The World Health Organization (WHO) said in December that its European region (which extends into parts of western and central Asia) saw an “alarming” increase in measles cases – from under 1,000 in 2022 to more than 30,000 last year. www.npr.org/sections/goatsandsoda/2024/02/08/1229540182/its-no-surprise-theres-a-global-measles-outbreak-but-the-numbers-are-staggering?
The WHO’s most recent global numbers, released in November, reveal that measles cases increased worldwide by 18% to about 9 million, and deaths rose 43% to 136,000, in 2022 compared to 2021. Some 32 countries had large, disruptive outbreaks in 2022, and that number ticked up to 51% in 2023, Dr Natasha Crowcroft, WHO’s senior technical adviser for measles and rubella control, told NPR.
The worrying uptick in measles outbreaks and deaths is, “unfortunately, not unexpected given the declining vaccination rates we’ve seen in the past few years,” noted John Vertefeuille directorof the U.S. Centers for Disease Control and Prevention’s (CDC) Global Immunization Division.
Measles is one of the most contagious infectious diseases, and also one of the most preventable: two doses of vaccine in childhood is 97% protective. WHO estimates that some 61 million doses were missed or delayed in 2021. In 2022, about 83% of the world’s children received one dose of measles vaccine by their first birthday – the lowest proportion since 2008, when the rate was also 83%.
“We’re going to see outbreaks any time we have an accumulation of people who haven’t been vaccinated,” says Cyndi Hatcher, unit lead for measles elimination in the African Region at the CDC. “When you have immunization disruptions, measles is always going to be one of the first epidemics that you see.”
Low-income countries continue to have the lowest vaccination rates – five sub-Saharan African countries have rates below 50% for the first dose.
“Measles is called the inequity virus for good reason. It is the disease that will find and attack those who aren’t protected,” says Dr Kate O’Brien, WHO director for immunization, vaccine and biologicals.
In Ethiopia, for example, conflict and weaknesses in the rural health system have taken a toll on vaccination rates, says Dr Ngozi Kennedy, UNICEF’s Ethiopia health manager.
Children who don’t get their vaccines on schedule are at risk of death and serious illness, particularly children under age 5 who are at highest risk for severe complications including pneumonia, encephalitis (brain swelling) and death. Measles can also put children at higher risk for other potentially fatal childhood diseases – such as diarrheal diseases and meningitis – because the virus can cause the immune system to forget its learned defences against other pathogens.
“I think that people may have forgotten how dangerous measles can be if they haven’t seen cases before,” Hatcher says.
But global health experts didn’t forget, and many predicted that outbreaks would be coming.
“During the pandemic, when everything was locked down, there wasn’t much measles being spread … because no one was going anywhere,” says WHO measles and rubella senior technical adviser Dr Natasha Crowcroft. “It’s the usual human thing that no one does anything until the problem starts. It’s really hard to sell prevention.”
Last year a coalition including the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance, launched “The Big Catch-Up” – an effort to get vaccination rates back up to at least their pre-pandemic levels. (Editor’s note: The Gates Foundation is one of the funders of NPR and this blog.)
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Every year, half a million children under five die of diarrhoea globally — but doctors and pharmacists often don’t prescribe a cheap lifesaving treatment for the condition. A large Indian study suggests that this happens because prescribers don’t think that their patients want the therapy.
Most private doctors and pharmacists in the study understand the benefits of an oral rehydration solution (ORS). The treatment, a pre-mixed sachet of salts and sugars that is mixed with water, has been around for more than half a century. It prevents dehydration and drastically reduces the risk of children dying from diarrhoea. www.nature.com/articles/d41586-024-00351-x?
To better understand why more children aren’t given ORS, Zachary Wagner, a health economist at the RAND Corporation, a non-profit research and policy organization in Santa Monica, California, and his colleagues launched a large experimental intervention in two Indian states, Karnataka and Bihar.
They sent actors pretending to be the fathers of a sick two-year-old child to more than 2,000 randomly selected private doctors and pharmacists in mid-sized towns. Three-quarters of carers in India seek help for their sick children from private clinics and pharmacies.
The interactions were designed to assess whether low levels of ORS prescription were due to supply shortages, incentives to sell more expensive drugs, such as antibiotics, or sensitivity to patient desires.
Each actor arrived at a facility unannounced and explained that their child had been experiencing diarrhoea for two days. Some told the provider that they had previously used ORS to treat their child and asked whether they should use it again. Some instead mentioned antibiotics, and others brought up no earlier treatments. Some actors noted that they would not be purchasing any medications at the facility and just wanted advice. The researchers also sent a six-week supply of ORS to half of the facilities.
The researchers found that a patient’s treatment preference was much more important than the clinic’s or pharmacy’s financial incentives or available stock in explaining why ORS is under-prescribed.
