tag:theconversation.com,2011:/us/topics/rubella-6404/articlesRubella – The Conversation2019-08-30T11:36:08Ztag:theconversation.com,2011:article/1226882019-08-30T11:36:08Z2019-08-30T11:36:08ZMeasles epidemic: parents reluctant to vaccinate their children need to hear of the horrors of forgotten diseases<figure><img src="https://images.theconversation.com/files/290185/original/file-20190829-106508-36u29k.jpg?ixlib=rb-1.1.0&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/hand-holding-syringe-vaccine-616263095?src=-1-13">Billion Photos/Shutterstock</a></span></figcaption></figure><p>There’s been a surge in measles cases across Europe, putting people’s lives at risk according to new findings from the <a href="http://www.euro.who.int/en/media-centre/sections/press-releases/2019/european-region-loses-ground-in-effort-to-eliminate-measles">World Health Organization</a>. </p>
<p>The official figures show that approximately 90,000 cases have been reported for the first half of 2019. This is already more than the number of cases recorded for the whole of 2018 (84,462). </p>
<p>This has in part been put down to disinformation about the MMR (measles, mumps and rubella) vaccine on social media <a href="https://www.pathologyinpractice.com/story/27090/measles-the-importance-of-vaccination-disease-monitoring-and-surveillance">putting parents off vaccinating </a>their children.</p>
<p>Recent outbreaks of measles, which is much more infectious than mumps and rubella, have been widely <a href="https://www.independent.co.uk/topic/measles">reported</a>. But what is less well known is that there have been a few babies born with congenital rubella syndrome in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954604/">the UK in the past few years</a>. This is an illness resulting from an infection of the rubella virus during pregnancy.</p>
<h2>Rubella babies</h2>
<p>People under the age of 50 are unlikely to have heard about “Rubella babies”, but in the 1940s, the Australian paediatric ophthalmologist, Norman Gregg, made <a href="https://sydney.edu.au/medicine/museum/mwmuseum/index.php/Gregg,_Sir_Norman_McAlister">the connection</a> between women being infected with German measles (rubella) during pregnancy and their children being born deaf and blind and sometimes with other disabilities.</p>
<p>Many babies infected with the virus while in the womb do not survive, but in the 1960s in the UK about 300 children each year were born with “congenital rubella syndrome” and needed care. By 1970, a safe effective Rubella vaccine was available and the UK began <a href="https://academic.oup.com/cid/article/7/Supplement_1/S11/398615">vaccinating school girls</a>. A screening programme, which involved testing blood samples from women of childbearing age to see whether they had previous immunity to the virus, also began. Those who did not did not have protection were offered the vaccine.</p>
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<a href="https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290190/original/file-20190829-106480-1a59rmq.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">Rubella is a viral illness that causes a mild fever and a skin rash.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/treatment-rubella-viral-infection-concept-girls-1056168554?src=-1-0">OneSideProFoto/Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/measles-should-vaccinations-be-compulsory-114481">Measles: should vaccinations be compulsory?</a>
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<p>Although women starting in particular jobs – such as health care and teaching – were screened, most of the tests were done on pregnant women as part of their 12 week check. In 1988, the Rubella vaccine become the R in the MMR and the strategy changed to vaccinating <a href="https://www.nhs.uk/conditions/vaccinations/mmr-vaccine/">all pre-school children</a>.</p>
<p>The idea was that if all young children were protected, then these infections would eventually not be circulating at all. During 2016 and 2017, routine screening for Rubella antibodies during pregnancy was phased out across the UK. It was considered not cost-effective, since Rubella infection during pregnancy was extremely rare and most people in the UK of child bearing age should have received MMR as children. But the recent outbreaks of measles across the world have illustrated the <a href="https://www.pathologyinpractice.com/story/27090/measles-the-importance-of-vaccination-disease-monitoring-and-surveillance">problems with MMR uptake</a>.</p>
<h2>Misinformation and memory</h2>
<p>Why are people reluctant to have screening tests and vaccinations to prevent diseases? While some of the reasons may include loss of trust in “experts” and people in authority, I wonder if it is also partly because the stories of such diseases have been long forgotten. </p>
<p>When Eva Peron, the First Lady of Argentina, died from cervical cancer at the <a href="https://www.biography.com/political-figure/eva-peron">age of 33 in 1952</a>, for example, early diagnosis was not possible – and chemotherapy treatment was in its infancy. So for women who developed this disease, a distressing illness and painful death were more or less inevitable. </p>
<p>The design of a laboratory method for detecting early changes in the appearance of cells in the cervical region – the “Pap smear” – eventually made regular mass screening possible. Since the introduction of the scheme into the UK in 1988, it has prevented thousands of <a href="https://www.sciencedirect.com/science/article/pii/S0140673604166749">premature deaths in women each year</a>.</p>
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<a href="https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290186/original/file-20190829-106504-1p0ujjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&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">‘Vaccinating the poor of New York City against smallpox in 1872’. In 1863, mass production of smallpox vaccine was developed, allowing for broad immunisation of North American and European populations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/vaccinating-poor-new-york-city-against-242820433?src=-1-2">Everett Historical/Shutterstock</a></span>
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<p>The discovery that most but, crucially, not all cases of cervical cancer are attributable to Human Papillomavirus (HPV) infection led to the development of the HPV vaccine which is now given routinely to <a href="https://www.who.int/immunization/diseases/hpv/en/">teenage girls</a> – and in some countries boys as well. Evidence from the UK programme, which began in 2009, suggests the vaccine is very effective and this should help to further reduce the number of women with cervical cancer among the under 30s. </p>
<p>Yet despite all that’s known about cervical cancer and the importance of going for a regular smear test, many women still appear to be reluctant to go. It’s estimated that about <a href="https://www.bbc.co.uk/news/uk-england-45593583">three million women</a> across England have not had a smear test for at least three-and-a-half years.</p>
<p>In the 20th-century, there were major advances in disease prevention, which improved both life expectancy and quality of life. But it seems these health and societal developments are now being overlooked. Indeed, giving people information and instructions is no longer working. So perhaps it’s time to appeal to people’s hearts by telling the stories of these diseases – and how they have affected real people. </p>
<p><a href="https://www.who.int/bulletin/volumes/87/8/09-069559/en/">Gruesome photos on cigarette packages</a>, for example, massively help to reduce tobacco use, so maybe something similar now needs to happen in terms of vaccinations to tackle the latest epidemic and anti-vaxxer campaigns around the world.</p><img src="https://counter.theconversation.com/content/122688/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Pitt 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>It’s not just measles you need to worry about.Sarah Pitt, Principal Lecturer, Microbiology and Biomedical Science Practice, University of BrightonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1060562018-11-01T19:08:04Z2018-11-01T19:08:04ZAustralia has eliminated rubella – but that doesn’t mean it can’t come back<figure><img src="https://images.theconversation.com/files/243427/original/file-20181101-83651-ejosib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rubella has been eliminated in Australia, but it still exists in other countries.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>The World Health Organisation (WHO) has <a href="http://www.who.int/westernpacific/news/detail/31-10-2018-singapore-wipes-out-measles-australia-brunei-darussalam-and-macao-sar-%28china%29-eliminate-rubella">officially declared</a> that Australia has eliminated rubella.</p>
<p>Rubella, also known as German measles, is a contagious viral disease. The <a href="http://www.who.int/en/news-room/fact-sheets/detail/rubella">symptoms in children</a> are generally mild – fever, rash and sore throat – but infection during pregnancy can be devastating for unborn babies. </p>
<p>Infection in the first trimester of pregnancy results in an <a href="https://www.sciencedirect.com/science/article/pii/S1744165X07000182">80% chance of miscarriage or birth defects</a>, known as congenital rubella syndrome (CRS), in the developing fetus. </p>
<p>Babies born with CRS can experience deafness, blindness, cataracts, intellectual disabilities and heart defects.</p>
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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>An Australian discovery</h2>
