Measles Outbreaks: What can you do to protect your family?

Any area can be affected by measles. My county is in the middle of an measles outbreak right now. This is despite relatively high MMR vaccine rates above 95% for at least 1 MMR by 3 years of age. There are a lot of questions about measles outbreaks, so I thought I’d tackle a few. Like most pediatricians, I’ve never seen measles and I hope to not miss it if I do. We all need to be aware of its symptoms so we can recognize it when we see it!

What is measles?

Measles is a viral illness that includes fever, cough, fatigue, red eyes, and a characteristic rash. The rash spreads from head to trunk to lower extremities.

Measles rash PHIL 4497 lores
Source: https://commons.wikimedia.org/wiki/File%3AMeasles_rash_PHIL_4497_lores.jpg

RougeoleDP
Source: https://commons.wikimedia.org/wiki/File%3ARougeoleDP.jpg
Measles is usually a mild or moderately severe illness. It can lead to pneumonia, encephalitis, and even death (risk of 2-3 per 1000).

One rare complication of measles infection that occurs many years after the illness appears to resolve is subacute sclerosing panencephalitis (SSPE). It is a fatal disease of the central nervous system that usually develops 7–10 years after infection.

 

 

 

Koplik spots, measles 6111 lores
Source: https://commons.wikimedia.org/wiki/File%3AKoplik_spots%2C_measles_6111_lores.jpg
Koplik spots are a specific rash seen in the inner cheek. Koplik spots are visible from 1 – 2 days before the measles rash and disappears to 1 – 2 days later. They look like white spots with a blue center on the bright red background of the cheek. They can easily be missed because they are not present for long, but if seen are classic for measles.

What is the timeline of symptoms after exposure?

Measles is highly infectious. It is primarily transmitted by large respiratory droplets in the air, so handwashing doesn’t help prevent exposure.

An area remains at risk for up to 2 hours after a person with measles was there. This is why it is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician. DO NOT go to a walk in clinic or your doctor’s office unannounced. You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

More than 90% of susceptible people develop measles when they’re exposed.

The average incubation period for measles is 11–12 days. It takes 7–21 days for the rash to show. It is due to this long time for the characteristic rash that susceptible people who were exposed are put in isolation for up to 21 days.

Most people are contagious from about 4 days before they show the rash until 4 days after the rash develops. If a person has measles and the rash resolves, they can leave isolation when cleared by their physician and/or the health department.

What is a measles outbreak?

Measles outbreaks are defined as 3 or more measles cases linked in time and space.

How do outbreaks start?

I know the big question on everyone’s mind during an outbreak is, “Where did it start?”

Often an unimmunized traveler brings the measles virus into the US. Countries in Europe, Africa, Asia, and the Pacific continue to have outbreaks. Travelers who visit those countries can return to the US and share the virus for a few days before symptoms are recognized. Anyone who was in the same area as an infected person for up to 2 hours after that person left the area could be exposed.

In case you’ve heard that vaccines can lead to outbreaks: that’s not the case. Measles shedding from the MMR does not cause disease.

What happens during an outbreak?

Measles Outbreaks: What can you do to protect your family?During an identified outbreak of any reportable infectious disease, the health department directs what to do. They attempt to identify and notify all people who are at risk.

Our current outbreak involves several infants from the same unnamed daycare in addition to people not associated with the daycare. I know many families are worried that their child was at that daycare. Families at that daycare will have been notified by the health department already. The health department will track all known contacts of those families.

Local health departments also will notify the public of known locations of potential contact with the virus. The above linked article lists the known locations that infected people visited during their contagious period.

Why are infants at risk?

Infants are at particular risk because they are not typically vaccinated against measles until 1 year of age.

When the virus is in a setting with infants, such as a daycare, it can easily spread.

Infants under 2 years of age who are infected also tend to have more complications from the disease than older children and adults. This is one of the biggest reasons to not wait until 2 years to start immunizations, as some anti-vaccine groups suggest.

If you think you were exposed to or have symptoms of measles

It is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician.

DO NOT go to a walk in clinic or your doctor’s office unannounced.

You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

Do not go to the pharmacy to pick up medications. Don’t go to the grocery store for food.

Do not leave your home unless it is to a medical facility that knows you’re coming and is prepared.

(Yes, I know I repeated myself for much of this section, but it’s that important!)

The MMR vaccine can help stop the spread

The MMR vaccine is recommended routinely at 12-15 months and again at 4-6 years of age. Vaccines not only help the vaccinated, but provide herd immunity to those too young to be immunized and to those who are immunocompromised.

Please be sure your family is up to date on all their vaccines. All children over 1 year of age should have at least 1 MMR vaccine. All school aged children and adults should have 2 MMRs. By vaccinating your family, you not only protect them, but also those around you!

Why is a second dose given?

The second dose is used to provide immunity to the approximately 5% of people who did not develop immunity with the first dose. It is not a booster because it doesn’t boost the effect of the first dose.

