Can you explain why we will almost certainly have the second highest number of measles cases in one year since 1994, even though we see the devastation that high rates of measles is causing in Europe and other parts of the world?
How many people will get measles in the United States this year?
Although no one is reporting on this, with several large ongoing outbreaks still not under control – it will be another record year for measles in the United States.
And with several large outbreaks continuing overseas, next year doesn’t look like it will be much better, especially with reports of a measles resurgence in many regions of the world.
“Chickenpox (varicella) is generally a much milder illness in children than in adults, with considerably lower rates of severe disease and death. Varicella is also virtually universal in many populations, meaning that very few individuals escape infection over a lifetime. Thus, a sound logic underlies the idea of chickenpox parties, at which susceptible children can acquire the contagious causative pathogen, varicella zoster virus (VZV), from their peers. However, chickenpox is not without risks, even for children of this age; severe, complicated, and occasionally fatal varicella occur in previously healthy children, as well as the immunocompromised (who are at very considerable risk).”
Hambleton et al on Chickenpox Party or Varicella Vaccine?
Most folks understand that. They get their kids vaccinated and have helped get chicken pox under very good control, with outbreaks of chicken pox declining over 95%.
“Each year, more than 3.5 million cases of varicella, 9,000 hospitalizations, and 100 deaths are prevented by varicella vaccination in the United States”
CDC on Monitoring the Impact of Varicella Vaccination
Apparently, not everyone has gotten the message though.
Remember when CPS had to investigate the mom who was having chicken pox parties in Plano, Texas a few years ago?
“On the page, parents post where they live and ask if anyone with a child who has the chicken pox would be willing to send saliva, infected lollipops or clothing through the mail.”
CBS 5 Investigates mail order diseases
Or when anti-vaccine folks were selling and mailing lollipops contaminated with chicken pox to folks so that they could skip the trouble of finding a chicken pox party?
And then there’s that time that a family served chicken pox contaminated punch at their chicken pox party. Oh wait, that was The Simpsons…
So what are they up to now?
More of the same…
Apparently, there are still plenty of folks looking for chicken pox parties to infect their kids.
It is easy to see a lot of cognitive biases at play in the decision to host or bring a child to a chicken pox party, including ambiguity aversion (prefer what they think are the known risks of getting the disease), bandwagoning (they think everyone else is doing it, because in their echo chambers of anti-vaccine propaganda, everyone might), and optimism bias, etc.
There is also a very poor perception of risks, as the risks from a natural chicken pox infection are far, far greater than any risk from the vaccine.
In bigger news, Facebook has groups who’s mission is “finding pox,” so that parents can get their kids sick!
How many other PoX type groups are there on Facebook?
Do they understand the consequences of having these pox parties?
Of course, an investigation from CPS, the health department, or a medical board isn’t the most serious consequence that should discourage folks from hosting or attending a chicken pox party.
Chicken pox can be a serious, even life-threatening infection. Sure, many kids just get a mild case, but others get more serious cases and have bad complications, including skin infections, encephalitis, sepsis, or stroke.
And some people do still die from chicken pox, which is supposed to be a mild, childhood illness.
“This report describes a varicella death in an unvaccinated, previously healthy adolescent aged 15 years.”
Varicella Death of an Unvaccinated, Previously Healthy Adolescent — Ohio, 2009
Fortunately, these deaths have been nearly eliminated thanks to the chicken pox vaccine.
And that’s why parents who are on a mission for “finding pox” should rethink things and switch to a mission to get their kids vaccinated and protected.
News like that and folks getting exposed to other infectious diseases, probably has them wondering just how contagious these diseases are. Do you have to be sitting next to someone to get them? In the same row? On the same floor?
Understanding Your Risk of Catching a Disease
Fortunately, most diseases are not terribly contagious.
We worry about some things, like SARS and Ebola, because they are so deadly, not because they are so contagious or infectious.
Wait, contagious or infectious? Aren’t they the same thing?
To confuse matters, some infectious diseases aren’t contagious, like Lyme disease. And some vaccine-preventable diseases are neither infectious nor communicable. Think tetanus. You may have never thought of it that way, but you aren’t going to catch tetanus from another person. Of course, that’s not a good reason to skip getting a tetanus shot!
