Tag: California measles outbreak

How Is California’s New Vaccine Law Working?

As clusters of unvaccinated kids in California grew and so did outbreaks of vaccine-preventable diseases, legislators got ahead of the problem with a series of vaccine laws to get kids vaccinated and protected.

  • AB 2109 – signed into law in 2012, and in effect for the 2014-2015 and 2015-2016 school years, it required parents to get a signed form from a health care provider if they wanted to get a vaccine exemption
  • SB 277 – signed into law in 2015, it eliminated non-medical vaccine exemptions and has been in effect since the 2016-2017 school year

So are all of the kids in California vaccinated now?

How Is California’s New Vaccine Law Working?

Unfortunately, some folks have found a way around the new vaccine laws.

How?

Some California doctors have taken advantage of fearful parents, and instead of doing the work to help parents understand that vaccines are safe with few risks, they are writing unjustified medical exemptions.

And since many of these parents share their fears with their friends, these intentionally unvaccinated kids often attend the same schools and use the same doctors to obtain unwarranted exemptions of their own. That results in the pockets of susceptible children we often talk about.

Some of these doctors have even created an industry out of providing medical exemptions to kids to get them out of getting vaccinated and protected before attending school. It is reported that they are selling fake medical vaccine exemptions for conditions that are not true medical contraindications to getting vaccinated!

Bob Sears is having to post about the latest measles outbreaks from the sidelines. There are very few measles cases in California so far this year.
Bob Sears is having to post about the latest measles outbreaks from the sidelines. There have been very few measles cases in California so far this year.

Still, many others have gotten vaccinated.

In fact, after years of declines, the vaccination rates for kids entering kindergarten in 2017 were at the highest rate since at least 1998!

“The proportion of students attending kindergarten in 2017-2018 reported to have received all required vaccines is 95.1%, a 0.4 percentage point decrease (difference of unrounded values) from the 2016-2017 school year and a 4.7 percentage point increase over the three years since 2014-2015. The 2017-2018 rate of 95.1% is the second highest reported for the current set of immunization requirements for kindergarten, which began in the 2001-2002 school year.”

2017-2018 Kindergarten Immunization Assessment – Executive Summary California Department of Public Health, Immunization Branch

What about the exodus from public schools that many predicted?

Orange County was the site of several large measles outbreaks before SB 277 took effect.
Orange County was the site of several large measles outbreaks before SB 277 took effect.

Or the exodus of folks California?

Neither happened.

“About 130,000 more residents left California for other states last year than came here from them, as high costs left many residents without a college degree looking for an exit, according to a Bee review of the latest census estimates.”

More people left California in 2017 than moved here. Who they are and where they went

While some people are leaving, it is typically for economic reasons.

It isn’t because folks have to vaccinate and protect their kids.

So except for not predicting that folks would try to get fake medical exemptions, California’s new vaccine law is working well!

More on the Effectiveness of California’s New Vaccine Law

About Those Vaccine Strains in Measles Outbreaks…

A lot happens to control and contain a measles outbreak these days.

For one thing, you have to confirm that everyone with measles symptoms actually has measles. If you miss anyone, because measles is so contagious, then they could expose other people and the outbreak will keep getting bigger.

How do they confirm who has measles and who doesn’t?

While you could just make a clinical diagnosis, simply relying on the person’s history and pattern of symptoms, typically everyone just gets tested.

About Those Vaccine Strains in Measles Outbreaks…

What kind of testing?

“Laboratory confirmation is essential for all sporadic measles cases and all outbreaks. Detection of measles-specific IgM antibody and measles RNA by real-time polymerase chain reaction (RT-PCR) 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.”

Measles For Healthcare Professionals

It depends, but often a throat swab or a throat swab and urine are collected for PCR testing, especially if it has been 7 or fewer days since the patient came down with their rash.

If it has been longer than 7 days, then testing using urine and blood specimens can be performed.

“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.”

Measles For Healthcare Professionals

Because many people get vaccinated during an outbreak and a rash and fever is a side effect of the MMR vaccine, testing becomes very important in those who were recently vaccinated.

Statistics from the 2015 Disneyland measles outbreak...
Statistics from the 2015 Disneyland measles outbreak. Anti-vaccine folks, this slide doesn’t mean what you think it means.

After getting vaccinated, testing helps confirm that someone has vaccine strain measles and not wild type, a vaccine reaction, and don’t actually have measles.

“Here, we describe a real-time reverse transcription-PCR (RT-PCR) method that detects the vaccine genotype (MeVA RT-quantitative PCR [RT-qPCR]) and that can provide rapid discrimination between wild-type-virus infections and vaccine reactions.”

Roy et al on Rapid Identification of Measles Virus Vaccine Genotype by Real-Time PCR

An no, the vaccine reaction is not that they developed measles! They developed a rash and/or fever, a common side effect of the MMR vaccine.

