For Canadian health-care officials, it was never a matter of "Will we get a measles outbreak?" It was about knowing that one of the world's most infectious diseases would find a way to spread into parts of Canada, especially in areas where immunization rates are dangerously low.
And that's how it happened.
What started in the measles-plagued Netherlands wound up in Southern Alberta and B.C.'s Fraser Valley. What is still racing through the Philippines, infecting thousands and killing 23, has been found in Southern Ontario.
The other side of the planet got it first; we got it later. Health experts could see it coming.
On Saturday, a case of measles was confirmed in an infant in Brampton, Ont. The child tested positive for the virus after being on a March 25 flight from Abu Dhabi to Toronto. Health officials have issued an alert to all the passengers on the same flight.
In Calgary, after two Western Canada High School students were stricken with measles, 100 unimmunized students at Western Canada were ordered to stay home until they could provide proof of vaccination. Last week, two students from the school were stricken with the measles. They also visited a pair of Calgary restaurants on March 24 and 25, which prompted a public warning for other diners on those two occasions. Manitoba now has four cases of measles, while Southern Ontario has had cases from Hamilton (three) to Ottawa (four).
"What's going on is not unusual, particularly in Southeast Asia and Africa," said Shelley Deeks, medical director, immunization and vaccine-preventable diseases with Public Health Ontario. "It is continually happening there, which is why it is so important for Canadians to maintain a high vaccination rate and for travellers to make sure they're up-to-date on their vaccinations.
"We have to want it gone everywhere," Dr. Deeks added, "before we can feel comfortable."
Measles was never gone completely, not in countries such as Vietnam, Turkey and Italy. In the Netherlands, the most recent run of measles began in the country's designated Bible Belt, an area occupied by conservative Protestants who refuse to vaccinate their children. That belief allowed the disease to go on a rampage, infecting more than 2,000 people with at least one death connected to the outbreak.
In Southern Alberta, it was a student who spread the disease after a visit to the Netherlands. The importation resulted in 42 confirmed cases in southern Alberta before the outbreak was declared over. As for the Fraser Valley and its 353 cases, it began with two students at a Christian school in Chilliwack, B.C.
But the numbers have been more severe in the Philippines due to a lack of immunization and health care in the country's poorer regions. Health-care infrastructure there was pushed to the limit after massive Typhoon Haiyan struck six months ago.
Health assistant secretary Eric Tayag of the Philippines said many victims of Haiyan came to Metro Manila and "they may have lacked anti-measles shots or not have been vaccinated at all." But, he quickly added, "We are not pinning the blame on the calamity victims."
With the measles virus on the loose, its introduction into Canada was inevitable. People travelled, contracted the disease, then brought it home to share. And where immunization rates were low, there was plenty of measles to go around for all.
"In Ontario, my impression is all the cases have been identified and so are people who have returned from travelling to other countries where there have been outbreaks," said Danielle Martin, vice-president of medical affairs and health solutions at Women's College Hospital in Toronto. "That's why we have to keep educating people on the need to be vaccinated."
The Measles & Rubella Initiative – a global venture that involves the World Health Organization, the United Nations Foundation and the American Red Cross, to name but three partners – reports there were 122,000 measles deaths worldwide in 2012, about 330 deaths a day. On the bright side, more than one billion children in high-risk countries have been vaccinated against measles since 2000.
It's one victory in an ongoing battle.
A brief history
Measles is the most contagious and deadly of what were once called the routine childhood illnesses.
Before a vaccine became widely available in 1963, virtually every child contracted the measles; traditionally, there were epidemics every two to three years, affecting up to 350,000 children and filling hospitals.
Measles is recognizable by lesions in the mouth known as Koplik's spots, and a rash made up of large, flat reddish-brown blotches. For most, measles will run its course after a week of itching. But the real danger is fever, which can lead to pneumonia, meningitis and encephalitis.