<p>In the 1940s, Australian ophthalmologist <a href="http://adb.anu.edu.au/biography/gregg-sir-norman-mcalister-10362">Sir Norman McAlister Gregg</a> was the first to describe the connection between rubella infection in mothers, and cataracts and other birth defects in babies. </p>
<p>This led to <a href="https://www.historyofvaccines.org/content/articles/rubella">development of the rubella vaccine</a> in the 1960s and the exciting possibility of eliminating the disease.</p>
<p>Before the rollout of rubella vaccination, large outbreaks were recorded. <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi40suppl.htm#append">In 1963-64</a> there were more than 3,000 documented cases of rubella. </p>
<p>Our first vaccination program, <a href="http://www.ncirs.edu.au/assets/provider_resources/history/Measles-mumps-rubella-history-March-2016.pdf">introduced in 1971</a>, only targeted schoolgirls, with the aim of preventing infection during pregnancy and the subsequent risk of CRS. </p>
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<h2>Sign up for the newsletter</h2>
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<p>But because most infections occurred during childhood and males were not vaccinated, the rubella virus continued to circulate, causing outbreaks. By the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-1999-cdi2308-cdi2308a.htm">early 1990s</a> there were still an average of 4,000 cases a year.</p>
<h2>Achieving rubella elimination</h2>
<p>Elimination <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/su48a7.htm">is defined</a> as “reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area”. This means there can be no ongoing (also known as endemic) circulation of the virus in that area.</p>
<p>Australia was verified as having <a href="https://www.sciencedirect.com/science/article/pii/S2210600615300903">eliminated measles</a> in 2014. We were able to “piggyback” our rubella elimination efforts onto those for measles by switching from the schoolgirl rubella program to a single-dose childhood measles-mumps-rubella vaccine (MMR) vaccine for both 12-month-old girls and boys in 1989. </p>
<p>From 1993, a second dose was added to capture those who missed the first dose or who weren’t fully protected.</p>
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<img alt="" src="https://images.theconversation.com/files/243428/original/file-20181101-83657-ophqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/243428/original/file-20181101-83657-ophqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/243428/original/file-20181101-83657-ophqm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/243428/original/file-20181101-83657-ophqm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/243428/original/file-20181101-83657-ophqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/243428/original/file-20181101-83657-ophqm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/243428/original/file-20181101-83657-ophqm.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">
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<span class="caption">Rubella symptoms are often mild in children, but if contracted during pregnancy, can be very dangerous for the unborn baby.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>Australia made a concerted effort to boost its MMR vaccine coverage by conducting a <a href="http://www.who.int/bulletin/archives/79(9)882.pdf">mass school-based vaccination campaign</a> in 1998. </p>
<p>Since then, coverage has continued to climb, with more than 94% of infants now vaccinated with MMR. A recent study estimated that <a href="https://www.sciencedirect.com/science/article/pii/S0264410X1830464X">about 92%</a> of one- to 49-year-olds were immune to rubella.</p>
<p>The impact has been clear: in 2012-17 there were <a href="http://www9.health.gov.au/cda/source/cda-index.cfm">only four cases</a> of CRS and fewer than 40 cases of rubella reported each year. This is a far cry from the thousands reported in the pre-vaccination era.</p>
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Read more:
<a href="https://theconversation.com/want-to-boost-vaccination-dont-punish-parents-build-their-trust-40094">Want to boost vaccination? Don't punish parents, build their trust</a>
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<h2>Verification of Australia’s rubella elimination status</h2>
<p>As was required for <a href="https://www.sciencedirect.com/science/article/pii/S2210600615300903">measles</a>, Australia had to submit a detailed report to the World Health Organisation, providing evidence that rubella had been eliminated. This included proof that most of the population is immune to rubella and that vaccine coverage is high. Showing low numbers of rubella and CRS cases was also important. </p>
<p>This evidence is backed up by a surveillance system that is sensitive enough to pick up and respond to cases when they occur and to test whether the rubella virus strain was circulating locally or imported from overseas. In the past three years, the cases of rubella identified were strains from overseas, rather than from a virus spreading within in Australia.</p>
<h2>Elimination doesn’t mean eradication</h2>
<p>Eradication only occurs when all countries in the world have achieved elimination of a disease. The only human disease to have been eradicated is <a href="http://www.who.int/features/2010/smallpox/en/">smallpox</a> in 1979. </p>
<p>The Americas region, and <a href="http://www.who.int/westernpacific/news/detail/31-10-2018-singapore-wipes-out-measles-australia-brunei-darussalam-and-macao-sar-%28china%29-eliminate-rubella">five countries within our region</a>, have been verified as eliminating rubella and CRS. But it remains prevalent in many countries.</p>
<p>Not all countries have introduced rubella vaccination. As of December 2016, <a href="http://www.who.int/en/news-room/fact-sheets/detail/rubella">just 152 of 194</a> countries had introduced vaccination. </p>
<p>Even in some countries with vaccination programs, coverage is so low that large outbreaks are still occurring. In Japan, <a href="https://www.precisionvaccinations.com/cdc-level-2-practice-enhanced-precautions-travel-alert-issued-japan">more than 1,100 cases</a> have been reported this year.</p>
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Read more:
<a href="https://theconversation.com/want-to-boost-vaccination-dont-punish-parents-build-their-trust-40094">Want to boost vaccination? Don't punish parents, build their trust</a>
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<h2>No room for complacency</h2>
<p>We need to maintain high coverage with our routine vaccination programs to ensure elimination is sustained, as rubella is still likely to be imported from other countries.</p>
<p>Travellers should have had two MMR vaccinations before going overseas. And every effort must be made to ensure new arrivals in Australia <a href="https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/rubella">are up to date with their vaccinations</a>, especially women of child-bearing age. </p>
<p>Finally, to eradicate rubella we need to support other countries in our region, and globally, to strengthen their control efforts.</p><img src="https://counter.theconversation.com/content/106056/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heather Gidding receives funding from The National Health and Medical Research Council (NHMRC). </span></em></p><p class="fine-print"><em><span>Kristine Macartney is the Director of the National Centre for Immunisation Research and Surveillance (NCIRS) which receives funding from the Australian and NSW Governments. She also receives funding from the NHMRC.</span></em></p><p class="fine-print"><em><span>Aditi Dey 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>Thanks to successful vaccination programs, Australia has just been declared free of rubella. Continued vigilance is important to make sure it doesn’t come back.Heather Gidding, Associate Professor, University of SydneyAditi Dey, Manager, Coverage, Evaluation & Surveillance, NCIRS; Conjoint Senior lecturer, Discipline of Paediatrics and Child Health, University of SydneyKristine Macartney, Professor, Discipline of Paediatrics and Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/749582017-04-19T22:34:51Z2017-04-19T22:34:51ZWhy your child still needs vaccines, even if you may not know someone with the disease<figure><img src="https://images.theconversation.com/files/163924/original/image-20170404-5736-dgqnb8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sleeping Beauty's castle at Disneyland, where a measles outbreak in 2015 led to children being sickened in several states. </span> <span class="attribution"><span class="source">Jae C. Hong/AP</span></span></figcaption></figure><p>At the turn of the 21st century, the Centers for Disease Control and Prevention published an article about the 10 greatest public health achievements <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm">over the past 100 years, from 1900-1999</a>. One of them was vaccination, which likely has saved millions of lives over the past 100 years. </p>
<p>Yet, in more recent years, some parents of infants and children have questioned the necessity and safety of vaccines. Grossly inaccurate information that wrongly linked vaccination to autism was a key factor. That claim has now been thoroughly <a href="https://www.cdc.gov/vaccinesafety/vaccines/mmr/mmr-studies.html">debunked</a> by countless high-level studies, but there is still skepticism about vaccination.</p>
<p>In addition to misinformation about safety, vaccination today faces questions from a new corner. Some parents have begun to question whether children still need vaccination for diseases that many of us never even see. </p>
