Experts provide historical context to measles management and review the current paradigm of disease prevention versus spread.

Hello, and thank you for joining us today for this 

® program. Although it was declared eliminated in the United States in 2000, measles has once again captured the public’s attention as the number of outbreaks surges across the country and globally. We continue to see alarming statistics. But a discussion about measles is more than just a discussion on the disease itself. The current outbreaks involve the issues of vaccination, individual state laws, exemption definition, and the role of clinicians and public health officials. We’ll cover a lot of that today. I’m Dr. Glenn Fennelly, professor and chair of pediatrics at Rutgers New Jersey Medical School and a pediatric infectious disease specialist.

 Hi, I’m Dr. Tina Tan. I’m state epidemiologist and an assistant commissioner with the New Jersey Department of Health.

Thank you, Tina. Today we’re going to have an important conversation about the current measles outbreaks. Let’s get started. Why is measles such a public health threat?

 Well, measles is 1 of these diseases that has been around and with us in general for many, many centuries. In fact, dating back to the seventh century, this was described in the literature. That was the first reference. It had worldwide impact before the vaccination era, and we described the vaccination era as anything after 1963, when the first licensed vaccine was made available. There were something around 500,000 reported measles cases in the United States every single year and about 500 deaths also reported every single year. But we believe that’s also an underestimation of what we were seeing here in the United States, where there were probably millions of cases of measles during this prevaccination era.

So measles still is an issue. As mentioned a little bit earlier, we’re seeing measles worldwide. The epidemiology of measles is that it still does exist in many places of the world right now. We just have to be aware of this and recognize that this is a vaccine-preventable disease. We have tools in our armamentarium to try to combat this.

Very good, very good. And I think it’s important to note that the transmission of measles was eliminated in the United States in the year 2000 in the wake of a major outbreak in 1989 to 1991 that included upward of 50,000 cases total. And since then, all the cases have been linked to imported cases, mainly among pockets of underimmunized populations.

Why is measles such a threat, such a concern? There’s a very, very high incidence of complications. Children, about 1 in 10, can get a severe ear infections of otitis media. It can cause deafness. About 1 in 20 will get pneumonia from a bacterial superinfection. And that’s actually the major cause of death. Measles can kill 1 to 2 in 1000. And in populations that are immunosuppressed or are malnourished, those rates can be much, much higher: as high as 5% overall, or higher. It can cause an encephalitis, which in many cases causes severe sequela in about 1 in 1000 cases. This is why we have to be vigilant. This can happen to any child anywhere who gets measles.

Where are the current epidemics in the United States? It’s hit several states. We had an outbreak in New Jersey at the end of last year, which we’ll discuss a bit further later on. There are ongoing epidemics in New York, in New York City. There have been more than 90 cases in the last couple of weeks reported. And 90% of these kids are unimmunized. Now we’re seeing outbreaks in Washington, Oregon, and I hear most recently Texas. Internationally there is a major epidemic in Europe that’s been going on over the last year with about 85,000 cases and more than 70 deaths, even though paradoxically Europe is at its highest in terms of rates of immunization: 90% receiving first dose, 95% receiving the total 2-dose recommended regimen. Still, there are pockets of vulnerability that have allowed this to be possible.

Examining the Epidemiology and Etiology of Measles

A comprehensive breakdown of how public health institutions report on and respond to potential measles outbreaks in the United States.

In terms of the local response to the outbreak in 2018 in New Jersey, could you explain the protocol for investigating the outbreak? What’s the public health response? How do we interrupt?

 To your point, even though we’re seeing all these outbreaks throughout the country, we’re also seeing it in New Jersey as well. That demonstrates that basically these types of measles outbreaks show no borders in general. As you had mentioned, Glenn, we actually had a New Jersey outbreak that impacted about 33 New Jersey residents here in our state in the last several months. These were all travel-associated cases, and the importation of an individual who had become infected while visiting a country outside the United States that was experiencing an outbreak.

