As the number of measles cases in the United States already has outstripped total cases for last year, employee health professionals should prepare for incoming cases that can wreak havoc in a hospital if undetected.
Even if staff are fully immunized, all bets are off if an undiagnosed case of measles gets into a healthcare facility.
“It’s really about trying to identify cases as soon as possible because of that risk of exposure,” Sarah Lim, MD, a medical specialist in the Minnesota Department of Health, said at a recent news briefing held by the Infectious Diseases Society of America. “In a healthcare setting, you have children who are extremely vulnerable because they may be too young to have been vaccinated. For example, premature infants in a neo-natal ICU, or oncology patients who can’t receive their live vaccines because they’re on chemotherapy. You really need to identify cases quickly and put them in an airborne isolation room.”
There were 56 cases of measles in all of 2023 in the United States. As of March 21, 2024, 64 measles cases were reported by 17 states: Arizona, California, Florida, Georgia, Illinois, Indiana, Louisiana, Maryland, Michigan, Minnesota, Missouri, New Jersey, New York, Ohio, Pennsylvania, Virginia, and Washington, according to the Centers for Disease Control and Prevention (CDC).1
“A person with measles can infect anywhere from 12 to 18 others,” Lim said. “It’s airborne, spreading through the air in tiny droplets when an infected person coughs or sneezes. If someone isn’t fully vaccinated and is exposed, nine times out of 10, that person will go on to develop measles.”
“We communicate all the time with healthcare providers, including alerting them when there are local cases,” she added. “We remind them to have that high index of suspicion, because a lot of providers — especially younger folks — have never seen a case of measles. It’s about reminding them what the rash looks like, what the initial signs can look like, thinking about a child’s vaccine status.”
For all its vaunted transmissibility, measles can show no signs of infection for an incubation period of seven to 14 days. Then, high fever, cough, runny nose, and red, watery eyes often are followed by the tell-tale signs of small white “Koplik spots” inside the mouth two or three days later. The classic rash appears at three to five days — flat, red spots that often appear on the face at the hairline and spread downward to the trunk and extremities.
Employee health professionals should ensure healthcare workers have evidence of immunity, such as two doses of MMR (measles, mumps, rubella) vaccine, serologic evidence of immunity, or laboratory confirmation of disease.
“The majority of people born before 1957 are likely to have been infected naturally, [but] healthcare personnel born before 1957 without laboratory evidence of immunity or disease should consider getting two doses of MMR vaccine,” the CDC recommended.2
One dose of MMR vaccine is 93% effective against measles, 78% effective against mumps, and 97% effective against rubella. Two doses of MMR vaccine are 97% effective against measles and 88% effective against mumps. Do not assume that vaccinated healthcare workers are immune.
“About three out of 100 people who get two doses of MMR vaccine will get measles if exposed to the virus,” the CDC stated. “However, they are more likely to have a milder illness and are also less likely to spread the disease to other people.”
If administered to an exposed non-immune employee, the measles vaccine can be used as a post-exposure prophylaxis if given within 72 hours. MMR is an attenuated live virus vaccine, too weak to cause an infection but strong enough to generate an immune response. However, the CDC acknowledges that rare side effects can include a sore arm from the injection or redness where the shot is given, fever, a mild rash, swelling of the glands in the cheeks or neck, or temporary pain and stiffness in the joints.
“MMR vaccine rarely causes a temporary low platelet count, which can cause a bleeding disorder that usually goes away without treatment and is not life-threatening,” the CDC stated. “Extremely rarely, a person may have a serious allergic reaction to MMR vaccine. Anyone who has ever had a life-threatening allergic reaction to the antibiotic neomycin, or any other component of MMR vaccine, should not get the vaccine.”3
Elimination Status in the Balance
In 2000, measles was declared eliminated from the United States, which is defined by the absence of continuous disease transmission for greater than 12 months. Essentially, it does not circulate endemically but occasionally can be introduced by travelers from measles outbreak areas. The antivax movement threatens to change that equation to homegrown cases, but be aware of international travel due to several outbreaks in Europe.
