Summary and Key Takeaways
In the newest installment of our Medscape Masters series, a panelist of experts tackled the current onslaught of the measles virus that physicians are seeing more than they ever thought they would in their lifetime.
To discuss measles, vaccine hesitancy, and fighting disinformation, moderator and WebMD’s Chief Physician Editor Neha Pathak, MD, was joined by Paul Offit, MD, an expert virologist, immunologist, and co-inventor of the rotavirus vaccine, as well as Margot L. Savoy, MD, MPH, senior vice president, Department of Education, Inclusiveness & Physician Well-Being at the American Academy of Family Physicians; and Robert M. Jacobson, MD, a population health researcher and pediatrician at the Mayo Clinic.
Dispelling Myths
Many parents might think their children don’t need the MMR vaccine because measles was eradicated — and it was. But it’s back, and in order to prevent the spread, children should be vaccinated.
“We eliminated measles in this country by the year 2000 when we had a two-dose vaccine; we had school mandates that were enforced,” Offit said. “We were able to eliminate the world’s most contagious infectious disease… [f]ive times more contagious than influenza, SARS-CoV-2, or RSV.”
Offit, who had measles as a child, explained that when immunization rates decline, the measles virus is the first to come back into the mainstream. It’s “the canary in the coal mine” of viruses, he noted.
At the time of the webinar recording, there were approximately 340 confirmed cases of measles in West Texas. According to Offit, that number is probably a severe underestimate.
For those who wonder whether they need to get a booster, or whether they were ever vaccinated against measles in the first place, Offit has some advice: If you were born before 1957, you can assume that you were naturally infected, which means you have lifelong immunity. A birth year from 1957 to 1967 is a grey area; if you got inoculated as a child during those years, Offit said it’s worth it to get revaccinated.
Children as young as 6 months can get the shot, as maternal immunity probably has faded by then, putting them at extremely high risk. In those situations, children should be immunized again once they hit the 12-15 months mark, with another at 4-6 years old.
Is Your Practice Prepared?
For physicians like Margot Savoy, measles was never high on the list of concerns in her practice because of its previous eradication. In this moment, healthcare professionals are asking each other, what does measles actually look like and how would I diagnose it?
“Many people were spending a lot of time worrying about the rash,” said Savoy. “But the rash is kind of the least of your problems, because by the time you get the rash, you’ve already infected everybody.”
This is why physicians must pay attention to the earlier symptoms, which might look a lot like influenza or COVID-19, with fevers, cough, and runny nose. Now, around spring, it can even look like bad allergies. A high fever is a critical component, especially if a patient has been traveling or was exposed to the virus. Patients with measles are typically contagious 4 days before the rash starts and 4 days after it appears. The virus is highly contagious because it can remain suspended in air for 2 hours.
The associated rash may feel like sandpaper and not always be itchy. In people with darker skin, Savoy said, the rash may not even be detectable unless a very close, thorough examination is performed. Physicians should familiarize themselves with images of measles rashes across an array of skin tones. The rash travels from head to toe and can produce small white spots inside the mouth.
Savoy said that patients suspected of having measles shouldn’t necessarily come into the office or stay in the waiting room with other potentially vulnerable people. In this situation, screening outside of the office or via a telemedicine visit may be crucial.
Fighting Vaccine Hesitancy and Disinformation
According to Jacobson, measles has returned because of general complacency, our country’s growing distrust in healthcare, and a resurgence of the disproven notion that vaccines cause autism. That’s why physicians need to use every visit to educate patients and their families about the value of immunization and get them vaccinated.
“Use the ankle sprain visit for immunization; use that depression follow-up visit for this,” Jacobson said.
Before going into the exam room, physicians should know whether and when their patients are due for a vaccine, the benefits of getting vaccinated now vs later, and how to address vaccine hesitancy.
Jacobson said physicians should also recognize the difference between true and false contraindications. Mild illness, having an injury, and even a low fever are not contraindications for vaccination. A true contraindication is being moderately to severely immunocompromised. Physicians won’t give the MMR shot (a live-virus vaccine) to someone who is pregnant, but there’s no need to test someone for pregnancy before deciding to immunize.
Offit said it’s also crucial to understand why parents are hesitant to vaccinate their children.
“It can mean as many as 25 inoculations; it can mean as many as five shots at one time to prevent diseases most people don’t see, using biological fluids most people don’t understand,” Offit said. “Their hesitancy makes perfect sense.”
For Jacobson, issuing strong recommendations and using presumptive language in the exam room is a good way to get patients leaving with a vaccination.
“They’re coming to us for our advice. We talk to them in terms of the order of the day, what they can expect. If they want to hesitate, they will.”
Savoy said physicians also have to work on breaking down their own biases and preconceptions about patients’ relationships with vaccines, which sometimes can lead to discussions about hesitancy concerns with patients who may not have had any doubts to begin with.
“The vast majority of people [who have doubts] are hesitant but not resistant,” she said. “Take your own pulse first.”
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