MEASLES
Clinical Features
Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis -the three “C”s -, a pathognomonic enanthema (Koplik spots) followed by a maculopapular rash, The rash usually appears about 14 days after a person is exposed. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do not develop the rash.
The Virus
Measles is caused by a single-stranded, enveloped RNA virus with 1 serotype. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts of measles virus.
Complications
Common complications from measles include:
otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea.
Even in previously healthy children, measles can cause serious illness requiring hospitalization.
One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.
One or two out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.
Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection.
People at High Risk for Complications
People at high risk for severe illness and complications from measles include:
Infants and children aged <5 years
Adults aged >20 years
Pregnant women
People with compromised immune systems, such as from leukemia and HIV infection
Transmission
Measles is one of the most contagious of all infectious diseases; up to 9 out of 10 susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area.
Diagnosis and Laboratory Testing
Healthcare providers should consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms, especially if the person recently traveled internationally or was exposed to a person with febrile rash illness. Healthcare providers should report suspected measles cases to their local health department within 24 hours.
Laboratory confirmation is essential for all sporadic measles cases and all outbreaks. Detection of measles-specific IgM antibody in serum and measles RNA by real-time polymerase chain reaction (RT-PCR) in a respiratory specimen are the most common methods for confirming measles infection. Healthcare providers should obtain both a serum sample and a throat swab (or nasopharyngeal swab) from patients suspected to have measles at first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples can increase the likelihood of detecting measles virus.
Molecular analysis can also be conducted to determine the genotype of the measles virus.
Genotyping is used to map the transmission pathways of measles viruses. The genetic data can help to link or unlink cases and can suggest a source for imported cases. Genotyping is the only way to distinguish between wild-type measles virus infection and a rash caused by a recent measles vaccination.
Evidence of Immunity
Acceptable presumptive evidence of immunity against measles includes at least one of the
following:
written documentation of adequate vaccination:
o one or more doses of a measles-containing vaccine administered on or after the
first birthday for preschool-age children and adults not at high risk
o two doses of measles-containing vaccine for school-age children and adults at
high risk, including college students, healthcare personnel, and international
travelers
laboratory evidence of immunity
laboratory confirmation of measles
birth before 1957
Summary Recommendations of the Advisory Committee on Immunization Practices
Vaccination
Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Single-antigen measles vaccine is not available.
One dose of MMR vaccine is approximately 93% effective at preventing measles; two doses are approximately 97% effective. Almost everyone who does not respond to the measles component of the first dose of MMR vaccine at age 12 months or older will respond to the second dose.
Therefore, the second dose of MMR is administered to address primary vaccine failure.
Vaccine Recommendations:
Children:
CDC recommends routine childhood immunization for MMR vaccine starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or at least 28 days following the first dose.
Students at post-high school educational institutions:
Students at post-high school educational institutions without evidence of measles immunity need two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose.
Adults:
People who are born during or after 1957 who do not have evidence of immunity against measles should get at least one dose of MMR vaccine.
International travelers:
People 6 months of age or older who will be traveling internationally should be protected against measles.
Before travelling internationally,
Infants 6 through 11 months of age should receive one dose of MMR vaccine
Children 12 months of age or older should have documentation of two doses of MMR
vaccine (the first dose of MMR vaccine should be administered at age 12 months or
older; the second dose no earlier than 28 days after the first dose)
Teenagers and adults born during or after 1957 without evidence of immunity against
measles should have documentation of two doses of MMR vaccine, with the second dose
administered no earlier than 28 days after the first dose
Post-exposure Prophylaxis:
People exposed to measles who cannot readily show that they have evidence of immunity against measles should be offered post-exposure prophylaxis (PEP) or be excluded from the setting (school, hospital, childcare). To potentially provide protection or modify the clinical course of disease among susceptible persons, either administer MMR vaccine within 72 hours of initial measles exposure, or immunoglobulin (IG) within six days of exposure. Do not administer MMR vaccine and IG simultaneously, as this practice invalidates the vaccine
MMR vaccine as post-exposure prophylaxis:
If MMR vaccine is not administered within 72 hours of exposure as PEP, MMR vaccine should still be offered at any interval following exposure to the disease in order to offer protection from future exposures. People who receive MMR vaccine or IG as PEP should be monitored for signs and symptoms consistent with measles for at least one incubation period.
If many measles cases are occurring among infants younger than 12 months of age, measlesvaccination of infants as young as 6 months of age may be used as an outbreak control measure.
Note that children vaccinated before their first birthday should be revaccinated when they are 12 through 15 months old and again when they are 4 through 6 years of age.
Except in healthcare settings, unvaccinated people who receive their first dose of MMR vaccine within 72 hours after exposure may return to childcare, school, or work.