“During outbreaks, measles vaccine is administered to help control the outbreak, and in these situations, vaccine reactions may be mistakenly classified as measles cases.”

CDC on Genetic Analysis of Measles Viruses

So the reports that you might have seen that 31 people in the California measles outbreak had a vaccine strain of measles aren’t true. There were at least 31 people who were recently vaccinated during the outbreak and had a rash and/or fever, and they tested positive for the vaccine strain, proving that they weren’t actually part of the outbreak. None of them actually had measles though.

Has anyone ever gotten the measles after being vaccinated?

“Vaccine‐associated measles is a possible, but extremely rare event.”

Sood et al on Vaccine‐associated measles in an immunocompetent child

Yes, there are a few case reports.

Very rare case reports.

Who's to blame for low immunization rates and continuing outbreaks?
Who’s to blame for low immunization rates and continuing outbreaks?

We know who’s responsible for the rise in measles outbreaks and no, it ain’t folks who have recently been vaccinated. Vaccines are safe and necessary.

Get vaccinated. Stop the outbreaks.

More on Vaccine Strains in Measles Outbreaks

Fake News About Measles Outbreaks?

Many news organizations ran with a story about a multi-state measles outbreak recently.

The CDC tweeted a correction about the multi-state measles outbreak story.
The CDC tweeted a correction about the multi-state measles outbreak story.

They got something wrong though.

There is no ongoing, single, multi-state outbreak of measles this year.

Fake News About Measles Outbreaks?

Is it understandable that some media outlets would have been confused by recent CDC reports?

Not really.

The CDC Measles Cases and Outbreaks page hadn’t been updated since late-July and is still reporting case numbers that are “current as of July 14, 2018,” so there really was no recent CDC report to generate all of this extra attention.

“From January 1 to July 14, 2018, 107 people from 21 states (Arkansas, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Maryland, Michigan, Missouri, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, and Washington) and the District of Colombia were reported to have measles.”

CDC on Measles Cases and Outbreaks

Although it has been changed to say “107 individual cases of measles have been confirmed in 21 states,” there was nothing to indicate it was a single outbreak that the CDC was monitoring as many sites reported:

Few sites were immune to using a click-bait title to scare folks about the "outbreak."
Few sites were immune to using a click-bait title to scare folks about the “outbreak.”

Unfortunately, many of these reports are still online.

How did it happen?

It’s likely because you have reports from organizations and websites that seem to want to push out content, but don’t have much of a budget to pay health or medical writers to make sure it is accurate.

2018 Measles Cases and Outbreaks

It’s also unfortunate that some of these sites, in trying to correct the idea of a single, nation-wide outbreak, are now trying to minimize this year’s measles outbreaks.

No, there isn’t one large outbreak that is spreading across the United States, but there are a lot of smaller outbreaks, some of which are still ongoing.

And these outbreaks are not something that should still be expected, as we have had a safe and effective measles vaccine for over 50 years and measles was declared eliminated in the United States in 2000!

There is also something very much different about 2018, that not surprisingly, no one is reporting about.

With over 107 cases, things seem very similar to last year right, when we had about 118 cases?

The thing is, in 2017, there was one large outbreak, in Minnesota, with 79 people.

In 2015, at least 139 of 189 cases were from just three large outbreaks, in California (Disneyland), Illinois, and South Dakota.

See what’s different?

This year seems to have more individual cases in more states, each with the potential to grow into one of those big outbreaks.

Why?

You can blame the rise in measles outbreaks in Europe and other parts of the world. And some folks not getting vaccinated and protected and exposing the rest of us when they get sick.

Putting us at risk even though measles is a life-threatening infection, a safe and effective vaccine has been available for 50 years, and every anti-vaccine myth that scares folks has been refuted a thousand times.

That’s the story.

Who’s telling it?

More on Reporting on Measles Outbreaks

Costs of a Measles Outbreak

The endemic spread of measles was eliminated in the United States in 2000, but unfortunately, that hasn’t stopped us from having outbreaks of measles each year.

Since reaching a record low of just 37 cases of measles in 2004, other milestones in the measles timeline we should all know about include that there were:

  • 220 measles cases in 2011, a 15-year record and the highest number of cases since 1996 at least until 2014, when we had at least 667 cases
  • 58 cases in the 2013 New York City measles outbreak and for a short time, the largest outbreak since the endemic spread of measles was eliminated in the United States
  • 382 cases in the 2014 measles outbreak in Ohio and now the largest outbreak since the endemic spread of measles was eliminated in the United States
  • 170 measles cases in the first few months of 2015, including a large outbreak in California that was linked to Disneyland.
  • 188 cases and a measles death in 2015

That’s still far below where we used to be though, especially when you consider that before the first measles vaccine was licensed, there was an average of about 549,000 measles cases and 495 measles deaths in the United States each year.