<p>This reasoning is inaccurate and can be dangerous. The viral and bacterial pathogens that cause these diseases still exist. Only one disease – smallpox – has ever been eliminated from Earth.</p>
<p>Bottom line: We have vaccines that have prevented misery in millions of children. Vaccination not only works; it is a godsend. Why is there resistance to these? As a professor of pharmacy who specializes in pediatrics, I will try to explain. </p>
<h2>When things get good, we forget when things were bad</h2>
<p>Ironically, vaccines have been the victim of their own success. </p>
<p>When was the last time that you met or heard of someone in the United States with polio? Diphtheria? Rubella? Likely, never. However, morbidity statistics indicate that in the 20th century, each year in the United States, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm">more than 16,000</a> were ill from polio, more than 21,000 were ill from diphtheria and more than 47,000 were ill from rubella. </p>
<p>In 2015, 0 cases of polio (a 100 percent reduction), 0 cases of diphtheria (a 100 percent reduction) and 10 cases of rubella (a more than 99 percent reduction) <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm">were reported</a> in the U.S. These dramatic differences are a testament to the <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6552md.htm">effectiveness and importance of vaccines in improving public health.</a></p>
<p>Many of the diseases listed in the <a href="https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html">2017 pediatric immunization schedule</a> have not been so dramatically reduced, however. In 2012, <a href="https://www.cdc.gov/pertussis/downloads/pertuss-surv-report-2012.pdf">48,277 cases of pertussis</a> (whooping cough) were reported in the U.S., resulting in 20 deaths, with 18 of these deaths occurring in infants and children. In 2014-2015, <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6552md.htm">855 cases of measles</a>
were reported. </p>
<p>A decline in the number of cases of a disease does not mean that the diseases do not exist, as shown by the measles outbreak and others. </p>
<h2>Vaccine skepticism gets a presidential booster shot</h2>
<p>What should be a settled scientific matter – that vaccines prevent disease and that they do not cause autism – still arises from time to time as a contentious, emotional issue. Nonscientists are usually the ones fueling the confusion.</p>
<p>President Trump has stated repeatedly that he thinks there <a href="https://www.washingtonpost.com/politics/trump-to-meet-with-proponent-of-debunked-tie-between-vaccines-and-autism/2017/01/10/4a5d03c0-d752-11e6-9f9f-5cdb4b7f8dd7_story.html?utm_term=.5e3ca08ec5d8">could be a link</a> between vaccines and autism. </p>
<p>Trump even hosted perhaps the most vocal critic of vaccines, whose controversial study that falsely claimed a link between vaccines and autism was later retracted – at an <a href="https://www.statnews.com/2017/01/21/andrew-wakefield-trump-inaugural-ball/">inaugural ball</a>. That author, Andrew Wakefield, said the night of the ball that a <a href="https://www.statnews.com/2017/01/21/andrew-wakefield-trump-inaugural-ball/">“huge shakeup”</a> is needed at the Centers for Disease Control and Prevention. </p>
<p>Wakefield, incidentally, was additionally investigated for ethical violations and professional misconduct, and has since lost his license to practice medicine in the United Kingdom. <a href="https://www.statnews.com/2017/01/21/andrew-wakefield-trump-inaugural-ball/">He</a> currently lives in Texas, and he continues to promote the false premise that the MMR vaccine causes autism.</p>
<p>When I began my career in 1989, the bacterial pathogen <a href="https://www.cdc.gov/mmwr/PDF/rr/rr6301.pdf">Haemophilus influenzae type b</a> (Hib) was one of the most common causes of bacterial meningitis in children 5 and younger. I can recall young children admitted for meningitis to the pediatric hospital I was associated with. </p>
<p>Thousands of children in the U.S. were similarly treated then for meningitis resulting from Hib. In 2015, only <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6552md.htm">29 cases of serious illness</a> from Hib were reported in children 5 and younger. Effective vaccines to prevent serious illness from Hib were licensed for use at about the time I began my career. They are now routinely recommended. </p>
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<img alt="" src="https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163929/original/image-20170404-5706-752fdz.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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</figcaption>
</figure>
<h2>Mercury misunderstanding contributes to confusion, too</h2>
<p>Another scapegoat for a cause of autism has been thimerosal, a preservative agent that had been used in some vaccines, but never in MMR vaccines. Thimerosal contains ethylmercury and differs chemically from methylmercury, the form of mercury commonly found in the environment, including some fish. </p>
<p>Although mercury can be dangerous to humans in high amounts, ethylmercury differs, as it is eliminated from the body quicker than methylmercury. </p>
<p>Although some had suggested that thimerosal was a cause of autism, a 2013 review of the <a href="https://www.cdc.gov/vaccinesafety/concerns/thimerosal/faqs.html#5A">scientific literature has demonstrated that this is not true.</a>. Even so, pharmaceutical companies removed thimerosal from the majority of pediatric vaccines in 2001, and it remains in only a few multi-dose influenza vaccine products.</p>
<h2>Vaccine safety is carefully studied</h2>
<p>Vaccine products, similar to other pharmaceutical products, are evaluated for safety and efficacy over many years, prior to their public use as allowed by the Food and Drug Administration (FDA). </p>
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<img alt="" src="https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163933/original/image-20170404-5736-1kmglwe.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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<p>Because of their therapeutic importance for disease prevention, vaccines are additionally evaluated for safety after the FDA has granted their approval for public use. Several monitoring systems carefully track vaccine product safety, including the Vaccine Adverse Events Reporting System, the Vaccine Safety Datalink and the Post-Licensure Rapid Immunization Safety monitoring system. These programs help ensure that <a href="https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Safety-The-Facts.aspx">vaccine products remain safe,</a> once they have been made available for public use.</p>
<p>Because of the importance of vaccines in preventing many serious infectious diseases, the medical community has carefully and thoroughly reviewed the science of vaccines and their potential adverse effects. Vaccines, as any pharmaceutic drug product, have risks – a potential to result in adverse effects, such as a sore arm or leg. The majority of these adverse effects are not serious. The benefits of vaccines – the prevention of fatal infectious diseases – greatly outweigh their risks for the vast majority of infants and children. </p>
<p>As a parent, if you have concerns about giving a vaccine to your child, talk with your child’s pediatrician or physician. Ask specific questions and express your concerns. Good internet sites, with accurate, easy-to-read information you can additionally read, are the Centers for Disease Control <a href="https://www.cdc.gov/vaccines/index.html">website on vaccines</a>; the <a href="https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunization/Pages/default.aspx">website</a> for the American Academy of Pediatrics; and the <a href="http://www.immunize.org">Immunization Action Coalition</a>. Pediatric health care professionals, such as myself, desire infants and children to be as healthy as possible. This includes your children. Vaccines are a safe and effective means to accomplish this.</p><img src="https://counter.theconversation.com/content/74958/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edward Bell 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>You may not know anyone with an infectious disease covered by the immunizations on the 2017 list of recommended vaccines. Here’s why that doesn’t matter, and why children still need to be protected.Edward Bell, Professor of Pharmacy Practice, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/649312016-09-12T10:42:16Z2016-09-12T10:42:16ZWhy are vaccination rates in England falling?<figure><img src="https://images.theconversation.com/files/137089/original/image-20160908-25253-1bsc7an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-432466561/stock-photo-vaccination-for-women-in-vaccine-roomselective-focusmedical-concept.html?src=MGpi8gJPZveksm6kA4A9DA-1-12">Komsan Loonprom/Shutterstock.com</a></span></figcaption></figure><p><a href="https://www.nice.org.uk/news/article/nice-to-tackle-falling-child-vaccination-rates">Millions of children</a> in England risk contracting potentially fatal diseases as vaccination rates continue to fall for the second year running. According to Gillian Leng, deputy chief executive of the UK’s National Institute for Health and Care Excellence, about 3m children and adolescents may have missed their mumps, measles and rubella (MMR) vaccine.</p>
<p>It is not possible to vaccinate every child in the country. At any given time, some children will be too young and a very small number will have allergies or other conditions that make vaccination unacceptably risky. However, if a sufficient proportion of the population are vaccinated, a disease cannot spread and everyone is protected. This is known as “<a href="https://theconversation.com/explainer-what-is-herd-immunity-52377">herd immunity</a>”. The World Health Organisation (WHO) considers that a 95% uptake is necessary to achieve this protection. </p>
