>
<p>“I feel all sleepy,” she said.</p>
<p>An hour later, she was unconscious. Twelve hours later, she was dead.</p>
<p>The doctors confirmed that the measles virus had entered Olivia’s brain to cause <a href="https://www.nhs.uk/conditions/encephalitis/">encephalitis</a> (inflammation). Dahl was distraught and spent years trying to understand how it had happened. Of all those who had measles, why had she suffered such a terrible outcome?</p>
<p>“I wanted to study it, to set up a careful investigation,” he told me. “I was prepared to get in touch with every parent of every child in this country who had had severe complications from measles.”</p>
<h2>Fanciful stories?</h2>
<p>At the time, I thought this sounded rather fanciful. He was, after all, a storyteller. And in our late-night chats he would often tell me barely believable tales, especially about medicine. He mentioned a neurosurgical device he had invented and his role in founding the Stroke Association. At times I wondered whether he was pulling my leg, or perhaps had become muddled with some of the drugs he was on. Years later, in researching my book <a href="https://www.liverpooluniversitypress.co.uk/books/id/40651/">Roald Dahl’s Marvellous Medicine</a>, I discovered it was all true, and more.</p>
<p>After Olivia’s death, Dahl had indeed contacted scientists in Britain and the US to discuss measles and its complications. He corresponded with them for years, sharing his theories, while they shared their data. He even started planning a national study, but once measles vaccines became available, he figured the problem would largely be erased.</p>
<p>And he was right; cases of measles decreased dramatically. But Dahl was horrified to learn that some parents chose not to vaccinate their children. He campaigned on the issue, contacting ministers and health officials in the 1980s. He wrote a letter, which was widely distributed, telling the story of Olivia and imploring parents to vaccinate their children. It is <a href="https://www.newsweek.com/read-roald-dahls-heartbreaking-letter-anti-vaxxers-after-his-daughter-died-1311258">still used today</a> when there are measles outbreaks. </p>
<p>Dahl understood parents’ concerns about very rare serious side-effects of the vaccine, but he explained that the chances of this were about a million to one. “The probability of a child choking to death on a chocolate bar is probably greater,” he said.</p>
<p>Measles vaccine uptake increased for decades but was set back in the 1990s by the publication in The Lancet of a <a href="https://www.bmj.com/content/342/bmj.c7452">fraudulent research paper</a> by Andrew Wakefield. This was jumped on by anti-vaxxers, who are passionately against immunisations, whatever the science says.</p>
<h2>Obvious benefits</h2>
<p>Were Dahl still alive today, he would have been fascinated by the rapid medical developments during the coronavirus pandemic, especially <a href="https://theconversation.com/how-are-covid-19-vaccines-made-an-expert-explains-155430">the vaccines</a>. I suspect he would also be encouraged by their uptake. </p>
<p>Despite the understandable hesitancy of some over the new vaccines, and the malignant attempts of the anti-vaxxers, the vast majority of people are getting the vaccine <a href="https://ig.ft.com/coronavirus-vaccine-tracker/?areas=gbr&areas=isr&areas=usa&areas=eue&cumulative=1&populationAdjusted=1">as soon as they can</a>. Unlike measles, where most people now rarely see a case, with COVID-19 the risks are up close and personal, and for most people, the benefits of vaccination are immediately obvious.</p><img src="https://counter.theconversation.com/content/155725/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tom Solomon receives funding from the UK MRC and NIHR, and is President of the Encephalitis Society. He tweets @RunningMadProf.</span></em></p>Roald Dahl’s daughter Olivia died of measles aged seven.Tom Solomon, Director of the National Institute for Health Research (NIHR) Health Protection Research Unit in Emerging and Zoonotic Infections, and Professor of Neurology, University of Liverpool, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1533072021-01-21T18:51:26Z2021-01-21T18:51:26Z4 of our greatest achievements in vaccine science (that led to COVID vaccines)<figure><img src="https://images.theconversation.com/files/379847/original/file-20210121-23-1ycuc99.jpg?ixlib=rb-1.1.0&rect=0%2C3%2C1022%2C430&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/vaccination-medical-banner-syringe-ampoules-coronavirus-1793844784">from www.shutterstock.com</a></span></figcaption></figure><p>All eyes are on COVID-19 vaccines, with Australia’s first expected to be approved for use shortly.</p>
