The Return of Measles

In 2000 the CDC considered measles eliminated in the U.S. Now cases have returned. This article explores the history of measles and its recent recurrence today in the U.S. and around the world. 

First it is important to define the word outbreak. According to the CDC, an outbreak is the occurrence of more cases of a disease than would normally be expected in a specific place or group over a given period. Based on this definition one case can be an outbreak. This definition is important when looking at numbers in the areas of the U.S. reporting measles cases because they may appear to be small. 

A Brief History

In 1757 a Scottish physician first linked the cause of measles to an infectious agent. In 1912 measles became a reportable disease under U.S. law. This required healthcare providers and laboratories to report all cases to public health authorities. Local numbers are sent to states, then states report to the CDC. This is how all cases of communicable diseases are tracked.

In the first 10 years of reporting, at least 6,000 cases of measles were reported to the CDC each year. Tracking showed 400–500 people a year died from it, and 48,000 were hospitalized. Another 1,000 developed encephalitis, and many became disabled as a result. Many healthcare personnel are not aware of this because they grew up with a preventive vaccine. 

Complications from measles appear most often in children under 5 and adults over 20 years old. They can include diarrhea, pneumonia, and ear infections that may result in hearing loss. In children pneumonia may occur in 1 out of every 20 cases, leading to hospitalization and death. Approximately 1 of every 1,000 children diagnosed develops encephalitis. This may result in convulsions, deafness, or intellectual disability.

Another long-term complication is subacute sclerosing panencephalitis (SSPE). This is a rare but fatal disease that affects the central nervous system. It is the result of developing measles early in life. It tends to appear 7–10 years after apparent recovery. The risk for SSPE is higher in persons who contract measles before 2 years of age.

Measles vaccine became available in 1963. This vaccine is now combined with those for mumps and rubella (German measles) and known as MMR. In 1989 a second dose of measles vaccine was recommended, resulting in a further decline in cases. This is what led to measles being declared eliminated in the U.S. in 2000. 

The U.S. Today

So how did it come back? A bit of history is necessary to frame where we are today. 

Vaccine skepticism began growing in 1998 when gastroenterologist Andrew Wakefield and 12 colleagues published an article in the British journal The Lancet that suggested the MMR vaccine might predispose children to “behavioral regression and pervasive development disorder.” The sample size for their paper was 12 children. The study was said to be of an uncontrolled design, and its conclusions appeared speculative. 

After this paper was published and other researchers began epidemiologic studies to try to validate its findings, 10 of the 12 coauthors issued a short retraction of their published data, saying “no causal link was established between MMR vaccine and autism, as the data were insufficient.” The Lancet then reported Wakefield and his colleagues had failed to disclose financial interests related to the study’s results and conceded several elements of the paper were incorrect and not in line with earlier findings. It was discovered Wakefield had been funded by lawyers engaged by parents in suits against vaccine manufacturers. Later The Lancet exonerated Wakefield and his colleagues from ethical and scientific misconduct charges, but they were found guilty of deliberate fraud and falsified facts by the U.K.’s General Medical Council.

Based on this paper and press reports of its conclusions, however, parents became concerned the MMR vaccine might give their children autism, and vaccination rates began to drop. 

The consequences came rapidly: In 2008–2009 there were measles outbreaks in the U.S., the United Kingdom, and Canada. These were linked to fear of autism related to the MMR vaccine. In July 2011 the U.S. reported its first death as a result of measles in 12 years: a woman in Washington believed to be exposed in a medical facility during an outbreak. She was unvaccinated and immunocompromised and died of pneumonia. 

While Wakefield’s fraud is likely to go down as one of the most serious in medical history, it has led to the proliferation of antivaccination (antivax) groups across the U.S. and world. In 2010 the General Medical Council banned Wakefield from practicing medicine, saying he’d shown “callous disregard” for children in the course of his research. 

Current Outbreaks

Several states have reported measles outbreaks in the past three years, and the number is increasing. From January 1–May 3, 2019, 764 individual cases were confirmed in 23 states. This is the greatest number of cases reported in the U.S. since 1994 and since measles was declared eliminated in 2000. For current numbers and states that have reported cases, see www.cdc.gov/measles/cases-outbreaks.html. 

As of May 7 nine outbreaks (defined as three or more cases) were ongoing, in the following jurisdictions: New York City and Rockland County, N.Y.; Los Angeles, Sacramento, and Butte counties in California; and Georgia, Maryland, Michigan, and New Jersey. 

These outbreaks have been linked to travelers who brought measles into the U.S. from countries such as Israel, Ukraine, and the Philippines. The CDC has published a travel advisory for persons planning international travel; its countries include England, France, and Italy. 

An outbreak in Washington state, contained by early May, exceeded 70 cases and spread to Portland, Ore. Most of the affected children were unvaccinated. The vaccination rate in the Portland suburb of Clark County, Wash., was found to be just 78%, and as low as 40% in some schools. These rates are among the lowest in the U.S. 

