Tag: measles symptoms

How Could Seven of My Vaccinated Kids Have the Measles Right Now?

Seven vaccinated kids with measles?!?

But doesn’t the measles rash typically show up after three to five days of fever?

Wait, that couldn’t really happen, could it? Seven vaccinated kids with measles in one family?

How Could Seven of My Vaccinated Kids Have the Measles Right Now?

While anything is possible, this story is very improbable once you look at the details…

“When her 12-year-old son spiked a fever and started complaining of a sore throat right before Passover, Mrs. Pearl (not her real name) wasn’t worried. She confidently crossed off a host of possible infections that he was fully vaccinated for.
She thought he had strep throat, like two of his siblings.
They headed to urgent care for a rapid strep test, but the result was negative. Undeterred, she put her son on antibiotics at the nurse’s recommendation, and sent her son to bed.
He’d worsened by morning.
He woke feeling feverish and broken out in a rash.”
Jennifer Margulis

Could that be measles?

He ended up testing positive for measles, even though he was fully vaccinated. Only two days of fever before he developed his rash though, and no word that the fever continued, as you would expect with measles…

“Not long after, Mrs. Pearl’s 10-year-old broke out in a similar rash.
This child didn’t spike a fever but his breathing was labored and he complained that his eyes hurt.
He also tested positive for the measles.”
Jennifer Margulis

Although they all could have been exposed to someone else, it is important to note that the incubation period for measles is 7 to 14 days. The “not long after” scenario sounds like too short a time to get “measles” from his brother. Also, no fever, which would be very strange for measles…

But the other five kids had more classic symptoms of measles, right?

Nope.

“Of the seven other children that Mrs. Pearl had tested—all of whom had been fully vaccinated—five more showed no immunity to measles.”
Jennifer Margulis

What about the negative titer tests?

That’s actually not unusual after measles vaccination. It’s not proof or any kind of indication that the vaccine didn’t work. It has been long known that most vaccinated people who have negative measles titers will show an anamnestic immune response if they get another dose of MMR.

What does that mean? It means that they were likely immune, even with the negative titer.

“In the event that a HCP who has 2 documented doses of MMR vaccine is tested serologically and determined to have negative or equivocal measles titer results, it is not recommended that the person receive an additional dose of MMR vaccine. Such persons should be considered to have presumptive evidence of measles immunity. Documented age-appropriate vaccination supersedes the results of subsequent serologic testing.”
Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices

In fact, we don’t routinely check titers after MMR, at least not for measles.

And their symptoms?

“Two hours after getting the MMR booster, Mrs. Pearl’s 16-year-old spiked a 102-degree fever and broke out in a measles rash.
Four days later her three other children, all of whom had received the MMR booster, all had measles rashes, canker sores in their mouths, gastrointestinal problems, and lethargy.”
Jennifer Margulis

Canker sores with measles? Kids with measles get Koplik spots, but no one describes them as canker sores.

Fever and a rash developing at the same time?

Yeah, none of that sounds like measles. At all.

Remember, the classic symptoms of measles include 3 to 5 days of a high fever with cough, coryza, and conjunctivitis, followed by a rash, with continued fever.

“According to Mrs. Pearl, the health department official also told her that measles vaccine failure is common and that about half the people getting measles in the current measles clusters in Brooklyn are fully vaccinated.”
Jennifer Margulis

Actually, only 27 of the 566 people in Brooklyn with measles have been known to be fully vaccinated, with two doses of MMR. How much less than half is that? It is less than 5% of cases.

Measles vaccine failure is not common at all.

Why Did They Say That Seven of My Vaccinated Kids Have Measles?

So how do you explain what happened to this family?

Besides the likelihood that they had another, more common virus causing their symptoms? With mouth ulcers and diarrhea, like maybe Coxsackie virus?

Do you really need another explanation?

How do you explain the positive measles tests?

They were almost certainly a false positive.

“The test kits in use have been shown to have high sensitivity and specificity. However, cross-reactions with other viral diseases, e.g. rubella and Parvovirus, may occur.”
Dietz et al on The laboratory confirmation of suspected measles cases in settings of low measles transmission: conclusions from the experience in the Americas.

They didn’t state which test was done, but it is important to note that several are available. This includes an immunoglobulin test, PCR from a throat swab, and PCR from a urine specimen. The most accurate testing is done by the CDC.

“Detection of specific IgM antibodies in a serum sample collected within the first few days of rash onset can provide presumptive evidence of a current or recent measles virus infection. However, because no assay is 100% specific, serologic testing of non-measles cases using any assay will occasionally produce false positive IgM results.”
Serologic Testing for Measles in Low Prevalence Setting

Did they have confirmatory tests, after their initial positive test? Were they done at a state lab? Did all of her other kids test positive for measles?

“She’s angry at the measles vaccine failure and worried about her family members, especially her pregnant daughter.”
Jennifer Margulis

She should be angry at folks pushing misininformation in her community.

