The true story of the Samoa measles outbreak

Who is at fault?

Many commenters link RFK Jr to an outbreak of measles in Samoa that killed more than 80 children. What actually happened? And who is at fault?

I had a chance to brief myself on the facts of the case and this is my summary.

Measles was not present on Samoa till brought by visitors in the 1880s.

In July 2018, two nurses killed two kids with the MMR shot when they drew it up with expired atacurium (a paralytic) rather than saline. They took the vials home and hid them, realizing their mistake. They would be convicted in 2019 for manslaughter.

Headlines were not aware of the cause of the deaths, and were panic inducing, including (more in REF 1):

The government then paused the MMR vaccination program for 10 months. News of that spread across the island nation, and vaccination declined from 75 to 30 percent between 2017 and 2018. Notably other Pacific islands have higher and lower rates. Papua new guinea had only 37% coverage. Here is WHO’s data on MMR rates in Samoa.

Note: the methods to generate this figure include self-recall if vaccination cards are not present, so it is not perfectly accurate, typical of WHO.

In June 2019, RFK Jr visited, along with others and a conference was held regarding vaccine skepticism. In August/ Sept of 2019 measles was introduced from a visitor from New Zealand and the outbreak began then. A state of emergency was declared. Vaccination was then doggedly pursued.

Samoans have high trust in traditional and alternative medicine. When children and adults became sick with measles, many did not seek care, and those that did were often treated with unproven therapies like vitamin C, zinc or other putative remedies. The Samoan health system is also limited.

Who is at fault?

The Samoan measles outbreak occurred because of a constellation of factors including a impoverished population, a recent history (in historical terms) of having measles, longstanding poor vaccination rates, the manslaughter of two children, a cover up, poor health literacy, poor health infrastructure, poor government messaging, suspending MMR vaccination by the government, and a country drawn to traditional ideas of health and medicine.

It seems to me that the root inciting event of the measles outbreak are the two nurses who killed the kids. The second major factor was the government’s poor response which included halting the vaccination program.

Did some local activists seize upon the deaths to discourage vaccination? Possibly, but that is inevitable. After any tragedy some people will discourage exposure. I know someone who advises against moving walkways because they read about a woman whose leg got caught. Chipotle famously had a huge drop in business after an E.coli outbreak. Often these responses are disproportionate-- more than rational. Naturally, Samoans, who are often poor with low health literacy, would be quick to drop MMR vax after someone died. But notably this was sanctioned by the government.

What did RFK say in Samoa? I don't know but the time course makes no sense. He visited in 2019, but vax rates were already low. The die had been cast.

And what about the high death rate? Ultimately the case fatality rate for measles was very high. That feels like iatrogenic harm (with inappropriate therapy) or there are serious limitations to the health system. Both of these are true.

Ultimately, I find the narrative that RFK Jr is responsible for the measles deaths in Samoa to be a stretch. The time course doesn't fit, and the root causes are systemic and multi-factoral, as is often the case in life.

It is not surprising that a poor island nation with poor health literacy, who 3 generations before never had the disease at all, would be highly skeptical of a medical intervention brought to them by those who previous brought the disease.

I think the MMR vaccine is safe and effective. But the US overall vaccine schedule is likely excessive (compared to Europe) and we need cluster RCTs and better safety systems.

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