<p>Low vaccination rates are a particularly English problem: Scotland, Wales and Northern Ireland all achieve the WHO target, although there are pockets, particularly in economically deprived urban areas, where they fall short. In England, the national rates are 2-3% below WHO recommended levels. In some urban areas, particularly those with high levels of deprivation and minority ethnic populations, rates fall towards 80%. This creates a high risk of outbreaks of serious childhood diseases.</p>
<h2>Reasons for the fall in uptake</h2>
<p>The decline in vaccination rates is often attributed to parental resistance provoked in the late 1990s by the <a href="https://theconversation.com/mondays-medical-myth-the-mmr-vaccine-causes-autism-3739">now-discredited claim</a> made by Andrew Wakefield of a link between the MMR vaccine and autism. However, the comparisons between the different nations within the UK suggest a more complex picture. </p>
<p>Before we blame parents, we should consider whether they have easy access to child health advice and vaccination services. If they are not aware of the benefits and cannot get to the places where vaccines are available, we should not be surprised if their children are not vaccinated. </p>
<p>Although the UK has a single framework of principles and funding for the NHS, each component nation chooses how to organise their delivery. Scotland, Wales and Northern Ireland have had less reorganisation than England so they have been able to focus on providing rather than reforming their services. </p>
<p>An improvement in <a href="https://www.gov.uk/government/statistics/cover-of-vaccination-evaluated-rapidly-cover-programme-2015-to-2016-quarterly-data">vaccination rates</a> in England coincided with the rebuilding of the health visiting service under the 2010-15 UK coalition government. Health visitors are specialist nurses who provide screening, counselling, advice and support to all families with children from birth to the age of five. <a href="http://www.unitetheunion.org/uploaded/documents/Health%20visiting%20in%20England%20May%20201611-26805.pdf">Health visitor numbers increased</a> by 49% and the average caseload for each health visitor fell from just over 400 to around 280 children. Staffing shortages remained in the urban areas where low vaccination rates are found. </p>
<p>However, much of this investment has since been negated by <a href="http://www.unitetheunion.org/uploaded/documents/Health%20visiting%20in%20England%20May%20201611-26805.pdf">local authority cuts</a> since they took over responsibility for the service in October 2015. The improvement in vaccination rates seems to have come <a href="https://www.nice.org.uk/news/article/nice-to-tackle-falling-child-vaccination-rates">to a halt or reversed slightly</a> in the last two years. This is a time when there have been increasing cutbacks in Sure Start children’s centres – their <a href="http://sticerd.lse.ac.uk/dps/case/spcc/RR04_SUMMARY.pdf">numbers and budgets</a> are down by about a quarter since 2010 – and problems in <a href="https://www.nice.org.uk/guidance/GID-QS10015/documents/briefing-paper">sustaining GP vaccination clinics</a> among the other pressures on primary care. </p>
<p>The lack of support for reaching out to parents contributes to the low uptake. Traveller groups, for example, have difficulty accessing healthcare. Some minorities have distinctive medical traditions. These beliefs are often dismissed as irrational or primitive by health professionals – a poor foundation for persuading parents of the benefits of change. Recent migrants may simply not understand how the health system works and what is available to them. </p>
<p>All these problems are familiar to health visitors, whose interpersonal skills can make an impact, provided that caseloads allow enough time to engage parents. </p>
<p>Overt resistance is much less common. There are a small number of “new age” parents, whose preferences for alternative medicine could probably be accommodated without compromising herd immunity. </p>
<p>Of more concern is the emerging group of affluent parents who are opting out because they believe they can micromanage all risks to their children. This group has not been studied in the UK, but <a href="http://sociology.nd.edu/students/kevin-estep/">recent work</a> in California found that where there is a critical mass of parents who think this way in a school catchment, refusal rates are high because the parents believe that the minimal risks from vaccination need not be accepted. They can insulate their children from the “others” who carry infectious disease. Their children do not share school classrooms, public transport or public leisure facilities with children from poorer backgrounds. Their children’s social contacts are carefully supervised so that they only mix with other children from a similar background whose parents think in the same way. They seem to be the forerunners of the “helicopter parents” who hover over their children at university and even into first employment. </p>
<p>We may need to relearn the lessons that drove public health reform in 19th-century Britain: infectious diseases are a potential threat to everyone. No one can buy protection on an individual basis.</p><img src="https://counter.theconversation.com/content/64931/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Dingwall 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>We can’t keep blaming the MMR-autism scare – there are other forces at play.Robert Dingwall, Professor, Nottingham Trent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/617762016-08-01T03:07:18Z2016-08-01T03:07:18ZIn Zika, echoes of US rubella outbreak of 1964-65<figure><img src="https://images.theconversation.com/files/132268/original/image-20160727-21564-16ebip6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A display used to educate the public on rubella vaccination and the mother-to-fetus transmission of this virus.</span> <span class="attribution"><a class="source" href="https://phil.cdc.gov/phil/details.asp">Centers for Disease Control and Prevention via Public Health Image Library</a></span></figcaption></figure><p>Just over 50 years ago, a highly contagious but seemingly harmless virus swept through the United States, infecting as many as <a href="http://www.cdc.gov/vaccines/pubs/pinkbook/rubella.html#congenital">12.5 million people</a>. In both adults and children, the virus presented as a mild illness, but caused birth defects in some babies born to women who were infected while pregnant.</p>
<p>Does this sound familiar? Though separated by time and place, there are surprising similarities in the social issues raised by the rubella outbreak of 1964-65 and the recent Zika outbreak in South America. </p>
<p>Both viruses can cause birth defects, a fact that ties them to social issues surrounding pregnancy, women’s health and the politics of abortion. </p>
<p>The rubella epidemic, with an estimated <a href="http://aje.oxfordjournals.org/content/92/3/162.full.pdf+html">20,000 affected newborns</a>, changed medical and public consciousness about the virus. Some have recently argued that it even <a href="http://news.nationalgeographic.com/2016/02/160205-zika-virus-rubella-abortion-brazil-birth-control-womens-health-history/">changed ideas about abortion</a>. </p>
<p>As a sociologist who studies medicine and science, I am interested in understanding the narratives we develop about disease. I examined the rubella outbreak in my 2008 book, <a href="https://books.google.ca/books/about/The_Vaccine_Narrative.html?id=9fqdGAAACAAJ&redir_esc=y&hl=en">“The Vaccine Narrative,”</a> and how perceptions of the disease interacted with stories about vaccination. </p>
<p>Unlike other vaccines, the rubella vaccine conferred no direct benefits to recipients. Instead, it promised to prevent possible future birth defects and to reduce rubella-related abortions; for rubella vaccine, the health of the woman mattered almost entirely in terms of her status as a potential mother.</p>
<h2>The rubella outbreak of 1964-65 – and access to abortion</h2>
<p>In the spring of 1964, doctors in North America confirmed that the <a href="http://www.cdc.gov/vaccines/pubs/surv-manual/chpt15-crs.html">deafness and blinding cataracts</a> they found in massive numbers of children had been caused by rubella. </p>
<p>Before the this outbreak, rubella was obscure, but not unknown. Unlike Zika, which is primarily transmitted by mosquitoes, rubella can spread through casual contact. In fact it was was endemic in Western populations, with <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=503198">more than 80 percent of the population exposed to the disease</a> before rubella vaccination was introduced in 1969. </p>
<p>Health professionals had known <a href="https://books.google.ca/books?id=yiUrAAAAYAAJ&pg=RA1-PA168&lpg=RA1-PA168&dq=Congenital+Defects+in+Infants+Following+Infectious+Diseases+during+Pregnancy&source=bl&ots=3AddxjRWU4&sig=Lba4ti_sazcTTTibpZdBfWnIL18&hl=en&sa=X&ved=0ahUKEwiUq6qrp_jNAhXMHx4KHfUSCuIQ6AEINzAE#v=onepage&q&f=false">since 1943</a> that rubella sometimes caused birth defects, called Congenital Rubella Syndrome (CRS). In another parallel with Zika, people infected with rubella are often asymptomatic. Even when people do have symptoms, they are fairly mild.</p>
<p>Researchers isolated the rubella virus <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=503144">only in 1962</a>, and there was <a href="http://query.nytimes.com/gst/abstract.html?res=9E06E1DF1F30E033A25752C2A9629C946491D6CF&legacy=true">no blood test until 1965</a>. </p>
