It begins with a rigor, followed by heats and chills during the first day. On the second day there is fever with intense malaise, thirst, lost of appetite, white tongue not actually dry, slight cough, heaviness of the head and eyes, and constant drowsiness. In most cases a humor distills from the nose and eyes, the effusion or suffusion of tears being the most certain sign of sickening for measles, more certain indeed than the exanthem. The child sneezes as if
it has taken cold, the eyelids swell. There may be vomiting. More usually, there are loose green stools, and there is excessive fretfulness. On the fourth or fifth day, small red maculae like flea bites begin to appear on the forehead and the rest of the face, which coalesce as they continue to come out in increasing numbers so as to form Rasimo's clusters. These maculae will be found by the touch to be slightly elevated, although they seem level to the eye. On the trunk and limbs to which they
gradually extend, they are not elevated. About the sixth day, the maculae begin to roughen and scale from the face downwards, and by the eighth day are scarcely discernible anywhere. On the ninth day the whole body is as if dusted with bran. The common people say that the spots had quote turned inwards, by which they mean that if it had been smallpox, they would have remained out longer and
have proceeded to separation or maturation. The rash having thus gone in, there is an access of fever, attenuated with labored breathing and cough, the latter being so incessant as to keep the children from sleep day or night.
Oh that's awful.
It's not great.
Yeah, but that sounds really miserable.
Yes, So that was from Sydenham's account of London measles epidemic that happened all the way back in sixteen seventy.
But it could be an account of what's going on today.
It really could. It actually was very similar in a lot of ways to things that I read in my textbooks about describing measles.
Including the common people.
Part, maybe not that part, the common people.
Hi i'm erin Welsh and i'm eron.
Alman Updyke and this this podcast will kill you.
And we're obviously talking about measles. If you haven't caught the hint yet.
A lot of you asked for it and we've been wanting to do it, so here it is.
Yeah, thanks for asking everyone.
This one is there's a sense of urgency here though, which is very real.
Yeah, why is that, Aaron?
Well, I mean spoilers. There's measles going on right in the world today.
So much measles today.
There's a lot that's happening, and I think this is I this is a really interesting one to cover because it deals with a lot of different issues that we have sort of skirted around or skirted past, maybe touched on very briefly here and there, in terms of vaccination, in terms of how to view historical epidemics in the light of today. Yeah, measles is really one that's going to bring it all home.
So I'm excited me too.
It's gonna be fun. Yeah.
So, speaking of fun, I think it's quarantine absolutely.
And what are we drinking today today?
We're drinking a rash decision.
That's named because for.
The characteristic measles rash.
And the poor decision making of some people to not vaccinate their children.
What yep, yeah, we said it. Okay, So what's in this drink that we're drinking.
Well, we've got vodka, We've got grenadine, We've got ginger.
Liqueur or ginger.
Ale up to you. We've got lime.
Juice and linoennberries.
Oh yeah, if you're in Finland.
Otherwise cherries if you're.
Not in Finland where Lincoln berries are so abundant.
Whatever small red berry to mimic the spots of the mees.
And as always, we'll post the full recipe for this quarantine along with our place ba Rita, our non alcoholic version on our website as well as all of our social medias. This podcast will kill You on Instagram and Facebook and tpwky on Twitter.
And also someone has someone has started a subreddit called tpwky which is really thrilling and we have seen the quarantine's posted there, So whoever is doing that, thank you very much.
And you should know that Aaron Welsh checks it all the time and loves it and.
Is I'm our lurker. Okay, so measles.
Measles, should we talk about it?
I think that's why we're here, all right.
We're going to do that right after this break. All right, measles. Before I dive into the biology of measles, I want for everyone to know that we are going to be doing an entire episode focused on vaccines, where we'll talk about the history of vaccine development. Well, when I say we, I mean Aaron Welsh, I don't do that. I'll talk about how vaccines actually work in your body to give you immunity, and then we'll talk more generally about the
status of vaccination across the US and the globe. Today we're talking about one disease, measles, that's often a large part of the conversation about vaccines, and we'll talk about why that is. But I'm not going to talk super broadly about vaccines because I do want to give measles the attention that it deserves specifically if that makes sense.
Makes sense to me. Yeah, So stay tuned, people.
Yeah, but we will talk about vaccines because vaccines are an important part of the measles story. Yes, okay, so measles. First of all, it's a virus. It's an RNA virus, which usually I say that means it's scarier than DNA viruses because they mutate and they're hard to target. But actually, it turns out measles has like very low antigenic diversity, so it hasn't changed over its history with humans.
We got lucky, yeah, very.
So that means that the vaccines that we developed way back when are still effective against the wild circulating virus today. So that's like the best news I have for you about measles. Downhill from here, cool, Yeah, gotta start off on a high, you know. Okay, So when you get infected with measles, the incubation period, which again is that period from when you first get infected until you start showing symptoms, lasts between ten and fourteen days.
Okay, Okay.
However, you become infectious up to five days before those symptoms start.
You know, those are the deadly ones. Those are the ones really are.
It's a very very big deal, and we've talked about it before with flu and things like that, but in the case of measles, the fact that you're infectious before you have any symptoms is an even bigger deal because the are not of measles, which again is the number of secondary infections that a single infected individual will cause if the entire population is susceptible for measles. That number is between thirteen and eighteen.
Yep.
It's highest one that we know, right, the highest one we know.
Yeah, And what this essentially means is that for every single person who's infected, on average, ninety percent of the people they come in contact with who are susceptible will become infected with measles.
That that's a horrifying statistic.
Exactly.
Yeah.
I mean if you think about smallpox and how like massive of outbreak smallpox was able to cause. The are not of smallpox is between five and seven. And people are terrified of things like ebola or sars, and the are notts of those are like less than two for ebola or between two and three for sars. Yeah, and yet measles is this thing that infects almost everyone who comes into content act with an infected individual.
Do you remember what the r not is of the virus that's in contagion.
