By Timothy J. Jones BHSc. (Paramedic), Grad. Cert. (ICP), Grad. Cert. (Aero.Med.)
In 2019, the Pacific nation of Samoa was affected by an outbreak of Rubeola (measles). A total of 5,707 people contracted the disease, with 1,868 requiring hospitalisation and 83 people dying, many of whom were children. This paper will examine factors that led up to this epidemic and whether there are lessons that can be learned with regards to anti-vaccination sentiment and the role that this may play into the post Covid-19 world.
Vaccine hesitancy refers to a delay in acceptance, or refusal of vaccines despite the availability of vaccine services. Vaccine hesitancy is complex and context specific, varying across time, place andvaccines.(1) It is influenced by factors such as complacency, convenience and confidence.(2) The term covers outright refusals to vaccinate, delaying vaccines, accepting vaccines but remaining uncertain about their use, or using certain vaccines but not others.(3) Among the hesitant are groups known as "anti-vaxxers" or "anti vax", who are generally against vaccination.(4) There is an overwhelming scientific consensus that vaccines are generally safe and effective, and therefore the World Health Organisation (WHO) characterises vaccine hesitancy as one of the top ten global health threats.(5)
Rubeola (measles) is a highly contagious viral disease, which is characterised by aprodrome of fever, coryza, conjunctivitis, and cough, followed by a diffuse exanthema (a rash or eruption on the skin) that evolves in head-to-toe order. Illness may be severe; fevers tend to be quite high, precipitating febrile seizures in very young children. There is no known antiviral treatment and left untreated this disease can result in death.(6)
In 2019, the Pacific nation of Samoa was hit with a measles epidemic that affected 5,707 people. In the space of just three and a half months, 83 people died and 1,868 were admitted to hospital. Vaccination rates as low as 31% were blamed, with Samoa becoming the exemplar of what can happen in an under-immunised population. The biggest contributing factor to such low vaccination rates were believed to be the anti-vaxxer sentiment that resonated in the community.(7)
Worldwide, the number of cases of measles quadrupled in the first three months of 2019 compared with the same time the previous year, according to the World Health Organization.(5) Before the introduction of a vaccine in 1963, "major epidemics occurred approximately every 2-3 years and measles caused an estimated 2.6 million deaths each year".(5) Numbers of measles cases were steadily declining worldwide until three years ago, when the illness saw a resurgence. Earlier this year, four European countries, including the United Kingdom (UK), were no longer seen as measles-free and it is estimated that a global total of 110,000 people die from measles each year.(5)
Measles vaccination has a degree of notoriety with regards to vaccine hesitancy. This is tributary to the history and investigation into the Measles, Mumps and Rubella (MMR) vaccine. In the UK, the MMR vaccine was the subject of controversy after publication of a 1998 paper by Andrew Wakefield and others in The Lancet reporting case histories of twelve children with new onset autism spectrum disorders (ASD) shortly after administration of the vaccine.(8) In 1998, Wakefield suggested that giving children the vaccines in three separate doses would be safer than a single vaccination. This suggestion was not supported by research, and several subsequent peer-reviewed studies have failed to show any association between the vaccine and autism.(9) It later emerged that Wakefield had received funding from litigants against vaccine manufacturers and that he had not informed colleagues or medical authorities of his conflict of interest.(9) Wakefield has been heavily criticized on scientific and ethical grounds for the way the research was conducted and for triggering a decline in vaccination rates, which fell in the UK to 80% in the years following the study.(9) In 2004, the MMR-and-autism interpretation of the paper was formally retracted by ten of its thirteen co-authors and The Lancet's editors fully retracted the paper. (10) Wakefield was struck off the UK medical register with a statement identifying deliberate falsification in the research published in The Lancet, and was barred from practicing medicine in the UK. (10)
About the Disease
Part of the reason that this disease is able to spread so prolifically is that patients are highly contagious before eruption of rash, potentially exposing susceptible people before diagnosis is clinically evident. In developed countries, rubeola has become uncommon and many physicians have never seen a case. It is important to have a high index of suspicion and to ascertain potential for exposure (e.g., recent international travel, attendance at mass gathering) to facilitate timely and accurate diagnosis. (11)
The onset of illness is marked by an influenza-like prodrome.Characteristic symptoms include fever, coryza, cough, conjunctival irritation,and photophobia. Patients may present with a fever that may be as high as 40.5 °C and may precipitate febrile seizures in very young children.(6) Defervescence often occurs several days after appearance of rash. (11) Persistent fever may indicate secondary bacterial infection complicating the course of the illness.
