By KEN LEISER
As director for infection prevention at PeaceHealth, Catherine Kroll has fielded phone calls about suspected measles cases. Most of the time, it turns out to be a false alarm.
But the call Kroll received from a clinician at PeaceHealth Urgent Care — Memorial in Vancouver, Wash., on New Year's Eve was different. A child who traveled from an Eastern European country to visit family had developed symptoms of measles. Kroll's level of worry increased the more she talked to the provider.
Kroll
Kroll got in her car and drove from her Vancouver office to the clinic. Once there, she worked with the nurse and another provider to make sure that the county's public health department was alerted, and that specimens were collected and sent to the appropriate labs.
The diagnosis was among the first confirmed measles cases in Clark County, Wash., this year, where the total number of cases stood at 65 as of Feb. 24, according to the county public health department. In addition there have been four cases in Multnomah County, Ore., and one in King County, Wash., through Feb. 23 according to The Oregonian. The Washington outbreak and less-widespread ones in Texas and New York, have rekindled a national debate over the rights of parents to have their children skip the measles-mumps-rubella vaccination based on personal or philosophical grounds. Eighteen states — including Washington and neighboring Oregon — allow parents to secure nonmedical exemptions based on personal or philosophical grounds. (Washington state lawmakers have undertaken a new look at the nonmedical exemptions amid the recent measles outbreak).
Of the 65 Clark County cases, 57 patients had not been immunized, according to the public health agency. The county was unable to verify the immunization status of the six other patients. Only two patients had received the MMR vaccine. Nearly three-quarters of the cases were in children ages 1 to 10. Washington Gov. Jay Inslee declared a state of emergency on Jan. 25 in response to the outbreak, directing state agencies to assist the affected area and permitting requests for out-of-state medical resources.
Upswing in cases
Based on its preliminary numbers, the Centers for Disease Control and Prevention said there were 372 measles cases reported in 2018. There have been 159 cases this year, as of Feb. 21.
Hotez
"What we're seeing is an increase in the size and frequency of measles epidemics in the United States," said Dr. Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston.
The MMR vaccine was introduced in the early 1960s. The measles vaccine is 93 percent effective after the first dose. The CDC recommends the first inoculation be given between 12 months and 15 months of age, with a second dose given when the child is between age 4 and 6. The second shot increases effectiveness to 97 percent, according to the CDC.
Measles were prematurely declared eliminated the United States in 2000. Since then, the annual number of cases has ranged from a low of 37 in 2004 to a high of 667 in 2014, according to the CDC.
Anti-vaccination movement
Since the late 1990s, the influence of an anti-vaccination movement has gained a foothold in state legislatures around the country, where parents have been granted the ability to forego immunizations for their children based on philosophical grounds, Hotez said. Initially, the vaccination opponents piggybacked on a since-debunked 1998 study in The Lancet medical journal, suggesting a link between the MMR vaccine and autism. The study was later retracted.
"So, what started as a fringe group has now kind of its own media empire with hundreds of websites," said Hotez. Its message is amplified on social media and through "phony books and phony documentaries, even political action committees."
Hotez, whose daughter has autism, wrote Vaccines Did Not Cause Rachel's Autism, as a counterweight to the anti-vaccine lobby. Organizations such as Vaccinate Your Family and the Immunization Partnership in Texas do good work, Hotez said, but "they are out-funded ... by the anti-vaccine lobby."
The World Health Organization has identified "vaccine hesitancy," the reluctance or refusal to vaccinate despite the availability of vaccines, as one of the top 10 threats to global health in 2019. The organization said the reasons why people opt not to vaccinate are complex and include complacency, inconvenience in accessing vaccines and lack of confidence in vaccinations.
In an article distributed by the Public Library of Science in June 2018, Hotez and his co-authors identified the Portland, Ore., metropolitan area — which encompasses Vancouver across the Columbia River — as a potential measles hot spot. The study based its findings on declines in vaccination coverages in those regions where nonmedical exemptions from vaccination as a condition of school enrollment are permitted.
PeaceHealth's Kroll said that in the Evergreen school district, which takes in Vancouver, the percentage of students who have been vaccinated against measles is just 78 percent. "For measles, you really want to be up above 90 percent," she said.
In Texas — one of the states that permits nonmedical exemptions — the number of unvaccinated schoolchildren has increased from roughly 3,000 in 2003 to about 57,000 last year, Hotez said. And that number does not account for children who are homeschooled, he added. As Catholic Health World went to press, there were six confirmed cases of measles in the Houston area this year — including four in Harris County — where Baylor St. Luke's Medical Center is located, according to the CDC. (Baylor St. Luke's is a joint venture hospital between CHI St. Luke's Health and Baylor College of Medicine.)
So far, Hotez said, the medical center has not taken any extraordinary precautions in anticipation of new cases.
"I think we'll have to see how it goes," Hotez said. "Historically, when we've had measles outbreaks in the country, it starts around late winter or early spring."
PeaceHealth cases
Because the first suspected case in Vancouver surfaced on New Year's Eve, and the next day was a holiday, PeaceHealth officials had to move swiftly to deliver specimens and documentation to the public health department. PeaceHealth officials set out to identify caregivers and patients who were in its urgent care clinic at the same time as the patient diagnosed with measles, and to figure out if anyone was at particular risk of contracting measles. (To date, no known measles cases developed because of exposure at the urgent care clinic or other PeaceHealth facilities, Kroll said.)
More cases of measles began to surface at PeaceHealth facilities around Jan. 9, Kroll said. So far, 10 patients with confirmed measles diagnoses have been treated at PeaceHealth facilities and 14 more suspected cases were ruled out. The most recent measles case was reported on Feb. 16 by the PeaceHealth Southwest Medical Center Emergency Department in Vancouver, according to Clark County health officials.
"It was obvious early on to us that there were preventable exposures happening," Kroll said.
In response, PeaceHealth Vancouver posted visitor restrictions at its medical offices, urgent care facilities and hospital emergency departments throughout Clark County. Those who were exposed to measles or experiencing symptoms were urged to call before visiting any facilities.
Measles, Kroll said, is "exquisitely contagious." The virus can be spread when someone with measles coughs or sneezes in the presence of another who is not immunized. A major challenge, Kroll added, is that people infected with measles are contagious before the onset of the telltale rash. Hotez added that the virus can linger in the air or on surfaces for an hour or two after an infected person leaves a room.
Kroll said PeaceHealth took steps to ensure its employees had been vaccinated against measles. The system also made sure enough immune globulin was on hand to bolster the immune response of individuals who were exposed to measles, but not immunized. PeaceHealth has administered the immune globulin to 36 people at high risk of contracting measles.