Even though it’s been raging for a while now, yesterday represented the first time that I’ve written about the deadly measles outbreak in Samoa. Since then, Prime Minister Tuilaepa Aiono Sailele Malielegaoi has announced that two more have died, bringing the death toll to 62, of whom 54 were children under 4 years of age and 26 were under one year of age:
By any stretch of the imagination, it’s a truly catastrophic situation, and it’s gotten so bad that beginning on Thursday the entire government of Samoa, as ordered by Prime Minister Tuilaepa Aiono Sailele Malielegaoi, has shut down for two days to devote all its effort to vaccinating its citizens. Given that, as I noted yesterday, the vaccination rate against measles had fallen to 31%, this is a monumental task, particularly given the vaccine hesitancy and mistrust of the government fueled by a the deaths of two children last year due to a nigh unbelievably dumb mistake mixing up doses of MMR vaccine, augmented by antivaccine misinformation spread antivaxers such as Tay Winterstein and outside antivaccine activists, such as Robert F. Kennedy, Jr..
RFK Jr. is, of course, well known here and, thanks to his longtime history of spreading antivaccine misinformation and pseudoscience, has been a topic of many a blog post here. Let’s just put it this way. RFK Jr. is fond of Holocaust and Nazi analogies when it comes to describing vaccine mandates, and the latest iteration of his antivaccine group, Children’s Health Defense, is fond of spreading myths that the current generation of children is the “sickest generation” and antivaccine misinformation galore. Meanwhile, US-based antivaxers have organized to infest the social media pages run by the Samoan government, flooding them with antivaccine misinformation, up to and including comparing the mass vaccination campaign to the Holocaust. The images in this video report from a New Zealand news crew are both heartbreaking and infuriating:
Unsurprisingly, for the most part, the antivaccine movement has been notably quieter than usual. After all, more than five dozen people, of which for and a half dozen are children, have died so far, and nearly every day brings new deaths, with no sign yet that the outbreak has peaked. However, I recently learned that a couple of weeks ago, when the outbreak’s toll hadn’t yet become as deadly as this, Robert F. Kennedy, Jr. wrote a letter to Prime Minister Tuilaepa Aiono Sailele Malielegaoi about the measles outbreak. This morning, I and a number of others, came into possession of the actual letter, which had been described and quoted in a Washington Post article. The letter itself (PDF) is a masterpiece of antivaccine dissembling, misinformation, distortion, and lies and appears to have served as a template providing antivaccine talking points to be used by quacks who have thus far tried to deflect blame for the deadly outbreak from the low vaccine uptake rate in Samoa and their role in discouraging people from vaccinating their children.
The letter begins:
I write with profound sadness to offer my condolences for the measles outbreak that has recently affected your country and taken the lives of precious Samoan children. These deaths are a personal tragedy for their bereaved families and for all the people of your tight-knit nation.
I was dismayed—but not surprised—to see media reports that linked the current measles outbreak to the so-called “anti-vaccine” movement. While we can expect pundits to engage in uninformed finger-pointing, Samoa’s public health officials must undertake the serious tasks of containing the infection and—equally importantly—to thoroughly understand its etiology. To safeguard public health during the current infection in and in the future, it is critical that the Samoan Health Ministry determine, scientifically, if the outbreak was caused by inadequate vaccine coverage or alternatively, by a defective vaccine.
Stop right there! Just stop! There is no evidence—zero, nada, zip—that the outbreak in Samoa had anything whatsoever to do with a “defective” vaccine. RFK Jr. was just pulling this right out of his nether regions. Moreover, when you have vaccine uptake well south of 50%, measles outbreaks happen. Measles is an incredibly contagious disease, one of the most contagious in existence, and easily spreads. In the background of low vaccine coverage (particularly as low as it was in Samoa before the outbreak), one case coming in from another country can rapidly become hundreds and then thousands of cases.
After that inauspicious and disingenuous introduction, RFK Jr. asked three questions:
- What were the ages of the victims?
- Were Samoa’s fatal measles cases caused by strains of measles not targeted by Merck’s vaccine?
- Were the fatal Samoan infections from a vaccine strain?