“I used to think people who don’t vaccinate were crazy,” Mrs. Pearl says. “Now I’m not so sure. Maybe they’re right. Maybe my body doesn’t want to take garbage. Something is a red flag. After my story, I’m not so sure where the measles started. I’m legit. I did vaccinate. All my kids are up to date. Children ages 22 to 7 all getting the measles?”
Jennifer Margulis

Something is indeed a red flag. To get to the bottom of it, Mrs. Pearl should revisit the idea that her kids really had measles.

What Is Your Protocol to Stop Measles Before Kids in Your Office Get Exposed?

Measles outbreaks have reached record levels this year. Unless you’re prepared, with a strict protocol to stop measles, that could mean that someone could get exposed in your office.

“Many of today’s physicians may never have seen a patient with measles— a disease that can cause serious complications in infants, young children, and adults. CDC is urging all physicians to “think measles” when evaluating patients who have fever and rash, and to know what to do to prevent, control, and report measles cases.”
CDC Asking Physicians to “Think Measles” and Help Stop the Spread

Have you ever seen a child with measles?

What Is Your Protocol to Stop Measles Before Kids in Your Office Get Exposed?

To help everyone understand how important it is to think about measles and prevent unnecessary exposures, it can help to understand what happens when a child with measles does go to their pediatrician, an urgent care center, or the ER.

Part of your protocol to stop measles will be making sure th unvaccinated children exposed to measles are quarantined for at least 21 days. — Unvaccinated children exposed to measles are quarantined for at least 21 days.

Since measles is so contagious and can remain infectious for up to two hours after a person has left a room, with each measles case, you will have to:

isolate the person with measles (or suspected measles) in a negative pressure isolation room. If that’s not possible, at least have the person wear a mask in their own private room and/or schedule them at the end of the day, bypassing the waiting room. You might even go out to their car for a quick interview and exam before they come into the office.
not use that exam room for at least two hours after the person with measles leaves.
report the case to your local health department ASAP, as they will likely have more extra resources to help you manage your patient.
locate everyone who could have been exposed, including anyone who was in the same area as the suspected case or entered the area over the next two hours. If they aren’t already immune, these folks might need immune globulin (younger than six months or immunocompromised) or a dose of MMR. They will probably also be quarantined to make sure they don’t develop measles and expose others.
only allow those who are immune to measles (two doses of MMR or natural immunity) to take care of the suspected case. Everyone should still wear an N95 respirator or at the very least, a general facemask, just in case.
limit anyone else’s exposure as you work to confirm that they have measles (PCR testing of throat swab and urine), provide supportive care as necessary, or quarantine them at home.

Unfortunately, it usually ends up being more than a single exam room that has to be closed when a child shows up with measles. After all, before they got to that exam room, they were probably in the waiting room and other general areas of the office.

And that’s why you will want to have a protocol in place to avoid or minimize these exposures.

Don’t Spread Measles

Of course, that starts with trying to get everyone vaccinated and protected, including an early dose of MMR when appropriate, so that your patients don’t get measles in the first place!

“Failure to promptly identify and appropriately isolate measles cases has led to the investigation of hundreds of healthcare contacts this year. Measles transmission has occurred in emergency departments and other healthcare settings, including transmission to one healthcare worker.”
Recommendations for Measles Case Identification, Measles Infection Control, and Measles Case and Contact Investigations

Next, make sure everyone understands how to recognize the signs and symptoms of measles. Otherwise, some of these kids might unexpectedly end up in your office when they are sick.

The classic measles rash, which begins on the face, typically doesn't begin until these kids have had fever for two or three days. — The classic measles rash, which begins on the face, typically doesn’t begin until these kids have had fever for two or three days. Photo by Jim Goodson, M.P.H.

Think that’s easy? You just watch out for kids with a fever and a rash, right?

Wrong.

If you wait until they have the classic measles rash, you will likely miss the diagnosis the first time they come to your office. Remember, the rash typically doesn’t show up until they have already had a fever for three or four days.

Unfortunately, these kids are contagious well before they have a rash. They are even contagious before they have a fever and know they are sick.

As part of your protocol to stop measles, post a warning sign before parents come into your office.

So you should suspect measles in kids:

with a high fever and cough, coryza, and conjunctivits, even if they don’t yet have a rash
with classic measles symptoms who have had a possible exposure. This includes kids who recently traveled out of the country (get a travel history), had contact with international travelers, or just because there are a lot of cases in your area.
who are unvaccinated or not completely vaccinated, with two doses of MMR. Keep in mind that even fully vaccinated kids can sometimes get measles though.

And then, if you suspect that a child has measles, work to limit their exposure to others. Patients should know to call ahead. Staff at your office, lab, or the ER should be alerted and ready to see anyone with suspected measles. That way the family knows to wear a mask before going inside.

Ideally, if you have a strong suspicion that the child has measles, this visit will occur in a facility with a negative pressure airborne infection isolation room.

What’s the problem with this kind of protocol?

Lots of kids have fever and rashes! And since you can’t send everyone that calls with adenovirus, roseola, or hand, foot and mouth disease to the ER, part of your protocol should likely be that a health care professional carefully assesses the child’s signs, symptoms, and risks for measles before deciding what to do.

