State of Emergency in Samoa due to measles outbreak

[Fishnut]

Things are not looking good in Samoa. The measles outbreak has so far killed 16 people, mostly children under the age of 2. A state of emergency has been declared, closing schools, banning children from public gatherings and even closing roads.

Poor vaccination rates and problems with malnutrition and access to healthcare have led to the outbreak,

University of Auckland Vaccinologist, Dr. Helen Petousis-Harris [said].. “...children in Samoa are more likely to suffer malnutrition or die in early childhood than children in New Zealand. In Samoa about 18 per 1000 children die before five-years where as in New Zealand this is about six.” She said on top of all this, the true burden of measles is likely higher than reported figures, simply because not all infected people will report to the healthcare system. [source]

The Samoa Observer also noted that the outbreak isn't restricted to Samoa,

Hotspots in the region are also facing measles outbreaks. In American Samoa, two cases were discovered and immediately quarantined. When a blood test in Hawaii confirmed their measles status, the government declared a health emergency and closed its borders to non-vaccinated people. In Tonga, there are 251 either confirmed or suspected cases as of November 12, whilst in Fiji there were four confirmed cases as of November 16.

New Zealand is sending medical personnel and supplies. Last week they sent 12 vaccination nurses and 18 more are on the way.

While it sounds like the government is doing all it can to get the outbreak under control they've got a long way to go and most likely there will be more deaths before this is over. While anti-vax sentiments are not helping, poverty and poor access to healthcare are clearly exacerbating factors.

[basementer]

My friend who you've recently met on Twitter was speaking at a symposium there just the weekend before last... she's sure to have been vaccinated but I do fret slightly.

[Fishnut]

This is how a global epidemic takes hold...

[basementer]

This is how a global epidemic takes hold...

Indeed

[mikeh]

Few days old this one, but antivaxxers including Robert Kennedy have been hanging out in Samoa
https://www.tvnz.co.nz/one-news/world/c ... utbreak-v1

1 NEWS has learned of a high-level anti vax meeting organised in Samoa in June, shortly before the deadly measles outbreak.

A US Embassy staff member facilitated a meeting between vaccination critic Robert Kennedy Jnr, invited to Samoa for its independence celebrations, and Australian anti vax blogger Taylor Winterstein.

What's worrying is that, depending on when this meeting(s) and other shenanigans took place, the impact from that may not actually being felt in this outbreak. But that might have caused further mistrust in public health, resulting in an ongoing decline in vaccine uptake and thus future cases may occur as a result of these scumbags.

So who knows, despite the big public health response, we may well have not seen the end of the measles cases, hospitalisations and deaths.

[Fishnut]

That is very concerning. The outbreak coinciding with the anti-vax meeting seems like ironic timing and hopefully it has been sufficiently dire to show Samoan anti-vaxxers that there are significant dangers to not getting vaccinated.

The BBC reports that the death toll has risen to 22, mostly children under the age of 5. It also reports that UNICEF has sent 110,500 doses of measles vaccination. The population of Samoa stands at around 196,440 according to google, and UNICEF estimate that between 28-40% of the population have been vaccinated against measles. By my calculations that means that between 117,864 and 141,437 people are unvaccinated and if all the doses are used then there will be a new vaccination rate of between 84-96% which should be sufficient to significantly slow or even stop the outbreak (googling suggests that a coverage of 93-95% is needed to provide herd immunity).

[mikeh]

More than enough doses but depends if the population will accept them, given part of the decrease is also due to the two infants that died after receiving MMR (from what looks like a contaminated vaccine batch)
https://www.immune.org.nz/hot-topic/inf ... mr-vaccine

[Fishnut]

sh.t, that's bad.

During the sentencing hearing, it was confirmed that one of the nurses mixed the MMR vaccine powder with expired muscle relaxant anaesthetic instead of water for injection supplied in a vial with the vaccine.

