Update 2/28/2019: As of today, there have been 65 confirmed and 4 suspected cases of measles in Clark county , Washington; 57 of the cases were in those unvaccinated; 6 cases with unverified vaccine status. The majority (47) of cases were in children 11 and under. There was 1 confirmed case of measles in King county. In Multnomah county, there have been 4 confirmed cases of measles and 1 suspect.
Update 2/12/2019: As of today, there have been a total of 53 confirmed cases of measles in Clark County, Washington. The majority of cases have been found in unvaccinated (47/53) and in children within the ages of 1 and 10 (38/53). With no new cases reported in the last few days, there are hopes that the current outbreak may be dissipating. Nevertheless, measles has an attack rate of 90%, so it is possible there could still be new cases in the next several days — the greatest period of infectivity is up to 4 days after the presentation of the rash.
At this point, many in Clark County Washington and adjacent Portland, Oregon are in a little bit of a scare. As of January 28th, there have been 35 confirmed cases and 11 suspected cases of measles in Clark County. In Portland, there has been 1 confirmed case of measles. This is likely going to be a moving target for the next several weeks. Measles was a disease that was essentially wiped out in the United States in the early 2000s. Since then, there have been outbreaks yearly from imported disease and unvaccinated children. The same goes with this outbreak.
What is an outbreak? An outbreak defined by WHO as the “occurrence of cases of a disease in excess of what would normally be expected in a defined community, geographical area or season. As with measles in the United States, only one confirmed case is consistent with an outbreak.
Still in the world there are an estimated 7 million cases of measles yearly (2016 data), with the majority of deaths occurring the developing countries. Places in Europe like Romania, Ukraine and Italy saw a 300% increase in measles cases in 2017. Last year, Ukraine had an estimated >30,000 cases of measles and the Philippines saw 18,000 cases.
These cases are largely due to a breakdown in vaccination programs in these countries. Reasons include infrastructure, logistics and vaccine declination under the basis of fear of severe side effects (extremely low risk and largely fleeting), autism (debunked) and philosophical (get vaccinated). Otherwise, measles is a vaccine-preventable disease.
With such few cases of measles in the US, it is likely that many physicians haven’t actually seen a case in the clinic. A heightened awareness is necessary. This is not equivalent to panic. Regarding the outbreak that has hit the regions of the NE and the NW, I will go through 8 questions that may come to mind, now that all of this has gotten our attention and we already read something about the disease:
1. Do I need to worry about measles if I have been vaccinated?
No – The vaccine is 97% effective after receiving the second dose (age 4-6y), unless you are in the unlucky 3% like me (I got the measles at age 15 traveling to see family in Italy). After the first dose (age 12-15 months) of vaccine, there is likely 93% effect. If you have not been vaccinated, it is not too late. Get vaccinated.
2. Do I need to worry about measles if my child is younger than 1?
Yes and No – Maternal antibodies are little gifts that mothers give their infants. If a mother was vaccinated or had the disease, the infant should have a robust passive immunity for 3-6 months after birth. The severity of a measles outbreak relates to the caseload and the herd immunity (goal >90% or more immune). For now in Portland (est. 87%), only having one case is low enough to make acquiring measles still extremely unlikely. In Clark county (est 78-80%), there is a little more concern, but this is still a disease in direct contacts only and almost all of the cases are unvaccinated.
3. How contagious is measles and does a mask help?
Very highly contagious. Yes. Measles can be transmitted on fine respiratory droplets (<5 micrometers) and are more densely packed on these than larger droplets (this is based on a study of influenza virus and masks in 2013). A person with measles becomes contagious 4 days before and 4 days after they develop the rash. Wearing a mask likely results in a three-fold reduction of transmission of virus — this means in short – that a mask over the mouth and nose is very useful. Any child that is presenting with the early findings of measles the 3 c’s– cough, conjunctivitis (red, itchy eyes) and coryza (runny nose) — should wear a mask and avoid social settings for now. Whether they actually will allow this is another thing. Contact your doctor for further instructions if you believe that someone you know may have the infection. The public health group or clinic will sometimes go as far as take a sample in the parking lot to confirm this.
4. When does the rash appear and does everyone get it?
3-4 days after symptoms start. Yes. When you get the measles, expect to get a rash (exanthem). The rash usually starts initially inside the mouth (enanthem) as Koplik’s spots. Next, the rash starts along the trunk and neck as sparse spots (maculae) and then become confluent in a generalized red, itchy rash.
