Saturday, June 15, 2013

Meanwhile, measles break out in the Dutch Bible Belt...

The Netherlands do have a "Bible belt" - an area which has a high density of fundamentalist protestants, characterised by their vaccine refusal (and a generally conservative attitude amongst the very liberal Dutch). This has, over the years, given rise to serious outbreaks of vaccine preventable diseases, extending far beyond the belt region. For example, in 1978, a polio outbreak in the Netherlands, totalling over a 100 cases, of which 80 (all unvaccinated) were paralytic and one was fatal, spread to Canada and the United States leading to 14 cases of paralytic polio in unvaccinated Amish, and a further 2 non-paralytic cases in unvaccinated non Mennonite in the area. Apart from the molecular analysis of the virus, showing that the cases were related, the infection chain was also clear:
During the 1978 outbreak, members of the affected religious group traveled from the Netherlands to Canada, where cases subsequently appeared. An Amish family from an Ontario town 15 miles from the affected area moved in late summer 1978 to the Pennsylvania town where the first U.S. Amish case subsequently occurred, in January 1979.
Another polio outbreak struck the area in 1992/3, most of the 71 cases amongst the unvaccinated Bible belt inhabitants. This outbreak also spread to Canada.

In 1999/2000, a measles epidemic struck the Bible belt and neighbouring regions, totalling just under 3300 cases, of which 94% were entirely unvaccinated, and only one patient had had both MMRs. 16% had complications, over 150 were hospitalised, and 3 patients died. Importantly No association was observed between preexisting illness and either reason for admission (P = 0.5) or residual symptoms at discharge (P = 0.5) contradicting the notion that measles are a generally "harmless" disease in "healthy" children.

More recently, in 2004/5, rubella (the "r" in the MMR) swept through in the Bible belt, also spreading to Canada. The consequences were devastating:
In The Netherlands and Canada, 387 and 309 rubella cases were reported, respectively. Of these, 97% were in unvaccinated individuals of orthodox protestant denomination. Reported consequences of rubella in pregnancy were 2 fetal deaths and 14 infants with congenital infection. Of the latter, 11 had clinical defects including deafness in all but eye defects in none. 
The reason should be crystal clear - low vaccination uptake. The Dutch equivalent of the CDC, the RIVM publishes the numbers in handy maps - see the MMR vaccination coverage in the 1998 cohort (as school children, the baby chart was not available) vs measles cases:

The darker, the bad

Now, 13 years after the last big outbreak (enough time for the next generation of unvaccinated Bible belters), the next outbreak has started, with one protestant primary school boasting an impressive 1 in 5 pupils infected:

the "belt" even more visible in infant vaccination gaps

This is an impressive illustration how vaccine refusal (in religious and quasi-religious groupings) leads to large national and international disease outbreaks, causing significant illness, disability and death. These communities effective provide CPR to diseases that should have long been eradicated by providing a "renewable" population of susceptible individuals. Since it may not be possible to change the attitude of certain groups, it is even more important to uphold vaccination coverage around them, to reduce the potential for spread as much as possible.

11 comments:

  1. case count is up to 107, still along the Bible belt - that is an increase of 40 in one week - the prospects to contain this outbreak are not good:
    view map

    ReplyDelete
  2. and a week later, we are up to 161 cases, an increase of 54 in a week - the map has been updated and overlaid with the vaccination coverage.

    ReplyDelete
  3. 69 new cases in a week - view updated map here

    ReplyDelete
  4. The sheer stupidity of people amazes me sometimes.

    ReplyDelete
    Replies
    1. Dingo, I invite you to read Jan Willem Nienhuys' comments below. They do explain the background of the Dutch Protestants in the Bible belt. You are not dealing with "stupidity", you are dealing with a different world view which might be difficult to grasp from the outside.