Immunoglobulin (IG) as post-exposure prophylaxis
People who are at risk for severe illness and complications from measles, such as infants younger than 12 months of age, pregnant women without evidence of measles immunity, and people with severely compromised immune systems, should receive IG. Intramuscular IG (IGIM) should be given to all infants younger than 12 months of age who have been exposed to measles. For infants aged 6 through 11 months, MMR vaccine can be given in place of IG, if administered within 72 hours of exposure. Because pregnant women might be at higher risk for severe measles and complications, intravenous IG (IGIV) should be administered to pregnant women without evidence of measles immunity who have been exposed to measles. People with severely compromised immune systems who are exposed to measles should receive IGIV regardless of immunologic or vaccination status because they might not be protected by MMR vaccine. IG should not be used to control measles outbreaks, but rather to reduce the risk for infection and complications in the people receiving it. IGIM can be given to other people who do not have evidence of immunity against measles, but priority should be given to people exposed in settings with intense, prolonged, close contact, such as a household, daycare, or classroom where the risk of transmission is highest.
After receipt of IG, people cannot return to healthcare settings. In other settings, such as
childcare, school, or work, factors such as immune status, intense or prolonged contact, and
presence of populations at risk, should be taken into consideration before allowing people to
return. These factors may decrease the effectiveness of IG or increase the risk of disease and complications depending on the setting to which they are returning.
The recommended dose of IGIM is 0.5 mL/kg of body weight (maximum dose = 15 mL) and the recommended dose of IGIV is 400 mg/kg.
Post-exposure prophylaxis for healthcare personnel
If a healthcare provider without evidence of immunity is exposed to measles, MMR vaccine
should be given within 72 hours, or IG should be given within 6 days when available. Exclude healthcare personnel without evidence of immunity from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine. [2]
Isolation
Infected people should be isolated for four days after they develop a rash; airborne precautions should be followed in healthcare settings. Regardless of presumptive immunity status, all healthcare staff entering the room should use respiratory protection consistent with airborne infection control precautions (use of an N95 respirator or a respirator with similar effectiveness in preventing airborne transmission). Because of the possibility, albeit low, of MMR vaccine failure in healthcare providers exposed to infected patients, they should all observe airborne precautions in caring for patients with measles. The preferred placement for patients who require airborne precautions is in a single-patient airborne infection isolation room (AIIR).
People without evidence of immunity who have been exempted from measles vaccination for medical, religious, or other reasons and who do not receive appropriate PEP within the appropriate time frame should be excluded from affected institutions in the outbreak area until 21 days after the onset of rash in the last case of measles.
Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis -the three “C”s -, a pathognomonic enanthema (Koplik spots) followed by a maculopapular rash, The rash usually appears about 14 days after a person is exposed. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do not develop the rash.
The Virus
Measles is caused by a single-stranded, enveloped RNA virus with 1 serotype. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts of measles virus.
Complications
Common complications from measles include:
otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea.
Even in previously healthy children, measles can cause serious illness requiring hospitalization.
One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.
One or two out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.
Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection.
People at High Risk for Complications
People at high risk for severe illness and complications from measles include:
Infants and children aged <5 years
Adults aged >20 years
Pregnant women
People with compromised immune systems, such as from leukemia and HIV infection
Transmission
Measles is one of the most contagious of all infectious diseases; up to 9 out of 10 susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area.
Diagnosis and Laboratory Testing
Healthcare providers should consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms, especially if the person recently traveled internationally or was exposed to a person with febrile rash illness. Healthcare providers should report suspected measles cases to their local health department within 24 hours.
Laboratory confirmation is essential for all sporadic measles cases and all outbreaks. Detection of measles-specific IgM antibody in serum and measles RNA by real-time polymerase chain reaction (RT-PCR) in a respiratory specimen are the most common methods for confirming measles infection. Healthcare providers should obtain both a serum sample and a throat swab (or nasopharyngeal swab) from patients suspected to have measles at first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples can increase the likelihood of detecting measles virus.
Molecular analysis can also be conducted to determine the genotype of the measles virus.
Genotyping is used to map the transmission pathways of measles viruses. The genetic data can help to link or unlink cases and can suggest a source for imported cases. Genotyping is the only way to distinguish between wild-type measles virus infection and a rash caused by a recent measles vaccination.
Evidence of Immunity
Acceptable presumptive evidence of immunity against measles includes at least one of the
following:
written documentation of adequate vaccination:
o one or more doses of a measles-containing vaccine administered on or after the
first birthday for preschool-age children and adults not at high risk
o two doses of measles-containing vaccine for school-age children and adults at
high risk, including college students, healthcare personnel, and international
travelers
laboratory evidence of immunity
laboratory confirmation of measles
birth before 1957
Summary Recommendations of the Advisory Committee on Immunization Practices
Vaccination
Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Single-antigen measles vaccine is not available.
One dose of MMR vaccine is approximately 93% effective at preventing measles; two doses are approximately 97% effective. Almost everyone who does not respond to the measles component of the first dose of MMR vaccine at age 12 months or older will respond to the second dose.
Therefore, the second dose of MMR is administered to address primary vaccine failure.
Vaccine Recommendations:
Children:
CDC recommends routine childhood immunization for MMR vaccine starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or at least 28 days following the first dose.
Students at post-high school educational institutions:
Students at post-high school educational institutions without evidence of measles immunity need two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose.
Adults:
People who are born during or after 1957 who do not have evidence of immunity against measles should get at least one dose of MMR vaccine.
