(updated to reflect new outbreak figures released by AFP on Nov. 25, 2019)—A total of 2,194 cases of measles have been reported in Samoa this year. The government has declared a state of emergency and closed all schools, including the nation’s only university. Samoan health authorities are developing plans to implement compulsory MMR (mumps, measles, rubella) vaccinations on Nov. 25, 2019.1 2 3 4 5 6 7 8
According to the AFP, when declaring the state of emergency the Samoan government issued a statement that, “MMR vaccinations for members of the public who have not yet received a vaccination injection is now a mandatory legal requirement for all of Samoa.” It is unclear how the MMR vaccinations will be administered or what types of sanctions people will face for refusing to comply.9
Twenty-five deaths, all but one in children under four years of age, have been attributed to the measles outbreak and Samoa’s Director General of Health, who expressed concern that the epidemic may worsen. “The way it is going now and the poor [vaccination] coverage, we are anticipating the worst to come,” said Dr. Leausa Toleafoa Take Naseri. He estimated that 66 percent of the country’s population of 200,000 people has been vaccinated against measles.3 4 5 6 7 8
The relatively low rate of vaccination in Samoa has been cited by that country’s Ministry of Health as the main reason for the 25 deaths.6
But is this necessarily true?
There is some question about whether the high measles mortality in Samoa this year is solely due to the 66 percent vaccination rate among Samoans. While the fact that only two-thirds of Samoa’s population has been vaccinated for measles may explain the high incidence and spread of the disease, there may be other factors that account for the high mortality rate associated with Samoa’s current measles outbreak.10 11
While measles is a highly contagious infection, it very rarely causes death or disability in the United States and other developed nations.11 12 The Centers for Disease Control and Prevention (CDC) estimates that there are one or two associated deaths for every 1,000 cases of measles.10 11 However, this year in the U.S. there have been 1,261 confirmed measles cases reported in 31 states as of Nov. 7, 2019 and no deaths.13
Why such a disparity between the U.S. and Samoa in the number of deaths associated with measles? One reason might be the wide disparity in socio-economic conditions between the two countries. According to the World Health Organization (WHO):
The overwhelming majority (more than 95%) of measles deaths occur in countries with low per capita incomes and weak health infrastructures.14
There is also the issue of the impact of diet on the susceptibility of people to become severely ill or die from infectious diseases like measles. Malnutrition, for example, is a significant and growing problem in Samoa, particularly among the country’s children.15 16 17
The nonprofit organization The Borgen Project, which focuses on poverty and hunger around the world, says on its website:
Malnutrition in Samoa occurs in a variety of forms. In Samoa, the most common form of malnutrition is Protein-Energy Malnutrition, or P.E.M. Because P.E.M. is caused by an inadequate protein intake, it has its greatest impact on children, due to the low intake of protein in their diet.15
As it does in the rest of the world, malnutrition leads to many health problems in Samoa. In 2014, four children died and 19 were hospitalized as a result of diarrhea outbreaks. A ministry of health report connected poor dietary practices, and the use of Devondale milk as a substitute for both adequate baby formula and poor nutritional practices, to pediatric ward visits during the outbreak.15
The impact of malnutrition on Samoa, and particularly on the children of Samoa, is shocking.15
Given the malnutrition among Samoan children, it is reasonable to assume that part of the reason for the high measles mortality rate in that country’s ongoing measles outbreak has do with environmental factors that raise risks for measles complications. A study by Peter R. Belamarich, MD published in the journal Pediatrics in Review noted:
Children who were more than 100% of their expected weight for age (the 50th percentile) experienced no measles mortality, those whose weight was 90% of expected (mildly malnourished) had a 10% mortality rate, and those who were 55% of expected weight (very severely malnourished) had a mortality rate of almost 50%.18
Clearly, the nutritional status of a country matters when it comes to lowering mortality from measles. This has certainly been the case in the United States, where measles mortality rates in the U.S. dropped by more than 90 percent during the first half of the 20th century prior to the introduction of the first measles vaccine in 1963.19
Deaths from measles had decreased from 21 deaths per 1000 reported cases during 1911-1912 to less than one death per 1000 reported cases in 1953-1962. This improved measles morality rate was owed to several factors unrelated to the measles vaccine, including better sanitation and living conditions, as well as better nutrition and improved access to health care.19
2 AFP News Agency. Samoa makes measles vaccine mandatory to stop deadly outbreak. Al Jazeera Nov. 17, 2019.
3 Davidson J. Measles Outbreak in Samoa Kills 6. Schools Closed. State of Emergency Declared. EcoWatch Nov. 18, 2019.
4 AFP. Death toll from Samoa measles epidemic reaches 25. Yahoo! News Nov. 25, 2019
5 Reuters. Samoa declares state of emergency over deadly measles epidemic. The Guardian Nov. 17, 2019.
6 Wibawa T. Samoa’s measles crisis has claimed 15 lives but how did the outbreak start? ABC News Nov. 18, 2019.
7 Woodyatt A. Samoa declares state of emergency after measles deaths. CNN Nov. 19, 2019.
8 Zialcita P. Samoa Closes Schools And Mandates Vaccinations Amid Deadly Measles Epidemic. NPR Nov. 18, 2019.
9 Samoa makes measles vaccine mandatory to stop deadly outbreak. AFP Nov. 18, 2019.
10 MacMillan A. Can You Die From Measles? Why Doctors Are So Worried About Recent Outbreaks Health.com Mar. 1, 2019.
11 Scutti S. Measles rarely kills in the US — but when it does, here’s how. CNN Feb. 5, 2019.
12 Centers for Disease Control and Prevention. Measles Data and Statistics. CDC.gov Apr. 16, 2019.
13 Centers for Disease Control and Prevention. Measles Cases and Outbreaks. CDC.gov Nov. 12, 2019.
14 World Health Organization. Measles. WHO. int May 9, 2019.
15 Michaels A. Malnutrition in Samoa. The Borgen Project.
16 Food and Agriculture Organization of the United Nations. Dietary patterns of households in Samoa. FAO.org 2017.
17 World Samoa Nutrition Profile. GlobalNutritionReport.org.
18 Belamarich PR. Measles and Malnutrition. Pediatrics in Review February 1998; 19(2) 70-71.
19 Cáceres M. The Story of Measles’ Sharp Decline. The Vaccine Reaction Apr. 12, 2016.