Measles, Not Just Your
Grandmother’s Disease
Steven Pergam, MD, MPHDirector, Infection Prevention SCCA
Associate Member, VIDD & CRD, FHCRC
@pergamic
Goals
• Review measles disease
• Measles complications
• Measles vaccine history
• Measles outbreaks worldwide
• Anti-vaccine movement
• Measles in high risk patients
• What can you do?
©2014 Fred Hutchinson Cancer Research Center 2
Measles basics
• Is a single-stranded, enveloped
RNA virus with only 1 serotype
• It is classified as a member of
the genus Morbillivirus in the
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Paramyxoviridae family
• Humans are the only natural hosts of measles
virus
• Transmission is through respiratory
droplets
Measles pathogenesis after infection
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Initial symptoms after exposure
• NONE – the virus incubates for 10-14 days
before you develop symptoms
• Makes tracking patients after exposure very
difficult and requires lots of people to be
quarantined if exposed and not protected
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Early symptoms – Prodromal Phase
• Like most respiratory viruses
• Cough, Coryza and Conjunctivitis (3 “C”s)
• Common symptoms:
• Cough
• Runny nose *1 in 10 will have diarrhea
• Sore throat – Koplik Spots
• Eye inflammation*
• NO RASH
• Contagious at this time 3-4 days prior to the rash
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Rash phase
• Ongoing symptoms but now associated with fever and
rash
• Start out as small raised bumps may also appear on top
of the flat red spots. The spots may become joined
together as they spread from the head to the rest of
the body.
• “Poured on” – head to toe pattern
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Measles
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Contagious?
• 4 days prior to rash to 4 days after the rash
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Diagnosis
• Clinical presentation after high-risk exposure?
• Serology – IgM (can be false positive)
• Molecular testing – PCR from blood, urine, CSF
• Pathology – e.g. giant cell pneumonia
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Complications of Measles
• Ear infections occur in about one out of every 10 children
with measles and can result in permanent hearing loss
• As many as 1 in 20 children with measles gets
pneumonia, the most common cause of death from
measles in young children
• About 1 in 1,000 children will develop encephalitis
(swelling of the brain) that can lead to seizures, deafness
or long term intellectual disability
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Subacute sclerosing panencephalitis
• Starts with mild mental deterioration (such as memory
loss)
• Changes in behavior (such as irritability)
• Followed by disturbances in motor function, including
uncontrollable involuntary jerking movements of the
head, trunk or limbs called myoclonic jerks – seizures
• Inability to walk, blindness may occur
• Progressive disease which leads to death within 1-3
years from diagnosis – no treatment
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Immune dysfunction
• Patients with measles develop weakened immune systems
following infection:
1) lymphopenia
2) a prolonged cytokine imbalance consistent with
suppression of cellular immunity to 2ndary infections
3) silencing of peripheral blood lymphocytes, which
cannot expand in response to ex-vivo stimulation
• Population data shows that non-measles infectious disease
mortality is linked to measles incidence in both the pre- and
post-vaccine eras (but prevented by vaccination!!)
• Up to 2-3 years post-illness
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Schneider-Schaulies Curr Top Microbiology Immunol 2009
Mina Science 2015
Treatment for measles
• Antipyretics for fever (don’t give aspirin)
• Ribavirin (IV and inhaled) has been tried but unclear if
efficacious
• Vitamin A – low levels associated with increased risk of
death, so recommended for some young children with
measles
• IVIG doesn’t work for acute illness
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Measles vaccination
• Developed by in early in 1960’s using a
weakened form of the virus
• Eventually combined in a triple vaccine (MMR)
for measles mumps and rubella in 1971
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Measles rates after introduction of the vaccine
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Vaccine
licensed
Eliminated but not gone
• In 2000 Measles was declared eliminated from
the US – i.e. no cases originating from the US
• All current outbreaks are related to imported
measles cases into large unvaccinated (at-risk)
populations
• This continues to be a problem because
vaccination rates in the US have declined
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International Measles
• Canada (Vancouver)
• Israel
• Brazil
• Venezuela
• Georgia
• Poland
• Philippines (>30,000, >300 deaths), Ukraine
(>3000 cases)
• Congo (>155,000, 1000’s dead)
• Madagascar (>127,000 cases, 1000’s dead)
• Thailand, etc.©2014 Fred Hutchinson Cancer Research Center 19
Measles in US
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Antivaccine movement
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Antivaccine / “Vaccine Hesitancy” Movement
• Has been present since first vaccines, including smallpox
• Often related to personal choice vs. government
mandated, concerns about contents of vaccines, interest
in getting “real immunity”, vaccine side effects, etc.
• Expanded with now-debunked “Measles vaccine and
autism” pseudo-”study” in the Lancet in 1998
• Events that happen to kids that occur around timing of
vaccines – scapegoat
• Issues have occurred (no medicine is perfect) with
vaccines – e.g. vaccine related polio cases from live polio
vaccine (rare)
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Pockets of risk?
Traditional tight-knit communities – believed to be
75% of recent measles cases currently and related
to recent vaccine outbreaks – targets of antivaccine
movement
• WA Measles – Ukrainian/Russian community
• MN Measles – Somali Americans
• OH Measles – Amish populations
• NY Measles – Ultra-orthodox Jewish community
• IN Mumps – Mennonite community
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US Non-medical exemptions
©2014 Fred Hutchinson Cancer Research Center 24Hotez PLOSMed 2016
Hot spots for Measles/Antivaccine movement in US
©2014 Fred Hutchinson Cancer Research Center 25Olive PLOSMed 2018
Hot spots for Measles/Antivaccine movement in US
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Costs for Measles to Public?