And as soon as we hear about a report of any sort of travel-associated measles case—measles are immediately reportable to public health agencies in New Jersey&mdash;our public health departments get into action. We have local health departments and the state Health Department stands ready when we hear about these particular reports. And when we get these reports we treat them very seriously, because measles is very highly infectious, as you know as a practicing physician. It’s important to try to take steps to mitigate that spread.

So what we do in public health is once we get a report of a suspected measles cases, we’ll work closely with the local health department—as well as with the treating physicians, the treating medical facilities&mdash;to confirm the diagnosis first of all, because not all febrile rash illnesses are measles.

 We get an epidemiology history. We look at travel history. Because the vast majority of all the measles cases that we see here in the United States, and in New Jersey, are all travel associated. And then we’ll see the secondary cases related to the importation of measles into our state.

And then, after we get a confirmation that we are indeed dealing with measles, the local health department begins the process of collecting information on people who have had contact with that report of measles, so that you can get an idea of who might need to have a public health intervention. And those types of disease measures include making sure you check on the immunization status. We know that the 2-dose vaccination with MMR [measles, mumps, and rubella] is extremely effective in preventing disease.

Sometimes there will be recommendations for immunoglobulin treatment. It all depends on what the circumstances are with these particular close contacts. And in the situation of our Ocean County measles outbreak that we just experienced several weeks ago, it lasted over 2 months, and this was a really terrific effort that involved the New Jersey Department of Health and the Ocean County Health Department. It involved medical providers, the federally qualified health center down in Ocean County, to mount an impressive response to try to figure out who all those contacts were, in addition to working with the federally qualified health center to run vaccination clinics to identify and to vaccinate those who might be potentially susceptible to getting measles.

Right, right. I think 1 challenge with measles is that it’s highly contagious. If a child is unimmunized or vulnerable, there’s a 90% likelihood they’re going to get the infection if exposed. And also, if there’s a space a case has been in for up to 2 hours, the virus can still be contagious through aerosol exposure. So this represents a major challenge, and there could be even many unknown exposures. So that compounds the problem.

Public Health Responses to an Outbreak of Measles

Key opinion leaders address faulty reasoning behind vaccination aversion, for measles or otherwise, given trends in the disease-prevention paradigm.

The main tool that we have to prevent measles is vaccination.

And as you pointed out earlier, the vaccine has been available since 1963. It led to a very rapid and impressive reduction in measles both in the United States and globally. Currently the recommendation in the United States is that the vaccine is first administered at 12 months of age, and then it should be administered a second time between 4 and 6 years of age, prior to school entry, which drives, if you will, the enforcement of vaccination.

It’s important to note also that the second dose could be given within 28 days. Many of the children I think who get measles have been immunized only once. The first dose is only about 93% effective; 2 doses gets you to about 97%. So again, this is the best tool. Parents should know that it’s safe and highly effective and to not vaccinate the child could make them vulnerable to the sort of outbreaks we’ve been talking about.

And we commented also on the travel concerns. I think it’s important to note that if you plan travel, there are many, many pockets around the world where there are major outbreaks right now: most of Europe, Israel, other parts of the Middle East, many parts of Africa, Southeast Asia, Madagascar, the Philippines, and Japan, to name a few. So the recommendation here would be to immunize the child beginning at 6 months of age. And then there would be a requirement to reimmunize them because the vaccine may not take because of interference from maternal antibody before a year of age. But I think it’s very important to be aware of that. So could you share with me some of the reasons you’re aware of why parents choose not to vaccinate themselves or their children?

 It seems that there are a variety of reasons why parents may choose not to vaccinate their child, depending on what kind of information parents might have related to concerns about safety of the vaccine—including not even having enough knowledge about the vaccines themselves. So as far as understanding vaccines, that really is at the crux of trying to help parents understand the importance of vaccinating and to dispel any sort of myths related to vaccine-safety concerns.

