Samoa are experiencing a devastating measles epidemic. It is possible that 2-3% of the population will ultimately be infected by the time it is over. Hopefully the mass immunisation campaign currently under way can mitigate some of this, for many it is too late. (Updated 3 Dec 2019)(Updated 7 Feb 2020)
The first question many people ask is “why?”
The general answer is simple. Samoa has long term low immunisation coverage. The tables below illustrate this. The top table is the first dose of MMR vaccine and the next is the second dose. These figures are some of the lowest in the world.
This low immunisation coverage has left Samoa extremely vulnerable to measles – a lit match to dry tinder and gasoline. With the global resurgence of measles, the risk of an importation to this vulnerable community was almost inevitable.
Why has the coverage been so low?
There is a degree of distrust by the Samoan community in the health system. This is not entirely misplaced. Events last year highlighted some of the issues with the health practices when two infants were administered a muscle relaxant drug when it was used to reconstitute a five-dose vial of MMR vaccine instead of water. Both infants died within minutes of injection. The grave errors that led to this occurring are monumental both in number and in magnitude.
Following this tragic event the immunisation programme was halted for months. The public were not informed that it was not a vaccine that caused the deaths. The anti-vaccine movement thrived, spreading misinformation, and vaccine coverage plummeted further. The Washington Post highlighted some of the behaviour and it is pretty
disappointing disgusting. Alison Campbell has discussed some of the claims lies spread by those who prey.
Other factors contributing to the magnitude of this epidemic
There are two tools available to us to control epidemics such as measles. One is employing isolation and quarantine, the other is through rapid mass vaccination. These interventions must occur swiftly. If there is no disease in the community, a single case can be considered an outbreak. Once secondary cases appear it is most definitely an outbreak. Some 200 cases had appeared before Samoa declared a problem. Even though the first cases appeared in August, a mass immunisation campaign has only just begun. These things together have contributed to the magnitude of this epidemic.
Why are so many children dying?
The average mortality rate for measles in low/middle income settings is around 2 per 100 cases. Also, I have read some literature that suggests mortality is higher when cases are clustered close together – such as when immunisation coverage is very low – and it may have something to do with infective viral load. Anyway, the death rate we are seeing is not unexpected for a setting such as Samoa. Here is an interview with one of the Australian doctors on the ground, he explains the sort of complications they are dealing with in intensive care.
It is important to keep in mind the level of health care and access to health care in Samoa is not the same as it is in NZ, also there were a few near deaths in NZ during this last epidemic.
How much worse will the Samoan epidemic get?
Predicting is never easy without a crystal ball. However, past, present, and future epidemics can be modelled using mathematics. The more information/data you have about the disease and the population, the better the model.
To estimate the trajectory of the Samoan epidemic, academics from the University of Auckland’s Department of Engineering Science and Auckland Bioengineering Institute used some techniques they have been developing recently. The model uses the number reported cases from Samoa’s National Emergency Operations Centre releases, and to keep it simple it does not use the age/spatial information (because it would become much harder to estimate). In other words, it’s quite a simple model that doesn’t capture all the complexity of the outbreak.
Based on the information available the model predicts a total of 4500-6500 cases, with almost all the remaining cases occurring in the next month – 95% of these within 2-3 weeks and 99% within a month. With current mortality rates (1.3% of reports), we expect around 70 deaths. This is in the absence of the mass campaign now ramping up.*(UPDATED VERSION BELOW)
With further information the model can be refined, and I will update this post accordingly. However, right now this is the best estimate available.
What was the final outcome of this devastating epidemic?
5707 cases,1,868 hospitalisations, 83 deaths. Around the midpoint of the modelling estimates above of 4500 to 6500 cases.
- The measles virus strain was not some weird mutated killer variant. It was the same as one of the strains causing havoc in NZ – D8. No one in NZ died from this.
- The epidemic was not caused by measles vaccine, this is biologically impossible. The vaccine virus is not transmitted for person to person. Also, the measles strain in the vaccine is a genotype A. As above, the one that was causing the epidemic was genotype D. The vaccine strain of measles have never been detected circulating in a population during an outbreak. The vaccine protects against all the strains of measles.
- Kids did not die because of malnutrition or Vit A deficiency. They died because the first line of treatment for many was traditional healing, which is not effective against measles. By the time they got to the hospital it was too late to save them, their condition was too serious. Also, many people in Samoa live in remote villages where care is not easley accessible. In NZ health care is excellent and close for most people. Children with measles were admitted to hospital promptly where very high level of care is available, especially intensive care, where quite a number needed admission to.
- Re Vit A deficiency. Not a recognised issue in Samoa. Corroborated by front line medical staff who did not see evidence of this. Also, vitamin A supplementation has limited effect on infection but does help with pneumonia associated mortality in those already infected. Vit A was provided and utilised as recommended.
Thanks to Mr David Wu, Dr Oliver Maclaren, Dr Vinod Suresh (University of Auckland), and Samoa Observer for the collaboration.