<p>But their development in <a href="https://www.nature.com/articles/d41586-020-03626-1">record time, without compromising on safety</a>, wouldn’t have been possible without the development of other vaccines before them.</p>
<p>These existing vaccines are some of the greatest achievements of medical science, preventing the spread of infectious disease, saving <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4024226/">millions of lives</a> around the world <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402432/">each year</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1350108854193975296"}"></div></p>
<p>Here’s what we’ve learned from other vaccines over the past 200 years or so that allowed us to go from discovery of the virus we now know as SARS-CoV-2, to regulatory approval in some countries in less than a year.</p>
<h2>1. Smallpox</h2>
<p>Vaccination as we know it started over 200 years ago. <a href="https://www.cdc.gov/smallpox/history/history.html">Edward Jenner</a>, an English physician, noticed people exposed to cowpox virus, which caused only mild illness, were protected from the severe disease caused by smallpox. </p>
<p>Cowpox and smallpox are part of the <a href="https://www.cdc.gov/poxvirus/index.html">poxvirus family</a>. Both share characteristics the immune system recognises. By inoculating people with cowpox, Jenner produced cross-protection against smallpox infection. </p>
<p>With successive development of smallpox vaccines, in 1979 smallpox became the first human infectious disease <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4024226/#RSTB20130433C1">to be eradicated</a> by vaccination.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-short-history-of-vaccine-objection-vaccine-cults-and-conspiracy-theories-78842">A short history of vaccine objection, vaccine cults and conspiracy theories</a>
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</em>
</p>
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<h2>2. Polio</h2>
<p>Poliovirus is a highly infectious virus that spreads through close contact with infected people, particularly in areas with poor hygiene. Infection can lead to <a href="https://www.who.int/health-topics/poliomyelitis#tab=tab_1">paralysis</a>, typically affecting infants. </p>
<p>The first widely used polio vaccines were <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782271/">developed in the 1950s</a> using newly available methods, known as tissue culture, to grow the virus in the lab.</p>
<p>Tissue culture allowed researchers to grow and inactivate poliovirus, or grow a live form of the virus that was attenuated (or weakened), to form the basis of vaccines that could be given orally. These were distributed in the late 50s.</p>
<p>Researchers still use variants of these early tissue culture techniques to research and develop vaccines today.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1350310572198416390"}"></div></p>
<p>The success of mass vaccination in developed countries led to the launch of the <a href="http://polioeradication.org">Global Polio Eradication Initiative</a>. Poliovirus is now <a href="https://www.who.int/health-topics/poliomyelitis#tab=tab_1">close to global eradication</a> with only two countries (Afghanistan and Pakistan) reporting low numbers of new infections.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-ridding-the-world-of-polio-30200">Explainer: ridding the world of polio</a>
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</em>
</p>
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<h2>3. Measles</h2>
<p>The measles virus is <a href="https://www.clinicalkey.com.au/#!/content/playContent/1-s2.0-S0891552015000835?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0891552015000835%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F">highly contagious</a>, and <a href="https://www.health.gov.au/health-topics/measles">is spread by</a> through the air when someone coughs and sneezes, as well as via direct contact with fluid from a person’s coughs or sneezes.</p>
