Measles Outbreak 101: What Dermatologists Need to Know
As the incidence of measles in 2019 increases, the likelihood of health care providers, including dermatologists, seeing patients with this highly infectious disease will also increase. As of August 22, 2019, the Centers for Disease Control and Prevention (CDC) reported 1215 cases of confirmed measles in 30 states in the United States–an increase of 12 cases from the week before.1 This is the largest measles outbreak in the United States since 1992 and has resulted in a mandatory vaccination requirement and fines against unvaccinated individuals in Brooklyn, NY, as well as a quarantine of two universities in Los Angeles, CA.1-3
Other parts of the world are experiencing major outbreaks as well, with over 34,000 cases confirmed in Europe (predominantly in Ukraine) by the World Health Organization on May 7, 2019.4 Chad is expected to experience one of the worst outbreaks due to low vaccination rates.5 Other countries impacted by the outbreak include Israel, Philippines, Japan, and Brazil, for which the CDC has issued travel warnings.6 Visit the CDC for a full list of areas impacted by measles.7
Due to the success of vaccinations, which led to the declaration by the CDC that measles was eradicated in the US in 2000, many dermatologists and health care providers likely have not seen or treated patients with this disease. Steven Tyring, MD, PhD, with the department of dermatology at McGovern Medical School in Houston, TX, spoke with The Dermatologist about the recent epidemic, symptoms of measles, and what dermatologists need to know in order to effectively reduce the impact of this outbreak among patients, especially those who are more susceptible to infectious diseases.
Rise of the Vaccine and Antivaccination Movement
Prior to the measles vaccine, which was first made available in 1963, approximately 549,000 cases and 495 measles-related deaths were reported per year in the United States.6 Unreported cases were estimated to be about 4 million among US children. Of the reported cases, 48,000 patients were hospitalized, and 1000 patients developed chronic disabilities from acute encephalitis associated with measles.6 Recommendations for two vaccines, one at 12 months and one between 4 to 6 years, were issued following a large outbreak in 1989.
Despite the efficacy of vaccines for preventing highly infectious diseases, the circulation of antivaccine sentiments has led to decreases in vaccination below the needed threshold for herd immunity. According to Dr Tyring, there are two reasons people are not vaccinating. “One is people who are having children now have not had measles or know of anyone who has had measles,” he said. “They do not realize the disease is still around because in 2000, the CDC considered it eliminated from the US. However, it was not eliminated from the world and when people travel to areas without the vaccine, they can potentially bring it back into the US.”
The second reason, according to Dr Tyring, “is the unfounded fear of vaccinations.” Since the publication of a paper that fabricated a “link” between vaccines and autism and other adverse events, an antivaccination movement has spread throughout the United States, the United Kingdom, and parts of Europe. While the paper has been widely discredited and a multitude of findings show no connection between autism and vaccines, the dissemination of false information from the paper and other misinformation through social media continues to fuel antivaccination sentiments and vaccine hesitancy among parents.
Antivaccine sentiments, in combination with laws allowing religious exemptions for certain communities in the US, has led to reduced vaccination rates and created an environment where measles can easily spread. Parents wanting to do what they believe is best for their children are often vulnerable to misinformation and can be swayed by narratives and fears propagated by antivaccine groups. Providers in all disciplines should be aware of ways to encourage vaccination compliance among patients and caregivers. These resources can help providers discuss misinformation and create dialogue with caregivers and patients who are hesitant to complete the required vaccinations (Table 1).
Who Is at Risk?
Measles is a highly infectious disease that predominantly affects children. However, both children and adults who have only received one dose of the vaccine are at increased risk of measles. Adults born between 1963 and 1989, when the second dose of the measles, mumps, and rubella (MMR) vaccine was first recommended, may only have had one shot. Likewise, adolescents and young adults whose parents were not compliant with both doses could have only received a single dose. These patients will need a booster to improve their immunity to measles, as a single dose of MMR does not ensure the 97% protection against the virus that is provided with two doses (Table 2).6
Additionally, providers should be vigilant as more patients who would have “aged out” of the traditional age group for measles may present with symptoms, particularly in outbreak areas, because the first few generations of children born to parents with antivaccine sentiments are now becoming young adults.
Patients who are immunocompromised are more likely to experience the worst outcomes and die from measles. These could be patients with cancer or HIV/AIDS, and those who are receiving an immunosuppressive medication or underwent an organ transplant. Malnourishment is another immunocompromising state that is associated with worse disease outcomes, particularly in less developed countries were famine is high and access to vaccines is low.
“Thousands of people around the world die from measles because they are malnourished and do not get a chance to receive the vaccine. As a result, they often get measles pneumonia, and/or secondary bacterial infections, and die from it,” said Dr Tyring.
Additionally, Dr Tyring added, newly born infants are at risk because the vaccine is not administered until 12 months of age. “They have about a 6-month window where they might be partially susceptible to the virus,” he explained. Infants and those who are unable to receive the vaccine rely on herd immunity to avoid measles.
Confirming a Measles Diagnosis
A provider should consider measles in a child or adult who was potentially exposed to someone with measles, said Dr Tyring. The incubation period is 7 to 14 days, when symptoms first appear, he added. Symptoms of measles include a high fever (about 104 °F), cough, runny nose, and watery eyes. Koplik spots appear 2 to 3 days after the symptoms begin and present as tiny white spots inside the mouth (Figure 1), back by the molars, said Dr Tyring. However, these spots may actually be gone by the time a dermatologist sees a patient with measles, he noted. The rash typically appears once the Koplik spots fade, but there is still a chance the spots are present when the rash first begins (Figure 2).