I don't remember what it actually is. I remember her listing. I don't know if they ever actually said it, because she just was like, we need to figure out what the r not is, But I don't remember. Yeah, we'll have to look it up.
I remember her writing on the board measles fourteen.
Yeah. I think she wrote polio on there too, which was like six or seven.
Yeah, I think.
Anyways, Okay, let's get worse. Okay, so measles is transmitted airborne, not just in respiratory droplets, but actually airborne. I told you it gets worse. So what that means is that measles can stay the virus infectious. Measles viral particles can stay suspended and alive and infectious in the forking air for up to two hours after an infected person leaves the room.
Wait a second, So it's sort of like you know how pig pen in peanuts when he's got that cloud of dust around him. So if you were a measles kid, it would just be a cloud of measles that would stay in the room two hours after he left.
Yeah, that's the thing. It stays in the room. And so what happens when there's okay, we have had some measles cases here in Champagne, and every time there's a new case, public Health sends out an alert and they give you a list of all the places that this person was during the time that they were infectious, along with the times that they were there, and those times include a two hour window after that person left because
the room itself remains infectious. Good gracious, my god. Okay, all right, let me summarize the things we've learned so far. Measles is a virus that if I haven't before I even know I'm sick, for five full days, I can be walking around breathing, coughing into a room, and once I leave that room for two hours, people can walk into it and become infected by the air which contains my measles. And if those people are susceptible, meaning if
they're unvaccinated, ninety percent of them will become infected. And then for four to five days after my symptoms resolve, I'm still infectious.
Oh wow, yep.
I'm just wondering the total amount of time that an individual is infectious.
The total amount of time is probably a good two weeks. Okay, So okay, So let's talk about the symptoms. It starts, as the name of our future spinoff podcast would suggest, with a fever, and in this case with measles, we're talking about a really high fever, often up to one hundred and four ooh, one hundred and four fahrenheit forty degrees celsius. So the virus invades your bronchioles first. Your bronchioles are the tubes in your lungs.
Where the air goes.
It infects the epithelial cells, which we've talked about a lot in this podcast, because a lot of viruses infect those epithelial cells, which are the cells that line your bronchioles. And so that's why the first set of symptoms that you see after fever are respiratory symptoms, a cough, runny nose, You can get conjunctivitis if it moves up into your eye. And then within two to three days of after symptoms begin, you'll often get something called I believe it's coplic. It might be coplic.
Oh yeah, coplic spots. Yeah yeah, I've read about the dude.
Yeah, oh cool.
So these are these small white spots in your mouth. And while these spots don't appear in every single case, they are a very common manifestation and there's pretty much nothing else that causes these particular types of spots. So they're what we call You're going to learn how to talk like a doctor pathonemonic for a disease pathonomonic. It's a really fun word. It basically means that it's a specific symptom that is very specifically characteristic and indicative of
a particular disease. So once you see this symptom coplic spots, you can say that kid has measles.
Can you spell that.
Pa thho gno monic?
Huh pathonomic it's.
A weird word. Yeah, But so other examples, We've actually talked about some other diseases that have pathanomonic findings. Rice water stool is pathonomonic for what disease. So it's like a dead giveaway of cholera exactly. Yeah, it's like dead giveaway. It's like there's nothing else. There's no other diseases that you would see this symptom in essentially, So anyways, that's your voguet word for the day.
I love it.
So after those copleic spots, in another few days, you'll break out in a rash. And this is the classic measles rash. It's often called the bucket of paint rash. That's how I learned it in class.
Can you explain to me what that means? Because you suggested that as a drinking.
Like if someone took a bucket of paint and spilled it over your head, okay, because the rash starts up at your hairline and then it slowly works its way down across your face, over your trunk, onto your arm. So it's literally like if you took a bucket of paint, like the gatorade buckets after a football game or something, and you dumped it on top and now you have gatorade dripping down your face.
Okay, So it's like the trajectory of exactly of where it's going to pass through. Yeah, not that you look like a bucket of paint has been dropped on you.
Well, well, it also is that the rash becomes confluent and so it does pretty much cover your whole body. So it starts out as individual spots, but then those spots kind of merge together, so it does I mean, it doesn't actually look like paint because it's your skin, but you know, right.
But that don't help me visualize what this what this looks like?
Yeah, oh good, I'm glad. And so that rash, that rash is mostly caused actually by your immune system killing cells that are infected with the virus. So not caused by the virus itself necessarily okay. Now, in most cases, this rash is kind of one of the final symptoms. After a few days of this rash, both the rash and the fever will start to subside, and you'll recover
in most cases. But not everyone will recover. For every one thousand people infected with measles, one or two will die, and at least one will develop acute encephalitis, which is an infection of your brain that can cause permanent brain damage. You can also get a lot of secondary bacterial infections like pneumonia, which is pretty common after a measles infection because of the damage that measles does to your respiratory tract.
But and this part is a really big deal, measles also causes suppression of your immune system in general, and not just while you're infected, but for weeks or months after infection after you recover. If you recover, your immunal compromised, which means you're more susceptible to infection from other pathogens. And not yet done. It gets even more serious than that, because recent data has shown that infection with the measles
virus destroys your immunologic memory. What so yes, this is the part I was hoping you didn't know because it's so terrifying. So it destroys your immune system's capacity for memory. And our immune system is essentially built on the fact that we have cells that live for a really long time and provide us with defenses against things we've already been exposed to. That's what immuneo logic memory is. Diesels
wipe that out. So anything that you had been previously exposed to and should be able to fight off, you can't. It's like you had never been exposed.
Oh my god.
Okay, first question, Okay, I have two questions.
Okay.
The first one is that you said that it destroys the capacity. So does that mean that if you get infected, let's say, with something again, then you will not develop protective antibodies to that you could continue to get reinfected with that.
So I that's a really good question. I don't know if it transiently suppresses your immune system overall and then it wipes out all of your memory cells. But I believe after the period of immune suppression, so like after a few weeks or months, you would be able to then mount an immune response. But it's just that it would have. It would be like mounting an immune response all over again, like you had never been exposed.
