Measles has been spreading throughout Europe, particularly in Romania. According to this recent article from the World Health Organization, Romania has “reported over 3400 cases and 17 deaths since January 2016”. Unfortunately, these deaths mostly occurred among individuals “who were immunocompromised or had other co-morbidities.”
I recently shared an article about this outbreak on Facebook, and several individuals commented asking whether it was tied to the recent wave of refugees that have entered Europe, particularly as a result of the Syrian war. It led to discussions about the possibility of refugees choosing to waive vaccinations due to religious beliefs, about the vaccination status of undocumented children in the United States, and other topics. As an individual of Middle-Eastern descent and immigrant of the United States, such discussions are challenging and hard not to take personally. I tried to steer the discussion towards the evidence, which I will outline here.
In this post, we’re going to explore how the current outbreak in Europe is spreading across the continent, and whether there’s any evidence to support the idea that refugees or immigrants are more/less involved in disease outbreaks in the United States.
Is the current measles outbreak in Europe associated with refugee populations?
Romania’s measles outbreak began in February 2016, and measles cases in Europe have been linked to individuals who travelled to Romania (see here and here). The World Health Organization (WHO) recommends that the vaccination rate for measles be greater than 95% so that the virus does not continue its transmission. This number is particularly high and is because of how contagious measles can be. The CDC states that “if one person has it, 90% of the people close to that person who are not immune will also become infected.”
Despite the recommendation from WHO, Romania’s vaccination coverage for the first dose of the MMR vaccine was estimated to be 88% in 2015, with a wide range in coverage across the nation. The World Health Organization states that these pockets of suboptimal immunization rate around the country are due to “certain cultural traditions, religious beliefs, fear of adverse effects of the vaccine or lack of confidence in public authorities”. The recent outbreak finds the majority of its cases in regions of Romania “where immunization coverage is especially low”.
Before anyone jumps to the conclusion that the “religious beliefs” exemption referred to above implies Islam, I could find no evidence to support this notion. A 2013 review published in the medical journal Vaccine explored the stance of major religious groups on the topic of vaccines. Although there are Islamic communities around the world that have opposed vaccines, Islamic leaders and thinkers have outlined how vaccinations are acceptable. Islamic medical scholars have examined the components in vaccines and have provided guidance to encourage Muslims to receive vaccinations.
The 1951 Refugee Convention as well as the “European Vaccine Action Plan” outline that refugees and asylum seekers should receive vaccines and/or preventive care, regardless of the individual’s legal status. Catching up on missed vaccines, particularly in children, is of importance as noted by WHO’s regional office in Europe:
“Most of the refugees and migrants now arriving in Europe come from Middle Eastern countries where vaccines are widely accepted and coverage has traditionally been high. Those most at risk for vaccine-preventable diseases are young children who have not yet been vaccinated because the vaccination programmes in their home countries have been interrupted by civil unrest and war.”
WHO provides further guidance and recommendations in the document on how vaccinations should be provided to refugees across Europe.
In conclusion, I could find no evidence linking the current measles outbreak in Europe to refugees.
So, why has the vaccination rate in Romania declined? According to this document prepared by UNICEF, anti-vaccine sentiments have grown on social media in Romania, particularly by preying on parents’ fear around the use of chemicals and “toxins”. In other words, regions across Romania are just as susceptible to anti-vaccine arguments as Marin County, California.
Vaccines and Immigrants in the United States
Before we broach this topic, it bears noting that countries around the world include medical check-ups and vaccination records as part of the documents required for residency applications. I’ve lived in four different countries in three different continents. Each residency application required a visit to the doctor, including my green card application in the United States. My green card medical check-up took place while I was pregnant: I received a TdAP vaccine and I had to show my other immunization records.
The immigration process for refugees to the United States also involves medical examinations. Medical and religious exemptions can be granted to all immigrants and reasons for these exemptions are clearly provided. Most involve additional paperwork. In my personal experience, the immigration process is convoluted and long enough that I find it difficult to believe that an individual would seek an exemption unless it were absolutely necessary.
The question that remains is: are vaccine-preventable outbreaks associated with undocumented immigrants, particularly children, in the United States?
Such claims have been made by many individuals, including politicians, in the United States. However, there is no evidence to support the claim. The CDC has found that unaccompanied children that arrive at the US border pose little risk:
“Countries in Central America, where most of the unaccompanied children are from (Guatemala, El Salvador, and Honduras), have childhood vaccination programs, and most children have received some childhood vaccines. However, they may not have received a few vaccines, such as chickenpox, influenza, and pneumococcal vaccines. As a precaution, ORR [Office of Refugee Resettlement] is providing vaccinations to all children who do not have documentation of previous valid doses of vaccine.”
However, to ensure that all children across the country receive the required vaccinations, laws such as California’s SB277 are needed, which ensure that children enrolling in the public school system are up-to-date on their immunizations.
It is my biased opinion that immigrants and refugees would be more likely to receive vaccinations. Individuals leave their home country in search of safer and better opportunities, and that includes better healthcare for their families. Vaccines have been a victim of their own success: many North Americans have not experienced the harms of forgotten diseases and have not experienced a dangerous disease outbreak. Yet many South Americans know and fear diseases: as a child living in Venezuela I remember a cholera epidemic, as a teenager my entire family got dengue fever, and we got our yellow fever vaccinations before moving to South America. It is my perspective that South American immigrants would have an immunization rate equivalent or greater than that of US-born Americans, and there’s some evidence to support this.
Finally, a paper published in 2016 examined the risk of importing measles from undocumented immigrants versus US travellers. The paper concluded (emphasis has been added):
“Overall, there are 10 times more annual US visitors to high measles incidence countries than there are unauthorized immigrants in the US from high measles incidence countries.
Efforts to prevent reestablishment of indigenous measles transmission in the US should focus on evidence-based risk assessments, highlighting a greater potential measles importation risk of from US residents travelling internationally than unauthorized immigrants coming to the US.”
It bears noting that there have been instances where vaccine-preventable illnesses have had outbreaks in refugee camps. These were associated with the living conditions in some camps and provided much learning to the organizations involved. However, vaccine-preventable illnesses have also had outbreaks in Disneyland and Manhattan. That we should assume that refugees or immigrants are more likely to “carry disease” points to our own prejudices about segments of our society that should be embraced rather than shunned and assimilated rather than outcast. We should be mindful of the agenda behind websites that promote such myths, and turn to health organizations such as WHO or CDC for information on disease outbreaks.