<p>Before the development of a measles vaccine <a href="https://www.cdc.gov/measles/about/history.html">in 1963</a>, measles was one of the most lethal infectious agents, causing an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/measles">2.6 million deaths</a> each year. </p>
<p>In Australia, the vaccine can be given with mumps, rubella and varicella (chickenpox) vaccines to give the <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/conditions/immunisation/vaccines/measles+mumps+rubella+and+varicella+mmrv+vaccine/measles+mumps+rubella+and+varicella+mmrv+vaccine">combination MMRV vaccine</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Measles virus illustration showing surface spikes" src="https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/379846/original/file-20210121-15-1y7rd13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Measles virus killed millions of people each year before there was a vaccine.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/measles-virus-3d-illustration-showing-structure-505972177">www.shutterstock.com</a></span>
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<p>Global action to <a href="https://www.who.int/news-room/fact-sheets/detail/measles">eliminate measles</a> via vaccination resulted in a <a href="https://www.who.int/news-room/fact-sheets/detail/measles">73% drop</a> in measles deaths worldwide between 2000 and 2018. </p>
<p>Despite this, global coverage of measles vaccines is not enough to prevent outbreaks. Deaths from measles <a href="https://www.who.int/news/item/05-12-2019-more-than-140-000-die-from-measles-as-cases-surge-worldwide">rose</a> from 140,000 in 2018 to <a href="https://www.who.int/news/item/12-11-2020-worldwide-measles-deaths-climb-50-from-2016-to-2019-claiming-over-207-500-lives-in-2019">207,500 in 2019</a>. </p>
<p>And in many countries, including Australia, <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-measles-outbreaks-2019.htm">measles outbreaks</a> continue to occur in areas where vaccination rates have fallen.</p>
<p>Engineered versions of the measles vaccine are now being developed to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5863094/">deliver</a> pieces of other viruses, including dengue and HIV, into the body to generate a protective immune response.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/measles-in-samoa-how-a-small-island-nation-found-itself-in-the-grips-of-an-outbreak-disaster-128467">Measles in Samoa: how a small island nation found itself in the grips of an outbreak disaster</a>
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<h2>4. Diphtheria, tetanus and pertussis (whooping cough)</h2>
<p><a href="https://www.who.int/immunization/diseases/diphtheria/en/">Diphtheria</a>, <a href="https://www.who.int/health-topics/tetanus/#tab=tab_1">tetanus</a> and <a href="https://www.who.int/health-topics/pertussis#tab=tab_1">pertussis</a> (or whooping cough) are three separate diseases all caused by different bacteria. </p>
<p>Inactivated toxins produced by these bacteria, and pieces of the bacteria that are safe and mount an effective immune response, have been used since the 1940s <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwidpb2ryJfuAhXJ73MBHc-BBAsQFjAAegQIBBAC&url=https%3A%2F%2Fwww.who.int%2Fvaccine_safety%2Finitiative%2Ftools%2FDTP_vaccine_rates_information_sheet.pdf&usg=AOvVaw1m0u6xouSYx21ALwaJj182">in combination</a> to vaccinate against all three diseases.</p>
<p>The diphtheria, tetanus and pertussis (DTP) vaccine was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068581/">the first</a> combination vaccine. In other words, it was the first vaccine to prevent against multiple diseases. Combination vaccines continue to provide benefits to immunisation schedules by reducing the number of injections required.</p>
<p>These DTP combination vaccines are part of the <a href="https://www.health.gov.au/health-topics/immunisation/immunisation-throughout-life/national-immunisation-program-schedule">Australian National Immunisation Program Schedule</a>, and further vaccines have since been added to the mix. </p>
<p>DTP vaccines can now be delivered as a single injection with <em>Haemophilus influenzae</em> type b and poliovirus vaccine. Other combination DTP-based vaccines are also available.</p>
