As the West Texas measles outbreak continues to spread, and we report on the latest developments, we frequently mention that this is the worst measles outbreak in 30 years. Well, what happened 30 years ago with measles and how bad was it? And how did public health efforts beat the outbreak back then?
I decided to take a look.
To be precise, it was 36 years ago that Texas and the nation faced a historic measles outbreak. It lasted from 1989 to 1991.
“So it was a really scary time,” said Dr. Julee Morrow, a pediatrician at Fort Worth’s Cook Children's Hospital during that outbreak. She still practices there today. She remembers what the outbreak was like.
“We started seeing measles cases in 1989. The outbreak in Texas actually started in the Houston area and traveled throughout the state, spread throughout the state in a matter of months. So we started seeing cases in the Dallas-Fort Worth area. Our patients that were affected were mostly younger children and several children that had not been, were younger than the age that had been vaccinated. So that is the group that's under 12 months of age. We were having to do lots of similar [things] to what we had to do during Covid. We had to use lots of protective equipment because the contagiousness of measles is so incredibly high at that time,” she said.
Morrow said children were being brought to the hospital with the painful red rash covering their entire bodies, including their scalps. They had high fevers —some as high as 105.
“It was a tough time. It was a very concerning time. It was concerning for us. We were trying to manage taking care of patients in the office, plus taking care of these children in the hospital. And there were lots of calls, lots of questions,” Morrow said.
1989 to 1991 saw one of the worst measles outbreaks in the nation since the vaccine was introduced in the mid '60s. During that time, there were over 55,000 reported national measles cases and 123 measles-related deaths.
In Texas alone, 10 deaths were reported in 1989. The next year, the toll was 12 deaths. This is according to a report by Dr. David Smith, the Texas Health Commissioner at the time.
Dr. Adam Ratner is the author of “Booster Shots: The Urgent Lessons of Measles and the Uncertain Future of Children's Health.” He said the problem was Reagan budget cuts to Carter’s immunization programs.
“Those were rolled back under Reagan and what we saw was sadly predictable. A drop in vaccination rates and then this huge multi-city and multi-state outbreak.”
President George H. W. Bush restored that funding in 1992.
Bush spoke in the White House Rose Garden, announcing the restoration of that funding. Audio from that event was obtained from the George H.W. Bush Presidential Library archive in College Station.
“When we announced our national education goals, the very first was that by the year 2000, all children in America will start school ready to learn, and that's one reason we put such emphasis on our Healthy Start initiative. Every child deserves a chance, and in the 1990s, no child in America should be at risk to deadly diseases like diphtheria and polio or the measles. A decade ago, we hoped to eradicate these threats,” Bush said.
Using the presidential bully pulpit. Bush called on parents to get their children immunized, and he didn't mince words.
“Today I call on every parent everywhere in America. Don't take a chance. The facilities are there; the vaccines are available. Call your local public health official or your own physician. Please make sure your child is immunized. A deadly plague called polio, threatened of my generation, darkened the fun of summers and crippled and killed kids, but American ingenuity, fantastic research stopped that killer. And while some say each generation repeats the mistakes of the last, no generation in America should suffer the plagues of the past America. Decency demands that we not let complacency lead to contagion, and never let apathy lead to epidemic,” Bush said.
I'm going to highlight a point here. Bush said generations should not repeat the mistakes of the past, but Ratner says he sees that mistake happening again. The same mistake that Ronald Reagan made cutting funding to vaccines for budgetary purposes. It's happening again now with Trump's cuts to the CDCs vaccination programs.
“It's probably no more effective public health program and the idea that you would cut that, it is such a bargain in terms of reducing unnecessary medical costs and saving lives of children, and it makes no sense. It makes no sense from a financial point of view like the amount that you would ostensibly save by cutting the FFC is more than offset by the amount of money that you save in preventing hospitalizations and deaths. So that has got to be a just politically motivated and vindictive move. That doesn't make any sense,” said Ratner.
During the 1990 measles outbreak, there was a congressional hearing broadcast live on CSPAN that was looking for answers as to how the virus was allowed to spread unchecked.
From that broadcast: “Coming up next, we bring you live coverage of a hearing held to investigate the nationwide measles epidemic, chairing the House Energy and Commerce Subcommittee on Health and is Congressman Henry Waxman.”