But once that, once you had been re exposed to whatever it was, then subsequently, if you were exposed that you can still build memory.
It's just sort of it wipes out.
It basically clears out your hard drive. Yeah, starts you back in zero add stuff again.
Okay, yeah, second question.
Yeah, how great question. There is a paper on that, but it was getting very in depth technically on the like this is how these immune blah blah blahs, and I couldn't I couldn't deal with it, So I'll link to that paper. Yeah. And the other thing is I don't think that it's entirely clear. This is a pretty recent paper. We didn't realize just we knew about the short term suppression of your immune system. We didn't know
until very recently. And the way that we actually found this out is looking at like long term data trends of mortality rates. So I don't think that it's entirely clear. There's mouse models that show that it's possible for measles to wipe out those cells, but it's not one hundred percent clear how the heck, measles is so powerful and destroys your immune system so.
Much, that's amazing.
It's it's oh my gosh. So measles infection is not just it can kill you by killing you outright. It's also associated with short term increases in opportunistic infection and long term I'm talking years increased mortality rates due to non measles disease. This is something that makes a lot of sense in light of vaccination, because what we know is that vaccination with the measles vaccine not only protects you from measles, but at a population level, it decreases
mortality from non measles diseases for years after vaccination. And the reason that that is what's happening with vaccination is because of how strong the effect of infection with measles is on your immune system. It just destroys it.
I think that the long and short of it is that being vaccinated against measles and getting measles naturally and then gaining immunity to it are not the same thing any respect.
What's that exactly?
Being naturally infected will lead you to have adverse health outcomes, probably ones that you won't even realize vaccinated protects you exactly.
They're not even comparable, because that's something that I think a lot of people, you know, it's like, oh, well, why can't I just let my kid get the chicken pox instead of you know, giving him the chicken pox vaccine or whatever. And in this case, especially with measles, that is not the case. Vaccination protects you not just from measles, but it protects your immune system, and infection with measles wipes your immune system out. It's amazing, remarkable.
I had no idea.
I'm glad. It was really fun to get to tell you. Yeah, so that is that's measles, that's the virus. That's how it makes you sick. So it's all I've got aaron. Okay, so how did we get here? How did we learn how to fight this sucker?
It's a good story.
Cool, shall we take a quick break.
Let's do it, but for real, because I'm gonna get a quarantinie. The measles virus probably came from something like bovine render pest.
Oh future episode.
Someday, or canine distemper virus, but archaeological evidence isn't really clear on that, so we don't really know exactly where it came from.
Okay, but what do we know?
Well, we know that the musles virus would have needed a pretty large population density with a sufficient influx of susceptible people in order for it to be sustained. Makes sense, it's a crowd disease. Yeah, But saying pretty large population density isn't exactly me being precise.
So let's get some precision here.
Erin, I mean that's my middle name, not at all. Okay, but there is some pretty cool math here actually. All right, So some researchers calculated that the virus has to move to a new host at least twenty six times a year if it's going to survive in a population.
Interesting, that makes sense if it's too too weak two weak disease.
Yeah, yeah, at a bare minimum, there needs to be twenty six susceptible people in a population every year for measles to persist.
Okay, but there are a lot of butts.
But then those people would have to be inclose or frequent enough contact for transmission, and then you know, once infected and hopefully recovered, you were immune. So new susceptibles had to come in from somewhere either being born whatever. Basically, while in theory you only need twenty six new hosts, but in practice you need.
A whole lot more. So the more reasonable estimate.
Was calculated to actually be a population this includes both susceptibles and immune of two hundred and fifty thousand people.
Wow, that's a huge jump up.
And so that's that's for maintenance, Okay, to keep the virus around, right, because otherwise, I mean, of course the virus could could go get into a population and sweep through it, no problem of any size. But this is for these cyclic outbreaks to happen. Yeah, but yeah, that is that is a pretty big size. So then when and where did people start to even form settlements that big?
Yeah, the authors of.
This Measles book that I read, which by the way, has a million cool maps figures so full of information, Holy cows, they did so much work on it. Anyway, So they started looking through archaeological records to make a list of possible places where a there would be enough people and b there would also be agriculture and exposure to domesticated animals because that's probably where the virus came from.
And so then they came up with a list and dates for these so called urban nuclear areas, most of which were in the Fertile Crescent, but some were also in Central and South America and West Africa. But the most likely place where measles was first establis was in Sumaria and the Tigris and Euphrates River valley around three thousand BCE.
Wow.
So it's old.
That's a long time ago.
Five thousand years Yeah, okay, cool, So done, there we go established and that's the history of.
Okay.
But still we're there. Measles Sumeria three thousand BCE.
Okay.
But it wasn't there for.
Long, or at least it wasn't only there for very long. Measles did what diseases do.
Spread.
The virus spread north to southern Europe, the rest of the Middle East, and east to India, China, and Japan, where early writings indicated it was there by like three hundred or eight hundred AD.
Wow.
As for Africa, measles didn't seem to establish there the way it did in Europe and Asia, possibly because of lower population density, I don't know, possibly because because of physical or landscape barriers making pathogen exchange not super frequent, or possibly it was there, and we just don't know about it because there aren't as many written records. Okay, I don't know. Distinguishing between measles and smallpox and historical.
Text is really quite tricky, that makes sense.
Yeah, I mean physicians didn't often, at least at various points, didn't make a distinction between the two. But that would change in the Middle Ages when measles really came into its own.
H It's like I need to distinguish myself, my own person. I'm my own person, measles going through its teenage years.
Yeah, I mean that side swept bangs and the heavy eyeliner top.
I'm hitting too close to home. Yeah, I know, right.
Right, Okay, all right.
So by the Middle Ages, which let's say the fifth to fifteenth century, measles was fully established throughout the Old World.
I mean it was there.
If the population center was big enough, it was there. Although I wonder, I read this as a little side note to myself, I wonder how the Black Death, the bubonic plague in the fourteenth century, how that disrupted the measles epidemic pattern.
Oh, it probably just it screws everything up as we saw, as we've seen.