How does that happen? How do you mistake an anaesthetic for water and why do you have expired anaesthetics hanging around?!

Do you know if there's been any further information about this,

There have also been media reports of two other deaths of Samoan siblings on separate occasions more than a week after MMR vaccination – these deaths occurred in 2017 and April 2018. A very rare genetic immune disorder is expected to have contributed to the death of the second sibling, who died in New Zealand. It is suspected that the first sibling had the same disorder. The family are undergoing genetic testing.

It's incredibly unfortunate for such a small country to have so many vaccine-related deaths and the distrust seems more understandable in that context. I can't help but wonder if, with such a small population, there's any chance of the genetic immune disorder being more prevalent than normal due to founder effects and the like.

[mikeh]

How do you mistake an anaesthetic for water and why do you have expired anaesthetics hanging around?!

I haven't seen much more beyond what's been reported in the media. Badly-labelled bottles, maybe? Though given they were convicted of manslaughter, perhaps there was some obvious evil intent in their actions (though I presume manslaughter in Samoa can also be due to gross incompetence, no idea what their thresholds would be).

Do you know if there's been any further information about this,

There have also been media reports of two other deaths of Samoan siblings on separate occasions more than a week after MMR vaccination – these deaths occurred in 2017 and April 2018. A very rare genetic immune disorder is expected to have contributed to the death of the second sibling, who died in New Zealand. It is suspected that the first sibling had the same disorder. The family are undergoing genetic testing.

It's incredibly unfortunate for such a small country to have so many vaccine-related deaths and the distrust seems more understandable in that context. I can't help but wonder if, with such a small population, there's any chance of the genetic immune disorder being more prevalent than normal due to founder effects and the like.

Well, two seemingly actually vaccine-related deaths, and two deaths after a vaccination, which is of course very different.

Looking at
a) global burden of disease data, and fiddling with the variables, http://ghdx.healthdata.org/gbd-results-tool
b) Samoa vaccine given, e.g. https://www.who.int/immunization/monito ... ta/wsm.pdf

And thinking out loud a bit here -
- Samoa under 5 deaths (from all-causes) about 71 per year.
- Of these 22 die in the early neonatal period (typically meaning in first week of life). That's about 31% of deaths in the first 7 days , when you're measuring 1825 days in total
- They give the hep B vaccine, which is typically administered on the first day of birth, if not as soon as possible afterwards.
- Therefore, given the majority of deaths are at a time period very close to when at least one vaccine is administered, perhaps not too surprising that even in a small population like Samoa, there will be a few deaths each year at a similar time to the hep B immunisation, even though they're not linked.

[mikeh]

144 new cases in the last 24 hours.
https://twitter.com/samoagovt/status/11 ... 8136176641

[Fishnut]

bl..dy hell, that's bad. I tried to look for figures to see if the number of cases are plateauing yet but I couldn't find any information. I suspect people are too busy dealing with the situation on the ground to worry about publishing publicly available figures. That twitter account has figures for the 25th November (144 new cases), 23rd November (153 new cases) and 22nd November (202 new cases) which hopefully means that new cases are falling and the outbreak is slowing.

[Herainestold]

Is the government of Samoa getting the resources they need to deal with this crisis? Or are they being ignored because they are a small developing country of brown people?

[Fishnut]

UNICEF has been helping a lot,

UNICEF has deployed health and communication staff in Samoa to boost the government’s immunization campaign and delivered a total of 110,500 doses of measles containing vaccines (100,000 MR and 10,500 MMR) and 30,000 Vitamin A tablets. In addition, 6 refrigerators and three emergency response trolleys used as immunization service stations are being shipped to Samoa.

Both New Zealand and Australia have sent medical assistance too,

Australia has sent a team of 34 doctors, nurses and clinical assistance to help relieve staff at the main hospital in the capital Apia, where the team has set up a temporary eight-bed emergency intensive care unit... Meanwhile, New Zealand will be deploying a total of 30 vaccination nurses over the next four weeks as well as 3,000 vaccinations.