Containing a Measles Outbreak

Several factors help to limit the measles outbreaks that we continue to see in the United States. Most important is that fact that despite the talk of personal belief vaccine exemptions and vaccine-hesitant parents not getting their kids vaccinated, we still have high population immunity.

In the United States, 90.8% of children get at least one dose of the MMR vaccine by the time they are 35 months old and 91.1% of teens have two doses. While not perfect, that is still far higher than the 81% immunization rates the UK saw from 2002 to 2004, when Andrew Wakefield started the scare about the MMR vaccine. Instead of overall low immunization rates, in the U.S., we have “clusters of intentionally under-vaccinated children.”

It also helps that the measles vaccine is highly effective. One dose of a measles vaccine provides about 95% protection against measles infection. A second, “booster” dose helps to improve the effectiveness of the measles vaccine to over 99%.

To further help limit the spread of measles, there are a lot of immediate control measures that go into effect once a case of measles has been suspected, from initiating contact investigations and identifying the source of the measles infection to offering postexposure prophylaxis or quarantining close contacts.

That’s an awful lot of work.

A 2013 measles outbreak in Texas required 1,122 staff hours and 222 volunteer hours from the local health department to contain.

Costs of a Measles Outbreak

In addition to requiring a lot of work, containing a measles outbreak is expensive.

A study reviewing the impact of 16 outbreaks in the United States in 2011 concluded that “investigating and responding to measles outbreaks imposes a significant economic burden on local and state health institutions. Such impact is compounded by the duration of the outbreak and the number of potentially susceptible contacts.”

We still don’t know what it cost to contain many big outbreaks, like the one in Ohio, but we do know that it cost:

  • over $2.3 million to contain the 2017 outbreak in Minnesota – 75 people got measles, 71 were unvaccinated, and more than 500 people were quarantined over a 5 month period
  • up to an estimated $3.91 million (but likely much more) to contain the 2015 outbreaks in California
  • $394,448 and 10,054 personnel hours in total personnel time and total direct cost to the New York City Department of Health and Mental Hygiene responding to and controlling the 2013 outbreak in NYC
  • two unrelated cases in Colorado in 2016 cost $49,769 and $18,423, respectively to investigate
  • $50,758.93 to contain an outbreak at a megachurch in Texas
  • $150,000 to contain (13 cases) an outbreak in Cook County, Illinois
  • $223,223 to contain (5 cases, almost all unvaccinated) to contain another outbreak in Clallam County, Washington, an outbreak that was linked to the death of an immunocompromised woman.
  • more than $190,000 of personnel costs in Alameda County, with 6 cases and >700 contacts, it is estimated that over 56 staff spent at least 3,770 hours working to contain the outbreak
  • $5,655 to respond to all of the people who were exposed when a 13-year-old with measles was seen in an ambulatory pediatric clinic in 2013
  • $130,000 to contain a 2011 measles outbreak in Utah
  • $24,569 to contain a 2010 measles outbreak in Kentucky
  • $800,000 to contain (14 cases, all unvaccinated) a 2008 measles outbreak at two hospitals in Tuscon, Arizona
  • $176,980 to contain a 2008 measles outbreak in California
  • $167,685 to contain a 2005 measles outbreak in Indiana – unvaccinated 17-year-old catches measles on church mission trip to Romania, leading to 34 people getting sick, including an under-vaccinated hospital worker who ends up on a ventilator for 6 days
  • $181,679 (state and local health department costs) to contain a 2004 measles outbreak in Iowa triggered by a unvaccinated college student’s trip to India

Ending with 667 cases, 2014 became the worst year for measles in the United States since 1994.
Ending with 667 cases, 2014 became the worst year for measles in the United States since 1994. How much did these outbreaks cost to contain?

It is important to keep in mind that these costs are often only for the direct public health costs to the county health department, including staff hours and the value of volunteer hours, etc. Additional costs that come with a measles outbreak can also include direct medical charges to care for sick ($14,000 to $16,000) and exposed people, direct and indirect costs for quarantined families (up to $775 per child), and outbreak–response costs to schools and hospitals, etc.

We should also consider what happens when our state and local health departments have to divert so much time and resources to deal with these types of vaccine-preventable diseases instead of other public health matters in the community. Do other public health matters take a back seat as they spend a few months responding to a measles outbreak?

There were 220 cases of measles in the United States in 2011. To contain just 107 of those cases in 16 outbreaks, “the corresponding total estimated costs for the public response accrued to local and state public health departments ranged from $2.7 million to $5.3 million US dollars.”

In contrast, it will costs about $77 to $102 to get a dose of the MMR vaccine if you don’t have insurance. So not only do vaccines work, they are also cost effective.

What to Know About the Costs of a Measles Outbreak

Containing a measles outbreak is expensive – far more expensive than simply getting vaccinated and protected.

More on the Costs of a Measles Outbreak