Doctors Talk: Measles

Doctors Talk: Measles

Katie Lockwood, MD: So, I remember learning in medical school that measles has fever and then those three Cs: cough, runny nose and conjunctivitis, and then the rash comes later, but that looks like a lot of the different viral infections that I see in primary care in kids. I know the rash looks a little bit different, but until that point, I imagine it's pretty hard to tell measles from other viruses.

Paul Offit, MD: Not hard at all. When children come into our hospital, Children's Hospital of Philadelphia, and there's a suspicion of measles, they ask older people like me to come down and take a look because honestly, I can tell within 30 seconds whether somebody has measles.

Katie Lockwood, MD: And 1 in 5 kids with measles were hospitalized.

Paul Offit, MD:  You're right. I mean, measles causes congestion, cough, runny nose, and rash and pink eye. And the rash usually starts at sort of the hairline here and then spreads down to the face, the trunk and then out to the arms and legs. And the rash is the so-called measles-like rash, but there are rashes that look similar. So, you could argue, how do you distinguish fever and a rash in someone who has measles from fever and a rash in these other viral infections that can do the same thing? And the way that you do that is children with measles are sick. You can really tell within 30 seconds of walking into the room who has measles and who doesn't because children with measles are miserable.

Katie Lockwood, MD: And then there are long-term complications from measles that we don't see with many routine childhood illnesses.

Paul Offit, MD: That's right. So, measles causes the rash we all know about, but it also can cause severe and occasionally fatal pneumonia. Measles can also infect your brain. And every year in this country before there was a measles vaccine, which was first available in the early 1960s, we would see 48,000 hospitalizations with measles, and we would see 500 deaths from measles. But there's one long-term complication of measles that I think few people know about and has the fancy name subacute sclerosing panencephalitis, and that's just a progressive neurological degeneration. Initially, it starts as sort of poor handwriting and then eventually an invariably progresses to death. And once that symptom cascade starts, it's inevitable that it's a fatal outcome.

Katie Lockwood, MD: But the measles vaccine is a live vaccine. So, I would imagine that some parents would worry that they could have that SSPE complication from the vaccine. We don't see that though.

Paul Offit, MD: No. The key is not just live, it's live attenuated. So, it is a highly, highly weakened form of the virus. So, it induces the immunity that's a consequence of the natural infection without having to pay the price of natural infection, and it worked. I mean measles is the most contagious of the vaccine-preventable disease. I mean if someone comes into our hospital and into one of the rooms in the emergency department, no one can go in that room for another two hours until all those tiny little droplets settle. But, nonetheless, we were able to eliminate measles from this country by the year 2000. Unfortunately, measles has to some extent come back because a critical number of parents have chosen not to vaccinate their children.

Katie Lockwood, MD: The contagiousness is what worries me the most as a primary care doctor. As you mentioned, it hangs out in the air for a while, and if you're not vaccinated and you're in the same space as someone with measles, 9 out of 10 of those people will contract measles, which is unlike any other infection that's in my waiting room, which is so scary because there have been periods in time where many people are not getting measles vaccine, and we see outbreaks even in the U.S. because people travel.

Paul Offit, MD: You're right. It's frightening. Take a disease like smallpox, which was fatal 30-plus percent of the time, but that was spread by large droplets. You really need to have face-to-face contact with someone with smallpox to get that disease. For coronavirus, for this virus, the COVID virus, it's generally small droplets. So again, you need to be, you know, fairly close to somebody who has that virus and then is spreading it via talking or sneezing or coughing. Measles is spread by aerosol. So, it just, it's very, very tiny droplets that can hang in the air like a ghost before they settle down, and that's what makes that virus so remarkably contagious.

Katie Lockwood, MD: In 2019, we saw some of the highest rates of measles in the United States since the early '90s, and we think that some of that is due to people refusing the vaccine. During the pandemic with social distancing, we were distancing, and we didn't see measles, thankfully, but I do worry that as we start coming back together again that we might see measles coming back.

Paul Offit, MD: I think you're right. I think what worries me actually is that because of this pandemic, children have become undervaccinated for a variety of potential infectious diseases, and I really do feel that as we all now get back together again and unmask and no social distance that you're going to see some of these vaccine-preventable diseases come roaring back in that group that is unvaccinated.

Katie Lockwood, MD: And you're right that we forget about how serious measles is because many people who were born after the vaccine haven't seen it, and it does feel like something that was just in the textbook. But as you mentioned, these kids get so sick that it's something that we can't forget about.

Paul Offit, MD: I think you're right. I think at some level vaccines have become a victim of their own success.

When you see some young parents today say, you know, I'll take the measles every time, it tells me that not only have we largely eliminated measles from this country, I think we've eliminated the memory of measles because measles makes you sick.