“[Measles elimination] took a great deal of work in terms of vaccine programs [and] millions of parents getting their children vaccinated. I think if we were to lose that, it would be an absolute tragedy, and it would be a real setback for public health in this country,” Lim said.
Epidemic intelligence surveillance data collected in the European Union between March 11 and March 14 revealed 3,038 new cases in Romania and two more deaths. Romania reported eight measles deaths, and one fatal infection occurred in Ireland. There also were 249 new cases in Austria, 63 in Germany, and 44 in France.4 The World Health Organization has issued an urgent warning over measles after a staggering thirtyfold increase in European measles cases in 2023.5
As of March 24, the Chicago Department of Public Health (CDPH) has “identified 17 confirmed measles cases in Chicago, most of which have been found in the Pilsen new arrivals shelter on Halsted Street,” Precision Vaccinations reported. “Of the 17 confirmed cases, 11 are in children below the age of 5 [years]. The CDPH has established vaccine operations at new arrival shelters and the landing zone. Since the measles outbreak began, about 4,000 people have received [vaccination].”6
According to KFF, in 2022, at the height of the COVID-19 pandemic and all the vaccine disinformation that came with it, “almost three in 10 (28%) [adults] say that parents should be able to decide not to vaccinate their school-age children [for measles], even if this creates health risks for others, up from 16% in 2019. While most of the public continues to have confidence in the benefits of childhood vaccines for measles, mumps, and rubella, the experience of the COVID-19 pandemic and debates over vaccine requirements and mandates appear to have had an impact on public attitudes toward MMR vaccine requirements for public schools.”7
All 50 states enacted legislation requiring specific vaccines for students, although exemptions vary from state to state. All school immunization laws grant exemptions to children for medical reasons. “There are 45 states and Washington, DC that grant religious exemptions for people who have religious objections to immunizations,” a legislative group reported. “Currently, 15 states allow philosophical exemptions for children whose parents object to immunizations because of personal, moral, or other beliefs.”8
Still, both public schools and hospitals must set a high bar for a religious exemption to a disease as infectious as measles. The U.S. Equal Employment Opportunity Commission (EEOC) fined a hospital $45,000 for denying a religious exemption and firing an employee who refused influenza vaccination.9 However, research for this report did not find any EEOC ruling supporting a religious exemption to measles vaccination. This story will be updated if such cases come to light.
Why did measles immunization decline enough to start seeing cases? There were logistical problems of children missing school-required immunizations during the pandemic. The active propaganda of antivax groups cannot be underestimated.
A recent KFF report cited this false statement circulating on social media: “Getting the measles vaccine is more dangerous than becoming infected with measles.”10 This feeds into the “happy days” myth that people held measles “parties” in the 1950s so their children could develop a benign infection that provides immunity.
“Measles is the most infectious [virus] — it’s just not really serious if you are a child and you are well nourished,” Mary Holland, JD, president of the anti-vaccine organization Children’s Health Defense said in a recent broadcast by the group. “It’s a couple of days of spots and then you move on. … This is such a crying wolf kind of thing. …We also know that some of the live virus vaccines like measles harm our children.”11
This view contrasts rather sharply with the CDC’s official historical account, which reports that in the decade before the vaccine was available in 1963, 3.5 million people were infected annually, resulting in 400 to 500 deaths, 48,000 hospitalizations, and about 1,000 cases of encephalitic swelling of the brain.12
The Enduring Lie
A 2023 literature review to assess why parents refuse to vaccinate their children found many still think the MMR vaccine causes autism.13
“Parental concerns regarding MMR continued to be influenced by the fear of autism,” the researchers noted. “This concern appeared repeatedly throughout the literature regardless of the type of study — suggesting how powerful and lasting false information can persist in parents’ minds despite MMR’s established safety and efficacy.”
