Safoora Fatima, M.D., Pavani Nathala, M.D., Steven Lippmann, M.D.

Introduction

Measles is a highly contagious disease transmitted via respiratory droplets from person-to-person. Before the advent of the measles vaccination, there were over half million cases reported annually in the United States, with 500 measles related deaths each year (1).  

Clinical

Measles starts with a 2-4 days prodrome of fever, anorexia, conjunctivitis, coryza, and cough (2). Temperatures can rise up to 104 degrees F, late in the prodrome. Koplik spots are pathognomic signs of measles and appear 1-2 days before the rash onset, as bluish-gray specks on an erythematous base at the buccal mucosa of the second molar (2). They last only about two days, often disappearing early in the disease course (2).  

The classic measles rash is an erythematous, maculopapular eruption lasting for 4-5 days, beginning on the head and face and then spreading to the entire body (2). The rash then fades in the same order as its appearance.

Elimination

Measles immunizations began in the United States in 1963. Serious epidemics prompted an illness elimination initiative in 1978. By the early 1980s, measles was nearly eradicated in this country; however, there was a recurrent epidemic with 17,850 measles cases reported in 1989 (3).

Subsequently, there was a new vaccination effort to increase immunization coverage. A second dose of measles vaccination for children was recommended to protect those who did not respond to the initial vaccination (4). Nevertheless, lack of herd immunity resulted in new epidemics among unimmunized preschool age children, especially in communities honoring religious or philosophical vaccination exemptions (5).  

By 2000, measles was considered to be eliminated because of high population immunity and broad vaccination coverage (6). Concern about this disease was fading.

Outbreaks

Between January-July 3, 2019, there were 1,109 cases of measles reported; the highest number since 1994 (8). The greatest percentages of these outbreaks occurred in communities with many vaccination-refusals, individuals who travel internationally, and/or others who were unvaccinated (7). States most affected include Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Texas, Tennessee, and Washington (8).  

The 2018 epidemics in Washington and New York states are among the largest and also the longest lasting (9). The Williamsburg area of Brooklyn, in New York City, experienced the largest outbreak, with nearly 300 cases concentrated in an Orthodox Jewish community (10). Their first measles-infected person had recently travelled internationally, in an under-vaccinated community (11).

When imported into a highly vaccinated population, measles yields only a few cases and no epidemic. However, when such a person enters an undervaccinated group, the disease spreads widely (9).

Cause

New measles epidemics are most common among people who claim that vaccines are dangerous or even causing autism (12). In New York and many other states, children are sometimes exempted from vaccinations because of medical, religious, or philosophical reasons (12). Exemptions are sometimes granted because of perceived fear of vaccine-induced harm. These include that vaccines cause illnesses, overload the immune system, perceptions of not being at risk, that measles is not dangerous, or that vaccines might not be effective.

Ethical, moral, and/or religious beliefs include vaccine preparation with aborted cells and/or the use of fetal or blood tissue. Testing in animals is another reason (13). Some people object to governmental interference into their personal lives and/or fear dangerous conspiracies.

Currently, the New York epidemic is due to vaccination refusals because of perceived religious and/or safety concerns (14). In Washington, parents reportedly opted out of immunizations because of the mistrust in health officials and/or pharmaceutical companies (14).  

Unvaccinated people who develop measles are contagious to their community, especially to infants too young for vaccination and others with contraindications to immunization. To protect them from exposure, these persons depend on high vaccination coverage among those around them (15). Measles vaccinations are first administered at the age of 12-15 months and followed by a second dose between 4-6 years.

Viral importations are likely to continue causing measles in unvaccinated groups, despite global control and elimination efforts. To prevent further epidemics, broad vaccination coverage is necessary. To maintain a disease-free population, high-density immunization should continue (16).

Conclusion

Universal childhood immunization and vaccination of all susceptible individuals is indicated. Measles vaccination is effective and safe. Disease outbreaks may occur because of immunity gaps, despite vaccine coverages. Vaccine refusal remains problematic and accounts for current epidemics.

References

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12. Andrews M. Why Measles Hits So Hard Within N.Y. Orthodox Jewish Community. 2019 https://khn.org/news/why-measles-hits-so-hard-within-n-y-orthodoxjewish-community/ Accessed on May 1, 2019
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14. Belluz J. The era of religious and moral vaccine exemptions needs to end — and fast. 2019 https://www.vox.com/science-and-health/2019/2/16/18223764/measlesoutbreak-2019-vaccines-anti-vax Accessed on May 1, 2019
15. Centers for Disease Control and Prevention. Measles: United States, January–May 20, 2011. Morbidity and Mortality Weekly Report. 2011; 60(20):666 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6020a7.htm?s_cid= mm6020a7_w Accessed on May 1, 2019
16. Centers for Disease Control and Prevention. Measles-United States, January 1-August 24, 2013. Morbidity and Mortality Weekly Report. 2013; 62(36):741