International travelers:
People 6 months of age or older who will be traveling internationally should be protected against measles.
Before travelling internationally,
Infants 6 through 11 months of age should receive one dose of MMR vaccine
Children 12 months of age or older should have documentation of two doses of MMR
vaccine (the first dose of MMR vaccine should be administered at age 12 months or
older; the second dose no earlier than 28 days after the first dose)
Teenagers and adults born during or after 1957 without evidence of immunity against
measles should have documentation of two doses of MMR vaccine, with the second dose
administered no earlier than 28 days after the first dose
Post-exposure Prophylaxis:
People exposed to measles who cannot readily show that they have evidence of immunity against measles should be offered post-exposure prophylaxis (PEP) or be excluded from the setting (school, hospital, childcare). To potentially provide protection or modify the clinical course of disease among susceptible persons, either administer MMR vaccine within 72 hours of initial measles exposure, or immunoglobulin (IG) within six days of exposure. Do not administer MMR vaccine and IG simultaneously, as this practice invalidates the vaccine
MMR vaccine as post-exposure prophylaxis:
If MMR vaccine is not administered within 72 hours of exposure as PEP, MMR vaccine should still be offered at any interval following exposure to the disease in order to offer protection from future exposures. People who receive MMR vaccine or IG as PEP should be monitored for signs and symptoms consistent with measles for at least one incubation period.
If many measles cases are occurring among infants younger than 12 months of age, measlesvaccination of infants as young as 6 months of age may be used as an outbreak control measure.
Note that children vaccinated before their first birthday should be revaccinated when they are 12 through 15 months old and again when they are 4 through 6 years of age.
Except in healthcare settings, unvaccinated people who receive their first dose of MMR vaccine within 72 hours after exposure may return to childcare, school, or work.
Immunoglobulin (IG) as post-exposure prophylaxis
People who are at risk for severe illness and complications from measles, such as infants younger than 12 months of age, pregnant women without evidence of measles immunity, and people with severely compromised immune systems, should receive IG. Intramuscular IG (IGIM) should be given to all infants younger than 12 months of age who have been exposed to measles. For infants aged 6 through 11 months, MMR vaccine can be given in place of IG, if administered within 72 hours of exposure. Because pregnant women might be at higher risk for severe measles and complications, intravenous IG (IGIV) should be administered to pregnant women without evidence of measles immunity who have been exposed to measles. People with severely compromised immune systems who are exposed to measles should receive IGIV regardless of immunologic or vaccination status because they might not be protected by MMR vaccine. IG should not be used to control measles outbreaks, but rather to reduce the risk for infection and complications in the people receiving it. IGIM can be given to other people who do not have evidence of immunity against measles, but priority should be given to people exposed in settings with intense, prolonged, close contact, such as a household, daycare, or classroom where the risk of transmission is highest.
After receipt of IG, people cannot return to healthcare settings. In other settings, such as
childcare, school, or work, factors such as immune status, intense or prolonged contact, and
presence of populations at risk, should be taken into consideration before allowing people to
return. These factors may decrease the effectiveness of IG or increase the risk of disease and complications depending on the setting to which they are returning.
The recommended dose of IGIM is 0.5 mL/kg of body weight (maximum dose = 15 mL) and the recommended dose of IGIV is 400 mg/kg.
Post-exposure prophylaxis for healthcare personnel
If a healthcare provider without evidence of immunity is exposed to measles, MMR vaccine
should be given within 72 hours, or IG should be given within 6 days when available. Exclude healthcare personnel without evidence of immunity from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine. [2]
Isolation
Infected people should be isolated for four days after they develop a rash; airborne precautions should be followed in healthcare settings. Regardless of presumptive immunity status, all healthcare staff entering the room should use respiratory protection consistent with airborne infection control precautions (use of an N95 respirator or a respirator with similar effectiveness in preventing airborne transmission). Because of the possibility, albeit low, of MMR vaccine failure in healthcare providers exposed to infected patients, they should all observe airborne precautions in caring for patients with measles. The preferred placement for patients who require airborne precautions is in a single-patient airborne infection isolation room (AIIR).
People without evidence of immunity who have been exempted from measles vaccination for medical, religious, or other reasons and who do not receive appropriate PEP within the appropriate time frame should be excluded from affected institutions in the outbreak area until 21 days after the onset of rash in the last case of measles.
Measles: Perilous but Preventable
By Denise Grady : WSJ ; Feb 2, 2015
Measles has been spreading in the United States at a rate that worries health officials, with 102 cases so far this year in at least 14 states.
Most infections are linked to an outbreak that began in Disneyland in December, almost certainly started by someone who brought the disease in from another country. A “smattering” of other imported cases have also occurred, according to Dr. Anne Schuchat, the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention.
Measles was eliminated from the United States in 2000, meaning that the infection no longer originates here. But worldwide, there are still about 20 million cases a year; in 2013, about 145,700 people died of measles. Travelers can bring the virus into the United States and transmit it to people who have not been vaccinated.
