Hello, beautiful people. On this edition of the Filth in America podcast, we're going to talk about a disease that has been with humanity for a long, long time. A disease that humans have investigated, written about, and studied for really, really, really as long as we can trace back specifics of studying diseases we'll talk about today. A disease that most people from say 50, 100, 200, and 250 years ago would be familiar with, but yet is still with us today. That disease is measles. And in this particular episode, we're going to talk about measles, not only from a historical perspective, but also from the perspective of both a public health success for listeners in the United States. Measles was actually declared eliminated in the United States in the year 2000. But yet, as I record this, we have yet another raging outbreak of measles here in the United States. And measles continues to be a problem throughout the world, despite significant activities that we as public health uh authorities have undertaken to deal with this particular disease. And successes that we've had, certainly since the 1950s, on controlling this disease as a matter of public health. So we'll dive right into measles. Public health won and maybe public health lost. As we said, measles is one of those diseases that goes way, way, way back. Uh, the first detailed description distinguishing smallpox from measles was by uh the chief physician at the hospital in Baghdad in the 900s, right? He wrote a book in that was published in the year 910, which distinguished measles from smallpox. And that's generally considered to be the earliest uh description of measles as a distinct entity. This book written by the physician Razes. Now that's spelled R-H-A-Z-E. So I say Razes, there are different pronunciations, I'm sure there's an Arabic pronunciation, is a little bit different, but he he very much recognizes it as a distinct entity from smallpox. Although, as we'll see throughout time, throughout our history, smallpox and measles uh go hand in hand in certainly public health, epidemiologic, and clinical thinking, uh, even though we've known of them as separate disease entities for quite that long. He very much describes it as a uh a disease of too much bilious blood, although he does say that it does take some experience to distinguish uh some stages of measles disease from smallpox disease. He also very much recognizes it in a way that we would now consider to be an infectious disease. Now, remember, this is a long time before germ theory and the idea of communicable diseases as we think of it today, but he does add that the best thing to do during the first phase of measles is to stay away from patients. So the the average person should stay away from someone suffering from measles to avoid an epidemic. Now, this particular treatise was widely known in the ancient Arabic world and it came to Europe certainly by the 13th century, when it was translated into Latin. In the Middle Ages, measles was referred to by the Latin word morbili, which means uh little disease, um, which is derived from the word morbus. In the 11th and 12th centuries, there are several measles epidemics reported. There is also discussion of measles and mumps as separate entities. So you see this kind of narrowing down and specific description of measles as a distinct entity from other rash-oriented diseases. And now, this disease uh we now know, of course, is the result of an infection of what we call a morbilla virus. This is the family of viruses that is also responsible for render pest, uh, which is cows mostly. It is the same family as the distemper virus that those of you who are dog and cat owners will know. And actually, there's a version of this family of viruses that will uh infect dolphins and porpoises and seals and in kind of an outbreak fashion. So it's a type of virus that causes disease in quite a lot of uh different species. It's thought to have emerged from the rinderpest virus around uh 600 years BC. So it's been with us as humans uh for a long, long, long time. There are about 24 or so different genetic strains of measles virus, although they behave very similarly in the human body. And the virus has now really evolved to the point and has for some time that there is no natural reservoir of the virus in other species. So the measles virus that affects people uh only affects people, and that's important for how our public health approach to this particular virus has been. Now, we know quite a lot about it, having studied it for quite some time, and we're gonna talk about kind of the measles virus disease and then kind of get into some of the history of it, which, despite the fact that we have descriptions that are fairly detailed in the year 910, the complete clinical description of measles wasn't really finished until the mid-20th century. I think we we generally will say about 1945 is when we uh truly had described all the particular complications that can happen and all the things. So, so why measles? Why are we talking about this? It's, you know, it's it's a disease, and I think sometimes mistakenly considered to be a fairly benign disease. You know, after an incubation period of about 14 days, the disease transitions to an invasion phase, which um usually lasts about four days, the actual range of two to four days, with a fever that can get to be about 40 degrees Celsius, with kind of Yumbelase, tiredness, and headaches. Patients at this point generally will suffer with rhinitis, a runny nose, cough, conjunctivitis, you can inflammation around the eyes. They can cause watery eyes, and something called coplex sign that we'll talk about in a minute is observable in about 70% of cases. Occasionally you can get diarrhea or abdominal pain, vomiting can happen. But the thing that most people are aware of when it comes to measles are, of course, the rash. Officially, we would call it a machiopapular rash. It's a flat rash that starts usually on the hairline, goes down the face and neck, and will spread in a single outbreak over about three or four days to the entire body, importantly, including the palms of the hands and the soles of the feet. So when physicians are working up patients with the rash, they will look at the palms and the hands and the soles of the feet. The fever will go away in three to four days. The rash is around and then uh will ultimately disappear. That's not a scarring rash. Like I said, it's flax. Patients are really contagious for two or three days before that invasion phase, and they start having those symptoms and remain contagious for about 10 days after that, throughout the whole the rash period. And for most folks, that's the long and the short of it. That's all they experience with measles. However, it does some other things sometimes that can be problematic. Um, it can progress and infect the brain and cause a meninageal syndrome or encephalitis, depending on how you want to look at it. That happens in about one out of a thousand cases or so. Uh, and that can be really problematic, particularly younger children. Uh, and unfortunately, in our modern era of vaccination, there is a window of time that's a little bit too early to give uh the vaccine for a couple of reasons that we'll talk about. And so unfortunately, kids can't get it then, especially kids that are not being breastfed from someone who has been exposed. Other things that can happen, it really, as part of the natural course of infection, it kind of beats up the bronchus, the windpipe, and the bronchioles, the top of your lungs, the tubes that the air goes through as it goes down to the alveoli, the sacs that are in the lobes of the lungs. And when it does that, uh, it can certainly make you vulnerable to secondary infections, particularly bacterial infections that can