Moving the Needle – Local Measles Case Renews Debate About Need to Vaccinate

The first step, of course, was treating the patient — and then making sure a quarantine was enforced. According to the state Department of Public Health (DPH), “people with measles should be kept away from people who are not immune until they are well again. State regulations require anyone who catches measles to be isolated for four days after the rash appears. That means they must be kept away from public places like day-care centers, school, and work.”

But just as important was quick and repeated communication with the public. “We’ve had six media releases to inform the community,” said Mary Ellen Scales, Baystate’s chief infection control officer. “That’s part of our mission statement; it’s important for Baystate to be proactive and support our community, tell them what needs to be done.”

Especially, she added, in a situation with the potential of turning dangerous on a wide scale. Not only can the condition be fatal, but it’s more easily spread than any other disease, according to the DPH.

“Measles is transmitted through the air; it’s something you breathe. You don’t even have to be in the same space as the infected person,” Scales said. “Think about being out in the community in January, in the grocery line, and the person behind you is coughing and sneezing. If he has measles, all he has to do is breathe, and there’s a chance of transmitting measles. You don’t think about that.”

Measles is caused by a virus and usually lasts a week or two. It typically looks and feels like a cold or the flu at first, with symptoms like cough, high fever, runny nose, and red, watery eyes. A few days later, a red, blotchy rash develops on the face, then spreads to the rest of the body.

It’s not a disease to be trifled with; it often causes diarrhea, ear infections, and pneumonia, while less common but more dangerous effects include deafness, blindness, seizure disorders, and other brain diseases. In rare cases, measles can also cause swelling of the brain and death. It is most dangerous for children under 5 years old, adults over 20 years old, pregnant women, and people with weakened immune systems.

All of which makes the transmission of measles frighteningly easy. The virus is sprayed into the air when an infected person sneezes, coughs, or talks — and can stay in the air for up to two hours, where other people can inhale it. The first symptoms of the disease appear 10 to 14 days after a person is exposed, but they can begin spreading the disease four days before the rash begins, and keep transmitting it until four days after the rash appears.

“We’re sharing this message widely with the community because we want people to be aware and informed, and we want to take the highest level of precautions to prevent the spread of the illness,” said Dr. Douglas Salvador, vice president of Medical Affairs for Baystate Medical Center, in one of those six public statements after the patient’s diagnosis. “Most people are immune or have been vaccinated, but given that measles is now present in our community, we encourage anyone with concerns to check into their vaccinations and immunity to measles, and be on the lookout for symptoms.”

That pre-rash contagious period is what makes measles especially dangerous in a community, said Linda Riley, manager of infection prevention at Cooley Dickinson Hospital.

“There may have been people in the community exposed when in the infectious period,” she said. “With an airborne spread of infection, 90{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the people not immune could get measles after exposure. It’s particularly problematic for babies or people with poor immune systems.”

What worries public health officials across the country are outbreaks of diseases that are beginning to make a comeback because of decreased vaccination rates, which lowers what’s known as ‘herd immunity’ in a community and makes all non-vaccinated or immune-compromised people more susceptible.

What’s happening across the Atlantic, in Wales, is a good example. Anti-vaccination sentiment ran particularly high there in the late 1990s, which may have contributed to a measles outbreak that infected 1,219 people in southwest Wales between November 2012 and July 2013, compared with 105 cases in all of Wales in 2011. Many victims were teenagers whose parents refused vaccines for their infant children.

Less-serious outbreaks have struck in the U.S. as well, including the reported infection of at least 15 people in Texas affiliated with a megachurch whose leader, Kenneth Copeland, advocates against vaccines; 12 of those people were not vaccinated as children.

Much of the current anti-vaccination sentiment stems from a study, since discredited almost universally in the medical community, by Dr. Andrew Wakefield in 1998. He reported on 12 children who allegedly developed gastrointestinal problems and developmental disorders, including autism and bowel disorders, after being vaccinated. He alleged a possible connection between the measles, mumps, and rubella (MMR) vaccine and autism.