Let’s take on #1 first. I’ve already told you the age of most of the victims, with 26/62 being under one year of age and 54/62 being under four years of age. So what was RFK Jr. playing at? Nothing good:
Media reports from Samoa suggest that the infection is targeting young infants who are not yet of age to receive the measles vaccine. If true, the culprit is most likely a vaccine that failed to produce antibodies in the vaccinated mothers sufficient to provide the infant with maternal immunity. Young infants contracting measles is a relatively new phenomena first recognized in the 1990’s. Prior to the development and widespread use of Merck’s measles, mumps and rubella (MMR) vaccine, mothers passed protection to their infants via passive immunity derived from the placenta and breast milk. In contrast, mothers vaccinated with a defective Merck vaccine provide inadequate passive immunity to their babies. Merck’s version of the MMR has created a crisis where infants under the age of one are now highly vulnerable to these infections. These young infants suffer a much higher morbidity and mortality compared to populations historically impacted by wild measles later in childhood.
First of all, passive immunity to a disease like measles doesn’t come primarily from breast milk. It comes from the IgG antibodies passed to the infant through the placenta into the blood. Thus is immunity to diseases the mother has had passed on to the baby for a time. At term, dependent on the immunological experience of the mother, placental transfer allows the newborn to acquire different specificities of IgG antibodies. This results in an identical recognition pattern of antigens between the mother and her offspring. After birth, the baby receives no further IgG antibodies that can result in measles immunity from the mother, and levels of IgG antibodies in the infant wane to zero by between 6-12 months of age. The antibodies in the breast milk consumed by the baby are primarily secretory IgA, a class of antibody that is adapted to resist digestion by the GI tract and that serves primarily to protect the mucosal surfaces (e.g., mouth, nasal passages, etc.) from environmental pathogens. There are antibodies to measles in milk, but, contrary to the myth that breast feeding can protect against measles, in a study of Nigerian women and their infants the level of measles-specific antibodies in milk dropped below the protective level within two weeks of birth.
But what about antibody levels in babies born to mothers who had natural immunity to measles versus those born to mothers who had been vaccinated against measles? A 2010 study sought to answer that question in 207 mother-infant pairs in Belgium, measuring serum IgG antibody level over the first twelve months of life in women who had natural immunity to measles and comparing those levels to what was observed in mothers vaccinated against the measles. These investigators reported the already known and accepted result that at birth babies born to vaccinated mothers have significantly lower anti-measles antibody titers than babies born to mothers with natural immunity. However, here’s the key sentence: “At 6 months of age, more than 99% of infants of vaccinated women and 95% of infants of naturally immune women had lost maternal antibodies according to the model.”
Basically, high vaccine uptake is the best way to protect these infants, coupled with earlier vaccination during outbreaks. If herd immunity is high, faster waning of immunity due to maternal antibodies is much less of a problem. If herd immunity is not high, than vaccinating earlier is a viable option to protect these infants. I also repeat that there is no evidence that the vaccine was defective.
An earlier review of the literature found that, yes, antibody level does tend to start out lower and wane to lower than needed for protection against measles in the children of vaccinated mothers compared to children of mothers with natural immunity, although not all studies showed a difference. The whole issue is, as you might expect, way more complicated than RFK Jr. lets on. For example, part of the reason that the first dose of MMR isn’t recommended before age 12 months is because the persistence of maternal antibodies can interfere with the generation of an immune response to the vaccine. However, in nations with high vaccination rates, waiting until 12 months of age to administer the first dose of MMR is not a problem, due to herd immunity. Also, although it might blunt an immune response to vaccine, persistence of maternal antibodies doesn’t prevent an immune response. That’s why the CDC recommends:
In outbreak settings with community-wide transmission in which infants are affected, health departments may recommend vaccinating 6- to 11-month-olds, but it would not count toward the two-dose series. The CDC updated its Manual for the Surveillance of Vaccine-Preventable Diseases to clarify that infants living in and traveling to these areas should follow the advice of the health department in the outbreak area.
“Benefit of early protection against measles during a period of increased transmission and exposure should be carefully weighed against the potential risk of decreased immune responses following subsequent doses of MMR in infants less than a year,” said Manisha Patel, M.D., M.S., measles surveillance team lead for the CDC.
Health departments in outbreak areas also may recommend a second dose of MMR at least 28 days after the first for children ages 1 through 4 years who are living in or visiting the area.
If children are traveling abroad, infants ages 6 months through 11 months should have one dose of MMR, and those 12 months and older should receive two doses at least 28 days apart, according to the CDC.