cause pneumonia. Other complications include otitis, an ear infection. That pneumonia can be pretty significant in some cases, depending on which bacterium cause it. It can cause bestreptococci or staphylococci, sometimes someopolis, uh, but usually strep or staph, other risk factors, uh, malnutrition really increases the likelihood of a bad course when you get measles infection, particularly vitamin A deficiency can contribute to a really, really bad infection of measles so much so that we actually can treat the vitamin A deficiency in some cases, not all cases, but some cases, and improve outcomes. Of course, any patient that might be immunosuppressed, patients with AIDS, chemotherapy, undergoing steroid therapy for a variety of things, transplant patients can be a problem. It also is particularly problematic for pregnant women, right? Measles infection significantly increases the threat of miscarriage of what we call fetal demise, especially in the first trimester of pregnancy. It can also get the fetus in trouble and cause other things that can lead to fetal demise and other problems depending on when in the course of pregnancy. And one of the problems with measles is, of course, there's no actual direct therapy for measles, but the vaccine currently used is a live virus, an attenuated vaccine that we'll talk about. And generally speaking, live virus vaccines are not appropriate for use in pregnant women. So it's really important that people look to see if they have measles immunity or receive measles vaccination before becoming pregnant, uh, because it can really do some bad things for the pregnancy. One other thing that becomes really important in the history of measles is that it also towards the end of the course of disease causes an immunosuppression in and of itself. So the measles virus, just infection with it as you go through the disease, will suppress your immune system. And when it does that, you are vulnerable to other coinfections, particularly pneumonias, although again the ear infections are very common, but bacterial pneumonias. And in fact, in the outbreaks and a lot of the military issues with measles virus, that has in fact been what the problem was. Folks that may have had bacteria in their body that could cause disease, but weren't. They were otherwise healthy, younger people, particularly in military settings, didn't have any problem until they got the measles. And then they were immunosuppressed, so the immune system can't fight off the bacteria. Well, then they get a pneumonia that can be problematic. Especially when you think of it in the context of somebody who's already been dealing with a viral infection that's kind of beat up the upper part of their respiratory tract. So it's really, really a problem in some cases. Most people, again, do fine. Most children do fine, but one out of a thousand can definitely have the encephalitis, again, about the same these days, can have some of these other issues. Now that varies from outbreak to outbreak. And there is other, one other thing that rarely occurs that's very, very, very problematic: something called subacute sclerosing panencephalitis. This is a disease that occurs between four and as many as 14 years after measles. It's a progressive encephalitis or infection, inflammation of the brain that is characterized by demyelination of the cerebral neurons. It does not occur that often. The frequency has varied in studies conducted over the years, probably related to uh the nature of the initial measles infection. It can be fatal uh in two to three years after you see it. So the so patients start having seizures and all kinds of other problems, and there's uh very, very little that can be done. Again, that is a rare complication, but it doesn't emerge until much, much, much later, and is uh very, very, very, very problematic. So it can be one of these things that can cause problems. All again, albeit most times, it really, really doesn't. Measles has played a role that's fairly prominent in the history of the Americas, right? That's our kind of our focus on this. Certainly uh with European colonial expansion in the 17th century, the 1600s onwards, measles spread throughout the world. Uh, and it's really spreading from the Renaissance on, but for our purpose, we're gonna think about the 17th century. Although during the Spanish conquest in the New World, both smallpox and measles lead to epidemics with high mortality among the native peoples that the Spanish encountered, especially during the conquest of Mexico in 1521 and the conquest of the Inca Empire in 1532. Uh, there are uh reports of measles outbreaks in Cuba in 1529 that resulted in the death of two-thirds of the indigenous population that had survived smallpox, right? So these are people that had had one wave one wave of disease in smile and then were killed by the measles. There is also famously in 1531 a measles epidemic that wipes out, by some accounts, 50% of the population of Honduras. Uh, when the Portuguese arise in Brazil, there's uh a big uh measles outbreak in 1522. And certainly along the East Coast by the 1600s, measles is pretty significant. Now, the French colonists describe measles outbreaks. Again, this is a pretty well-known disease, pretty well-understood disease. And of course, it's hard to miss the bright red rash. So I think we feel pretty good about what they're saying, but certainly as early as 1635, the Jesuits report a mild outbreak among French and Indians. There was another outbreak by 1687 in Quebec that really was very, very, very problematic. The first case in what in the colonies that became the United States, all reports point to 1657 when a guy by the name of John Hull, who was in Boston, records in his diary that the disease of measles went through the town. Now, he says that few families escaped the infection, but though through the goodness of God, scarce any died of it. So that is generally considered by most authors to be the first case of measles in what is what is now the United States. And it's really important there are different other outbreaks throughout the 1600s and really large outbreaks later on. In 1693, Governor Edmund Andros and the Council of Virginia issue a proclamation appointing a day of humiliation and prayer because of measles in the province. So they're trying to deal with it. Also, measles was the subject of the first medical document published in what became the United States. And of course, at this time it's still the British colonies, but in 1677, Reverend Thomas Thatcher uh writes a kind of a broadside, a poster. And those of you that follow the uh Instagram page or the X page for the podcast will see uh a copy of that poster. That poster uh was the first medical document originated and printed basically north of Mexico. So it is uh a disease that really plays uh a role. That document was reprinted in 1702 and later in some military circles in 1721 and 1722. The uh original of those documents is available in Boston, the 1677. The Smithsonian, I believe, has the original, as the first of the 1702 printing, and the the Office of the Surgeon General of the Army has the first and only copy known to exist, the 1721 and 1722 uh printing. The 1702 printing was actually reprinted as people are debating over uh smallpox inoculation. This particular document does cover both measles and smallpox and uh was pretty widely circulated. So it was one of the first diseases that the American minister physicians really are trying to engage in public information, public health activities. And that was on the heels of some big outbreaks in England and Scotland in 1670 and 1674. Thomas Sittingham, again, regular listeners of the podcast will recognize that name from other things, particularly smallpox. He has a chapter in uh one of