I just want to know. I didn't look it up though, Okay.
Anyway, So during the Middle Ages is when physicians started to recognize and describe measles as a disease, although the term mezsles, for instance, was used to refer to the lesions from leprosy, and so it's not fully clear when it switched from being used interchangeably to being reserved just
from measles alone. Okay, but the earliest reference that we can say for sure is talking about measles is from the physician Rasis, which was latinized from I'm going to try to pronounce this Abu Bakar Mohammad Eben Zakaria al Razzi. So he was from close to where Tehran is today. Not only was he one of the first people to suggest that a fever might be your body's natural defense
against a disease. Oh in like the year nine hundred. Wow, he also wrote a whole treatise on how measles and smallpox were different things and how to tell them apart. Cool in nine hundred Yeah, wow, super cool.
That's awesome. All right.
So now all of that was just me laying the groundwork for getting to the real part of the story, which is fifteen hundreds onward. So by fifteen hundred, which is the end of the Middle Ages, measles was established in pretty much all parts of the Old World, but how much of it was actually impacting populations. As we've talked about, if you want to trace historical patterns of disease,
you have to rely on some pretty iffy records. One of these, which is absolutely fascinating I came across is the London Bills of Mortality, which I think was started to keep track of plague outbreaks, but now they're a gold mine, not just for like statistics and looking backwards
in time, but also for ridiculous names for diseases. For instance, in sixteen sixty five, which was a plague gear, three hundred and ninety seven people died of quote rising of the lights, which had to do with lungs, possibly crup Okay, eighty six people died of King's Evil, which is tuberculosis.
Because they got it from the king.
Well this was the whole royal touch, right.
The king didn't cure them, so yeah, yeah, and five died of distracted distracted driving.
It happens early.
That horse and Buggy when we're buggies invented okay anyway, but you should look into it. It's it's fascinating and you'll also see some recognizable ones on there, you know, scurvy, leprosy, smallpox, and so on. And even though these records are incomplete and not super reliable, they can help to paint a picture of some of the disease trends, especially year to year. In London, there were measles deaths every year from sixteen
seventy six to the mid eighteen hundreds. Wow, which shows that the disease was fully endemic.
Yeah, but if.
You look at the yearly trends, you can also see that there were some years with a lot of cases and some with just a few, and the interval between these outbreaks got shorter and shorter as time went on, and the deaths due to measles also grew, probably because population was growing, probably because crowded conditions, nutrition, et cetera, et cetera. And measles was also not just variable year to year, but also throughout the year, so it was
a very seasonal disease. You knew that it was springtime in Europe when measles was on the rise, and then smallpox would follow in its footsteps in the fall, and some researchers have suggested that the measles epidemic in the spring weakened the population and led to a super intense smallpox epidemic in the fall.
Oh my god, are you serious?
Yeah?
Oh dude, yeah, Oh it's really yeah.
Oh my gosh, I love it.
Flabbergasted, good work things this.
So, this seasonality of measles was viewed as evidence that the origin was my asthma, bad air, of course, but a few people said, no, no, it's it's infected clothing or other agents or the air. And you know, but measles would shown to be contagious conclusively by someone with probably only the best intentions. The Scottish physician France's home had heard about Turkish physicians inoculating aint smallpox.
I thought I can do that with measles.
First, he tried to get some pus like material from the rash and bumps of his volunteers, but there, I guess there wasn't really it's.
A pretty flat rash. It's not really a pussy situation.
So he's like, I'll just go for the blood.
The blood's fine, So he sliced open the most measly section of measles, the most easily awful. Yeah, and then he soaked put some cotton balls in there to soak up the blood. And then he sliced open the arms of twelve children and put those blood soaked cotton balls slices.
Guy, what on earth?
Well, he ten of the twelve came down with measles shining. But he was like, oh no, it's much milder. It's it's super mild. I don't know for sure whether it was milder, but they didn't die, and he viewed his experiment as a success.
I'm sure he did.
It was debated amongst his peers.
So okay, but let's let's go back to some of these measles outbreaks though, because you know, I say, oh, an outbreak happened there there, and an epidemic happened here. You know, But what what numbers really am I talking about? For instance, the Great Glasgow epidemic of eighteen oh eight led to seven hundred and eighty seven measles deaths, most of which were children out of a population of around
one hundred thousand people. Oh my gosh, which you know, compared to some of the other diseases that we've talked about, looks like a relatively small mortality rate. But measles did still kill. Yeah, when he was seventy three years old, Louis the fourteenth lost his son, his grandson, and his great grandson, all within eleven months of each each other to Measles. WHOA so his soul surviving great grandson would succeed him at the age of five.
WHOA So.
I don't claim to know anything about French history, but a quick Wikipedia skame tells me that Louis the fifteenth, which is the five year old who didn't die of measles, was one of the longest reigning monarchs and also the one whose excessive spending helped to lead to the collapse of the government and the French Revolution, and thus his grandson being beheaded.
So so, pretty much we have Measles to thank for the French Revolution.
Well, I just wanted someone to write an alternate history book on or TV show of what would have happened if Measles didn't wipe out so much of.
The French royal line.
Wow. Also, I didn't know that Louis the fourteenth lived to be so old seventy three. That's old. Yeah back then.
Well he lived I think a few years beyond that as Wow, that's just when he lost everyone.
That sucks, by the way for them.
Yeah, But in general, measles was viewed in Europe as a moderately deadly disease that killed mostly children. But let's remember a couple of things about that. First, there are many other diseases going on at the same time that had horrific mortality rates, like plague, smallpox, tuberculosis, et cetera that may have overshadowed measles deaths. And second, these are
populations that have some history of exposure to measles. But what happens when measles gets into a population that has never experienced it before?
Can you tell us?
I think I'm about to excellent.
So let's go to the New World for another round of Colombian exchange.
I guess how many people die?
So you know, those those quaint measles mortality rates of like three.
To five percent.
Or even lower these days, Oh yeah.
Way lower.