The audio from the broadcast continues: “Measles was once thought to be an inevitable childhood disease, but in four years it was shown to be a hundred percent preventable. Over the past years of tight budgets, however, the immunization programs have been eroded. When money was limited, it was spent to buy the vaccines, but the workers who would administer the vaccines to children were moved to other jobs or dismissed. Fewer and fewer people were left to reach unvaccinated children. The result has been predictable. After years of work and then years of erosion, there were almost 25,000 cases of measles in 1990, virtually where we began. The problem is clear to see vaccination programs are limited, clinics are inaccessible. Public awareness is also low. Many parents are waiting until their child is ready for school, even though the biggest danger is to infants, and sadly, some parents are complacent. They mistakenly think that measles is only a rash and a few days in bed when in fact it's a dangerous disease,” said Waxman.
The hardest hit areas were inner-city, low-income communities, but the exception was San Antonio. The city's vaccination success was noted and in that 1992 congressional hearing representative Henry Waxman asked the city's director of public health, Dr. Fernando Guerra, how he did it.
“The Committee on measles that was brought together by the National Vaccine Advisory Committee served the purpose of calling attention to a healthcare system that is in some state of disarray and that is not so user-friendly as it has perhaps contributed in one way or another to an emerging measles epidemic in this country. Over the last two years, I would initially state that the measles outbreak is a sentinel event again, for a system that has not always been so responsive to the needs of its communities.”
Waxman asked Guerra “Can you tell us why the program in San Antonio has been successful? Since the problems in San Antonio are so close to the problems of other areas of the country where we've lagged behind in getting children immunized for measles.”
Guerra responded “We have tried through the shared responsibilities in both the public and the private sector and the delivery healthcare system to keep immunization as a concern for the entire community. It is something that is day after day and month after month and year after year, something that we try to keep out in front of the community as a shared responsibility and one that maintains a state of awareness across all sectors.”
Guerra explained that San Antonio consistently worked with the city's hard to reach households and made vaccinations available wherever and whenever they could.
“We at times even do door to door campaigns in some of the housing projects where we have observed that the immunization rates are quite low. We use the media quite often to put out a variety of messages, try to make them as culturally sensitive and relevant to all sectors of the community. We try to have extended hours of immunization services, including evenings and weekends, Guerra said.
Guerra’s relentless approach became the national model, and within a decade, measles was declared eliminated from the United States.
But now it’s back. “I can't believe that we're doing this again,” said Morrow. She said she sees the outbreak of 1990 playing out again in Texas.
“And I have a feeling we are in the same situation again. Some folks are really heeding the warnings, and some folks are really not, and I have a feeling that we are going to see spread for quite a while. This is something we're going to be dealing with for quite a while,” she said.
The data predicts that we will be dealing with measles for quite a while and it's going to get much worse before it gets better unless vaccination rates start to improve, which is unlikely under President Trump and his appointed Secretary of Health and Human Services, Robert F. Kennedy Jr. They are defunding vaccination programs and spreading disinformation about vaccines and the seriousness of the measles outbreak. This week, Kennedy was in College Station, Texas, and again, he downplayed the Texas measles outbreak and he disparaged the news media for covering the outbreak.
“One of the things that I've tried to get the press to focus on is that we have a chronic disease epidemic at the same time. We have a hundred thousand autism cases diagnosed every year. We have now 38% of our children are diabetic or pre-diabetic. When I was a kid, there was virtually no diabetes among children. We should be giving headlines to that because those are much more devastating epidemics,” said Kennedy.
Yes, there's no denying that there is a public health crisis with childhood diabetes but downplaying an infectious disease outbreak like measles that is easily prevented with a low cost safe and reliable vaccine, does nothing to address that problem of the explosion of early onset type two diabetes. But Kennedy goes on and spreads disinformation about measles.
“We're doing everything that we can, not only with those populations like the Mennonites in Gaines County, and I've been to Gaines County. I attended a funeral down there of one of the little girls who died not of measles, but she had had measles,” Kennedy said.
Kennedy has a long and documented history of denying that measles is a fatal disease. He said the two girls in Gaines County did not die from measles. He said they had measles when they died. This follows a narrative pushed by anti-vaccine advocates, but medical authorities confirmed that the two school-aged children in West Texas who died from measles did indeed die from direct result of the measles virus. The Texas Department of State Health Services reported that both children were unvaccinated and had no known underlying medical conditions. The second death specifically cited measles pulmonary failure as the cause and the Center for Disease Control and Prevention also reports these deaths as being caused by measles. Then Kennedy goes on to promote unproven and dangerous medical treatments for measles.
“Those that have religious objections to vaccination ... and we need to be able to treat them even though they're not vaccinated. There are many, many good ways to treat measles and doctors need to know that and to know those methods. And we are developing now a worksheet for doctors to address the epidemic, to address people who have it, not just with vaccination, but actually with budesonide, with clarithromycin, with vitamin A and many, many other treatments that have been shown very effective,” he said.
