Measles deaths, United States, 1999-2013

Over the last several weeks I've read comments in op-ed pieces and on social media about the measles epidemic that began at Disneyland. There is one comment that I have read several times that troubles me:

"No one has died."

That may be true, but 20% of people with measles have been hospitalized with measles or complications of measles so far during this outbreak. During the first five months of 2011, 40% of people with measles were hospitalized. Measles is not a benign disease. Complications include pneumonia, encephalitis, otitis media (middle ear infection), seizures, and diarrhea.

Another claim that I have heard is that no one has died from measles in the U.S. in the last ten years. That is not true. The data aren't easy to find, but measles deaths are reported in the National Vital Statistics Reports and in the CDC's summaries of notifiable diseases. Another source of data on measles deaths is the CDC's Wide-ranging Online Data for Epidemiologic Research (WONDER). That's where I retrieved the following data.

There were a dozen measles deaths reported in the U.S. between 1999 and 2013. Five of those deaths were measles complicated with encephalitis, 3 were measles complicated with pneumonia, and 4 were reported as measles without complications. The last column is deaths from subacute sclerosing panencephalitis (SSPE).

Measles deaths, United States, 1999-2013

Year	Encephalitis	Pneumonia	Uncomplicated measles	Measles total	SSPE
1999		1	1	2	5
2000		1		1	5
2001	1			1	2
2002					5
2003			1	1
2004					1
2005	1			1	2
2006					3
2007					3
2008					3
2009	1	1		2	2
2010	2			2
2011					4
2012			2	2	1
2013					1
Total	5	3	4	12	37

Subacute sclerosing panencephalitis (SSPE) is a rare and almost always fatal complication of measles. It is caused by persistent measles virus infection in the brain. The virus fails to complete replication and release from infected neurons and glial cells. The onset of SSPE usually occurs around 7 years after the person had measles, but can occur as soon as 2 years later or as long as 15 years later. The symptoms begin with personality changes, behavioral changes, and poor scholastic performance. The symptoms can be subtle and only recognized when more severe symptoms begin. The disease progresses with muscle jerking and twitching (myoclonus), seizures, and other movement and muscular disorders; difficulty controlling movements, difficulty walking, uncontrollable movements, and spasticity. The final stage SSPE is characterized by weakness in all four limbs, inability to speak, blindness, uncontrolled sweating, and uncontrolled changes in blood pressure, heart rate, and temperature. Death usually occurs 1 to 3 years after the onset of symptoms. The risk of SSPE is highest in people who had measles as infants. Wild-type measles viruses cause SSPE. There is no evidence that measles vaccine virus causes SSPE.

A couple of deaths every year or so might not seem like a lot, but let's set the record straight: people in the U.S. are hospitalized with measles and people in the U.S. die from measles.

References

Beckham, J. D., Solbrig, M. V., & Tyler, K. L. (2012). Infections of the central nervous system: viral encephalitis and meningitis. In R. B. Daroff, G. M. Fenichel, J. Janjovic, & J. C. Mazziotta (Eds.). Bradley's neurology in clinical practice, 6th Ed. [Electronic version]. Philadelphia: Saunders.

Beckham, J. D. & Tyler, K. L. (2015). Encephalitis. In J. E. Bennett, R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglass, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version]. Philadelphia: Saunders.

 

Berger, J. R. & Nath, A. (2012). Cytomegalovirus, Epstein-Barr virus, and slow virus infections of the central nervous system. In L. Goldman & A. L. Schafer (Eds.). Goldman's Cecil medicine, 24th Ed. [Electronic version]. Philadelphia: Saunders.

 

Buchanan, R. & Bonthius, D. J. (2012). Measles virus and associated central nervous system sequelae. Seminars in Pediatric Neurology, 19(3). doi:10.1016/j.spen.2012.02.003. http://www.sempedneurjnl.com/article/S1071-9091(12)00004-6/abstract.

 

Campbell, H., Andrews, N., Brown, K. E., & Miller, E. (2007). Review of the effect of measles vaccination on the epidemiology of SSPE. International Journal of Epidemiology, 36(6). doi:10.1093/ije/dym207. http://ije.oxfordjournals.org/content/36/6/1334.short.

 

Centers for Disease Control and Prevention. (2011). Measles – United States, January – May 20, 2011. Morbidity and Mortality Weekly Report, 60(20), 666-668. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6020a7.htm.

 

Centers for Disease Control and Prevention. (2015). Measles outbreak – California, December 2014-February 2015. Morbidity and Mortality Weekly Report, 64(6), 153-154. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6406a5.htm.

 

Centers for Disease Control and Prevention, National Center for Health Statistics. (2015). Multiple Cause of Death 1999-2013 on CDC WONDER Online Database. Accessed February 22, 2015 at http://wonder.cdc.gov/mcd-icd10.html.

