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WIn New York, where two large-scale outbreaks push the number of measles cases to their highest level in a quarter of a century, public health officials are beginning to struggle with an uncomfortable perspective.
The outbreaks in Rockland County and Brooklyn have been going on for eight months. If the transmission of one or both of these outbreaks continues until the end of September, the United States will probably lose the hard-fought and popular status of 39, a country deemed to have "eliminated" measles.
And if that happens – Venezuela and Brazil are the only other countries in the Americas where measles is considered endemic or circulating constantly – the implications could be profound, say the experts.
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Although there are no international sanctions involved, the decline in the status of measles elimination would mean more than just crossing a psychological divide. Experts say the United States may face much larger outbreaks in the future, with epidemics that could affect the capacity of health departments that are already struggling to extinguish each measles transmission chain in the country.
"Prevention is better than doing a ton of work," said Dr. Thomas Clark, deputy director of the Division of Viral Diseases at the Centers for Disease Control and Prevention, who thought about what could happen if the US lost its measles. free status in the fall.
"In practice, you can not react in the same way that our local health services treat 20, 30 and 50 cases a week," Clark said. "If you have hundreds, you do not call everyone. You do not see who they exposed. You do not recommend that individuals isolate themselves in case they get measles. You just have endemic measles. You understand that everyone is at risk of measles in unvaccinated people. "
Is this where the United States is heading? Clark and others are wondering.
"Are we getting to a place where measles is acceptable? And some rare but real cases of measles deaths are acceptable despite safe and effective vaccines, "he said. "This is not a place where we want to go back. We do not want measles to be endemic in the United States. "
After the introduction of measles vaccines in the 1960s, several efforts were made to stop the transmission of the virus in that country. After all, it was the heady days when major breakthroughs in vaccine development – first polio, then measles – opened up new prospects for the fight against the disease. The successful campaign to rid the world of smallpox has been launched. Infectious diseases could be prevented.
Two attempts to stop measles transmission in the United States – the first in the 1960s, the second in the 1970s and early 1980s – have failed, said Dr. Walter Orenstein, director of the US program. from 1988 to 2004. The failures highlighted the problems to be solved and galvanized the collective will to do the work, he said. A third attempt in the 1990s was successful and the country was declared measles-free in 2000.
Orenstein, who is now part of the Atlanta-based global health task force, said he hoped that if the elimination status of measles was lost, the setback would be temporary.
"Are we going to give up if measles is restored? My feeling is no, that public health officials will continue to work to regain elimination, "he said.
He pointed out that the recent crises had brought about some positive reforms, such as legislation passed by the state of Washington and Maine to limit the types of exemptions that parents can claim to avoid vaccinating their children .
"I think the problem is: can we use this failure to take constructive action to strengthen our immunization programs? It's my hope, "said Orenstein. "And it's certainly the American experience of the country. Failure has been helpful in getting the message across: these things do not have to happen. "
Dr. Kristen Ehresmann also believes that the fight to regain her elimination status would continue if she failed in the fall. As Director of Epidemiology, Infectious Disease Prevention and Control for the Minnesota Department of Health, Dr. Ehresmann recently fought a major measles outbreak. Two years ago, a major epidemic occurred in children of a large Somali community in his state.
Losing measles-free status would be an urgent reminder, Ehresmann said. "We must take this seriously or we will completely back down." But she insisted that the Ministry of Health would adopt the same "all-in-one-bridge" approach to contain measles outbreaks, as is the case now.
Dr. Jeffrey Duchin fears that this will become more difficult if the annual number of measles in the country goes back thousands and beyond. As of May 31, 981 cases had been reported to the CDC. Before the development of measles vaccines, half a million children a year in the United States contracted the virus and about 500 children a year died of it.
"I do not think we're going to go back to that level of measles transmission because a lot of people will still be vaccinated. However, we will see an unpredictable number of measles cases leading to an increase in the number of secondary hospitalizations, encephalitis and deaths, depending on the evolution of vaccination coverage in the United States during of the next decade, "said Duchin, director of communicable diseases for the Seattle and King County Health Department.
Duchin, who said that losing the country's elimination status would be "a tragedy," shares Clark's concern that it is possible that health departments may not be able to prosecute all cases of measles as they currently do, looking for all the risk. Measles outbreaks place a heavy burden on health departments, which often have to rely on staff from other programs to facilitate contact tracing.
"The public health system will never ignore cases of measles and the risk of infection of high-risk people. It will take a response, "said Duchin. "But it may be necessary to limit the project to a small subgroup of exposed people. Exposures to the health system, young children, infants, pregnant women, immunocompromised people. "
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