Measles, Are We Being Lied To? Part 1

Part 1

I decided to start my reading around vaccines with measles.  The Scary Mary of illnesses, the one people rush en masse to vaccinate for should a local outbreak occur.  Canadian and American doctors have even discussed whether they should ban the unvaccinated from attending their surgeries when there is an outbreak.

I want to make it clear this post isn't an anti vaccine entry, and the information below does not mean people shouldn't vaccinate - far from it (as I will discuss more in part 2); but if we truly support informed choice, we surely need to separate fact from fiction when it comes to risks of a disease? Transparency is key, right? Furthermore I'm not a doctor, my blog is not medical advice and you are responsible for your own decisions.

I can still clearly remember a feeling of nauseating panic when my youngest got a suspicious rash at just over a year - pre even being offered the vaccine.   I had suffered fairly mild measles as a child, and my mother tells of how the doctors advised how much worse it would have been had I not been vaccinated.   

I ended up on Doctor Google and this was the sort of page I landed on.  This particular one belongs to the CDC: 

"Measles can be dangerous, especially for babies and young children. In the United States in 2011, 38% of children younger than 5 years old who had measles had to be treated in the hospital."

"For some children, measles can lead to pneumonia, a serious lung infection. It can also cause lifelong brain damage, deafness, and even death. One to three out of 1,000 children in the U.S. who get measles will die from the disease, even with the best care.

Remember this 1-3 per 1000 figure, we come back to it in a moment!

As luck would have it my son's rash subsided, and I didn't really think about the above again until recently, when I added this timeline of measles history in the UK to the blog.  The chart wasn't intended to prove or disprove anything, it was purely a sharing of historical interest.

But here's what I noticed.

1-3 per 1000 as quoted by the CDC is a mortality rate of 0.1 - 0.3%.  For ease let's average it out at 0.2%

In the UK pre vaccine in 1967, 460,407 cases of measles were reported - and of these 99 died. This is a mortality rate of 0.02%

Hmmmm, so mortality was 10 times higher in 2011 USA  than it was in 1967 UK? Really?

Using their figures, 460k cases would have resulted in between 460 and 1380 deaths, rather than the 99 recorded in the UK? For the record 1967 wasn't a fluke year, the mortality rate had consistently been at 0.02% since 1956.

In fact to get figures even close to those quoted by the CDC, we have to go back to 1940, pre NHS, pre the affluence of the 1950's and pre wider antibiotic use. Even then it was 0.2% i.e. 2 per 1000, not the potential "up to 3 per 1000" quoted.

To me it seems there are three possible reasons for this:
1.  The CDC have grossly exaggerated figures.
2.  Measles is up to 14 times more deadly in the US than the UK.
3.  The death rate from measles is now up to 14 times higher than it was in 1967.

The death rates may actually be a far lower percentage than either source state - because until more recently many may not have sought medical assistance for measles, and thus a significant number of milder cases are likely to have gone unreported. People may have been more likely to call the doctor should the illness progress differently or with more severity than expected. This makes sense as I know a lot of parents didn't see the doctor when their child got chickenpox for example (and thus it would never be recorded anywhere).  Even today people with mild measles symptoms who have received the MMR, may not be tested and thus this figure would not be recorded.

I also recently wrote about how different health authorities described chicken pox, ie if there was a vaccine on offer, it sounded scary and serious - where there isn't it's typically described as a mild self-limiting condition.

In this case, although both countries offer the MMR, the NHS data still isn't comparable to that provided by the CDC.  Instead they say:

"It's estimated that around 1 in every 5,000 people with measles will die as a result of a serious complication. (rather different from the 1-3 per 1,000 recorded by the CDC)

Complications of measles are more likely to develop in certain groups of people, including:

• babies younger than one year old 

• children with a poor diet

• children with a weakened immune system, such as those with AIDS or those having chemotherapy for leukaemia, teenagers and adults

Children who are older than one year and otherwise healthy have the lowest risk of developing serious complications."

So using the CDC figures we would have 10-30 deaths from 10,000 people.  Using NHS figures we would have 2 deaths from 10,000 people.  Hmmm extrapolate that to a wider scale and I'm glad I didn't live in the US when I caught measles!

It gets even more interesting.

In 1967 (several years after the introduction of the first measles vaccine), D.J Spencer co-authored a paper that stated the following:

“For centuries the measles virus has maintained a remarkably stable ecological relationship with man. The clinical disease is a characteristic syndrome of notable constancy and only moderate severity. Complications are infrequent, and, with adequate medical care, fatality is rare. Susceptibility to the disease after the waning of maternal immunity is universal; immunity following recovery is solid and lifelong in duration.”(2)

Why is that particularly noteworthy?

Dr David J Spencer was the longest serving director of CDC, a highly qualified and respected professional. So much so the CDC now have a museum dedicated to him.