      Delete
  5. phoar - we have 321 cases now map updated

    ReplyDelete
  6. You can see the most recent map and all older maps on http://www.skepsis.nl/blog/2013/07/mazelen-2013-chronologie-van-een-epidemie/

    This subset of protestants attach great value to their version of the Heidelberg Catechism, which explicitly states that weather, crops, disease and health and poverty or wealth are distributed by God. So, taking insurance (health insurance, for instance) and vaccination is considered sinful by them because it transgresses on the domain of God. They don't doubt that insurance or vaccination works.

    In the Netherlands health insurance is compulsory, but for this group there is a special arrangement: they pay exactly the same amount as the insurance to a special savings account in their name for health expenses. But if that account is emptied because of sickness, they can only rely on the charity of the other church members.

    They make up a small portion of the total population (appr. 1 percent of the population doesn't vaccinate for this reason) but they all live in the same area, send their children to the same religiously founded schools, and the disease is spread through these schools.

    Four times as numerous are the non-religious antivaxers, mostly believers in homeopathy, but they are spread out more evenly.

    If those numbers seem large to you, you should keep in mind that only one out of ten cases is reported (of course the cases that end up in hospital are reported). So 921 cases have been reported now, but this probably represents about 10,000 cases.

    ReplyDelete
  7. PS. the English translation of the literal text of question 17 and its answer of the Heidelberg Catechism is:

    "Question 27. What dost thou mean by the providence of God?

    Answer: The almighty and everywhere present power of God; (a) whereby, as it were by his hand, he upholds and governs (b) heaven, earth, and all creatures; so that herbs and grass, rain and drought, (c) fruitful and barren years, meat and drink, health and sickness, (d) riches and poverty, (e) yea, and all things come, not by chance, but be his fatherly hand. (f)"

    The footnotes refer to the Bible texts that are supposedly the reasons.

    Among the people that believe all this there are many that consider vaccination as basically also 'from his fatherly hand'; but the opinions vary. In these communities there is a lot of social pressure to stick to traditions - which can't be said about homeopaths.

    ReplyDelete
    Replies
    1. thank you Jan Willem, that was really helpful! I read somewhere that some parents secretly take their children to get vaccinated, which would also speak for extreme peer pressure. Poor kids (and parents).

      Delete
    2. In the affected area all parents (must be thousands) of unvaccinated children that were in schools of this strict religious type got a letter in July with an offer that their children could be vaccinated at home (less conspicuous than sitting in the waiting room of the child health center). Altogether 69 such vaccinations were given.

      Incidentally, this epidemic shows how effective 2xMMR is. In the Netherlands the first MMR is given at 14 months (that's rather late, but the later you give the first jab, the better it works, it seems) and the second at 9 years.

      I think that people who have been vaccinated AND get measles usually see a doctor (9 out of 10 religious nonvaxers don't call the doctor in case of measles). Until now there have been in the estimated 10,000 measles cases only 2 people with 2xMMR. It is difficult to estimate how many doubly vaccinated people the 10,000 measles cases have been in contact with. But it must be many hundreds. One of these two people was a 'health worker' who was infected in the line of duty. I think one may conjecture that nursing one or several seriously ill measles patients brings one into very intensive contact with the virus. Many people with a low level of antibody are partially protected and may get an asymptomatic infection (if they meet a small amount of virus), but the same amount of antibody with a massive virus load may result in a visible disease.

      Un the 'up side', the vaccination rate in these areas with lots of strict Christians is higher now than it was 10 years ago. People (younger generations) do change their minds, but slowly. And they certainly won't change their minds if you call them names.

      Delete
    3. Thank you Jan Willem - I agree that name calling is totally uncalled for. I do sympathise with people's WTF thoughts, because it is really difficult to understand a closed/secluded community like that if you have round the clock access to the internet and relative freedom. I am glad that the community is developing in their pace, although it is horrifying to see the damage that vaccine preventable diseases are causing in their midst (rubella probably worse than measles).

      Delete