The onset of rash occurs 3 to 4 days into the illness beginning on the head and neck and traveling down over the ensuing 1 or 2 days. The rash then begins to fade after several days in the same descending pattern. Interestingly, this characteristic rash may be absent in immunocompromised hosts. (12)
Some patients experience diarrhoea whereas some younger patients experience croup-like symptoms (i.e. barky cough, raspy voice) or bronchiolitis (i.e.difficulty breathing). (12) Respiratory transmission occurs via direct contact with respiratory secretions or airborne contact with respiratory droplets. The virus remains infective in droplet form in air for several hours.(11) Measles is highly communicable, infecting the majority (more than 90%) (13) of susceptible exposed hosts, according to experts. Contagious from several days before to several days after rash onset. Most infectious during late prodrome at peak of cough and coryza.(11) The incubation period for the disease is approximately 8 to 12 days from exposure to onset of symptoms. (14)
Lifelong immunity develops after primary infection with the disease.(13) Most people develop lifelong immunity after appropriate vaccination.(15) In developing countries with low immunizationrates; Rubeola is primarily a disease of childhood. Most children acquire the infection at some point; therefore, disease in adults is relatively uncommon.(15) In developed countries with high immunisation rates; outbreaks may include nonimmune people of any age. Very young children, who have not been fully vaccinated yet, are affected most often.(15) In temperate climates, infection occurs most often in winter. Outbreaks in developed countries can be attributed to; lack of or incomplete vaccination, clusters of intentionally unvaccinated children, measles imported from international travel and the immunocompromised. (16)
Although there is no anti-viral treatment once the patient has contracted the disease, vitamin A is recommended for young children to mitigate disease and prevent complications. Most common complications are otitis media, viral or bacterial pneumonia, encephalitis, and keratoconjunctivitis.(6) In developing countries, Rubeola remains a common cause of death in children, usually due to dehydration, pneumonia, or encephalitis. (6) Rubeola vaccine is highly effective in preventing infection among vaccinated people, but a 95% uptake rate is required to provide herd immunity and to prevent Rubeola from becoming endemic in a population. (6)
The Samoa Epidemic
Immunisation rates declined in Samoa after two babies died on Savai'i island following measles, mumps, and rubella (MMR) vaccinations that were wrongly prepared by nurses who were later jailed. The Expanded Programme of Immunization (EPI) was interrupted for 8 months while the incident was investigated and, afterwards, the Ministry of Health ordered that doctors check all babies before immunisations by nurses. The outbreak has been attributed to a sharp drop in measles vaccination from the previous year, which led the country to suspend its measles vaccination program.(17) The reason for the two infants' deaths was incorrect preparation of the vaccine by two nurses who mixed vaccine powder with expired anaesthetic.(17) As of November 30, more than 50,000 people were vaccinated by the government of Samoa . (17)
Several vaccination myths contribute to parental concerns and vaccine hesitancy. These include the alleged superiority of natural infection when compared to vaccination, questioning whether the diseases vaccines prevent are dangerous, whether vaccines pose moral or religious dilemmas, suggesting that vaccines are not effective, proposing unproven or ineffective approaches as alternatives to vaccines, and conspiracy theories that centre on mistrust of the government and medical institutions. (18)
Other safety concerns about vaccines have been aggressively promoted on the internet, as well as through numerous other mediums. These include that vaccination can cause epileptic seizures, allergies, multiple sclerosis, and autoimmune diseases, such as type 1 diabetes, as well as hypotheses that vaccinations can transmit bovine spongiform encephalopathy, hepatitis C virus, and HIV. (19)
New Zealand immunologist Dr Helen Petousis-Harris stated that, judging by social media activity, Samoa has a “thriving anti-vaccine community”. She said international anti-vaccination advocates have become more active after the 2018 deaths of the two infants due to a nurse error while administering the MMR vaccine. “Certainly, the international anti-vaccine community have moved in since last year,” she said. “Their pursuit of self-interest at the expense of the Samoan community is deplorable”. (7)
