ITP is an abbreviation for idiopathic thrombocytopenic purpura.
It is a condition in which our platelets get destroyed, leading to excessive bruising and bleeding, since platelets are needed for normal blood clotting.
What Causes ITP?
To understand what causes ITP, it is important to know it is also often referred to as immune thrombocytopenic purpura, because it is typically the cells of our own immune system that destroys our platelets.
Why?
Well, that’s where the idiopathic part comes in.
We don’t know why people develop ITP, although classically, ITP is thought to follow a viral infection, including Epstein-Barr virus (mono), influenza, measles, mumps, rubella, and varicella (chicken pox). ITP has also been associated with many other viral infections, from Dengue fever to Zika.
“Often, the child may have had a virus or viral infection approximately three weeks before developing ITP. It is believed that the body’s immune system, when making antibodies to fight against a virus, “accidentally” also made an antibody that can stick to the platelet cells. The body recognizes any cells with antibodies as foreign cells and destroys them. Doctors think that in people who have ITP, platelets are being destroyed because they have antibodies.”
These children with ITP, usually under age 5 years, develop symptoms a few days to weeks after their viral infections. Fortunately, their platelet counts usually return to normal, even without treatment, within about 2 weeks to 6 months. Treatments are available if a child’s platelet count gets too low though.
Can Vaccines Cause ITP?
The measles vaccine is the only vaccine that has been clearly associated with ITP.
“The available data clearly indicate that ITP is very rare and the only vaccine for which there is a demonstrated cause-effect relationship is the measles, mumps and rubella (MMR) vaccine that can occur in 1 to 3 children every 100,000 vaccine doses.”
Cecinati on Vaccine administration and the development of immune thrombocytopenic purpura in children
Even then though, the risk of ITP after a measles containing vaccine, like MMR or ProQuad, is much less than after getting a natural measles infection, so worry about ITP is a not a good reason to skip or delay getting vaccinated.
What about other vaccines?
There is no good evidence that other vaccines, including the chicken pox vaccine, DTaP, hepatitis B vaccine, or flu vaccine, etc., cause ITP.
What about Gardasil? ITP is listed in the package insert as an adverse reaction for Gardasil, but only in the postmarketing experience section, so it does not mean that the vaccine actually caused the reaction, just that someone reported it.
Although ITP is listed in the PI for Gardasil, studies have shown that there is no association.
Several large studies have actually been done that found no increased risk for ITP after getting vaccinated with Gardasil.
What to Know About Vaccines and ITP
Although measles containing vaccines can rarely cause ITP, vaccines prevent many more diseases that can cause ITP.
We have come a long way since the development of the first measles vaccines in the early 1960s…
Pre-Vaccine Era Measles Outbreaks
Unvaccinated children exposed to measles are quarantined for at least 21 days.
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
Measles cases usually begin increasing in April and May. How many cases will we see this year?
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
An infant hospitalized during a measles outbreak in the Philippines in which 110 people died. Photo by Jim Goodson, M.P.H.
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 infant in Suffolk County, New York who had been overseas
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.
a young child in Macomb Count, Michigan who required hospitalized and has been linked to international travel
a suspected case at William Allen White Elementary School in Lyon County, Kansas which has led to the quarantine of unvaccinated students for 3 weeks
an unvaccinated student at Laguna Beach High in Orange County, California, which led to the quarantine of at least 6 unvaccinated students
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 teen visiting the United States from India who developed measles and exposed others at a hotel and a hospital in Bergen County, New Jersey and in upstate New York.
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:
83 cases
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.
Although the endemic spread of measles was eliminated way back in 2000, we still have measles outbreaks in the United States.
How does that work?
They are usually imported from outside the country, often by an unvaccinated child or adult who travels overseas, gets measles, and returns while still contagious.
How Contagious is Measles?
Measles is highly contagious.
“Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also become infected.”
CDC on Transmission of Measles
In addition to the fact that people with measles are contagious for at least four days before they develop the classic measles rash until four days after, the measles virus can survive for up to two hours in the air and on contaminated surfaces wherever that person cough or sneezed. So you don’t technically need to even be in direct contact with the person with measles – simply entering a room or getting on a bus that the infected person recently left can do it.
An infant hospitalized during a measles outbreak in the Philippines in which 110 people died. Photo by Jim Goodson, M.P.H.
Still, you are not going to get measles from simply being in the same city as someone else with measles.
The tricky part though, is knowing what to do if your child is exposed to someone with measles, even if you think they are up-to-date with their vaccines.
