An Alberta Doctor’s Back-to-School Memo on Measles and Vaccines

As Albertan parents send their children back to school this week, the province continues to lead Canada in number of measles cases per capita. The latest count, reflecting the week ending Aug. 16, tallies 47 new cases, more than half of all in Canada and nearly double those in next-highest British Columbia.

Ontario had just three new cases, despite leading all provinces in total measles cases over the past 33 weeks (2,369) compared with runner-up Alberta (1,778).

The numbers underestimate the true number of cases. Those who don’t present to the health-care system aren’t counted, although they are at least as likely to transmit their infection. Patients who decline testing or whose doctors make the diagnosis without lab confirmation also reduce the number reported.

Measles is generally considered the most infectious of all human diseases and can be readily transmitted, for example, to the far end of the classroom or even to students in the next group in the classroom after the infectious student has left. And people can infect others for about four days before any rash symptoms appear.

Everybody with measles feels pretty sick, but most recover on their own (and there is no specific treatment). However, significant complications are far from rare. In fact, measles caused two million deaths a year prior to the advent of the vaccine.

Ear infections or pneumonia each occur in about one in 10 patients. A significant proportion require hospitalization and a few need intensive care. Patients can be left with deafness or permanent neurological effects. Infants less than two years old and people with immune suppressive conditions or treatments are particularly at risk.

Measles in pregnant women increases the risk of low birth weight, prematurity and fetal death. The overall measles death rate is estimated at between one and 10 per 10,000 people infected in wealthy countries like Canada — still much too high for a totally preventable disease.

Less well known is that the overall immune system takes a major hit from measles, increasing vulnerability to other infections in subsequent months.

As an infectious disease specialist and professor of public health, I feel compelled to remind that there is no need for Albertans to face such risks, because vaccination has long been proven an effective prevention.

Vaccines have saved over 150 million lives

Vaccinations against not just measles but a number of infectious diseases have had an enormous impact on increasing life expectancy and on children’s health. As a result, their deployment has long been an important element of health care and the public health policy of governments of all political stripes around the world.

Smallpox was estimated to have killed 500 million people in the last 100 years prior to its eradication by resolute, innovative programs to deliver the vaccine everywhere in the world.

Polio terrorized Canadian parents as recently as the 1950s and has continued to cause deaths and cases of paralysis in low-income countries. Cases have been reduced by more than 99 per cent by a massive global vaccine delivery program to surmount incredible operational challenges in some of the world’s poorest countries and active war zones. It is estimated that over 20 million people are able to walk today who would have been paralyzed in the absence of the vaccine program.

Polio was headed for eradication like smallpox, until a combination of factors, including varied local forms of anti-vaccine sentiments, stalled progress in the final stages.

A recent article in the pre-eminent medical journal Lancet estimated that vaccines have saved 154 million lives in the past 50 years, mostly in children under five. The impact of vaccines on the remarkable increase in life expectancy of the last century almost certainly surpasses that of advances in medical care such as surgery and antibiotics.

Among over 20 diseases for which vaccines are licensed in Canada, each disease/vaccine pair has some unique features depending on the frequency and severity of the disease and the characteristics and efficacy of the specific vaccine. However, the overall benefit and cost benefit of vaccines available in Canada are overwhelmingly positive.

Discussion about vaccines often focuses on individual benefit and perceived risk as well as on individual autonomy and rights. This limited perspective overlooks the critical fact that a fundamental intrinsic benefit of vaccination is the protection of other individuals, especially those who cannot benefit from vaccine protection themselves, and blocking ongoing transmission in the population as a whole. When enough people in a community are vaccinated against a contagious disease, then most others are protected from infection because there is little opportunity for the disease to spread — so-called “herd immunity.”

Hence vaccination can be thought of as a responsibility analogous to other expectations of citizens such as stopping at red lights and paying taxes.

Anti-vaccine beliefs and movements have been with us as long as vaccines. Early opponents of the smallpox vaccine raised concerns related to the bovine origin of the vaccine. Some religious authorities interpreted vaccines as interfering with God’s will. In more recent times, pushback against mandatory vaccination, among other unprecedented restrictions imposed during the COVID pandemic, has extended to affect attitudes toward vaccines in general for some people.