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<strong>
Read more:
<a href="https://theconversation.com/vaccines-to-expect-when-youre-expecting-and-why-50587">Vaccines to expect when you're expecting, and why</a>
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<h2>Which brings us to COVID-19</h2>
<p>On January 10, 2020, <a href="https://www.bbc.com/news/science-environment-55565284">Chinese and Australian scientists</a> provided open access to the newly discovered <a href="https://virological.org/t/novel-2019-coronavirus-genome/319">genetic sequence</a> of the novel coronavirus we now know as SARS-CoV-2.</p>
<p>Australian scientist Eddie Holmes then <a href="https://twitter.com/edwardcholmes/status/1215802670176276482">tweeted</a> a link to the SARS-CoV-2 genome:</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1215802670176276482"}"></div></p>
<p>This simple act of open science kick-started vaccine development at a rapid pace. On December 2, less than a year later, the Pfizer vaccine became the <a href="https://www.nature.com/articles/d41586-020-03441-8">first</a> fully-tested COVID-19 vaccine to be approved for emergency use, in the UK.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/what-do-we-know-about-the-novavax-and-pfizer-covid-vaccines-that-australia-just-signed-up-for-149522">What do we know about the Novavax and Pfizer COVID vaccines that Australia just signed up for?</a>
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<h2>What’s next?</h2>
<p>Despite extensive efforts to develop vaccines, diseases such as malaria and tuberculosis still kill millions of people each year.</p>
<p>As we enter the next generation of vaccine design, we can look forward to trialling technologies such as mRNA vaccines, which clinical trials show to be successful against COVID-19, to <a href="https://www.nature.com/articles/nrd.2017.243">combat other diseases</a> of global importance.</p>
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<strong>
Read more:
<a href="https://theconversation.com/covid-19-isnt-the-only-infectious-disease-scientists-are-trying-to-find-a-vaccine-for-here-are-3-others-145271">COVID-19 isn't the only infectious disease scientists are trying to find a vaccine for. Here are 3 others</a>
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<img src="https://counter.theconversation.com/content/153307/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Taylor receives funding from The Australian National Health and Medical Research Council. </span></em></p>We’ve gone from a novel virus to several COVID-19 vaccines in less than a year. Here’s what we’ve learned from earlier vaccines to allow this to happen.Adam Taylor, Early Career Research Leader, Emerging Viruses, Inflammation and Therapeutics Group, Menzies Health Institute Queensland, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1477332020-12-02T13:28:00Z2020-12-02T13:28:00ZCicely was young, Black and enslaved – her death during an epidemic in 1714 has lessons that resonate in today’s pandemic<figure><img src="https://images.theconversation.com/files/369846/original/file-20201117-15-sppuek.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C1280%2C960&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over 1.4 million people have died from COVID-19 so far this year. How history memorializes them will reflect those we most value.</span> <span class="attribution"><span class="source">Author provided</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>What I believe to be the <a href="https://www.brown.edu/news/2020-03-23/acre">oldest surviving gravestone</a> for a Black person in the Americas memorializes an enslaved teenager named Cicely. </p>
<p>Cicely’s body is interred across from Harvard’s Johnston Gate in Cambridge, Massachusetts. She died in 1714 during a measles epidemic brought to the college by a student after the summer recess of 1713. Another tombstone in the same burial ground remembers Jane, an enslaved woman who died in 1741 during an outbreak of diphtheria, or “throat distemper.” </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An old grave marker sits in a grassy burial ground" src="https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368259/original/file-20201109-13-gw0emy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A grave marker for an enslaved woman named Jane uses the archaic ‘1740/1’ Julian calendar notation to denote her death in early 1741.</span>
