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.”
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.
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
“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
“…California patients were genotyped; all were measles genotype B3, which has caused a large outbreak recently in the Philippines…”
Measles Outbreak — California, Dec 2014–Feb 2015
It wasn’t a vaccine strain.
For example, during 2011, 222 cases of measles and 17 outbreaks were reported in the United States, with most cases originating from just five countries (France, Italy, Romania, Spain, and Germany). Six different genotypes were identified, including B3, D4, G3, D8, H1, and D9. No vaccine strains…
And no, it doesn’t matter that the vaccine strain of measles, genotype A, differs from all of the wild strains of measles we see in the outbreaks.
“Vaccine induced immunity protects against all virus strains. Measles is considered a monotypic virus despite the genetic variations.”
Factsheet about measles
Unlike the flu, HPV, and pneumococcal bacteria, in which vaccines only protect against different serotypes, in the case of measles, the genotype simply helps us figure out where the measles case came from.
But if it isn’t the vaccine strain, then why do they that is it important to rapidly identify wild strains vs vaccine strains?
“During measles outbreaks, it is important to be able to rapidly distinguish between measles cases and vaccine reactions to avoid unnecessary outbreak response measures such as case isolation and contact investigations.”
Roy et al on Rapid Identification of Measles Virus Vaccine Genotype by Real-Time PCR
That’s easy to answer.
Outbreaks typically trigger a lot of folks to get vaccinated. While that’s great, one possible problem is that some of those folks might develop a fever and/or rash after their MMR vaccine. So it is important to quickly figure out whether they are part of the outbreak and have a wild strain (maybe they were exposed before their vaccine could start to work) or are having a common, mild vaccine reaction.
But couldn’t they have vaccine-associated measles if they have a rash and fever and a vaccine strain? Theoretically, but then they would likely have true measles symptoms. And even in these rare case reports, the children didn’t spread the measles to anyone else.
So why are you waiting to know the genotype of the measles strain causing the outbreak in your area? Hopefully, it isn’t to help you decide whether or not to vaccinate and protect your kids. While it is interesting to know where the outbreak originated, you can bet that it isn’t a vaccine strain.
Breaking News – There is 1 new case in Clark County (62 cases), bringing the total case count to 67 cases.
It started with a confirmed case of measles in a child in late December.
There were soon reports of more cases.
And more cases.
The Pacific Northwest Measles Outbreak of 2019
But the measles cases didn’t stay in Clark County.
As with other recent large measles outbreaks, cases soon spread to neighboring counties.
As of late January, there are now measles cases linked to this ongoing outbreak in Clark County and King County (Washington) and Multnomah County (Oregon).
The rapid growth of the outbreak led Clark County to declare a local public health emergency and Washington’ governor to declare a State of Emergency in all counties in the state of Washington.
“The measles outbreak and its effects impact the life and health of our people, as well as the economy of Washington State, and is a public disaster that affects life, health, property or the public peace.”
Are they going to realize that unless they are malnourished or have a vitamin deficiency, that taking extra vitamin A that you order from someone’s online store will not reduce their risk of severe complications if their unvaccinated child gets measles?
“Please contact your pediatrician or doctor if your child is scary sick, struggling to breathe or unable to eat or very lethargic or otherwise seriously ill. Let them know you are worried they may have measles so they can arrange not to contaminate the waiting room or the whole office.”
whether the death rate of measles is 1 in 1000 or 1 in 10,000 cases, remember that just before the measles vaccine came out, in the early 1960s, nearly 500 people would die of measles each year. And it isn’t that a person dies after 1,000 or 10,000 cases. With more cases, there is just a higher chance that someone will eventually die.
Breaking News – 1 new cases in Washington (see below).
2019 has just started, but we already have reports of measles cases and exposures in at least 152 people in 9 states, including Colorado (1), Connecticut (3), Georgia (3), Hawaii (2), Kentucky (1), Illinois (4), New York (65), Oregon (5), Texas (7), and Washington (63).
as expected, 12 more cases in Clark County, Washington (14 total) – all children, all unvaccinated (one unverified), with multiple exposures in Vancouver, including 5 different schools, 2 churches, and 6 health care facilities
3 new cases in the Borough Park section of Brooklyn (58 total)
an adult in Denver, Colorado who became sick while traveling internationally and exposed others in Denver from Jan 10-14
2 more cases in Clark County, Washington (16 total), with 5 more suspected cases remaining and exposures in Battle Ground (Jan 8 and 14) and Vancouver (Jan 14 and 15)
2 kids from the Washington outbreak had traveled to Hawaii while contagious (January 4 to 13)
2 residents of the metro Atlanta area, with exposures between Jan 7 to 14, although there is some speculation that these cases were also travelers from the Washington outbreak
3 more cases in Clark County, Washington (19 total), with 7 more suspected cases remaining and exposures in Camas (Jan 10- 15), Portland (Jan 11 and 14), and Vancouver (Jan 11 to 16), leading the Clark County Council Chair Eileen Quiring to declare a public health emergency.
