Measles in Brooklyn

The question a story like this prompts, is why? Why, in the face of easy, accessible vaccination do people still not vaccinate their children? There are currently 34 reported cases in a Measles outbreak in Brooklyn, NY. All were unvaccinated at the time of infection–23 who had refused vaccination, 6 who had delayed vaccination, and the saddest part: 5 who were too young to be vaccinated. 26 were children.

Some of you who read this may think, “so what? Measles isn’t so bad…a little rash, a little fever…” Not in this case, from the New York DOHMH themselves: “Complications have included pneumonia, a miscarriage, and two hospitalizations.” Measles can injure. Measles can kill. It is not a joke. For the parents of the children who have been infected to have willfully either delayed or denied vaccines to their children, is akin to have purposefully done them harm.

Just as bad, the actions of this (for now) relatively small group has inflicted considerably larger damage to those around them. The 34 people infected have exposed more than 700 people, resulting in mass screening and prophylaxis at local hospitals that equates to considerable time and healthcare expenditure. And those 700 who may not be ill, but who have to take time out of their life to prove their measles immunity or receive a dose of post-exposure vaccine or antibody that they may not have wanted to take, well I guarantee you they are not happy about the impact this outbreak has had on them.

Finally, the 5 children who were too young to be vaccinated–they did not do anything to deserve a measles infection. Their parents may have even been planning to do their duty and vaccinate. But because of the ignorant actions, or lack thereof, of a group of people who are anti-vaccination, innocent children have suffered. This is not okay. This is not right.

We do not allow child abuse. We do not allow child neglect. Well, where do we draw the line? For how long will we continue to tolerate willful vaccine delay or refusal? The outbreak is at 34. For now. Must it spread further? Must adults die? Must children die? Measles is preventable. This is preventable. Vaccinate yourselves and your children and help prevent outbreaks like this.

The text of the Health Department’s Alert e-mail follows:

May 21, 2013

ALERT # 12: Update on Measles in New York City

1) 34 cases of measles have occurred in Borough Park and Williamsburg, Brooklyn. Additional cases will likely occur, because a large number of children and adults have been exposed to infectious cases. 2) Providers are reminded to consider the diagnosis of measles in clinically compatible cases, immediately report and isolate suspect cases, and vaccinate children and adults. 3) Children need to receive their first dose of MMR vaccine at 12 months of age. Older unvaccinated children should be immunized immediately.

Distribute to All Primary Care, Infectious Disease, Emergency Medicine, Internal Medicine, Pediatrics, Family Medicine, Laboratory and Infection Control Staff

Dear Colleague,

The measles outbreak in Brooklyn is continuing to grow. To date, there have been 34 confirmed cases, including 27 in Borough Park and 7 in Williamsburg. Additional suspected cases are being investigated. All cases are part of the Orthodox Jewish community and were unvaccinated at the time of exposure, including 5 cases too young to have been vaccinated, 23 cases who refused vaccine, and 6 cases whose vaccines were delayed. Cases range in age from 0 to 32 years (median 7 years), including 5 infants, 21 children, and 8 adults. Complications have included pneumonia, a miscarriage, and two hospitalizations. Measles is highly contagious. We have identified over 700 people who have been exposed, predominantly in health-care settings. Home isolation is required for up to 21 days for exposed persons without evidence of immunity to prevent further exposures. To interrupt the spread of measles in your community, we ask for your assistance regarding reporting, isolation, prophylaxis, testing, and vaccination.

Reporting
Report any suspected measles case with generalized rash and fever to the Department of Health and Mental Hygiene (DOHMH) immediately. Do not wait for laboratory testing to report. Delays in reporting have resulted in missed opportunities to prevent disease using post-exposure prophylaxis. To report, call 347–396–2402 (weekdays 9–5pm) or 212–764–7667 (after hours and weekends).

Isolation
Place suspected cases immediately in an airborne isolation room. Alternatively, see them at the end of the day after all other patients have left the office. Avoid having patients with rash in the waiting room. Post a sign outside your office notifying patients with rash to call before entering. If an airborne isolation room is not available, place a mask on the patient, and don’t use the exam room for up to two hours. Tell suspected cases to stay home while contagious, until day five after rash onset.

Post-exposure Prophylaxis
If a suspected exposure occurs in your office, offer the 1st or 2nd dose of MMR vaccine within 72 hours to everyone aged 6 months and older who was in your office through two hours after the suspected case left and who does not have a contraindication to vaccine. Do not delay MMR if immunization records are not readily available; there is no harm to giving an extra dose to someone who is fully vaccinated. Wait at least 28 days between doses of MMR. Exposed staff without evidence of immunity should be furloughed from days 5 through 21 after exposure, regardless of receipt of post-exposure prophylaxis.

Immune globulin should be given as soon as possible to susceptible individuals exposed to measles who are at high-risk for complications: infants aged under 6 months, infants aged 6 - 12 months who do not receive MMR within 72 hours, immunocompromised persons, and pregnant women who are not immune to measles. Immune globulin must be given within 6 days of exposure to prevent or modify measles.

Laboratory Testing
Collect blood for measles IgM and IgG and nasopharyngeal swabs for PCR testing of suspected cases. DOHMH will pick up and test specimens. Synthetic (non-cotton) swabs and liquid viral transport media can be purchased from commercial laboratories. These are the same kits used for influenza testing. DOHMH can also provide kits as needed, while waiting for your supply. Do not send specimens to a commercial lab for testing as this will only delay the diagnosis and delay outbreak control measures.

Timely vaccination
Ensure patients are up to date with their 1st dose of MMR at age 12 months and 2nd dose at age 4 to 6 years. Administer immunizations at the start of recommended interval. Do not delay. For assistance generating recall letters for patients not up to date with MMR or for assistance ordering MMR vaccine, call 347–396–2400. Children aged 6 to 11 months who will be traveling internationally should receive a dose of MMR before travel, although this dose does not count towards completion of the routine schedule. Ensure all healthcare staff have two documented doses of measles-containing vaccine or a positive measles IgG titer.

Please call DOHMH if you have questions at 347–396–2402 (weekdays 9–5pm) or 212–764–7667 (after hours and weekends). Your cooperation is appreciated.

Sincerely,

Jennifer Rosen, MD
Director, Epidemiology and Surveillance
Bureau of Immunization
NYC DOHMH

Jane Zucker, MD, MSc
Assistant Commissioner
Bureau of Immunization
NYC DOHMH