5. Are there any treatments for measles?
No. There are no treatments available for measles other than a big dose of TLC (tender loving care, not THC) and a tincture of time. There have been some interesting studies performed on a similar virus model in animals – (science jargon alert) canine distemper virus (CDV). Ferrets given an oral RNA polymerase inhibitor after a lethal CDV dose (this is even a more severe disease as well in ferrets (100% lethality) at time of viremia recovered from infection. Vitamin A (historically in developing countries) and pooled serum have been used.
6. What can I do to prevent getting the measles?
Get Vaccinated. This is an easy question. The majority of cases already reported in Clark County and the child in Portland were NOT VACCINATED. I cannot locate the vaccination status of the Brooklyn and Rockland county cases but I would predict that most were unvaccinated. If you were concerned about the vaccination for your child, now would be a good time to get vaccinated. Although it would take about 2-4 weeks to confer maximal resistance, it would likely be protective against this outbreak and future ones to come. The risk of vaccination is mostly injection site related pain. It is a live, attenuated vaccination but not a risk if you have a normal immune system. Anyone with HIV, cancer, cirrhosis or on medications that impair the immune system, should not get vaccinated.
7. Will there be more outbreaks of this vaccine-preventable disease?
Sadly, Yes. This is a serious illness. Take it from me — At 15, I was in the tourist destination of Italy, yet couldn’t move more than the steps it took to get to the bathroom and back to bed for 8 days. There are still children mostly under 5 that die of this illness every year. In the US, the mortality rate is 1 in 1,000, the risk of encephalitis (infection swelling of the brain) is 1 in 1,000, but as many as 1 in 4 may need hospitalization. We have a world in which one can encircle it in 18 hours or less. As long as there are hot zones of measles in the world, any place in the US with a low herd immunity will get outbreaks. Especially in the Northwest.
8. Are there any risks from the measles vaccine (MMR)? Can I get it now? Why do parents decline vaccination for their children?
Yes. Yes. A brief discussion on human behavior. When it comes to vaccination, anytime is fine to receive a vaccination, if you do not have the infection, for which you are vaccinating. The MMR vaccination is a live, attenuated vaccination and includes measles, mumps and rubella viruses. It is usually given initially at the age of 12 through 15 months, followed by a booster at the age of 4 to 6 years. In 1989, a second dose was recommended by the Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP). If you were in the same cohort as me who just received the initial vaccination, you would have been at risk of contracting measles – like I had.
Regarding severe side effects of vaccination, the rate of a serious consequence from vaccination is 1 in 100,000 – which includes anaphylaxis (3.5 to 10 per million doses), seizures (mostly febrile seizures) 1 in 1,150 to 3,000 doses. These are related to vaccine-associated fever and not long-standing seizure disorder precipitated by the vaccination. Thrombocytopenia (low platelet counts) risk is 1 in 30,000 to 40,000 and is usually transient and benign. Encephalopathy/encephalitis: compared to the natural risk of measles of 1 per 1,000 infected persons, the risk with vaccination has been found to be about 1 per million doses (1,000 times less than risk from measles infection). Subacute sclerosis panencephalitis (SSPE) vaccination has reduced these cases and there has not been an association of vaccine-strain measles virus in a patient with SSPE. Guillain-Barre Syndrome (GBS): has not been determined to be causally linked. Autism or Inflammatory Bowel disease : the MMR has not been causally linked to these conditions.
The risks of developing complications from the wild-type measles virus is much higher than from vaccination with the attenuated virus. With regards to complications, the severity of outcomes is very low with measles (1 per 1,000) less than 0.1%. Statistically this is SIGNIFICANTLY HIGHER (by a hundredfold) than the risk of complications with the measles vaccination, our minds generally go toward the RARE SEVERE EVENTS. This is the way we as humans are wired – all of us.
There will be those who have declined and will continue to decline vaccination for their children, even in the setting of a measles outbreak. Although concern for vaccination complications is present, other reasons of opposing vaccination in these groups include autonomy (opposing regulation), distrust (holding back information, more focus on group over individual) and deferring to natural immunity. There is likely to be a component of social acceptance or social capital and symbolic capital (perceived as a positive sign). You can refer to this link for everything you want to know about the sociology of vaccination refusal and more. Ultimately, it is a decision that usually isn’t modified by education or a measles outbreak, as in this case since it has a low enough severity. The risks and benefits ratio of disease:vaccination would undoubtedly sway toward vaccination if the disease were to have a greater risk of complications, like smallpox or Ebola virus.
“Vaccines save lives; fear endangers them. It’s a simple message that parents need to keep hearing.” Jeffrey Kluger
Thanks for reading! Dr. Cirino