The number of confirmed measles cases in the United States has now topped 300, according to the CDC(www.cdc.gov). As of May 30, a total of 334 confirmed cases from 18 states had been reported, with the largest outbreaks in Ohio and California.
Although measles was declared eliminated in the United States in 2000, importation of the disease from other countries has precipitated its return. A massive outbreak in the Philippines(wwwnc.cdc.gov) alone had racked up more than 40,000 confirmed and suspected cases through May 20, and 22 U.S. travelers returning from the Philippines had become sick with measles as of May 30.
This importation paired with a rising population of U.S. parents who are not immunizing their children with the readily available measles, mumps and rubella (MMR) vaccine has created a burgeoning public health dilemma. Fortunately, family physicians across the country, including those in one of the heaviest-hit states, are meeting the challenge head on, treating measles cases and learning as they go.
Spots in the Sunshine
Although California AFP President Del Morris, M.D., medical director for the Stanislaus County Health Services Agency in Modesto, says there have been no current measles cases reported in his jurisdiction, he does recall seeing patients with the disease some four decades ago.
- More than 300 confirmed cases of measles had been reported to the CDC as of May 30. The states with the largest outbreaks are Ohio, with 249 cases, and California, with 60 cases.
- Recently diagnosed measles cases in Orange County, California, are providing an important learning opportunity for family medicine residents.
"I haven't seen a case of measles since I was in my residency program from 1974-77," Morris said. "By then, you already had a dramatic drop in measles from the epidemic era that ended about 1957, once we had the vaccine." He went on to say that most currently practicing physicians, outside of the active outbreak areas, probably have never seen a case in person.
After the measles vaccine became available, the people who still contracted the disease tended to be poor. Then, the Vaccines for Children (VFC)(www.cdc.gov) program started in 1993, making vaccines available for free to school-age children across the country.
"At that point, you saw a dramatic increase in coverage of all children," Morris said. "The irony is that the children who are catching measles now are much more likely to be coming from affluent families. So this has sort of turned on its head."
Increasingly, parents -- especially those who are well-educated and higher-income earners -- are choosing not to have their children vaccinated, said Morris. According to the CDC, 82 percent of measles cases that were reported in 2013 were individuals who were unvaccinated; 79 percent of that group reported they rejected vaccines because of philosophical reasons.
"California has been struggling with this issue of parents deciding more and more to not get their children immunized," Morris said. "The trend appears to be that the outbreaks with measles will get worse before they get better."
Conversely, many of the patients in Morris' health care safety-net facility are getting vaccines through the VFC program. "We don't have a high number of people who do not want their children vaccinated," he explained. "If anything, it's the other way around -- they really want their kids vaccinated. But that is different in affluent populations."
What to Look For
Morris is part of a local medical group in Modesto that includes family physicians and pediatricians and meets on a monthly basis. At this month's get-together, he plans to present a brief description of measles. "We haven't had a case in our county yet, but this is only six months into the year. So I'm just giving people a heads-up on what it looks like," he said.
Regardless of travel history, measles should be considered in people of all ages, not just children, who have fever and a rash, said Morris. The fever can be 104°F or higher, and the rash is red and splotchy, typically starting in the hairline and then moving down behind the ears, across the face and down the rest of the body.
"The rash can appear a day or so after the fever begins, so the patient can be spreading the virus for four days before breaking out in the rash," Morris said. "Fluids from the cough, the nose and the eyes make the spread of the virus very efficient."
Isolation of patients diagnosed with measles is key, said Morris. There is no antiviral treatment, and medical care is supportive to help relieve symptoms and prevent bacterial infection. The most common serious disease complication and the No. 1 cause of measles-related hospitalization is pneumonia.
A Teaching Opportunity
On July 1, AAFP member Esther Ho, M.D., will become director of the Family Medicine Residency Program in the University of California-Irvine (UC-Irvine) Department of Family Medicine. The program is housed in a federally qualified health center in Orange County, which has seen highest concentration of measles cases in the state(www.cdph.ca.gov). Three measles cases so far have been diagnosed at the facility.
None of the affiliated hospital's 15 faculty members had treated a case of measles before, said Ho. The hospital quickly put a protocol in place that included immediately masking patients suspected of having measles, moving them out of the waiting room and other common areas and placing them in an airborne infection isolation room. All health care personnel entering the room of any patient with suspected measles was required to use an N95 mask and observe other precautionary measures, she added.
For the program's residents, in particular, these patients offered a valuable teaching opportunity, said Ho.
"Learners were included during bedside rounds to discuss differential diagnoses," she explained, "and once measles was confirmed, they re-evaluated the patient ... to see and learn something most of us have only read about."
From a public health perspective, said Ho, these outbreaks show how important it is for patients to receive the MMR vaccine. "It emphasizes and reiterates to us our duty as family physicians to promote and provide vaccinations and catch-up vaccinations," she said.
"One of our innovative programs is our mobile van school program, in which we take the mobile van out twice a week to local underserved schools to treat children who do not normally receive regular medical care and who can fall behind with vaccinations," Ho said. "A big part of that care is providing vaccinations, including the MMR for measles, to make sure kids are on target, and if they are not, to do catch-up vaccinations for them."
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