Whole Kid Newsletter
February 13, 2015 - Brought to you by GetzWell Pediatrics (www.getzwell.com)
Measles: what you should know
In light of the recent measles outbreak this winter, we have been fielding many questions from our families. In this summary, we hope to address some common questions and concerns about the disease in order to help you make informed decisions surrounding vaccination, prevention and treatment for your family.
As of February 10th, there have been a total of 121 cases confirmed in 17 states and Washington DC, with the majority being in California, and we are aware of at least one confirmed case in San Francisco this week. At this rate, the number of cases will easily surpass the 644 cases in 2014—the greatest number of cases since the disease was nearly eradicated in the early 2000s. Some of this year’s cases can be traced to exposure at Disneyland, while others are seemingly not linked.
Measles is an extremely contagious, airborne viral infection that produces flu-like symptoms and a red rash all over the body. It is commonly spread by coughing and sneezing but can survive in the air for up to 2 hours after its host has left the area. Measles multiplies rapidly in the nasal cavity and then spreads to the lymphatic system, respiratory tract, and other organ systems. Symptoms usually appear 10-12 days after exposure, well after the virus is contagious, meaning that an exposed individual can spread the disease before they experience any symptoms. The virus can be killed by heat, light, and solvents so preventive measures can be effective especially if you suspect exposure. Nasal irrigation with a solution like Xlear can help flush out the virus before it spreads beyond the nasal cavity. Sanitization of surfaces and hand washing can help reduce the potential for exposure.
Rate of Infection
Despite the relative ease of killing the virus, its rapid proliferation makes rates of infection high. A person is contagious as soon as they are infected, for days before symptoms begin and for days after a rash develops. The likelihood of an unvaccinated person becoming infected after exposure is over 90% on average, and 94% for unvaccinated children ages 1- 4.
Initial symptoms are similar to influenza, and may include a fever of up to 105F, runny nose, cough, and pinkeye. One significant differentiating symptom is the brief appearance of white spots (called “Koplik spots”) inside the cheek during the early onset of measles. Following respiratory symptoms and Koplik spots, a red blotchy rash typically appears—first on the face, then spreading downward over the body. Unfortunately, because Koplik spots appear only briefly during early onset of measles, this symptom has often passed by the time a patient presents to their doctor.
Complications are greater among children under 5 and adults over 20, as well as those with nutritional deficiencies and individuals with weakened immune systems.
Common complications of measles include diarrhea, ear infection, and pneumonia. A less common but severe complication is brain infection, called encephalitis, which occurs in about 1 per 1000 cases. Encephalitis carries a 15% mortality rate and a 25% prevalence of lasting neurological damage. As pediatricians, this is a risk that we worry about especially for unvaccinated children. Very rarely, a fatal degenerative neurological condition known as SSPE may present up to a decade after apparent full recovery. This condition presents in about 1 per 100,000 measles cases, but always results in death.
Overall mortality for measles is 1-2 per 1000 cases, with the proportion being higher among young children. The risk is higher for infants under 1 year for whom the measles vaccine is not recommended except for short-term protection while traveling to high-risk areas, or in the event of an epidemic, which has not been declared in California. These very young children must rely on “herd immunity” to avoid infection, as their developing systems are less likely to respond to the vaccine. Most experts say that herd immunity depends on a vaccination rate of 95%. Our understanding is that the measles vaccination rate in the San Francisco Bay Area is currently around 91%.
Among confirmed cases of measles in California, fewer than 2% were vaccinated against the disease.
MMR (measles-mumps-rubella) is the vaccine used to prevent measles infection. It is a live virus that creates a mild infection to elicit an immune response. The first dose is typically given at 12 to 18 months of age, with about 95-98% of these children developing protective antibodies. A second dose is given to ensure that those remaining 2-5% also develop immunity. This second round is typically given at 4 years but can be administered as early as 4 weeks after the first. An alternative to receiving both rounds of the vaccine is to draw titers (bloodwork to check for antibodies) to confirm immunity from the first vaccine.
Because MMR is a live virus, certain populations are not able to receive it and must rely on others’ immunity to be protected. This includes babies under 6 months, pregnant women, and immunocompromised individuals. Those with severe allergic reactions to certain components of the vaccine should also avoid MMR, though this is rare. MMR is considered safe for people with egg allergies.
Very rarely, the MMR vaccine may trigger an autoimmune reaction that causes brain inflammation, though this occurs less frequently than with the measles virus itself. Individuals with autoimmune disorders seem to be more susceptible to this complication. As noted above, compromised immunity is one of a few contraindications to receiving MMR.
So while we cannot say that MMR carries zero risk, we do know that the risk of developing serious complications like SSPE is many times higher among individuals who contract the measles virus compared to those who receive the vaccine (1 in 100,000 vs.1 in 1 million).
Prevention & Treatment
Vaccination at 12-15 months provides the most certain protection against the virus. Vaccination within 72 hours of exposure has been shown to prevent the disease in previously unprotected individuals. Unvaccinated adults who are around young children should consider vaccination.
In the event of infection, a high dose regimen of vitamin A may reduce risk of complications. The regimen is recommended by the World Health Organization for all children with measles. While there is a risk of toxicity with high dosing of vitamin A, this short-term protocol may help diminish adverse complications with relatively low risk of toxicity:
Administer once per day for two days…
• 50,000 IU for infants under 6 mos.
• 100,000 IU for infants 6-11 mos.
• 200,000 IU for children 12 mos. +
To boost the immune system and reduce the possibility of infection, maintain sufficient levels of vitamin D throughout the winter and be sure to eat plenty of vegetables and keep sugar intake to a minimum. Here are our tips on staying generally healthy through the winter months: Eat a Rainbow
Try to avoid fever reducers such as Tylenol and Motrin, which may actually worsen the severity of measles by tempering the body’s natural response to fighting infection. Reserve these for when discomfort from fever prevents adequate hydration and sleep, which are vital for recovery.
Please don’t hesitate to contact us for a custom consultation to further discuss measles and the MMR vaccine.
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