The rash presents as erythematous macules that appear at the hairline or behind the ears, according to Dr Tyring, then spread downward, as opposed to other rashes, to the neck, trunk, arms, legs, and feet. There can be confluent areas of red macules and a high fever. “Sometimes when the rash fades, it goes from red to copper colored,” he added.
Dermatologists, and other providers who have not seen or been eposed to measles should consult the CDC website (https://www.cdc.gov/measles/about/photos.html) or other sources, such as textbooks, to determine if the rash is consistent with depictions of the virus. “This is important for dermatologists and everyone who works for dermatologists to know because most of the younger practicing providers were vaccinated and did not have measles as children, which means they trained in a time when they never saw measles outside of pictures in textbooks,” he said. Dr Tyring also recommends younger practitioners reach out to older dermatologists or pediatricians who have seen or been exposed to measles to confirm a case.
In cases where a dermatologist or provider is unsure, they can take a picture of the patient’s rash to share with an older provider. This helps avoid contamination of another provider’s office. Additionally, patients with partial immunity may present with milder disease. Thus, providers who have never seen measles may need to consult someone who has in cases like these that are more difficult to diagnose, he added. If there is a high suspicion of measles, patients should be isolated at home, which is preferable to a hospital.
Serological tests are available to confirm measles, which include IgM antibodies and measles RNA by real-time polymerase chain reaction. The CDC recommends health care providers obtain throat and serum samples of patients with suspected measles during the first appointment.6
Treatment
Unfortunately, there is currently no antiviral treatment for measles, said Dr Tyring. “All you can do is treat the fever, cough, and other symptoms symptomatically,” he explained. Isolation to avoid spreading the disease requires children and adults to remain at home until they are no longer considered infectious, which is approximately 4 days before and 4 days after the rash appears.6
At the Office
After sending a patient with suspected measles home, the best course of action to prevent its spread is to be sure all patients and providers are up-to-date on their vaccinations. “Measles is one of the most infectious diseases in the world,” said Dr Tyring. For example, if a patient with measles coughs in the waiting room, other patients in the waiting room, even those furthest away, are exposed to a large dose of the virus and have about a 90% chance of catching the disease if not properly vaccinated. “Two hours later, a susceptible person, such as someone who is immunocompromised or never been vaccinated, enters the room and they also have a high risk of measles because it takes fewer virus particles to cause that disease than any other disease,” he said. “Just one virus particle can infect others.”
Dr Tyring recommended asking individuals who were in the waiting room with the patient with measles or suspected measles whether they had been vaccinated against measles, or if they are older, if they had ever had measles. He also suggests discussing vaccination with patients seen at least 2 hours after a patient with measles leaves. Because measles is an airborne virus, disinfecting surfaces, although recommended, will not prevent its spread.
Prevention
Until vaccination is widely adopted globally, measles will continue to be an ever-present threat to public health in all countries, even those that “eliminated” the virus, as the highly infectious disease can easily resurface.
The current outbreak will only continue to increase. Dermatologists and other providers will need to be vigilant when treating patients with an erythematous rash, high fever, runny nose, watery eyes, and cough. While other bacterial and viral infections can cause these symptoms, measles can no longer be ruled out completely. The endemic areas, such as New York, California, among others, which have low vaccination rates, will continue to experience outbreaks. Legislation on mandatory vaccinations remains to be seen, said Dr Tyring. “Personally, I know of no religion that says it is better to make a child suffer than prevent it,” he explained. “If you can prevent the disease, then I feel that not preventing it is child abuse.”
Preventing measles going forward will mean mass vaccination for all who are not contraindicated for vaccination to create herd immunity and protect those who are more susceptible to measles and the adverse outcomes associated with this illness. n
References
1. Measles cases and outbreaks. Centers for Disease Control and Prevention. https://www.cdc.gov/measles/cases-outbreaks.html. Updated August 26, 2019. Accessed August 26, 2019.
2. Pager T, Mays JC. New York declares measles emergency, requiring vaccinations in parts of Brooklyn. New York Times. April 9, 2019. https://www.nytimes.com/2019/04/09/nyregion/measles-vaccination-williamsburg.html. Accessed May 21, 2019.
3. Brice-Saddler M. Hundreds of students and staff from two L.A. universities remain quarantined amid measles scare. Washington Post. April 26, 2019. https://www.washingtonpost.com/health/2019/04/26/two-la-universities-quarantine-more-than-students-staff-measles-outbreak/?utm_term=.7eb0b92d1692. Accessed May 21, 2019.
4. Kelland K. WHO issues warning as measles infects 34,000 in Europe this year. Reuters. May 7, 2019. https://www.reuters.com/article/us-health-measles-europe/who-issues-warning-as-measles-infects-34000-in-europe-this-year-idUSKCN1SD0SA. Accessed May 21, 2019.
5. Payton N. Measles threatens all of Chad as children go unvaccinated. Reuters. May 9, 2019. https://af.reuters.com/article/commoditiesNews/idAFL5N22L530. Accessed May 21, 2019.
6. For healthcare professionals. Centers for Disease Control and Prevention. https://www.cdc.gov/measles/hcp/index.html. Updated February 5, 2018. Accessed May 21, 2019.
7. Plan for Travel. Centers for Disease Control and Prevention. https://www.cdc.gov/measles/travelers.html. Updated May 1, 2019. Accessed May 21, 2019.