To understand your risk of getting sick, you want to understand a few terms, including:
infectious disease – a disease that can be transferred to a new host
communicable – an infectious disease that can be transferred from one host to another
non-communicable – a non-infectious disease which can not be transferred from one host to another
contagiousness – an infectious disease that is easily transferred from one person to another
infectivity – the ability of an infectious agent to cause an infection, measured as the proportion of persons exposed to an infectious agent who become infected. Although this doesn’t sound much different from contagiousness, it is. The Francisella tularensis bacteria is highly infectious, for example, to the point that folks exposed to a culture plate are given antibiotics or put on a fever watch. Few of us get tularemia though, because transmission is through tick bites, hunting or skinning infected rabbits, muskrats, prairie dogs and other rodents, or inhaling dust or aerosols contaminated with F. tularensis bacteria. So if you get exposed, you will probably get sick, but there is a low probability for getting exposed.
incubation period – the time it takes to start having symptoms after you are exposed to an infectious disease. A longer incubation period increases the chances that someone will get exposed to a disease and travel home before getting sick. A shorter incubation period, like for influenza, means that a lot of people can get sick in a short amount of time.
contagious period- the time during which you can spread the illness to other people and may start before you have any symptoms
quarantine – used to separate people who have been exposed to a contagious disease and may become sick, but aren’t sick yet
isolation – used to separate people who are already sick with a contagious disease
transmission – how the disease spreads, including direct (direct contact or droplet spread) vs indirect transmission (airborne, vehicleborne, or vectorborne)
R0 (r nought) – the basic reproductive number or the number of new infections originating from a single infectious person among a total susceptible population
Rn – the net reproductive number, which takes into account the number of susceptibles in a community
infectious period – how long you are contagious
Got all that?
How Contagious Is Measles?
If not, understanding how easily you can get measles should help you understand all of these terms.
Measles is highly contagious, with a very high R0 number of 12 to 18.
the measles virus can live for up to two hours on surfaces and in the airspace where an infected person coughed or sneezed
infected people are contagious for up to four days before they have a rash and even know that they have measles, so expose lots of people even if they get put in isolation once they get diagnosed
infected people continue to be contagious for up to four days after the rash appears, so can continue to expose people if they aren’t put in isolation
So you don’t need to have someone with measles coughing in your face to get sick. If they coughed or sneezed at the grocery store, on the bus, or at your doctor’s office and then you entered the same area within two hours, then you could be exposed to the measles virus and could get sick.
As we continue to see outbreaks of vaccine-preventable diseases in the post-vaccination era, it is important that these outbreaks be quickly contained.
But it is important to understand that these outbreaks don’t simply stop on there own. A lot of work goes into containing them.
Working to Contain an Outbreak
And that work containing outbreaks is expensive. Much more expensive than simply getting vaccinated.
For example, the total personnel time and total direct cost to the New York City Department of Health and Mental Hygiene responding to and controlling the 2013 outbreak in NYC were calculated to be at least $394,448 and 10,054 personnel hours.
Why it is so expensive is easy to see once you understand all of the work that goes into containing an outbreak. Work that is done by your local health department as soon as a case of measles, or other vaccine-preventable disease, is suspected.
Work that, for a measles outbreak for example, includes:
initiating a case and contact investigation
quickly confirming that the patient actually has measles, including testing
assessing the potential for further spread – identifying contacts who aren’t immune to measles and are at risk for getting measles
isolating people with measles and quarantining contacts who aren’t immune to measles for at least 21 days after the start of the measles rash in the last case of measles in the area, including everyone who is intentionally unvaccinated
having targeted immunization clinics in the affected population, such as a school or church, to get as many people vaccinated as possible, even after 72 hours, so they have can be protected in the future
That’s an awful lot of work.
Work that continues until the outbreak officially ends.
Finding the Source of an Outbreak
Another big part of the work that goes on to contain an outbreak is identifying the source of the outbreak.
Was it someone who had recently been traveling overseas, a visitor from out of the country, or someone that was already part of an another outbreak?
Why is that so important?
If you don’t find the source of the outbreak, then you can’t be sure that you have found all of the people that have been exposed, and the outbreak might go on for an extended period of time.
A week after returning home from the trip, he gets sick, but returns to school after a few days. He then develops a rash and sees his family physician, followed by his pediatrician, and then makes a trip to the emergency room because he continues to have a high fever and rash (classic measles symptoms).
He is eventually diagnosed with measles, but not before eleven other children are infected with measles. This includes two of his siblings, five children in his school, and four children who were exposed at his pediatrician’s office.
It is not as simple as that though.