his treatises published in 1693, where he distinguishes again from smallpox and scarlet fever. He's the first person that we know of that coined the modern term the measles. His chapter is called On the Measles, and it's spelled the way we would spell it today, unlike the 1677 broadside, which was called a brief rule to guide the people of New England how to order themselves and theirs in the smallpox or measles. So he's really the first one to do it. Now, he had written that before, but it wasn't published until 1693. So we get um a lot of thought and study of the measles. In 1757, Francis Howe, or Francis Holmes, excuse me, proves that it is an infectious agent. Now remember, he does not know that it is what we would call a virus, right? He just he does prove, however, that it is infectious. Um, the disease spreads widely through uh what is now North America and the United States, really by the beginning of the 19th century. Only the North Atlantic and Pacific Islands were spread, uh were spared from the measles because of how long it took to get them, how isolated they they were. Uh, it's made it all the way across the continent, certainly in Oregon by 1829, uh, as we have westward expansion. It was there were large outbreaks in 1846 in California, uh, in Alaska in 1848, and way out on the islands of Alaska and Kodiak Island in 1875. Importantly, during this spread, there were a variety of outbreaks that were problematic that went back and forth as we go. So even though it may have come and go, but it was definitely continually described through the revolution across the area and in all the different colonies. In South Carolina, particularly, they describe an outbreak in 1747 as common and fatal, principally by the bowel complaints that follow them. So it has all these different manifestations and different Things that are going on. And so it was always on the mind in an epidemic sense throughout the colonies. And some of these were short-lived, others were not. Philadelphia was continually harried by widespread infection. In fact, Benjamin Franklin writes about this as early as 1749, and there were different outbreaks. And again, now they didn't always spell it. You know, they have measles, E-E-A-Z-E-L-S, and other things like that that go on. On the eve of the revolution, there was a large outbreak in 1772, and it kept going. Now, it didn't just affect children as we think of it today. It certainly did get young adults, but by the end of the colonial period, I think we have a transition of measles from kind of an outbreak or an epidemic disease, like so many others we talk about, to an endemic disease. And this is the nature of what we see, an endemic disease in most cases, again, with the exception of distant islands in the Pacific and North Atlantic. By 1848, one of the biggest and most devastating outbreaks of measles occurs in Hawaii, where it kills a huge number, as many as 30% of people infected. There in Hawaii, there were other outbreaks among Pacific Islanders, not just in the United States, but elsewhere in New Zealand and Tonga and Fiji. Some of them may have killed as many as 50%. So in history, some of these outbreaks of measles have really been devastating for populations, particularly isolated populations around different parts of the world. Famously, there was an outbreak in the Faroe Islands, and that very much contributes to our understanding of it because there was an epidemic in October 1846 that was studied in one of the first epidemiologic studies that was published in 1847. And since the Faroe Islands are very isolated, very static populations, the measles come through and affects what's thought to be about 80%. We could see the progression, we could see how long, and this was very, very well documented. And so a lot of the early epidemiologic understanding comes from the outbreak of the Faroe Islands, despite the fact it's been around and nearly ubiquitous by that time. By 1896, we have a fairly good description of the clinical disease, although, like I said, they're still describing some of the complications, like the encephalitis and the other long-term complications, the demyelinating encephalitis that we talked about. By 1911, uh John Anderson and Joseph Goldberger successfully transmitted measles to rhesus monkeys, small monkeys, from blood samples of measles patients. And so they very much were able by that time to identify the viral cause of measles, right? So we get quite a lot of understanding once that happens. The American Henry Koplik ultimately describes what we now call Coplex spots, which are bluish-white patchy patterns on the mucosal and the skin tissue, kind of in the back of the mouth near the molars. We now refer to those as Coplex spots. They were a really important discovery because those tend to occur before, maybe two days before the rash that starts at the hairline and goes down. So that gives us some early indications of what's going on with a given patient. And the different infection control measures can then be taken early to deal with this thing. As we said, it's a very infectious. And we say, well, how infectious? How do we know this? What are we talking about? Like everything else, as epidemiologists, we do try to quantify infectiousness. One of the common things that you hear about nowadays, particularly in a kind of post-pandemic world, is the idea of an R naught, or an R with a little zero. That is the concept of how many people will be infected by a given person, right? You will also see things like LD50 and ID50 with other diseases that come up, but the R0 is the one that you see the most because it gives us a good indication around the disease. With this, most people will look at measles. And most of the data that they've looked at measles has an R naught of around 16. The data averages from about 12 to 18. And so this is like infectiousness, not contagiousness, right? So uh infectiousness. How many people will be infected? So that means for every measles person that uh comes down with this disease, goes in that infectious period, they can potentially infect 16 people, 16, uh, with the ranges right from 12 to 18. Now, to put that in context, again, in this post-pandemic world, right, the average or the median value for that R naught value for COVID, the pandemic, was 2.79, right? So the average for measles is 16, right? Eight times as much, right? Um, even the range of the COVID was 1.5 to 6.68, depending on which author you read and how they they they did it. So you're looking at hugely more infectives. And that's how we can see in our modern era. Uh in an era where you have unvaccinated folks, you have a patient coming in with measles, and it seems like you have hundreds of cases nearly overnight. That's because you get this 16. So you figure that one person infects 16 others, who then each of those 16 would infect 16 others. And you can see how you get this exponential growth of this disease, making it very, very, very difficult to deal with if you have large numbers of susceptible individuals. Now, uh, as with a lot of these diseases that have epidemic potential, they also have had some pretty significant effects on the military, particularly in the United States. The Civil War, really, there's quite a lot of discussion of measles because, again, the measles well described, well known by that time in American history, right? The disease was endemic. But when we say that, we really mean that it was very common and widely occurring in young people in the cities, right? In areas of higher density, where you have a lot of back and forth and a lot of going on. But at that time in America, of course, we still have a lot of fairly isolated farmers, um, particularly in the rural south or in places like Vermont or in the areas that were being