Mostly, be suspicious if a child has returned from a trip oversees, especially if they are unvaccinated, and they have a febrile illness.

More on Your Protocol to Stop Measles Before Kids in Your Office Get Exposed

The Puget Sound Measles Outbreak

Breaking News – there is a new case in King County (see below)

Everyone is likely familiar with the large outbreaks that we have been seeing this year in New York (Brooklyn and Rockland County), Michigan, and the Pacific Northwest.

There have already been 79 cases of measles in Washington so far this year.

After all, those outbreaks make up the majority of measles cases that have occured so far this year.

The Puget Sound Measles Outbreak

Have you heard of the latest outbreak?

This one, also centered in the Pacific Northwest, began with exposures to a traveler with measles at Seattle-Tacoma International Airport on April 25.

“A Canadian resident from British Columbia who traveled to the Seattle area in late April 2019 has been diagnosed with measles. The traveler, a man in his 40s, has since recovered from his illness.
Prior to arriving in King County, he spent time in Japan and New York during the period that he was infected, two places that currently have measles outbreaks. This case has no connection to the recently-ended measles outbreak based in Clark County, Washington state.
While he was infectious with measles, he spent time in the Seattle area at several locations, including popular tourist attractions and Sea-Tac Airport. Anyone who does not have immunity to measles through vaccination or from previously having measles is at risk for infection if they were at a location of measles exposure.”
Measles case in traveler to King County

Those exposures have led to cases in:

King County – 6
Pierce County – 2
Snohomish County – 1

The latest case is a six-month old infant in King County, with exposures at the Seattle Children’s Hospital Emergency Dept on May 24.

“This case was a household contact of a person diagnosed with measles earlier this month, and was not exposed to measles in the community.”
A new case of measles diagnosed in a King County resident

With exposures in Bothell, Lynnwood, Mill Creek, Orting, Bonney Lake, Puyallup, Renton, Auburn, Issaquah, Woodinville, Kent, and Seattle.

And that’s what has led to the name Puget Sound outbreak. The Puget Sound is an inlet of the Pacific Ocean along the northwest coast of Washington, near Everett, Olympia, Seattle, and Tacoma.

How big will this outbreak get?

Immunization rates in the Puget Sound area are a bit better than in Clark County, where the last Pacific Northwest outbreak was centered.

It’s anyone’s guess at this point, keeping in mind that all it would take is for one of these exposures to be in a “pocket of susceptibles” with low immunization rates to start a big outbreak.

And all it would take to stop the outbreaks is for folks to get vaccinated and protected, understanding that vaccines are safe and necessary.

Why Have We Forgotten About the Importance of Vaccination Against Measles?

While most of us know that measles is a serious, life-threatening disease, there are still some folks that want you to think that it is nothing to worry about.

It’s just a rash and fever, right?

The Importance of Vaccination Against Measles

Actually, while most people did recover after having a high fever, irritability, and other symptoms for a week or more, some didn’t. That’s why doctors at the time called it a harmless killer.

In the pre-vaccine era, hospitalizations, tracheotomies, encephalitis, sepsis, death from measles were not rare.

And why many were looking forward to a vaccine to get measles under control, as measles was a leading killer at the time.

Seymour Musiker calls on pediatricians to take action to get more kids vaccinated against measles. — A call for pediatricians to take action to get kids vaccinated against measles.

While measles vaccination was getting off to a slow start at the time, it should be obvious that there was a big need for these vaccines.

“Thus it is up to each one of us to convince our own segment of the population since this seems to be the only way to do it. And it is up to each one of us to remind our fellow physicians to cover his segment of the population.”
Norman Lewak, MD

Fortunately, everyone did finally take action and while it was a little later than originally planned, we got measles under control.

“Vigorous endorsement and execution of this aim by physicians and responsible health authorities should eliminate measles by 1970, and a suitable motto for the five-year period might well be “Mortus a morbilli.”
Lewis L. Coriell, MD

And the endemic spread of measles was eliminated in the United States in 2000.

Of course, that doesn’t mean that we eliminated or eradicated measles. It simply means that all cases and outbreaks are linked to someone from outside the United States.

Now, as too many people are either scared or have forgotten about the importance of vaccination against measles, cases are rising, continuing to reach new record levels.

So what’s next?

“All we need is one concerted campaign to get every susceptible vaccinated. One death, one brain-damaged child, or even one child who needs hospitalization is one too many.”
Norman Lewak, MD

Let’s get everyone vaccinated and protected.

Vaccines are safe, with few risks, and they are obviously necessary.

Measles is not a mild disease. And it never was.

VAXOPEDIA

How Could Seven of My Vaccinated Kids Have the Measles Right Now?

How Could Seven of My Vaccinated Kids Have the Measles Right Now?

Why Did They Say That Seven of My Vaccinated Kids Have Measles?

More on Vaccinated Kids with Measles

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What Is Your Protocol to Stop Measles Before Kids in Your Office Get Exposed?