During this measles outbreak:
Three of the children who became infected were younger than 12 months of age, and were therefore too young to have been vaccinated
Eight of the nine children who were at least 12 months old were intentionally unvaccinated because they also had personal belief vaccine exemptions
About 70 children were placed under voluntary quarantine for 21 days after their last exposure because they were exposed to one of the measles cases and either didn’t want to be vaccinated or were too young
One of the infants with measles traveled to Hawaii, raising fears that the measles outbreak could spread there too
All together, 839 people were exposed to the measles virus.
At least one of them was a 10-month-old infant who got infected at his well child checkup, was too young to have gotten the MMR vaccine yet, and ended up spending three days in the hospital – time his parents spent “fearing we might lose our baby boy.”
The parents of this 10-month-old weren’t looking for a vaccine exemption and didn’t want their child to catch measles, a life-threatening, vaccine-preventable disease. Instead, they were counting on herd immunity to protect him until their child could be protected with an MMR vaccine. They were one of “those who come into contact with them” that got caught up in a decision of some other parents to not vaccinate their child.
The kids who are at risk and get a vaccine-preventable disease because they are too young to get vaccinated, have an immune system problem that prevents them from getting immunized or their vaccine from working, and the kids who simply didn’t get protected from a vaccine are the hidden costs of these measles outbreaks that we don’t hear about often enough.
What to Know About Finding the Source of an Outbreak
Without all of the hard work that goes into containing outbreaks, the outbreaks of measles, pertussis, mumps, hepatitis A, and other vaccine preventable diseases would be even bigger.
What to most folks worry about when they go on a cruise?
That’s right. Norovirus…
While it isn’t as common as most folks think, norovirus is still often thought of as the cruise ship disease.
Measles on a Plane, Train, and a Cruise Ship
Not surprisingly, many of the same conditions that put you at risk for getting norovirus, including that it is very contagious and you are in close quarters with a lot of other people on a ship, puts you at risk for getting other diseases.
In 2014, 136 people got measles after an unvaccinated person developed measles on a cruise ship, including 28 people on the cruise.
More recently, an unvaccinated teenager exposed others to measles on a Norwegian Cruise Lines ship while visiting Alaska. It seems like the same person also exposed folks to measles on a few planes and trains too.
How did they get measles? In Thailand.
This is almost certainly the same person who arrived at Vancouver International Airport from Tokyo on an Air Canada flight (July 30), leaving for Portland on Air Canada Jazz that same day.
While in Portland, they exposed people to measles at multiple locations:
They then traveled back to Vancouver International Airport on an Alaska Airlines flight (August 6) and boarded a Norwegian Jewel cruise ship to Alaska.
Fortunately, the teen was placed in medical isolation shortly after boarding the ship and may have left the typically 7 day cruise early, as they were transferred to PeaceHealth Ketchikan Medical Center on August 8.
That’s still far below where we used to be though, especially when you consider that before the first measles vaccine was licensed, there was an average of about 549,000 measles cases and 495 measles deaths in the United States each year.
Containing a Measles Outbreak
Several factors help to limit the measles outbreaks that we continue to see in the United States. Most important is that fact that despite the talk of personal belief vaccine exemptions and vaccine-hesitant parents not getting their kids vaccinated, we still have high population immunity.
In the United States, 90.8% of children get at least one dose of the MMR vaccine by the time they are 35 months old and 91.1% of teens have two doses. While not perfect, that is still far higher than the 81% immunization rates the UK saw from 2002 to 2004, when Andrew Wakefield started the scare about the MMR vaccine. Instead of overall low immunization rates, in the U.S., we have “clusters of intentionally under-vaccinated children.”
It also helps that the measles vaccine is highly effective. One dose of a measles vaccine provides about 95% protection against measles infection. A second, “booster” dose helps to improve the effectiveness of the measles vaccine to over 99%.
To further help limit the spread of measles, there are a lot of immediate control measures that go into effect once a case of measles has been suspected, from initiating contact investigations and identifying the source of the measles infection to offering postexposure prophylaxis or quarantining close contacts.
That’s an awful lot of work.
A 2013 measles outbreak in Texas required 1,122 staff hours and 222 volunteer hours from the local health department to contain.
Costs of a Measles Outbreak
In addition to requiring a lot of work, containing a measles outbreak is expensive.
A study reviewing the impact of 16 outbreaks in the United States in 2011 concluded that “investigating and responding to measles outbreaks imposes a significant economic burden on local and state health institutions. Such impact is compounded by the duration of the outbreak and the number of potentially susceptible contacts.”
