Intended for healthcare professionals


Philippines measles outbreak is deadliest yet as vaccine scepticism spurs disease comeback

BMJ 2019; 364 doi: (Published 14 February 2019) Cite this as: BMJ 2019;364:l739
  1. Owen Dyer
  1. Montreal, Canada

Seventy people, most of them children, have died of measles in the Philippines since the start of 2019,1 the country’s health ministry has said, as many as were killed by the virus in the entire World Health Organization European region in all of 2018.2

There were over 18 000 cases of measles in the Philippines in 2018, compared with about 2400 in 2017. Measles vaccination rates fell from a 2014 high of 88% to 73% in 2017, then plummeted to about 55% last year.

The sharp drop came in the wake of a political battle over Sanofi’s dengue vaccine Dengvaxia, which was discontinued in the Philippines last year over safety concerns despite the company’s protests, as politicians traded blame.3

Lotta Sylwander, Unicef representative in the Philippines, said the agency was “deeply concerned” about the outbreak, adding that about 2.5 million children under five are not vaccinated against measles. “There has been a notable unwillingness on the part of parents to vaccinate their children on time,” she said.

The country’s Epidemiology Bureau said that 79% of those killed by measles this year were not vaccinated.

Measles has now gained a firm foothold in the densely populated capital Manila, as well as four other regions, and risks spreading further, said the government, urging parents to take up free vaccinations.

The Philippines is an exception in WHO’s Western Pacific region, where vaccination rates have been climbing faster than elsewhere in the world.

But measles has also been on the rise in regions such as Europe where overall immunisations are up, because of uneven coverage that leaves pockets of increased susceptibility. The deadliest recent outbreak before the Philippines was in Thailand, which has generally good coverage, but where 22 people died of measles last year in the predominantly Muslim southern region.

The number of cases worldwide rose 30% from 2016 to 2017, according to WHO. Globally, first dose vaccine coverage has stalled at 85% for several years, while second dose coverage is 67%. The coverage needed for herd immunity is 95%. Last month, WHO named vaccine hesitancy as one of its top 10 threats to global health for 2019.4

Discussing the European data for 2018, WHO epidemiologist Zsuzsanna Jakab said: “The picture for 2018 makes it clear that the current pace of progress in raising immunisation rates will be insufficient to stop measles circulation. While data indicate exceptionally high immunisation coverage at regional level, they also reflect a record number affected and killed by the disease. This means that gaps at local level still offer an open door to the virus.”

The biggest gap in Europe has been in Ukraine, where the outbreak of war in 2014 severely disrupted immunisation programmes. Ukraine leads the world in measles cases, with 53 218 cases in 2018, or 121 per 100 000 people. Some 3142 cases were registered in Ukraine in the past week. But the average patient is older than in the Philippines, and there have been fewer deaths, 16 since 2019 began.

In the US, a measles outbreak in Washington state appears to have stabilised, with 53 cases found, but new cases continue to crop up in other states, and there are 101 cases in 10 states overall. Washington state has a 90% measles immunisation rate and 90% of those infected were unvaccinated. New York state also faces a concentrated outbreak, in a non-vaccinated religious community.

American media this week carried several stories about teenagers seeking out their own vaccines against the wishes of anti-vaccine parents, after one 18 year-old’s Reddit post on the subject went viral.56

Ethan Lindenberger, of Norwalk, Ohio, wrote of his parents: “Because of their beliefs I’ve never been vaccinated for anything, God knows how I’m still alive.”

He sought out his own vaccinations on turning 18, but told the Washington Post that his 16 year old brother is being prevented from getting shots by their mother against his wishes. Of his 2 year old sister, also not vaccinated, he said: “It breaks my heart that she could get measles and she’d be done.”

The American Academy of Paediatrics has called on Facebook to do more to remove misleading anti-vaccine information from its website. Facebook has accepted advertising revenue from groups like Vax Truther, Anti-Vaxxer, and Vaccines Revealed.

Britain’s Guardian newspaper gained access to closed groups on Facebook where pre-approved members are fed false anti-vaccine information, often by people with a clear financial interest in discrediting vaccines.7

One such group, called Vitamin C and Orthomolecular Medicine for Optimal Health, tells its 49 000 members it is “not an anti-vax group” but its administrator wrote in one message: “Until they become safe and not driven by money I would avoid all vaccines.”

That administrator, Katie Gironda, also runs another Facebook group called Vitamin C Against Vaccine Damage. She is listed on LinkedIn as chief executive of an online business called Revitalize Wellness, which sells high dose vitamin C. Warnings about vaccines are interspersed with injunctions to “shop now” for vitamin C.

The Guardian related a December post to one of the groups from a mother in Canada, describing herself as a “first time mom with a 6 month old daughter who is completely vax free. My daughter is sick, I’m so upset and worried. I have always felt confident in my decision to not vax but I’m worried about what she may have contacted [sic].”

A fellow member wrote back: “Baby needs a vitamin C IV.”


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