settled. Remember Minnesota and Iowa, just states for the 1860 election. And so you have some isolated areas. And so what you saw during the Civil War as uh people came into the camps at the beginning of the war, and then really throughout the war for initial military training, the measles would spread like wildfire because you had these folks coming from all over mixing in these camps as they trained before they would go off. And you know, a lot of the physicians, you read what they write in their diaries at the time, they were kind of surprised because a lot of these were based in the cities, and they said, Well, we thought this was a disease of younger people, right? It would have cleared up and gone. We're talking about 10 to 14 days. So, you know, you see these things going on, and they're they're a little bit surprised at all the folks that get it. Ordinarily are very healthy, military-age males, but many of these folks coming from rural America had not been exposed. So they get it when these camps, and of course, with it being as infectious as it is, it spreads really, really dramatically through the cramped conditions. At the beginning of the war, these camps are built up. Um, there's very little in the way of infection control measures that are pulled in. So ultimately, around 11,000 uh military recruits die of measles in the Civil War. Now, that number is certainly an underestimate, right? We're really not completely sure on, especially on the southern side, as the records were destroyed. But this was a significant morbidity infecting nearly all the soldiers. And again, you have huge, huge amounts of deaths, and they had to take measures. But again, they had a fairly limited understanding of infection control, and they had limited practical ability to deal with this disease. So you see measles being a huge problem in Civil War camps, and particularly when units uh of new recruits would show up. Uh, they couldn't uh train uh because so many of their members would get sick early on. In fact, there was a movement during the Civil War to increase the length of time you trained new recruits, not only to make them more prepared for the realities of modern war and doing the things that they needed to do and having the discipline that needed to be successful on the battlefields of the time, but also so that these diseases could go through the population. I mean, if you think about it, you know, if you go in there and say you have a couple of weeks training, which is all that they needed to do to do how to put on uniform, how to march in the formations of the time. Not great, but you probably can fire your weapon uh and learn some of those basics. So, you know, they would march them off. And at the beginning of the war, they absolutely did this. The initial training was weeks, uh, it was not very long. And that was not always successful because the discipline may take longer. But uh, what would then happen as these diseases went through, uh, a good number of the soldiers would come down with the disease while they're on the march to the battle or right around the time of battle, which is a really bad time uh to get the fever and and and debilitation of the measles. So commanders learned to increase the time that initial entry training cadets were spinning at the camps to let the diseases go through. This was in a this was informally referred to as measling, measling the troops. And so that became standard practice throughout U.S. military forces as the result of the effect that the measles had. Uh, measles tended to go away a little bit after the Civil War because you had so many people that were exposed. Again, all the soldiers, right? Two million uh or so federal soldiers and a million or so Confederate soldiers served. I mean, obviously there were several killed, uh, hundreds of thousands killed, but but the ones that returned, oftentimes they had been exposed to measles and had lifelong immunity from their exposure. So measles really became, again after 1911, this suspected viral disease that tended to occur in cycles in large cities and uh affecting probably 80-90 percent of folks, and then kind of irregularly in rural areas, depending in, you know, the we fast forward to just before World War I, there were around 178,000 uh to 529,000, again, depending on what type of clinical criteria you use to define it as a measles case. Remember, they don't really have a test like we would uh today, it's all clinical. There were between 178,000 and 529,000 annual hospital admissions from measles, and between 2,300 and 9,900 annual deaths in the United States. Most of the deaths, of course, occur in children under 10 years old. And that was pretty stable. The measles mortality, like we said, did drop kind of after the Civil War. Uh, while it was a problem in the Spanish-American War, it still dropped as we saw other things, right? Nutritional status going up, uh, particularly in the soldiers better supplied, better fed, better food technology to be able to get food, logistical uh improvements made during the Civil War and later during the Spanish-American War, all of these things uh kind of diminish the importance of measles in certainly the way the military looks at it, and in a lot of American life before World War I, even though that's a huge amount of hospitalizations. But the mortality, again, you know, if you had at the worst numbers 530,000 hospital admissions that led to only 9,900 deaths, that's pretty good. Most people are going to survive. Uh, and so it just, like a lot of things, just becomes less on the minds of people uh until we get the massive troop expansion uh related to World War I, right? So we almost overnight go from a 217,000-man army to a one and a half million man army just in 1917. I mean, this so they're they're doing a lot of enlistments, people are rushing to enlist, but there's also draft-based mobilization. And so, in order to train up this huge influx of soldiers, there were about 40 uh mobilization camps built across the country, particularly in the Southeast. They uh brought in a lot of National Guard soldiers. The National Guard have been around for several years uh now. And so you get uh a huge, huge amount of soldiers. The average during the World War I period of the United States, um uh average aggregate annual strength of the Army was 4 million. I mean, that's huge. Um uh almost uh you know around ballpark of 10 times as many people as we have today in the Army. And this is, again, probably an understatement, not everybody got counted and so on. And there was, in fact, screening. Um, if somebody showed up with the measles rash, they would not be sent on to these camps. But nonetheless, because you have this period of time when somebody's gonna be infected before they really show symptoms. Um, and of course, this is uh pretty rapid screening, so we don't know how valuable all of them were. The recruits arrived and did seed these camps with incubating cases of measles. And it really wasn't clear uh how this was happening, but you all of a sudden have massive explosion of cases in the military camps of World War I and a much, much higher depth death race. Now, of course, this is really an era of modern pathological types and medical terminology. So when you read these descriptions, we know a lot about what they're going on. We understand they have some modern medical tools for diagnosis. As we're talking about, X-rays are available, but infection rates were uh were very, very high, as were fatality rates. And we also saw a lot of these pneumonias that tend to follow the initial measles infection occurring. Those were both infection rates and these more severe pneumonia cases were highest in camps whose recruiting areas included rural and remote locality. Again, where we would think