Note from Linda Tate: This blog is a reprint by permission from one of our local DOs. We thank Dr. Cirino for this timely information.
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With all the talk about the recent measles outbreak in Clark County and now a confirmed case in Multnomah County, folks are getting into online disagreements about what measles can do and what they cannot do, and debating the worthiness of vaccines. We decided to go to the experts and ask some simple questions. What follows are the answers…please share this information so that others can benefit. To share, click the Facebook icon at the top of this blog. But first, grab A Cup of Coffee, and let’s chat!
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.
Still in the world there are an estimated 7 million cases of measles yearly (2016 data), with the majority of deaths occurring in 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 54,000 cases of measles and the Phillipines saw 18,000 cases.
These cases are largely related to a breakdown in vaccination programs. 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). 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 this region, I will go through 7 questions that may come to mind, now that this has all got our attention, and we already read something about the disease:
- 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 to 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 (enathem) as Koplik’s spots. Next, the rash starts along the trunk and neck as sparse spots (maculae) and then becomes 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 with 100% lethality) at time of viremia, recovered from infection.
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. 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.
“Vaccines save lives; fear endangers them. It’s a simple message that parents need to keep hearing.” Jeffrey Kluger
Thanks for reading! Dr. Cirino
I appreciate your comment and contribution to the discussion. I will be adding other infectious disease related information for patient advocacy in my blog. The anti-vaccination groups are polymorphous, so not as easy to address. Hopefully, through more education and evidenced-based strategies, the groups opposing vaccinations will diminish. It is hard to compete with a viewpoint, e.g. conspiracy, religious denial, natural approach, autism association, that already objects the scientific method. It is human nature to look at the most severe, low likelihood complications rather than the most likely result and greatest protection to the society. It is still an individual’s right to decline vaccinations no matter how much we oppose of it. It is too bad that it affects their children. Even though the outbreak in Washington (Clark County) and New York city area were tied to insular groups coming back from areas of outbreaks (e.g. Israel, Ukraine), it is possible that there could be a spillover in other unvaccinated, too early to vaccinate or even vaccinated groups. The United States will continue to have outbreaks that may spill over into the population at large. Maybe strengthening vaccination campaigns during these outbreaks might help, as well as buffering the areas of origin with vaccination programs (e.g. the rate of the second measles vaccination falls precipitously in these countries).
Dear Dr. Cirino,
Great job on the article! I am happy that this was evidence based and rooted in traditional medicine. if AT were around today, he would be wanting to flog the parent of kids not immunized.
I hear intelligent people everyday discussing this from the perspective of opinions, but short on facts and some of these are my colleagues here in Maine.
I will be forwarding this to everyone I know.
Brian Kaufman DO
I am glad someone is trying to impress on parents that autism is NOT caused by immunizations. I still hear that stinker of a line despite me telling these parents that autism has been in our gene pool for at least 200 years (probably a few thousand years prior to that) based on physician journal testimony and we have had vaccines (rabies) since 1885. (I’m still combing ancient Roman literature regarding autism, so I’ll get back to you on that one.)
The sorry excuse of depending herd immunity should be shot down. But keep in mind that though I do trust the oldies but goodies vaccinations, I do recognize the need to improve the newer ones (e.g. varicella zoster) because I believe there are still plenty of kinks to work out of those.
What concerns me to most is what is happening to our world’s immunity status? I mean, I remember when those who came down with shingles were 1:20 if you were 65 or older. When I went into medical school, that ratio dropped to lower and lower ages with higher and higher chances. Now I’m seeing it in young people (the youngest I’ve diagnosed was 8 years old) and those 50 years old or more, it’s a 1:2 chance of getting it!! We have to rebooster the boostered? Why can’t anyone keep a decent titer anymore these days? Don’t look at me, though. I had my initial Hep B series in 1987, and even today, I still have very high titers that didn’t require any boosters so far, and my smallpox (per the VA), is still at higher-than-usual for what is needed to avoid that bug, and my last scheduled dose was 50 years ago. Why me and not others in younger generations? I think that’s what we need to focus our attention span on now because we are weakening immunologically as a species. We physicians should get back into the business of playing Sherlock Holmes again because we are at the forefront of it all.
We’re over 167 cases in New York.
Thanks for reading the post! You are protected from measles if you had the disease in childhood. You are conferred lifelong immunity thanks to memory B cells. I am thinking of any exception to that and I cannot clearly determine. Fortunately, there should be no controversy over this.
Here is a little more in depth response for “googlers”:
Out of the interest of curiosity, I googled “relapse of measles” and found about four references, all from articles dated in 1941 or earlier (1936, 1925 and 1905). The 1941 article reported nine — but were mostly directly following the first diagnosed case. This was a time when it was more frequent and based on the clinical syndrome of measles – although serologies have been around many years before and measles was nationally notifiable since 1912.
The 1936 article detailed a case report with two relapse 20 days apart. This form of relapse following the original presentation after a few weeks from initial rash (recaida) usually is a relapse/recrudescence — which I would imagine would be seen primarily in unvaccinated infants who do not have a fully functioning immune system. Some mention was made of a second relapse a few months or sometimes years later (recidiva), which were extremely rare. This is back when there were MANY cases of measles, so certainly the uncommon manifestations could be seen more commonly. Also, I would not find these as reliable as our current knowledge base.
I encourage you to see for yourself. After that, please refer to the CDC website for measles.
Thanks for your comment,
Dr. Christopher Cirino
I am hearing contraversy over, can I get the measles if I had it as a child in the 60’s?