Measles spreads through the air and is among the most contagious of all viruses; in past epidemics, it was not uncommon for one patient to infect 20 others. Some 90 percent of people exposed will get sick (unless they are immune because they have had measles already or have been vaccinated). The virus can hang suspended in the air for several hours, so it is possible to catch measles just by walking into a room where an infected person has recently spent time. Inhaling a tiny amount of viral particles is enough to cause illness.
The disease is cause for particular concern because it can have severe complications, including pneumonia and encephalitis, which can be fatal. Those who survive encephalitis can wind up with brain damage. Measles can also cause deafness. And even without complications, the virus makes children very sick, with high fevers, a rash and sore eyes. Painful ear infections are also common.
Here are some commonly asked questions about measles and the vaccine that prevents it.
Q. Has the United States been particularly hard-hit?
A. Many relatively wealthy countries are having worse outbreaks. Virtually all of continental Europe has been undergoing a large outbreak since 2008, with more than 30,000 cases in several years.
France, which gets more tourists than any other country, had 15,000 measles cases in 2013, with at least six deaths. About 95 percent of the cases were in people who had never been vaccinated or had not had both recommended doses.
In the United States, vulnerable communities have had outbreaks in the last few years, including Orthodox Jews in Brooklyn and the Amish in Ohio. But vaccination rates are also relatively low in some wealthy, liberal neighborhoods. The Seattle suburb of Vashon Island is believed to have the lowest vaccination rates of any health district in the country.
Q. Who is most at risk of becoming seriously ill from measles?
Babies and young children who have not been vaccinated are most vulnerable, and most at risk for dangerous complications.
“Even in developed countries like the U.S., for every thousand children who get measles, one to three of them die despite the best treatment,” Dr. Schuchat said during a news teleconference last week. In the United States from 2001 to 2013, 28 percent of young children with measles needed to be treated in the hospital.
In pregnant women who have never been immunized or never had measles, the disease increases the chance of premature labor, miscarriage and having a baby with a low birthweight. People with leukemia and other diseases that weaken the immune system are also at risk of severe illness from measles.
The best protection for high-risk people, Dr. Schuchat said, is a high rate of vaccination in everyone else, so the disease cannot gain a foothold and start spreading.
Q. Is the measles vaccine safe?
There is no evidence that the vaccine causes harm. Research in 1998 linking it to autism was proved fraudulent and was retracted. Children may briefly run a low fever — an increase of about 1 degree Fahrenheit — after the shot and may develop a mild rash.
Q. When should children get the measles vaccine?
They need two shots, one when they are 12 to 15 months old, and another when they are 4 to 6 years old, according to the C.D.C. The injections contain a mix of vaccines to prevent measles, mumps and rubella.
Q. Why do babies have to wait until they are a year old to receive the vaccine?
During the first year of life, infants may carry antibodies from their mothers that can prevent the vaccine from working, so the shot is delayed. But if there is a risk of exposure — say, from international travel — the first shot can be given at 6 months and is thought to provide some protection. But those babies will need two more shots: the second at 12 months and the third at least 28 days later.
Q. How long does it take the measles vaccine to start working?
The shot usually provides protection in 10 days to two weeks.
Q. How effective is the measles vaccine?
More than 95 percent of people will become immune after receiving one dose, according to the C.D.C. With two shots, the efficacy reaches about 97 percent. The vaccine does fail in a small percentage of people for unknown reasons. One possible cause is mishandling of the vaccine; failure to keep it cold can inactivate it.
Q. Is there anyone who should not receive the measles vaccine?
Pregnant women, and people with weakened immune systems and with certain illnesses are among those who should not be given the measles vaccine. The C.D.C. maintains a detailed list on its website of conditions in which the measles vaccine should be postponed or avoided.
Q. I don’t know if I’ve ever had measles or the measles vaccine. What should I do?
The easiest solution is to be vaccinated. Even if you had been vaccinated, there is no harm in getting another shot. Measles vaccine is always given in combination with the mumps and rubella vaccines.
People born before 1957 are assumed to be immune to measles, because the disease was so common in the prevaccine era that virtually everyone caught it and became immune.
It is possible to have a blood test that will look for measles antibodies, which would indicate that you had had measles or the vaccine, and therefore are immune. But testing would require two doctor visits and a wait for lab results. Just getting the shot is simpler, easier and cheaper.
Q. Is it safe to stretch out the immunization schedule so babies do not receive more than one or two vaccines at a time?
Some parents fear that multiple vaccinations will overwhelm an infant’s immune system. But infectious disease experts say there is no reason to stretch out the vaccination schedule or to worry that a child’s immune system cannot handle multiple vaccines administered at one time.
“From the moment the child enters the world through the birth canal, that child’s immune system is being stimulated by all kinds of bacteria,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University. “ The child is constantly being stimulated, and that’s the way the child’s immune system was designed by nature to work and become competent.”
A child’s immune system can easily respond to all the vaccines given according to the standard schedule recommended in the United States, Dr. Schaffner said.
He warned that stretching out the schedule was not only unnecessary, but may endanger children by lengthening the time during which they are susceptible to the diseases that vaccines can prevent.
Q. Do people catch measles from animals?
No. It is strictly a disease of humans.