In addition to that educational piece, the health care providers are probably the most important piece as far as trying to get support for vaccination among parents, for parents to vaccinate their children. But a lot of states have requirements related to school entry as far as immunization requirements are concerned. So all 50 states require immunization for school entry, and there is an allowance for medical exemptions in all 50 states. There are some states that have variations as far as some allowing religious exemptions and some allowing philosophical exemptions. We know of 3 states right now, for example, that do not allow religious exemptions, and they happen to have some of the lowest rates of vaccine-preventable diseases because of these school-entry requirements—because they’re able to keep their vaccine coverage rates really high.

Yes. And I think it’s noteworthy that in New Jersey the overall rate of exemption, I think, is under 2%. The highest proportion, though, is the philosophical or religious exemptions, and it’s in communities where there are high pockets of exemptions that we’re seeing the biggest risk for measles. It’s analogous to the risk of a wildfire. These children are the tinder that can drive that outbreak.

And I think it’s very important to note the population of children who are medically exempt. That makes up a very, very small proportion. But why can we not immunize them? Mainly because they have an immunodeficiency. To give the vaccine could cause some harm. So it’s important for the community to protect those individuals. I recall that during the outbreak in 1989 to 1991 in New York City, in 1 year, there were 5 deaths in New York City from measles. And 4 out of these 5 children were children who could not have been immunized because they had an immunodeficiency.

 Or they’re too young for that matter, yes.

Or if they’re too young, yes, and in the same years there were actually, as I mentioned earlier, 40 cases of measles in infants less than a year of age, who were too young to be immunized. So the entire population of children less than a year of age are at risk, particularly as they hit the 9th through 12th months, when they lose the protective paternal antibodies. So the decision not to immunize a child puts many, many others at very high risk.

Measles: Addressing Aversion to Vaccination

Following their analysis of vaccination aversion, experts expand on how health care professionals can educate patients and ensure vaccination.

 The issues are related to how a lot of times, it is misconceptions about the vaccines and being able to turn to reliable sources for information. And that segues into a question for you, Glenn, related to what you’re seeing in your practice and trying to get correct information out there to your patient population.

Yes, yes. So most immediately in our practice in Newark at New Jersey Medical School, of the patients who we serve, a very high proportion agree to immunization. They trust our recommendation. And when there’s an explanation necessary about potential adverse effects, really the facts are that upward of maybe 5% will get local swelling, pains, and redness. A much smaller proportion may get a mild fever, a sense of malaise. But beyond that, really the adverse effects overlap with those if you were just to give an injection of saline or salt water, and I think that’s a very important thing to note. I think the challenges are coming now in other parts of the country. So the outbreak of 1989 to 1991 in the United States was mostly in urban areas, which were underimmunized. Some of it had to do with access, and some of it had to do with just single-dose immunization. It may have had to do with waning immunity. So most of the outbreaks were in urban areas. Now it’s the reverse. It’s in suburban areas where there is a lot of vaccine hesitancy. So that’s the area I think that has to be targeted in better ways through social media, through helping to give the providers the tools to translate the science or the facts to their patients. That’s becoming increasingly important.

 Well, public health wants to help providers as well because we know from a lot of research on examining attitudes toward vaccines that parents will always say having that recommendation from the providers is the No 1 source of trusted information, and that’s what influences parents to vaccinate. And so the CDC [US Centers for Disease Control and Prevention], the state health departments like New Jersey’s, all have various tool kits that help clinicians, because we know that it’s a multifaceted approach to try to get correct information out there for trusted sources.

 So for example, the CDC has a variety of resources that are available to help physicians have conversations with patients and has developed evidence-based strategies related to how to approach parents. Because the first thing is recognizing that a lot of times, we assume the parents are going to accept the vaccine in a vast majority of situations. But then also make that strong recommendation and be available to offer any sort of answers to questions that they may have, because it’s understandable why parents want to ask these questions, because this is their child whom they’re trusting to you.