Those are going to seem ridiculous to what I will tell you about.
The New World.
So Caribbean islands and Central American regions were the first hit by measles and other diseases brought over from Europe, and Cuba, for instance, may have lost up to two thirds of its entire population due to measles in fifteen twenty nine. O two thirds.
That's my plague status. Yeah, Jesus, I had no idea.
I didn't either. Measles was the leading cause of death in many of these places, competing with smallpox, typhus, mumps, influenza.
Et cetera, et cetera.
Wow.
Yeah, I mean, the history of measles in the New World reads pretty much like you would expect it to, just a horrific tragedy. The conquistad or of Francisco Pizaro brings it to Nicaragua and then to Peru as he's on his mission to destroy the Incan Empire, and then from there it just sort of spreads all throughout South America, completely unimpeded by anyone or anything. And it also moves north, all within the span of a century or so from
when Columbus landed. But it's not like it swept through, killing an enormous chunk of various populations and then disappearing. It became endemic in many of these regions with more
major epidemics happening at irregular intervals, killing thousands regularly. So mortality rates they ranged from sixty percent at the beginning, then fifty, then twenty five, then sixteen, you know, sort of slowing down or creeping down a bit over time as the immune population built Upright, And obviously it's hard to separate out the effects of measles and smallpox and all the other diseases that were going on at the same time, but took a much larger toll than I knew.
Yeah it did.
Yeah, So, measles and smallpox are considered to be the two big killers of Native American populations of the New World, with only smallpox outranking measles and the number of deaths caused.
Wow.
And measles was also an epidemic disease in European settlements in North and Central America, primarily affecting children, but also every now and then getting its script on a larger proportion of the population. And it seemed for some reason like measles was more severe in the colonies than it was back in Europe. And our good friend Cotton Mather, you remember.
Him, Why does that name sound familiar smallpox. Oh, I have such a hard time aeron with the names and the dates and things.
Cotton Mather, we lost our minds over it, I believe. Yeah, I'm sure it was smallpox. Anyway, Well, Cotton lost his wife, three children, and his maid to measles in a span of two weeks. To ooh, he has a bunch of I found an article that had his diary entries during this time and it's really heartbreaking. Oh yeah, he so he noticed this big difference.
He was like, why is it so deadly here? Back in the back in Europe?
You know, this is seen as a routine illness, And probably it had to do with the lower population density. Maybe a larger susceptible population was built up. But yeah, Also, I wanted to shout out a listener named Meredith who sent us an email who had some fun Cotton mathered tidbits such as the fact that he may have been an instigator of the Salem witch trials and his father's first name was Increase.
It's just fantastic, Oh, I remember that.
Okay.
Over the years from eighteen forty to the early nineteen hundreds, the world's population grew tremendously so almost doubled. And during this time we see a lot of measles epidemics of two kinds, so the typical cyclic measles outbreaks in endemic countries and the epidemic devastation in naive populations. Broadly, urbanization increased, as did transportation, and as did our understanding of how
measles spreads. Okay, so this dude named Peter Ludwig PanAm, who is the measles guy, Okay, he really set the groundwork for what we understand about measles, or at least what we did going into the twentieth century, how measles moved through population. And so he developed all this information when he was tracking an epidemic in the Faroe Islands in eighteen forty six. So in eighteen forty six, in the Pharaoh Islands there were seven thousand, seven hundred and
eighty two people living there. Of those, six thousand became infected by measles, So that's seventy seven percent became infected because the population was isolated, they had never had measles.
So this dude PanAm went.
Those to the Faroe Islands to watch the spread of the disease, making observations such as incubation period, classic symptoms, the time when someone's most infectious, so on.
And he also noticed that all.
Age groups seemed to be impacted, which wasn't normally the case. So he was like, oh, this could be because the population has never experienced it before and so on. So it was a pretty big conclusion to draw back then, and it made a big impact in terms of understanding future outbreaks and how they differed among different populations. So the final big impact of his report on this epidemic was his complete dismissal of miasma as the way it spread.
It was like, no, measles is clearly contagious and the only way to prevent someone from getting infected is to isolate the infectious person.
It's the only way.
As for mortality rates due to measles, they did drop over time, but again, looking just at death due to measles infection during the epidemic is only going to show you the tip of the iceberg because of all of these things that we talked about, immunocompromise, this immune system, forgetfulness, not really forgetfulness.
Just decimation. Really.
Yeah, So major cities like London and Glasgow would see a few thousand cases of measles every year, with a few hundred deaths. Iceland experienced some intense epidemics. For instance, to quote an Icelandic surgeon during the eighteen forty six epidemic, it would be easier to count the people who escape the disease than to count those who were affected by it.
For it spared very few.
Wow.
So similar was Hawaii, who lost one fifth of its population over the decade between eighteen fifty and eighteen sixty.
Whoa uh huh.
But also even in places where measles was supposedly endemic, like in the US, measles could still cause a huge problem. During the American Civil War, over the course of that over two hundred and four thousand troops were killed on the battlefields due to you know, fighting, but over twice that number died of disease, not measles alone, but just disease. Camp measles was one of them. So camp measles seemed to be more severe than regular measles. Weird, yeah, and
had much deadlier complications. So you probably wouldn't die directly from measles, but you'd probably die from how it had weakened you. And sort of a more foreshadowing of this whole thing. Some surgeons during the war said that they thought the bulk of all serious illnesses nine out of
ten cases during the Civil war were traceable to measles. Wow, all right, if you've ever learned the term virgin soil epidemic in a biology or public health class, never heard that term, no virgin soil epidemic, No, I haven't.
It's basically like naive population epidemic.
Oh okay, right, yeah, but okay, if you've heard either of those terms, it was probably in association with the Fiji measles epidemic of eighteen seventy five.
Which destroyed close to a quarter of the entire population of that country. Let's track the sequence of events. In September eighteen seventy four, the most prominent chief of Fiji, King Kakabau, signs over Fiji to be under British rule. Obviously, this was a big deal politically, and many discussions had to follow so that people could figure out how things were going to fall out, basically, how things were going to work after Fiji became part of the British Empire.
