What happens when an irresistible force meets an immovable object? The question is rooted in antiquity and seems to be playing out again in the realm of public health. This time, the force is the overwhelming evidence supporting vaccination against infectious diseases such as measles. The object is comprised of people refusing vaccines for a number of reasons.
Although academically, the paradox makes for some lively -- and newsworthy -- discussion, there are consequences. In the case of measles, the unfortunate innocent bystanders are individuals who come down with the virus leading to infection. The majority suffers the usual symptoms - including very high fever, cough, red eyes and that all too familiar rash. But some 10 per cent can experience complications ranging from hearing loss to brain swelling and even the onset of a condition similar to multiple sclerosis.
The path to victory for the scientific and public health community has been theorized and played out in labs as well as conferences worldwide. The results, however, suggest the odds of achieving this goal are not good due to the strength of the refusers. Those who choose individualism and skepticism over general public health have a strong presence and continue to pump out messages detracting from vaccination. Over the last decade, the political and public messaging may have worked enough to allow measles to make a return quite possibly for good.
Ten years ago, the spread of the virus had been successfully attenuated with only a handful of cases each year. But in 2007, an outbreak lasting half a year suggested the virus could be making a comeback. Eventually, the Public Health Agency of Canada initiated the measles and rubella surveillance project to identify whether a trend could be observed. Indeed, the data revealed measles had returned albeit in smaller numbers compared to the pre-vaccination era.
Then in 2011, the numbers exploded. An outbreak in Quebec took the levels from single digits to well over 700 people. When the outbreak was analyzed, the reasons for the high numbers became clear. Only 21 cases -- less than three per cent -- were due to importation. The rest happened on Canadian soil and was due to a lack of proper vaccination in the community. Even more problematic was the realization 13 had been vaccinated once and three had received two doses. Unfortunately, they did not have the lasting immunity to prevent symptoms.
In the context of the paradox, this latter case may appear to harm the irresistible force of evidence and help the object comprised of those who suggest the vaccine is useless and even harmful. Yet, the opposite is true. This case, and all others for that matter, reveals the means to end measles outbreaks. Quite simply, enough people needed to be vaccinated effectively and properly.
Officially, this level is known as the elimination threshold and its dynamics are easy to understand. When measles circulates, everyone can be exposed. It's airborne and can spread in any public gathering. Those who have strong immune function will experience mild to no symptoms; anyone with less immunological strength may suffer. By having enough people protected -- in this case 93 per cent with two doses of the vaccine -- the virus won't have a chance to infect on a wide scale. Over time, the circulation stops and the pathogen is eliminated.
If the elimination threshold is not met, the chance to beat measles is lost. The presence of susceptible people would suggest an outbreak could happen anywhere at any time. Public health officials would be left to impose restrictions in the hope of preventing the virus from causing outbreaks. This includes preventing susceptible children from going to school, forcing non-vaccinated healthcare workers to adorn protective equipment such as masks, asking people who may be at risk to avoid going to major events, such as the Super Bowl, and closing borders to individuals exhibiting symptoms in the same manner as Ebola.
While some of these measures are feasible -- and already in place -- there is no guarantee measles won't continue to cause trouble. This is because the virus is continually circulating in many areas of the world including certain parts of Europe. Travelers to endemic nations may inadvertently become exposed and if not properly protected, acquire infection. Because symptoms may take up to two weeks to appear, most will bring the virus back home and spread it locally. Even if all the restrictions were enacted, the virus could still make its way into the country and into the population.
But this isn't the worst of it for public health. With each new outbreak, measles gains more ground for a permanent return. The virus becomes present year-round and causes seasonal infection like the cold and the flu. Every January to April dozens if not hundreds of people will become infected leaving public health officials with little option than to accept the future is a return to a dark past.
Despite the information and the knowledge, the immovable object of refusal has become emboldened and as we have seen this year, gone on the attack. Vaccines have become front and centre in the media with those who refuse, condemn or decry their use coming out to reveals the dangers of all preventative shots. Moreover, people are listening.
Should this continue, there is little doubt refusers will win. Over time, people will continue to lose trust in public health authorities, scientific evidence will be ignored, and any attempt to gain ground will only happen once an epidemic takes over the news headlines. In the meantime, vaccination rates will continue to drop far below the elimination threshold. Though this outlook may appear overly gloomy, two news stories from last week reveal the problems may already be happening.
First, polls on public perception of vaccines revealed up to one in five people believe in a link with autism and would refuse vaccination. Considering the elimination threshold is 93% for two doses, the results are not good. If this trend occurs all over Canada, this is a death knell to the elimination efforts.
Then there is the news of a series of non-related measles cases in the Toronto area. Even Toronto Public Health has indicated the virus is circulating as opposed to causing outbreaks. This essentially means the virus has now joined the ranks of the common cold and the flu as being seasonal.
It seems at least for the moment, the immovable object is the victor in this paradox. The refusers have gained ground and helped to reduce the vaccination rate to levels allowing for the return of measles. Their actions have outweighed the long standing concern about a virus that still kills some 145,000 people a year.
Whether this situation will reverse itself is only a matter of time and epidemics. Once infection, complications and death start to arise in Canada due to this infection -- much like it had before vaccines were available -- the trend may make a one-eighty. When that happens, public health officials will have to be ready to face that immovable object yet again but this time be prepared to win.
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