• Washington State over 3 million to control
outbreak
• NY – over 500 Department of Health Staff
working on Measles, preliminary costs over 8
million because over 20,000 exposures had to be
followed
• Costs to healthcare – hospital and ICU
admissions
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Myths and Concerns about Vaccines?
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Vaccine concerns – They make you sick
• I got the “flu” from the vaccine (No)
• Worse than the disease (No)
• Neurologic complications
• Movement disorders
• Depression
• Cancer
• etc, etc, etc…..
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MMR and Autism? - NO
• A study suggested possible links between MMR and
autism in 1998
• Study based on 12 patients
• Work by Brain Deer (journalist) found that study was
organized for financial gain of main author
• Numerous studies which have refuted these claims – but
remains part of anti-vaccine movement arguments
• Paper retracted and main author lost medical license
• Recommend reading How the case against the MMR
vaccine was fixed – BMJ 2011
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MMR and Autism? - NO
• NUMEROUS studies show no association
• Largest study to date – of 657,451 children born
in Denmark between 1999 and 2010 – with
5,025,754 person-years of follow-up
• Using Danish registries to identify vaccines
given, autism, and other behavioral disorders
• Comparison over time between those who
received MMR and those who did not
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MMR and Autism? - NO
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Vaccine concerns – “Contaminants/Products”
• Mercury and heavy metals (Thimerosal)
• Live viruses
• Formaldehyde
• Fetal DNA
• “Chemicals”
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Media representations matter
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Stock images of vaccination
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Self Magazine and AAP
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Combating anti-vaccine movement
• California SB 276 and SB277
• Washington HB 1638 - 2019-20 Promoting immunity
against vaccine preventable diseases
• Removed personal belief exemption for school mandated MMR
• Social media….
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Combating anti-vaccine movement
• California
• Washington
• Social media
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Why is vaccination so important?
Why do singular measles cases scare
cancer patients and providers?
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Risk of Transmission?
• R0 – the basic reproduction rate is the transmission
potential of a disease. Estimates the number of
secondary transmission that happen when population is
totally susceptible
• Influenza = 1.5
• Ebola = 1.86
• Smallpox = 3.5-6
• Measles = 12-18
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95% vaccination rate needed to limit spread
• 4/30 EU countries had reached 95% fully
vaccinated
• Median per county in WA (median 88.5% (IQR =
84.9-91.6%) – King County (88.8%)
• Only 3 counties >95%, 13/39 (33%) of counties
>90%
• Lowest rates in San Juan county (56%
vaccinated)
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Simulations of Measles to Demonstrate
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Low & High rates of
vaccination uptake
Cancer/Immunosuppression and Measles?
• Chinese outbreak 23 children with malignancies and
HCT – 13 (56.5%) had pneumonia/acute liver failure, 5
deaths (21.7%)1
• 5 Liver transplant patients, 1 died of respiratory failure2
• 8 measles cases in HCT patients in Sao Paulo, 7 were
mild, 1 with measles pneumonia (nearly all after 1 year
post-HCT)3
• 15 children in a Hem/Onc ward in India, 2 deaths4
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1. Ge Chin Med 2017
2. Liu Clin Transp 2015
3. Marchado Blood 2003
4. Moulik Ped Blood Cancer 2013
Cancer patients present differently
More likely to present with:
• Symptoms similar to an other URI
• No rash
• Atypical rash
• No fever
• Presentation with tissue invasive disease (e.g. hepatitis,
encephalitis or pneumonia)
*Last death in US of measles was an immunosuppressed
woman found to have measles pneumonia at autopsy
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Decline in measles immunity after HCT in the absence of posttransplant vaccination
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Ljungman et al, Blood 1994;2:657-63
Pro
babili
ty
What can happen?
• Transplant patient came to clinic with 5 children
• 2 (youngest) were noted by nurse to have “full body
rashes” and so were put in isolation
• Discharged from clinic after approval from SKC public
health
• To ER in Pierce county due to development of fever and
rash – tested for measles
• Delays in testing – results finally at nearly 5 days after
exposure
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Scenario
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46
known pt
contacts
in clinic
IVIG
prophylaxis
Developed National Guidelines
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Check your immunity/vaccine status
• Written documentation of adequate vaccination: • 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
• 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
Ask your Healthcare provider/Employee Health to
see your status!©2014 Fred Hutchinson Cancer Research Center 50
Increase your awareness
• BE MEASLES AWARE
• Learn signs and symptoms of the illness
• Get educated about vaccine-preventable illness
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Talk about the importance of vaccines
• Everyone in healthcare has an important role
• The community listens
• All of us must be advocates for vaccination in the
community to help protect our patients
• Talk to your communities, preschool parents,
church groups, or others to promote the
importance of vaccination – we all need to
contribute
• Post a #flushotselfie©2014 Fred Hutchinson Cancer Research Center 52
#Flushotselfie
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#WhyIVaccinate
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Protecting yourself helps to improve herd immunity
“Community Immunity”
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Questions?
Steven Pergam, MD, MPH
Seattle Cancer Care Alliance
University of Washington
Fred Hutchinson Cancer Research Center
Email: [email protected]
@PergamIC