 

Gershon, A. A. (2015). Measles virus (rubeola). In J. E. Bennett, R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglass, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version]. Philadelphia: Saunders.

 

 

 

Washington State House Bill 2009: Concerning exemptions from immunizations for school-age children

Background:

• Immunization laws are state laws. There are no federal immunization laws.
• All 50 states have laws requiring immunizations for school entry.
• All 50 states allow medical exemptions from school immunizations.
• 48 states allow religious exemptions from immunizations (Mississippi and West Virginia do not).
• 19 states allow personal belief/philosophical exemptions.

Washington is one of a minority of states that allow personal belief/philosophical exemptions to school immunizations. Prior to July 22, 2011, obtaining a personal exemption from school immunizations required only a parent's signature. Now the form must be signed by a licensed health care practitioner (physician, naturopath, physician assistant, or an advanced registered nurse practitioner) stating that he or she provided the parent or guardian with information about the benefits and risks of immunizations.

A bill has been introduced into the Washington State Legislature that would remove the personal belief/philosophical exemptions option, leaving only medical and religious exemptions from immunizations. A similar bill has been introduced in California.

I have been conflicted about this bill. As part of investigating cases of notifiable conditions, I am required to ask if a child with a vaccine-preventable disease has been vaccinated and, if not, why. Sometimes, parents who have chosen not to vaccinate their children are hesitant to answer that question. I also speak to parents who have chosen not to vaccinate in other settings. I am sincere when I tell them that I respect their decision. I am happy to discuss the benefits and risks of vaccines with anyone who is interested, but I don't try to convince parents to vaccinate their children when they tell me that they have chosen not to.

Every year, schools in Washington are required to report their immunization exemption data to the state Department of Health (DOH). This includes the number of students enrolled, how many students are exempted from immunizations, and how many students are up-to-date on their immunizations. County- and district-level data are available on the DOH website. School-level immunization data are available here and here.

Immunization exemptions for Pierce County are low. There are a few school districts that have higher percentages of exemptions than others but, overall, Pierce County has lower percentages of immunization exemptions than the state as a whole. However, aggregate data can be deceiving.

Several studies, including a recent study in California, have demonstrated that people who exempt their children from immunizations tend to cluster geographically (Imdad et al., 2013; Lieu et al., 2015; Omer et al., 2008; Smith et al., 2004). Because no vaccine is 100% effective, these clusters not only increase the risk of outbreaks of vaccine-preventable diseases among unimmunized people, they also increase the risk vaccine-preventable diseases in immunized people (Feiken et al., 2000; Omer et al., 2009; Salmon et al., 1999). People who are not vaccinated include babies who are too young to receive a vaccine and those who have medical contraindications to one or more vaccines. In the U.S., the highest incidence of pertussis (whooping cough) is in babies less than one year of age who are not old enough to have completed their primary diphtheria, tetanus, and acellular pertussis (DTaP) immunization series. Babies are also much more likely to develop complications of pertussis than older children or adults.

Measles is a highly contagious disease. The measles virus is transmitted by small respiratory droplets that can remain suspended in the air and infect another person hours later. A person with measles is contagious up to four days before the onset of rash; that is, before anyone recognizes that the person has measles.

Measles is a notifiable condition. Investigating a case of measles requires taking a history of every place the person had been for the four days before rash onset and every person that the infected person came in contact with. The health department in required to notify the public of potential exposures to measles virus. Here are some recent notifications from Pierce and King Counties:

• April 2, 2014: Possible measles exposure reported in Pierce, King and Whatcom counties
• June 27, 2014: More measles exposures occurred this week at emergency departments for Tacoma hospitals
• January 9, 2015: Measles makes it to Seattle from Disneyland; several areas risky for infection
• February 4, 2015: Brazilian’s Seattle visit may have exposed hundreds to measles

 

The authors of a study published last year estimated that, in 2011, each case of measles costs local and state health departments $11,933 to $29,833. The average length of measles outbreaks was 22 days at a cost of $4,091 to $10,228 per day, depending on the number of contacts to each case (Ortega-Sanchez et al., 2014).

There are schools in Pierce County with high percentages immunization exemptions and dozens of students who are potentially susceptible to measles. One student infected with measles could simply walk through the halls of one of those schools and start an outbreak that would cost taxpayers hundreds of thousands of dollars. Some of those schools are in my neighborhood, so my perspective on this situation is both as a public health professional and a parent.

Our society places high value on controlling vaccine-preventable diseases. That's the reason elected officials in every state have made immunizations mandatory for school entrance. Most parents in this country vaccinate their children. Nevertheless, even parents who vaccinate have concerns about vaccine safety. Vaccines have side effects. Most vaccine side effects are minor and self-limiting. Serious reactions to vaccines are rare.