Remember, kids get their first dose of MMR when they are 12 to 15 months old. While the second dose of MMR isn’t typically given until just before kids start kindergarten, when they are 4 to 6 years old, it can be given earlier. In fact, it can be given anytime after your child’s first birthday, as long as 28 days have passed since their first dose.
“Evidence of adequate vaccination for school-aged children, college students, and students in other postsecondary educational institutions who are at risk for exposure and infection during measles and mumps outbreaks consists of 2 doses of measles- or mumps-containing vaccine separated by at least 28 days, respectively. If the outbreak affects preschool-aged children or adults with community-wide transmission, a second dose should be considered for children aged 1 through 4 years or adults who have received 1 dose. In addition, during measles outbreaks involving infants aged <12 months with ongoing risk for exposure, infants aged ≥6 months can be vaccinated.”
CDC on Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices
And although it won’t count as their first dose, in special situations, kids can get an early MMR once they are six months old.
What to Do If Your Unvaccinated Child Is Exposed to Measles
To be considered fully vaccinated and protected against measles, kids need two doses of MMR – one at 12 to 15 months and another when they are 4 to 6 years.
“During measles, rubella, or mumps outbreaks, efforts should be made to ensure that all persons at risk for exposure and infection are vaccinated or have other acceptable evidence of immunity.”
CDC on Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices
If your unvaccinated child is exposed to measles, you should talk to your pediatrician or local health department about starting post-exposure prophylaxis as soon as possible, including:
a dose of immune globulin (IGIM) if they are less than 6 months old
either a dose of immune globulin (IGIM) or the MMR vaccine if they are between 6 and 12 months old (this dose of MMR doesn’t count as the first dose of MMR on the immunization schedule and will need to be repeated when the child turns 12 months old)
a dose of the MMR vaccine if they are at least 12 months old
a dose of immune globulin (IGIV) if they are severely immunocompromised (even if they were previously vaccinated)
Immune globulin should be given within 6 days of exposure, while a dose of MMR vaccine within 72 hours of exposure can decrease their chances of getting measles.
“Persons who continue to be exempted from or who refuse measles vaccination should be excluded from the school, child care, or other institutions until 21 days after rash onset in the last case of measles.”
Manual for the Surveillance of Vaccine-Preventable Diseases
Be sure to alert your pediatrician if you think your child might have measles or another vaccine-preventable disease.
What if your child is incompletely vaccinated, with just one dose of MMR? They could get their second dose of MMR, as long as they are over 12 months old and it has been at least 28 days since their first dose (see below).
Unvaccinated kids who don’t get post-exposure prophylaxis should be quarantined, as you watch for signs and symptoms of measles developing over the next 21 days. Your child might still need to be quarantined if they got immune globulin instead of the vaccine, and the quarantine might extend to 28 days, as immune globulin can prolong the incubation period.
If your exposed child develops measles, be sure to call your health care provider before going in for a visit, so that they can be prepared to see you and so you don’t expose other people to measles. Your child with suspected measles should be wearing a mask before going out in public and if possible, will be put in a negative pressure room in the emergency room or doctor’s office. If a regular exam room is used, it can not be used again for at least two hours. It is very important to understand that simply wearing a mask doesn’t eliminate the risk that your child with measles could expose others, it just reduces the risk. You still want to avoid other people!
What to Do If Your Vaccinated Child Is Exposed to Measles
If your fully vaccinated child is exposed to measles, does that mean you are in the clear?
Again, it depends on what you mean by fully vaccinated.
Is your child fully vaccinated for his age or has he had two doses of MMR?
Since kids get their first dose of MMR at 12 to 15 months and the second when they are 4 to 6 years old, it is easy to see that many infants, toddlers and preschoolers who are following the immunization schedule are not going to be fully vaccinated against measles, even if they are not skipping or delaying any vaccines.
“In the case of a local outbreak, you also might consider vaccinating children age 12 months and older at the minimum age (12 months, instead of 12 through 15 months) and giving the second dose 4 weeks later (at the minimum interval) instead of waiting until age 4 through 6 years.”
Ask the Experts about MMR
In some cases, documentation of age-appropriate vaccination with at least one dose of MMR is good enough protection, which means that toddlers and preschoolers don’t necessarily need an early second dose. That’s because the focus in controlling an outbreak is often on those folks who don’t have any evidence of immunity – the unvaccinated.
And one dose of MMR is about 95% effective at preventing measles infections. A second dose does increase the vaccine’s effectiveness against measles to over 99%, but it isn’t a booster. The second dose of MMR is for those kids that didn’t respond to the first dose.