Why has the CDC information about measles changed so dramatically?

I then remembered a book my children used to enjoy reading...

Mr Mischief wakes up feeling pretty pants:

The book continues with a highly amused Mr Mischief, entertaining himself by thinking about how each will pass it to another and how it might affect them all differently. As it turns out Mr Happy had already had measles, and the book tells us you can't get it twice so he didn't pass it anywhere!

Clearly the Mr Men doc hadn't read the CDC page to warn Mr Mischief of the risks of pneumonia, brain damage or death.  And perhaps it's just me but I can't imagine a similar story playing out for say Smallpox or Meningitis?  It would be more Stephen King than toddler fun?

There is also a Tom and Jerry cartoon featuring measles: 

Polka Dot Puss
7.38 minutes | 26 Feb 1949
"Jerry paints Tom's face while he is sleeping. Jerry convinces the cat that he has measles. He puts himself in Jerry's hands for some rather creative nursing. In the end the hoax is discovered, but Jerry does get the measles and then gives it to Tom."

1949 was pre any sort of vaccine, so again I found it interesting it was treated as an apparently lighthearted subject if the disease were as deadly as the CDC now state.

I decided to dig around more to see how measles was perceived pre vaccine - were people sat in fear like they were of other diseases?  Did they experience complications or did they know of anyone that did?

I asked pensioners - most of whom were children of the 40's/50's and it provoked some really interesting discussion. 

There was reference to measles parties, everyone wanted their child to catch it as they knew it was much

more serious to have as an adult. One developed a chest infection as a complication, his mother hadn't sought antibiotics as his siblings had all been fine, and as a result he developed pneumonia (he made a full recovery).  Another said it was typically mild, but if it was more severe you were just more carefully monitored - but of course this was in the days of the doctor making house-calls.  It certainly wasn't feared in the way some diseases were and most considered it something most children got, typically mildly and got over - with the odd child having a more severe case.  Nobody I spoke to knew anyone who had suffered acute encephalitis or death. Rather like chicken pox then?  Another illness that can cause encephalitis.  They were also surprised at the CDC statistic that 38% of 0-5 year olds ended up hospitalised.

Of course (as one pointed out), there is presumably also potential for doctors who are not used to treating measles (and potentially subject to litigation) to admit a patient "to be on the safe side"?  Particularly if they've stumbled across the CDC page!

Measles though isn't all about mortality.

We also need to explore other potential significant or long lasting side effects.

Pneumonia
The CDC state "For some children, measles can lead to pneumonia, a serious lung infection."

We're often told that measles is a virus and thus antibiotics are useless - this is why it's so scary. So it's worth considering that the majority of complications are bacterial and could not only be treated by antibiotics should they occur, but prophylactic antibiotic use in the "at risk/vulnerable" groups could significantly reduce incidence.  A 2006 study confirmed what previous "less rigorous" research had already highlighted, that antibiotic use could result in "80% less pneumonia"(1).

Great Ormond Street say:

"In most cases, pneumonia can be treated with oral antibiotics given to the child at home. The type of antibiotic used depends on the type of pneumonia. Sometimes, if a child does not begin to get better after 48 hours of treatment at home, hospital treatment may be needed."

Of course it's significant to note at this point that given the mass overuse of antibiotics in both humans and animals, the crisis we now face is the number of bacteria becoming resistant to them.  This could mean that should we have outbreaks of measles, such complications could again become much more significant - and potentially at a higher rate than the 1950s.  What's perhaps more worrying though is that without antibiotics to fall back on, anything potentially can.   In the vulnerable a chest infection can quickly progress to pneumonia, a urinary tract infection to kidney failure.

Encephalitis
One thing antibiotics can't treat is encephalitis, a serious condition where brain tissue becomes inflamed; furthermore nobody seems very sure what the rates of this condition are and it seems hotly debated in many circles.

The CDC (who I think we've established are going to give us absolute worst case, and then a bit more) state 1 per 1000 children will develop encephalitis, and I found this  2004 study linked from a couple of pages.  The problem however is I can't establish whether this figure is just for US children or globally.  It reads:

"Encephalitis occurs in less than 1 of every 1000 children with measles. Concurrent vitamin A deficiency increases rates of complications. Children under 5 years of age, adults, and persons with malnutrition or immunodeficiency disorders are at increased risk of complications.

Others who cite this study refer to "1 of every 1000 patients with measles" ie including adults or those who are at increased risk as highlighted by the NHS.

A study examining data from 1962-1979 found that of the children who developed encephalitis, around 15% died.  A further 25% suffered long-term problems as a result.

It gets more controversial right about now as some are adamant vaccines themselves are linked with encephalitis, and here whilst others absolutely refute such a condition exists.  A figure generally accepted by official authorities is 1–2 per million develop encephalitis following measles vaccination.  Others claim this figure is not accurate as doctors are not adequately diagnosing mild to moderate encephalitis in post-vaccinated infants.  Going to move along otherwise this piece could run forever I fear - however you can read more about encephalitis here.  It's also interesting to note that the herpes virus (that causes coldsores) is currently the leading cause of encephalitis in the US/UK & Ireland.

