Emerging Measles Epidemic: A Preventable Crisis

The past few months have seen a rising crescendo of news articles highlighting a growing global measles epidemic and crisis. The following list is drawn from just the BBC alone.

  1. 20 August 2018: Measles cases reach record high in Europe
  2. 15 February 2019: Measles is evil. We have to vaccinate
  3. 25 March 2019: The measles has made my life
  4. 27 March 2019: US County declares measles outbreak emergency.
  5. 27 March 2019: Explaining the US measles outbreak
  6. 5 April 2019: Measles: How a preventable disease returned from the past
  7. 9 April 2019: New York measles emergency declared in Brooklyn
  8. 24 April 2019: Measles: Greater Manchester outbreak rises to 47 cases
  9. 26 April 2019: Measles outbreak: Trump tells Americans to “get their shots”

The sad reality is that this is a crisis that could largely have been prevented in the developed world. UNICEF reports that, globally, over the past 8 years an average of 21.1 million children have missed out on essential measles vaccines each year, giving a total of approximately 169 million unvaccinated children in that time period alone. In high-income countries, the statistics make for some sobering reading. The raw data over this time period is shown on the following table, courtesy of UNICEF.

The United States is significantly over-represented, as the equivalent doughnut chart shows below.

The reasons for failures to achieve required measles vaccination rates are varied. Measles has had a hard time because of the influence of disproven scare stories linking the MMR vaccine with autism. This misinformation has led to increasing fear or skepticism about the vaccine.

In low and middle-income countries, on the other hand, the causes are related to poor governance, poor health systems, complacency, logistic and economic challenges. Data from 2017 alone show that the countries that contributed the most were Nigeria, India, Pakistan, Indonesia and Ethiopia.

UNICEF highlights that two doses of the measles vaccine are essential to protect children from the disease. However, the global coverage of the first dose of the measles vaccine was reported at 85 per cent in 2017, a figure that has remained relatively constant over the last decade despite population growth. Global coverage for the second dose is much lower, at 67 per cent. The World Health Organization recommends a threshold of 95 per cent immunization coverage to achieve so-called ‘herd immunity’.

The BBC has a useful video that discusses vaccines, particularly the measles vaccine, in some detail. It is helpful to watch and is added below for reader convenience.

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Parkinson’s Disease: Towards Finding a Cure

The BBC has reported exciting developments in the treatment of some of the symptoms of Parkinson’s disease. Researchers in Canada have managed to develop a new treatment that helps restore the ability to walk in affected patients through an implant that provides electrical stimulation in the spine. The following video, provided courtesy of the BBC, provides further details.

The British National Formulary (BNF) defines Parkinson’s disease as a progressive neurodegenerative condition resulting from the death of dopaminergic cells of the substantia nigra in the brain.

Substantia Nigra
Substantia Nigra

Motor-symptoms may include hypokinesia (decreased bodily movement), bradykinesia (slowness of movement), rigidity (stiffness), rest tremor, and postural instability. Non-motor symptoms include dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss. Patients with suspected Parkinson’s disease should be referred to a specialist and reviewed every 6 to 12 months.

Both the BNF and the National Institute for Health and Care Excellence (NICE) highlight the need for both pharmacological and non-drug treatment options for the various symptoms. In respect of non-drug treatment, patients should be offered physiotherapy if balance or motor function problems are present, speech and language therapy if they develop communication, swallowing or saliva problems, and occupational therapy if they experience difficulties with their daily activities. Dietitian referral should be considered.

Drug treatment has centred on negating the effects of the loss of dopamine through replacing dopamine (via levodopa), using dopamine agonists or using a range of drugs that offset the negative effects of dopamine loss. The medical challenge is being able to attain the fine balance that mimics normal brain and motor function without the development of unacceptable side effects from the drugs themselves.

NICE highlights that initial drug treatment should be subject to a consideration of the relative benefits and harms of the treatment options, using the following comparative chart for reference:

Screenshot 2019-04-22 at 23.03.57

The guidance highlights that in early stages of Parkinson’s disease, patients whose motor symptoms decrease their quality of life should be offered levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa), which help prevent the peripheral metabolism of levodopa. Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

The NICE guidance goes on to provide more guidance on what to do in the event that a patient develops motor fluctuations, uncoordinated movements or simply that the medicines stop being as effective due to progression of the disease.

The news of the development of new treatment via electrical stimulation therefore offers promise as an option with comparatively low side effects, particularly where traditional approaches have reached their limits. It also comes on the back of recent findings that Parkinson’s disease may start in the gut, a promising field of research that may yet yield other avenues towards treating, preventing or reversing this debilitating condition.  

 

Immunisation: Crisis and Benefits

The discovery of the benefits of vaccines has arguably been among the greatest developments in modern healthcare. Based on objective data, UNICEF states that,

Immunization is one of the most cost-effective public health interventions to date, averting an estimated 2 to 3 million deaths every year. As a direct result of immunization, the world is closer than ever to eradicating polio, with only three remaining polio endemic countries – Afghanistan, Nigeria and Pakistan. Children under 5 deaths from measles, a major child killer, declined by 85 per cent worldwide and by 89 per cent in sub-Saharan Africa between 2000 and 2016. And as of March 2018, all but 14 countries have eliminated maternal and neonatal tetanus, a disease with a fatality rate of 70 to 100 per cent among newborns.

However, recent articles on the WHO, UNICEF, BBC and CNN websites have highlighted emerging challenges that are counteracting the attempts at achieving universal coverage. The WHO quotes Dr Seth Berkley, who summarises the factors as the following:

Complacency about the disease and the spread of falsehoods about the vaccine in Europe, a collapsing health system in Venezuela and pockets of fragility and low immunization coverage in Africa are combining to bring about a global resurgence of measles after years of progress.

That the spread of falsehoods about vaccines is not limited to Europe is evident from the CNN article, which highlights problems in the USA and steps being taken by some local authorities to try to mitigate against the risks posed by unvaccinated individuals who may be carriers.

UNICEF provides some useful data on vaccine coverage, some of which is shared below. The first series of pictures are based on global coverage of the first dose of diphtheria, polio and tetanus.

The review of the third dose of DTP is presented in an interesting way, highlighting the countries with the greatest deficits in care. Of the 19.9 million infants who are not fully vaccinated with DTP3, almost 8 million (40%) live in fragile or humanitarian settings, including countries affected by conflict. About 5.6 million of them live in just three countries – Afghanistan, Nigeria and Pakistan – where access to routine immunization services is critical to achieving and sustaining polio eradication.

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When it comes to a review of measles vaccination, we see that rates remain too low to prevent outbreaks. Globally, 85% of children have been vaccinated with the first dose of measles vaccine by their first birthday through routine health services and 67% with a second dose. 167 countries have included a second dose of measles vaccine as part of their routine vaccination schedule. Nevertheless, coverage levels remain well short of the WHO recommended measles immunization coverage of at least 95% to prevent outbreaks, avert preventable deaths. and achieve regional elimination goals.

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The final image relates to the coverage of HPV vaccination. Human papillomavirus (HPV) is the most common viral infection of the reproductive tract, and can cause cervical cancer, other types of cancer, and genital warts in both men and women. The benefits of HPV vaccination are discussed in greater detail here. By 2017, the HPV vaccine had been introduced in 80 countries covering 22  percent of global cohort of 15 year old girls.

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To summarise, it is important that we maintain vigilance and continue to both promote and practice effective vaccination so that we can reduce and eventually eliminate the burden of unnecessary deaths that affects vulnerable people across the globe.