So King Kakabau, along with a couple of his sons went to Australia to chat with the Governor of Sydney. While there, Kacabau picked up measles, but he recovered before getting back on the ship, but his sons didn't, so their illnesses weren't detected until they were well on their way back to Fiji, and the doctor on the ship was like, Okay, you guys are sick. You're going in
an isolation room. But when the HMS didoh arrived at the Fijian capital on January twelfth, eighteen seventy five, no yellow quarantine flag was flown and no notice of measles.
Was made oh No.
Over the next ten days after the ship got back, about sixty nine high up political people from all over Fiji and other nearby islands came to Kacaba's house and other political gatherings were taking place to discuss what it meant that the Kingdom.
Of Fiji was no longer.
So everyone after this goes their separate ways back to wherever they had come from. Oh no, bringing measles back as a souvenir unexpectedly.
The worst souvenir.
Within a couple of weeks, nearly all of those sixty nine chiefs would be dead and the epidemic would be unstoppable. Cases exploded, It just tore through. Oh my god, I mean it was enormously high mortality, which was probably exacerbated by the breakdown of infrastructure and any medical attention, as there just weren't people around to do it.
It was also a.
Really bad year weatherwise, with lots of hurricanes, which meant ruined crops and starvation or at the very least poor nutrition, which makes measles more deadly. Vitamin A deficiency really bad, very bad. So for two months, the epidemic raged, and the rest of the outside world had no idea because all of the harbors were closed to isolate the islands, to not allow any more cases in or any more cases out. So at the end of those two months,
the world was like, how many people died? How many In a population of around one hundred and fifty thousand people estimated forty thousand, forty thousand died of measles, No one virtually, no one was spared, and a quarter of the population died.
Oh my god, I had.
No idea how absolutely devastating measles has been me.
Neither, Yeah, I'm so glad we're doing this episode me too.
On that note of the Fiji epidemic, I came across this incredible paper by doctor David Morins about this epidemic and also re examining in light of today, in today's political climate, in today's educational system. It was just a really eloquent, wonderful read, and we will definitely link to that.
Moving on.
In the first half of the twentieth century, measles was endemic nearly everywhere, at least in all places with the population large enough to sustain it, and it had its fun during both World Wars, of course, but fortunately the reign of measles was coming to an end, or at least that's the illusion.
Okay.
Although the mortality rate due to measles had dropped quite a bit in the twentieth century, it was still killing children, so it was still a big priority for vaccine development. Enter John Enders, so he's He's the reason I suggested the quarantining name Enders fame.
Which would have been so good, just slightly too obscure, Yes, quite obscure.
Maybe we can make a T shirt.
Yeah, oh my god, Enders fame.
Ender's fame in with the design of the Enders game book.
Gut yeah, one hundred percent.
But I've mentioned.
Him at least once before on the podcast. I think in the context of polio, because he's the super famous virologist who, among other things, isolated the poliovirus which allowed people to make a vaccine. Salkn Saban and one Enders the Nobel Prize in nineteen fifty four.
Okay, that does sound vaguely familiar.
Okay, but in that same year, So in nineteen fifty four, he and another scientist named TC Peebles isolated the measles virus from an eleven year old boy. And having this virus that they could finally isolate, they could then measure it to see how much virus was present in particular culture, which made standardization really possible. So anyway, vaccine was just around the corner.
Cool.
So within six years they had a vaccine they could test, wow, which they did on uh oh, fifteen hundred developmentally delayed children in New York City, Oh dear, and four thousand children in Nigeria.
Oh God, it's like we just never managed to get it right, do we? Oh dear?
What I can tell those vaccine trials worked?
Oh thank god? But fortunately not that much solace.
I know, I know, and mass vaccination campaign started shortly after in nineteen sixty three. So in the first two years of the campaign, over ten million doses were given to kids in the US. But that wasn't enough, and the vaccination effort wasn't equal in all places, so for instance, rural and inner city areas had lower rates of vaccination,
so new initiatives were planned. The target was to get at least ninety to ninety five percent of the population vaccinated, because that was the only way to actually break the cycle of outbreaks. Yeah, the year before the vaccine was introduced, there were over four hundred and eighty one thousand cases of measles in the US. Within four years, that number had dropped by more than half, and by nineteen sixty eight there were only twenty two thousand, two hundred cases in the US.
That's amazing, bananas.
But then tragedy struck because all of the campaign funds for measles were diverted for the rubella vaccine, and vaccination rates for measles dropped, and as a result, they tripled.
A few years later, the cases tripled.
Interesting but anyway, I bet I know how they fixed fat problem though. Mmr, yeah, they just put it together. You to put it in the same vaccine.
Well, when I read that sentence, I was like, but wait a second, they read the same vaccine.
Yeah.
I want to quickly shout out some of the measurable positive impacts of the measles vaccine in the first eighteen years of its implementation. Okay, so cases averted between nineteen sixty three and nineteen eighty one, an estimated forty eight point four million cases. Wow, and over in almost five thousand lives saved.
Is this in the US alone? Wow?
And the benefits achieved in terms of monetary things four point five roughly billion dollars saved.
Yeah.
Yeah.
Wow.
International vaccination campaigns were started by the WHO in nineteen seventy four, and they were operated on basically a shoe string budget. But they did get the job well, they didn't get the job done necessarily, but they did really
a lot of good work. And vaccination rates were high in some areas geographically variable due to logistical and other reasons, but all in all, measles cases, complications, and deaths went down, and many researchers said that there was no reason to believe that eradication is impossible, which brings us appropriately to the current status of measles and the dumpster fire slash poop parade slash Yeah.
That's going on today.
So tell me, tell me what is happening with measles today?
Okay, all right, I'll take a quick break. So measles was eliminated from the US in the year two thousand.
What aired?
There's hundreds of cases going on right now and it's twenty nineteen.
You're right, you took the words right from my mouth.
