America and Europe’s new normal: the return of vaccine-preventable diseases

Heading into 2019 we are seeing a return of vaccine-preventable diseases in Europe and the United States, much of it because of well-organized, well-funded, and mostly unopposed antivaccine groups and lobbies, together with the rise of populist regimes touting “medical freedom” from vaccines. The World Health Organization (WHO) has just expressed concern in its newly issued press release.

The success

Through global vaccination programs that expanded at the end of the twentieth century and accelerated in this century, there have been dramatic declines in the deaths from childhood infectious diseases in Africa and Asia and in much of Latin America. For example, measles prior to widespread immunizations ranked high among the leading killer of children worldwide, when it caused an estimated 2.6 million deaths annually.1 Then, following a highly successful WHO-led smallpox vaccination eradication campaign, a follow-up Expanded Programme on Immunization that began in the 1970s (which added measles and other vaccines) cut this number of deaths to less than one million, before the Gates Foundation helped to launch Gavi, a global vaccine alliance in 2000. By accelerating measles vaccine coverage, Gavi dramatically reduced the number of deaths to just under 100,000 (http://ghdx.healthdata.org/gbd-results-tool?params=gbd-api-2017-permalink/2b57f63c15fce3a393f7661aea4c7a3a), more than a 95% reduction.

The impact of measles vaccinations was especially apparent in America and Europe. Measles was eliminated in the United States in 2000,2 and by 2016 the WHO had declared measles eliminated from the Western Hemisphere.3 In that same year, the WHO European Region reported that measles reached its lowest point in Europe, just over 5000 cases in 2016.4 Global elimination was in sight.

The reversal

But lately things have begun to unravel. In Europe measles cases skyrocketed to 53,000 for the first three-quarters of 2018,5 resulting so far in almost 40 deaths, with estimates that seven countries each had over 1000 cases, including France and Italy in Western Europe.4 Measles outbreaks also occurred in Israel.6 Europe’s rise is part of a larger global resurgence with the WHO just reporting on a 30% increase compared to 2016.7 In the United States, Minnesota experienced a terrible measles outbreak in the Twin Cities in 2017,8 and in 2018 the United States has experienced 220 measles cases, including outbreaks among mostly unvaccinated individuals in New York and New Jersey, and Kansas and Missouri.9 The year 2018 was also noticeable for one of the worst US flu seasons in decades, which resulted in 80,000 deaths, including many young children who were not vaccinated against flu in spite of recommendations.10 And while Australia envisions eliminating cervical cancer caused by the human papillomavirus by the year 2028,11 the United States is not even close to projecting a target.

The gaps

The single major reason these diseases have either returned or remained is because of sharp declines in vaccine coverage. Measles is classically the first breakthrough infection we see among unvaccinated school children because it is so highly contagious.12 Sadly, it is the infant siblings of these kids who are the most susceptible and end up hospitalized for severe illness.

In European nations and at least 18 US states that allow vaccine “conscientious objections” for reasons of personal or philosophical beliefs, large numbers of school children and adolescents have stopped receiving their vaccines. In Italy, both the decline in vaccine coverage and the rise in measles are linked to a new populist coalition government working to stop mandating vaccines.13 Similar populist sentiments may explain why parents are exempting their children out of vaccines in record numbers in US Western states. Our studies find that currently the largest numbers of children not receiving their vaccines live in the American Southwest and Pacific Northwest14 (Fig. 1).

Fig. 1
figure1

State of the Antivax World in Europe and the United States Top: Heat map of counties showing kindergarteners with non-medical vaccine exemptions in 2016 to 2017. https://doi.org/10.1371/journal.pmed.1002616.g002. Bottom: Measles in Europe https://www.statista.com/chart/15856/measles-cases-in-europe/ (January–August 2018)

The US Centers for Disease Control and Prevention (CDC) just reported that about 100,000 American children have not been immunized against 14 diseases for which vaccines are recommended.15,16 Similarly the overwhelming majority of the children who died in the 2018 US flu epidemic were not vaccinated. For cervical cancer, in nine states fewer than 39% of adolescents (ages 13–17 years) receive their cervical cancer vaccine,17 so we have needlessly condemned many girls to the risks of cervical cancer.

The antivaccine movement

Fueling the decline of vaccines are well-shaped and organized antivaccine lobbies in the United States and Europe. Through more than 400 internet websites and social media,18 antivaccine groups inject fear into parents that vaccines cause autism, with claims that autism represents a form of “vaccine injury.” Their rhetoric has a populist tone invoking terms like “medical freedom” and “choice,” and promotes fake conspiracies that include a ridiculous yet vast cover-up by the CDC and other federal agencies. We are paying the price in terms of global child health.

The evidence is clear. We now have extensive scientific data showing that there is no link between vaccines and autism, while at the same time we have learned a lot about the developmental neurobiology of autism.19 We have learned that although autism is often not diagnosed until the second or third year of life, the changes in the brains of kids with autism actually begin prenatally, meaning well before a child ever becomes immunized.19 We have identified at least 99 genes associated with autism,20 and are learning more every day how those genetic changes move a child into the autism spectrum.

The uncertain future

As measles and other serious infections continue to emerge in Europe and the United States, there are additional concerns that these diseases would not stop there. I am fearful that antivaccine sentiments and attitudes are reaching the upper and middle classes of the large middle-income nations, such as Brazil and India.21 The consequences of declining vaccine coverage are nothing short of catastrophic as it could potentially reverse global goals for sustainable development.

To counter the populist rhetoric used to justify withholding childhood vaccinations, we should understand how children have a fundamental right to be vaccinated and protected against deadly infections like measles and flu. This right supersedes parental choice and freedom—just as children have a fundamental right protected by law to be placed in car seats or to live in homes where firearms are kept locked and out of reach.22 Unfortunately, the pro-vaccine voices are currently drowned out by more sophisticated and better funded antivaccine organizations.

We can slow or halt this trend. The European Commission recently identified the antivaccine movement as a health security threat and is shaping proposals to fight it. They include programs of advocacy, the creation of electronic vaccination cards to identify drops in compliance, and databases to identify emergency stockpiles of vaccines should they be needed in future outbreaks.23 In the United States where much of vaccine policy is controlled at the state level, we need to step up measures to close vaccine exemptions, especially for the 18 states highlighted above, just as this was successfully achieved in California in 2016. In parallel, we need to strengthen advocacy efforts from our major public health federal agencies, including the CDC, Food and Drug Administration, and Office of the Surgeon General. The leaders of the major social media sites and computer search engines should create a task force to address blatantly antiscience activities.

As both pediatric vaccine scientist and autism dad, I have concerned about the erosion or even loss of public health gains due to the consequences of a movement founded on incorrect assumptions, and the propagation of pseudoscience and phony conspiracy theories. We will need to find strategies to counter the antiscience and create a vibrant pro-vaccine message that supports pediatricians and helps parents to recognize the overwhelming benefits and minimal risks of vaccinations. In parallel, we must be cognizant of how antivaccine movements threaten global health and are now moving into resource-poor countries and continents.

Peter Hotez MD Ph.D. is a dean and professor of pediatrics at Baylor College of Medicine. His latest book, just released, is entitled Vaccines Did Not Cause Rachel’s Autism (Johns Hopkins University Press)

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Correspondence to Peter Hotez.

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