Could a measles outbreak happen in New Hampshire?

A look at the numbers, the laws and the disease itself

Photo © Mayo Foundation for Medical Education and Research.

Measles was declared eliminated in the United States almost 20 years ago largely due to the success of the measles vaccine.

But there were 17 measles outbreaks in the United States in 2018, according to the Centers for Disease Control, and more than 70 cases so far have been recorded in just one outbreak — in Washington State — this year.

The number of parents opting out of vaccinations combined with the number of international travelers entering the country with the infection is spreading measles cases. Could an outbreak — defined as three or more cases — like the one in Washington State happen in New Hampshire?

What is measles?

Measles is a virus that starts like a cold or flu with fever, runny nose, cough, red eyes, and sore throat, according to the CDC. It’s followed by a rash that spreads over the body.

“The issue with measles is that it’s one of the more — one of the most — infectious agents that we deal with in public health because of how it’s transmitted and how easily it’s transmitted,” state epidemiologist Dr. Benjamin Chan said.

“Measles is a virus that is transmitted through air. So someone can contract measles by breathing the air or breathing in an airspace that someone infected with measles has passed through, and that measles virus can remain suspended in the air for up to two hours.”

According to the CDC, if one person has measles, 9 out of 10 people around him or her will also become infected if they are not protected, and an infected person can spread measles to others even before knowing they have the disease — from four days before developing the measles rash to four days afterward.

Measles usually runs its course, but for some the virus can lead to lung infections like pneumonia or encephalitis, a swelling of the brain.

“There are kids who get encephalitis, for example, or who have post-infection complications, which can be devastating, even fatal,” said Dr. Alex Granok, infectious disease specialist Southern NH Medical Center in Nashua.

About one in four people in the U.S. who get measles will be hospitalized; one out of every 1,000 people with measles will develop brain swelling, which could lead to brain damage; one to two of 1,000 people with measles will die, even with the best care, according to the CDC.

The vaccine

Generally speaking, any child older than 12 months can get the measles, mumps, rubella (MMR) vaccine and it’s roughly 99 percent effective at preventing infection.

Granok said the side effects from the vaccine itself includes redness and swelling at the injection site and can include a slight fever and rash. He said this happens because the body is doing its job in creating antibodies to fight the virus.

There are some people who can’t get the vaccine for medical reasons. They include newborn babies, pregnant women and those who are immunosuppressed. Some cannot get the vaccine due to religious reasons. Combined this is about 2 percent of the population in New Hampshire.

Vaccination can be a philosophical issue. Some parents and caregivers think the vaccine will harm their children so they opt out.

One of the early concerns relative to vaccinating children, Granok said, was the mercury in the preservatives used in the shot.

“Even though the amounts were very small and you could actually get more mercury by eating certain fish, for example, on a regular basis, most vaccine manufacturers ended up taking those preservatives out,” he said. “… And then later on we would hear lots of claims about worries about autism, which I think medical sciences has more than sufficiently debunked, but people don’t always want to believe that.”

Chan adds that a Danish study released in March 2019 further debunked these claims after researchers studied more than 600,000 vaccinated children to look for a possible connection between the MMR vaccine and autism. They found none.

Granok said another argument is that because these diseases are very rare, why vaccinate my child and take the chance they could have a reaction to a vaccine when the chances of them catching the disease in the first place are so low?

“It’s those kinds of arguments that lead to a disease like measles being reintroduced into a group of people,” said Granok.

Granok said one of the most important things when it comes to vaccinating a population is to make sure that enough people in that population are vaccinated.

“Otherwise the disease can still be present within the population as a whole,” he said. “And then it can spread to people who maybe have not been vaccinated for one reason or another, or for those people that the vaccine doesn’t work as effectively.”

What he’s explaining is the concept of “herd immunity.” The idea is if you have a certain number of people in the population vaccinated, the disease can’t get a foothold in that population.  “It might affect one or two people out of 100, but then it kind of stops there,” he said. “For most of our diseases we need vaccination coverage of 90 plus percent to prevent it from spreading within a population.”

For a disease that’s not very contagious, you may only need 80 or 85 percent vaccinated, he said to prevent the disease from spreading. But a disease like measles, you need the numbers to be in the mid-90s to prevent it from spreading.

“In New Hampshire, vaccination numbers are a little bit harder [to determine] than in other states because we haven’t had a vaccine registry. But the CDC estimates there are probably like 92 percent to 93 percent for most of those early childhood vaccines [in New Hampshire].