that susceptibility to measles was most common. The severity statistics of the World War I, again, the 1917 outbreak is striking. As we go through this Army-wide, we end up seeing nearly 96,000 cases of measles, of which 22, uh 22,809, which is about 23%, 23, 24 percent of people were admitted to hospital for complications. Now, remember, this is where this is on a data where they're thinking, well, there's 530,000 people and only um 9,900 deaths. Now all of a sudden we have this, and just in the military hospitals, we see in this one year 3,200 people dying. Now, to put that in context, this is one military year of a pretty big army. In 20 years of fighting Afghanistan, we had 2,459 deaths. So we're seeing more deaths from all of 20 years of Afghanistan in one year of World War I in these camps. Most of this happening before uh and really preventing or slowing the shipment of troops to the war effort in Europe. So it's an important thing. It's um it really peaks by the time uh by November of 1917 when we're trying to ramp up and rush and get things going. Remember in World War I history, you know, both sides are pretty exhausted by the time the U.S. is in there. But there was one more push by the Germans, which was showing results, and the British and French were very concerned about this. They really want to get American forces in as quickly as possible. In some camps, however, as many as 50% of the soldiers affected by the measles went on to develop these pneumonias, uh, or something called an empyema or empyema, which is an infection which results in pus in the space, we call the plural space, and outside of the plural space, uh, between the chest wall and the lung. So you've got in the lung and out of the lung, and it's really something that was only historically diagnosed by 2% of the time. Now, all of a sudden, in cases where folks had a pneumonia, about 90% of them also had this infection, this pus outside the lungs in some camps. So it's really, really a problematic. It takes up a lot of the military's time looking at why are we getting uh this empyemas and what's going on with that, and why are we having all this post-measle pneumonia? We noticed that soldiers with measles were 10 times more likely to die of secondary bacterial pneumonia or pneumonia with this empowema than those without measles. We saw huge rates of acquisition jumps, and this was an unusual thing that really threatened to derail World War I's efforts as it goes on. And you know, you we think of in this time in the World War I era, obviously, you know, industrialized war and the big artillery. We see those in movie clips, but really measles and measles-related activities are the fourth biggest cause of death in U.S. forces. The number one ultimately becoming the Spanish flu, which is ill named, as we'll talk about it in a future episode. But you have influenza and related pneumonia, gives the pneumonian influenza of that period, is the number one killer of U.S. forces. Number two then was uh kind of the combat injuries. Number three was non-combat injuries, accidents, and so on. And number four was measles and its complications. Now that's quite a lot. That's quite something if you think about this, again, slowing our entry into World War I. So they started looking at this, and it's this military outbreak that really, really changes our understanding of the secondary infections and the consequences of the measles infections. You know, this is an era when they're not doing a whole lot of these prospective studies and whatnot, but there are some that look at uh various causes and they swab people when they scale up in the camps to look for streptococcal carriage. Do they have strep bacteria in an otherwise healthy individual, right? Do they have staph bacteria in the throats and areas of otherwise healthy individuals? And they have several different studies which show this kind of silent streptococcal carriage as a risk factor for severe or fatal measles. So they were able to definitively show you have people showing up in these camps that have these potentially disease-causing bacteria in their nose, in their throats, but they weren't causing this individual any problem. They were healthy, they're young, they could just deal with it. These things typically do self resolve, your body will get rid of it eventually. But in this case, what would happen is the person with these bacteria would Not only be shedding them, some other people who didn't show up with the bacteria would get them, even if they were still healthy. Then somebody would get measles. And the measles would do what it does, right? It would infect that upper respiratory tract, really beat it up, and make it easier for those bacteria to become worse and ultimately become invasive and cause disease, as well as suppressing the immune system of the sufferer of measles. So you get folks with tremendous risk for these pneumonias, and just why they kept having, and they would go on and on and on. And they would get airsipolis or tonsillitis and then the pneumonias, ear infections were not particularly uncommon either. And it became a real, real problem in military camps. So with the camps, they really for the first time start trying to do a lot of infection control measures. Now, again, by this time, they know about these bacteria. Obviously, they know measles is a viral illness. So they're trying to do various things, cleanliness and spreading people out and really being aggressive about limiting the number of people and putting beds in a head-to-toe fashion. And there's also modern treatments. Now, this is an era before antibiotics, right? There's not a whole lot that they can do on that side, but there's advanced surgical, we have antiseptics, uh, surgical survival rates were very high. And so, you know, while uncomplicated camp measles, if you just got regular old measles and somehow dodged a lot of the secondary consequences of this, most doctors kind of thought about it as unremarkable. But these complicated cases, they got laryngitis, then onto a tracheitis, then full inflammation of the throat, leading to bronchitis, the cough, uh, then their lungs would get bad. They started using the relatively new technology of X-ray, and they could see it and detect it in the absence of typical pneumonia signs and symptoms. And what do we mean by that? Well, one of the things that was very interesting, because the measles tends to uh infect the upper part of the respiratory tract, right? The bronchus, the windpipe there as it goes to the lungs and the bronchioles, the smaller part, rather than the lobes down where the air sacs are of the lungs, the pneumonia pattern was a little bit different. It really was kind of a tracheobronchial pneumonia rather than what we call a lobar pneumonia or a lobular pneumonia down there. So it didn't appear the same way clinically. A lot of us have had a physician at one time or another listen to our lungs, listening for crackles or rails or moist sounding, the gunk in the lungs and all that. And you wouldn't have that with the pneumonia that followed the measles. And so there was a delay until the clinicians really were able to use new tools and understand the different nature of this type of pneumonia. And so they really were able to look at lung changes, early lung changes with chest radiography, which was, of course, new and it was still being optimized. And it really comes into its own as a diagnostic modality for these types of diseases because of the World War I experience, which of course has tremendous implications for the way we would diagnose people going forward, all because of this. They also have surgical capabilities. Uh early on, again, this is the pre-antibiotic era. If the lungs started getting really bad, um, they would oftentimes