Jarbas Barbosa: “Having nine measles deaths in Mexico is unacceptable.”

Mexico is experiencing the worst measles outbreak of the century: nine people have died, and there are more than 2,500 confirmed cases in the country, rising to over 5,400 when including probable cases. The most critical situation is occurring in the northern border region, particularly in the State of Chihuahua, which accounts for 90% of the confirmed patients and eight of the fatalities. In recent weeks, however, cases have been spreading, now affecting 18 of the 32 states in the country, a rise that experts label as a national emergency.

The Pan American Health Organization (PAHO), the WHO’s regional office, has offered assistance since the first epidemiological alert and is training health personnel from the Secretary of Health. The agency estimates that, in the case of Chihuahua, approximately 1.8 million people under 40 years old need to be vaccinated with an additional dose. Currently, 287,000 doses have been administered in the last six months, among children and adults.

Jarbas Barbosa, director of the organization since February 2023, speaks with the newspaper via video call from Washington, detailing the main challenges the country and the region face in addressing the infectious outbreak. The Brazilian doctor commends the “great effort of the Mexican authorities,” particularly the president and the health secretary, David Kershenobich, with whom he has spoken by phone and whom he describes as “very committed.” Their hopes are centered on containing the outbreak before the one-year anniversary of its onset, to prevent the state from losing its status as a disease-free country.

Question. In 2024, the Americas were certified as a region free of measles. Why is such a large outbreak occurring now?

Answer. Saying that the region is free of measles is a tremendous achievement because it is the only region in the world with that status. All other regions have significant measles transmission. This also shows us that maintaining that status requires a combination of good vaccination coverage, surveillance, and the ability to respond very quickly when we have a case since we will have imported cases every week from travelers and business people from Europe, Asia, and Africa. It is a significant challenge because if a case reaches a community with low vaccination coverage, an outbreak can begin, like the one we have now in Mexico.

Q. Most of the cases in the region have occurred in North America. Is the north less immunized than the south?

A. No, I don’t think that’s the case. The risks in the countries are very similar. Surely, countries with more international connections, more tourists, and more business with other regions of the world are the ones that generally receive the highest number of imported cases. Therefore, there is a higher risk if they arrive in a community without adequate vaccination coverage.

Q. Why is this disease so severe?

A. Measles is one of the most contagious diseases. Unfortunately, there is still a false perception that it is not serious. In Mexico, we have more than 2,400 cases to date, but we already have nine deaths, nine people who died from a disease that can be prevented through vaccination. For me, that is unacceptable in any way. We need to change that perception: measles is serious.

Q. Is the state’s response sufficient?

A. From the beginning, we have been working with the Secretary of Health. We’ve sent international consultants to support Mexico’s response, and they are promoting training for the health personnel in the Secretary and also in the states. So, there is an effort. The problem is that once transmission starts, it takes time to interrupt it. It is so contagious that the criterion for a country to lose its measles-free status is failing to halt transmission within 12 months. We are still within that period.

Q. With summer, mobility will increase. What precautions should the authorities take? Is there any coordination mechanism in the region?

A. Yes, we share epidemiological information about how the outbreaks are progressing with all countries, and we have launched an alert to draw attention to three measures that can completely prevent [infections]. They are difficult to achieve, but not impossible. The first is to have 95% vaccination coverage with both doses of the vaccine in a homogeneous manner. Often, total coverage is good, but there is a community that, for some cultural, religious, or other reasons, does not have good acceptance of the vaccine. It is crucial for coverage to be homogeneous.

The second is to quickly identify each imported case that is received. Coordination is necessary with public and private health services, as international travelers often go to private services.

And third, have blocking or containment measures ready. If a case is identified, immediately begin contact tracing and vaccinate those who are not vaccinated.

Q. In some states, like Guanajuato, there are almost 400 probable cases detected but only two confirmed. What can explain that difference?

A. It could be a sign that the flow needs improvement, but containment measures are adopted immediately when there is a suspected case; confirmation is not awaited, so it is not a barrier to taking those measures.

Q. What is the biggest challenge for the Mexican healthcare system in facing this outbreak?

A. There is a problem because the outbreak is in the State of Chihuahua (90% of cases), in a Mennonite community that has, due to their worldview and way of life, a reluctance toward vaccines. It is vital to maintain a respectful attitude and dialogue with community leaders from the very start so that, with the leaders’ support, vaccination can be achieved.

The other challenge, in a country with over 120 million inhabitants and large cities, is to ensure that vaccination is high and homogeneous. Maintaining well-organized services open on weekends, using tools to identify unvaccinated children, and partnering with the educational sector are needed to facilitate access for families.

Q. In Chihuahua, those currently getting infected are agricultural workers, some in isolated areas with difficult access due to the terrain.

A. Agricultural workers are a vulnerable group because they move frequently from one area to another for harvest. There is a recommendation for municipalities and states receiving these individuals to provide them with vaccinations, as they may be a high-risk group. Generally, they are young adults who fall exactly between the generation that all had measles—because it is so contagious that those currently 40 or 50 years old all had measles as children—and the generation that is already protected by the vaccine. We support countries to vaccinate in remote areas, like the Amazon. We go by boat, by small plane, on horseback, walking—whatever it takes; we must reach them.

Q. How can education be conducted in religious communities opposed to vaccination?

A. In a respectful manner. Find out what doubts they have and address each one, not treating them as if they are a problem or something invalid. Everyone has the right to their philosophy and religious beliefs. It is important to listen, clarify, and show the benefits vaccines provide to prevent deaths.

Q. Should states consider making vaccination mandatory?

A. There are countries that have mandatory vaccination for children attending school. We do not have a recommendation on that. Each country has its laws, but the most important thing is to ensure effectiveness because if there is a law that mandates it, but the health center is not open on weekends, how can a woman, who is the only adult earning income in a poor family working in the informal economy, go ten times in the first year of her baby’s life to get all the necessary vaccinations? I believe it’s not a matter of obligation but of listening and mobilizing the community and health professionals.

Q. How might it affect the region that the United States has a Secretary of Health who spreads confusion about the adverse effects of vaccines?

A. We don’t have information on whether that has any impact in the United States or other countries. Our stance is always to share information based on the best scientific evidence. The programs in the countries of the region are well-established and have ensured that the Americas were the first region to eliminate smallpox, polio, and also the first to be certified measles-free. Misinformation is a problem, but better organization of services is a more significant issue. The data we have shows us that challenge. The coverage of the first dose vaccination is generally very high. Misinformation is not a barrier because people go, and coverage reaches 88%, 90%. The second dose drops to 60%. This indicates that it is much more necessary to identify unvaccinated individuals and adopt suitable strategies, such as opening health units at night and on weekends, going to markets, fairs, etc.

[Although] it is also necessary to respond to the fake news, and the best way to combat them is with information and involving professionals. Surveys we have conducted in Latin America and the Caribbean tell us that health professionals are the main source of information for families.

Q. What differences and similarities exist between the measles outbreak and the pertussis outbreak?

A. Measles is much more contagious, and we also have a vaccine that is much more effective. The pertussis vaccine does not have the same efficacy, which is why it is not considered possible to eliminate the disease but can reduce its incidence.

Q. Are there any lessons from COVID that can help address the current outbreak?

A. For COVID, we utilized lessons learned from the fight against polio and smallpox, particularly on how to organize vaccination campaigns well. Undoubtedly, one significant issue from the pandemic is that fake news and misinformation have grown significantly. It is crucial to communicate with people in a simple way so that families can understand and recognize the great benefits vaccines bring.