Steven J. Goldstein, MD, FAAP
(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens. He is president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health. This blog post was originally published in AAP Voices on April 30, 2019)
The outbreak of measles in New York City brings back vivid memories more than half a century old. I was 5 years old and was very ill, with a terrible cough, dry lips, crusted eyes, extensive rash, and high fever. My pediatrician visited while I was sick, and he was a welcome sight. I had terrible light sensitivity and spent most of the time in a semi-dark room.
Only in medical school did I learn that I had exhibited classic measles symptoms: cough, coryza, and conjunctivitis with photophobia, fever and rash. The virus infected more than three-quarters of a million people and killed hundreds in the United States that year, a decade before the measles vaccine would become available. Fortunately, I escaped serious complications of the disease.
I think the experience helped influence me to become a pediatrician. Not a reason to contract measles, though.
As I age, I am less patient waiting for positive change as I realize the work of individual pediatricians to make the world a better place is time-limited. This is one reason I am incensed by the return of measles to the neighborhoods where I practice. As of April 29, there have been 423 confirmed cases of Measles in Brooklyn and Queens. The vast majority of patients, roughly 84 percent, are infants, children and teens.
Vulnerable communities targeted with vaccine misinformation
My Brooklyn office serves a largely Chasidic clientele, with a melting pot of families from other backgrounds. My Queens office patients are reflective of one of the most diverse communities in the US. We first noticed a troubling trend in the Brooklyn office. Starting in late 2017, there was a significant drop-off in babies and children coming in for well visits and immunizations.
An anti-vaccine group calling themselves PEACH (Parents Educating and Advocating for Children’s Health) in the ultra-Orthodox community of Lakewood, New Jersey sent out an illustrated, 40-page booklet filled with false information about vaccines. Targeting isolated and fundamentalist communities, where the science of immunizations is not well known and accepted, is a known tactic of the anti-vaccine activists.
A helpful publication from the Hudson Valley Health Coalition that countered the misinformation with facts was distributed by the New York City Department of Health and supported by the CDC. Our immunization rates dropped nevertheless, and it was the rare visit that did not engender a long discussion about vaccine risk, efficacy, and timing. Long discredited claims of a possible MMR immunization and autism link were revived, and questions about the need for vaccines against “eliminated diseases” arose.
The ultra-Orthodox community in Brooklyn has seen measles before. In 2013, an unimmunized child returned from London incubating measles, resulting in 58 cases in New York City. Forty-five of the affected patients were eligible to receive vaccine but had not.
The toll of outbreaks on the health care system & practices
The costs to society of outbreaks such as these, which divert funds from worthy initiatives, are not trivial. The costs to the Department of Health in the 2013 outbreak were calculated to be about $400,000. According to federal estimates, the direct and indirect costs of each case of measles can run as high as $142,000.
As I write this, the ongoing spread of measles from Brooklyn causes worry about the possible spread to other municipalities, especially with recent holidays when many families traveled long distances. The question of how to protect very young children remains, other than advising families not to travel and isolating them as much as possible. But what about someone inadvertently bringing measles into our office, hospital, ED, or clinic? This should be of major concern to all of us, because it has implications for structuring our schedules and patient encounters.
Facilities must close for two hours after measles is diagnosed because of the continued contagion of virus in the air. Suspected cases also disrupt practices. Last week in Queens, we saw a 2 1/2 year old child with history of one MMR vaccine who attended a childcare nursery in Brooklyn, near to an affected community. He’d had 4 or 5 days of fever and then developed a rash, so we had to consider measles.
We learned two days later from his lab work that the polymerase chain reaction was negative. It was not measles. Still, the burden on staff to check the immunization status of each child in the office those days and if needed, to contact their families, was huge. Because of the time frame and age, some children would need immune globulin prophylaxis or vaccine, and might need to be quarantined for up to 28 days. Newborns might have been exposed. I lost sleep.
The return of measles has the potential to profoundly influence the way we, in the affected communities, practice pediatrics. We were extremely unhappy about the possibility that a child in our office might have exposed others. Pediatricians will need to consider measles immunity, the possibility of measles in the pre-rash stage, and the incubation period when scheduling patients, and attempt to isolate susceptible patients from others if the epidemic spreads.
Wild measles: trampling families’ freedom from disease
Because of the spread of measles to the Detroit community, with 50 cases documented at last count, my own daughter has decided to forego daycare for her new baby and will hire a nanny to minimize the infant’s chance of getting the disease.
One argument the anti-vaccine community makes is that by insisting on immunization, we are infringing on individual freedoms. What about the rest of the world that stands to suffer, with risk of death or disability, because of measles spread by vaccine refusers? Wild measles is the gift that keeps on giving, with subacute sclerosingpanencephalitis (SSPE), a fatal, late onset measles complication, a real possibility. Some of us think, given the number of cases so far, that there will be a major spike in SSPE in a few years. Measles is not a benign disease.
This issue — the inability of young children and others susceptible to infectious diseases — is a cogent argument for the passage of bills eliminating all but medical exemptions for vaccines. New York is considering this issue and other states should as well, joining California, West Virginia and Mississippi. The most recent estimates suggesting that for every 1000 cases of measles, one or two patients die, it is clearly a public health issue.
In the meantime, as pediatricians fighting on the front line of outbreaks, we are faced with a new normal as we continue to factor measles into our decision-making when booking and seeing patients to protect our most vulnerable patients. Most importantly, we continue our efforts to educate families about the dangers of measles–and how the decision not to vaccinate affects everyone around them.