As of March 28, 2019, there were 387 cases of measles reported in the United States — shattering the 2018 total of 372 cases, the CDC reports.1

The total includes large outbreaks in several states, including Washington and New York. Employee health professionals probably need no reminding about the chaos that can result from a single undiagnosed case of measles sitting in the ED. It can set off an outbreak response that includes time-consuming and disruptive contact tracing of exposed patients and confirming immunity of healthcare workers. For example, one case in Arizona cost two hospitals some $800,000, largely due to ensuring the immunity of employees and furloughing exposed workers.2

Typically, hospitals require new employees to receive two doses of the measles, mumps, and rubella (MMR) vaccine or show proof of prior vaccination. CDC guidelines do not require employees born before 1957 to be immunized but recommend that they receive two doses in the event of an outbreak.

Possible Role of Healthcare Workers

Remarkably, a disease for which there is a vaccine so effective that measles was declared eradicated in the U.S. in 2000 has returned. It threatens not only those who refuse vaccination, but those too young to be vaccinated, and the frail and immune-compromised who cannot mount an immune response.

Measles is one of the most contagious of the infectious diseases. It is an airborne pathogen and can spread from contaminated surfaces and fomites near the infected patient. Healthcare workers caring for measles patients should be immunized, and wear an N95 respirator due to some reports of vaccine breakthrough. Two doses of the MMR vaccine confer 97% immunity, but fully immunized workers have been infected by patients.3

How did we get here? An antivaccine movement launching misinformation on the internet is largely responsible, but are some healthcare workers contributing to the problem?

There is some anecdotal information that suggests some physicians may be giving parents a bogus medical reason to decline vaccination in states and school districts with strict exemption policies, says William Schaffner, MD, professor of preventive medicine at Vanderbilt University in Nashville.

“Frankly, we ought to review the practices of physicians who glibly provide erroneous medical exemptions,” he says. “They ought to be obliged to explain their practice and, if necessary, have their practice supervised and corrected. I think it is unethical to provide a medical exemption that is not valid.”

Another vaccine advocate, Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology, shares a story that happened within her own family.

“We know that vaccines are the safest proven way to prevent disease,” she says, adding that she recently tried to make this very point to a relative at a family gathering. Hoffmann said one of her relatives explained she was not immunizing her child because her pediatrician said that all of the vaccines are not necessary.

Such anecdotal accounts are not uncommon, as a recently published commentary by public health experts cited “some pediatricians who publicly cast doubt on vaccine safety.” Given the ongoing outbreaks and inconsistent state laws, the authors called for the federal government to mandate vaccinations.4

Asked to respond, the American Academy of Pediatrics (AAP) said it was of aware of no such reports involving its 67,000 members. However, the AAP added, not all pediatricians are members of the group.

Prior to the widespread influenza vaccination mandates now in place, many nurses were resistant to being immunized, which they regarded as a personal choice. A 2010 study cited some of the reasons for declining the flu shot among nurses were self-perceived good health, skepticism of the vaccine’s value, and fear of side effects.5

“There were data to that effect, but the recent data that I have seen indicate that nurses are right up there with other healthcare providers [for flu immunization],” Schaffner says. “One of the contributors to the change is that nurses who work within institutions are increasingly subject to mandates and requirements. The bar has been raised.”

Although it has been amplified exponentially by the internet, the antivaccine movement is generally traced to an infamous 1998 article in The Lancet that fueled fears that the MMR vaccine may cause autism. This article was “proven to be false” and fully retracted by the journal in 2010 after years of criticism from the medical community.6

Science recently struck back, with a massive study involving more than 650,000 children in Denmark. The researchers compared autism rates in unvaccinated children and those who had been immunized against measles, finding that “MMR vaccination does not increase the risk for autism, does not trigger autism in susceptible children, and is not associated with clustering of autism cases after vaccination.”7

“That is a huge, powerful study,” Schaffner says. “The Danes have medical care from birth to death, and they have a totally comprehensive medical record on everybody.”

With the current appeal and constant repetition of conspiracy theories, Schaffner says it was just as well the study was not published in the U.S.

“It is important that it was done in Denmark and not in the United States,” he says. “I have heard on occasion from antivaccine folks that we in the U.S. have created this ‘myth’ of vaccine safety.”

Added to the accumulated weight of preceding data, the Danish study should finally put the autism-MMR link to the sword.

