Measles Outbreaks and Overcoming the Challenges
William Schaffner, MD
National Foundation for Infectious Diseases
Schaffner W. Measles outbreaks and overcoming the challenges [published online June 5, 2019]. Infectious Diseases Consultant.
The number of reported US measles cases in 2019 has surpassed the record-breaking number reported in 1992 during the last outbreak.1 Now more than ever, it is important to educate patients, parents, and the general public about vaccination.
One of my favorite analogies to tell patients is that we all agree to drive when there is a green light and stop when there is a red light. Many of us have been in circumstances when someone has gone through an intersection on the red light. It not only endangers the driver of that car, but also everyone around them is put in danger. If you do not get vaccinated, you put yourself at risk, but you also put others around you at risk. Therefore, we all have to make contributions to healthier communities to ensure all of us get the benefits of protection.
A LOOK BACK
To put the current public health response into context, let’s step back and remember that before we had vaccines, measles was a major problem in the United States. Virtually every child growing up experienced measles, and many of these children developed complications such as otitis media, pneumonia, and encephalitis. Before we had the vaccine, when the population in the United States was smaller than it is now, 400 to 500 people died every year from measles and its complications.2
Once the live attenuated measles vaccine was developed, it was recommended to be administered routinely to every child in the United States.3 In practice, when 2 doses of the measles vaccine are given, they are 97% (or more) effective. Therefore, if patients with measles had presented to clinics, they were to be reported to the local public health department immediately. Measles was defined as a disease of immediate public health importance at that time. However, the vaccine was so successful that measles was declared eliminated in the United States in 2000, as well as in the entire Western hemisphere, in 2011. That means there was no sustained endemic transmission.
When measles occurs now, it is a public health urgency, and a team is sent to investigate the individual case. Who is this case? How and where did they acquire measles? Is this an imported case from abroad? Then, who has been exposed? Measles is the most contagious, most transmissible virus that we know of. According to the National Foundation for Infectious Diseases, for every person who gets measles, 9 out of 10 of their close contacts who are not vaccinated will get it, too. Measles is contagious from about 4 days prior to the development of the rash to about 4 days afterward. During the early period, the patient may not have prominent symptoms. So, they may be out and about in the community. The questions then become: Where have they been? Whom have they exposed?
The importance here is that we would like to define exposed individuals who are susceptible so we can provide them preventive treatment. If we can find them within 72 hours of exposure and vaccinate them, they will not develop measles. Of course, there will always be infants who are too young to be vaccinated and immunocompromised persons who cannot receive the vaccine (they could be given immunoglobulin prophylaxis instead, which might reduce the severity of disease).
Then we would like to know the characteristics of this person with measles and try to define whether this is a one-off case or if they represent a group of susceptible people—a congregation, a school, a neighborhood. This is important because we need to reach out to them to persuade them to get vaccinated. We would provide vaccines for them as well as education and reassurance that the vaccine is effective.
OVERCOMING THE CHALLENGES
This is all easy to say but, in practice, is often difficult and time-consuming to persuade these groups. One challenge to overcome is that if you have a group of people who have withheld their children from vaccination, they usually have their reasons for doing so, whether religious or otherwise. They also may have misinformation, such as the widespread rumor that the measles vaccine causes autism. It has been debunked many times,4 but it is difficult to unring the bell, as it were.
When health care workers go out into the field and interact with the population—I call this “shoe leather” work—it often has to be done outside of conventional business hours. They might have to attend community meetings, which costs the workers valuable time away from their own families and costs the local or state health department overtime to be paid. In addition, health care workers might need to be recruited from other tasks to help with the outbreak, which means that the routine work of the health department is disturbed or at the least deferred for a period of time. So, the challenges of measles occurring in any health jurisdiction are very substantial. All of this could be prevented by routine immunization.
The measles, mumps, rubella (MMR) vaccine is recommended in the United States for children, adults born in 1957 or later, international travelers, and anyone who is unsure about their vaccination status. When in doubt, vaccinate!
William Schaffner, MD, is the medical director of the National Foundation for Infectious Diseases (NFID) and is a professor of preventive medicine in the Department of Health Policy and a professor of medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee.
- Vogt C. CDC: measles cases surpass those reported in 1992 [published online May 31, 2019]. Consultant360. https://www.consultant360.com/exclusive/consultant360/primary-care/cdc-measles-cases-surpass-those-reported-1992.
- Measles history. Centers for Disease Control and Prevention. https://www.cdc.gov/measles/about/history.html. Reviewed February 5, 2018. Accessed June 5, 2019.
- Routine measles, mumps, and rubella vaccination. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/vpd/mmr/hcp/recommendations.html. Reviewed March 28, 2019. Accessed June 5, 2019.
- Hviid A, Hansen JV, Frisch M, Melbye M. Measles, mumps, rubella vaccination and autism: a nationwide cohort study. Ann Intern Med. 2019;170(8):513-520. doi:10.7326/M18-2101.