Parents who vaccinate have chosen to take responsibility for protecting the health of not only their children, but also the health of their communities. While I respect the rights of parents to decide what is best for their children, I also recognize that parents who exempt their children from immunizations benefit from the protection other parents have provided their communities by vaccinating their children without taking the extremely small risk of their child having a serious adverse reaction to a vaccine.

States in which parents can easily exempt their children from immunizations have higher percentages of exemptions than states with more stringent requirements for immunization exemptions (Blank et al., 2013; Omer et al., 2006; Rota et al., 2001; Wang et al., 2014). To obtain a personal belief/philosophical exemption from school immunizations, some states require parents to write a statement explaining their reasons for seeking an exemption. Some states require parents to obtain an exemption form from a local health department and/or have the form notarized before submitting it. Other states, including Washington, require the exemption form to be signed by a licensed health care provider. Most states do not allow personal belief/philosophical exemptions from school immunizations.

The World Health Organization (WHO) estimates that 145,700 people died from measles in 2013. Measles is an eradicable disease. The WHO Region of the Americas has been free of endemic measles since 2002. Other countries and regions are close to achieving measles elimination. Measles was eliminated from the U.S. by parents who vaccinated their children against the disease. In my opinion, it would be a disservice to those parents and their children to allow measles to become endemic in this country again. For that reason, I support HB 2009. I encourage Washington State residents to contact your state legislators and let them know your thoughts on HB 2009.

Find Your Legislator

More information:

• Vaccination Exemptions
• States With Religious and Philosophical Exemptions From School Immunization Requirements
• HB 2009 – 2014-16: Concerning exemptions from immunizations for school-age children
• [Governor] Inslee supports bill to limit vaccine exemptions

References:

Blank, N. R., Caplan, A. L., & Constable, C. (2013). Exempting schoolchildren from immunizations: states with fewest barriers had highest rates of nonmedical exemptions. Health Affairs, 32(7). doi:10.1377/hlthaff.2013.0239.

Feikin, D. R., Lezotte, D. C., Hamman, R. F., Salmon, D. A., Chen, R. T., & Hoffman, R. E. (2000). Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA, 284(24). doi:10.1001/jama.284.24.3145.

Imdad, A., Tserenpuntsag, B., Blog, D. S., Halsey, N. A., Easton, D. E., & Shaw, J. (2013). Religious exemptions for immunizations and risk of pertussis in New York State, 2000-2011. Pediatrics, 132(1). doi:10.1542/peds.2012-3449.

Lieu, T. A., Ray, G. T., Klein, N. P., Chung, C,. & Kulldorff, M. (2015). Geographic clusters in underimmunization and vaccine refusal. Pediatrics, 135(2). doi:10.1542/peds.2014-2715.

Omer, S. B., Enger, K. S., Moulton, L. H., Halse, N. A., Stokley, S., & Salmon, D. A. (2008). Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. American Journal of Epidemiology, 138(12). doi:10.1093/aje/kwn263.

Omer, S. B., Pan, W. K. Y., Halsey, N. A., Stokley, S., Moulton, L. H., Navar, A. M. et al. (2006). Nonmedical exemptions to school immunization requirements. Secular trends and association of state policies with pertussis incidence. JAMA, 296(14). doi:10.1001/jama.296.14.1757.

Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, P., & Halsey, N. (2009). Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New England Journal of Medicine, 360(19). doi:10.1056/NEJMsa0806477.

Ortega-Sanchez, I. R., Vijayaraghavan, M., Barskey, A. E., & Wallace, G. S. (2014). The economic burden of sixteen measles outbreaks on Unites States public health departments in 2011. Vaccine, 32(11). doi:10.1016/j.vaccine.2013.10.012.

Rota, J. S., Salmon, D. A., Rodewald, L. E., Chen, R. T., Hibbs, B. F., & Gangarosa, E. J. (2001). Process for obtaining nonmedical exemptions to state immunization laws. American Journal of Public Health, 91(4), 645-648.

Salmon, D. A., Haber, M., Gangarosa, E. J., Phillips, N. J., & Chen, R. T. (1999). Health consequences of religious and philosophical exemptions from immunization laws. Individual and societal risks of measles. JAMA, 281(1), doi:10.1001/jama.282.1.47.

Shaw, J., Tserenpuntsag, B., McNutt, L. A., Halsey, N. (2014). United States private schools have higher rates of exemptions to school immunization requirements than public schools. Journal of Pediatrics, 165(1). doi.org/10.1016/j.jpeds.2014.03.039.

Wang, E., Clymer, J., Davis-Hayes, C., & Buttenheim, A. (2014). Nonmedical exemptions from school immunization requirements: a systematic review. American Journal of Public Health, 104(11). doi:10.2105/AJPH.2014.302190.