The United States last week announced three deaths associated with measles, including a seven-month-old baby in New York and a postpartum woman in Pennsylvania, underscoring the need for a more aggressive vaccine approach – but US recommendations have not changed.
The dismantling of the Advisory Committee on Immunization Practices (ACIP) has made the U.S. response to the measles outbreak more difficult, with vaccine recommendations remaining the same despite a historic increase in cases and deaths, four former advisers say.
A functioning committee would likely consider recommendations on how to vaccinate adults; accelerate the vaccination schedule for children against measles, mumps and rubella (MMR) in affected areas; and identify exactly which groups and areas need vaccination campaigns, they said.
Months after Robert F Kennedy Jr, the secretary of the US Department of Health and Human Services (HHS), replaced vaccine advisers with his own hand-picked allies, a federal judge halted the committee’s work, ruling that the Trump administration had failed to properly constitute the committee.
The ACIP makes recommendations to the U.S. Centers for Disease Control and Prevention (CDC) on vaccine policy — and it would “definitely” discuss updating its advice as measles continues to spread, said Yvonne “Bonnie” Maldonado, chief of infectious diseases in the department of pediatrics at Stanford Medicine and a former ACIP member.
Today, “we don’t have an ACIP,” Maldonado added. “This is going to impact illness and death in the United States.”
The committee was monitoring the measles outbreak early last year before Kennedy disbanded it, and its replacements have not publicly assessed evidence of the outbreak. The CDC is now accepting applications for a new committee, but the nomination process can take months or years – and the process of making or changing recommendations is also lengthy.
“It typically took 12 to 18 months from the start of considering new recommendations to their adoption,” said Noel Brewer, distinguished professor of health behavior at the UNC Gillings School of Global Public Health and former ACIP member. Meanwhile, the epidemic continues to accelerate.
The seven-month-old baby who died in New York state was not vaccinated against measles, authorities announced Monday. Another infant has died during a measles outbreak in Wisconsin, authorities said Thursday. Both states recorded their first measles-associated deaths in three decades.
Normally, babies in the United States do not receive their first MMR injection until they are one year old. But during outbreaks, babies at risk of infection can get vaccinated as young as six months old — one of the few CDC recommendations that gets less attention than it normally would, experts say.
Guidance on vaccination during outbreaks could be emphasized more and recommendations could be changed to “tell pediatricians and providers that we are in a huge outbreak,” said Edwin Asturias, a professor of pediatric infectious diseases at the University of Colorado and a former ACIP member.
The CDC is also offering the option to increase the second MMR shot to ensure children in outbreak areas are fully protected from the virus. During an epidemic, it can be administered as early as four weeks after the first dose. The vaccine is usually given between ages four and six.
The delay between doses could contribute to what Asturias calls a “susceptible cluster” who have not been protected against measles for decades and are now getting sick and dying.
Some people are ideologically opposed to vaccines, while others lack consistent access to health care. “But that’s only part of the explanation,” Asturias said. The number of visits to the doctor decreases significantly after the second year of life, with fewer opportunities to get vaccinated. “By delaying the second dose of vaccination for four to six years, are you more likely to miss or not give a second dose to many children? he asked.
A duly appointed ACIP would review these data points to “try to understand how this gap in vaccination or protection occurred,” Asturias said.
In the United States, childhood vaccination requirements are set at the state and local level, based on daycare and school attendance. But moving the recommendation forward sooner could increase vaccination rates, as families tend to have more trust in their doctors than in local authorities, for example.
An unusually high number of adolescents and young adults are getting sick and dying from measles. Vaccine advisers will likely explore why and what could be done to achieve them.
“Are you actually tracking the number of infected adults? I doubt it,” said Paul Offit, an infectious disease doctor at Children’s Hospital of Philadelphia and a member of ACIP two decades ago. “Do we try to vaccinate them? It’s harder. You can have school mandates, but what do you do for adults?”
It is especially important to reach unvaccinated or undervaccinated people before they become pregnant, because vaccines cannot be given during pregnancy. Cases of congenital measles – when a baby becomes ill in utero – have increased sharply this year, Pennsylvania authorities recently warned.
Such infections threaten the lives of newborns and pregnant women. In Pennsylvania, a 21-year-old woman died shortly after giving birth from complications related to measles, authorities announced this week. Earlier this year, a baby infected with measles died shortly after birth.
“That’s the real heart of the situation,” Maldonado said. “What we’re seeing now is something I’ve literally never seen myself, and I’m a seasoned infectious disease clinician,” she added. “Before, having even one case was a remarkable event, but now they have so many.”
Anyone starting treatment for cancer or other immunosuppressive treatments should also first ensure they are protected with vaccines, Asturias said. And anyone born between 1968 and 1989 may have only received one shot and should receive a second dose.
ACIP should also work to identify which groups of people and regions are most at risk and how to reach them, Brewer said.
“Measles vaccination rates are pretty high in most places, but there are places where they are very low, and the United States doesn’t have a good mechanism for identifying and responding to those geographic areas,” Brewer said.
ACIP and CDC offer evidence-based recommendations that are sometimes not publicly available. But states can take steps on their own to change vaccination recommendations. “The decisions are up to the states and the counties,” Maldonado said.
With measles, “there are serious risks” and “most bad things happen to young babies under a year old,” Maldonado said. Hospitalizations, complications and deaths are more common in this group – and the risks persist long after the rash has gone. Maldonado cared for two children who developed subacute sclerosing panencephalitis years after contracting measles.
“These are terrifying cases,” she said.
Yet U.S. officials have lagged in their public communication about the risks — and their avoidability, Maldonado said. Erica Schwartz, director of the CDC, has been criticized for her silence on outbreaks and the importance of vaccination.
“She came to the CDC in the middle of a huge series of outbreaks and didn’t talk about it for weeks,” Maldonado said. For families seeking advice, “it’s already pretty chaotic right now, and it’s unfortunate — no one knows where to turn,” Maldonado said.
U.S. officials must speak with “one voice” to outline a plan to combat the outbreak, Brewer said. “The United States currently faces a terrible measles problem, which is largely preventable. We must increase vaccination rates.”
He added: “That’s really the key priority: just get vaccinated. »
Gn Health
