Question Period Note: Measles and Vaccine Hesitancy

• Beginning in late 2023 a large increase in measles has been observed worldwide, particularly in the World Health Organization’s (WHO) European Region. The WHO reported that the number of cases of measles worldwide increased by 18% and deaths increased by 43% globally in 2022 compared to 2021.
• Currently, cases of measles have been reported in several provinces in Canada. As of May 22, 2024, PHAC is aware of at least 77 measles cases in Canada. While some are associated with international travel, most cases in 2024 in Canada were a result of a Canadian exposure. Many cases are in unvaccinated individuals.
• An unvaccinated child has died of measles. This is the first measles death reported to PHAC since Canada achieved elimination status in 1998.
• A number of factors including the global rise in mistrust in government and science is leading to increasing rates of vaccine hesitancy thus creating declines in vaccine coverage. As a result, we are seeing a re-emergence of certain vaccine preventable diseases (VPDs) in Canada and around the world, such as measles.

• The Government of Canada is aware of the recent reports of large increases in measles in Canada, and tragically a death in an unvaccinated child.
• Investigations are underway for cases that do not report international travel or a link to a known case – sporadic cases are not unexpected, however.
• Thanks to vaccination, measles is rare in Canada, but this is not the case in all countries.
• Travelers should make sure they are fully protected from vaccine preventable diseases such as measles before travelling outside of Canada.
• Routine immunization programs remain one of the most effective measures to protect people in Canada against vaccine-preventable diseases such as measles.
• Ensuring people in Canada have reliable information on vaccination is an important part of preventing and combating vaccine hesitancy.
• Investments through the Immunization Partnership Fund are one way the Government is reaching people in Canada, particularly among underserved communities and those with persisting gaps in vaccine coverage.
• We will continue to monitor the situation and provide people in Canada with reliable information to protect them from serious illnesses.
IF PRESSED ON RECENT MEASLES DEATH
• PHAC is aware that Public Health Ontario has reported a recent death due to measles in a child under the age of five who was unvaccinated.
• Although rare, measles can lead to severe complications, including deafness and brain injury caused by inflammation of the brain, and even death. Measles and complications associated with a measles infection can be prevented through vaccination.
• Measles deaths are extremely rare in highly vaccinated populations.
• No deaths from acute illness due to measles have been reported to PHAC since elimination of the disease was achieved in Canada in 1998.
IF PRESSED ON VACCINATION
• While vaccination is not mandatory in Canada, the Government of Canada is committed to vaccination as a safe and effective measure that can help prevent disease and disability.
• Provincial and territorial governments deliver vaccination programs and determine public health requirements in their jurisdictions.
• If you believe you or your family may have been exposed to measles and have not received two doses of a measles-containing vaccine, or are immunocompromised, contact your healthcare provider or local health department immediately for guidance.
IF PRESSED ON ROUTINE VACCINATION COVERAGE IN CANADA
• The most recent national data available from the 2021 Childhood National Immunization Coverage Survey (cNICS) show that between 2019 and 2021, national vaccine coverage has remained generally stable.
• The results also show that despite some parents and guardians encountering obstacles and delays in receiving vaccinations, the majority (80%) of parents and guardians of all age groups reported that there was no change in their decision to vaccinate their child due to the COVID-19 pandemic and 18% were more inclined to vaccinate their child.

The measles virus spreads very easily, primarily through respiratory particles released when a person who is infected breathes, talks, coughs or sneezes in a shared space with people who are susceptible. It can also spread through direct contact with mucus from the nose or throat of someone who is infected or contaminated surfaces or objects. The virus can live in the air or on surfaces for up to 2 hours after a person who is infected has left the space.

It is a leading cause of death among young children globally. Measles has been eliminated in Canada since 1998. In July 2023, the National Certification Committee re-verified Canada’s elimination status for measles, rubella and Congenital Rubella Syndrome (CRS) for the 2021-2023 period. There was notable measles activity in the Region of the Americas in 2021, specifically in Brazil where over 650 cases were reported. Measles is relatively rare in Canada due to effective vaccination programs. However, it is important that people in Canada continue to be vaccinated against measles given the travel-related risks of infection and spread to people who are unvaccinated or not immune.

The rise of mistrust in government and science is increasing rates of vaccine hesitancy (which refers to a reluctancy to receive recommend vaccines that may lead to a delay in or refusal of one, some, or all vaccinations). Vaccine hesitancy is an ongoing threat to public health. In 2019 the World Health Organization cited vaccine hesitancy as one of the top 10 risks to global health. Addressing vaccine hesitancy requires a multipronged approach at all levels of government, at the community level, and through engagement of healthcare providers as key trusted messengers of vaccine information. While vaccine confidence in Canada is generally high, the continued support for vaccination cannot be taken for granted and sustained efforts are needed to improve vaccine literacy, build resilience to mis and disinformation and to support the social norm of vaccination.

PHAC acts as the focal point for vaccine confidence policy, research and behavioral analysis to inform development of evidence-based awareness and outreach campaigns, tools and training to help healthcare providers communicate credible information about vaccine effectiveness and safety to Canadians. As a core part of vaccine confidence efforts, the Immunization Partnership Fund is a grants and contributions program that supports public health actors and communities to increase vaccine acceptance and uptake. It supports local, regional and national organizations, and provinces and territories develop evidence-based approaches designed to improve vaccination coverage rates and combat mis- and dis-information.

Measles is a notifiable disease in all provinces and territories (P/Ts). When a healthcare provider diagnoses a case of measles, notification is also made to the respective jurisdictional public health agency. This helps P/Ts implement measles prevention and control strategies as quickly as possible. There is no specific antiviral medication for measles infection. However, treatment is available to help relieve symptoms, and in some cases, treat or help to prevent severe complications.