However, the section of the study dealing with an autism link was subsequently retracted by 10 of the paper’s 13 authors. In 2010, the Lancet, which first published Wakefield’s study, formally retracted it, and the British General Medical Council revoked his license to practice medicine in the U.K. He now practices in the U.S., where a significant number of adherents, many of them parents of autistic children, continue to claim a link between vaccinations and autism.

Across the pond, however, the damage was done; rates of inoculation in the U.K. fell from 92{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to below 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} after the publication of Wakefield’s study, and confirmed cases of measles in England and Wales rose from 56 in 1998 to 1,348 in 2008, with two child fatalities.

Vaccination rates haven’t fallen as precipitously in the this country, but persistent skepticism about the safety of vaccines contributed to 189 cases of measles in the U.S. in 2013 — a 250{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} increase over the 54 cases reported in 2012.

Some states are fighting back, including Massachusetts. Earlier this year, the state Legislature passed a bill establishing the Massachusetts Childhood Vaccine Program. The effort will involve two new programs: a vaccine purchase trust fund and a state immunization registry.

“The creation of the Childhood Vaccine Program demonstrates a critical investment in the future health of the children of the Commonwealth,” said Dr. Ronald Dunlap, president of the Mass. Medical Society, and Dr. John O’Reilly, president of the state chapter of the American Academy of Pediatrics, in a joint statement. “This law now puts all recommended vaccines within reach of all children in the Commonwealth and recognizes that immunization is a public-health priority as well as a personal health issue.”

The trust fund will pay for the distribution of vaccines to children through a public-private collaboration. The law charges an assessment on Massachusetts insurers for the cost of all vaccines for the children covered in their plans. The vaccines can then be purchased through the Department of Public Health at reduced rates under the department’s federal contract. This financing system has been implemented for the last three years — saving the state nearly $50 million in 2013 alone — and the new law makes this financing mechanism permanent.

Meanwhile, the immunization registry will interact with electronic health records, helping to ensure high immunization rates for children and adults, generating savings by reducing waste associated with over-immunization, and allowing for the tracking of the approximately 3.5 million doses of vaccine distributed annually by the DPH.

Dunlap and O’Reilly noted that Massachusetts has one of the highest vaccination rates and lowest rates of vaccine-preventable diseases in the country, but the law will help doctors and parents remain vigilant at a time when more states are granting medical and philosophical exemptions from childhood vaccinations.

Keeping vaccination rates up helps ensure that incidents like the one in Springfield and two recent measles cases in Framingham don’t turn into outbreaks. In fact, although Baystate believes its measles patient exposed up to 300 people at the hospital — and more in the community — no further cases have been reported, and the patient has been cared for and poses no further risk.

In the meantime, Baystate directly notified those determined to be at elevated risk, and worked closely with primary-care providers to ensure patients get what they need, including information, immunizations, or other preventive treatment where appropriate. The hospital recommends that people who suspect they’ve contracted measles call their healthcare provider before visiting a practice, which puts others at risk.

“If there are other cases, those people are quarantined at their house,” Riley said. “But that’s all managed by the Department of Public Health — it’s not something that happens inside the hospital. DPH actually manages community exposures.”

However, hospitals play a key role when a measles case is confirmed, she added. “We would put up systems to protect people in the hospital and our office practices, and people who work with schools in the community. It’s all part of local planning. Really, lots of people have a role in helping keep our community safe from infectious diseases.”

After all, Scales said, nobody wants an outbreak that easily spreads through the air.

“People with little kids always ask, ‘are the toys in the library safe? Are they clean?’ ‘No, you can’t play with that.’ Those are surfaces, but we’re talking about the air you breathe. It’s a different type of infection, so we take different types of precautions,” she told HCN. “We want to support education and prevention, to make sure our patient population in the community knows what’s going on out there.”