An unusual silence fills the waiting area of my fellow paediatrician’s office in suburban Maryland, in the United States. On a typical day, one would expect to see the animated bustle of children. Nowadays, only two out of 10 scheduled visits might take place. Unused vaccine vials rapidly accumulate as families shelter at home.
With lockdowns and fears of the pandemic, this scene has been playing out in paediatricians’ offices around the country.
Data from the Centres for Disease Control and Prevention’s Vaccine Safety Datalink show an almost 50 per cent drop in children being vaccinated for measles during the first quarter of 2020, compared with the same period in 2019.
This situation also unfolded across the world as countries ordered lockdowns of varying severity. At least 25 countries suspended mass measles immunisation campaigns in the face of the pandemic as of late last month, according to Unicef. As the coronavirus continues its relentless spread, leaving death and economic devastation, other ancient diseases may gain a foothold as vaccination rates drop precipitously.
Disease surveillance within and across nations is essential to these public health efforts. Neither the coronavirus nor the measles virus respects geographic boundaries.
Measles can cause pneumonia, swelling of the brain and death. Very young children and susceptible adults are more likely to suffer from these complications. Like the coronavirus, it is spread person-to-person through droplets in the air. But the measles virus is about 10 times more transmissible than the coronavirus, and often deadlier. Vaccination coverage of up to 95 per cent is needed to prevent measles transmission in communities.
Before the pandemic, global measles cases were already surging, reaching an estimated 10 million in 2018 with 140,000 measles-related deaths — a 58 per cent increase from the previous two years. Although measles was all but eliminated in the United States in 2000, misinformation and a loss of public trust in vaccines resulted in 1,200 cases of measles in 2019 — the highest number in almost three decades.
In recent years, many measles cases entered the United States from foreign travel destinations. Now, with diminished vaccinations of children causing a wider gap in community immunity, there is clear and present danger that hard-won gains could be reversed. As schools start reopening their doors, vaccination rates among children could improve. However, school vaccination requirements are not ironclad; medical and non-medical exemptions will leave some children unprotected. Public understanding of this risk and improved confidence in vaccines is crucial.
The return of polio
And yet, the anti-vaccine movement has seized on the COVID-19 pandemic as a rallying point, inexplicably arguing against any vaccine that may be developed. The assertions are baseless and endanger public health.
At the same time, other deadly scourges lurk in the shadows. Poliomyelitis, one of the most feared diseases of the early 1900s, was headed toward global eradication, with only a few remaining pockets of transmission in the world. Now these clusters are expanding. The Global Polio Eradication Initiative’s interactive map indicates that polio cases have increased this year. Diphtheria, another deadly disease of the early 20th century, has resurged recently in places like Venezuela, Bangladesh and Yemen, where state failure, conflict or the displacement of populations have severely weakened public health systems.
The danger is that the continuing pandemic will disrupt immunisation and monitoring of infectious diseases, which could lead to the further spread of these ancient diseases into new populations instead of being consigned to history.
Governments should establish vaccination as an essential service and reinstate services to stop diseases from re-emerging, particularly among vulnerable populations.
No example from the recent past could be more poignant than the West African Ebola virus disease outbreak in 2014, whose devastating impact extended far beyond just Ebola cases and deaths. Ebola overwhelmed local health care systems, while societal stigma and anxiety led to reduced vaccination. An estimated 200,000 cases of measles may have resulted because of these disruptions.
And then, in 2019, twice as many children died from a fast-moving outbreak of measles in the Democratic Republic of Congo than from an Ebola outbreak there that received far more public attention.
As the pandemic advances and universal immunisation keeps slipping worldwide, preventable diseases in children will keep surging in the background. Many outpatient dispensaries and vaccination clinics were shuttered as health care systems shifted to support the response to the coronavirus, public transport became unavailable, and fear of COVID-19 became rife. The World Health Organisation says routine immunisation services should be prioritised, yet estimations indicate that over 100 million children around the world are unlikely to receive their basic vaccines.
The Greek historian Thucydides vividly described the plague of Athens of 430 BC. He attributed the strikingly deadly toll not just to disease but also to the failed societal response. History can be instructive, but only if we take its lessons seriously.
Avoiding vaccine-preventable deaths is critical for nations to preserve their gains in child survival. To do so, governments should establish vaccination as an essential service and reinstate services to stop diseases from re-emerging, particularly among vulnerable populations. Next, while COVID-19 control measures are being instituted, countries must catch up on missed immunisation. Third, governments should improve how they communicate with the public, to allay concerns about vaccinations and re-establish community demand for them.
Finally, health agencies should expand collaborations with nutrition, education and other government operations — and especially with regional and national governments. Disease surveillance within and across nations is essential to these public health efforts. Neither the coronavirus nor the measles virus respects geographic boundaries.
In the face of the current pandemic, it can be easy to lower our guard against the potential for future public health disasters. We cannot let that happen. Governments at all levels must work together to protect children from the deadly preventable scourges we have done so much to eradicate.
— Anita Shet is the director of child health and senior scientist at the International Vaccine Access Center and a pediatric infectious diseases specialist at the Johns Hopkins Bloomberg School of Public Health.