do a thoracotomy. They would open up the chest and try to take out the disease part of the lungs. And the thinking at the beginning of the World War I era was to be real aggressive about that, to stop the disease spread in the body. But those patients really did not do particularly well because, of course, as they they found out rapidly, right, the the um the post-measles pneumonia typically affected both sides, affected both lungs. So you take, you open up the chest, you take out part of the diseased area, you've got the other area, which is still diseased, and so those lungs would collapse and not do particularly well. So being aggressive, going in early with thorcotomy was rapidly determined to not be the best thing. And instead, they developed more ability to put in chest tubes uh to do drainage with a needle and get the fluid out of the lungs, and then, if necessary, do a thorcotomy later, which is kind of what we would do today. If you get somebody with the fluid in the lungs or an embedded email or something like that, we might put a tube in and drain it. And they learn really to be more aggressive about that and less aggressive about thorotomies, which again saved who knows how many lives. And of course, chest tubes are a standard part of practice today for a variety of clinical situations. They do a lot of uh autopsy and pathology to really learn about what's going on and they really, really figure out the overall progress of this disease. So the response to this 1917, 1918 measles epidemic was a striking moment in time where medicine really becomes noticeably modern. And while the, you know, the the a lot of the uh equipment would have seemed kind of primitive looking to us today, you would recognize what's going on. Most people today would know what an x-ray is, and they would understand that, oh, okay, pneumonia is an infection of the lungs, and we can see it on an x-ray if we look for it. All of that comes out of this World War I experience. Uh, and it also, I think, gave rise to the way we later in that period looked and were able to manage the Spanish influenza complications, right? They were already used to dealing with lung uh issues. Uh, and while that was a really a horrible disease uh outbreak killed lots and lots of people, certainly more than the measles did, uh, it really helps physicians and their ability to manage this massive outbreak that goes on. And it helps physicians understand co-infection and how different organisms like measles and strep, or measles and staph, uh, or measles and hymophilus might work together to have to affect outcomes, right? The immunosuppression that the measles could stop. And so it really drove home that a lot of these otherwise healthy people were dying not just of one thing, but of multiple things. And this gives rise to one of the things that you hear about measles or people that are anti-vaccine or anti-whate will comment about the measles and say, oh, look, well, they know no one actually died of measles. They died of these pneumonias. And while that is in some ways true, um, what the what the Army experiments and the experience of 1917 definitively proved was if you stopped the measles, you'd stop these pneumonias, right? So much so we saw people that had the bacteria in their bodies that wasn't doing them a bit of harm until they got measles. We saw, you know, an immunosuppression, a vulnerability to diseases generally that would happen as measles infection progressed. So you stop the measles, you stop the other things. The other things wouldn't happen uh necessarily on their own, right? We know that definitively from this experience and later experiences in the post-vaccine era. Fortunately, for much of uh humanity, measles does tend to go down in frequency after World War I. Again, probably because so many people were, particularly military-age males, were exposed to the virus during the run-up and early days of World War I in the trenches and so on. And so there's fewer vulnerable people out there. And so it goes back into that kind of typical pattern. We do start seeing uh some changes in, particularly in the United States sociologically after World War I, right? More and more urbanization, higher standards of living, better nutrition, all of these things that improve measles' outcomes and measles incidents both. And so, you know, fewer malnourished people, they're less vulnerable to measles. You have particularly vitamin A deficiency, you know, less of that. There's less vulnerability to measles infection. If you don't have measles infection, you don't develop some of the pneumonias that come with that and some of the real horrible diseases that follow on. So things got better. Um, it became really thought of again as a childhood disease. There were quite a lot of infections, most likely, but you weren't having these devastating infections because of the nature of what was going on. Patients were just in better. They were nutritionally in better status, they were better overall health status. And so when they got the measles, they were less likely to have these bad complications, the encephalitis, the pneumonias, and so on, and so we're less likely to die. So you get that, although it's still a fairly common disease, and it would go up and down throughout time. Now, there were sulfonamide drugs available by 1936. These, depending on who you are, whether you're a pharmacist or an infectious disease doctor or not, some people say those are antibiotics, some people would say they're not antibiotics. Uh, they are antibacterial compounds, there are drugs that we can use. And so there were some treatment rudimentary. We wouldn't really think of them as first-line antibiotic treatments, kind of in the interwar years, but they did exist and they did probably improve outcomes, but it still happened, especially in spurts and fits and starts. And most people, certainly 80 or 90 percent of people in the U.S., were exposed to measles at one point in their life, usually as a child. As we fast forward to World War II, measles is accordingly less of a problem than it was in World War I and the Civil War. It still did affect people, but again, nutrition, logistics, uh, the concept of longer periods of training where we would go through recruits to military service in an area that's a little more advantageous, a lot easier to take care of somebody in a camp back in the States than it is as they're marching to go fight the Japanese or the Germans or whatever. And so it was while still known and managed and still untreatable directly, they could still provide pretty good supportive care. And the survivability of measles infections was better as we entered World War II. Uh, there had also been the development of some antibody therapies where they could harvest antibodies from plasma, from blood donations, or so on, or what we call fractionated plasma, as they spun it down and give that to people. Uh, the early preparations of this were actually relatively easy to give and didn't cause a whole lot of problems for patients, and so were widely used when you had cramped environments like a ship getting ready to go overseas or some other training type environment where somebody developed measles, particularly those that had never had the disease, were given this, and they had very good results, generally speaking, with preventing an outbreak of measles using these antibody treatments, which we still try for various uh diseases around, but they seem to work pretty well for measles. They didn't store all that long. Uh so they typically reserved it for when there was a known exposure or a known sick person. Later on, they developed some more stable, more broad-acting uh IgG type things. The problem with those is that's really uh very thick gamoglobulin, and it's