By Denise Grady : WSJ ; Feb 2, 2015
Measles has been spreading in the United States at a rate that worries health officials, with 102 cases so far this year in at least 14 states.
Most infections are linked to an outbreak that began in Disneyland in December, almost certainly started by someone who brought the disease in from another country. A “smattering” of other imported cases have also occurred, according to Dr. Anne Schuchat, the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention.
Measles was eliminated from the United States in 2000, meaning that the infection no longer originates here. But worldwide, there are still about 20 million cases a year; in 2013, about 145,700 people died of measles. Travelers can bring the virus into the United States and transmit it to people who have not been vaccinated.
Measles spreads through the air and is among the most contagious of all viruses; in past epidemics, it was not uncommon for one patient to infect 20 others. Some 90 percent of people exposed will get sick (unless they are immune because they have had measles already or have been vaccinated). The virus can hang suspended in the air for several hours, so it is possible to catch measles just by walking into a room where an infected person has recently spent time. Inhaling a tiny amount of viral particles is enough to cause illness.
The disease is cause for particular concern because it can have severe complications, including pneumonia and encephalitis, which can be fatal. Those who survive encephalitis can wind up with brain damage. Measles can also cause deafness. And even without complications, the virus makes children very sick, with high fevers, a rash and sore eyes. Painful ear infections are also common.
Here are some commonly asked questions about measles and the vaccine that prevents it.
Q. Has the United States been particularly hard-hit?
A. Many relatively wealthy countries are having worse outbreaks. Virtually all of continental Europe has been undergoing a large outbreak since 2008, with more than 30,000 cases in several years.
France, which gets more tourists than any other country, had 15,000 measles cases in 2013, with at least six deaths. About 95 percent of the cases were in people who had never been vaccinated or had not had both recommended doses.
In the United States, vulnerable communities have had outbreaks in the last few years, including Orthodox Jews in Brooklyn and the Amish in Ohio. But vaccination rates are also relatively low in some wealthy, liberal neighborhoods. The Seattle suburb of Vashon Island is believed to have the lowest vaccination rates of any health district in the country.
Q. Who is most at risk of becoming seriously ill from measles?
Babies and young children who have not been vaccinated are most vulnerable, and most at risk for dangerous complications.
“Even in developed countries like the U.S., for every thousand children who get measles, one to three of them die despite the best treatment,” Dr. Schuchat said during a news teleconference last week. In the United States from 2001 to 2013, 28 percent of young children with measles needed to be treated in the hospital.
In pregnant women who have never been immunized or never had measles, the disease increases the chance of premature labor, miscarriage and having a baby with a low birthweight. People with leukemia and other diseases that weaken the immune system are also at risk of severe illness from measles.
The best protection for high-risk people, Dr. Schuchat said, is a high rate of vaccination in everyone else, so the disease cannot gain a foothold and start spreading.
Q. Is the measles vaccine safe?
There is no evidence that the vaccine causes harm. Research in 1998 linking it to autism was proved fraudulent and was retracted. Children may briefly run a low fever — an increase of about 1 degree Fahrenheit — after the shot and may develop a mild rash.
Q. When should children get the measles vaccine?
They need two shots, one when they are 12 to 15 months old, and another when they are 4 to 6 years old, according to the C.D.C. The injections contain a mix of vaccines to prevent measles, mumps and rubella.
Q. Why do babies have to wait until they are a year old to receive the vaccine?
During the first year of life, infants may carry antibodies from their mothers that can prevent the vaccine from working, so the shot is delayed. But if there is a risk of exposure — say, from international travel — the first shot can be given at 6 months and is thought to provide some protection. But those babies will need two more shots: the second at 12 months and the third at least 28 days later.
Q. How long does it take the measles vaccine to start working?
The shot usually provides protection in 10 days to two weeks.
Q. How effective is the measles vaccine?
More than 95 percent of people will become immune after receiving one dose, according to the C.D.C. With two shots, the efficacy reaches about 97 percent. The vaccine does fail in a small percentage of people for unknown reasons. One possible cause is mishandling of the vaccine; failure to keep it cold can inactivate it.
Q. Is there anyone who should not receive the measles vaccine?
Pregnant women, and people with weakened immune systems and with certain illnesses are among those who should not be given the measles vaccine. The C.D.C. maintains a detailed list on its website of conditions in which the measles vaccine should be postponed or avoided.
Q. I don’t know if I’ve ever had measles or the measles vaccine. What should I do?
The easiest solution is to be vaccinated. Even if you had been vaccinated, there is no harm in getting another shot. Measles vaccine is always given in combination with the mumps and rubella vaccines.
People born before 1957 are assumed to be immune to measles, because the disease was so common in the prevaccine era that virtually everyone caught it and became immune.
It is possible to have a blood test that will look for measles antibodies, which would indicate that you had had measles or the vaccine, and therefore are immune. But testing would require two doctor visits and a wait for lab results. Just getting the shot is simpler, easier and cheaper.
