It was 5pm on a Wednesday when I saw D, a 9-month-old with a rash. No, nobody else at home is sick. Yes, he is up to date with his vaccines. No, he has no fever now, but he did a few days ago. Yes, he has a runny nose and cough. On exam, D had injected conjunctivae, clear rhinorrhea, mild cough and a macular rash on his body with confluence on the face and neck. While his babysitter was away, D had gone to the store where his mother worked. The managers had been accommodating; everyone eager to play with the cute little boy. Unfortunately, the store was located in a measles hotspot. D’s parents waited patiently as I called the NYC Department of Health, and relayed the details.
The next few hours turned into a whirlwind of activity. Locking office doors, documenting everyone that had been in the office, checking vaccine statuses, cancelling evening patients. Samples were collected, vaccines were given. D, looking well, was sent home with his parents under quarantine. D’s parents had done everything right. He had received all appropriate vaccines on time, was healthy and growing well. D, like other young children, was too young for a measles vaccine.
Measles, an airborne virus, remains infectious for 2 hours after an infected person has left the area. Once exposed, measles will infect 90% of unvaccinated people.1 The contagious nature of this virus, along with a decline in global vaccination, and endemic measles around the world, enables the spread of the once almost-eradicated disease. Worldwide, rates of measles and measles deaths had been declining. In recent years, cases have increased, 2019 having a 300% increase over 2018.2 Worldwide, 110 000 deaths were attributed to measles in 2017.2 In the US, prior to the vaccine’s introduction, 3-4 million cases of measles occurred yearly. A steady decline in incidence occurred after the vaccine’s introduction in 1963, with elimination (absence of continuous disease transmission for 12 months) occurring in 2000.1 As of July 29, 2019, there are 1164 documented measles cases in the US, the highest number since 1992.3
Recent US outbreaks are often imported from countries with ongoing measles activity. The largest outbreaks have occurred among close-knit, inadequately vaccinated communities, most recently Amish (2014), Somali-American (2017) and Hassidic Jewish (2018). In 2014, a large multistate measles outbreak occurred after an ill traveler visited Disneyland.3
In response to recent outbreaks, many states have passed legislation requiring vaccines for school admission and preventing non-medical vaccine exemptions. Most cases during US outbreaks have been under-vaccinated children. While 1 dose of the vaccine provides 93% of people with immunity, the recommended 2 doses provide 97%, surpassing the required 95% needed for herd immunity.4
While pediatricians and family physicians deal with vaccine hesitancy in daily practice, the emergence of preventable disease has required us to become more proactive. During our recent measles outbreak in Brooklyn, multiple community-based campaigns were organized to educate and vaccinate. Vaccine information sessions, phone hotlines, print and online articles have addressed this issue. Local doctors, nurses, and paramedics have all worked together with schools, camps, and places of worship to ensure a safe environment for those unable to be vaccinated. Schools and camps, in conjunction with the local health department, have denied admission to under-vaccinated children. In our medical facility, we utilize pre-screening during scheduling, signage to avoid entering the building with “rash and fever” and a separate office to provide medical care for those with suspected cases. If a suspected case enters the center, a “lockdown” procedure occurs as above.
During my time at MSIH and beyond, in Beer Sheva, Sevagram and Maluti, I encountered a vast array of pathologies of the “textbook only” variety. These experiences have contributed to making me a better doctor, to continue to think outside-of-the-box. It is ironic that I first encountered measles in New York, in a child without a passport.
Why do parents choose not to vaccinate? Most are hesitant, questioning vaccines and their safety, gathering misinformation from social media or friends. As physicians, we must provide confidence in the science that has protected us from preventable diseases. It is up to us to advocate for the best care of our patients. We must be sensitive to the concerned parent, while working together to reach our common goal of raising healthy children.
1. CDC Prevention of Measles, Rubella, Congenital Rubella, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2013 62;1-34
2. WHO New measles surveillance data for 2019. https://www.who.int/immunization/newsroom/measles-data-2019/en/
3. CDC Measles Cases and Outbreaks. Page last reviewed 7/29/19.
4. CDC Vaccine for Measles. Page last reviewed 6/13/19. https://www.cdc.gov/measles/vaccination.html