As reports of escalating measles outbreaks spread worldwide, public health experts are sounding alarms about the geographical clustering of people who refuse to immunise themselves, creating vulnerabilities despite the overall high rate of vaccination.

Increasing numbers of people are refusing to vaccinate either themselves or their offspring, creating a phenomenal public health risk.

In Europe measles cases are at the highest they have been for 20 years as the anti-vaccine movement grows. With an increase in cases of measles across the globe it’s hardly surprising that ‘vaccine hesitancy’ has made it onto the top ten list of health issues the World Health Organization (WHO) will tackle this year.

Typically referred to as the antivax movement, WHO defines vaccine hesitancy as, ‘the reluctance or refusal to vaccinate despite the availability of vaccines’, warning it ‘threatens to reverse progress made in tackling vaccine-preventable diseases’. According to WHO, SA reported a total of 305 cases of rubella and 48 cases of measles between 01 January 2018 and 31 August 2018.

In September 2018 (based on measles data from The European Surveillance System) the European centre for disease prevention and control (ECDC) stated all 30 European Union countries reported measles data for July 2018, with a total of 758 cases reported by 21 countries, and nine countries reporting zero cases. In December an analysis of WHO data by The Guardian showed measles cases in Europe would top 60 000 in 2018 – more than double that of 2017 and the highest this century. There were 72 deaths, twice as many as in 2017.

In Australia the New South Wales (NSW) Government issued a measles alert in January. The first for 2019, it follows on a series of alerts issued in 2018. In the US, on 23 January 2019, a Washington state community near Portland, Oregon described as an anti-vax ‘hotspot’ has declared a public health emergency after 23 reported cases of measles were confirmed. Experts warn that a climate of doubt about vaccine safety is putting lives at risk.

According to the Centers for Disease Control and Prevention, measles is so contagious, if one person has it, 90% of the people close to that person who are not immune will also become infected. “It’s unimaginable that we have deaths because of measles – children dying because of measles,” said the European Union’s health commissioner, Vytenis Andriukaitis. One of the most cost-effective ways of avoiding disease, “vaccination currently prevents 2-3 million deaths a year and a further 1.5 million could be avoided if global coverage of vaccinations improved,” said WHO.

TOP 10 HEALTH THREATS OF 2019

The list, which focuses on issues that ‘demand attention’ from both the WHO and health professionals, also offers solutions. “The world is facing multiple health challenges,” said WHO announcing the 10 health issues the organisation will tackle this year. “These range from outbreaks of vaccine-preventable diseases like measles and diphtheria, increasing reports of drug-resistant pathogens, growing rates of obesity and physical inactivity, to the health impacts of environmental pollution and climate change and multiple humanitarian crises.”

To address these and other threats, 2019 sees the start of WHO’s new five-year strategic plan – the 13th General Programme of Work. This plan focuses on a triple billion target: ensuring one billion more people benefit from access to universal health coverage, one billion more people are protected from health emergencies, and one billion more people enjoy better health and wellbeing. Reaching this goal will require addressing the threats to health from a variety of angles.

1. VACCINE HESITANCY

Measles has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. A vaccines advisory group to WHO identified complacency, inconvenience in accessing vaccines, and lack of confidence are key reasons underlying hesitancy. The WHO reported some countries that were close to eliminating the disease have seen a resurgence.

According to the WHO, health workers, especially those in communities, remain the most trusted advisor and influencer of vaccination decisions, and they must be supported to provide trusted, credible information on vaccines. Vaccination continues to be one of the most cost-effective ways to avoid disease. In 2019, WHO will ramp up work to eliminate cervical cancer worldwide by increasing coverage of the HPV vaccine, among other interventions.

2. NONCOMMUNICABLE DISEASES

Non-communicable diseases, such as diabetes, cancer and heart disease, are collectively responsible for over 70% of all deaths worldwide, or 41 million people. This includes 15 million people dying prematurely, aged between 30 and 69. “The rise of these diseases has been driven by five major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, unhealthy diets, and air pollution,” said WHO. “These risk factors also exacerbate mental health issues that may originate from an early age: half of all mental illness begins by the age of 14, but most cases go undetected and untreated – suicide is the second leading cause of death among 15-19-year-olds.