We still don’t know what it cost to contain many big outbreaks, like the one in Ohio, but we do know that it cost:
over $2.3 million to contain the 2017 outbreak in Minnesota – 75 people got measles, 71 were unvaccinated, and more than 500 people were quarantined over a 5 month period
up to an estimated $3.91 million (but likely much more) to contain the 2015 outbreaks in California
$394,448 and 10,054 personnel hours in total personnel time and total direct cost to the New York City Department of Health and Mental Hygiene responding to and controlling the 2013 outbreak in NYC
two unrelated cases in Colorado in 2016 cost $49,769 and $18,423, respectively to investigate
$50,758.93 to contain an outbreak at a megachurch in Texas
$150,000 to contain (13 cases) an outbreak in Cook County, Illinois
$223,223 to contain (5 cases, almost all unvaccinated) to contain another outbreak in Clallam County, Washington, an outbreak that was linked to the death of an immunocompromised woman.
more than $190,000 of personnel costs in Alameda County, with 6 cases and >700 contacts, it is estimated that over 56 staff spent at least 3,770 hours working to contain the outbreak
$5,655 to respond to all of the people who were exposed when a 13-year-old with measles was seen in an ambulatory pediatric clinic in 2013
$130,000 to contain a 2011 measles outbreak in Utah
$24,569 to contain a 2010 measles outbreak in Kentucky
$800,000 to contain (14 cases, all unvaccinated) a 2008 measles outbreak at two hospitals in Tuscon, Arizona
$176,980 to contain a 2008 measles outbreak in California
$167,685 to contain a 2005 measles outbreak in Indiana – unvaccinated 17-year-old catches measles on church mission trip to Romania, leading to 34 people getting sick, including an under-vaccinated hospital worker who ends up on a ventilator for 6 days
$181,679 (state and local health department costs) to contain a 2004 measles outbreak in Iowa triggered by a unvaccinated college student’s trip to India
It is important to keep in mind that these costs are often only for the direct public health costs to the county health department, including staff hours and the value of volunteer hours, etc. Additional costs that come with a measles outbreak can also include direct medical charges to care for sick ($14,000 to $16,000) and exposed people, direct and indirect costs for quarantined families (up to $775 per child), and outbreak–response costs to schools and hospitals, etc.
We should also consider what happens when our state and local health departments have to divert so much time and resources to deal with these types of vaccine-preventable diseases instead of other public health matters in the community. Do other public health matters take a back seat as they spend a few months responding to a measles outbreak?
There were 220 cases of measles in the United States in 2011. To contain just 107 of those cases in 16 outbreaks, “the corresponding total estimated costs for the public response accrued to local and state public health departments ranged from $2.7 million to $5.3 million US dollars.”
In contrast, it will costs about $77 to $102 to get a dose of the MMR vaccine if you don’t have insurance. So not only do vaccines work, they are also cost effective.
What to Know About the Costs of a Measles Outbreak
Containing a measles outbreak is expensive – far more expensive than simply getting vaccinated and protected.
And that brings up to a few very easy ways to avoid getting quarantined during an outbreak:
make sure you are always up-to-date on all of your vaccines
if you think that you have natural immunity (already had the disease) or were vaccinated, but don’t have your immunization records, then getting a titer test might keep you out of quarantine if you can prove that you are immune
“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
That’s right, especially in the case of measles, you can often avoid being quarantined if you simply get vaccinated.
Why are quarantines important?
Can’t you just isolate yourself if you get sick?
The problem with that strategy is that you are often contagious before you develop symptoms. That’s especially true of measles, when you likely won’t even realize that you have measles until you get the measles rash, after having a high fever for three to five days. That’s why people with measles are often seen at clinics and emergency rooms multiple times, exposing many people, before they are finally diagnosed. It is the classic signs of a rash with continued fever that helps to make the diagnosis.
Without quarantines of unvaccinated people, especially those who are known exposures to other cases, today’s outbreaks would be even bigger and harder to control.
If you don’t want to take the risk of being quarantined and missing weeks or months of school or work, then don’t take the risk of being unvaccinated. Tragically, that’s not the only risk you take when you skip or delay your vaccines. In addition to getting sick, you also risk getting others sick, including those who didn’t have a choice about getting vaccinated yet.
What to Know About Avoiding Quarantines During an Outbreak
The easiest way to avoid getting caught up in a quarantine for a vaccine-preventable disease is to simply make sure your kids are up-to-date on all of their vaccines.