<p>Before the blood test was available, a doctor’s clinical diagnosis of rubella could access a <a href="http://scholarlycommons.law.case.edu/cgi/viewcontent.cgi?article=4360&context=caselrev">medical exception</a> to the ban on abortions that existed in most states, called a “therapeutic abortion.” This exception considered the physical and mental health of the woman as medically relevant for whether an abortion could happen. Decisions about rubella-related abortion happened in the context of the doctor-patient relationship.</p>
<p>Because rubella was so common, and because an infected person could be asymptomatic, some physicians had argued as early as the 1950s that <a href="http://scholarworks.umb.edu/cgi/viewcontent.cgi?article=1205&context=nejpp">rubella served as a convenient way to circumvent the laws restricting abortion</a>. </p>
<p>In fact, prior to Roe v. Wade in 1973, a rubella diagnosis was <a href="http://scholarlycommons.law.case.edu/cgi/viewcontent.cgi?article=4360&context=caselrev">one of the main ways</a> for women to obtain safe abortions, performed by qualified doctors, without either physician or patient subject to prosecution. </p>
<p>Even when abortion was illegal throughout the U.S., the law recognized the primacy of the doctor-patient relationship, deferring to <a href="https://books.google.ca/books?id=FK4pBXGvQzoC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false">the authority of American medicine</a> and the privacy of women’s medical decisions. Roe v. Wade, which legalized abortion in the U.S., is built on the right to privacy.</p>
<h2>The development of the vaccine</h2>
<p>In the aftermath of the 1964-65 epidemic, epidemiologists predicted that another rubella epidemic – along with thousands of babies born deaf or blind – would begin in 1970. This spurred the effort to develop a rubella vaccine to prevent birth defects. However, another goal was to reduce what vaccine researchers at the time often referred to as “fetal wastage,” a euphemism for abortion. In fact, many in the medical profession at that time appeared to view women’s health as secondary to the importance of pregnancies brought to term with healthy babies and avoiding “<a href="http://scholarworks.umb.edu/cgi/viewcontent.cgi?article=1205&context=nejpp">unnecessary abortions</a>.”</p>
<p>A preventive vaccine became available in 1969, and versions are currently in wide use; it is the “R” in the trivalent childhood MMR vaccine. Today, the Centers for Disease Control and Prevention reports that rubella, once endemic, has been <a href="http://www.cdc.gov/vaccines/pubs/surv-manual/chpt15-crs.html">all but eliminated in the U.S.</a>, and rubella-related birth defects with it.</p>
<p>In 1970 when the predicted epidemic failed to materialize, credit went to mass vaccination <a href="http://www.nejm.org/doi/full/10.1056/NEJM197602052940604">(despite some uncertainties, as the population had already been largely immune)</a>. This meant that the underlying social issues that rubella had raised – the role of medicine in regulating access to abortion; whether the physical and mental effects of birth defects <em>on women</em> justified an abortion – would be deferred. </p>
<p>Still, the realization that birth defects were an important consideration in the politics of abortion <a href="http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=2089&context=fss_papers">made therapeutic abortion more available</a> between 1965 and the 1973 Roe v. Wade decision, as blood tests replaced clinical diagnoses, though the rate of rubella-related birth defects remained unknown. </p>
<h2>Parallels with Zika</h2>
<p>The rubella outbreak happened in a context where abortion was illegal – save for medical exceptions. In much of South America, where Zika’s effect has been greatest, access to <a href="https://theconversation.com/zika-and-abortion-will-the-virus-prompt-latin-america-to-rethink-abortion-and-birth-control-55200">safe abortion is severely restricted</a>. </p>
<p>As Zika has spread in Latin America, researchers have found that <a href="http://news.utexas.edu/2016/06/22/abortion-demand-increases-with-zika-virus-advisories">abortion requests have increased</a>, setting the stage for a replay of the history of rubella. As with rubella, in areas where Zika has become prevalent and abortion is almost always illegal, <a href="https://www.theguardian.com/global-development/2016/jul/19/zika-emergency-pushes-women-to-challenge-brazil-abortion-law">women have begun to demand access to therapeutic abortions</a>. </p>
<p>Perhaps, therefore, medical and public health measures will stop Zika, as they did rubella for North Americans. </p>
<p>But developing a vaccine for Zika or halting its spread will not address the social issues that the virus has raised: women’s right to control their own bodies, concerns about “fetal wastage” and the relative importance of healthy, live births versus women’s mental and physical health.</p><img src="https://counter.theconversation.com/content/61776/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacob Heller 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>Though separated by time and place, there are surprising similarities in the the social issues raised by the rubella outbreak of 1964-65 and the recent Zika outbreak in South America.Jacob Heller, Associate Professor, SUNY Old WestburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/603962016-06-03T09:28:27Z2016-06-03T09:28:27ZShould Zika really stop you going to the Rio Olympics? Here are the facts<figure><img src="https://images.theconversation.com/files/124997/original/image-20160602-23270-cxexrd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cidade maravilhosa.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=Rio&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=328110866">Aleksandar Todorovic/Shutterstock.com</a></span></figcaption></figure><p>Over 200 academics from around the world have now signed <a href="http://rioolympicslater.org/">an open letter</a> to the Director-General of the World Health Organisation (WHO) calling for the Olympics and Paralympics in Rio de Janeiro to be postponed or moved to another venue, owing to the threat posed by the ongoing Zika virus pandemic. The evidence concerning Zika virus so far, however, does not justify this course of action. The <a href="http://rioolympicslater.org/">RioOlympicsLater.org</a> authors misunderstand the nature of Zika virus, its history since its discovery in 1947, and also the relative risk posed by Zika virus versus other risks affecting any large event in a tropical country. </p>
<p>The letter begins by referring to the movement of the <a href="http://www.fifa.com/news/y=2003/m=5/news=sars-fifa-executive-decides-relocate-fifa-women-world-cup-2003-87152.html">2003 Women’s World Cup</a> from China to the USA owing to the outbreak of SARS, and the disruption of the <a href="http://www.nytimes.com/2014/11/12/sports/soccer/morocco-wont-host-africa-cup-of-nations-because-of-ebola-fears.html?_r=0">African Cup of Nations</a> schedule during the Ebola epidemic. Neither of these is, however, a valid comparison. </p>
<p>Both <a href="http://onlinelibrary.wiley.com/doi/10.1046/j.1365-3083.2003.01302.x/abstract;jsessionid=5EC933F85FDD4A286A7376B1DEE53824.f02t03">SARS</a> and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870382/">Ebola</a> were high-mortality diseases. Also, SARS was a completely new pathogen. Mortality in Zika is very low, and where deaths occur they are often due to complications of <a href="http://www.nhs.uk/Conditions/Guillain-Barre-syndrome/Pages/Introduction.aspx">Guillain-Barre Syndrome</a> rather than a direct result of the virus’s usual symptoms.</p>
<p>The real concern with Zika is <a href="https://theconversation.com/explainer-what-is-microcephaly-and-what-is-its-relationship-to-zika-virus-54049">microcephaly</a> and other damaging effects on foetuses via infection in pregnant women. But the authors’ statement that “Zika virus harms health in ways that science has not observed before” is not correct. <a href="http://www.ncbi.nlm.nih.gov/pubmed/27180225">Recent experiments</a> on laboratory mice, on brain <a href="http://www.ncbi.nlm.nih.gov/pubmed/27118425">organoids</a> (small balls of nervous cells that have <a href="https://www.technologyreview.com/s/535006/brain-organoids/">some of the structure and properties of developing brains</a>) and in brain tissue culture, as well as <a href="http://www.ncbi.nlm.nih.gov/pubmed/27028667">detailed observation</a> of the signs and symptoms of Zika-associated microcephaly in foetuses and infants, show that Zika <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878297/">can be categorised with other TORCH-syndrome pathogens</a>. </p>
<p>TORCH is an acronym for “TOxoplasma, Rubella, Cytomegalovirus, Herpes”, <a href="http://rarediseases.org/rare-diseases/torch-syndrome/">all agents which cause similar defects in foetuses</a> when the mothers are exposed in pregnancy. Zika is the only TORCH-like pathogen that is spread by mosquito bites, but based on what we have seen so far, there is no reason to think that Zika is particularly virulent. If one insists on drawing comparisons with other diseases, Zika is not the new Ebola, but the new <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4316306/">rubella</a>. </p>