2 new cases in Clark County, Washington (21 total), with 4 more suspected cases remaining and exposures in Vancouver (Jan 7 to 11)
4 new cases in the Borough Park and Williamsburg sections of Brooklyn (62 total)
2 new cases in Clark County, Washington (23 total), with 2 more suspected cases remaining and exposures in Vancouver (Jan 15 and 19) and Portland (Jan 15-16), including at the Portland International Airport (where did they go?)
2 new cases in Clark County, Washington (38 total), with 13 more suspected cases, and exposures in Bend, Oregon (Jan 19-20)
a 4th case in Spencerport, New York, an unvaccinated neighbor of two previous cases.
3 new cases in Clark County, Washington (41 total) with exposures at an after-school activity at Minnehaha Elementary School (Jan 17) triggering exclusion of unvaccinated students and staff, and there are also 15 more suspected cases
What kind of measles year will 2019 turn out to be? Unfortunately, we already have the potential for another record year…
These outbreaks are a great reminder to review the special vaccine travel requirements, including that adults who “plan to travel internationally should receive 2 doses of MMR at least 28 days apart,” that infants traveling abroad can get their first dose of MMR as early as age 6 to 11 months, with a repeat dose at age 12 months, and that “children aged who are greater than or equal to 12 months need 2 doses of MMR vaccine before traveling overseas,” even if they aren’t four to six years old yet.
While the oral polio vaccine is indeed associated with shedding and vaccine associated disease, that doesn’t happen with MMR. Experts don’t even recommend any restrictions for use of the MMR vaccine for household contacts of people who are immunosuppressed. And yes, your kids can even visit a cancer patient if they just had their MMR, as long as they don’t have RSV, the flu, or some other contagious disease.
What about the fact that a study once found measles virus RNA in the urine of of kids who had recently been vaccinated? Doesn’t that mean that they were shedding the vaccine virus?
No. It doesn’t.
To be considered shedding, those measles virus RNA particles in their urine would have to be contagious. Now, measles is spread by respiratory secretions. So how are measles virus RNA particles in urine going to become airborne and get someone else sick?
But what about that case in Canada? Anti-vaccine folks like to bring this up when they talk about shedding. In 2013, there was a case of vaccine-associated measles. That proves that the vaccine sheds, right?
“Of note, only one case report of transmission from vaccine-associated measles has been identified.”
Murti et al. on Case of vaccine-associated measles five weeks post-immunisation, British Columbia, Canada, October 2013
That child got measles about 5 weeks after she was vaccinated in the middle of a measles outbreak. Because she had no links to the other cases and she tested positive for vaccine-strain measles, it is thought that she had MMR vaccine-associated measles, which is extremely rare.
Shedding Light on Measles Outbreaks in Daycare
MMR shedding is not causing outbreaks of measles – or rubella and mumps, for that matter.
If shedding from the MMR, by any method, got kids sick, then why aren’t there even more cases of measles?
When a case of measles does pop up though, it isn’t because of shedding, it is typically because someone who wasn’t vaccinated traveled out of the country, got measles, and brought it back home, exposing others.
What to Know About MMR and Shedding
Measles outbreaks are not caused by shedding from the MMR vaccine.
We have come a long way since the development of the first measles vaccines in the early 1960s…
Pre-Vaccine Era Measles Outbreaks
In the pre-vaccine era, measles was a very common childhood disease.
As it is now, it was also a deadly disease.
In the 1950s, there were 5,487,332 cases (just under 550,000 a year) and 4,950 deaths (about 500 each year).
In 1962, there were 469,924 cases of measles in the United States and 432 deaths.
Post-Vaccine Era Measles Outbreaks
The first measles vaccines were licensed between 1963 and 1965, but it was the first national measles eradication campaign in 1966 that got people vaccinated and measles rates down.
In 1970, there were only 47,351 cases and 89 deaths.
Rates continued to drop until the large outbreaks between 1989 to 1991, when there were 55,622 cases and 123 deaths. The addition of a measles booster shot got measles outbreaks under control again. By 2000, when measles was declared eliminated in the United States, there were just 86 cases and one death.
