Measles: Still "A Thing" (in the US in 2016)

Buried amongst the myriad Zika virus headlines, so hard to find it took some looking, is news of measles cases in the US...again. While not as explosive as the recent Disneyland-linked outbreak the 2 cases that have occurred this year are instructive as they are cases that should not be occurring in the US.

The cases occurred in the states of California and Texas. In Texas, an unvaccinated child who traveled internationally -- where measles is rampant -- was infected and later exposed classmates at an elementary school early in January. That this happened in Texas is not surprising as it is the 2nd least vaccinated state and this low rate of vaccination is reflected in the fact that some of the students exposed were not vaccinated. It appears, however, that herd immunity as well as luck delimited the impact of this case as no secondary cases occurred and the incubation period has since passed.

California, where the other 2016 case occurred, is the state in which a new law was enacted to increase the rates of vaccination in schools by eliminating religious and "philosophical" exemptions. California, being the epicenter of the 2014-2015 outbreak, also had a major reminder of the danger of measles that had ripple effects that led to increased vaccine confidence among the vaccine-hesitant. The details of the California case haven't been released and it will be important to determine the circumstances surrounding this case.

More measles cases will occur in the US this year and many children will remain unvaccinated kindling for this virus.

Measles Still Has A License to Kill

The news of the 1st acute measles death in the US in over a decade is an event that should serve to remind those who doubt the ability of this virus, which kills 145,000 people per year, to inflict damage in the developed world. However, I doubt it because if people can blow off the 20% hospitalization rate that occurred during the Disneyland outbreak, one immunosuppressed person's death isn't enough to crack through layers of evasion.

I am interested to learn the details of this unfortunate case that resulted in a fatal measles pneumonia to see how the diagnosis was made, when it was made, and what confounding variables were present (I know no rash was present, something that occurs in the immunocompromised).

To date there have been 178 cases of measles reported this year, with nearly half of the 50 states being affected. The numbers are largely driven by the Disneyland outbreak that began last year.

Letting our guard down against this plague carries dire consequences.

Measles in a More Rational Bygone Era

For those who brush off a disease such as measles, that hospitalizes 1 in 4, as no big deal because it was a routine illness pre-vaccine I recommend watching a specific episode of the 3rd season television series Lark Rise to Candleford, which aired on the BBC from 2008-2011. 

This series catalogs the daily comings and goings of two towns in turn-of-the-century England, one of which is rural. Stories center on various aspects of daily life and are thoroughly interesting. One episode I recently watched brought up the issue of what measles could mean to a rural community in that era and it was devastating. 

Cases begin within a trickle and then an onslaught, reflecting the sheer power of this contagion to infect a naive population. Many townsfolk recounted prior bouts of measles which made children "fodder for the epidemics" and thinned families as not every case is uncomplicated. One character, who runs a post office out of her home and is caring for a sick child in the household, astutely moves activities to an alternate site. She matter of factly states she would not have the post office, which is the social focal point of the town, be exploited by the virus as a source of new victims.

One point which is heavily emphasized is the burden sick children place on caregivers as this incident occurs during harvest season when all hands must be on deck in order to have food for the winter. While this is an obvious issue in an agrarian population in the late 1800s, it is still a very instrumental fact today as is evident when a child gets sick and often requires a parent to take time away from productive endeavors until the child convalesces. The caregivers of children with influenza, for example, miss an average of 73 work hours.  

In the 4 current US measles outbreaks that have occurred thus far this year, there is no doubt that each of the children afflicted rightly requires special care from their parents--hospitalized or not--and such a requirement has ripple effects. This phenomenon, often overlooked, is another example of the life-enhancing aspect of vaccines as they not only diminish the burden of disease but minimize the impact on those who are not directly infected.

This crucial fact was grasped by the human race in a more rational era when vaccines against many childhood illnesses had not been developed and the toll of these scourges was a threat from which no one could escape.

Measles & Making a Quick $100,000+

When someone offers to pay over $100,000 to someone for proving something that is already incontrovertible, it makes me wonder. 

In this case, a "biologist" in Germany  offered a cash prize, not for proving a fancy mathematical conjecture, but for proving that measles is an infectious disease versus a disease of social separation (!). This scenario is odd for numerous reasons that include:

• Rhazes, before the year 1000, counseled people to avoid the disease lest it become an epidemic.
• The virus that causes the disease was isolated in the 1950s.
• Instead of social separation being a cause, as conjectured by this biologist, it is social interaction that abets the virus as a susceptible population of a certain size is required for the virus to sustain transmission.

That, in the 21st century, we are faced with a debate over a fact of reality long established is more than just a curious novelty--it is evidence of an erosion of the intellect and a true return to the primitive in which nebulous causes for diseases held sway and humans lived in a demon-haunted world.

A Measlely Journey Through Social Media

Last night and today I was immersed in an interesting social media adventure that, at once, concretized the good, the bad, and the ugly of the medium.

As everyone knows, the U.S. is in the midst of a measles outbreak that has logged 141 cases so far in 2015. Pennsylvania, fortunately, has only had one case but it is only a matter of time before more accrue.

I am a member of a Facebook group whose mission is to improve vaccination rates in the state and seek an end to the philosophical exemption to school vaccination.  Last night, a message on the page alerted members that a mayor of a Pittsburgh suburb had announced on his publicly visible Facebook page that his fully vaccinated son was diagnosed with measles. Such an announcement set off a storm of questions in my and others’ mind including:

·      How was the diagnosis made?

·      How sick was the child?

·      What was his exposure history?

·      Were appropriate public health interventions taking place?

There had been no formal announcement of a case--possible, probable, or confirmed—from public health authorities as there had been with other instances.

The next day the mayor publicly tweeted and posted on Facebook that the diagnosis was made at an urgent care center without any laboratory testing.

This immediately triggered several more thoughts centered on stand-alone urgent care centers  (i.e. those not affiliated with a hospital). In general, I support these facilities and many excellent health care providers work at them. However, one shortcoming that I have noted is that they are not particularly well integrated into the public health emergency apparatus as they tend not to be part of health care emergency coalitions (unless they are owned by a hospital system)—a fact my colleagues and I noted in a paper focused on Hurricane Sandy.

Even a suspect measles case--let alone telling a patient they have measles—no matter how unlikely it is, should trigger notification of appropriate public health authorities because of the need for appropriate testing (PCR), isolation, a contact investigation, school notification, and the need to administer post-exposure prophylaxis to those not vaccinated.

The mayor’s follow-up tweet and postings confirmed what I thought when he wrote that measles was highly unlikely.

The lesson to me is that responsible health care providers, in all settings, need to take the right actions at the point-of-care and communicate the level of diagnostic certainty and appropriate protective actions needed to the patient who.

Social media has immense power for improving infectious disease management but can only be harnessed if its content is based on sound information.