“In Washington State they are right around 90 percent for a disease like measles. They are pretty much at the threshold where you can start to see outbreaks and we’re a little bit above that.”

“We’re certainly not 98 percent like some states are so it could happen here if it gets into our population, particularly where vaccine coverage is low.”

Where is measles coming from, where is it now?

Measles is still common in many parts of the world, including countries in Europe, Asia, the Pacific, and Africa, the CDC said. Worldwide, 19 cases of measles per 1 million persons are reported each year and 89,780 people, mostly children, die from the disease, according to the CDC.

“Even if your family does not travel internationally, you could come into contact with measles anywhere in your community,” according to the CDC website. “Every year, measles is brought into the United States by unvaccinated travelers (Americans or foreign visitors) who get measles while they are in other countries. Anyone who is not protected against measles is at risk.”

In fact, on March 1, 2019, the state’s Department of Health and Human Services reported that the state had been notified an international traveler with confirmed measles took a bus on Feb. 26, from South Station in Boston to the Manchester Transportation Center.

According to the CDC there have been six official outbreaks reported in 2019 so far occurring in New York State, Washington State, Texas, Illinois and California. Other cases have been reported in Colorado, Connecticut, Georgia, Kentucky, New Jersey, and Oregon and New Hampshire.

“These outbreaks are linked to travelers who brought measles back from other countries such as Israel and Ukraine, where large measles outbreaks are occurring,” the CDC said.

But another reason, Chan said, has to do with the laws in those states.

“The states that have been seeing some of these measles outbreaks are states that have more lax laws around this, namely many of them allow what we call philosophical exemptions,” Chan said. “Meaning that because of belief or desire, people can opt out of getting vaccines and still go to school or child care.”

In New Hampshire, anyone entering school or child care must be vaccinated. The state only grants waivers to those who can’t get the vaccine for medical or religious reasons.

“We do not have a philosophical exemption,” Chan said. “And that’s something that a lot of other states, especially those that are currently experiencing measles outbreaks, are talking about getting rid of, because that has led to larger susceptible population and contributed to these measles outbreaks.”

The registry

Another way states can keep track of vaccinations and where there may be larger pockets of unvaccinated people is through a state registry. Every state except for New Hampshire keeps track through a voluntary repository.

This is not only convenient in terms of a person’s vaccination record traveling with them from doctor to doctor and state to state, but it can help with education and outreach in areas where there may be lower vaccination numbers, said Colleen Haggerty, the section chief for the state’s immunization program.

Plus, Chan adds, it can help infectious disease officials track the effectiveness of vaccines.

“In response to outbreaks,” he said, “you may or may not have heard we’re in the early stages of a Hepatitis A virus outbreak. An immunization registry is being used in other states to track the effectiveness of moving Hepatitis A vaccine out into the community in response to outbreaks.”

Haggerty said while the state got permission and a contract to set up this system in 2014, it has not yet been fully implemented. The first two years after getting the contract the state was working on updating expired administrative rules pertaining to vaccinations. And then in 2016, Haggerty said, they ran into trouble with “functionality of the system.”

“We want to make sure that any system that is rolled out for health care providers is really going to be a benefit to them and work without issues,” Haggerty said. “We’ve been working the last couple of years on assuring that all the things are in place to make for a very accurate system that will provide a benefit not just to us in public health and health care providers, but just citizens of New Hampshire.”

It is not clear when the registry may be available in New Hampshire.

Granok and Chan agree that vaccinating is a public safety issue and we have to take responsibility to protect others from getting sick, or dying.

“Most parents in our generation don’t realize that, you know, in parts of the world where they don’t have these vaccines kids die of these illnesses all the time,” Granok said. “I always use the argument that my kids were vaccinated then I would certainly want [other parents] to [vaccinate] and know not only are you protecting your kid, but maybe you’re protecting the baby next door who hasn’t had their vaccines yet.”

Chan said, “We have the best interest of kids, but also our populations that we serve in mind as well. So we have to consider what is the best public health recommendation or action for protecting not only the individual but also the population of our communities and the state that we live in.”

For more information on vaccinating children visit the CDC’s vaccination website at www.cdc.gov/vaccines.

Melanie Plenda is an award-winning freelance journalist and mom based in Keene. Her work has appeared in The Atlantic.com, The Daily Beast, American Baby, and Parents.com among other media outlets.

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