The second MMR helps some people develop immunity if the first vaccine did not work effectively.

This second dose can be given as early as 28 days after the first.

Why don’t we start the vaccine series earlier?

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

Sometimes we do vaccinate earlier

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection.

Many parts of the world have high measles rates so fit into this recommendation. When infants between 6 and 12 months travel internationally, they should receive one dose of MMR vaccine prior to travel.

Sometimes during US outbreaks it is recommended to vaccinate infants 6-12 months. The local health department helps to determine which infants should be immunized in this situation.

If the maternal antibody levels are still high in the infant, the vaccine won’t work. In this situation the baby should still be protected against the disease from mom’s antibodies. That is why this early vaccine does not “count” toward the two needed after the first birthday.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

What if someone who hasn’t been vaccinated is exposed?

measles outbreaks, what can you do to protect your family
Source: http://www.immunize.org/photos/measles-photos.asp

The MMR vaccine may be effective if given within the first 3 days (72 hours) after exposure to measles. This is why the local health department is so aggressive in identifying cases during an outbreak.

Immune globulin (IGIM, a type of immunity that doesn’t require a person to make their own immunity) may be effective for as long as 6 days after exposure. IGIM should be given to all infants younger than 6-12 months who have been exposed to measles. The MMR vaccine can be given instead of IGIM to infants age 6 through 11 months, if it can be given within 72 hours of exposure.

Are boosters of the MMR needed?

are mmr boosters needed
From my practice Facebook page. Note: In this reply I was going off of my experience many years ago. At that time the advice was only 1 additional MMR, but my research for this blog shows otherwise!

Those of us who work in healthcare must have titers checked to verify immunity to many of the vaccine preventable diseases.

Healthcare workers come into contact with sick patients and patients with weak immune systems, so this is one way to help control disease spread.

From Immunize.org:
Adults with no evidence of immunity (defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get 1 dose of MMR unless the adult is in a high-risk group. High-risk people need 2 doses and include healthcare personnel, international travelers, students at post-high school educational institutions, people exposed to measles in an outbreak setting, and those previously vaccinated with killed measles vaccine or with an unknown type of measles vaccine during 1963 through 1967.

Most people don’t know their immune status, and it’s not recommended at this time to check it for the general population.

During an outbreak exposed people might be asked to be tested to help identify risk factors and track disease patterns.

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It’s not the flu!

I was at the gym today and an otherwise great instructor who seems to know a lot about health was sharing incorrect information about the flu with the class of about 40 people. She said that she had received several texts from other instructors asking her to cover their classes because they were vomiting. Then she went on to say that many at first thought it was food poisoning, but it’s spreading like illness, so it’s the flu, not food poisoning. She made a big deal that the flu is here. Is vomiting from the flu?

She’s only partially right.

Yes…

There’s a stomach bug going around.

It’s not food poisoning.

Influenza is in town.

But this extreme vomiting is not “the flu”

vomiting from the flu
Vomiting can be associated with influenza, but is not the main symptom.

The flu causes predominantly fever, cough, sore throat, and body aches for many days. It can cause vomiting and diarrhea, but those aren’t usually the predominant symptoms. And the flu doesn’t cause just a few hours of extreme vomiting like we’re seeing these days.

Why do I care if people call this stomach bug “flu”?

Runny nose is one of the symptoms of influenza.

The biggest reason I care is that it leads people to make other incorrect assumptions and to get the wrong treatments.

I hear all the time that people had the flu the year they got a flu shot, so they don’t want to get it anymore.

When probed about their illness, it’s usually not consistent with the flu. It was either a cold and cough or a stomach virus.

If they think a common cold or vomiting is from the flu, they’re mistaken.

They need to know that this isn’t the flu.
Cough is one of the most common symptoms of influenza, along with fever, sore throat, and body aches.

Common colds and vomiting are not prevented with the flu shot.

The flu shot has nothing to do with protecting against most cases of vomiting and diarrhea or most upper respiratory tract infections.

Of course there are people who got the flu shot (or FluMist when it was available) who did come down with the flu. They had a positive flu test and symptoms were consistent with the flu. But if they get influenza after the vaccine they tend to have milder symptoms. They tend to not end up in the hospital or dead if they’ve had the vaccine. Yes, even healthy young people can end up very sick from influenza. They can even die. (The FluMist didn’t protect well and was removed from the market due to this.)

We forget about all the times people did get the vaccine and they didn’t catch the flu even with likely exposure. Lack of disease is easy to fail to acknowledge.

We know the flu vaccine is imperfect. But if the majority of people get vaccinated, we can slow the rate of spread and protect us all against influenza most effectively.

We don’t have great treatments for influenza, so vaccinating and using other precautions is important!

