Why has France not yet eliminated measles?

franceFrance has been facing a major measles outbreak which began in 2008 and seems to be coming to an endafter a dreadful peak in 2011. More than 23,000 cases have been reported in the past 5 years (see also the chart of reported cases below). In comparison, the recent outbreak in the Netherlands (a few hundred cases for now) seems to be a minor trouble in view of eliminating measles by 2015.

Editor’s note: This is a guest blog post by the author of the Rougeole Epidémiologie blog
The author does not have any conflicts of interest.

Mandatory notification of measles cases, France, January 2008 – May 2013, (provisional data for 2013), InVS.

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Vaccination against measles was introduced in France in 1968, five years after the United States which achieved measles elimination in 2000. So why has France not eliminated measles yet? Is it for the same reasons as the United Kingdom (about 1200 cases in Wales this year)? Surprisingly, the answer is no. As can be seen on the graph below, France, UK, and the Netherlands do not share the same history of vaccination coverage.

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As in UK, vaccination coverage in England and Wales was quite high (92%) in 1996. Then the coverage plummeted to 80% in 2003, because of the unfounded “Wakefield controversy” about the safety of the MMR vaccine (Measles-Mumps-Rubella). The coverage is now close to its level of 1996. The recent Welsh oubreak is the direct consequence of having left many children unprotected about ten years ago.

In the Netherlands, the coverage is high almost everywhere (more than 95%). However, in the “Bible belt”, local coverage can be lower than 90% because of religious opposition to vaccination. Therefere, as long as religious opposition continues, outbreaks are expected to occur.

Before the controversy in UK, France has always been behind in term of measles vaccination coverage. The coverage has been rising from the beginning, but too slowly to hope for swift elimination. For many years, many children have been left unprotected.

From the previous chart, it is obvious that the UK controversy has not really crossed the English Channel. According to the HCSP (Haut Conseil de la Santé Publique) and the Health Ministry, reasons of non-vaccination in France go from negligence to real opposition:

- There is a distinction between mandatory (diptheria, tetanus, polio) and recommanded vaccinations (e.g. MMR), and some parents come to think that recommended vaccinations are not that necessary.

- Some parents are honestly convinced of the mildness of the disease because they have contracted it in childhood and have recovered well.

- Besides, they are sometimes misled to think that MMR is more dangerous than the disease.

- Public distrust of authorities, medicines and/or pharmaceutical companies.

- The opposition to the MMR vaccination is correlated to the practice of homeopathy in general practionners and/or in parents. Some of them think erroneously that it is natural for kids to have measles, if not beneficial

Health authorities try to encourage the population to go and get vaccinated through media actions (dedicated website, letters to the parents…). However, such actions can not be fully effective because it is not easy to address clearly and convincingly the concerns and/or misconceptions of parents and doctors. Worse, anti-vaccination movements are well-organised and do not spare their efforts in sabotaging such information campaigns by counter-actions.

It is reasonable to expect other measles outbreaks in France in the future, but of less severity than the present one since, according to InVS (Institut national de Veille Sanitaire), the coverage for the second dose of measles vaccine is insufficient, but increasing.

See also ‘Vaccinology’ education can help fight infectious disease to learn more about The French exception.