This response appears to have accelerated a trend that was emerging some years before COVID. Complacency toward diseases such as measles, which has been officially eliminated from Canada since 1998, the unfolding emergence of a broader distrust in experts and the expanding influence of social media have also influenced attitudes to vaccines.

Questions that would long have been seen as belonging in the domain of health and science have become politicized. The appointment by U.S. President Donald Trump of a vocal anti-vaccine advocate, Robert F. Kennedy Jr., as secretary of health is an extreme example. However, we have recently seen political ideology have a huge impact on vaccination policy and health here in Alberta.

Getting to mass immunity

Because measles transmits so efficiently, a high proportion of the population must be immune to measles in order to block person-to-person spread when the virus is introduced into a community. Fortunately, two doses of the vaccine provide near 100 per cent lifelong protection so a person can avoid disease themselves and prevent spread to others over their lifetime.

Over six billion doses of measles vaccine have been administered worldwide. Significant side-effects are rare. The idea the vaccine was somehow connected to autism was based on fraudulent data and has been definitively and repeatedly debunked. In 2010, a group of scientists and epidemiologists determined that eradicating measles totally from the planet, as was done with smallpox, was entirely feasible and should be attempted. Sadly, that is not the direction we’re going in 2025.

From Jan. 1 to Aug. 23, a total of 152 Alberta patients have required hospital admission for measles. None died, but their hospitalization indicates that they were seriously ill, placing further strain on the health-care system and putting other vulnerable patients at risk as infections can spread in health-care settings.

Incredibly, we must now give the same travel advice to parents of infants less than 12 months old who are simply travelling in Alberta as we do to those heading to developing countries.

An effective response to a measles outbreak has multiple parts and the details are critical, but the basic principle is not complicated: more people need to be vaccinated to break the chain of transmission as well as protect their own health.

Albertans need to hear from the minister of health and the provincial medical officer of health with a clear and highly visible message.

We need to make it as easy as possible for Albertans to get vaccinated.

We also need to raise awareness and knowledge among health-care providers, most of whom have never seen a case, and promote the incorporation of vaccine education and availability into routine health-care encounters.

Fortunately, Albertans and dedicated public health staff have increased measles vaccine delivery markedly starting this spring. But we are still a long way short of the target level of “herd immunity.” Measles has highlighted the importance of bolstering provincial government public health programs and leadership in ways that support equitable, efficient and effective vaccine access.

Listen to the canary in the coal mine

Measles is not only a serious issue on its own, but the canary in the coal mine, reflecting the risk of other vaccine-preventable diseases making a comeback with falling vaccination rates. This is what happened with diphtheria, for example, after the breakdown of preventive health services in the former Soviet Union.

COVID caused millions of deaths globally and immense societal disruption.

Although there were differences in many aspects of the response in different jurisdictions, the level of vaccine coverage was clearly a critical factor in reducing deaths. COVID is winding down but it is definitely not gone. In the last full season, 753 Albertans died of COVID. The vaccine is not as good as the measles vaccine against current strains of COVID, but it substantially reduces illness and death.

Unexpectedly, and out of step with expert advice, the Alberta government has announced a radical change in coverage for COVID vaccines. It will be funded only for very limited groups, specifically not including the majority of the elderly who are at greatly increased risk of hospitalization and death.

The expected price of $100 is a significant deterrent to someone on a basic pension. This policy change will undoubtedly cost lives, further increase stress on the acute-care system and probably have a net financial cost due to the impact of increased illness.

Last, but not always least, what about flu? Influenza appears every winter with some years worse than others. This infection predictably places a huge burden on our already struggling acute-care system. Last season it accounted for 3,671 hospital admissions and 236 deaths, a number that has increased steadily since the 2020-21 season. The current vaccine is not as effective as we’d like it to be, but it does reduce illness and death significantly and it is safe.

Of note, the European Society of Cardiology recently recommended vaccination against respiratory infections to prevent heart attacks and heart failure, which have long been known to be increased by influenza illness. Alberta has shown in the past that energetic promotion and convenient access in pharmacies can increase vaccine uptake.

But as the Globe and Mail reported in 2023, the Alberta government actively downplayed the annual flu vaccine campaign, and this has predictably been associated with decreased flu vaccine numbers.

Ultimately, public health is a core provincial government responsibility, and the vaccine program is a key element. We cannot allow the health of our communities and our children to be held hostage to ideology and partisan posturing.