<p>The letter also claims that “most of South Asia and Africa” are “as yet unaffected places”. That is not true either. Many <a href="http://jgv.microbiologyresearch.org/content/journal/jgv/10.1099/jgv.0.000381#tab2">studies</a>, going back to the 1940s, have shown that humans, and often also monkeys, in several African and Asian countries have antibodies to the Zika virus, and we have direct evidence of Zika circulating in both <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321795/">West Africa</a> and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866850/">South East Asia</a> within the last ten years. These studies need to be repeated to determine the current levels, but it is very likely that many parts of the tropical world have already seen Zika virus in the past and there will probably be considerable herd immunity to the local Zika variant in the human population. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/124999/original/image-20160602-23291-35owpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/124999/original/image-20160602-23291-35owpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124999/original/image-20160602-23291-35owpc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124999/original/image-20160602-23291-35owpc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124999/original/image-20160602-23291-35owpc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124999/original/image-20160602-23291-35owpc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124999/original/image-20160602-23291-35owpc.jpg?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">
<figcaption>
<span class="caption">The rubella virus.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-208188670/stock-photo-rubella-german-measles.html?src=fLi9iCGaqf9D3L15SdAqTQ-1-0">decade3d - anatomy online/Shutterstock.com</a></span>
</figcaption>
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<p>Will that previous exposure be protective against more exotic strains of Zika? The likely answer is “yes”. The Brazilian and African varieties of Zika are about 12-13% different in terms of the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289602/">genetic variants accumulated</a> since their last common ancestor. The <a href="http://www.ncbi.nlm.nih.gov/pubmed/25545072">corresponding figure</a> for yellow fever virus, another member of the flavivirus family that includes Zika, is just under 22%. Yet a single <a href="http://www.nhs.uk/Conditions/yellow-fever/Pages/prevention.aspx">yellow fever vaccination</a> will protect against all variants of yellow fever and for a long period of time, so it would be very unusual if exposure to African or South-East Asian Zika did not similarly generate immunity against Brazilian Zika.</p>
<p>Brazil has many of the typical diseases found in the tropical world, including <a href="http://www.who.int/malaria/travellers/en/">malaria</a> and <a href="http://www.nhs.uk/Conditions/dengue/Pages/Introduction.aspx">dengue</a> as well as <a href="http://www.avert.org/professionals/hiv-around-world/latin-america/brazil">levels of HIV</a> about <a href="http://www.avert.org/professionals/hiv-around-world/western-central-europe-north-america/uk">three times higher</a> than the UK. These are things that travellers and athletes need to prepare for. All are clinically more serious than Zika, but none has been proposed as a reason to cancel the event.</p>
<p>There is no major event that is ever 100% safe, and that especially applies to major events in tropical countries. When Zika is seen as it should be, as an insect-borne rubella-like agent, the proper perspective for prevention becomes evident. </p>
<p>Pregnant women, those planning pregnancy and those predisposed to Guillain-Barre syndrome perhaps would be best advised to stay away. Other groups simply need to monitor their health carefully during their visit, use insect repellent and avoid risky sexual behaviour – and thereby also reduce their risk of catching HIV in the process. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/125002/original/image-20160602-23270-1x1gkji.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/125002/original/image-20160602-23270-1x1gkji.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/125002/original/image-20160602-23270-1x1gkji.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/125002/original/image-20160602-23270-1x1gkji.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/125002/original/image-20160602-23270-1x1gkji.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/125002/original/image-20160602-23270-1x1gkji.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/125002/original/image-20160602-23270-1x1gkji.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Go, but take the precautions.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=NSfsObRvTSMfWCGAbjYbaA-1-11&clicksrc=download_btn_inline&id=295527683&size=medium_jpg&submit_jpg=">lazyllama / Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The <a href="https://www.gov.uk/foreign-travel-advice/brazil/health">travel advice</a> for the topics has not changed much because of Zika, unless you are pregnant or starting a pregnancy soon. The one new important point is that all travellers should <a href="http://apps.who.int/iris/bitstream/10665/204421/1/WHO_ZIKV_MOC_16.1_eng.pdf">abstain from unprotected sex for 60 days</a> following their return, since a Zika infection often does not have symptoms. Everyone who has been in a Zika area needs to assume that they may have been infected. </p>
<p>More importantly, all travellers with a fever or rash, or both, during or after their trip need to go to their doctor. But the first test will be for malaria rather than Zika, because the really important and dangerous tropical diseases must take priority. If these principles are observed, there is no reason why the Olympics cannot take place.</p><img src="https://counter.theconversation.com/content/60396/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Derek Gatherer is affiliated with the WHO Expert Committee On Biological Standardization as a participant in their project "WHO collaborative study to assess the suitability of an interim standard for antibodies to Ebola virus"</span></em></p>Academics have sent an open letter to the World Health Organisation calling for the Olympics to be postponed or moved because of the Zika threat. They’re overreacting.Derek Gatherer, Lecturer, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/582372016-04-24T07:08:13Z2016-04-24T07:08:13ZAfrican leaders step up to the plate to narrow immunisation gaps<figure><img src="https://images.theconversation.com/files/119926/original/image-20160423-22390-14qs5q6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An Ethiopian boy receives a polio vaccination. Africa has done well with polio eradication but lags behind other vaccination efforts. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/unicefethiopia/13102269545/in/photolist-kXNyg4-gkYLcp-bwUa4-gkYtis-gkYtwd-kXNvVc-gkYfVk-gkYsFq-o3iFki-gkY6NG-ojK32N-dv6HeW-ohJYKd-dv17Ca-dzX4Kc-eeey42-n68C7H-dv7fCj-gkYLyX-n6aspG-kXNGwv-gkYfAH-dALrWj-dAEYE4-vXGh3C-kXQ1T9-n68FDc-dv6N1d-gkYL6x-n6aryJ-dNHJFa-n68ET4-gkYeTv-dCUHhs-ojK3xY-dv1ar2-dv19iX-dv6Kxm-dv19xR-dv196V-kXP7Ek-n68AJT-n68NTa-kiSKzz-kXNFgV-mLdz9x-n6awZd-n6cAgD-9RRXyx-n68GiX">Unicef Ethiopia/2013/Sewunet</a></span></figcaption></figure><p><em>Six of the ten countries that are home to 60% of unvaccinated children in the world are in Africa. There have been fresh steps to narrow this gap: African ministers have <a href="http://immunizationinafrica2016.org/">committed</a> to increase resources to improve coverage as well as to target missed opportunities for vaccinations. The Conversation Africa health and medicine editor Candice Bailey spoke to Professor Charles Shey Wiysonge about gaps in vaccination coverage on the continent and efforts to narrow them.</em></p>
<p><strong>Where has Africa done well, where has it done badly in vaccines?</strong></p>
<p>Vaccination is one of the most successful and cost-effective ways to save children’s lives and help them grow into healthy adults.</p>
<p>Africa has done particularly well with polio eradication and introducing new and underutilised vaccines. Nigeria, the last polio endemic country in Africa, has been polio free since <a href="https://theconversation.com/africa-is-within-reach-of-being-declared-a-polio-free-region-44786">July 2014</a>, which is an enormous achievement. </p>
<p>The original target was to stop global polio transmission by 2000. This target and several others were missed because of lack of progress in Nigeria, Afghanistan and Pakistan. The Nigerian government and its technical partners established and enforced clear accountability systems that helped them achieve their goals. </p>
<p>But Africa is still lagging behind with vaccinations. The countries with the largest numbers of unvaccinated children are Nigeria, Ethiopia, the Democratic Republic of Congo, Uganda and <a href="http://www.who.int/wer/2015/wer9046.pdf?ua=1">South Africa</a>. And many other countries have large geographic areas with thousands of unvaccinated children. This is measured by the number of children who have not yet received the required three doses of the diphtheria, tetanus and pertussis vaccines.</p>
<p>Overall immunisation coverage in Africa is only 77%. </p>
<p>Measles and rubella have not yet been eliminated on the continent. And 14 African countries have not been able to eliminate maternal and neonatal tetanus. </p>
<p>Tetanus is a stark reminder of the shocking inequality in health-care provision in Africa. Of the 14 countries, Angola, the Democratic Republic of Congo, Equatorial Guinea, Ethiopia and Guinea are close to elimination. Chad, Kenya, Niger, Nigeria and Sudan are drastically behind. The Central African Republic, Mali, Somali and South Sudan are held back by conflict. </p>
<p>In these countries, thousands of pregnant women still become infected with tetanus during delivery and too many babies become sick with tetanus and die because their mothers were not vaccinated. It is of utmost importance to reach all girls and women with tetanus vaccination. </p>