Post-Elimination Era Measles Outbreaks
Declaring measles eliminated in the United States didn’t mean that we didn’t have any more measles, after all, it hasn’t been eradicated yet. It just that we are no longer seeing the endemic spread of measles. Since 2000, all of the latest measles outbreaks have been imported from outside the country, or at least they are started by cases that are imported.
We have seen more than a few records in the post-elimination era, including:
the year with the historic low number of measles cases – 37 cases in 2004
the year with the largest number of cases since 1994 – 667 cases in 2014
the largest single outbreak since the endemic spread of measles was eliminated – 377 cases in Ohio in 2014
In 2015, we got a reminder of how deadly measles can be. Although there have been other measles deaths and SSPE deaths in the past ten years, unlike the 2015 death, they are usually buried in CDC reports and aren’t published in the newspaper.
2017 Measles Outbreaks
The first new case of 2017 was an unvaccinated adult in San Luis Obispo County, California who was exposed to international travelers over the holidays. The person exposed others to measles at the Twin Cities Community Hospital emergency department in Templeton while contagious in early January.
The second case of 2017 was related to an LA county outbreak that started at the end of 2016 – a resident of Ventura County.
And it went on, with other measles cases in 2017 including:
at least 122 cases
cases in 16 states, including California, Florida, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Utah, and Washington
an infant in San Luis Obispo County that was too young to be vaccinated and who had contact with an unvaccinated adult with measles
one new case in the Los Angeles County outbreak, which is now up to 20 confirmed measles cases (including 18 in LA County), all unvaccinated
four new cases in Ventura County, California that are linked to another Ventura County measles case and the LA County outbreak, which is now up to 24 cases
a case in Jersey City, New Jersey following international travel who exposed people at multiple places, including a hospital, pharmacy, mall, and on a commuter train
an unvaccinated 7-month-old baby from Passaic County, New Jersey who had been traveling out of the country and may have exposed others at area hospitals (a good reminder that infants who are at least 6 months old should get an MMR vaccine before leaving the country)
two cases in Salt Lake County, Utah – which began in a resident who had “received all appropriate vaccinations” and developed measles after traveling outside the US and then spread to another person “who had contact with the first case.” According to the SLCoHD, “One of the two individuals with measles had received one MMR vaccine.”
two cases in King County, Washington – a man and his 6-month-old infant, both unvaccinated, developed measles after traveling to Asia, and exposed many others around Seattle, including at a Whole Foods, a sandwich shop, their apartment building, and two Amazon buildings.
a confirmed case in Omaha, Nebraska, who exposed people on a Delta flight and multiple places in Douglas and Sarpy counties, including the Bergan Mercy Hospital Emergency Room.
two children in Minnesota without a known source of infection
another child in Minnesota – among the three Somali Minnesotans in this outbreak are two children who are just two years old – all of the cases were unvaccinated and two required hospitalization, although the common source is still not known. Vaccine hesitancy has been a problem among the Somali Minnesotans because of Wakefield‘s MMR study.
five more unvaccinated children in Minnesota, as the outbreak grows to 8.
a confirmed case in North Platte, Nebraska who may have exposed others at a middle school, church youth group, the Great Plains Health Emergency Room, a medical office, and a lab.
a resident of Livingston County, Michigan who exposed others at area restaurants and St. Joseph Mercy Brighton Hospital after getting measles on a plane ride with an unvaccinated child
another case in Minnesota, bringing the outbreak count to 9 unvaccinated children.
three more cases in Minnesota, bringing this outbreak case count to 12, with at least 200 people in quarantine.
eight more cases in Minnesota, bringing this outbreak case count to 20 young children under age 5 years, and now including an infant under age 12 months.
four more cases in Minnesota, bringing this outbreak case count to 24 young children under age 5 years and surpassing the size of the 2011 measles outbreak in the Somali community in the same area, which was also mostly among intentionally unvaccinated children.
five more cases in Minnesota, including the first outside of Hennepin County – spreading to nearby Stearns County, bringing this outbreak case count to 29 young children under age 5 years, with only one that was vaccinated.
three more cases in Minnesota, as the outbreak spreads to the third county – Ramsey County.
more measles (2 new cases) in Minnesota (Hennepin County, Ramsey County, Crow Wing County, and now Le Sueur County), where the ongoing outbreak is up to 66 cases, almost all unvaccinated children and where there has been a call to accelerate the two dose MMR schedule for kids over age 12 months.
a child in Maryland who was admitted to Children’s National Medical Center in Washington, D.C.
