The Rising Threat of Measles and Vaccine Hesitancy: Q&A with Sabin Gold Medal Winner Dr. Paul Offit

Editor’s note: On November 14, 2024, the WHO released 2023 estimates that showed a 20% increase in measles cases over 2022 numbers. Inadequate immunization coverage globally is driving the surge in cases.

When Dr. Paul Offit received the Albert B. Sabin Gold Medal in 2018, it was both for his contributions as co-inventor of an oral rotavirus vaccine and for his leadership as one of the United States’ most vocal and dedicated advocates for immunization. A pediatrician and virologist, he serves as director of the Center for Vaccine Education at Children’s Hospital of Philadelphia, is an advisor to the Food and Drug Administration, and continues to be one of the most active scientists in the world when it comes to explaining and educating about vaccines, infectious disease, and the need for an evidence-based approach to public health. While his latest book, “Tell Me When It’s Over: An Insider’s Guide to Deciphering COVID Myths and Navigating our Post-Pandemic World,” includes perspective on managing COVID into the future, we spoke with him about the increasing number of measles outbreaks around the world this year.

Why are we seeing so many more measles outbreaks – even in countries where these outbreaks were all but eliminated?

Before 1963 when a measles vaccine was first available, every year in the United States there would be three to four million cases of measles, about 48 ,000 hospitalizations and 500 deaths. When children were hospitalized or died from measles, they died because they had severe pneumonia, severe dehydration, or encephalitis, which is inflammation of the brain.

Then we had a vaccine. Within about 10 years, we had a pretty dramatic decline in the incidence of measles, about a 90% decline.

There were two things really that helped to decrease that even further. One was school mandates. By 1981, all 50 states had school mandates. The second was that a second dose was recommended in the early 1990s. For those two reasons, you had basically eliminated measles from the United States by the year 2000.

What changed?

There were a couple of hits. The first hit was the false concern that the combination measles, mumps, rubella vaccine caused autism, which raised its head in 1998. And that caused people to stop vaccinating. As a result, was an erosion in vaccine rates so that by 2004, you were starting to see measles again.

And then the second hit really was the COVID pandemic, for reasons I would have never predicted. You saw thousands of people dying a day and you had a vaccine to prevent it. And that vaccine was readily taken up by this country such that by July of 2021, 70% of the U.S. population had been vaccinated. But then we hit a wall. About 30% of the U.S. population simply refused to get vaccinated because they did not like that vaccines were mandated to go to school, mandated to go to church, mandated to go to restaurants, etc. It created a real backlash. As a result, over the last couple of years, there have been hundreds of pieces of legislation pushing back on school mandates.

School mandates were probably the most important way we had to eliminate this virus. Whenever there is an erosion in vaccination rates, the first disease to come back is measles. It is the canary in the coal mine because it is the most contagious of the vaccine-preventable diseases.

Are we going to see other diseases make a comeback?

We are already starting to see that happen. Two years ago, you had a case of polio in Rockland County, New York. Now, that was in an area where the immunization rates were 30%. I think people assumed that polio was gone from this country. If we lower immunization rates enough, even diseases as remote as polio can come back. I’m a child of the 1950s and believe me, you don’t want to relive that disease.

What makes measles so infectious?

Like the respiratory syncytial virus or influenza virus or COVID, measles is spread by small droplets. The difference with measles is it’s spread by very small droplets, sort of aerosolization. And so, for example, when someone comes into our emergency department and is suspected of having measles and then comes to a treatment room, no one can go in that treatment room for two hours. You have to wait for those small droplets to settle, because they kind of hang in the air like a ghost. That makes it incredibly contagious.

Could measles mutate to have different variants? Or has it been a fairly stable virus throughout history?

Measles is like COVID or respiratory syncytial virus or flu in that it’s a single-stranded RNA virus, but it really hasn’t appeared to mutate away from the vaccine. We’ve had a vaccine really for 60 years in this country, and there’s been a lot of pressure created by that vaccine, if you will, for the virus to mutate away from the immune response induced by the vaccine. But that hasn’t happened yet in 60 years. So, in that sense, it’s very different from say influenza or SARS-CoV -2, the virus that causes COVID.

Do you think that there’s a case of collective amnesia about how dangerous measles is, given the success of the vaccine?

Not only have we largely eliminated measles from this country, we have also eliminated the memory of measles. I mean, this year we’ve had over 200 cases of measles, which is three times more than last year, but that’s still only about 200 cases in a population of hundreds of millions. So, most people haven’t seen measles, most doctors haven’t seen measles. And I think that the tragedy of this is that we’ve forgotten exactly how sick or how dead that virus can make you.

Why do such a large percentage of children with measles end up in the hospital?

Most commonly, when children are hospitalized with measles, it’s because they have pneumonia or severe dehydration. I think a large percentage of those with measles are getting hospitalized today because doctors aren’t familiar with measles. I hope we never get to the point where we’re so familiar with this disease again but I do fear that we’re just seeing the beginning of this.

I fear there’s going to be a continued erosion in school mandates and, as a consequence, continued erosion in vaccine rates, and you’ll just see measles go up. If you get to a thousand cases of a virus that has a mortality rate of roughly 0.1%, you’ll start to see children die again of measles in this country, which is unconscionable.

What, in your opinion, would help overcome the hesitancy about getting the vaccine?

There are two ways out of this, out of having to stand back and watch more and more children suffer measles. One is to change people’s minds with education, to make it clear what this virus is, what it can do, what the extremely effective and safe vaccine can do.

The second is the only way people are going to change their minds is by seeing the disease again, which is sad because what that means is that the most vulnerable among us — our children — will once again have to suffer.

Around 2004, I was interviewing a man named Maurice Hilleman, who really is the one who invented the measles vaccine that we use in this country. We were just starting to see cases of measles again. I asked him that question: do you think that that children are going to have to suffer and that’s the only way we’re going to be familiar with this disease and be scared of it enough to vaccinate our children or can we educate away from this? He spent a long time answering the question. I remember it was a winter day, he’s looking out of his back window, and he finally turned around to me almost with a tear in his eyes and said, “No, I think children are once again going to have to suffer this disease in order for us to be aware of how bad it can be.” (Editor’s Note: Hilleman was awarded the Sabin Gold Medal in 1997.)

There must be some way to avoid that suffering, given that we know the vaccines are safe and prevent measles?

I think that while certainly groups like the Centers for Disease Control and Prevention, the FDA, and others can put out statements and create advertisements, I do think all public health is local. And I’ll give you a perfect example. In Philadelphia, there was a surgeon named Dr. Ala Stanford, who took it upon herself during the beginning of this pandemic when vaccines were first available to create something called the Black Doctors COVID Consortium. And she went with 200 people, all funded by her, to go into North Philadelphia to sit in people’s living rooms and explain to them what this disease was, how it was when you are diagnosed with it, and how important it was to get the vaccine. And with that effort, over a period of really just months, she vaccinated 50,000 people in North Philadelphia, a primarily black and brown community. That’s what I mean. She was a point of light of the many points of light in this pandemic. And I think that can be true with measles. I think there could be points of light locally, who have sort of the trust of various communities, who can explain what’s at stake if you choose not to vaccinate.