Q. Is it safe to stretch out the immunization schedule so babies do not receive more than one or two vaccines at a time?
Some parents fear that multiple vaccinations will overwhelm an infant’s immune system. But infectious disease experts say there is no reason to stretch out the vaccination schedule or to worry that a child’s immune system cannot handle multiple vaccines administered at one time.
“From the moment the child enters the world through the birth canal, that child’s immune system is being stimulated by all kinds of bacteria,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University. “ The child is constantly being stimulated, and that’s the way the child’s immune system was designed by nature to work and become competent.”
A child’s immune system can easily respond to all the vaccines given according to the standard schedule recommended in the United States, Dr. Schaffner said.
He warned that stretching out the schedule was not only unnecessary, but may endanger children by lengthening the time during which they are susceptible to the diseases that vaccines can prevent.
Q. Do people catch measles from animals?
No. It is strictly a disease of humans.
Do I need a measles shot?
By Nicholas Bakalar : NY Times : August 1, 2014
If you were born before 1957, you probably don’t need the vaccine. Why 1957? The measles vaccine was first produced in 1963, so people who were children before the late ’50s or early ’60s were almost certainly exposed to measles and have lifelong immunity.
Adults born after 1957 who have not been vaccinated, as well as all infants and children, should get the vaccine. In the United States, it is given in one or two doses as the measles-mumps-rubella, or M.M.R., vaccine.
The Centers for Disease Control and Prevention recommends one or two shots for adults 18 to 59 who have not been vaccinated. Two shots should be given to highly vulnerable groups like college students, hospital workers, women of childbearing age, and people traveling internationally or on a cruise.
Pregnant women should not get the M.M.R. vaccine, and when a woman of childbearing age gets the shot, she should avoid getting pregnant for at least four weeks. Anyone who has ever had a life-threatening reaction to the antibiotic neomycin or any of the other components of the M.M.R. vaccine should skip it, and if you had a reaction to a first dose, you should not get a second. People on steroids or other medicines that suppress the immune system should not get the vaccine, but minor illnesses, even with a fever, are not a reason to avoid it.
Vaccination is unnecessary for anyone who has had a blood test that shows immunity to measles, mumps and rubella. What if you are unsure if you are immune?
“There’s no danger in getting the shot anyway,” said Dr. Marguerite Mayers, an infectious disease specialist at Montefiore Hospital in the Bronx. “You can go get your titers if you want,” she said, referring to the blood test for immunity, “but the easiest thing is to just get a vaccine. Even if you had mumps and rubella and know you are immune to those diseases, the M.M.R. is still important to guard against measles.”
Dr. Mayers said that travelers should get the vaccine at least three weeks, or preferably longer, before their trip. “There is measles in all parts of the world,” she said. “and it can take up to three weeks to get your antibodies started.”
Measles has largely been eliminated in the United States. Still, from 2000 to 2011, there were about four outbreaks a year, mainly attributable to imported cases. And vaccine refusal continues to be a problem. There were 162 cases of measles from 2004 to 2008 among people eligible for vaccination, and 110 of those were in people who refused the vaccine for philosophical, religious or personal reasons.
There are some risks in getting the vaccine, most of them minor like low-grade fever, a mild rash, pain at the injection site or swelling of the glands. More serious reactions are very rare. A serious allergic reaction occurs less than once in a million vaccinations.
All of these risks are small compared with the risks of getting measles: severe illness, hospitalization and death.
By Nicholas Bakalar : NY Times : August 1, 2014
If you were born before 1957, you probably don’t need the vaccine. Why 1957? The measles vaccine was first produced in 1963, so people who were children before the late ’50s or early ’60s were almost certainly exposed to measles and have lifelong immunity.
Adults born after 1957 who have not been vaccinated, as well as all infants and children, should get the vaccine. In the United States, it is given in one or two doses as the measles-mumps-rubella, or M.M.R., vaccine.
The Centers for Disease Control and Prevention recommends one or two shots for adults 18 to 59 who have not been vaccinated. Two shots should be given to highly vulnerable groups like college students, hospital workers, women of childbearing age, and people traveling internationally or on a cruise.
Pregnant women should not get the M.M.R. vaccine, and when a woman of childbearing age gets the shot, she should avoid getting pregnant for at least four weeks. Anyone who has ever had a life-threatening reaction to the antibiotic neomycin or any of the other components of the M.M.R. vaccine should skip it, and if you had a reaction to a first dose, you should not get a second. People on steroids or other medicines that suppress the immune system should not get the vaccine, but minor illnesses, even with a fever, are not a reason to avoid it.
Vaccination is unnecessary for anyone who has had a blood test that shows immunity to measles, mumps and rubella. What if you are unsure if you are immune?
“There’s no danger in getting the shot anyway,” said Dr. Marguerite Mayers, an infectious disease specialist at Montefiore Hospital in the Bronx. “You can go get your titers if you want,” she said, referring to the blood test for immunity, “but the easiest thing is to just get a vaccine. Even if you had mumps and rubella and know you are immune to those diseases, the M.M.R. is still important to guard against measles.”
Dr. Mayers said that travelers should get the vaccine at least three weeks, or preferably longer, before their trip. “There is measles in all parts of the world,” she said. “and it can take up to three weeks to get your antibodies started.”
