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Community Health Measles Outbreak in Southern California Unit

COMMUNITY HEALTH

CommunityHealth: Measles Outbreak in Southern California

Unit

LiteratureReview

Since late last year, several cases of measles infections have beenreported creating fears of an outbreak. Southern California is one ofthe hard hit areas. This area comprises of the ten southern-mostcounties of the state of California. The area is largely urbanizedand has a relatively high population with a total of 37.5 millionpeople as of 1st July 2011 creating a high spread risk.From a public health point of view, the area performs relatively wellwith statewide fertility rates at 63.3 per 1000 women aged 15-44years, death rates of 634.0 per 100 000 people (CDPH, 2014a). SanBernardino recorded a higher age-adjusted death rate of greater than160.6. By cause of death, cancer is a leading cause at 150.7 per100,000 people followed by coronary heart disease at 105.0Alzheimer’s disease at 30.2 and diabetes at 20.0. Communicableinfections are also high chlamydia leading at 434.5 cases per 100,000people, followed by gonorrhea at 326.2. From this, it is clear thatcommunicable diseases are not common diseases. About 22.6% of allindividuals aged 18 years and above live in poverty. Measles, amongother preventable diseases, have shown higher prevalence rate amongthe low income and minority groups (CDPH, 2014b)

As of 11th of April, 56 cases had been confirmed by theCalifornia State Department of Public Health for this year alone.Year 2013 reported a total number of 189 cases spread out through theUS. These cases were linked to infected immigrant populations fromChina (CDC, 2014). This year, no source has been identified so farbut the number of cases continues to grow. Orange county has reportedthe highest number of cases at 22, followed by Los Angeles with 10(CDPH, 2014). The California Department of Public Health (CDPH) hasresponded by carrying out awareness programs that emphasize onparents to take their children for immunization and providing basiceducation on vaccination. This is based on the fact that 99% ofchildren develop immunity to measles after two vaccinations (Gore &ampBourbeau, 2014).

Southern California has reported numerous cases of measles despiteavailability of vaccines. This begs the question on whether parentsare actually vaccinating their children as recommended by healthpractitioners. The risks of measles include death and seriouscomplications (Mishra et al., 2008). Vaccination isrecommended for infants at the age of 12-15 months (Flanagan 2014).Vaccination is recommended highly because the disease is viral andhighly contagious thereby putting people close to an infected personat risk (Moss &amp Griffin 2012). However, some people havereligious, cultural or self-imposed beliefs on the suitability ofvaccines that are not medically supported (Constable, et al.,2014).

There are two main opposing views on vaccine use and immunization.There are those opposed and those in support of vaccine use. Flanagan(2014) notes that these views on vaccines are not uniform as somepeople may accept some vaccines and resist others. Studies have shownthat social economic levels can influence timing of vaccination(Larson et al., 2014) while in most cases, religious,scientific and cultural beliefs influence attitude towards vaccines(Flanagan, 2014).

The health belief model explains the causes of hesitancy orresistance of vaccination. The model posits that individuals feelthat they can avoid negative health outcomes such as HIV and Measlesby staying ‘safe’ away from possible contaminants or by simply aperceived insignificant susceptibility. The model also posits thatindividuals can hesitate to take vaccinations if they feel that thetargeted illness is not very severe (Constable, et al., 2014).Such attitudes vary with age, sex, ethnicity, personality,socioeconomic status, cost, social group influences, motivation onhealth grounds and knowledge levels among others. Higher socialeconomic status, higher education levels are promote acceptance tovaccines while lower levels of the same promote hesitance tovaccination as per studies in the US and Nigeria. Furthermore,vaccination and general health awareness communication promoteacceptance of vaccination as per other studies in India andBangladesh while negative stories on vaccination hindered acceptanceof vaccination (Larson et al., 2014).

The WHO and other national health bodies have invested heavily inmeasles vaccinations to eradicate measles completely by 2020. Is thisa feasible outcome from a medical perspective? Bellini and Rota(2011) explore this possibility in depth. Measles can be eradicatedglobally as has smallpox and rinderpest, which are also viral, havebeen eradicated through vaccination. Measles and Polio are also on aprogram to be eradicated globally. Measles vaccination has achievedsignificant success so far with prevalence reducing by 90% from thepre-vaccine era. In 1980 alone, before the measles vaccine, 2.6million measles-related deaths were recorded globally. The WHOestimates that 4.5 million lives have been saved through measlesvaccination since 2008.

The US is reversing on progress made in vaccination. A study byConstable et al. (2014) indicates that increased investment inmeasles awareness has not resulted to increased uptake ofimmunization. The study shows that in some states, vaccine exemptionfor non-medical reasons for children stand at over 5% in some states.This explains the recurrence of measles in the US after beingdeclared completely eradicated in the US as of 2000. However, the CDCattributes the re-emergence of measles in 2011 to immigrants (CDC,2012) To curb such cases of non-medical exemption from vaccination,the federal and state government has responded legally in a ratherlethargic manner. Exemptions to vaccinations on religious grounds areallowed by law in 48 states, California included. Another 20 statesallow philosophical and personal belief vaccine exemption.Mississippi and West Virginia do not recognize the two grounds.