Actors who expressed a preference for ORS were twice as likely to get it as those who mentioned no treatment. A survey of more than 1,000 carers across the two states and representatives from the clinics and pharmacies revealed that 48% of carers feel that ORS is the best treatment for diarrhoea, but only 16% express that preference when visiting clinics. In turn, only 18% of doctors and pharmacists think that their patients want ORS.
The results “somewhat go against the belief among economists that financial incentives matter an awful lot”, says Karen Grépin, a health economist at the University of Hong Kong. Instead, informational barriers were more important.
But Ramanan Laxminarayan, an epidemiologist at Princeton University in New Jersey, says that financial incentives can be hard to disentangle from other motives. “We think of doctors as neutral decision-makers based on what is best for the patient, and that is often not the case,” says Laxminarayan. “Doctors make decisions based on what makes a patient happy,” he says, which has an underlying financial motive. “If a patient is not happy with you, they are not going to keep coming back.”
Overall, Grépin says the study is impressive, but there is still a lot more to unpack. For example, it is not clear why some patients don’t communicate their preference for ORS to their providers. The study also doesn’t offer a clear path forward on how to improve ORS uptake, she says. “It doesn’t really tell me what to do next.”
Wagner plans to design studies to test interventions for changing the perception of doctors and pharmacists, and how patients express their preferences. “Just telling people that ORS is a lifesaving medicine — we’ve hit the ceiling on what that can do.”
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In a global survey released last week, most scientists said the COVID-19 pandemic probably began when a natural virus jumped from an animal to a human, not because of an accident in a research lab studying coronaviruses. Organized by the Global Catastrophic Risk Institute (GCRI), a U.S. think tank, the poll set out to gauge opinions among a larger and more diverse set of researchers than is usually quoted about the controversy. (The pollsters excluded scientists in 60 countries and territories—including China, where evidence indicates the pandemic started—deemed “not free.”) www.science.org/content/article/news-glance-weird-early-trees-cern-s-next-big-collider-and-protecting-u-s-gray-wolves?
On average, the 168 respondents, most of them virologists and epidemiologists, assigned a 77% likelihood to the natural origin scenario and a 21% likelihood to a lab accident. Still, one in five said there was at least a 50% chance that COVID-19 resulted from a lab mishap. The results quickly triggered a fierce debate on social media about the study’s methodology and seemed unlikely to settle the question among scientists: Only 12% of respondents said no further studies into the pandemic’s origin are necessary.
Exactly how the COVID-19 pandemic began remains a topic of considerable scientific and political debate. However, the opinions expressed in the debate have thus far come from an ad hoc mix of experts and commentators who have spoken up. https://gcrinstitute.org/covid-origin/
The anonymous survey included 168 virologists, infectious disease epidemiologists, and other scientists from 47 countries in a geographic sample of both developed and developing countries. This is the first-ever systematic study of expert opinion on the origin of COVID-19.
While expert opinion does not necessarily match the underlying truth, carefully obtained expert opinion can indicate the current state-of-the-art thinking on a topic and the extent of consensus across experts. The survey results correspond to the beliefs expressed by the 168 experts who participated in the study.
Main findings from the survey include:
- The study’s experts overall stated that the COVID-19 pandemic most likely originated via a natural zoonotic event, defined as an event in which a non-human animal infected a human, and in which the infection did not occur in the course of any form of virological or biomedical research. The experts generally gave a lower probability for origin via a research-related accident, but most experts indicated some chance of origin via accident and about one fifth of the experts stated that an accident was the more likely origin. These beliefs were similar across experts from different geographic and academic backgrounds.
- The experts mostly expressed the view that more research on COVID-19’s origin could be of value. About half of the experts stated that major gaps still remain in the understanding COVID-19’s origin, and most of the other experts also stated that some research is still needed. About 40% of experts stated that clarity on COVID-19 origins would provide a better understanding of the potential origins of future pandemics. Given clarity on COVID-19’s origin, experts also proposed a variety of governance changes for addressing future pandemics, including measures to prevent initial human infection, measures to prevent initial infection from becoming pandemic, and measures to mitigate the harm once the pandemic occurs.
- The vast majority of the experts express the belief that a natural zoonotic event will likely be the origin of the next pandemic.
- The experts also provided a set of clear recommendations for preventing, preparing for and responding to future pandemics, which generally align with many previous studies.
“The COVID-19 pandemic was a major tragedy, but unfortunately, future pandemics could be even worse,” said Seth Baum, Executive Director of GCRI. “By studying COVID-19, including its origin, we can better reduce the risk of future pandemics.”
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Lalita Panicker is Consulting Editor, Views and Editor, Insight, Hindustan Times, New Delhi