I must admit that I laughed out loud at this passage from RFK Jr.’s letter to Prime Minister Malielegaoi:
When it first introduced its measles vaccine in 1963, Merck promised that a single dose of its vaccine would provide lifetime immunity and maternal immunity equivalent to that provided by wild measles. Merck predicted that its vaccine would eradicate measles by 1967, so long as 55% of children were immunized. Leading scientists including the world’s preeminent bacteriologist, Sir Graham Wilson and Harvard Virologist John Enders, who first isolated measles, warned against introducing a vaccine unless it provided lasting life-long immunity, as Merck promised. Measles, they cautioned, would rebound with increased virulence and mortality as the vaccine shifted outbreaks away from children—biologically evolved to handle measles— to young infants with inadequate maternal immunity and senior citizens vulnerable to measles-induced pneumonia. Unfortunately, we are now seeing the global emergence of the exact pattern that scientists cautioned against.
I do like how RFK Jr. pointed to nearly 60-year-old predictions by scientists, who clearly vastly underestimated the level of herd immunity necessary to keep measles in check in a population and likely didn’t envision how easily diseases can now jump borders, thanks to air travel, tourism, and people traveling to visit their families, over 55 years later. It’s a classic “science was wrong before” bit of misdirection. I also counter by pointing out that lifelong immunity can be provided with the help of booster vaccines. Indeed,, just to be safe, I myself recently got an MMR booster because I fall in the age range where immunity due to the old measles vaccine from the 1960s might be waning and I want to do everything reasonable to make sure I’m immune.
Next, RFK Jr. made this claim:
Both Dr. Enders and Dr. Wilson and other leading Virologists warned Merck that in addition to shifting the disease to vulnerable infants and the elderly, a defective vaccine with high initial failure rate, or substantial long-term waning, would provoke the evolution of more virulent measles strains.
American public health officials have recently admitted that, instead of providing lifetime immunity, Merck’s vaccine failed in about 10% of vaccine individuals within seven years. And, as scientists predicted, the measles virus has therefore mutated. Two new strains of measles that are not included in the current vaccine are now spreading like wildfire among populations worldwide. Global Public Health Officials have recently identified these deadly new rogue strains as measles genotype D4.1 and D4.2. The vaccine genotype A in the current MMR vaccine cannot adequately neutralize new strains. Merck cannot claim that this development is a surprise. Virologists have long known that viruses with multiple strains often shift to evade a vaccine that targets just a few strains. This is the reason that public health officials develop new flu vaccines each year to target the emerging viral strains.
I recognized this nonsense right away as coming from Andrew Wakefield and his risible speculation about an impending “sixth extinction” due to the evolution of resistant measles mutants due to—you guessed it!—vaccines. Thankfully for purposes of keeping this post from ballooning to 10,000 words, I dealt with Wakefield’s incompetent attempted prestidigitation with facts and science three months ago. That means I can just quote myself and you can read the whole piece if you want the gory details of this particularly unscientific and deceptive bit of antivaccine propaganda:
Naturally, I went straight to the source study. (It’s Wakefield. I’d be a fool to accept his description about any study.) Yes, this is what the authors observed, more or less. They identified two strains of measles virus less susceptible to neutralization by pooled human sera. Wakefield, however, took the significance of this observation beyond what the data support, because of course he did, and he left out something very important, but that’s more because the study authors pulled a trick that I hate. Here’s what I mean. What this study did not show is that these strains of measles identified by the authors are any more virulent or any more likely to cause disease in vaccinated children. Tellingly, Wakefield failed to mention that the difference between the strains in their susceptibility to neutralization by immune sera was not statistically significant—not even close. The p-value was 0.21. (The term “trend towards” is always a red flag that could indicate that an experiment’s results were not statistically significant. I’m shocked that peer reviewers allowed it. The correct interpretation is that the researchers did not observe a difference in neutralization between the strains, not that there was a “trend” towards resistance to neutralization. You might get away with that for p-values between 0.05 and 0.10, but certainly not for 0.21.) In other words, the experiment Wakefield cited is a negative experiment, at least as far as sera from vaccinated individuals being less able to neutralize these measles variants. I hate when researchers try to make a non-significant result sound real by saying there was a “trend,” and this was a particularly egregious example.