“Available data suggest that measles vaccine, if given within 72 hours of measles exposure to susceptible individuals, will provide protection or disease modification in some cases. Measles vaccine should be considered in all exposed individuals who are vaccine-eligible and who have not been vaccinated or have received only 1 dose of vaccine.”
AAP RedBook
An early second dose is a good idea though if your child is exposed to measles, has only had one dose of MMR, and is age-eligible for the second dose (over age 12 months and at least 28 days since the first dose). Your child would eventually get this second dose anyway. Unlike the early dose before 12 months, this early dose will count as the second dose of MMR on the immunization schedule.
You should still watch for signs and symptoms of measles over the next 10 to 21 days though, as no vaccine is 100% effective. Your vaccinated child won’t need to be quarantined though.
Most importantly, in addition to understanding that vaccines are safe and necessary, know that the ultimate guidance and rules for what happens when a child is exposed to measles will depend on your local or state health department.
What to Know About Getting Exposed to Measles
Talk to your pediatrician if your child gets exposed to measles to make sure he doesn’t need post-exposure prophylaxis to keep him from getting sick, even if you think he is up-to-date on his vaccines.
Unfortunately, we hear news reports about measles outbreaks a lot more than we should.
We don’t get much information in many of those news reports though…
Anatomy of a Measles Outbreak Report
The big reason we don’t get a lot of information in those news reports is that many of them are simply repeating health department press releases.
A news release from the Texas Department of State Health Services.
Those press releases often leave a lot of important information out though.
Although that information might not be available yet, if you are a journalist covering a measles outbreak, instead of simply repeating the health department news release, you might call the local or state health department and ask a few questions:
Where did the person get measles? Most cases these days are imported – an unvaccinated person travels out of the country and returns home with measles, starting an outbreak. If they didn’t recently travel out of the country, then there’s a problem – where did they get measles? Unless there is already an ongoing outbreak in the area, then that means someone else in the area has measles that we don’t know about.
Where did the person go while they were still contagious and might have exposed others?
Hold old are they and were they vaccinated?
Do we have a right to this information? While the Health Insurance Portability and Accountability Act (HIPAA) protects a person’s medical information, those rules don’t necessarily always apply in an emergency or outbreak situation. Plus, you are still getting de-identified information.
“Health care providers may share patient information with anyone as necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.”
HHS on HIPAA Privacy in Emergency Situations
How is knowing someone’s vaccination status going to be helpful? Unvaccinated folks tend to cluster together, so knowing the person is unvaccinated, especially an unvaccinated child, might indicate that many more people have been exposed. But then, most measles outbreaks are started by someone who is unvaccinated…
Important Points for Covering Measles Outbreaks
The symptoms of measles include a high fever, cough, runny nose, and red, watery eyes. The rash doesn’t start until 3-5 days later, as the fever continues. Photo by Jim Goodson, M.P.H.
In addition of covering the basics about the person with measles, there are other important points to cover, especially that measles is a vaccine-preventable disease!
Two doses of the MMR vaccine offers great protection against measles, and is especially important if you are unvaccinated and are going to travel out of the country. Even infants as young as six months old should get an MMR before international travel.
While most people hopefully know all that, they may not know:
the number of measles cases in your area and in your state over the past few years
that measles is very costly to contain
that the incubation period for measles is 10 to 21 days after you were exposed, so it can take that long before you show symptoms
that they should warn their doctor or hospital before getting evaluated so that they can make sure you don’t expose other people, as measles is very, very contagious
that the quarantine period for unvaccinated people who have been exposed to someone with measles is typically up to 21 days after their last possible contact
that a dose of MMR within three days of exposure can help prevent your child from getting measles if they aren’t already fully vaccinated
Vaccine preventable diseases are just a plane ride away.
You should avoid also false balance in your reporting.
You should fully cover each outbreak in your area, as they help remind people to get vaccinated and protected.
What to Know About Reporting on Measles Outbreaks
Journalists can help reduce the size of measles outbreaks with good reporting that vaccines work and that they are safe and necessary and by reminding folks to get vaccinated and protected.
More on Recommendations for Reporting on Measles Outbreaks
petechia and/or purpura – caused by temporary thrombocytopenia (low platelet count) in about one out of every 30,000 to 40,000 doses of vaccine given
And then there is the rash that up to 5% or people get about 7 to 10 days after their dose of MMR – a mild vaccine reaction that goes away on its own without treatment.