hard to give. So again, they they uh it's very painful for people getting a real thick jelly. You can imagine getting that injected into your muscles. So it hurts. Uh it's very effective at stopping outbreaks. It's less effective in treating active disease, although it does decrease the likelihood of some of these bad outcomes. You still run the normal course of measles, but it's fairly good if you can catch it at preventing somebody from developing the clinical disease if you catch them after they were exposed, but before they have symptoms, which they did a lot of in World War II and uh had good results. In post-war America, right, we have a lot of herbization, we have the suburbs, very, again, changing demographics, uh, and with it uh an explosion, really an explosion through the 1950s of measles cases, so much so it was thought of as a normal disease of childhood. Uh certainly over 90 percent of kids got it. And we still saw the encephalitis happening, and we still saw some of these complications, even though they are rare, because so many hundreds of thousands of kids got it. And so, you know, it was still a disease, while not feared the same way that it once was, that was on a lot of minds. And this prompted a lot of folks to continue to study this particular disease. In the 1940s, the virus was cultured in chicken embryos. And finally, in 1954, a guy by the name of Thomas Chalmers Peebles, working in Boston with another guy, John Franklin Enders, who was a future winner of the Nobel Prize in Medicine, goes to a nearby elementary school during a measles outbreak. Now, again, these were very common, uh, and he cultures nasopharyngeal swabs, the famous swabs that, again, a lot of COVID folks are familiar with, blood samples from various kids, including the ones from an 11-year-old named David Edmondston. And he puts these samples in a human kidney cell culture, and he starts seeing after a few days that these human kidney cells have been infected. And so he does kind of a wash. He pulls off liquid and injects them to the next uh petri dish of kidney cells and keeps doing this. And finally, he's able to pull off some of this supernatant, some of this liquid, and inject it into mul uh into mukeys, which develop a milder form of measles, still with some of the rash, but none of the other real severe. And this was the dubbed the Edmondston strain of uh measles. And it is from that strain, this strain which had been weakened or what we call attenuated in the lab, that they were able to develop, Industry was a measles vaccine strain. Uh so finally, with lots of dozens of these passages, right, on different other types of cells and so on. Uh, the vaccine strain was generated by 1958 and it has a very low virulence, but it still importantly retained its ability to induce a strong immune response with a lot of antibodies in the body, perfect for a vaccine. And so the vaccine strain was then administered. Now, unfortunately, you know, um, I think our medical ethics rules were a little different. Um, and it was a lot of times the initial studies were done in institutions for uh handicapped children or mentally disabled children and so on. But nonetheless, after six to nine days with uh after being exposed to this very mild strain, this attenuated strain, children developed a mild fever and uh maybe a rash on day 11 if they got it, with a strong immune response and were protected from measles vaccination forever. So they keep doing this. Uh, and ultimately, the first live attenuated measles vaccine was licensed in the United States in 1963. Now, at that time, again, we're looking at 500,000 or so cases per year. You're still seeing a good number of deaths, while not as many as we once did, still pretty high. Uh, they did field trials of this in Africa, in Nigeria specifically, and it worked pretty, really well. Uh, they did some trials in the United Kingdom, and it was very well tolerated. Um, there actually uh was a killed vaccine that was also developed, but ultimately it did not work as well. And the killed vaccine as opposed to the live vaccine actually had a high rate of complications. So it really didn't get used nearly as much as the live attenuated uh version. Uh, an improved uh version of the measles vaccine came out in 1968, um, and it rapidly replaced the original 1963 uh version. It didn't really cause the problems and didn't have the rashes associated with it. Um, and then by 1971, we have uh the familiar MMR vaccine, the measles, mumps, and rebella all put into one shot, a single dose uh at 9 to 12 months. And the 9 to 12 months ultimately came about because they did observe that since so many people were affected, many, many women, of course, were making antibodies when they were um new mothers. And if they're breastfeeding, those antibodies that they produce will be passed to the baby uh through the breast milk and could interfere with the live virus uh triggering uh the baby to produce antibodies. So they delayed getting that child until after kids were no longer uh breastfeeding. And in the United States, the sign this single dose vaccination was really the standard from 1978. Uh, there was a lot of places where you do have it for school entry, but it's not mandatory. But honestly, with so many people getting vaccinated, we have a 90% decrease in the number of measles cases. There were sporadic outbreaks uh in pockets of unvaccinated uh preschool children um that happened. But if you look at the charts, it's amazing just the plummeting of cases that we see up until uh the 80s, and you see a few uh more uh pockets. But again, they were able to what do you call ring vaccinate, go to the area, vaccinate around where the case was. And that goes on, and there was very few in the way of measles relative to what we had had until 1989 to 91. Somewhere in there, there was a resurgence of measles in the United States. And in those years, we saw 55,000 cases, which is up from maybe a thousand cases uh before, and there's 123 deaths. And so when they really look at it, they found that the modern MMR was 95% effective. You say, well, that's pretty good. Yeah, it prevents it 95% of the time. But if we get a huge amount of exposure, that 5% could potentially be uh a large number of people that don't respond to just the first shot or it waves. They respond, but then it goes away. So they changed uh at that time to the two dose, which raises the overall efficacy from that 95% mark to 97 or 98 percent. And the number of measles cases again plummet down to 958 uh in 1994, uh, and then down to 508 by 1996. And so this goes on, and endemic measles, this ongoing chronic measles infection in the population, disappears from the United States by the year 2000. I mean, if you think about it, that's amazing. We go for something that's getting a half a million kids a year, that's killed thousands. Uh, it was the fourth leading cause of death in World War I, and it's basically gone. Um, the cases in the United States observed in the 2000s, at a time were all just maybe somebody who got it and was on a plane coming here, and so they get diagnosed in the US, but they didn't get it here in the US. So, you know, there was a two-dose vaccination that that goes on from the eighties on, and it's really, really, really a public health suc success story. And I would like to end the broadcast there, to end the cast there, but that's not, as Paul Harvey said, the rest of the story. We have one other problem that happened in the personage of a guy by the name of Andrew Wakefield. And in 1998, he published a study in The Lantis describing a new form of enterocolitis, a GI disease that was associated with autism. And in his argument, although his data did not show this, uh, he argued that it was uh it was uh children who received this