HPV Vaccine Concerns

The large majority of the parents who bring their children to my office want their children to be vaccinated against any disease we can protect them against. The HPV vaccine is one exception. While most of my patients are given the Gardasil at their 11 or 12 year check up, some parents still “want to do their research” or “have heard things” so they decline to protect their kids at those visits. Sadly they often return year after year and say that they still haven’t done their research, so their child remains unprotected. Sometimes they’ll say that they will let their child decide at 18 years of age. Sadly, by that age many will have already been infected.

I recently had a parent share HPV Vaccine: Panacea or Pandora’s Box? The Costs and Deceptiveness of the New Technology with me. She had concerns based on the information in this article. The first thing I noted was that it is from 2011. This is outdated, since we have learned so much in the six years since it was published, yet like many anti-vax articles, it continues to circulate online.

 The first argument is that it won’t last long enough.

It is therefore possible that the protective effects of the vaccination will wane at the time when women are most susceptible to the oncogenic effects of the virus (those over 30), providing protection to those who do not need it (adolescents) and failing to provide protection to those who do (women over 30).

Studies show protection lasts 10 years and hasn’t dropped by that time. If future studies show a booster is needed, we can add that. That in no way should mean to not give protection for the years it is really needed – adolescence and young adult life. I cannot agree with the statement that providing protection “to those who do not need it (adolescents)” at all. Yes teens need protection. I’ll get more into their risks below. And the fact that women over 30 are more likely to develop the cancer does not mean that is when they come into contact with the virus. It’s kind of like saying that kids don’t need to brush their teeth because they don’t have cavities. If you wait for the cavities to develop, it’s too late!

The second argument is based on old version of the vaccine.

We now use the 9 valent variety, which covers the large majority of cancer causing strains. Again, even if there are other strains, why not protect against what we have?

Natural immunity lasting longer than vaccine immunity?

The argument that natural immunity will last longer than the vaccine immunity is not a valid argument. Natural immunity can wane with some diseases too, and if we can protect against the disease, it is preferable. Boosters for many vaccines are needed when we know immunity wanes. That’s okay. Some parents advocate to not vaccinate and get the real disease. When their kids get whooping cough they’re miserable. Many are hospitalized. Some even die. I’d rather do boosters! (This may be a bad example because I don’t think our booster for whooping cough lasts long enough and there are complications with giving boosters more often, but ongoing surveillance and research will continue and hopefully improve the situation.)

The cost issue is interesting.

If it was not cost effective in the long run, insurance companies wouldn’t pay for it. It’s that simple. They’ve done the math. Australia is a great example. Their cancer rates are down because HPV is a mandatory vaccine.

Debunking Risks

The risks listed have all been shown to not be as risky as once shown.

Abstinence as prevention?

The article also alludes to this being a sexually transmitted disease so we can just teach abstinence until marriage.

There are so many things wrong with this.

First, this virus can spread through non-intercourse activities, which can be part of a normal and healthy teen relationship.

Second, even if your child is a virgin at marriage, their spouse might not be. Or the spouse could die and they remarry.

Or there could be infidelity in marriage.

There may not be signs of this virus during an infection. Testing for HPV is recommended for women over 30 years of age, but is not available for men at any age, so teens and young adults will not know if they have the virus or not.

And we know that abstinence only teaching fails. Some people raised in strict Christian households have sex outside of marriage.

Teaching kids to protect themselves is much more effective to prevent many sexually transmitted infections, but condoms don’t always protect against HPV transmission.

And there’s always rape. One out of four women has been sexually assaulted. One in four! What a horrible thing to be raped. Then to find out you get cancer from that…

What about males?

They argue it hasn’t been tested in males.

It has.

And it cuts cancer rates in men too. They’re not just vectors as stated in the article.

We keep learning

This article is several years old.

It didn’t yet know that the cancer rates in Australia would fall like we now know.

We’ve learned much more information than they knew in 2011 when it was written.

We know the HPV vaccine is safe.

It is best given before the teen years to induce the best immune response and to get kids protected before the risk of catching the virus becomes more likely.

It isn’t a lifestyle choice to get this virus, as it seems the author claims. People have sex. This virus and other infections can spread through sex. But this virus is also spread without intercourse (such as through oral sex or skin to skin contact without sex), which is why 80% of the adult population has had the virus at some point.

If you don’t think the risk is real

Someone You Love is a documentary that follows several women with HPV related cancer. If you still think the vaccine isn’t worth it for your child, watch it. I am not paid in any way to recommend this. It simply is a powerful documentary that shows the devastation of HPV disease and you should see that before saying your child doesn’t need protection.

Do I recommend the vaccine?

I strongly feel this is a safe and effective vaccine. So much so that my own teens received three doses of the original Gardasil and one dose of Gardasil 9 despite no official recommendations for this booster. I want to protect them in any way that I can.

If I had any concerns about its safety I would not have given it to my own children.

I don’t think I can list any study or give any argument stronger than that.

Many people raise concerns about the HPV vaccine, but the studies show it's safe and effective to prevent cancer in both men and women.