This is the devastating legacy of Andrew Wakefield, a defrocked physician who falsely linked autism and MMR vaccine in a 1998 paper that ultimately was retracted by the Lancet.
The United Kingdom (U.K.) General Medical Council investigation of the incident in 2010 recommended that Wakefield be struck from the medical register of licensed physicians. Wakefield can no longer practice medicine in the U.K. or the United States. According to the report, “The panel concluded that it is the only sanction that is appropriate to protect patients and is in the wider public interest, including the maintenance of public trust and confidence in the profession and is proportionate to the serious and wide-ranging findings made against him.”14
Another point made with at least partial seriousness is that not only did the United States eliminate measles, it eliminated the memory of it. “You don’t want to scare people unnecessarily, but I do think that reminding people what these childhood diseases really look like and what they do is incredibly important,” Lim said. “It’s so much easier to see stories about potential side effects of vaccines than it is to see stories about parents whose children were in intensive care for two weeks with pneumonia because of severe cases of measles.”
Recently, an American physician volunteering in an impoverished region of Africa wrote an opinion piece contrasting those with insufficient measles vaccine — “I’ve never seen a mother turn it down” — to the complacency in the United States.15 Paul Law, MD, MPH, MS, is the only pediatrician in Sankuru Province in the Democratic Republic of Congo.
“Over the past year, I have watched many children die of measles,” Law wrote. “In the final stages, little lungs, filled with fluid and racked with inflammation, struggle for oxygen. The victims breathe faster and faster, gasping for air until, exhausted, they stop.”
Law argued quite convincingly that no U.S. parent who has seen a child dying of measles would ever turn down measles vaccination again. “Last year, we had one of our periodic measles epidemics,” he recalled. “According to our limited ‘official’ data, there were almost 21,000 cases and more than 500 deaths, mostly very young children. A better estimate would be to multiply those numbers by at least four. I decided to tell this story after the measles outbreak in Florida so that parents would know what a miracle vaccines are.”
Public health officials and measles experts were aghast at the decision in Florida — counter to established public health policy — to let parents decide whether to send their children to school after an outbreak at a Broward County elementary school, which has infected nine children. Another case has been identified in a neighboring county and 8% of kindergartners in Broward County are not vaccinated for measles.
In his letter to parents, Joseph Lapado, MD, PhD, Florida surgeon general, mentioned the measles vaccine and it its 97% efficacy, but astonishingly made no direct recommendation for susceptible children to be immunized.
“When measles is detected in a school, it is normally recommended that individuals without history of prior infection or vaccination stay home for up to 21 days,” the letter stated. “This is the period of time that the virus can be transmitted. Up to 90% of individuals without immunity will contract measles if exposed. Because of the high likelihood of infection, it is normally recommended that children stay home until the end of the infectious period. … However, due to the high immunity rate in the community, as well as the burden on families and educational cost of healthy children missing school, [the FL] DOH [Department of Health] is deferring to parents or guardians to make decisions about school attendance.”16
With critics calling for resignation, Lapado stood by his decision in a March 15 news interview. “Fortunately, it’s a vaccine that has high efficacy for protecting people,” he said. “That was part of the reason that I thought it was a totally reasonable strategy to allow parents of kids who didn’t have a history of prior measles or prior MMR vaccination to decide whether they want to bring their kids to school.”17
Some found this to be pretzel logic, as Lapado was essentially relying on the immunity of others in telling parents of unvaccinated children they could come to school. There is also the fact that the CDC warns that three of every 100 fully immunized people could still acquire measles.