People with measles, or symptoms of measles, should isolate at home and away from others to help prevent onward transmission, and call a health care provider immediately. When seeking medical care, people should let their health care provider know ahead of time that they think they have measles. Their health care provider will take appropriate precautions to help prevent the spread to others.

Vaccination is the most effective prevention measure for measles. In addition to vaccination, people can also use personal protective measures to help reduce their risk of getting or spreading a respiratory infectious disease, like measles. This includes:
• Staying home when sick
• Wearing a well-fitting respirator or mask
• Improving indoor ventilation, when possible
• Cleaning their hands regularly
• Covering coughs and sneezes with their elbow or a tissue, not their hands
• Cleaning and disinfecting high-touch surfaces and objects

Measles Outbreaks Nationally and Internationally
As of May 22, 2024, seventy-seven cases have been reported in Canada this calendar year. Last year, in 2023, twelve cases were reported in Canada, eleven of which were related to travel. This indicates an increase in measles activity compared to the COVID-19 pandemic years during which measles activity had declined significantly (1 case in 2020, 0 in 2021, 3 in 2022). However, it is aligned with recent pre-pandemic years, where an average of 62 measles cases were reported each year (ranged from 29 to 113 cases between 2017 and 2019). Public Health Ontario has reported a death due to measles in a child under five who was unvaccinated.

As a nationally notifiable disease in Canada, every confirmed case of measles is reported by provinces and territories to PHAC for national monitoring purposes. Deaths due to measles are reported to PHAC annually. However, deaths that occur months or years after a measles infection may not be reflected in PHAC’s annual report.

Measles deaths are extremely rare in highly vaccinated populations. There have not been any reported measles deaths in Ontario since 1989. The most recent documented deaths from measles in Canada were in 1989 in Quebec where 5 cases died during an outbreak of more than 10,000 cases.

No deaths from acute illness due to measles have been reported to PHAC since elimination of the disease was achieved in Canada in 1998. However, it is possible that there have been a few deaths attributed to Sub-acute Sclerosing Pan-encephalitis (SSPE) in Canada. SSPE is a rare and fatal degenerative central nervous system disease that results from a measles virus infection acquired earlier in life.

The United States (U.S) Centers for Disease Control and Prevention provides monthly updates on the measles situation in the U.S. As of May 16, 2024, 139 measles cases were reported by 21 jurisdictions. In 2023, 58 cases were reported by 20 jurisdictions, and in 2022, 121 cases were reported by 6 jurisdictions.

In late 2023 and into 2024, a large increase in measles is being reported worldwide, particularly in the World Health Organization European Region. According to the European Centre for Disease Prevention and Control’s risk assessment (published in May 2024), measles cases are expected to continue increasing in European Union countries in the coming months due to sub-optimal vaccination coverage; the high probability of importation from areas experiencing high measles circulation; the seasonal peak of the virus, and the majority of new cases are associated with risk of local and community exposure and transmission.

Measles vaccination
The National Advisory Committee on Immunization (NACI) recommends that routine immunization for children 12 months to less than 13 years include 2 doses of measles-containing vaccine, using either MMR or MMRV vaccine, which are highly effective at preventing infections.

Vaccination is not mandatory in Canada; however, some P/Ts, including British Columbia, Ontario, and New Brunswick, require proof of vaccination for measles and other vaccine-preventable diseases (VPDs) in order to register in public schools.

PHAC estimates vaccine coverage through the Childhood National Immunization Coverage Survey, conducted every two years. The latest survey completed in 2021 estimated that 92% of Canadian children had received at least one dose of measles vaccine by two years of age and 79% of seven-year-old children have received at least two doses. This is below the 95% coverage target for measles vaccines.

Federal Role
PHAC works with P/Ts in the management of outbreaks of VPDs by providing technical advice and assisting with laboratory testing when requested by a P/T. P/Ts and local public health are responsible for delivering public health programs, including vaccination programs and investigation and follow-up of measles cases and outbreaks.
The federal government has a role in regulatory approval of vaccines, national surveillance for VPDs and adverse events following vaccination, bulk purchasing of vaccines, national leadership, and coordination in knowledge development, innovation, and sharing of best practices.

Each week, PHAC receives measles surveillance data from P/Ts and reports cases to the Pan American Health Organization. Weekly measles surveillance reports are publicly available on the Canada.ca website.

• Between 2017 and 2019, there was an increase in the number of confirmed measles cases reported in Canada with between 29 to 113 cases reported each year. This coincided with a global increase of the disease.
• This declined sharply between 2020 and 2022, due to the implementation of COVID-19 border measures and public health measures which led to a reduction in measles importations and outbreaks.
• Measles began to re-emerge in Canada in 2022, with 3 cases detected by the end of the year and 12 cases reported in 2023.
• As of May 22, 2024, seventy-seven (77) measles cases and one death have been reported in Canada already this calendar year.
• In Canada, increases in measles cases are observed every 3-5 years due to outbreaks, with the most recent outbreak year, prior to this year, being 2019.
• Vaccine hesitancy is a contributing factor to these outbreaks.
• The reasons for vaccine hesitancy are complex, and may include several intersecting factors, such as concerns about vaccine safety, experiences of stigma and mistrust, belief in misinformation and disinformation, and logistical, financial and other barriers to vaccination.
• Canada’s 2021 Childhood National Immunization Coverage Survey (cNICS) showed that over 97% of parents of 2 year olds felt that vaccines were safe and effective, similar to pre-pandemic.