The validity of these exemptions has elicited a major debate. On oneside are people who feel that vaccination should be made mandatory toprotect other people if not themselves while on the other arepro-choice people arguing that people should have a choice to receiveor not to receive vaccination as a basic human right (Welch, 2014).In the past, the federal government has made some vaccinationsmandatory such as for hepatitis B. This somehow validates the questfor mandatory vaccination of measles in all states. Another reasonthat supports mandatory vaccination is recent activities ofindividual seeking exemption from vaccination. Constable et al.,(2014) report that during the 2008 measles outbreak in San Diego, 41%of people who had applied for vaccine exemption or deferredvaccination for their children gladly opted for post exposurevaccination after their children were exposed to the virus.

The outbreak of measles in California and the larger US can also beexplained by inefficiency of the current vaccine rather thanincreased cases of vaccine exemption. Bellini and Lota (2014) notethat there have been a handful of cases of measles infection invaccinated individuals. Gore &amp Bourbeau (2014) say this handfulamounts is 1% of all immunized individuals. These cases, known asvaccine failure cases, have exhibited significantly modified and lesssevere case of measles. Bellini and Lota explain this modification ofthe disease and accompanying symptoms show that the vaccine is alsolargely effective in key areas. In a decade long study on theprogress of a number of children after measles vaccination, theauthors report the study reported a significant decrease in antibodyconcentration. They thus suggest that to completely eradicate thedisease as envisioned by WHO and other bodies, there is a need tokeep vigilance even on the vaccinated population.

With such challenges in the measles eradication, there are a numberof alternatives suggested to address them. Constable et al.(2014) suggest increased public education and awareness creation onthe need for vaccination. The author believes that more targetededucation can be directed towards persons applying for vaccineexemption on various grounds. Flanagan (2014) believes that there isno significant difference in mandatory vaccination against hepatitisB and voluntary vaccination of measles given that the objectives arethe same. Another strategy is suggested by Mishra et al.(2008) who say that vitamin A supplementation reduces measles relatedcomplication for the confirmed cases. The authors also suggestvitamin supplementation alongside vaccine especially among people oflow socioeconomic status in the society.

It is therefore clear that southern California is greatly affected bypoor public knowledge and awareness on the need for measlesvaccination. The loop in the law that recognizes vaccine exemption onreligious and personal beliefs grounds works against the plan oferadicating measles from the world by 2020. The CDPH should embark onmore intensive public awareness programs and offer targeted andspecialized education to applicants to vaccine exemption to make themunderstand the need for measles vaccination and the risk that lack ofvaccination poses to them and others due to reported cases ofvaccination failures. Alternatively, there is the option of taking ataking a legal approach to the issue by introducing the debate inlocal congress in a move to make measles vaccination mandatory.

References

Bellini, W. &ampLota, P. (2011). Biological feasibility of measles eradication. Virusresearch. 162:

72-79.

CDC (2014). Measlesoutbreak. Retrieved online on 15.04.14 from

http://www.cdc.gov/measles/outbreaks.html

CDPHa. (2014).Health Advisory – February 19, 2014: 14 Measles Cases in theState of

California in2014 Look for Signs of this Highly Contagious Disease. Retrievedonline on

15.04.14 from http://www.cdph.ca.gov/HealthInfo/discond/Documents/CDPHMeaslesHealthAdvisoryFeb2014.pdf

CDPHb (2014). Countyhealth status profiles 2014. Retrieved online on 15.04.14 from

http://www.cdph.ca.gov/programs/ohir/Documents/OHIRProfiles2014.pdf

Constable, C.,Blank, N. and Caplan, A. (2014). Rising rates of vaccine exemptions:Problems

with current policyand more promising remedies. Vaccine 32(16)1793–1797

Flanagan, J. (2014).A defense of compulsory vaccination. FEC Forum 26: 5-25.

Gore, A. &ampBourbeau, H. (2014). Public Health Director Stresses theImportance of Measles

Vaccination. Retrieved online on 15.04.14 fromhttp://www.cdph.ca.gov/Pages/NR14-023.aspx

Mishra, A., Mishra,S., Jain, P., Bhadoriya, S., Mishra, R. &amp Lahariya, C. (2008).Measles related

complications and the role of Vitamin A. Supplementation IndianJournal of Pediatrics, 75:887-890.

Larson, H. Jarrett,C., Eckersberger, E., Smith, D. &amp Paterson, P. (2014).Understanding vaccine

hesitancy aroundvaccines and vaccination from a global perspective: A systematic

review of publishedliterature, 2007–2012. Vaccine 32: 2150–2159.

Welch, M. (2014).Should Vaccines Be Mandatory? A libertarian debate on immunizationand

government. Reason.45(11):18-20.