<span class="attribution"><span class="source">Nicole Maskiell</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>When diseases struck in the Colonial era, many city residents fled to the safety of the country. Poor and enslaved people, like Jane and Cicely – the essential frontline workers of the time – stayed behind. </p>
<p>Why were Cicely and Jane memorialized when so many other enslaved people were not? The archival record doesn’t provide a clear answer, but the question of <a href="https://theconversation.com/will-there-be-a-monument-to-the-covid-19-pandemic-146827">who should be remembered</a> with monuments and commemorations is timely. </p>
<p>Throughout the United States, as COVID-19 affects frontline workers and communities of color <a href="https://www.epi.org/publication/black-workers-covid">far more than other demographic groups</a>, and protesters agitate for racial justice, American society is wrestling with its racial memory and judging <a href="https://abcnews.go.com/US/historians-debate-americas-sordid-history-racism-confederate-monuments/story?id=71486827">which monuments and memorials</a> deserve a place. </p>
<p>Against this backdrop, I believe it’s important to look back at how a few marginalized and oppressed people who served on the front lines of prior epidemics have been treated and remembered. After all, those whom society chooses to memorialize reflect what accomplishments – honorable or horrific – <a href="https://www.gothamcenter.org/blog/monuments-roundtable-stuyvesant-and-hudson">society values</a>.</p>
<h2>Unsung sacrifices</h2>
<p>The lives, labor and sacrifices of women and girls of color have been overlooked for centuries. Of the 3.5 million books in Widener Library – the <a href="https://gsas.harvard.edu/student-life/harvard-resources/libraries">centerpiece of Harvard’s vast library</a> system – I found that not one was devoted to Cicely or Jane, and few focus on women like them. </p>
<p>For early-American <a href="https://www.nicolemaskiell.com">historians of Northern slavery like me</a>, such fragmentary and untold stories are both intriguing and challenging. But this particular story was also personal, because when I first stumbled on Cicely’s tombstone, I was also a Black teen. </p>
<p>I was a sophomore studying history at Harvard when I came upon the headstone while wandering in the Colonial-era graveyard adjacent to campus. It had a carving of a <a href="https://www.boston.gov/departments/parks-and-recreation/iconography-gravestones-burying-grounds">death’s head</a> on top and winding vines down the sides. It was both ordinary and extraordinary – it looked like other tombstones in the graveyard, but this one memorialized a young Black girl.</p>
<p>I wondered about Cicely. She most likely did domestic work in and around Harvard, as <a href="https://www.colonialsociety.org/node/2055">her enslaver</a> was a Cambridge minister and a tutor at the college. But what else did she do during her short life, and why did her enslavers memorialize her with a tombstone? These questions and the mystery of her life inspired me to become a historian. Over the years, I have been passionate about piecing together fragments of her and Jane’s lives. </p>
<p>Jane’s enslaver kept <a href="https://hollisarchives.lib.harvard.edu/repositories/4/resources/4254/collection_organization">a diary</a> that provided some details about her life, but I found little written about Cicely beyond her <a href="https://play.google.com/books/reader?id=Iufi5eVXCGoC&hl=en&pg=GBS.PA134">adult baptismal record</a>, dated just two months before her death.</p>
<h2>Racial unrest and disease</h2>
<p>Cicely lived and died during a time of racial unrest and disease. A slave revolt in 1712 in New York City led to several brutal <a href="https://www.gilderlehrman.org/sites/default/files/inline-pdfs/AppenC.pdf">executions and deportations</a>. News of the revolt spread throughout the Colonies, stoking concerns of a wider uprising. <a href="https://infoweb.newsbank.com/apps/readex/openurl?ctx_ver=z39.88-2004&rft_id=info%3Asid%2Finfoweb.newsbank.com&svc_dat=EANX&req_dat=0D0CB4F0E6B93180&rft_val_format=info%3Aofi%2Ffmt%3Akev%3Amtx%3Actx&rft_dat=document_id%3Aimage%252Fv2%253A1036CD221971FE08%2540EANX-1056625160187997%25402346459-1056625196BEC5B4%25401-10566251F0040E27%2540New-York%25252C%252BApril%252B7th%2Fhlterms%3A">Colonists armed themselves</a> in fear. </p>