“If this doesn’t put — at least scientifically — the question to rest, nothing ever will,” Schaffner says. “But I don’t think the antivaccine folks will be convinced. They have not been moved by data in the past.”

An Astonishing Decision

A recent CDC report underscores that, as the parents of a child who nearly died of vaccine-preventable tetanus infection still declined immunizations after he recovered.

A six-year-old boy in Oregon, who had never received the tetanus shot or other routine childhood immunizations, cut his forehead while playing outside. His parents cleaned and sutured the wound, but six days later, an infection developed, likely due to Clostridium tetani, bacterial spores commonly found in soil, the CDC reports.8 The diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is recommended for children under seven, with the first three doses given to infants at two, four, and six months. The vaccine is a large part of the reason there has been a 95% decrease in tetanus — including a 99% reduction in fatal infections — since the 1940s, the CDC reports.

The unvaccinated child in Oregon began experiencing brutal neuromuscular symptoms associated with this infection. These included “episodes of crying, jaw clenching, and involuntary upper extremity muscle spasms, followed by arching of the neck and back, and generalized spasticity,” the CDC reports. “Later that day, at the onset of breathing difficulty, the parents contacted emergency medical services, who air-transported him directly to a tertiary pediatric medical center.” Diagnosed with tetanus, the boy was an inpatient in a pediatric ICU for 47 days, so sensitive to light and sound he wore earplugs under care in a darkened room. A tracheostomy was placed for prolonged ventilator support and was not removed for 30 days.

After the child recovered, the ICU stay was followed by more than two weeks of additional rehabilitation therapy. He completely recovered after receiving medical care costing some $812,000. Although clinicians explained that tetanus infection does not confer immunity — meaning the child needed to complete the vaccination schedule to avoid future infections — the family declined all immunizations, the CDC reported.

“Now that’s an antivaccination family,” Schaffner says. “Despite their son’s incredible life-threatening illness, they still declined vaccination. [The CDC] describes this very concisely, but you cannot imagine the agony of this illness for this child.”

A nationally known vaccine advocate, Schaffner says clinicians and public health are in for a protracted battle to overcome resistance to vaccinations. For example, better health education is needed in schools to teach children about vaccines and the untold number of lives saved by them. With an effective measles vaccine preventing most cases since the early 1960s, the current resurgence in the U.S. finds even nursing and medical students shocked to learn about conditions before vaccination began, Schaffner says.

“When I tell our medical students that before we had vaccine, 400 to 500 people in the U.S. died each year due to measles and its complications, their jaws drop,” he says. “They have no concept of how severe measles can be and that in the developing world, it continues to be a major killer of children.”

Indeed, the World Health Organization offers this grim global snapshot: “Even though a safe and cost-effective vaccine is available, in 2017, there were 110,000 measles deaths globally, mostly among children under the age of five.”9

REFERENCES

  1. CDC. Measles Cases and Outbreaks. Available at: https://bit.ly/2iMFK71.
  2. Chen SY, Anderson S, Kutty PK, et al. Healthcare-associated measles outbreak in the United States after an importation: Challenges and economic impact. J Infect Dis 2011; 203: 1517-1525.
  3. Gohil SK, Okubo S, Dickey L, et al. Healthcare Workers and Post-Elimination Era Measles: Lessons on Acquisition and Exposure Prevention. Clin Infect Dis 2016;62:166-172.
  4. Ratzan SC, Bloom BR, Gostin LO, et al. States are failing on vaccinations. The federal government must lead. Washington Post. Mar. 7, 2019. Available at: https://wapo.st/2J3ydP2.
  5. Rhudy LM, Tucker SJ, Ofstead CL, et al. Personal choice or evidence-based nursing intervention: nurses’ decision-making about influenza vaccination. Evid Based Nurs 2010;7(2):111-120.
  6. Editors of The Lancet: Retraction—Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 2010;375:445.
  7. Hviid A, Hansen JV, Frisch M, et al. Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. Ann Intern Med 2019; DOI: 10.7326/M18-2101.
  8. Guzman-Cottrill JA, Lancioni C, Eriksson C. Notes from the Field: Tetanus in an Unvaccinated Child — Oregon, 2017. MMWR 2019;68:231–232.
  9. World Health Organization. Measles. Available at: https://bit.ly/2rN0iyE.