So, in brief, RFK Jr. laid down a stinky thick layer of bullshit. There is one of two possibilities. Either he was utterly clueless and was just regurgitating a particularly brain dead bit of Wakefield antivaccine propaganda, or he knew just what he’s doing and was lying. Take your pick. In his letter to Prime Minister Malielegaoi, he despicably weaponized that very bullshit in order to try to convince the leader of a country in which measles has already killed over five dozen people and sickened thousands more that the MMR vaccine both caused and has exacerbated the epidemic. Words fail me when it comes to describing how—dare I say?—evil this is.
Let’s look at RFK Jr.’s final question for Prime Minister Tuilaepa Sailele Malielegaoi:
There is also the possibility that children who received the live measles virus during Samoa’s recent vaccination drive may have shed the virus and inadvertently infected vulnerable children. It is a regrettable possibility that these children are causalities of Merck’s vaccine. Alarmed CDC officials documented this emerging phenomenon during the measles outbreak in California in 2015. Federal epidemiological investigations found that at least 1/3 of Californian cases were vaccine strain. In fact, CDC identified 73 of the 194 measles virus sequences obtained across the entire United States in 2015 as vaccine strain A sequences. This means that those children contracted measles from vaccination or from someone who received the vaccine.
For obvious reasons, it is critical for Samoa’s public health officials to quickly determine if the Samoan children who recently died suffered measles from the Merck vaccine or from a mutant strain that evolved to evade the Merck vaccine. In each of those cases, Samoa’s public health officers would react with a very different strategy than if the lethal measles genotype was a wild strain that spread due to inadequate vaccine coverage.
No, no, no, no, no! RFK Jr. was either lying or just misinforming Prime Minister Tuilaepa Sailele Malielegaoi There were no vaccine strain measles cases in the Disneyland outbreak. All measles cases in that outbreak were caused by wild-type measles. The claim that “vaccine shedding” can cause measles outbreaks is not scientifically supported. It is, in fact, utter nonsense. Again, there are only two possibilities. Either RFK Jr. was utterly clueless but didn’t care, or he knew and was lying. Again, take your pick. That he would have the temerity to write such a letter to Prime Minister Tuilaepa Sailele Malielegaoi, who’s struggling to lead a small, underdeveloped country through a major crisis, says a lot about RFK Jr.’s character, none of it good.
Meanwhile, quacks are echoing the antivaccine talking points that RFK, Jr. laid down. For instance, here’s Jim Meehan, an ophthalmologist turned antivaccine quack whom we’ve met before:
You can see the similarities in Meehan’s claims and RFK Jr.’s talking points. For example, Meehan parrots the lie claiming that it’s the vaccine strain, not a wild strain, of measles causing the outbreak and deaths. (One more time, it’s not.) To these claims, Meehan adds his support for Edwin Tamasese, a coconut farmer in Samoa and antivaxer who’s been arrested for promoting quack treatments for measles, including vitamin A and C supplements, and discouraging parents from taking their children to the hospital.
Meehan also pulls a claim out of his nether regions that giving patients the MMR vaccine is dangerous, particularly to children with symptoms of measles because it provides two additional attenuated live viruses in addition to the attenuated measles virus. He also does a bit of speculation that giving acetaminophen can be harmful because supposedly malnourished patients are deficient in glutathione and recommends supplementing them with glutathione. There is no evidence to support this recommendation.
Antivaxers cause real harm. First, they seize on tragedies like the deaths of two children due to a vaccine preparation mistake to introduce even more fear, mistrust, and misinformation about vaccines, thus exacerbating a situation. Then, in the middle of a deadly measles outbreak that is killing dozens of children, they make the situation worse still by promoting quack treatments for measles and spreading false and distorted information about the MMR vaccine designed to portray it as ineffective, dangerous, and even the cause of the outbreak and its resulting deaths.
Just to show you how despicable, RFK Jr.’s letter is, consider this. He undoubtedly knew that the Kennedy name would guarantee that Prime Minister Tuilaepa Sailele Malielegaoi would at least read his letter promoting this misinformation and would probably pass it to his health officials. (Never mind the obvious observation that Malielegaoi should not listen to a hack like RFK Jr. rather than the World Health Organization, UNICEF, and all the physicians and many public health experts from around the world streaming into the country to provide aid, vaccines, medicine. and advice.) In doing so, RFK Jr. clearly wanted to use the Kennedy name to persuade the Samoan government to undertake pointless investigations into whether the measles strain is causing the outbreak and to lead health authorities to hesitate to vaccinate infants. That goes beyond callous and into the realm of evil.