more measles (3 new cases) in Minnesota (Hennepin County, Ramsey County, Crow Wing County, and Le Sueur County), where the ongoing outbreak that has been confirmed to be from the wild type B3 strain is up to 68 cases, almost all unvaccinated children.
a case in Pennsylvania who exposed others at a visitor center
someone who visited the MIT Museum in Cambridge, Massachusetts.
two new cases in Minnesota, ending speculation that the outbreak, now up to 70 cases, was over…
one new case in Minnesota, raising the number of cases in this ongoing outbreak to 78 cases.
a healthcare worker in New York who is employed by Hudson Headwaters Health Network and also works at a Warren County medical practice.
someone in Franklin County, Maine (their first case in Maine in 20 years!) who traveled out of the country and caught measles, returning home and possibly exposing others at a movie theater, restaurant, farmers market, and hospital.
A case in Butler County, Kansas. Many remember that one of the largest outbreaks of 2014 was in Kansas.
an unvaccinated man who lives in Hennepin County, raising the number of cases in this ongoing outbreak (an outbreak that has already cost over $500,000 to contain and which many hoped would soon be over) that started in March to at least 79 cases. With the new case, the clock starts ticking again and Minnesota will have to wait to see if new cases appear over the next 3 weeks.
passengers from 13 states on an American Airlines flight from New York to Chicago were exposed to a person with measles in early July, including a 12-week-old infant who required preventative treatment with immune globulin (IG), as she was too young to be vaccinated.
a fully vaccinated resident of Onondaga County, New York who was exposed on a domestic flight, only developed mild symptoms, but did expose others.
someone who exposed others at the Penn State University Hetzel Union Building Bookstore and other places in State College, Pennsylvania.
a second case in the Wichita, Kansas area, this time in Sedgwick County, with exposures at a church, dental office, elementary school, and multiple stores over at least 3 days.
a possible case in Sedgwick County, Kansas, a child too young to be vaccinated who may have been exposed at a church. Three other exposed infants who were too young to be vaccinated and who were considered at risk to get measles in this outbreak received immunoglobulin treatment.
a traveler who spent time in Hampton Beach in New Hampshire, exposing others.
a 46-year-old male in Ohio that got the disease while traveling internationally.
2017 would have been a mild year for measles, except for the really big outbreak in Minnesota… 79 people got measles, 71 were unvaccinated, more than 500 people were quarantines, and the outbreak cost over $1.3 million to contain.
2016 Measles Outbreaks
Starting slow, 2016 ended as a fairly average year for measles:
cases in 17 states, including Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oregon, Tennessee, Texas, and Utah
a large outbreak in Arizona, 23 cases, linked to a private detention center
a large outbreak in Shelby County, Tennessee, at least seven cases, including six unvaccinated and one partially vaccinated child
a case in Colorado in which an unvaccinated adult traveled internationally and ended up exposing many people “from Dec. 21 to 29, 2016, who was at a wide variety of locations in the Denver-Boulder area,” including an Urgent Care center and the Parker Adventist Hospital Emergency Department
As in other years, many of these outbreaks involved unvaccinated children and adults. One case involved a child at the Yuba River Charter School in California, a Waldorf School with very high rates of unvaccinated children.
2015 Measles Outbreaks
With a large outbreak in California, 2015 got off to a very strong start.
Most concerning, more and more, cases don’t seem to have an source that is easy to find, which could mean that the endemic spread of measles has returned in the United States. So instead of having to travel out of the country or be exposed to someone who got measles with a link to international travel, you could get measles just by going to a ball game, a movie theater, or to Disneyland. That makes it more important than ever to learn how to avoid measles.
Among the 189 measles cases and outbreaks in 2015 were:
113 cases that were associated with a multi-state outbreak that was linked to Disneyland in California. Before it was declared over on April 17, a few unvaccinated travelers also help spread measles from this outbreak to large outbreak in Quebec, Canada. All in all, the outbreak was linked to at least 113 cases in California and an additional 169 cases in Arizona (5), Nebraska (1), Utah (3), Colorado (1), Washington (2), Oregon (1), Mexico (1), and Canada (155).
13 cases, including an adult worker and 12 infants too young to be vaccinated at the KinderCare Learning Center in Illinois.
At least 13 cases, all intentionally unvaccinated, in a South Dakota outbreak that started with an unvaccinated adult traveling to India.
Five cases in Clallam County, Washington, including four who were not vaccinated, which cost at least $36,000 to contain and led to the death of an immunosuppressed woman.