As a result of the outbreak, the governor of Washington declared a state emergency. In California the state legislature removed the personal preference exemption from vaccination law. Vermont has done the same. Table 1 shows state statutes governing vaccine programs.

Myths and Misinformation

Misinformation, much of it spread on widely used social media channels, may be one reason parents are declining to have their children vaccinated. Amazon recently pulled antivaccine material from its site. Pinterest announced it would not return results for vaccine-related searches. YouTube said it will demonetize videos that promote misinformation about vaccines. 

But misinformation comes from many sources; a member of the Texas legislature even reportedly said there was no need for concern over measles because there are antibiotics for protection! Antibiotics, of course, have no effect on viruses. The CDC has a program to educate parents on vaccine production and safety. 

In recent months, there have been instances in which young adults left unvaccinated by their parents have sought the MMR vaccine without parental consent. A New York county is trying to stop an outbreak by banning unvaccinated minors in public places. This area has had 153 cases since last fall. In New York City there have been 213 cases reported as of this writing. In Kentucky an unvaccinated student is suing to be able to continue participating in sports at school.

So we face a big question: When does public health override personal preference? The Supreme Court gave us an answer back in 1905 in Jacobson v. Massachusetts. The court upheld the authority of the Cambridge, Mass. Board of Health to require vaccination against smallpox. That case still stands today as the legal authority for government to impose restrictions on personal liberty for public health reasons.

The Role of EMS

EMS personnel need to be familiar with the signs and symptoms of measles. Measles presents with high fever, cough, runny nose, and red eyes (conjunctivitis). A rash starts on the head and spreads to the rest of the body. Since this is an airborne-transmissible disease, placing a surgical mask on the patient will prevent exposure. It is important to note that the measles virus can be present in the air in an indoor environment for at least two hours. 

As outbreaks continue across the country, it’s important that EMS personnel be protected from measles. The NFPA 1581 infection-control standard references the CDC guidelines for vaccination of healthcare personnel, and EMS is clearly listed as a member of the healthcare team. Protection up front before an exposure occurs is the goal.  

Resources

Bellini WJ, Rota JS, Lowe LE, et al. Subacute sclerosing panencephilitis: More cases of the fatal disease are prevented by measles immunization than previously recognized. J Infect Dis, 2005; 192: 1,686–93. 

Centers for Disease Control and Prevention. Chapter 10: Measles. In: Epidemiology and Prevention of Vaccine-Preventable Diseases, 8th ed., 2004. 

Centers for Disease Control and Prevention. Data & Statistics on Autism Spectrum Disorder, www.cdc.gov/ncbddd/autism/data.html. 

Centers for Disease Control and Prevention. Measles (Rubeola): For Travelers, www.cdc.gov/measles/travelers.html. 

College of Physicians of Philadelphia. The History of Vaccines, Measles timeline, www.historyofvaccines.org/timeline/measles. 

Eggertson L. Lancet retracts 12-year-old article linking autism to MMR vaccines. CMAJ, 2010 Mar 9; 182(4): E199–E200. 

Godlee F. The fraud behind the MMR scare. BMJ, 2011; 342: d22. 

Gstalter M. Amazon Reportedly Pulls Anti-Vaccine Documentaries. The Hill, 2019 Mar 2; https://thehill.com/policy/technology/432301-amazon-pulls-anti-vaccine-documentaries. 

Murch R, Anthony A, et al. Retraction of an interpretation. The Lancet, 2004; 363: 750. 

National Fire Protection Association. NFPA 1581: Standard on Fire Department Infection Control Program, www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=1581. 

Katherine West, RN, BSN, MSEd, is an infection-control consultant with Infection Control/Emerging Concepts in Clearwater, Fla., and a member of the EMS World editorial advisory board. 

Table 1: Vaccination Exemptions in A Sample of 15 States

State        Religious Exemption    Philosophical Exemption

 Alabama                Yes                                No
 California               No                                 No
 Colorado               Yes                                Yes 
 Connecticut           Yes                                No
 Florida                   Yes                                No
 Illinois                    Yes                                No
 Massachusetts      Yes                                No 
 Michigan                Yes                               Yes
 Missouri                 Yes                               Yes
 New Jersey            Yes                               No 
 New York               Yes                                No 
 Ohio                       Yes                               Yes
 Pennsylvania         Yes                               Yes
 Texas                     Yes                               Yes
 Virginia                  Yes                                No

Religious exemption indicates a provision in the statute that allows parents to exempt their children from vaccination if it contradicts their sincere religious beliefs.

Philosophical exemption indicates the statutory language does not restrict the exemption to purely religious or spiritual beliefs. For example, Maine allows restrictions based on “moral, philosophical, or other personal beliefs,” and Minnesota allows objections based on “conscientiously held beliefs of the parent or guardian.”

—Source: Immunization Action Coalition, Exemptions Permitted for State Immunization Requirements, www.immunize.org/laws/exemptions.asp