Asif Noor, MD, FAAP
Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)
It’s 5:00 p.m. on a Friday evening and I was about to finish seeing the last patient at our ID clinic. My colleague informs me that she got paged for a consult regarding an infant with fever and a rash. The concern is measles. It is an infection which was declared eliminated from the United States about 18 years ago. Several communities in New York are now grappling with it. We struck up a conversation about our experience with measles. As millennial pediatricians, we were able to recall plenty of false alarms but not many true measles cases. My iPhone buzzes! There is a message on “Physician Dad’s Group” on Facebook. One of the physicians witnessed a cancer patient, who survived cancer, now succumbed to measles. This brought in mixed feelings of frustration and devotion to immunization.
Measles is highly contagious. It is a serious infection and can lead to death among the vulnerable population: young children and the immunocompromised. On the contrary, the measles vaccine is highly effective. The first MMR vaccine, developed by Maurice Hillman and colleagues, was widely distributed beginning in 1968. By 1981 measles cases reduced by 80%. An outbreak of measles in the vaccinated group children in 1989 led to the recommendation of a second dose of MMR in all children which further reduced measles cases. The Americas were declared measles free in 2000 after a 12 month period with 0 reported cases. This was all made possible by pairing of a safe and effective vaccine with an efficient vaccination program.
Measles has reappeared. Since 2000, the annual number of cases ranged from 37 in 2004 to 667 in 2014. A few months into 2019 and we already have 127 confirmed cases nationwide. This time it’s not an outbreak in a Disneyland theme park, rather the affected children are from our neighborhoods in New York. Since October 2018 there have been 90 cases of measles in Brooklyn, 138 cases in Rockland County, and 64 cases in Clark County, Washington State. There is a strong possibility that the millennial pediatricians might encounter measles which was once declared eliminated before they even entered medical school.
The two plausible elements responsible for measles flare up are 1) unvaccinated infected foreign travelers and 2) unvaccinated people. Let’s see how both of these factors are contributing to the recent surge in measles cases:
Firstly, air travel has shrank the globe into a village. Measles outbreak in one part of the world can reach our neighborhood in less than 24 hours. In 2014, a large outbreak in Orange County, California was imported from a case of measles in the Philippines where there was an ongoing epidemic. The current, 2018-19 explosion of measles in the United States started with travelers returning from local outbreak regions in Israel and the Ukraine. Limiting travel of someone with measles is an unrealistic control strategy because the disease can be contagious 4 days before and 4 days after rash onset. Screening for prodromal viral symptoms and rash on this large scale is not possible by non-medical personnel at the air ports. Spread is inevitable! Sporadic measles cases from travelers will continue until measles is eradicated worldwide.
Secondly, unvaccinated pockets of people are highly susceptible to this contagious virus. Sure enough the ground zero in the ongoing measles outbreaks are communities with unimmunized children. There has been a gradual rise in unvaccinated children over the past 18 years. For example in Clark County only 76.5% of kindergarteners were vaccinated against measles, whereas 95% need to be vaccinated for herd immunity. This vacuum created by the unvaccinated provides the perfect recipe for spread of measles.
The tyranny of anti-vaccination is primarily parental refusal. As a pediatrician we need to understand the most common reasons to allow informative conversation in a timely fashion:
Religious: Majority of the parents base their choice of not vaccinating their children on religious backgrounds. No mainstream religion is against vaccination. Vaccines indeed serve to protect human life and respect the principles of not harming self or public.
Link to Autism: Some parents are concerned about autism and MMR. This claim was propagated in the flawed The Lancet article by Andrew Wakefield, which became the most infamous retractions in history of science. Multiple follow-up studies did not find any such association.
Vaccine safety: Few parents express great concern of vaccine safety due to vaccine components, i.e. thimerosal. These components were removed from the vaccines more than a decade ago and current vaccine are safer to administer. Some parents fear that overwhelming their child’s immune system with too many vaccinations at one time has negative outcomes. Again, this belief does not have any scientific evidence.
Personal beliefs: Some parents make it a matter of freedom of choice based on philosophical reasons. Such freedom should never harm the most susceptible and defenseless amongst us.
Parents who refuse vaccines should be advised that New York State law prohibits unimmunized children from attending school during outbreaks. Parents should be encouraged to read the applicable law(s). Information on religious, philosophical, and nonmedical exemptions for immunization are available online (http://vaccinesafety.edu/cc-exem.htm).
As a pediatrician we have dual responsibility of medical care and vaccine advocacy during this ongoing measles outbreak. In addition to the infected child at risk, there is also a societal cost for investigating the potentially large number of those exposed to the index case.
Medical care: We need to be vigilant and consider measles in a child presenting with fevers and rash if they are unvaccinated. A careful history of exposure to a case of measles and recent foreign travel from an endemic region should be obtained. Any suspected case should be placed under airborne precautions in a negative pressure room (hospitalized). Measles infection can be confirmed by using RNA PCR by at least nasopharyngeal swab and serum. New York State laboratory at Wadsworth can perform the PCR assays. A positive IgM can also be used to confirm the cases however it has low positive predictive value. IgG can be used for case confirmation with a 4 fold rise in acute and convalescent titers. There is no antivirals, however vitamin A should be given to all children admitted with measles to the hospital.
Vaccination: We should continue to be a passionate advocate for MMR vaccination. During this outbreak setting, if there is an exposed case, administer MMR vaccine if unvaccinated, or if history of single dose, provided ≥ 28 days have elapsed after the first dose. Infants’ ≥ 6 months of age should be given MMR if they are living in the currently affected communities in Rockland County, Brooklyn or Clark County. This however will not be counted towards the 2 dose MMR series.
Our infant luckily just had roseola. It did serve as a reminder to stay on guard for a measles case in the current outbreak situation and be a voice for vaccines in contempt of parental refusals.