As a result of complications, about one in five children who contract measles will be admitted to hospital and approximately one in 1,000 will die.
Canadians born before 1970 are assumed to have contracted measles and are likely immune. Most people who were vaccinated will be protected, but the quality of the vaccine has improved over the years and immunity can wane over time. People with compromised immune systems – such as those with cancer, heart disease, COPD, as well as pregnant women and babies – are most at risk.
Measles is highly contagious: A carrier typically infects 12 to 18 others who are unvaccinated and six to seven who are partially vaccinated. (By comparison a person with the flu infects one to three others.) The measles vaccine is typically administered in two doses along with mumps and rubella vaccine in a shot called MMR. The first dose is given at 12-15 months of age, and the second before entering school at age 4-5.
Why doctors should tell, and not ask
Parents are more likely to agree to vaccination when pediatricians leave no room for argument, according to a study published in December, 2013, in the journal Pediatrics.
The study, conducted in the Seattle area, found that 83 per cent of parents resisted vaccine recommendations when physicians used language that implied giving latitude, such as "What do you want to do about shots?"
In contrast, when pediatricians used presumptive language – "Well, we have to do some shots" – 26 per cent of parents balked, the researchers found.
Doctors call it the "tell, don't ask" study, said Noni MacDonald, a spokeswoman for the Canadian Paediatric Society and a pediatric infectious disease specialist at the IWK Health Centre in Halifax.
The key, she said, is that doctors emphasize the positives of immunity, and not be dismissive of a parent's concerns. For example, a doctor could explain to a parent concerned about mercury that a small number of vaccines may contain ethylmercury – which does not accumulate in the body and is considered safe – but vaccines never contain methylmercury, an entirely different compound that causes mercury poisoning.
"Too often we have not focused on the positive," Dr. MacDonald said.
Doctors also need to tailor their messages to a parent's socio-economic status, she noted.
Highly educated parents may respond more to evidence-based information about the risk of tetanus, for example, than to a doctor's recollection of treating an unvaccinated child with tetanus who almost died. For many parents, she said, "stories are more compelling than facts."
Should vaccination be mandatory for health care workers?
While it was once assumed all nurses and other health-care workers were immunized, that is no longer the case. Measles has an eight- to 12-day incubation period, during which health-care workers could be showing no symptoms of the disease yet be infecting immuno-compromised patients. According to the Public Health Agency of Canada's Immunization Guide, some health-care jurisdictions are looking at making vaccination a condition of employment. Currently, it's a patchwork system of differing requirements. Here's a look at what's happening at some of Canada's top children's hospitals:
At the Alberta Children's Hospital in Calgary, it is "strongly recommended" that health-care workers get the measles vaccine, but it's not mandatory, confirms Judy MacDonald, medical officer for Calgary. Although it was decided last year after outbreaks that health-care workers "need to have a higher bar" when it comes to vaccinations – and should be required to have two documented doses of the measles, mumps and rubella vaccine recorded and on file – no change to policy has been made.
At Sick Kids Hospital in Toronto, new employees must prove they have had two measles, mumps and rubella vaccinations to ensure workers comply with the measles surveillance protocol developed in part by the Ontario Medical Association. For employees hired before 2013, there is a medication catch-up process outlined in the surveillance protocol. The hospital then records who has been immunized and who hasn't.
Ottawa's Children's Hospital of Eastern Ontario also keeps tabs on which staffers are immune. Vaccinations are encouraged but not compulsory.
Vaccination is not mandatory at the B.C. Children's Hospital. Eva Thomas, corporate director for infection prevention and control, said that while they would like all their staff to be vaccinated, "we don't know who has been [and who hasn't]." Those records are with the occupational health department of the B.C. government.
Alan Maki with a report from Justin Giovannetti
Editor's note: This is a corrected version of the story that referred to the Measles and Mumps Initiative. The correct name is the Measles and Rubella Initiative.