April 12, 2024 – When a mother in Atlanta, Georgia noticed the measles symptoms in her son earlier this year, after returning from an international trip, she knew taking him straight to the local emergency room could put others at risk.
She kept him in the car outside the ER while she alerted the staff inside.
“We were able to immediately bring the child in and immediately place him in an isolated room and mask and avoid potential exposure, but it could have ended very differently,” said pediatric infectious disease specialist Matt Linam, MD, whose colleagues at Children’s Healthcare of Atlanta treated the patient.
The boy, who was over five years old and had not been vaccinated, recovered from measles after being hospitalized.
Federal health officials are urging medical and public health organizations to be alert to possible cases of measles as outbreaks of the disease are increasing rapidly this year.
“A lot of the symptoms of measles — fever, cough, red eyes, rash, even though it may not have developed yet — there are a lot of other things that can present themselves that way,” Linam said. “If you can’t identify it very quickly and isolate that child and their family very quickly, you can put a lot of health care risk at risk.”
The scenario in which the mother in Atlanta gives healthcare providers a warning is unusual. Numerous communities have received warnings in recent weeks that people may have been unknowingly exposed to measles in everyday places like a Walmart suburb of Chicago or a medical center California.
Measles is so contagious that 9 out of 10 unprotected people who come into contact with it can become ill, and as cases rise and vaccination rates fall, risks are increasing in some communities.
The CDC has one warning last week that measles vaccination rates among U.S. preschoolers have fallen below the herd immunity rate of about 95%. Meanwhile, the number of cases is rising. Within the first three months of 2024, the nation surpassed the total number of cases recorded in all of 2023.
The latest CDC count of nationwide measles cases will reach 113 by 2024, nearly doubling in less than two weeks. The pace is so rapid that data scientists at the CDC published a projection to investigate whether measles is headed for a record year.
What is the trajectory for measles in 2024?
The CDC’s new estimate predicts there will be about 300 cases of measles in the U.S. this year, a far cry from the peak year of 2019, when there were 1,274 cases. But at 300 cases, the year 2024 would still rank fourth for most cases in the past 25 years.
In 2000, measles was declared “eliminated” in the US, meaning the disease was no longer persistently present in the country. The measles vaccine came on the market in 1971, and it took the country nearly three decades to achieve herd immunity, which typically happens when about 95% of the population is vaccinated. Since 2000, measles outbreaks have resulted from unvaccinated international travelers bringing measles into the U.S. after becoming infected abroad and then spreading the disease to other unvaccinated people.
But vaccination rates have fallen so far that there is now a strong chance the disease will lose its “eliminated” status and begin circulating and spreading regularly in the US again, according to a new CDC report. report published on Thursday.
“This may be the only infection that is this contagious, so you really need to vaccinate to prevent transmission,” explains Catharine Paules, MD, adult infectious disease physician at Penn State Health Milton S. Hershey Medical Center in Hershey, PA.
Paules, along with Anthony Fauci, MD, and others, published an article in the New England Journal of Medicine titled “Measles in 2019 – Going Backward,” which examines that record year and recalls that the global impact of measles was in the millions prior to vaccine development. The disease was so common that there is ample data on its effects on the human body, including the risk that 1 in 1,000 cases results in potentially fatal neurological complications.
Lessons learned from measles in 2019
Today, health officials investigate measles on an outbreak basis, which depends almost entirely on whether people in a community have been vaccinated.
“It’s really different from other infections that are less transmissible,” Paules said. “We have been able to prevent the spread of COVID by doing things like social distancing and masking. But measles is so contagious that you really depend on vaccines to control outbreaks.”
Such was the case in one of the largest modern outbreaks in the US, which spanned 2018 and 2019 and occurred in and around Rockland County, NY. An Orthodox Jewish community has been at the center of the outbreak caused by international travel. The province ultimately had more than 300 cases of measles linked to the outbreak. In 2019 alone, New York state had 911 of the nation’s 1,274 cases of measles.
Unvaccinated children stayed home from school for 21 days if exposed to measles. Public health officials tried to track cases and ask people who had been exposed to isolate. There was what a health ministry official called an “all-in-one campaign” to get people vaccinated against measles, visiting local doctors’ offices, private and public workplaces and handing out door hangers with information in neighborhoods.
“There was a huge increase in the number of vaccines given, and I think that ultimately stopped the outbreak,” says Debra Blog, MD, MPH, medical director of the New York State Department of Health’s Vaccine Division, whose 25-year-old career includes his work as a pediatrician and public health official in New York, as well as his time at the CDC.
She noted that New York State repealed the religious exemption for school immunization after the measles outbreaks from 2018 to 2019.
Children typically receive their first dose of measles vaccine around age 1, and the second dose is recommended between ages 4 and 6, according to the American Academy of Pediatrics. But children can receive the second dose as early as 28 days after the first dose, which increases protection from 93% to 97%.
Last week, the CDC said the measles vaccination rate among U.S. preschoolers has fallen from 95% to 93%, and much lower in some communities. During the 2020-2021 school year, a quarter of a million preschoolers attended school who had not been vaccinated against measles.
CDC data scientists estimate that the current vaccination rate of 93% means that a single child with measles attending a school of 100 children would likely result in about 10 people becoming ill. As school vaccination rates decline, the number of people likely to get sick increases faster and faster, with nearly a third of the school potentially sick if vaccination rates drop to 70%.
Half of children who contract measles are typically hospitalized. There is no treatment, only supportive care.
Herd immunity not only protects vulnerable children, such as babies too young to be vaccinated, but also people with poor immune systems.
“I primarily see bone marrow transplant patients and help treat infections in that population,” Paules said. “We can’t give them some of these vaccines, including the measles vaccine, because it is a live vaccine.”
Close friends and relatives of people who have had a transplant are asked to ensure they are up to date on the vaccines.
“We continually encounter situations where people are not up to date on vaccinations for various reasons, and we find that people want to protect their loved ones,” says Paules, who suggests that anyone concerned about vaccination speak to a trusted medical professional with whom they can have a conversation about these concerns.
Talk about vaccine hesitancy
In New York State, the scale of outbreaks in 2018 and 2019 was fueled by low vaccination rates, although non-vaccination is not always the result of vaccine hesitancy or misinformation, according to Blog.
“People were quite complacent and thought, ‘Oh, everyone’s vaccinated and we’re not in danger,’” she said. “It doesn’t take much for vaccination rates to drop and a disease to become an outbreak. People won’t believe you if they don’t see it in their community.”
“We are such a mobile society and disease outbreaks are just a plane flight away,” Blog continued. “We still need to remain vigilant about getting vaccinated and addressing vaccine hesitancy. Community trust and involvement are crucial.”
For anyone who has a vaccine-hesitant friend, family member or co-worker and wants to help that person, the first step is to manage your own mindset when entering the conversation, and the second step is to be a patient listener, Linam advises . based on his interactions with his patients’ parents.
“There’s often a tendency to demonize these parents and say, ‘You’re hurting your child and you don’t care.’ I think this couldn’t be further from the truth. The most important thing when working with family, friends, colleagues or patients is to remember, first and foremost, that these parents are no different than you or me, and they want the best for their children and want to protect them.
Remember, they may feel really uncomfortable after hearing or reading about vaccines.
“What I try to do when I’m in those situations is I check myself first and remind myself that they want the best for their child. Then I listen to them. I try to understand their specific concerns because that often helps guide how you respond,” Linam said, suggesting that the American Academy of Pediatrics website could be a resource for them to learn more about their questions.
“It’s usually not a one-time conversation,” he said. “You have to have patience.”