By DAVID BROOKS
Even though New Hampshire has not seen an outbreak of measles for many years, the return of this once-eradicated disease in other parts of the country is raising concern here, including questions about how easily clinicians can diagnose measles when they have never seen it before.
“Oh, yes, it’s getting folks’ attention. It’s everything from my dental hygienist an hour ago – ‘what’s going on with measles?’ – to folks at the hospital and patients asking about it,” said Dr. Michael McCloud, a family medicine physician in Hopkinton and associate chief medical officer for Concord Hospital.
New Hampshire had a measles scare in February when an infected person rode a bus from Boston into New Hampshire, but no cases have been reported here.
“We have not had a documented case of someone acquiring measles for at least the last five or six years, probably longer. That speaks to the relatively good vaccination rates we have in New Hampshire,” said Dr. Benjamin Chan, the state epidemiologist.
New Hampshire provides free vaccinations of all sorts to people age 18 and younger and requires them for attendance in public school or daycare unless there are medical or religious reasons. The vaccination rate reported by schools regularly hovers around 95 percent at kindergarten and a few percentage points higher for young teenagers. This level generally provides what is known as “herd immunity” because an infected person so rarely encounters an unprotected person that diseases don’t get a chance to spread.
Measles is extremely contagious and there is no specific treatment for it, which makes prevention through vaccination particularly important. The disease is caused by a virus, so antibiotics are not effective.
Some people, including babies, pregnant women and immunosuppressed people, cannot be given the vaccine.
Before 1963, when national vaccination programs began, the U.S. suffered around 400 deaths and 48,000 hospitalizations a year due to measles, according to the federal Centers for Disease Control. It remains a global scourge: the U.N. estimates that it killed 110,000 people worldwide in 2017, with cases increasing since then.
On Wednesday the Centers for Disease Control said that 695 measles cases had been reported in 22 states already this year. That is more cases than the county has seen in any total year since 2000, when measles was officially declared to have been eradicated from the United States following decades of vaccination programs.
The new outbreaks are driven largely by people avoiding vaccines for various reasons, fueled by misinformation about the safety and effectiveness of the medication. Vaccines harness the body’s natural immune system to fight off pathogens.
Most measles outbreaks in the U.S. have occurred in small communities that shun vaccination for philosophical or religious reasons. In New York City the problem has become so serious that a public health emergency was declared and vaccinations are becoming mandatory in parts of Brooklyn.
“One challenge with measles is the fact that we have a whole generation, multiple generations, of medical professionals who have never clinically seen measles,” said McCord. He is among them: McCord said he has never seen a case of measles in a patient since he began practicing in 2000.
When people first get sick with measles the disease may not be obvious, as the distinctive rash only shows up later.
“It often presents as a fever, cough, runny nose, red, watery eyes – very non-specific symptoms,” said Dr. Chan.
A nurse or doctor faced with a patient who has those symptoms must decide which of many possible causes to test for or treat. In New Hampshire, measles usually isn’t one of them.
“I might think maybe you have the flu, maybe you have strep throat … until you break out in a whole-body rash, when it will be detected,” said McCord. A patient with measles could “walk out the door without a diagnosis,” spreading the disease further.
“The important part here is reminding clinicians to keep measles on their list of possible diagnoses when they see somebody presenting comparable symptoms,” said Dr. Chan. “As they run through their mind the list of possible causes, measles need to be on that list. Clinicians need to ask more targeted questions – have you traveled recently? been in contact with anybody who might have the disease?”
Both doctors encouraged parents to have their children vaccinated and acknowledged the difficulty of convincing people who have decided that vaccines are unnecessary or even dangerous.
“A good number of folks who don’t vaccinate don’t necessarily have a lot of sound footing for their decision when I ask them. It’s not that they have done lots of research they can cite – a lot of times it’s just a feeling,” said McCord. “A lot of times folks will say ‘I don’t want to, I’ve heard bad things.’ You can spend all of a (clinical) visit talking to folks and get nothing else done.”
“You can make a personal decision not to take cholesterol-lowering drugs – you only affect yourself, indirectly affect your family if something happens. But if you decide not to vaccinate you become a vector of infection for multiple folks who can have significant if not catastrophic effects,” said McCord.
Measles is a reportable disease in New Hampshire and the rest of the U.S., meaning any diagnosis must be reported immediately to the state health department.
One good thing about measles: If you’ve ever had the vaccine, either in the package known as MMR or individually, or if you had the disease as a child then you don’t have to worry about getting it again.
“(The vaccine) is expected to produce lifelong immunity. There’s no need or recommendation … for a booster,” even for seniors who received the shot six or more decades earlier, said Dr. Benjamin Chan, the state epidemiologist.
People who don’t remember if they have been vaccinated or are otherwise unsure about whether they are protected from measles can get a test, known as a titer, for most health clinics or doctors. It will determine whether they have the antibodies needed to fight off the measles virus.
