The War to End All Measles

By | November 13, 2018

Armistice Day was first celebrated in 1919, a year after the armistice that ended the long and terrible first World War, taking effect at precisely 11:11 a.m. on Nov. 11. It was renamed Veterans Day in 1954, to honor all those who had served, but also perhaps to acknowledge that the “war to end all wars” had done no such thing.

But this week at the centennial of that original armistice, as we think about the millions who died, it’s important to remember that many of them died from what are now preventable diseases. We can try to keep today’s children a little safer.

Back in 1940, Dr. Philip Stimson, who had served in World War I, spoke about his experiences at the 10th meeting of the still-relatively-new American Academy of Pediatrics. Wars and soldiers were on everyone’s mind, because World War II was already underway, and the pediatricians were thinking about what their role might be, though the United States was not yet in the war.

Looking back, Dr. Stimson told his colleagues, “It is not widely known that mumps, measles, scarlet fever and diphtheria between them caused a loss of almost six and a half million days of availability of United States soldiers in the last World War.” He went on to say, of himself: “In 1918, the speaker was on duty at a British hospital for contagious diseases at Rouen, in France, where at one time he had soldiers from 11 different nations as his patients in a single large ward for mumps.”

That’s about as good an expression of the pediatric nature of war and soldiers as you could want, boys from 11 different countries, all hospitalized with mumps, a classic childhood disease, all sick together in a single ward, watched over by what was then called a pediatrist, in the days before immunizations, which now could prevent the mumps and the measles and the diphtheria, and the days before antibiotics, which could treat the scarlet fever, caused by Strep.

And yet, here we are in the middle of a measles outbreak in Brooklyn at this centennial moment. There are 17 confirmed cases of measles among the Orthodox Jewish communities in Williamsburg and Borough Park, said Dr. Jane R. Zucker, assistant commissioner of the Bureau of Immunization of the New York City Department of Health and Mental Hygiene. All were 4 or younger, and 14 of them were unvaccinated (12 of the 14 were old enough to have been vaccinated, that is, over a year; the other two were infants). Three different unvaccinated children had brought measles back from trips to Israel, which is currently having a large outbreak, Dr. Zucker said.

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The health department works with medical providers and facilities, confirming diagnoses, trying to prevent infectious children from exposing others in waiting rooms, tracking down and immunizing people who are exposed, and carrying out a lot of community outreach. “Because we know we’ve had exposures, I am expecting additional cases, the outbreak isn’t over,” Dr. Zucker said. It isn’t only when we think about the great wars of the past that we need to try to learn important lessons, and there is no more important lesson than doing what we can do to protect our children.

“We’ve learned so much from people being crowded together in military barracks,” said Dr. Adam Ratner, the chief of pediatric infectious diseases at New York University School of Medicine and Hassenfeld Children’s Hospital.

“The most important takeaway is that even though it’s tempting to look back and say, isn’t that quaint, people in hospital wards due to measles and mumps,” Dr. Ratner said, “we’re seeing this now.” Children have been hospitalized with measles over this past month, he said.

Any time you crowd children — or adolescents, or young adults — together, there’s an opportunity for some of the more contagious childhood diseases to take advantage of those who are susceptible. That was true in the First World War, where barrack life and troop ship transports contributed to the virulent spread of the 1918 influenza, which unlike most strains of flu, was more deadly to the healthy young than to the elderly.

Many colleges require a specific list of immunizations before students move into dormitories, including meningococcal vaccine to prevent bacterial meningitis. But measles-mumps-rubella vaccine is always at the top of the list. That’s because measles is so contagious that if the herd immunity — when a high percentage of a population is protected by immunization — drops even a few percentage points, the measles virus can take full advantage.

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“The first things you see, the cracks in your public health system,” Dr. Ratner said, will be infections like this, “measles, infectious through the respiratory route and good at moving from susceptible people to susceptible people.”

When my own daughter went off to college, someone looked carefully at her immunization records, always accepted without question at her school, and discovered that her very first MMR had been given a couple of months before her first birthday, and therefore didn’t count; she had to go get one more dose before she took up residency in her dorm room.

I had asked for that early MMR, because we were going to take her traveling in a country where there was still, at that time, a danger of measles exposure (no, not Brooklyn). You can give the MMR as early as 6 months if a child is at increased risk of measles exposure, and it provides some protection, but you have to repeat the shot after the child turns 1. I had forgotten to do that, and no one had ever noticed. As the pediatrician mother of the child with the incomplete vaccine record, I was a little embarrassed, but mostly impressed.

Dr. Stimson went on to note that those World War I soldiers who had grown up in more isolated, usually rural circumstances, were less likely to be immune to the childhood diseases, and “when thousands of these rural young men are first massed together in army camps, contagious diseases are apt to be very common,” he said. This had also been noted in the American Civil War, when measles was a particularly devastating disease, and the recruits coming off the farm were especially vulnerable.

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The young men of 1918 were going into terrible danger (Dr. Stimson himself was wounded in action in Flanders, serving with the British troops) but they were also in danger because they were exposed to one another’s viruses and bacteria.

“Measles is a serious disease,” Dr. Ratner said. It used to be a disease everyone got, but even then, he said, “not a small number of children ended up hospitalized, ended up dead.” Children are still at risk for severe illness, for hospitalization, for pneumonia, for serious complications that can result in brain damage. And we haven’t gotten much better at treating measles, Dr. Ratner said. “What we’re good at is preventing measles.”

Herd immunity remains essential because there are some people who cannot be vaccinated, such as babies too young for the vaccine to work, or children who have gotten the first of the two childhood doses, like three of the 17 in Brooklyn, and thus are largely but not completely protected. Those with suppressed or damaged immune systems also cannot safely get the vaccine, which includes an attenuated version of the live measles virus.

“Make sure kids are up-to-date on their vaccines,” Dr. Ratner said. “It helps protect them and protect kids and adults who cannot get vaccinated — measles vaccine is safe and effective.”

We can use the centennial of the armistice as a moment to think about how to keep our world — and our children — from going to war again. But we might also remember those boys from 11 countries, all on the mumps ward, and make sure we immunize our children so that when they do go out into what we hope will be a peaceful great wide world, they are as well protected as possible.