So elimination means that for more than twelve months, there can't be any continuous disease transmission. Elimination does not mean eradication. It does not mean that there are zero cases. It just means there's not sustained transmission. Okay, So most of the cases of measles that we in the US begin as imported cases, So someone traveling who's unvaccinated comes back to the US or something like that. Most of the time, however, that wouldn't be an issue if the entire population was immune.
But that's not the case because we have outbreaks. So basically every time that you see more than three cases in any one place that are linked. In the US, it's considered an outbreak. Three cases makes an outbreak. I'm fairly sure that at some point in the last nineteen years they considered a single case an outbreak, but I could be wrong about that. So let's talk about how many cases we've seen in the US. The first ten years after elimination were going pretty great. Since twenty ten,
not so much. We've had several years of much much higher than normal cases. In twenty eleven, there were two hundred and twenty cases, in twenty thirteen, one hundred and eighty seven. In twenty fourteen, we hit an over twenty year high with six hundred and sixty seven confirmed cases across twenty three different outbreaks. Yeah, twenty fourteen a huge amount of those outbreaks or a huge amount of those cases. I think, like three hundred and eighty cases were in one outbreak alone.
Where was that outbreak?
The twenty fourteen there was three hundred and eighty three cases, primarily among unvaccinated Amish communities in Ohio. And then we get to twenty fifteen, probably the most infamous outbreak in recent days in the US, because that's the Disneyland outbreak. Oh yeah, So in twenty fifteen, there were one hundred and eighty eight cases that year in total, one hundred and forty seven of them happened from the Disneyland outbreak.
Oh my gosh, there's your fourteen. Those are not of fourteen, right exactly. We had eighty six cases in twenty sixteen, one hundred and twenty and twenty seventeen, three hundred and seventy two last year. But so far, as of February fourteenth, twenty nineteen, we have already had one hundred and twenty seven confirmed cases, and actually I can tell you we can up that to one hundred and twenty nine because two more cases have been reported in Champagne, Illinois that
aren't yet up to date on the CDC website. So the CDC website as of February fourteenth says there have been five outbreaks so far, but now we know there have been six because there are four confirmed cases in Champagne, which makes an outbreak.
So that means that we are on track to have a banner year for measles.
Yeah, in f US definitely. So the thing is that we can say that these are happening, These outbreaks are happening because of declining vaccination rates. So if you look at the US as a whole, the MMR vaccine rates are actually steady at about ninety one percent. However, that's not true across the entire country. There are pockets of the country where vaccination rates are much lower and where
vaccination rates are declining. Additionally, over the past I think three years, there have been declines in the number or the percentage of new kindergarteners entering with vaccine exemptions personal vaccine exemptions. So that means you have more kids going into the public school system who are not vaccinated, right, So yeah, so.
Obviously people who are becoming infected with measles are those who choose whose parents choose to not have them vaccinated, who choose not to be vaccinated, and those who cannot be vaccinated or those who don't have access. Yeah, the
ones who for health reasons cannot be vaccinated. Do we have any sort of measurable idea of how much they are being impacted by these outbreaks, whether what proportion they constitute, you know, because presumably these people are immunocompromised or might be in a way where they cannot be vaccinated against measles, they get measles. It makes everything worse.
Yeah, yeah, No, that's a really good question. I don't know, like I can tell you for sure that the vast, vast, vast majority of cases in meaesels outbreaks happened to unvaccinated individuals. So it's not like you got vaccinated and the vaccine just didn't work very well. It's actually a very effective vaccine. It's not one hundred percent effective, but it is pretty effective.
So there are not stats that I can find on why those individuals are not vaccinated, whether it's because of you know, compromise or personal exemption, religious exemption, or lack of access.
Okay, so let's zoom.
Out a little bit and we'll talk about the world, and I'll also address a little bit more about this idea of why some people can't get vaccinated, because it's an important part of the story. Right worldwide, measles is still a huge, huge problem. It's a little difficult to get really great numbers, just like it is for most diseases. It's estimated that only about ten percent of measles cases are actually reported.
Wow, that's very low.
It's very low. It's surprisingly low. But the Measles Rebella initiative, which is a collaboration between the CDC, the WHO, the United Nations, UNICEF, and the American Red Cross. They have this big initiative where their goal is to eliminate measles from five out of the six WHO regions by twenty twenty. It's one year away, by the way. Oh okay, Yeah, they're not going to hit their goals and they know it,
but they're trying. But they estimate that while in twenty seventeen there were one hundred and seventy three thousand cases reported worldwide, it's estimated that seven million people were infected with measles in twenty sixteen, for example. I'm sorry, yeah, seven million, seven million, but only.
The ones that were reported were at one hundred and seventy thousand.
It was Yeah, that was in twenty seventeen, so it was a little bit higher in twenty sixteen.
Oh my god.
And so it's estimated that ninety thousand children a year die from measles. Again, these are estimated numbers, not actual numbers of deaths that we know are confirmed. But that's like two hundred and forty six children a day it's major.
Ninety thousand prevent deaths.
Yeah, we're talking about ninety thousand human lives that are lost to a disease that we have the ability to prevent. It's horrifying that we have the ability to eradicate. Yeah, yeah, we do because we didn't mention this. But like smallpox, which we did eradicate, measles is a disease of only humans. There's no animal reservoirs to worry about. So if we can eradicate it from the human population, we eradicate it. Period.
It's a great target for yeah, eradication.