Hospitals in West Texas have reported overdose levels of vitamin A in children, which is causing liver damage. Kennedy didn't say anything about the one thing that has proven to stop the spread of measles, the MMR vaccine, and unless vaccination levels improve in the United States, not only will the measles outbreak continue, but it will also get worse and become endemic.
Measles was officially eliminated in the US in the year 2000, but research published this week using modeling to forecast the future of measles in America found that the United States could see millions of new measles cases over the next 25 years. If vaccination rates continue to fall, if vaccine rates hold steady at today's level, researchers predict just under a million cases of measles over the next 25 years and over 2,500 deaths.
The study was published in the Journal of the American Medical Association. Kate Bubar was one of the study's authors. She is an infectious disease expert at Stanford University. She's a co-author of the report “Modeling Reemergence of Vaccine Eliminated Infectious Diseases under declining Vaccination in the United States.”
Bubar: For our study, we were focused on four examples, measles, rubella, diphtheria, and polio. While we were interested in estimating both the total number of infections that we can expect over the next 20 years as well as infection related consequences. And the key part of our study that we are really interested in as well is what can we expect for endemic transmission? And the main takeaway is that undercurrent levels of vaccination, in the majority of simulations that we ran, we found measles would be endemic in about 20 years in the United States.
Davies: We're seeing measles now spreading in Texas quite a bit, and also in other parts of the country. The concern is that it's going to be very difficult to reign in the outbreak that we have now, and it's likely that we're not going to be able to claim that measles has been eliminated from the United States a year from now. Are we?
Bubar: Your question is really getting at the definition of what does endemic really mean? And I would say that there are a lot of different ways we could think about defining endemic, really. And there's differences because there's different expectations depending on the pathogen, how it transmits, and really what is the purpose of defining something as endemic versus eliminated. And so the definition that we used in our paper was a pretty kind of high bar for actually reaching that endemic level. And our definition is working under the assumption that measles would be commonplace and that everyone would know somebody who has had measles getting to a point of a lot of measles cases. That's around a hundred thousand cases of measles per year. And there's a lot more stricter definitions that you could use that would lead to coming to that conclusion within say, one to five years.
Davies: So you're looking at this at the current vaccination levels that it would be endemic in 20 years. But what if the levels continue to fall? Vaccination levels drop off still?
Bubar: We looked at that specifically in the paper. Say measles vaccine coverage fell by 10% across the country. Then that time to when measles would be endemic falls closer to 10 years on average. And we see even steeper effects if vaccine coverage drops even further.
Davies: So if vaccine levels were to fall, then we would actually see an exponential sort of growth of measles, wouldn't he?
Bubar: Yes, definitely. So I think maybe a different example for a different definition you could use for endemic, what the WHO uses is continuous transmission for a year, and if we had considered that sort of definition, then that's where, I mean, we could be at risk of losing our elimination status within this year just from the current ongoing outbreak as it is. So that's where the definition we use in the paper was kind of a very different framing, and we were really interested in when is it going to be extremely commonplace in the US.
Davies: And you're not just looking at measles. You're also looking ... polio, which is hard to imagine that that could become something that we have to worry about. Again, what are your conclusions?
Bubar: Measles is really kind of considered the canary in the coal mine when we're thinking about these reemerging infectious diseases because it is so infectious. And then the other pathogens that we considered, so also rubella and diptheria as well as polio, they're ones that we would not expect endemic transmission unless we see severe drops in vaccine coverage. That's not surprising, but it is important to keep in mind when there are so many questions of vaccine hesitation and potential changes to vaccine recommendations and everything. But with current levels of vaccine coverage, we would not expect really many cases at all.
Davies: That polio would not become the problem as long as people get vaccinated. But I'm hearing the term that a measles is a sentinel indicator of a troubled public health system. The fact that we're having, because it's so contagious and that we're able to see that the public health system is being frayed and vaccinations, they're not at the level where they should be. So the concern is we're seeing in real time that we have a problem.
Bubar: I agree.
Davies: Looking at it from another point of view is like, okay, the population sees, 'oh, we have people getting measles. It's really bad. The numbers are really high. Let's start getting vaccinated again.' And there is the elastic response. Okay, people start getting vaccinated again. Is that going to be enough to end an endemic status for measles?
Bubar: I think it is all going to depend about the timing of when would that coverage increase exactly? In comparison to how widespread is measles at the moment. But vaccination is our best tool to keep measles from becoming endemic. We found that if vaccination rates increased nationally by 5% for measles, we would not expect the endemic transmission within 20 years. We found no endemic transmission in that scenario when we ran that with our model.