<p><strong>African ministers are <a href="http://immunizationinafrica2016.org/ministerial-declaration-english/">committing more resources</a> to improve vaccination coverage. Where will this get us?</strong></p>
<p>The commitment is landmark and could allow for equal access to existing vaccines for all Africans. For many years immunisation programmes in Africa were plagued by insufficient national <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001405">leadership</a>. </p>
<p>The ministerial commitment is a positive sign of that leadership. National leadership can make a big difference. For example, national leadership led to the polio success story in Nigeria. In the same way, a lack of national leadership in Somalia affected immunisation service financing, staffing and delivery. Even if vaccines are provided and delivered by external aid agencies and nongovernmental organisations, underlying health-care system challenges imply that positive change will not be sustained. </p>
<p>To maintain current accomplishments and make further progress on immunisation in Africa, it is essential that African governments make the needed investments and efforts to achieve immunisation goals. The joint ministerial commitment is a step in the right direction, as there is power in joint action. </p>
<p><strong>Aside from money, what else is needed?</strong></p>
<p>Accountability is also needed. The ministerial commitment can only bring about sustainable positive change if the ministers walk the talk. They need to live up to that commitment by ensuring accountability and that there is implementation at country level. </p>
<p>As part of this accountability system, every country should have a national vaccine action plan. These systems should be able to review sub-national (district) progress towards national goals. The country plans should give proper attention to the quality of data, community ownership and uninterrupted availability of vaccines in all <a href="http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-578">vaccinating facilities</a>. </p>
<p>Without knowing who has been vaccinated for which diseases at local and country level, it is impossible to allocate resources where they will provide the most return or to understand how to improve programme efficiency. Data need to be useful and inform immunisation strategy at every level. </p>
<p>But to increase vaccination coverage, vaccines must be available and the community must be <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0037905">engaged</a>. Vaccine stock-outs are commonly reported in many African countries and these interrupt immunisation services. </p>
<p><strong>You identify missing gaps as being a big deal. Why?</strong></p>
<p>Missed opportunities occur when children or adults (who are eligible for vaccination) come in contact with health-care services but for some reason they don’t receive the vaccinations they need.</p>
<p>At least one in every four children in Africa is still not receiving the vaccinations they need. As a consequence, a substantial proportion of over 1.5 million children who die from vaccine-preventable diseases globally live on the African continent.</p>
<p>Many of the children who have not yet received the vaccinations they need have access to and actually visit health facilities. </p>
<p><a href="http://www.who.int/immunization/sage/meetings/2016/april/1_C_Wiysong_Missed_Opportunities_SAGE-April-2016.pdf?ua=1">Studies</a> have shown that the problem of missed opportunities is huge in many developing countries. About 32% of children who visit health facilities need vaccines, but do not receive them. </p>
<p>The problem is even bigger in Africa, where <a href="http://www.who.int/immunization/sage/meetings/2016/april/2_R_Mihigo_Missed_Opportunities_SAGE-April-2016.pdf?ua=1">studies</a> show that up to 96% of children in some areas visit clinics but do not get vaccines.</p>
<p><strong>How do countries fix this?</strong></p>
<p>Missed opportunities have to do with policies, training, organisation and management of health-care services. These are things that can be corrected quickly and with relatively little investment, and can have an impact on increasing immunisation coverage. They can also help Africa to achieve the goals of the <a href="http://www.who.int/immunization/global_vaccine_action_plan/en/">Global Vaccine Action Plan</a>. </p>
<p>African countries should regularly conduct field assessments to understand how opportunities to vaccinate people are being missed by health-care workers and their systems, and act to reduce their occurrence.</p>
<p>In countries where child vaccination was missed, there are now adolescent and adult unvaccinated populations. In addition, a new phenomenon is emerging in some African countries known as “<a href="http://www.sciencedirect.com/science/article/pii/S0264410X15005009">vaccine hesitancy</a>”. Vaccine-hesitant people may accept all vaccines but with concerns. Some may accept only some vaccines, or delay in taking up vaccines. Others may totally reject all vaccines.</p>
<p>It is very important to get the right <a href="http://www.scielo.org.za/pdf/samj/v105n11/10.pdf">information</a> about vaccinations to both the people who need vaccinations and those who provide the vaccinations.</p>
<p>Parents, guardians, adolescents, adults and health workers need to understand the vital importance of keeping immunisations up to date.</p><img src="https://counter.theconversation.com/content/58237/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Shey Wiysonge 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>Every year hundreds of thousands of children die from vaccine-preventable diseases. Africa leaders could change this if they improved vaccination efforts.Charles Shey Wiysonge, Professor of Clinical Epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/534512016-02-09T04:34:12Z2016-02-09T04:34:12ZNigeria cracked polio. So why does it have 3.5 million unvaccinated babies?<figure><img src="https://images.theconversation.com/files/110602/original/image-20160208-2625-1rxlxk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">REUTERS/George Esiri</span></span></figcaption></figure><p>Over 20 million children across the globe have not been vaccinated against measles, tetanus, rubella or polio. Half of them come from ten countries, five of which are in Africa. </p>
<p>Nigeria, Ethiopia, the Democratic Republic of Congo, Uganda and South Africa have the largest numbers of unvaccinated or under-vaccinated children on the continent. </p>
<p>There are several <a href="https://theconversation.com/why-africa-is-lagging-behind-in-child-vaccination-48699">reasons</a> for this. Aside from the public not understanding the benefits of vaccination and not trusting the health systems, access to care is also limited. In addition, there are too few health care workers for timely vaccinations, infrastructure is deficient and data is of a poor quality. </p>
<p>Of these countries, Nigeria may be in the worst situation. Despite its monumental success in eliminating Ebola and polio, it still has nearly 3.5 million infants not vaccinated against measles. And it is also among the eight nations that are behind in eliminating maternal and neonatal tetanus.</p>
<p>Vaccinations have been a worldwide priority since 2012 when the World Health Organisation ratified a global vaccination action plan to stop children from dying from vaccine-preventable diseases. These include <a href="http://www.unicef.org/immunization/23245_mnt.html">maternal and neonatal tetanus</a>, <a href="http://www.who.int/mediacentre/factsheets/fs286/en/">measles</a>, congenital <a href="https://www.nlm.nih.gov/medlineplus/ency/article/001658.htm">rubella</a> syndrome and <a href="http://www.polioeradication.org/polioandprevention.aspx">polio</a>.</p>
<p>The organisation dubbed it the “Decade of Vaccines” with a vision of having universal access to immunisation by 2020. </p>
<p>But according to an <a href="http://www.who.int/immunization/global_vaccine_action_plan/SAGE_GVAP_Assessment_Report_2015_EN.pdf?ua=1">annual assessment</a> of this plan that has been rolled out for the last five years, several countries are way off track. </p>
<p>The report is released by the Strategic <a href="http://www.who.int/immunization/policy/sage/en/">Group</a> of Experts on Immunisation. It makes annual recommendations to governments, international organisations and development partners on how to meet the goals and objectives of the global vaccination plan.</p>
<h2>Why Nigeria is off track</h2>
<p>Nigeria has successfully wiped out some diseases. It has not recorded any cases of wild poliovirus in over a year. In September 2015 the World Health Organisation removed the country from the polio-endemic list. That feat was achieved by working with technical partners to establish and enforce clear accountability systems, to measure results, reward those who achieve them, and to discipline or part company with those who did not.</p>
<p>But the country’s challenge is failing to translate its polio success to other diseases. Estimates based on the administration of three doses of the diphtheria-pertussis-tetanus vaccine show that in 2014 Nigeria had more than 2 million unvaccinated children. </p>
<p>Nigeria, like other countries that have not met vaccination targets, is also beset by healthcare data quality issues due to a lack of governance, technical know-how and infrastructure.</p>
<p>Political, ethnic and religious conflicts can also hamper vaccination efforts by disrupting health systems. Violent conflicts prevent the delivery of vaccines and displaced populations often struggle to receive basic services. This is the situation in northeastern Nigeria where Boko Haram is threatening immunisation programmes with ripple effects in neighbouring Cameroon.</p>