But so let's talk about the vaccine. So in terms of measles, the first thing I can tell you is that the MMR vaccine is safe. It's very safe. The rates of adverse events are extremely, extremely low, and the vast majority of those adverse events are things like fever and excessive crying compared to death and encephalitis, which is not that uncommon for infection with measles. Along with wiping out your entire immune system. The MMR vaccine is worlds
and worlds safer, right. It's also very effective. It's not one hundred percent effective, but one dose of the MMR vaccine is about ninety three percent effective against measles and two doses, which is what's recommended in the US and in the World Health Organization would like to have everyone vaccinated with two doses. It's ninety seven percent effective, So that means that ninety seven percent of people will have
immunity two measles after two vaccinations. So because of that, because it's not one hundred percent effective, and because of just how contagious measles is, ideally you have to have very very high vaccination coverage ninety five percent to interrupt transmission, and that is a huge challenge, and that's kind of the challenge behind why we haven't seen as much decrease in We've seen a huge decrease in measles. Don't get me wrong, but they have a hard road in front
of them for a number of reasons. Number one, so the MMR vaccine, which again is measles, mumps, and rebella, so it covers three different diseases. But this is a live attenuated vaccine. So what that means is that it's an actual virus. It's three actual viruses. They're a modified strain of the virus that can replicate, just like a real virus would, but they do not cause disease. They basically grow these viruses in cell culture until they lose
their virulence or their potency. So in some ways that makes for a better vaccine because your body responds to it in a way that's more akin to a real infection. But one of the challenges with a live virus vaccine is that, Number One, it has to be kept cold because it's a live virus, so when you're trying to go all over the globe, you might not always have
access to a refrigerator, so that's challenge number one. Number Two, you have to give this vaccine via injection, which means you need trained healthcare workers to actually administer that vaccine, and you have to jab a needle into a tiny baby human and usually they don't like that, so that's stressful both for the caregiver and for the infant. Number Three, when the baby is born. When a baby is born, they get antibodies from their mom, and their immune system
itself is super immature. It's basically nonexistent. Babies are like, they're just kind of useless. So you can't give a tiny baby human a live virus vaccine because a those maternal antibodies that are floating around in their blood will just destroy that virus, assuming that the mother has been either exposed or vaccinated to that virus, and b the baby wouldn't be able to mount a proper immune response anyways. So you can't give the MMR vaccine to babies until
ideally they're at least twelve to fifteen months old. But in some cases when there's outbreaks going on, they'll give the MMR vaccine to babies as young as six months, but then they're gonna need a third vaccine because we don't actually think it's that effective at six months. It's kind of one of those better than nothings if there's an outbreak going on, Yeah.
Which is tricky that you need that double dose and to time it right. So if you're part of the who mounting this campaign for vaccination, you can't just go to a place and vaccinate. You have to be at a place and vaccinate for a long periods of time.
Yep. And also because it's attenuated vaccine and not a killed vaccine, people like you said who are immunal compromised can't get this vaccine because in those populations, it can cause more serious adverse effects. So what that means is that you are always going to have some percentage of the population who cannot get get vaccinated because of an immunocompromise. And you're always going to have a certain percentage of the population that's under twelve months so they can't get
vaccinated either. So in order to hit that ninety five percent, you kind of have to vaccinate everyone who's capable of getting vaccinated. And like you said, the fifth point is that you have to give two of these. I mean, giving one is protecting ninety three percent of the population, So that's pretty good, but ninety seven is better. Oh yeah, right, So yeah, it's really challenging, and so I want to
give credit where credit is due. The Measles and Rubella Initiative has given vaccination to over two billion children since they started in two thousand and one, and worldwide global vaccination rates are increasing actually across the globe if you just take a very broad view of it, that's not true everywhere. There's a lot of places where vaccination rates are declining. There are a couple of really big measles outbreaks going on right now outside the US as well.
So in the Philippines there have been in the last two months from January to February of twenty nineteen, over eleven thousand confirmed cases oh my god, and one hundred and eighty nine deaths.
What.
And in Madagascar right now there's an output that's been going on since September that the last number I saw from the WHO said over sixty eight thousand cases and they're estimating nine hundred deaths. There's at least three hundred fifty eight sixty eight thousand, sixty eight zero zero zero.
In Madagascar where a plague epidets had just ravaged the entire population.
Yes, yep. And I should say too that in recent analyzes from the CDC, the vast majority of children in the US who are unvaccinated are also uninsured or underinsured. So we have a big problem with access in this country as well. It's I think it's sometimes easy to just blame it on, you know, the Disneyland outbreak. Oh, it's these rich people who are choosing not to vaccinate.
But it's not just that in this country or in any country, it's also an access issue, and an education issue and a miseducation issue.
Yeah.
So it's a double whammy.
We have gotten and would probably continue to get a load of questions from people living in certain fauci of outbreaks right now, so Seattle, Vancouver, New York.
Yeah, and then now we have one here where I am.
People who are vaccinated, people whose kids are vaccinated, whether there's any concern that they need to have for their own personal safety or the safety of their children.
Basically, if you got two MMR vaccines, you are ninety seven percent sure that you're immune. Yeah, and babies, like I said, in places where there is an active outbreak going on, you can get the vaccine for those children as young as six months. What a fun said, guys.
Well, it's very relevant and much more deadly.
I know, I really didn't know that it, you know, because the number you have always seen now is like one to two per thousand. That's what it tends to be in current times.
So not it killed a quarter of the population of Fiji.
Good God sources, Okay, So I mostly relied on a book called Measles and Historical Geography of a Major Human Viral Disease by Andrew Cliff, Peter Haggett, and Matthew Smallman. Rayner. I mentioned this earlier, but an article by David Morans called Measles in Fiji eighteen seventy five Thoughts on the History of Emerging Infectious Diseases and also the Cambridge World History of Human Disease edited by Kenneth Kipple excellent.
I had several good articles. This one on non medical exemptions is by main author is Jacqueline Olive and then the also Science article. On all of the articles and books we will always post along with links whenever we can on our website. This podcast will kill you dot com. You can find all of our sources from every single
episode there. And somebody on Twitter also was making like a what do you call it, like citation friendly source list too on some like bibliography website that I didn't know existed, So I'll find that and post a link to it somewhere too.
Great. Yeah, thank you all for listening.
Thanks for requesting this. This was a really interesting one for us to get to research, and I think it was. It's very timely and relevant unfortunately.
Yeah, thank you to Bloodmobile for providing the music for this episode and all of our episodes.
We love it and that's all of our thank yous.
Okay, Well, in that case, wash your hands.
You filed the animals, and get vaccinated.
Good lace
M