3. GLOBAL INFLUENZA PANDEMIC

“The world will face another influenza pandemic,” the WHO predicted. “The only thing we don’t know is when it will hit and how severe it will be. Global defences are only as effective as the weakest link in any country’s health emergency preparedness and response system. “WHO is constantly monitoring the circulation of influenza viruses to detect potential pandemic strains: 153 institutions in 114 countries are involved in global surveillance and response. Every year, WHO recommends which strains should be included in the flu vaccine to protect people from seasonal flu.

4. ANTIMICROBIAL RESISTANCE

The development of antibiotics, antivirals and antimalarials are some of modern medicine’s greatest successes. Now, time with these drugs is running out. “Antimicrobial resistance – the ability of bacteria, parasites, viruses, and fungi to resist these medicines – threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhoea, and salmonellosis,” said WHO.

“The inability to prevent infections could seriously compromise surgery and procedures such as chemotherapy.” Drug resistance is driven by the overuse of antimicrobials in people, but also in animals, especially those used for food production, as well as in the environment. WHO is working with these sectors to implement a global action plan to tackle antimicrobial resistance by increasing awareness and knowledge, reducing infection and encouraging prudent use of antimicrobials.

5. EBOLA AND OTHER HIGH THREAT PATHOGENS

In 2018, the Democratic Republic of the Congo saw two separate Ebola outbreaks, both of which spread to cities of more than one million people. “This shows that the context in which an epidemic of a high-threat pathogen like Ebola erupts is critical – what happened in rural outbreaks in the past doesn’t always apply to densely populated urban areas or conflictaffected areas.”

“WHO’s research and development (R&D) blueprint identifies diseases and pathogens that have potential to cause a public health emergency but lack effective treatments and vaccines. This watch list for priority research and development includes Ebola, several other haemorrhagic fevers, Zika, Nipah, Middle East respiratory syndrome coronavirus (MERS-CoV), and severe acute respiratory syndrome (SARS) and disease X, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic.”

6. WEAK PRIMARY HEALTH CARE

Primary health care is usually the first point of contact people have with their health care system, and ideally should provide comprehensive, affordable, community-based care throughout life. “Health systems with strong primary health care are needed to achieve universal health coverage. Yet many countries do not have adequate primary health care facilities. This neglect may be a lack of resources in low- or middle-income countries, but possibly also a focus in the past few decades on single disease programmes.”

7. DENGUE

Dengue, a mosquito-borne disease that causes flu-like symptoms and can be lethal and kill up to 20% of those with severe dengue, has been a growing threat for decades. An estimated 40% of the world is at risk of dengue fever, and there are around 390 million infections a year. WHO’s Dengue control strategy aims to reduce deaths by 50% by 2020.

8. HIV

The progress made against HIV has been enormous in terms of getting people tested, providing them with antiretrovirals (22 million are on treatment), and providing access to preventive measures such as a pre-exposure prophylaxis (PrEP, which is when people at risk of HIV take antiretrovirals to prevent infection). However, the epidemic continues to rage with nearly a million people every year dying of HIV/Aids. “Since the beginning of the epidemic, more than 70 million people have acquired the infection, and about 35 million people have died. Today, around 37 million worldwide live with HIV.”

9. FRAGILE AND VULNERABLE SETTINGS

“More than 1.6 billion people (22% of the global population) live in places where protracted crises (through a combination of challenges such as drought, famine, conflict, and population displacement) and weak health services leave them without access to basic care,” said WHO. “WHO will continue to work in these countries to strengthen health systems so that they are better prepared to detect and respond to outbreaks, as well as able to deliver high quality health services.”

10. AIR POLLUTION AND CLIMATE CHANGE

Nine out of 10 people breathe polluted air every day. In 2019, air pollution is considered by WHO as the greatest environmental risk to health. Microscopic pollutants in the air can penetrate respiratory and circulatory systems, damaging the lungs, heart and brain, killing seven million people prematurely every year from diseases such as cancer, stroke, heart and lung disease. In October 2018, WHO held its first ever Global Conference on Air Pollution and Health in Geneva. Countries and organisations made more than 70 commitments to improve air quality. This year, the United Nations Climate Summit in September will aim to strengthen climate action and ambition worldwide.