Measles: still with us

It's midday at a busy pediatrician's surgery in Karlsruhe, a mid-sized town in the southwest German state of Baden-Württemberg.

A mother carries her sleeping child into the waiting room, while a sick baby screams so loudly that the receptionist has difficulty making herself understood on the phone.

Over in a corner, an assistant is preparing a combined measles, mumps, rubella and chickenpox vaccination for the next patient.

She carefully puts a needle and a syringe on a tray together some medical swabs, and then removes the vaccine from the fridge. It still needs to be drawn and diluted before being injected.

The World Health Organization recommends that all children have two doses of the vaccine to ensure immunity from measles.

"All of my children have been vaccinated against measles," says Dr Dieter Knöbl from behind his desk.

From complications to a "wretched death"

Dr Knöbl, one of three pediatricians who work here, has been treating children in this surgery for 20 years. Before that he spent 14 years on the pediatric ward of the Karlsruhe public hospital.

He says he's seen so "many children suffering from measles and many from measles complications" that he always advises parents to vaccinate.

The measles complications Dr Knöbl is talking about include middle ear infections, pneumonia and measles encephalitis. The latter is an inflammation of the brain, which can cause permanent brain damage and even death.

Another complication is the quite rare but fatal disease with the unwieldy name of subacute sclerosing panencephalitis (SSPE). With SSPE, the virus slowly attacks the central nervous system.

"It's as if the children have Alzheimer's even though they are young," Knöbl says.

"As the disease progresses the infected children physically and mentally deteriorate. They can't speak, they are paralyzed and at the end, they just lie there and gasp for air. It is a wretched death."

Complications are common

During his time working at the hospital, Dr Knöbl experienced three children dying of SSPE and one of pneumonia.

Measles complications are more common than many people think.

Of the nearly three hundred people who caught measles in an outbreak in Berlin in 2013, more than a hundred ended up in hospital - that's a hospitalization rate of more than 30 percent.

On average, one in a thousand measles patients will develop encephalitis. In western countries, about one in three thousand people infected with measles will die (the figure is much higher in developing countries, where added factors, such as malnutrition, can result in measles fatality rates of up to 30 percent).

To make matters worse, measles is one of the most contagious diseases on the planet.

But many refuse to vaccinate

Despite the risks, there are many parents who refuse to have their children vaccinated.

Some doctor's surgeries in Germany refuse to take on children who haven't had all their jabs, saying it's the only way to protect their other patients.

"That isn't our philosophy," says Dr Knöbl.

He and his colleagues believe that by turning away unvaccinated children the parents may deliberately seek out doctors who share their opposition to vaccination.

By keeping the parents coming to his surgery, he hopes there is a chance the doctors can win them over.

"In our experience, the younger the child, the more worried the parents are about vaccinating," Dr Knöbl says. "But if you accept their fears and give them a bit of time, most of them change their mind."

But some parents remain vehemently anti-vaccination.

Resilient rumors

In 1998, the British medical doctor Andrew Wakefield alleged the MMR (measles, mumps, rubella) vaccine caused autism.

Although Wakefield's study has since been discredited and withdrawn - and Wakefield has been struck off as a British medical practitioner - rumors of the link continue to abound.

In addition, there are parents who are unwilling to risk their children getting encephalitis, which is a rare side-effect of the vaccine.

At around a chance of one-in-a-million, the risk is considerably less than the one-in-a-thousand chance of developing encephalitis from measles itself.

But add these fears to the general public distrust of doctors, medicines and pharmaceutical companies - which is more pronounced in the southern German states of Baden-Württemberg and Bavaria - together with those who simply forget to bring their child for a follow-up jab and you have a significant number of children who aren't immunized.

Failing to meet targets

In Germany, the measles immunization rate is 92 percent - in Baden-Württemberg it's even lower at 89 percent. This might sound like a lot, but it is well below the 95 percent goal set by Germany and other European nations to eradicate the disease by 2015.

In 2013, the then German health minister Daniel Bahr raised the idea of mandatory vaccination as a way of increasing the measles vaccination rate.

But Dr Günter Pfaff, the chief epidemiologist at the Baden-Württemberg State Health Authority isn't convinced that such measures would work in Germany.

"We probably would have to use more energy to fight against opposition to mandatory vaccination than we could use to convince people that vaccination is good, and that it would be a benefit for their children," he says from his office in Stuttgart.

For Pfaff, defeating measles in Germany is about minutely analyzing the data.

He turns around a giant whiteboard covered with a map of the state. It shows the measles vaccination rate for every health district. Some are dark blue - that's good because it means the vaccination rate is more than 95 percent. Others are light blue - which isn't so good.

The personal approach

"You can see there are a few communities, where there is quite a stark contrast between [them and] neighboring communities, and there is hardly another way of explaining this than that the practice of provision of medical services varies from town to town," he says.

One approach the state health authority (Landesgesundheitsamt Baden-Württemberg) is looking into is directly approaching doctors in villages and towns with low vaccination rates. It is something Dr Pfaff has tried in a few cases.

"What we [want to do] is ask the doctors 'did you notice that in your town vaccinations are much lower than in the neighboring village? And how come? We would like to draw your attention to this and we would like to talk to you about it,'" he says.

Another approach they have been using is publishing the measles vaccination rates for villages and districts in community newsletters along with comparisons to neighboring places.

This kind of specific, local information has been found to help more than public information campaigns on a national level or in mainstream, national media.

Whatever the approach, it is possible to eradicate measles.

The Americas - both north and south - succeeded in 2002. But Germany - one of Europe's most advanced countries - still has a long way to go.