On her blog, “Your Local Epidemiologist,” Katelyn Jetelina, PhD, MPH, said the response by Florida health officials was “unprecedented” and noted that Lapado did not address several nuances of vaccination in this situation.18
“[The FL letter] stated that unvaccinated kids who were exposed to measles could continue to attend school,” Jetelina wrote. “This is unprecedented. Those with no prior immunity need to isolate for 21 days. It failed to recommend kids without immunity get vaccinated. Many parents don’t know that unvaccinated kids can still get protection from a vaccine within 72 hours of exposure. Also, the standard of care is that if they get vaccinated within 72 hours, they can return to school as long as they don’t develop symptoms.”
REFERENCES
- Centers for Disease Control and Prevention. Measles cases and outbreaks. Last reviewed March 8, 2024. https://www.cdc.gov/measles/ca...
- Centers for Disease Control and Prevention. Measles, mumps, and rubella (MMR) vaccination: What everyone should know. Last reviewed Jan. 26, 2021. https://www.cdc.gov/vaccines/v...
- Centers for Disease Control and Prevention. Measles, mumps, and rubella (MMR) vaccination. Last reviewed April 25, 2023. https://www.cdc.gov/vaccinesaf...
- European Centre for Disease Prevention and Control. Communicable Disease Threats Report, Week 11, 10-16 March 2024. https://www.ecdc.europa.eu/sit...
- World Health Organization. A 30-fold rise of measles cases in 2023 in the WHO European Region warrants urgent action. Dec. 14, 2023. https://www.who.int/europe/new...
- Hackett DW. 17 Measles cases confirmed in Chicago. Precision Vaccinations. March 24, 2024. https://www.precisionvaccinati...
- Lopes L, Schumacher S, Sparks G, et al. KFF COVID-19 Vaccine Monitor: December 2022. KFF. Dec. 16, 2022. https://www.kff.org/coronaviru...
- National Council of State Legislatures. States with religious and philosophical exemptions from school immunization requirements. Updated Aug. 3, 2023. https://www.ncsl.org/health/st...
- Equal Employment Opportunity Commission. Children’s Healthcare of Atlanta to pay $45,000 to settle EEOC religious discrimination lawsuit. Dec. 22, 2023. https://www.eeoc.gov/newsroom/...
- Kearney A, Kirzinger A, Schumacher S, et al. Measles vaccines and misinformation in the courts: A snapshot from the KFF Health Misinformation Tracking Poll. KFF. March 14, 2024. https://www.kff.org/other/poll...
- Children’s Health Defense. Measles Mania. Jan. 28, 2024. https://live.childrenshealthde...
- Centers for Disease Control and Prevention. Measles history. Last reviewed Nov. 5, 2020. https://www.cdc.gov/measles/ab...
- Novilla MLB, Goates MC, Redelfs AH, et al. Why parents say no to having their children vaccinated against measles: A systematic review of the social determinants of parental perceptions on MMR vaccine hesitancy. Vaccines (Basel) 2023;11:926.
- General Medical Council. Dr. Jeremy Andrew Wakefield. Determination on Serious Professional Misconduct (SPM) and sanction. May 24, 2010. https://www.circare.org/autism...
- Law P. No parent who has seen the children I’ve treated for measles would refuse a vaccine. Stat. March 12, 2024. https://www.statnews.com/2024/...
- Ladapo, J. Letter to parents/guardians. Feb. 20, 2024. https://www.washingtonpost.com...
- Linsalata N, Boulandier K. ‘It was the right thing to do’: Florida Surgeon General Ladapo defends measles response at Weston elementary school. WSVN 7News Miami. March 14, 2024. https://wsvn.com/news/local/br...
- Jetelina K, Panthagani K. Florida’s recommendations give room for measles to spread: A slippery road we cannot go down. Your Local Epidemiologist. Feb. 27, 2024. https://yourlocalepidemiologis...
As the number of measles cases in the United States already has outstripped total cases for last year, employee health professionals should prepare for incoming cases that can wreak havoc in a hospital if undetected. Even if staff are fully immunized, all bets are off if an undiagnosed case of measles gets into a healthcare facility.
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