<p>Slavery existed in every Colony, including the North. At the time of the revolt, the Northern Colonies – from Nova Scotia down to Delaware – were home to around <a href="https://www2.census.gov/library/publications/1960/compendia/hist_stats_colonial-1957/hist_stats_colonial-1957-chZ.pdf">9,000 enslaved people</a>, representing a third of the enslaved population of the British mainland colonies. New York City had 5,841 residents, of which 975 were <a href="https://babel.hathitrust.org/cgi/pt?id=umn.31951000005142w&view=1up&seq=203&size=125">held as slaves</a>. Boston had roughly <a href="https://www2.census.gov/prod2/statcomp/documents/CT1970p2-13.pdf">400 enslaved people</a>.</p>
<p>Racial unrest was quickly followed by contagion. A measles outbreak the next year followed the same path up the coast as news of the revolt had traveled. </p>
<p>The <a href="https://www.google.com/url?q=https://www.usdeadlyevents.com/1713-oct-1714-measles-epidemic-boston-ma-also-ct-ri-ny-nj-nh-pa-109/&sa=D&source=hangouts&ust=1604992342010000&usg=AFQjCNFwXheWqyP12QgBg_xB8iGm91rKqg">epidemic</a> started in Newport, Rhode Island, in the summer of 1713 and hit Cambridge, Massachusetts, that September. It broke out at Harvard before spreading to Boston. More than 400 Bostonians died – about <a href="https://docs.newsbank.com/s/HistArchive/ahnpdoc/EANX/105662B6683AE209/0D0CB61A15FF3EC0">18% of them people of color</a> – at a time when <a href="https://www.jstor.org/stable/3491467">Black people</a> were only <a href="https://www.census.gov/history/pdf/colonialbostonpops.pdf">4% of the total population</a>.</p>
<p>Racial discord and disease continued throughout the Colonial period. Between Cicely and Jane’s deaths in 1714 and 1741, a smallpox crisis gripped Boston, <a href="https://www.wgbh.org/news/2016/07/03/local-news/slave-who-transformed-cotton-mather-witch-hunter-science-innovator">inflaming racial tensions</a>. An enslaved person named Onesimus helped introduce <a href="https://www.nlm.nih.gov/exhibition/smallpox/sp_variolation.html">an early form of inoculation called “variolation.”</a> This technique was practiced on both white and Black Bostonians, to the consternation of many. On its heels, a five-year diphtheria outbreak ravaged New England, <a href="https://www.newenglandhistoricalsociety.com/great-throat-distemper-1735">killing 5,000 people</a>, including Jane. </p>
<h2>History repeats</h2>
<p>Much like today, Colonists received mixed messages during disease outbreaks, with some leaders touting the <a href="http://resource.nlm.nih.gov/2546057R">value of inoculations</a> while others <a href="http://sitn.hms.harvard.edu/flash/special-edition-on-infectious-disease/2014/the-fight-over-inoculation-during-the-1721-boston-smallpox-epidemic">stood fast against them</a>. As Jane toiled in the shadow of Harvard in 1740, the male landowners of Cambridge held a contentious election that saw <a href="https://docs.newsbank.com/s/HistArchive/ahnpdoc/EANX/1056660DD83DF255/0D0CB61A15FF3EC0">very high voter turnout</a> amid a diphtheria epidemic.</p>
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<p>History can show us how diseases disproportionately harm vulnerable and marginalized populations; how discord and strife lead to racial antipathy; and how epidemics are managed and mismanaged. </p>
<p>Cicely’s and Jane’s lives mattered outside of the value they provided to their enslavers. In a time of disease and racial unrest that echoes the experiences of generations past, the lives of oppressed people like Cicely and Jane are worthy of remembrance.</p><img src="https://counter.theconversation.com/content/147733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole S. Maskiell does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>US monuments and memorials have overlooked frontline workers and people of color affected by past epidemics. Will we repeat history?Nicole S. Maskiell, Assistant Professor of History Peter and Bonnie McCausland Fellow of History, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.