Most importantly, the presence of this measles-like rash does not mean that your child has actually gotten measles from the vaccine.
How do we know?
For one thing, the MMR vaccine is made with an attenuated or weakened form of the measles virus, so it can’t actually cause full-blown measles, unless maybe a child has a severe immune system problem.
Also, there is no viremia after vaccination.
“There are no reports of isolation of vaccine virus from blood in normal humans.”
Plotkin’s Vaccines
It is also important to note that “person-to-person transmission of vaccine virus has never been documented.”
And kids who get a rash after their MMR vaccine are not considered to be contagious. At most, you would expect them to shed the weakened vaccine virus, but they don’t.
What’s causing this measles-like rash then?
Like the fever, it is thought to be a delayed immune response to the live, attenuated virus in the vaccine.
When the Rash Really is Measles
Are there any situations in which a child gets a rash after their MMR vaccine and it could really be measles?
Sure.
An infant with wild type measles hospitalized during a measles outbreak in the Philippines in which 110 people died. Photo by Jim Goodson, M.P.H.
Your child could have been exposed to wild type measles right around the time they got vaccinated, and then went on to develop regular measles.
While getting a measles vaccine within 72 hours of exposure (post-exposure prophylaxis) can reduce your chance of getting measles, it isn’t a perfect strategy.
Or your child could have been vaccinated and been one of the few people for whom the vaccine failed to work. So their rash, again, would be from a wild type strain of measles that they were exposed to and not from the shot.
Can you tell the difference if someone has measles from the vaccine or from a wild type strain?
Sure.
“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
You just have to test the measles strain to see if it is the wild type virus or a vaccine strain.
Does It Matter If It Is the MMR Vaccine or Measles?
About now, you are probably wondering why it matters knowing if a child’s rash is caused by measles or the MMR vaccine, right?
For one thing, if a parent thinks a vaccine gave their child measles, then they might not want to get vaccinated again. They will especially think twice about getting another MMR.
Also, if a child really does have full-blown, wild type measles and you simply blame their MMR vaccine, then you might miss someone else in the community that exposed the child to measles. And that’s why some outbreaks are hard to stop.
Lastly, if you simply blame the vaccine, you might miss something else that is causing the child to be sick.
Need an example?
During the 2010 measles outbreaks in Canada, a 15-month-old develop a rash, fever, and other symptoms 12 days after getting their MMR vaccine. Did the have measles, a vaccine reaction, or something else?
Turns out that he had scarlet fever.
The child tested positive for Streptococcus pyogenes (group A streptococcus), the bacteria that causes strep throat and scarlet fever. He also tested positive for vaccine strain measles. He did not have the wild strain of measles, and in fact, did not have measles at all.
Again, he had scarlet fever and it was just a coincidence that he had recently received an MMR vaccine.
But isn’t there another case report from Canada that does prove that you can get full-blown measles from the MMR vaccine? While there is such a case report, it is hardly proof of anything.
“It is possible that the case’s symptoms were not measles-vaccine-related but an inter-current illness confounding the presentation.”
Murti et al on Case of vaccine-associated measles five weeks post-immunisation, British Columbia, Canada, October 2013
The problem with the case?
For one thing, the child already had high levels of IgG antibodies at the time he had the rash, which developed 37 days after he got his vaccine.
“The two-fold rise between acute and convalescent measles-specific IgG suggests the vaccine-mediated immune response had been underway prior to the onset of symptoms.”
Murti et al on Case of vaccine-associated measles five weeks post-immunisation, British Columbia, Canada, October 2013
This was neither a typical reaction nor a typical case. And it very well might not have been measles. If it was, it was a very rare exception to the rule that rashes after the MMR vaccine aren’t full-blown measles.
What to Know About Rashes After the MMR Vaccine
The rash that your child can get after their MMR vaccine is not a sign that they have developed full-blown measles, instead, it is a mild vaccine reaction that will quickly go away without any treatment.
We know that vaccines are safe, even if they can have some side effects and risks.
And we know that vaccines work, even if they don’t work 100% of the time.
In fact, vaccines work so well, that they have eliminated or controlled many of the vaccine-preventable diseases that we still get vaccinated against.
Are Vaccines Still Necessary?
So that leaves some people asking themselves – even if the benefits of vaccines far outweigh their risks, are vaccines still necessary?
“So what I did on my schedule is, I took a more logical look at hepatitis B, and I realized that babies have no risk of catching this disease, so let’s not do the hep B vaccine while a baby’s young and small and more vulnerable.”
