This week, Washington State declared a state of public health emergency due to an outbreak of measles that started in Clark County earlier in the month. As I am writing, there have been roughly 30 confirmed cases reported, but this number goes up every day.
On Thursday, I spent a big part of my morning doing something I had hoped I would never have to do in my career. I put in place a set of protocols for my clinic to ensure the safety of our patients and staff should a measles carrier come in for care. I suggest that my colleagues in the Seattle and Portland metropolitan areas do the same, because this outbreak is probably going to last for a while.
What Is Measles?
Measles is a viral illness that is marked by high fever, cough, runny nose, pink eye, and a rash. This last feature is the most distinctive one, and the way that it generally gets diagnosed.
Measles is a dangerous disease. About 1 in 4 children who are infected will require hospitalization for management, and about 3 per thousand infected children will die from the disease. Rare, but uniformly fatal, neurologic complications from measles can be seen years after the infection is passed. Measles infection will also impair immune function for up to two years after infection, leading to more risk from routine colds and flus.
Measles is also one of the most infectious viruses known. A single person with measles can infect an average of 15 or more people. It is most contagious from the four days prior to the telltale rash until four days after it appears, so it is likely that by the time the diagnosis is made, there has already been significant risk of spread. These characteristics make measles very difficult to control once it comes to town.
Who Should I Be Most Concerned About?
The highest risk individuals will be people in the following categories:
- Unvaccinated children
- Children under the age of one
- Immunocompromised individuals (including those on medications that impair immunity)
- People who have recently traveled to an area where measles is currently circulating
This is the time of year when we are very likely to see other infectious diseases in kids, as well. Especially in the earliest stages of infection, it may be hard to tell the difference between measles and other respiratory virus presentations.
At the time of this writing, all of the cases in Washington State have been either in people who are unvaccinated against measles, or people whose vaccination status was uncertain. Because some people do not receive complete immune response from the vaccine, we may see some cases in vaccinated individuals. This should not be taken as evidence that vaccination is not important or an effective measure.
Note that pregnant women can have complications from infection that include miscarriage and premature labor. Let’s make sure to get this epidemic contained to protect these new families.
As we have learned in past outbreaks, it is very likely that your local school district will require that children who have either medical or personal exemptions from the vaccine schedule stay home until the outbreak is finished. In previous years, we have encountered families that had difficulty making child care arrangements on short notice. We recommend that families that have chosen not to vaccinate start making these arrangements as soon as possible in case the school district again chooses this option.
For the Clinicians
Nobody wants to see their clinic listed on the public health website as a hotspot for measles transmission. It can be very hard to prevent this from happening, especially in a small clinic with limited resources. Preparation may include the following steps:
- For a suspected case of measles, ask that your families alert your staff when making an appointment. This will help us ensure that you can separate the potential carrier from other children in the clinic, and will help you implement the precautions the CDC asks us to take to prevent spread
- If a child has a fever or any other potential symptoms of measles, ask that he or she wear a mask in the waiting room
- If a child is unvaccinated and has any symptoms of measles (fever, cough, coryza, conjunctivitis, rash), treat that child with all the precautions that you would use in a suspected case.
Clinics that see kids should have an alternate waiting space available for quarantine. Any room that encounters a suspected case should be kept closed for at least 2 hours after the child leaves. In a best case scenario, try to keep at risk individuals away from any common areas.
Generally, testing includes a serum sample, a urine sample, and a throat swab. This will give public health enough information to confirm the diagnosis.
You’ll want to check your local public health website to get instructions for how cases should be assessed and reported. For example, my local public health department (https://www.tpchd.org/healthy-people/diseases/measles) wants me to report any cases immediately and to send all testing samples directly to them so they can respond to cases as quickly as possible.
What Can I Do to Protect My Child?
If your child has not received the MMR vaccine (first dose at 12-15 months, second at ages 4-6), you should consider getting one as soon as possible. The vaccine will take effect in about 10 days (the same amount of time it takes to start developing symptoms after exposure), and will provide protection to about 95% of people who receive it. We recommend doing this sooner rather than later, as a local outbreak could lead to temporary shortages of vaccines.
New York state has responded to their outbreak crisis by recommending that infants age 6 months receive their first MMR vaccination, followed with the second before their first birthday. We will likely see a similar strategy deployed out west if our outbreaks spread.
We also recommend keeping up with updates from local public health officials. Their social media feeds are often providing regular updates on new cases and public places where measles virus could have spread. This may help to understand your exposure risk, and alert you to the possibility of the diagnosis before the rash is visible.
We have seen some online forums and social media content that suggest that you should expose your unvaccinated child to measles to provide immunity from future outbreaks. We strongly recommend against this practice. Though most children recover from measles without serious complication, about one in every 300 to 1000 cases will not. Even those who do recover without complication will be very sick for two weeks, and will need to be monitored by public health officials for disease control.
Adults who received the vaccination as children or who had measles infection in the past do not require booster vaccination according to current guidelines.
About the MMR vaccination
The current measles vaccine has been in use for 50 years with a strong track record of efficacy. The series of two MMR vaccines leads to lifelong immunity to measles in at least 96% of people.
The most likely side effects from the vaccine are local pain and swelling and mild fever or rash. Joint pain can occur, especially in people who wait until their teen years to have this vaccine. Febrile seizures have been associated with this vaccine, but they are far more likely to occur from measles infection than from the vaccination against it. You can read more about the MMR vaccine here: https://www.cdc.gov/vaccinesafety/vaccines/mmr-vaccine.html.
There were reports in the late 1990s that MMR vaccine was associated with increased autism risk. These reports have largely been discredited, and their author was found to have some serious conflicts of interest. Subsequent research has conclusively disproved any link between our current vaccinations and autism.
We realize that many parents have been choosing not to vaccinate their children because they are worried that the risks of vaccination have been underestimated by scientists and public health advocates. While the people behind this website disagree, we have met reasonable people who hold this opinion. Please note, however, that the return of this once eradicated disease shifts the balance of risk and benefit. What may have once seemed like a remote and unlikely risk of infection is now close at hand, and unlikely to go away without a mobilized effort.
Let’s work together to get vaccine coverage rates in our communities up to the levels required to prevent future outbreaks. There were 41,000 cases of measles in Europe in the first half of 2018, and at least 37 deaths. Many of these cases occurred in children under the age of 1. This is both horrifying and entirely preventable.