Measles has largely been eliminated in the United States. Still, from 2000 to 2011, there were about four outbreaks a year, mainly attributable to imported cases. And vaccine refusal continues to be a problem. There were 162 cases of measles from 2004 to 2008 among people eligible for vaccination, and 110 of those were in people who refused the vaccine for philosophical, religious or personal reasons.
There are some risks in getting the vaccine, most of them minor like low-grade fever, a mild rash, pain at the injection site or swelling of the glands. More serious reactions are very rare. A serious allergic reaction occurs less than once in a million vaccinations.
All of these risks are small compared with the risks of getting measles: severe illness, hospitalization and death.
Putting Us All at Risk for Measles
By Pauline W. Chen, MD : NY Times : June 26, 2014
This year, there has been a major resurgence of measles, a dangerous disease that for decades had been virtually unknown in the United States. And it’s become clear that measles has re-emerged as a public health issue in this country because large numbers of individuals remain unvaccinated.
By choice.
Up until the late 1960s, measles was an unavoidable scourge, infecting millions of children each year. Highly contagious, it could lurk in the air for hours after an infected individual had passed by, resulting in more than 400 deaths and nearly 50,000 hospitalizations annually, as well as innumerable chronic disabilities when it spread to the lungs and brain.
Happily, in 1966 scientists developed a safe and effective vaccine. With this vaccine in hand, public health officials, pediatricians and infectious disease experts began a series of campaigns to eradicate the disease. Their principal strategy was to create “herd immunity,” or “community immunity.”
In any given population, there would always be individuals who would not develop immunity to measles, even after receiving the vaccine, or who could not receive the vaccine because they were too young (less than a year old) or had immune systems already weakened from diseases like cancer or AIDS. But health care experts discovered that if at least 95 percent of a community were immunized against measles, all the members of that group would be safe. Even if someone with the disease entered the community, the immunized majority would serve as a “buffer zone” preventing further spread to unimmunized individuals.
If, however, the rates of vaccination fell below 95 percent and community immunity dropped, that safety net would disappear.
In 2000, after three decades of intensive efforts, public health officials declared that endemic measles had been eradicated in the United States.
But just as the experts were claiming victory, Dr. Andrew Wakefield, a British gastroenterologist, published in The Lancet a study of 12 children that posited a causal link between the measles vaccine and an intestinal disorder and autism. Subsequently, dozens of peer-reviewed studies based on the experience of millions of children found nothing to support such speculation, and in 2010 The Lancet retracted the study, citing fraudulent data and ethics violations. The same year, the British Medical Council barred Dr. Wakefield from practicing medicine because of ethical lapses.
The retraction, the disciplinary actions and all the subsequent scientific findings that refuted Dr. Wakefield’s assertion did little to dampen the enthusiasm of his most fervent supporters. They continued to promote his work and the idea that the measles vaccine could cause autism. Believing that they were protecting the young against neurological harm, these parents refused to vaccinate their children and encouraged others in their communities to do the same.
Pediatricians and infectious disease experts warned that these parents were putting their unvaccinated children at increased risk. Measles remains the eighth leading cause of mortality worldwide and the greatest vaccine-preventable cause of death among children. Studies have shown that unvaccinated children are 35 times more likely to contract the disease than immunized children.
Furthermore, the health care experts cautioned, it wouldn’t be just their own family members that these parents were putting at risk.
Over the last five months, there have been 16 outbreaks and almost 500 reported cases of measles. It’s the highest number of cases since 2000, and the number continues to rise. Almost all the outbreaks can be traced to an unvaccinated individual who contracted the disease while traveling abroad, and the majority of people who subsequently caught the disease were unvaccinated by choice.
Moreover, because as many as a quarter of all parents in certain communities chose not to vaccinate their children, pockets of the population have lost the protective effects of herd immunity. In these communities, measles has spread like wildfire, infecting not only those who were unvaccinated by choice but also infants too young to be immunized, and children and adults with immune systems already compromised.
And, it gets worse.
Given the earlier success of the measles eradication campaign, most patients and their doctors no longer know how to recognize the disease. Patients, unaware that they are ill with such a contagious disease, go to hospitals and clinics assuming that the providers there will know what to do to help them.
But most practicing doctors, myself included, have never cared for a patient with measles. Confronted with a patient suffering from a fever, red eyes, runny nose, cough and blotchy rash, we don’t even think of measles, let alone order the dramatic precautions necessary to prevent its spread, like mandating facial masks, isolating patients in rooms equipped with specialized ventilation systems and reporting to appropriate infection control experts.
And because measles was virtually nonexistent in the United States until this year, many clinicians still assume that patients are vaccinated against the disease and therefore not susceptible.
“We have a whole generation of physicians who have never seen measles,” said Dr. Julia Sammons, medical director of infection prevention and control at the Children’s Hospital of Philadelphia. Dr. Sammons has just published in The Annals of Internal Medicine a primer on the diagnosis, treatment, prevention and control of measles to help increase awareness among doctors. “You’re not going to make the diagnosis or make efforts to control spread if it’s not on your radar screen,” she said.