Dr. Robert W. Sears on Why Partial Vaccinations May Be an Answer
After all, most of us don’t travel to developing countries or do other things to put ourselves or our kids at risk of getting a vaccine-preventable disease, right?
And we probably don’t have conditions that put us at high risk of getting sick either?
So isn’t it safe to just skip or delay many of the shots on the routine immunization schedule?
Shouldn’t some of them just be optional now?
Vaccines Are Necessary
Alternative vaccine schedules? Optional vaccines? No risk of getting diseases? Those are the arguments you will see on many anti-vaccine websites and forums, but they certainly aren’t logical arguments.
“The reason I delay the polio vaccine on my alternative schedule is that we don’t have polio in the United States. We haven’t had it here for over 30 years. We’ve been very fortunate because the vaccination program for polio has been so successful, now we’re reaping the rewards of not having to worry about this disease.”
Dr. Robert W. Sears on Why Partial Vaccinations May Be an Answer
Did you know that an unvaccinated group of Amish children got infected with polio in 2005?
Or that an otherwise healthy, unvaccinated 22-year-old U.S. resident became infected with polio vaccine virus, developing paralytic polio, while traveling in Costa Rica in a university-sponsored study-abroad program in 2005? It turns out that the granddaughter of the host family that she was staying with lived next door and had recently been vaccinated with the OPV vaccine, which does shed, and in this case caused her to develop vaccine-associated paralytic polio.
And did you know that there was a lethal case of vaccine-derived poliomelitis in Minnesota in 2009?
Apparently Dr. Bob didn’t either.
“We know that a disease that is apparently under control can suddenly return, because we have seen it happen, in countries like Japan, Australia, and Sweden. Here is an example from Japan. In 1974, about 80% of Japanese children were getting pertussis (whooping cough) vaccine. That year there were only 393 cases of whooping cough in the entire country, and not a single pertussis-related death. Then immunization rates began to drop, until only about 10% of children were being vaccinated. In 1979, more than 13,000 people got whooping cough and 41 died. When routine vaccination was resumed, the disease numbers dropped again.”
CDC on What Would Happen If We Stopped Vaccinations?
But while polio is now on the brink of elimination, most other vaccine-preventable diseases are not. And that is why we see outbreaks any time vaccination rates drop:
measles – in addition to the outbreaks in the United States, there have been much bigger outbreaks across Europe, with much deadlier consequences
pertussis – yes, some of our pertussis outbreaks are because of waning immunity and occur in fully vaccinated children, but there were even larger outbreaks in Japan, Sweden, Italy, Ireland, Australia, and other countries in the 1970s and 1980s when immunization rates dropped, cases soared, and children died.
diphtheria – few people even know what diphtheria is anymore, but it is still around and causes outbreaks when immunization rates drop.
rubella – want to know what happens when you don’t vaccinate for rubella? just look at Japan – they had 14,357 cases of rubella and at least 31 cases of congenital rubella syndrome in 2013.
Hib – a 2008 outbreak in Minnesota during a temporary vaccine shortage likely reflected “increasing carriage and transmission affecting those with suboptimal primary series vaccination coverage, or a weakening of herd immunity”
tetanus – although tetanus isn’t contagious, we are seeing more cases in kids and pregnant women who aren’t vaccinated, as the bacteria which causes tetanus is present in spores in dirt and dust almost everywhere
polio – although polio is now endemic in only three countries, Afghanistan, Nigeria, and Pakistan, there are other countries where outbreaks can still occur, including the DR Congo and Syrian Arab Republic and many other high risk countries. This includes outbreaks of circulating vaccine derived polio virus, which increased this year in non-endemic countries, especially Syria because of years of poor immunization rates because of war.
Vaccines are necessary to avoid these kinds of outbreaks.
What Happens When We Don’t Vaccinate?
It should be very clear that everyone can’t try to hide in the herd.
We know what happens when too many people don’t vaccinate their kids.
At least those of us who understand herd immunity know what happens…
In Ukraine, for example, there was a “massive epidemic” of diphtheria and other vaccine-preventable diseases in the Newly Independent States of the former Soviet Union in the early 1990s.
“This epidemic, primarily affecting adults in most Newly Independent States of the former Soviet Union, demonstrates that in a modern society diphtheria can still spread explosively and cause extensive illness and death.”
Diphtheria in the Former Soviet Union: Reemergence of a Pandemic Disease
In Ukraine alone, there were 17,387 cases of diphtheria and 646 deaths from 1992 to 1997. Also high, were cases of measles (over 23,000 cases in 1993) and pertussis (almost 7,000 cases in 1993).