Of course. And I think for parents, the CDC website is a fantastic resource. There’s the AAP [American Academy of Pediatrics] website for providers in New Jersey locally. And interestingly in the state of New Jersey there’s been various legislation, if you will, or the laws around enforcing compulsory vaccination at the state level. There’s been pending legislation to insist or require all parents to go through some sort of counseling before they opt out. And I think that that’s been very popular in that the pediatrician or other provider could use some of those tools to engage the parents and persuade those who are sitting on the fence, which as you point out are the highest proportion and can be persuaded in the overwhelming majority of cases. More recently I think in part in the wake of certain outbreaks that have been seen globally in the United States and locally, there’s pending legislation to limit exemptions to only medical.

 Right. I think that unfortunately, we’re always the victims of our own success. As a practicing physician and as a public health practitioner, we are really proud of the impact that vaccination has made in terms of curbing vaccine-preventable diseases. And not seeing some of the diseases rampant as they were prior to the prevaccination era, as we call it—where you were seeing hundreds of thousands of cases of measles or other vaccine-preventable diseases&mdash;sometimes gives people a false sense of security.

Yes, yes. And I’m reminded of the children’s book writer Roald Dahl, who lost his daughter to measles when she was 7 years old in 1962, just before the vaccine was available. She died from measles and encephalitis. So he actually dedicated subsequent books to her, and he spoke very forcefully in 1984 about this when he said, “If you are a school-age child who has not been vaccinated, you should insist that your parents vaccinate you.”

So I would bet that would be another message to parents next time. Because they read to their children, they can remember the experience of Roald Dahl. So yes, it was highly prevalent. We do become complacent. I think this is what’s happening in parts of Europe as well. People just do not realize the risk, but it’s real; it’s out there. And again, keep in mind those statistics: 1 in 1000 severe encephalitis or 1 to 2 in 1000 deaths.

 And we can’t predict who will have those severe complications.

And that’s why it’s not only to protect the individual, because you can’t predict who’s going to get the severe complications, but also to create that herd immunity, as you said.

Measles: Overcoming Vaccination Hesitancy

Health care professionals provide their considerations regarding the future of measles prevention and management.

So looking forward, what is the future of potential measles elimination or measles eradication, both in the United States and globally?

 Well, we do get concerned right now because, for example, we’re seeing outbreaks occurring here in the United States. We’re seeing pockets of susceptibilities—susceptible populations in which it takes just 1 imported case to potentially impact that entire community. We saw it here in New Jersey very recently. So just how we were talking earlier about the different trends, secular trends, and measles activity over the centuries, for the longest time before the vaccine was available, we saw hundreds of thousands of cases that then dropped. And then we saw small increases in the early 1990s, some related to the need to get a second dose, some related to undervaccination of those urban populations, as you said. It’s very possible that we might see blips as well. We’ve seen this in our recent history too, where from time to time, we’ve seen large outbreaks occur, aside from the recent history this year. There was the outbreak that was associated with visits to a California amusement park. That was related to an imported case, and prior to that there was a huge outbreak in the Midwest among the Amish community. So we have to be very cognizant that as long as we have those pockets of vulnerability, and as long as we have Newark Liberty International Airport that can bring in imported cases, we always run that risk.

Yes, yes, absolutely. And I think it’s important to note that we live in a global village. The existence of measles anywhere is a threat to children everywhere. And in this regard there’s a raging epidemic in Europe now. And as I pointed out earlier, there’s paradoxically 90% first-time dose coverage, and 95% 2-dose coverage, but there are sufficient pockets around to allow that epidemic to continue to spread. And there was the news item earlier today that there are potentially imported cases to Costa Rica, which had eliminated measles in 2006, from France. And this will continue to occur.

The California outbreak, I think, was significant in that it heralded 1 of the major outbreaks, or highest number of cases that had been seen, since elimination in 2000 in the United States. And the response in California, again, was what we discussed earlier, to limit exemptions to only medical. That’s had a very, very strong impact on the state, according to colleagues out there, and I think it’s significant that the outbreak hasn’t spilled over to adjacent states in the Pacific Northwest.