Going back to the 2004 study above, they note another interesting point:

In developing countries, measles case-fatality rates are 10- to 100-fold higher than in developed countries; ∼770,000 children died of measles in 2000. Older age at infection, vitamin A supplementation, and antibiotic therapy for secondary bacterial infections have reduced measles-associated deaths in the developing world.

The CDC agree:

"About 150,000 to 175,000 people die from measles each year around the world—mostly in places where children do not get the measles vaccine."

Perhaps it's just me, but this statement appears to imply that lack of vaccine is why some areas have such high figures.  This could lead someone to believe without vaccination we would suffer the same fate.  As the previous paper highlights this is clearly not the case.

I decided to look into any papers published around the time of vaccine launch, and I turned up this - published in the British Medical Journal, London, 1963:

"Before large-scale vaccination against measles is undertaken certain problems must be considered. There can be no doubt that an effective vaccine is needed for children who are especially liable to develop severe measles-for example, mentally defective children in institutions or children in underdeveloped countries.  But the need or desire for a vaccine for the general population of Great Britain is much less certain. 

Measles is now a mild disease, and many parents and doctors may feel that no protection against it is required. However, it is necessary to consider the encephalitis which follows measles in about 0.1% of cases," for though the risk may be slight for an individual child there will be a significant number of cases of encephalitis in the country during the biennial measles epidemics.

Another problem to be considered is the long-term effect of mass vaccination and the possible eradication of measles in a country such as Britain. The disease has a world-wide distribution, but its effects vary in different populations. In Nigeria, India, and South America measles is endemic, but the disease is severe and an important cause of death in childhood. In Chile'" the annual death rate from the disease rose during the period 1950-60 to 27.7 per 100,000 of the population, and 6.5% of patients with measles died.
This is in sharp contrast to the picture in Britain, where the death rate from measles has been steadily declining.

When measles has been introduced to " virgin soil" in such isolated communities as Greenland, Tahiti, Tristan da Cunha, and Northern Australia devastating outbreaks have resulted in which the entire population has become infected. Like other infections which usually attack children measles tends to be more severe in adults. This has been observed in gold miners in South Africa. Many of the Africans contract the disease when they come to work in urban areas, and in them prolonged fever is common, with temperatures which often exceed 1040 F. (40° C.). No doubt better nutrition and living standards play a part in determining the mildness of measles in Britain to-day, but it is probable that, as Sir Graham Wilson has suggested, there is some natural immunity to the disease in this country. This has little effect in preventing attack but appears to protect against death. If herd immunity were not preserved by clinical attack or by vaccination, the population would be subject to epidemics. Thus if measles was eradicated by vaccination a high rate of vaccination in future generations would be essential to maintain herd immunity. If herd immunity were allowed to wane at a later date-and it is notoriously difficult to maintain a high rate of vaccination against a non-existent disease -then the reintroduction of measles from another country might result in epidemics in both children and adults much more severe than are seen in Britain to-day. These are problems which need further thought." (3)

So, basically measles was typically mild with roughly 0.1% developing encephalitis. What's more, in addition to the risk factors previously identified, socio-economic status also appears influential.  A study entitlted "Measles mortality in the United States 1971-1975" noted:

"Mortality rates were higher in non-metropolitan than in metropolitan counties. Measles mortality rates were inversely related to median family income."

Again, this doesn't mean vaccination isn't a good idea, but I can't help but feel that the methods used to try and increase vaccine uptake by some are worthy of further examination. It's well recognised in several areas of maternity care that health care providers may at times try and obtain control via fear - by the implication of, or direct statement that, one or both parties may die or suffer significant consequences if one does not do as advised.

The shifting language and portrayal of measles has successfully moved it in the minds of most people, from typically mild with complications mostly occurring in the vulnerable, to parents peeing themselves at every blemish their child develops.  

Whilst this is clearly likely to improve uptake rates, it feels deceptive - as though someone somewhere thought had I been in possession of the facts without added drama I might have been less likely to comply.

1.  Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ 2006; 333 doi: http://dx.doi.org/10.1136/bmj.38989.684178.AE (Published 14 December 2006)
2. D. J. Sencer, H. B. Dull, and A. D. Langmuir. Epidemiologic basis for eradication of measles in 1967. Public Health Rep. 1967 March; 82(3): 253–256.

3.  Br Med J. Sep 28, 1963; 2(5360): 759–760.
4. Herpes simplex encephalitis treated with acyclovir: diagnosis and long term outcome, J Neurol Neurosurg Psychiatry 2002;73:237-238 doi:10.1136/jnnp.73.3.237