Vaccine preventable diseases are just a plane ride away.
Need a more recent example?
Just look at the tragedy unfolding in Venezuela. In addition to all of the hardships the people are facing, because of a weakened health system, poor surveillance, and a lack of preventative measures, including immunizations, they are seeing a rebound of diphtheria, measles, and other infectious diseases.
After being eliminated in 1992, there have been at least 450 cases of diphtheria in Venezuela since 2016 and at least 7 deaths.
Vaccines are necessary.
Vaccine-preventable diseases will come back if we stop vaccinating our kids.
And tragically, they aren’t yet gone in many parts of the world, even those that are well controlled in more developed countries. That’s why we often say that these diseases are ‘just a plane ride away.’
Just remember that the planes travel both ways. It isn’t just you traveling to high risk areas. Sometimes folks who are sick with vaccine preventable diseases bring them home and start outbreaks.
Sure, there are the folks who think that all vaccine preventable diseases are so mild that they wouldn’t kill you unless you lived in a Third World country.
The Myth That Measles Isn’t Deadly
But there are also folks, usually the same folks, who think that the measles virus doesn’t actually kill you – it is instead the complications that are deadly.
For most people, that’s a distinction without a difference.
“The acute pathological effects of measles include the destruction of respiratory epithelium and depression of cellular immunity. These effects interact to transiently increase measles-infected hosts’ susceptibility to respiratory bacterial strains to which they are not immune.”
Measles epidemics of variable lethality in the early 20th century.
After all, if you have measles and die, you probably don’t care if you died because of:
viral pneumonia
a secondary bacterial pneumonia
acute respiratory distress syndrome (ARDS)
acute measles encephalitis (swelling of the brain)
Subacute sclerosing panencephalitis (SSPE) – a late complication of natural measles infections
In the pre-vaccine era, before the early 1960s, about 400 to 500 people would die each year from measles and these complications.
But didn’t they all have underlying medical problems – another measles myth?
No they didn’t. One study of measles deaths in the 1960s found that only about 17% of the people who died with measles as the cause of death had an underlying disease.
And we now know that having a natural measles infection lowers your immunity and puts you at risk of dying from something else, even after you have recovered from your measles infection. That’s why mortality rates go down so much more than expected after measles vaccine programs are introduced in an area.
Measles Is Still Not Marvelous
Although the first measles vaccine was licensed in 1963, an improved version wasn’t available until 1968.
While it is true that people rarely die of measles in the United States and other developed countries anymore, that’s just because most people are vaccinated and really big outbreaks aren’t that common, especially since the endemic spread of measles was eliminated in 2000.
You don’t have to go back to the pre-vaccine era to remember how measles kills though.
Measles is still deadly, even in this era of modern medicine, good nutrition, and clean water. Not that people in the United States didn’t eat well and have access to indoor plumbing in the 1950s, but medical care has improved.
People can still die when they get measles though.
Consider that at least 123 people died in the United States during the large measles epidemics from 1989 to 1991. Another 11,000 were hospitalized, among only about 55,000 cases.
a pregnant woman with measles was hospitalized and had a miscarriage (2013 measles outbreak in Brooklyn)
an immunocompromised woman died of pneumonia due to measles (2015 measles outbreak in Clallam County, Washington)
There have been other measles deaths and complications of these preventable infections.
Ending with 667 cases, 2014 became the worst year for measles in the United States since 1994.
Although before the Clallam County death, the CDC would say that “the last verifiable death in the United States from acute measles infection occurred in 2003 when there were 2 reported deaths,” death certificates had been filed in 2005, 2009 (2), 2010 (2), and 2012 (2) which listed measles as a cause of death code. These measles deaths are listed in the CDC “Summary of Notifiable Diseases — United States, 2012,” and in the CDC Wonder Compressed Mortality Files Underlying Cause-of-Death database.
Again, that there aren’t more simply reflects that most people are vaccinated.
But when we start seeing more and more cases of measles, more and more people will start to die. Just look at the outbreaks in Europe right now…
We also shouldn’t forget that worldwide, even after a 79% drop in measles deaths just since 2000, there were still 134,200 measles deaths in 2015, about 367 deaths a day.
What To Know About The Myth That Measles Isn’t Deadly
Not only are measles infections deadly, usually from pneumonia and encephalitis, but a natural measles infection can also cause years of immunosuppression, increasing your risk of death from other diseases too.