In addition to these large outbreaks, 2015 also saw a number of quarantines for unvaccinated students, closing of daycare centers, and a recommendation from a California Department of Health state epidemiologist that people who are not vaccinated against measles “avoid visiting Disney” and “crowded places with a high concentration of international travelers, such as airports.”
Other measles cases in 2015 include:
A student at UC Berkeley who may have exposed others to measles on a public bus.
A confirmed case in Fairbanks, Alaska – their first case in 15 years, who flew in from Seattle (and is probably the King County case discussed below) and may have exposed others at an area Walmart, Home Depot, Walgreens, several supermarkets, the airport, and hospital, etc.
A confirmed case in King County, Washington, who may have exposed others in Seattle, including at an area McDonalds, the Baroness Hotel, a drug store, and the Sea-Tac Airport.
A confirmed case in Branson, Missouri, a traveler from Asia, who was contagious when visiting the ER, three local businesses, and perhaps his flight to town.
A confirmed case in the Washington D.C. area.
Another case of measles in Spokane County, Washington – an unvaccinated person that was exposed to the other case in the area.
An unvaccinated student from Europe in Boston, Massachusetts who also traveled to Maine and New Hampshire.
Another unvaccinated child in St. Lucie County, Florida – bringing the total to five cases in central Florida in what so far looks like two separate outbreaks.
Another case in Indian River County, Florida – an unvaccinated child.
An unvaccinated adult in Spokane, Washington – the first case in the area since 1994.
Two unvaccinated adults in Indian River County, Florida, one of whom contracted measles while traveling out of the country.
An unvaccinated 6-year-old in St. Lucie County, Florida who attended Fairlawn Elementary School in Fort Pierce – leading to five unvaccinated students being kept out of school until early May.
The first case in Oklahoma since 1997, a case in Stillwater.
A case in Florida, a traveler who was contagious while attending a conference at the Gaylord Palms Resort and Convention Center and also in Maimi-Dade, Orange, and Sarasota counties.
A new case in Illinois, the 15th – and so far not linked to the other two outbreaks in the state.
A student at Princeton University in New Jersey.
Another case of measles in the Washington D.C. area, a case without a known source.
A case in a student at Elgin Community College in Kane County, Illinois.
A hospitalized infant in Atlanta, Georgia.
An unvaccinated 1 year old in Jersey City, New Jersey.
A traveler in King County, Washington that may have exposed others in Seattle. The unvaccinated visitor is from Brazil, where there was a large outbreak of measles last year (almost 400 cases).
At least one more case in Clark County, Nevada and four more possible cases in Southern and Northern Nevada, which led to the quarantine of at least 11 students at the Spanish Springs Elementary School.
A case in Franklin County, Pennsylvania.
Four cases of measles in travelers, including two international travelers, who visited Florida.
A case in Washington D.C.
A student at Bard College in Dutchess County, New York, who exposed many people while traveling on an Amtrak train to Penn Station in New York City.
An unvaccinated woman in New Castle County, Delaware who had recently traveled out of the country.
A case on the University of Minnesota Twin Cities campus in a student that had recently returned from out of the country. Although others were exposed, it is considered to be a “highly immunized” population, so hopefully the outbreak won’t spread.
Two more cases in Arizona that are tied to the Disneyland outbreak, including a woman in Phoenix who may have exposed others up to 195 children at the Phoenix Children’s East Valley Center, including a 3-year-old getting chemotherapy for leukemia.
An adult in Cook County, Illinois which in not linked to Disneyland.
A student at Valley High School in Las Vegas which led to the quarantine of 36 unvaccinated students until early February.
Four cases among an unvaccinated family in Kearny, Arizona that is directly linked to the Disneyland outbreak.
A child in Sioux Falls, South Dakota that is unrelated to 13 recent cases in the area and which has no link to travel out of the area.
A new case in Oakland County, Michigan that is likely linked to the Disneyland measles outbreak, meaning that the outbreak has now spread to include 7 states and 2 countries.
A case in Maricopa County, Arizona has been linked to the Disneyland outbreak.
A person in Nebraska who could have exposed others in Omaha and Blair, including at the Omaha Children’s Museum.
A case in Lane County, Oregon that has been linked to the Disneyland measles outbreak.
A resident of Tarrant County in North Texas who developed measles after a trip to India.
Another unvaccinated person in Utah with links to the Disneyland outbreak has tested positive for measles, bringing the total in that state to 3 cases.
In addition to the 36 measles cases that have been associated with the Disneyland outbreak, California already has 5 additional measles cases this year with no link to Disney, including cases in Alameda, Orange, and Ventura Counties.