trivalent MMR vaccine. Now he called that disease autistic enterocolitis, and he suggested, like we said, a causal low. Link with the MMR vaccine. Now, this, again, is the kind of the beginning of the social media era and the internet era, and this spreads widely because so many people were getting this, and it wasn't mandatory everywhere, even though a lot of people were getting it. Now, subsequent to this, there was a lot of folks, particularly in the media, that were suspicious. The studies that Wakefield did were not replicable. They couldn't find any evidence of this. It subsequently came out largely, unfortunately, because of media investigations, not so much initially because of medical authority investigations. They found that a lot of Wakefield's data was at first thought it was questionable. Several of the authors that had been co-authors with him on the paper said they'd never seen that and asked to be withdrawn. Wakefield was kind of the last guy on the paper. It was later determined that not only did he falsify the data, so that's why nobody else could reproduce it or find any evidence of it. It was all made up, all the link. He had experimented on a variety of children with developmental disabilities without the parents' knowledge, without the hospital's knowledge. He had done unnecessary surgeries and unnecessary procedures. He hadn't recorded all of them and was really doing some horrible abusive things to very vulnerable patients. Again, as we said, we he made up uh the day there was a series of lawsuits when he sued and he was sued and he was asked to produce that he never could. Ultimately, we also it also came to light that he was working for a group of trial lawyers who wanted to sue the manufacturers of the MMR vaccine and had retained him and paid him a lot of money as an expert to testify that there were problems that no one had previously seen. So he very clearly made up these problems so that he could testify if things ever came. Those cases were ultimately dismissed or thrown out. And he had also developed a single measles vaccine, not an MMR, that he wanted to patent, sell to a drug company, and make a gajillion dollars. If that was the dominant thing, and of course he was going to say it didn't cause this autistic enterocolitis that uh he had made up. Subsequently, other things were found, and and Andrew Wakefield, there were a lot of personal financial interests. And again, uh initially this was media. The Wall Street Journal did a lot, The Guardian, uh, The Times of London, because he was a British physician. Ultimately, he was brought up on charges. He was disbarred from the Order of Physicians in the U.K. He lost his medical license. Uh, he was given the s most severe penalties that the British medical establishment uh had. He was chastised for abusing children in these uh experiments. So he was definitely they put child abuse in the list of charges that got him removed, where he lost his license. He ultimately was dismissed from the hospitals that he worked at. Uh he came to the United States where he lives. He's still at the time of this recording, he's still alive, he lives in Texas. He brought additional lawsuits uh in uh U.S. courts, which were also withdrawn when he was asked to provide evidence. But this episode, I think most uh Mox folks identify as the beginning of the anti-vax movement. That guy's still out there, he's got other people, and he's out there doing all of it, it was false, really horrible guy, or did a lot of horrible things to children. And then so the details get changed as it gets sorry. But this has led to a vaccine hesitancy. Now, there were some other things that happened. There was uh a television program in the United States uh early on called Vaccine Roulette, and that was one of the first ones that kind of lumps all vaccines together, and it took adverse reactions from different vaccines, different products, which are very, very different, and put them all in and said, well, this is it. It didn't seem to have the impact that Wakefield did, uh, but it did kind of set the stage. But Wakefield did cause this particular problem, which goes on still today. Uh the Institute of Medicine actually did commission a study of this and completely disproved any connection with autism. The U.S. uh CDC did a similar study, and there's been 16, 18 studies specifically on autism and the MMR or other measles vaccines, and no connection has ever been found. There have been some other studies of different types. We have very good data showing that there's no connection. And there's additional other things that come up that we continue to study to this day. But the anti-vaxx, and so this is really result in a dramatic decrease in vaccination coverage. I mean, remember, it's up to 90% or so in Western countries, and in some Western countries, it's as low as 50% today. And so we see more and more uh outbreaks in France, United Kingdom, in the US, thousands of measles cases. And again, of course, when you get measles cases, you get these severe follow-ons. And so we are really at a crossroads in public health where we've we have a great example in a long-standing cause of morbidity and a significant cause of mortality for which we developed an intervention that was wildly successful, it did its thing, and now other things happen. People became less concerned about it because it wasn't as big deal. And then we have folks like Wakefield ceding the problem. And I think that the public health community did not do a particularly good job of communicating all of the problems and all the fouls and all the things. Indeed, you look at the the anti-vax charges against pro-vax, I guess is the other term, uh, and they they argue, well, you're just trying to take money from pharma or you're falsifying data or all this other stuff. Everything that Wakefield, no question, absolutely himself did is what they accuse other sides of doing. And so we are now in this kind of different era where fewer and fewer kids are getting uh vaccinated. We're seeing more and more cases. Uh, we see it popped up. We did an analysis here looking at TV coverage of measles. And again, we see over and over again in these pockets, and the pockets get bigger and bigger and bigger, bigger and bigger areas where you have we have low vaccine uptake. And clinicians are now spending larger and larger amounts of time discussing these things with them, which isn't in and of itself bad. I think it's a good thing. I think it's important to ask questions and know this history. But we also have to remember the opportunity cost, right? If you're doing, you only have so much time with a physician. If you're talking about these things that are pretty well settled, you're not talking about other things. Uh with our research money, there's only so much research time, there's only so many researchers, research space, research dollars, and it's not wrong to continue to study these things and prove their safety. But if you're doing that on something that's pretty well known, then you're not doing it on something else, right? It's out there. I saw recently where they said, oh, you know, there's only been two studies on vaccines. And I just went to ProMed and put in vaccines, and I got, as you might imagine, over 500,000 papers written about vaccines. And that's just Pro-Med, and that's just a really kind of back of the napkin kind of search. So there's a lot of data out there. But we are potentially uh at a turning point. Can we regain the trust in the public health and the medical community? And what do we have to do to do that? And uh I think there is that's an open question that we have to do. We'll talk about it in a future episode of the Filth in America podcast. But until then, stay healthy and stay safe out there. Bye bye.