As discussed above, the number of vaccines sent should be sufficient to halt the epidemic, but it relies on people accepting the vaccination which may not be easy due to several vaccine-related deaths in the country in recent years.

[Herainestold]

I hope the NZ/Oz nurses/docs are not all white people. The Samoans might be reluctant to accept vaxes from people they distrust. I fear that is what has contributed to this epidemic.

[Fishnut]

I read in one of the news articles that they're Samoan-speaking so hopefully that should help with some of the trust issues

[mikeh]

May be complex to disentangle who the locals do and don't' trust. Samoan nurses who got convicted of manslaughter, westerners with Andrew-Wakefield-faces rocking up to say hello and be all nice to them and take them under their wing.

But broadly speaking, yeah, hopefully a locally-led response, augmented by external expertise. As they say.

[basementer]

It's still getting worse for Samoa. 32 deaths now, 243 new cases in the last 24 hours - https://www.stuff.co.nz/national/health ... n-24-hours.

[Herainestold]

Have some of the victims been vaxxed?

[Fishnut]

I can't find any information on the vaccination status of the victims but given the low vaccination rate before the outbreak I suspect not. The epidemic was declared at the end of October following the first deaths and mandatory vaccinations were begun after a state of emergency was declared on Friday 15th November,

A vaccination program will be published on Monday, including where and when will be open for vaccination. There will be transport made available and certain age groups prioritised for vaccination.

Measles takes 7-14 days from exposure to produce symptoms, and the classic measles rash take a few more days to appear. The vaccine takes 2 to 3 weeks for full protection. One dose is 93% effective and two doses are 97% effective but the second dose isn't given until 3 months after the first dose [source]. Given that the mass vaccination programme only began 10 days ago it's unlikely that any of the recently-immunised people have produced sufficient antibodies to fully protect themselves against the virus, and they may have been exposed prior to vaccination but are not yet showing symptoms. So the combination of the latency period of the disease and the length of time it takes for the vaccine to fully protect people means it may well be the case that we will see recently vaccinated people go down with measles. However, fully vaccinated people show milder symptoms so even if they get sick the mortality rate should begin to decrease once the vaccination programme has got properly underway. It should also be noted that about 3% of people don't respond to the vaccine and can still get sick which is another reason high immunisation rates are important.

The tl:dr is that while there's no publicly available data on the vaccination status of patients, the latency period of the disease and the time it takes for the vaccination to become fully active means we may see people who have recently been vaccinated get sick. However, the vaccination should provide some cover that means they should get less sick than they would otherwise.

[Herainestold]

I am wondering if maybe the vaccination doesnt work on Samoans?

[Fishnut]

I am wondering if maybe the vaccination doesnt work on Samoans?

Why wouldn't it?

[mikeh]

Measles now into one of the prisons. It's a new prison, with approx 300 inmates. Could be a fair few cases in there.
https://www.rnz.co.nz/international/pac ... ct-measles

[Fishnut]

It keeps getting worse doesn't it

And the antivaxxers are coming. The wife of a Samoan international rugby league player is comparing the government's compulsory vaccine program to Nazi Germany.

The Attorney-General Lemalu Hermann Retzlaff said,

“(Samoan) Law enforcement is open to receiving notice, complaints, or evidence of any person … discouraging or going as far as preventing our community from vaccination”.

It'll be interesting to see if they prosecute her. I think she and her husband live in Australia which might make it difficult.

[Herainestold]

Does the measles vax have different efficacies in different population sub groups? ie. Pacific islanders vs Caucasians?

[basementer]

There are comparative studies from the US showing that Caucasian subjects have a somewhat weaker measles-specific antibody response after MMR vaccination than African-Americans have (as measured by mean and median neutralising antibody levels). I haven't found a similar study involving a Pacifica group.

ETA link to paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278779/