In a major blow to public health, Canada has formally lost its measles elimination status after a year-long effort to rein in an outbreak that has affected communities across the country.
The Pan American Health Organization, a specialized United Nations health agency, notified the Public Health Agency of Canada of the status revocation on Nov. 10 — a designation Canada has held since 1998.
“It is an embarrassment that with all our resources we weren’t able to stop the resurgence of measles,” says immunologist Dawn Bowdish, a professor in McMaster’s Department of Medicine and executive director of the Firestone Institute for Respiratory Health.
Bowdish has been outspoken about the dangers of measles and the consequences of Canada’s status being revoked.
A country loses its elimination status after sustaining an outbreak for more than 12 months. Regaining elimination status is possible — a country needs its outbreak to go interrupted for at least 12 months.
We spoke with Bowdish about Canada’s change in status, what it means for the average person and what needs to be done for Canada to get back on track.
Before we get too deep, what is measles?
Measles is a highly contagious viral illness. In the pre-vaccine, pre-antibiotic era, measles killed more people than influenza and is still the top killer of all the vaccine preventable infections in the world today.
The reason measles is so dangerous is that it kills immune cells, and with them dies our immune memory — a collection of all the immune responses we’ve built up to all the things we’ve experienced in our life.
It takes time to rebuild that immune memory, which is why people who have had measles have more visits to their doctor, more antibiotic prescriptions, and more infections for months to years after they’ve recovered.
Measles leaves people vulnerable to bacterial infections which need to be treated by antibiotics, but antibiotic resistance rates are much higher than in 1998 when measles was last eliminated in Canada.
There is a very real concern that this will make these measles-associated infections more difficult to treat and deadly.
The current measles outbreak has been happening for over a year. What were the causes for this?
There is no one factor that spiralled out of control and caused this outbreak; instead there are many reasons that intersected.
Prior to the pandemic, vaccination rates for measles, mumps, and rubella (MMR) were decreasing. During the pandemic, many childhood vaccination programs were disrupted, and our family doctor crisis has meant that it could be very difficult for families to get their children vaccinated.
Cuts to public health that proceeded the pandemic meant that enforcement and outreach efforts were being reduced.
There is no substitute for community-based public health outreach. Decades of research shows that you need long-term relationships to build trust in communities that have doubts about the importance of vaccination.
In many provinces, including Ontario, we have been too liberal with vaccine exemptions, which has also contributed to falling rates vaccination.
In addition to the systems issues, misinformation is obviously problematic and particularly difficult to stop.
Practically speaking, what does the revocation of the elimination status mean for Canada?
For most people, this won’t affect their daily life. Whether or not we have a formal designation does not change the amount of measles that is circulating.
However, it does mean that travellers to Canada will be warned that they should get a measles vaccination to stay safe. It also means we are on a list of other countries who are racked by war or civil unrest or don’t have public health infrastructure to keep measles at bay.
It is an embarrassment that with all our resources we weren’t able to stop the resurgence of measles.
How does Canada get back on track?
We will need to sustain investment in public health, especially outreach to vaccine-hesitant communities. We need to fix the family doctor crisis and to create places where parents can get vaccine information if they have questions or concerns. These could be nurse practitioners or physicians with special training in vaccination.
Many parents have questions that their family doctors can’t answer, and if they can’t get the answers they need, they will choose not to vaccinate.
Because measles is so dangerous during pregnancy, we will need to think about how we deliver prenatal care. In parts of the world where measles and other viruses circulate, people who are planning to get pregnant might have their antibodies checked or get vaccinated. We generally don’t give these vaccines to pregnant people, but knowing if they are vulnerable will help them make good decisions and can mean that their care team can prepare to provide prophylactic treatment should they be exposed.
We will need a national vaccine registry or at least easy to access provincial ones. School based catch-up clinics are one of the easiest ways to help parents out, especially working parents who would be challenged to find a public health unit or a family doctor to vaccinate their child.
Nothing is cheap, nothing is easy, but it is critical.
There are many ways people can take this news. Are there any glimmers of hope?
For years public health teams have been doing more with less and they have been doing an excellent job. Just think what they could do if properly resourced.
We also do have a childhood immunization survey that comes out every few years and shows that most parents are confident in childhood vaccination safety and its importance.
Most parents who didn’t get their children vaccinated didn’t do it because they had access challenges not because of distrust or misinformation. This means we must focus on access.