While there have been no deaths yet associated with the recent outbreaks, the lesson for patients and doctors is clear.
When it comes to public health, bad personal choices can have potentially devastating effects on others.
“It’s easy to believe that vaccines are harmful if you aren’t seeing the consequences for yourself and other people,” Dr. Sammons said. “But we need to remember that measles is a preventable disease.”
By Pauline W. Chen, MD : NY Times : June 26, 2014
This year, there has been a major resurgence of measles, a dangerous disease that for decades had been virtually unknown in the United States. And it’s become clear that measles has re-emerged as a public health issue in this country because large numbers of individuals remain unvaccinated.
By choice.
Up until the late 1960s, measles was an unavoidable scourge, infecting millions of children each year. Highly contagious, it could lurk in the air for hours after an infected individual had passed by, resulting in more than 400 deaths and nearly 50,000 hospitalizations annually, as well as innumerable chronic disabilities when it spread to the lungs and brain.
Happily, in 1966 scientists developed a safe and effective vaccine. With this vaccine in hand, public health officials, pediatricians and infectious disease experts began a series of campaigns to eradicate the disease. Their principal strategy was to create “herd immunity,” or “community immunity.”
In any given population, there would always be individuals who would not develop immunity to measles, even after receiving the vaccine, or who could not receive the vaccine because they were too young (less than a year old) or had immune systems already weakened from diseases like cancer or AIDS. But health care experts discovered that if at least 95 percent of a community were immunized against measles, all the members of that group would be safe. Even if someone with the disease entered the community, the immunized majority would serve as a “buffer zone” preventing further spread to unimmunized individuals.
If, however, the rates of vaccination fell below 95 percent and community immunity dropped, that safety net would disappear.
In 2000, after three decades of intensive efforts, public health officials declared that endemic measles had been eradicated in the United States.
But just as the experts were claiming victory, Dr. Andrew Wakefield, a British gastroenterologist, published in The Lancet a study of 12 children that posited a causal link between the measles vaccine and an intestinal disorder and autism. Subsequently, dozens of peer-reviewed studies based on the experience of millions of children found nothing to support such speculation, and in 2010 The Lancet retracted the study, citing fraudulent data and ethics violations. The same year, the British Medical Council barred Dr. Wakefield from practicing medicine because of ethical lapses.
The retraction, the disciplinary actions and all the subsequent scientific findings that refuted Dr. Wakefield’s assertion did little to dampen the enthusiasm of his most fervent supporters. They continued to promote his work and the idea that the measles vaccine could cause autism. Believing that they were protecting the young against neurological harm, these parents refused to vaccinate their children and encouraged others in their communities to do the same.
Pediatricians and infectious disease experts warned that these parents were putting their unvaccinated children at increased risk. Measles remains the eighth leading cause of mortality worldwide and the greatest vaccine-preventable cause of death among children. Studies have shown that unvaccinated children are 35 times more likely to contract the disease than immunized children.
Furthermore, the health care experts cautioned, it wouldn’t be just their own family members that these parents were putting at risk.
Over the last five months, there have been 16 outbreaks and almost 500 reported cases of measles. It’s the highest number of cases since 2000, and the number continues to rise. Almost all the outbreaks can be traced to an unvaccinated individual who contracted the disease while traveling abroad, and the majority of people who subsequently caught the disease were unvaccinated by choice.
Moreover, because as many as a quarter of all parents in certain communities chose not to vaccinate their children, pockets of the population have lost the protective effects of herd immunity. In these communities, measles has spread like wildfire, infecting not only those who were unvaccinated by choice but also infants too young to be immunized, and children and adults with immune systems already compromised.
And, it gets worse.
Given the earlier success of the measles eradication campaign, most patients and their doctors no longer know how to recognize the disease. Patients, unaware that they are ill with such a contagious disease, go to hospitals and clinics assuming that the providers there will know what to do to help them.
But most practicing doctors, myself included, have never cared for a patient with measles. Confronted with a patient suffering from a fever, red eyes, runny nose, cough and blotchy rash, we don’t even think of measles, let alone order the dramatic precautions necessary to prevent its spread, like mandating facial masks, isolating patients in rooms equipped with specialized ventilation systems and reporting to appropriate infection control experts.
And because measles was virtually nonexistent in the United States until this year, many clinicians still assume that patients are vaccinated against the disease and therefore not susceptible.
“We have a whole generation of physicians who have never seen measles,” said Dr. Julia Sammons, medical director of infection prevention and control at the Children’s Hospital of Philadelphia. Dr. Sammons has just published in The Annals of Internal Medicine a primer on the diagnosis, treatment, prevention and control of measles to help increase awareness among doctors. “You’re not going to make the diagnosis or make efforts to control spread if it’s not on your radar screen,” she said.
While there have been no deaths yet associated with the recent outbreaks, the lesson for patients and doctors is clear.
When it comes to public health, bad personal choices can have potentially devastating effects on others.
“It’s easy to believe that vaccines are harmful if you aren’t seeing the consequences for yourself and other people,” Dr. Sammons said. “But we need to remember that measles is a preventable disease.”