<p>Funding is also a concern. Currently, there is an estimated <a href="http://www.who.int/immunization/global_vaccine_action_plan/SAGE_GVAP_Assessment_Report_2015_EN.pdf?ua=1">funding gap</a> of $130 million to rid the world of maternal and neonatal tetanus. This is a minuscule amount when compared to the $1.1 billion the Global Vaccine Alliance spent in 2014 on its new and underused vaccine programmes. But the real challenge is that the funding is not getting to where it needs to go. This is all too familiar in Nigeria where the Business Anti-corruption Portal has noted that corruption risks are pervasive throughout all institutions, including the health care system.</p>
<h2>The way forward</h2>
<p>The latest report rightly focuses on leadership and the accountability systems as two investment areas that can take the vaccination action plan forward. But I believe that the factors highlighted in earlier reports - data quality, community involvement and vaccine supply - are still important to meet vaccination targets in countries like Nigeria.</p>
<p>The challenges to improving health care quality, including information and communication technologies, need to be addressed with legislation, better standards, greater investment and new infrastructure. A comprehensive approach that tackles poverty and the distribution of wealth is also needed to guarantee peace and security across the country.</p>
<p>Accountability and transparency at all levels of the vaccine procurement and distribution process will help ensure the right vaccines are available at the right time and place.</p>
<p>The plan’s goal of freeing all children from vaccine-preventable diseases is an ambitious one. At this time we are far from meeting the set targets, but it is true that significant progress has been made. With greater government commitment, it can be hoped that this lofty goal will soon become an achievement for all of humanity.</p><img src="https://counter.theconversation.com/content/53451/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Utibe Effiong 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>Despite Nigeria’s success in eradicating polio, it is struggling to get a grip on mother and child vaccinations.Utibe Effiong, Resident Physician at St Mary Mercy Hospital and Research Scientist for the Exposure Research Laboratory, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/159702013-07-11T05:43:33Z2013-07-11T05:43:33ZVaccination gaps led to rubella outbreaks in Japan and Poland<figure><img src="https://images.theconversation.com/files/27242/original/knsnjv8q-1373457699.jpg?ixlib=rb-1.1.0&rect=4%2C114%2C795%2C499&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mind the gap: Japanese school girls were covered but not the boys.</span> <span class="attribution"><span class="source">Flickr/thecrypt</span></span></figcaption></figure><p>Recent <a href="http://www.nytimes.com/2013/06/25/health/rubella-epidemics-in-japan-and-poland.html">rubella outbreaks in Japan and Poland</a> are the clearest evidence possible that herd immunity matters.</p>
<p>There are many reasons why people don’t get vaccinated for totally preventable diseases such as rubella. One major issue is anxieties around safety, such as in the case of the MMR (measles, mumps and rubella) combination vaccine in the UK. Faulty science published 15 years ago suggested a <a href="http://www.guardian.co.uk/society/2013/apr/25/measles-mmr-the-essential-guide#107">now debunked link</a> between the vaccine and autism. Fear spread and vaccinations plummeted. </p>
<p>In 2013, the <a href="http://bbc.in/149gpH4">recent serious measles outbreak</a> was fuelled by children who weren’t vaccinated a decade ago. The disease primarily affected teenagers but spread to infants who were too young to be vaccinated. There are <a href="http://bit.ly/12fS0f9">now also concerns</a> that outbreaks of mumps and rubella - the remaining “M” and “R” in MMR - could follow.</p>
<p>Outbreaks of vaccine preventable diseases can also happen, not because of individual or community refusals to vaccinate, but due to lack of access to a vaccine, because of supply or cost issues for example, or because of policy decisions as to who gets vaccines and who doesn’t.</p>
<h2>Japan and Poland - uneven vaccination cover</h2>
<p>Japan first introduced the rubella vaccine into its national immunisation programme in 1976 but it was only given to junior secondary school girls. In 1989, Japan introduced the MMR vaccine for all children aged one to six, but that left a 13-year gap where no boys were immunised. </p>
<p>Rubella vaccination is targeted at girls because although it only produces mild symptoms in sufferers, it can be <a href="http://www.nhs.uk/Conditions/Rubella/Pages/Causes.aspx">catastrophic for unborn babies</a>. If a pregnant woman catches the disease, it can spread to the fetus, causing miscarriage, stillbirth and <a href="http://www.who.int/immunization_monitoring/diseases/rubella/en/index.html">congenital rubella syndrome</a>, which can cause various severe birth defects.</p>
<p>But men still catch the disease and in Japan, where rubella cases have shot up to over 10,000 cases, [about 77% of them are in young men](http://www.cdc.gov/mmwr/pdf/wk/mm6223.pdf](http://www.cdc.gov/mmwr/pdf/wk/mm6223.pdf) aged between 20 and 40. </p>
<p>An additional issue with the MMR vaccine led to it being withdrawn in 1993 after an adverse event occurred related to the mumps part of the vaccine. In 2006, an MR (measles and rubella only) vaccine was introduced for children, leaving another coverage gap for both boys and girls for the years between 1993 and 2006. This time the government did a “catch-up” campaign to vaccinate those children who missed their vaccines during the time of the MMR vaccine suspension. </p>
<p>The value of this catch-up campaign is clear when you look at who contracted rubella in Japan’s outbreaks. Those boys who missed the rubella vaccine in the earlier “girls only” policy – now 20-39 year old men – were 68% of those who contracted rubella in the outbreak.</p>
<p>The introduction of the MR vaccine for all children, and the catch-up campaign for those who missed vaccination in the gap between MMR suspension and the introduction of the MR vaccine, paid off. <a href="http://www.cdc.gov/mmwr/pdf/wk/mm6223.pdf">Only 5.6% of the rubella cases</a> were among children aged under 15 years old.</p>
<p>In Poland, since the start of the year to mid-June there were <a href="http://wwwnc.cdc.gov/travel/notices/alert/rubella-poland">more than 26,000 cases of rubella</a>. Similar to Japan, over <a href="http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20485">80% of the cases were among males</a> aged between 15 and 29. And again this is the result of a policy decision to target 13-year-old girls when the rubella vaccine was introduced in Poland in 1989. </p>
<p>In 2004, the MMR combination vaccine was offered to both boys and girls in Poland (at 13-15 months old, with a second dose at 10-years-old) making coverage more gender neutral.</p>
<h2>Future repercussions</h2>
<p>Both the Japanese and Polish outbreaks are largely attributable to policy decisions made more than two decades ago.</p>
<p>Most of those who contracted rubella did not refuse, or rather their parents did not refuse, to take the vaccine - they were simply never offered it. Also in both of these outbreaks, the policy decision was to focus on immunising girls, not boys.</p>
<p>And Japan and Poland <a href="http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20485">aren’t the first countries</a> to pay the price of selective rubella vaccination policies. Romania had an outbreak of more than 20,000 rubella cases in 2011-2012 and Greece had large outbreaks in 1993 and 1999, all consequences of earlier vaccine policies.</p>
<p>The health threats posed by these historic decisions also stretch beyond the immediate countries affected. </p>
<p>In order to minimise the risk of importing rubella, as well as protecting individual health, the US Centers for Disease Control (CDC), for instance, <a href="http://stopmeaslesrubella.org/2013/06/20/cdc-issues-rubella-travel-alerts-for-japan-and-poland/">recently issued an alert</a> recommending that travellers to Japan or Poland ensure that their rubella vaccinations were up to date. Pregnant women were urged not to travel at all if they were unvaccinated.</p>
<p>While there are sometimes legitimate reasons to focus vaccine policies on those most immediately at risk, especially in times of limited vaccine supply or financial constraints, the value of vaccines depends on achieving a level of “herd immunity”. </p>
<p>In other words, if not enough of the “herd” or larger population get vaccinated, the virus continues to circulate and can infect anyone not vaccinated. And, as we’ve seen in Japan, Poland and elsewhere, the impact of these policies can hit years later.</p>
<p>Vaccination policies and programmes need to be designed to take a long-term view. And we need to stay vigilant to the risks of vaccination gaps before they become a crisis.</p><img src="https://counter.theconversation.com/content/15970/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heidi Larson has received research funding from
The Bill & Melinda Gates Foundation, Novartis, and WHO.</span></em></p>Recent rubella outbreaks in Japan and Poland are the clearest evidence possible that herd immunity matters. There are many reasons why people don’t get vaccinated for totally preventable diseases such…Heidi Larson, Senior Lecturer in Epidemiology & Population Health, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.