Segment Description: Health care professionals provide their considerations regarding the future of measles prevention and management.
Glenn Fennelly, MD, MPH: So looking forward, what is the future of potential measles elimination or measles eradication, both in the United States and globally?
Christina Tan, MD, MPH: 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.
Glenn Fennelly, MD, MPH: 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 police, 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.
Christina Tan, MD, MPH: 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—these are all vaccine-preventable diseases.
Glenn Fennelly, MD, MPH: Yes.
Christina Tan, MD, MPH: 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.
Glenn Fennelly, MD, MPH: 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—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.
Christina Tan, MD, MPH: 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.
Glenn Fennelly, MD, MPH: Right. And I think it’s important to note that we do have interventions that can prevent the spread.
Christina Tan, MD, MPH: Right.
Glenn Fennelly, MD, MPH: 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.
Christina Tan, MD, MPH: 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.
Glenn Fennelly, MD, MPH: 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.
Christina Tan, MD, MPH: Right. We’ve got a lot of different ways that we have to approach this particular situation right now.
Glenn Fennelly, MD, MPH: Yes.
Christina Tan, MD, MPH: But you know, we’re hoping that—at least from a public health perspective—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.