So that’s 1 example of a potential approach to stop future outbreaks. It’s significant, though, that there are reports of parents who are finding opportunities through their providers to get medical exemptions that aren’t true medical exemptions, which I think brings up another future issue. I don’t want to use the word 

, but how do we enforce whether this is a true medical exemption? And that’s an open-ended question that I think we as a society, and state licensing boards, etc, will have to think about.

 Right. I think school requirements, immunization requirements before school entry, are a very important tool that can be used to bring up the immunization coverage. But we have to look at it as part of a multipronged approach, because looking at the tasks of physicians—whether it’s related to getting the MMR [measles, mumps, and rubella] vaccine or to the challenge, every single year, of getting everybody vaccinated for flu&mdash;these are all vaccine-preventable diseases.

 And the first thing is getting back to ensuring that patients are well educated on the significance of how this can prevent disease. Because we have to remember that 1 of the big messages that we have to get out there is that there isn’t any evidence that shows vaccines have long-term impact or adverse effects on people. But you do run the risk of impacting your life with a vaccine-preventable disease. If you’re not vaccinated, you could have long-term sequelae related to, say, encephalitis or related to measles that will last you a lifetime.

Right. And again, there are other vaccines that are underutilized. With HPV [human papillomavirus], for example, the rates are well below where they should be, at 60% of completion of immunization. In most jurisdictions in the United States, there’s some hesitancy around that putting you at risk for cervical cancer over a lifetime. So I think, yes, the evidence is strong that providing those tools to the providers, to the frontline providers—whether it is a village health care worker in Africa or a pediatrician in the United States&mdash;is really among the most important strategies. The World Health Organization has named vaccine hesitancy as being among the top 10 threats to public health globally this year. And it’s not just a problem here, but it’s a problem internationally. And I think they agree in their guidelines that providers need the best evidence to share with the patients.

 Right, right. And we also have to be ready to respond because in the meanwhile, while we try to get that prevention message out there, it’s also important that we’re also reactive when we hear about suspect reports. And from our perspective, from the public health perspective, we also want to make sure that we just always reiterate to the provider community: As soon as you suspect something, like measles, call us right away. Call public health right away, because that way we can try to contain and provide immunization or do an assessment of who is vulnerable. Because unfortunately, it’s already been introduced. So then what can you do is mitigate the situation.

Right. And I think it’s important to note that we do have interventions that can prevent the spread.

There is immunoglobulin that, if given within 6 days, can prevent the spread for an exposed individual and immunization within 72 hours. That may play a role in mitigating some of the complications or severe disease.

The cost of all this, though, is very, very high. I mean, the relatively small outbreak in Washington State has already cost over $1 million, so we have to keep that in mind and look at that cost compounded globally. We have an opportunity to eliminate and eradicate. Not doing it costs a tremendous amount in terms of lives. There are 15 times as many cases in Europe this year than there were 2 years ago: Where there were only 5000, there are 80,000 now, and the cost of that in terms of lives is tremendous.

 And given the hospitalization costs, the expense related to the care, the issue is that when people become infected and go visit providers, we have to take all these extra precautions to ensure that you don’t expose any other people. And that also is a resource issue sometimes as well.

Sure, and then going back to the New York City outbreak of 1990, 1991, visiting an urgent care center or an emergency department put a child at 5-fold risk for getting measles. So I think that’s a very important point, that during these outbreaks we should instruct families not to run to the emergency department if they have an acute illness or suspected measles. Call ahead because you could be avoiding that exposure.

 Right. We’ve got a lot of different ways that we have to approach this particular situation right now.

But you know, we’re hoping that—at least from a public health perspective&mdash;this rise in these imported cases, these outbreaks, is at least bringing awareness that hopefully makes everybody more mindful about taking those steps to prevent it.

Measles Outbreaks, Vaccination, and Public Health

Examining the Epidemiology and Etiology of Measles

Public Health Responses to an Outbreak of Measles

Measles: Addressing Aversion to Vaccination

Measles: Overcoming Vaccination Hesitancy

Measles: Future Prevention and Management of Measles