Some of the sentiments that were shared by prominent Samoans’ within the community were as follows. Samoan anti-vaccination advocates like coconut farmer Edwin Tamasese are calling for Samoans to use vitamin A instead of the vaccine, while alternative healer Fritz Alai’asa has had his alkaline water ‘cure’ shut down (Hendrie, 2019). Samoan-Australian online influencer Taylor Winterstein has likened the new mandatory vaccination regime to Nazi Germany, claiming it is fascism, following similar claims by Samoan rugby player Eliota Fuimaono-Sapolu.(7)
Ms Winterstein states that undoubtedly the MMR deaths played a significantpart in the strong vaccination hesitancy. Nurses during that time recall their experience, stating when they did home visits, mothers would chase them away. Nurse manager Lonise Malo Time says, “They would say ‘get out of our place, you are killing our babies.’ We were not trusted by the public anymore.” Palanitina Tupuimatagi Toelupe, the former Director General of Health who was General Manager of the Samoan National Health Service at time of the deaths, called the incident a “wake-up call” for nurses that made them re-examine their practices and accept retraining.(7) Vaccine hesitancy was still strong at the start of the outbreak, but says that demand grew as the number of people affected by the outbreak continued to grow. A compulsory mass vaccination campaign brought rates back up to 95%.
To prevent under-immunisation in the future, the government introduced a new law in December requiring all children to be fully immunised before starting primary school, evidenced by a special yellow certificate. Encouragingly, Samoa was one of the first to introduce travel restrictions and quarantine when the COVID-19 pandemic began. As of June 24, 2021, the country has had no cases. (7)
Vaccination Hesitancy in Australian
Similar sentiments can be echoed within Australia, with numerous celebrities sharing their views on vaccination hesitancy. With the prominence and accessibility of social media, it has never been easier for people to not only express their views, but to also find a like-minded community to give credibility to their claims. In Australia, the majority of children receive all vaccinations according to the recommended schedule with rates in December 2018 recorded at 94.04% fully vaccinated at 12 months and 94.67% for 5-year-old children.(20) The rate of formal conscientious objection due to personal or religious beliefs was recorded from 1999 until 2015 and peaked at 1.77% in 2014.(21)
Thematic analysis focused on explaining decision-making pathways of parents who refuse vaccination. Common patterns in parents’ accounts included: perceived deterioration in health in Western societies; a personal experience introducing doubt about vaccine safety; concerns regarding consent; varied encounters with health professionals (dismissive, hindering and helpful); a quest for ‘the real truth’; reactance to system inflexibilities and ongoing risk assessment.(22)
Health professionals in general practice, maternal and child health, paediatrics and allied health may, at times, encounter families who choose not to vaccinate. Many clinicians find clinical encounters with non-vaccinating parents to be complex and challenging.(23)
There were many lessons to be learned from the Samoa outbreak of measles. It is a case study into how the mistakes of two nurses can lead to a mistrust within the greater community and a subsequent prominence in vaccination hesitancy taking hold.
Promisingly, the immunisation rate for MMR has drastically improved in Samoa. Public health campaigns continue to be in the forefront of the health care system in Samoa which is still celebrating zero COVID-19 cases.
In Australia, many health care professionals still have difficulty in appropriately managing objections regarding vaccination and vaccination hesitancy.
Perhaps additional training could be provided to healthcare professionals so that they might better be able to answer the questions and rebut the mistruths that many of the vaccine hesitant have. The author also suggests that greater public health campaigns could be introduced in Australia, similar to what occurred in Samoa, to ensure that public education is increased surrounding the efficacy of vaccinations. This was undertaken in Samoa following the measles epidemic and Samoa went from one of the lowest immunisation rates in the world to being on par with many developednations.
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TimothyJ. Jones BHSc. (Paramedic), Grad. Cert. (ICP), Grad.Cert. (Aero.Med.) is a final year medical student at the Oceania University ofMedicine. He has worked as a paramedic for 14 years including as a Critical Care Flight Paramedic on fixed wing and rotary wing aircraft as well as lecturing at the University of Sunshine Coast and Australian Catholic University. He has also worked as an trek medic and expedition leader on treks through austere environments throughout the world. His passions are expedition medicine and retrieval medicine.