Measles: The forgotten killer

As a medical student, the place I dreaded most was the ward at the children’s hospital where they kept the chronic ventilator patients. Unlike the other floors, where there was shouting and laughter and tears, and all the commotion and turbulence of youth, here it was dark and lifeless and eerie, with no sound except the hum of the ventilators, and the rattle of air being forced through plastic tubes. It was a place of failure and defeat, the desolate aftermath of some vast and tragic battle.

An unexpected aftermath of measles

My patient was a teenager who had been in a coma for years. His limbs had stubbornly twisted up in the contortions that a damaged brain inflicts on a body, despite operations to keep them straight. The expectations for my care were low. I was to try to keep his lungs from plugging up with sputum, to prevent him from getting more bedsores, to watch his feeding tube for clogs, and to make sure that his eyes were not drying out and getting ulcers.

He once had been a bright and healthy boy with measles, who apparently had made an uneventful recovery. But a few years later, he began to struggle in school. He became clumsy, dropped things, and fell for no reason. To the terror of his parents, he started to have seizures. A brain biopsy showed the culprit: a mutated measles virus that causes a progressive, incurable form of dementia known as subacute sclerosing panencephalitis (SSPE). And now he would never again play baseball, or hear birds sing, or feel the sun on his face. He would never learn to drive or go to prom. In fact, he would never leave this gloomy brick tower alive.

Nervous system complications after measles

We think of measles as a minor viral infection of kids that causes fever, rash, and a runny nose, and goes away without major complications. Unfortunately, that is not always so. Nervous system disease is a particular problem. SSPE occurs as a late, fatal measles complication in one out of 1,367 cases of measles in children younger than five. One out of 1,000 children with measles gets infection of the brain (encephalitis) early in the course of measles. About 15% of children with measles encephalitis die. Measles encephalitis led to the death of the writer Roald Dahl’s daughter, Olivia.

Children’s brains can also develop an allergic reaction to the measles virus several weeks after infection. This is called acute disseminated encephalomyelitis (ADEM). Children seem to recover, then get fever, confusion, headaches, and neck stiffness. Like SSPE and measles encephalitis, ADEM occurs in about one out of 1,000 cases of measles. It is fatal in 10% to 20% of patients. Survivors of measles encephalitis and ADEM often have epilepsy, brain damage, or developmental delay.

Measles has other serious complications. During pregnancy, it causes miscarriages. Measles can infect the cornea, and was once a common cause of blindness. Ear infections and hearing loss are frequent. Measles virus also infects the lungs, causing pneumonia in 3% to 4% of cases. Measles weakens the immune system for at least two months. Sometimes patients die of other infections immediately after they recover from measles. In a measles epidemic that killed more than 3,000 soldiers in the US Army in 1917–18, bacterial pneumonia was the major cause of death.

When vaccination rates plummet, measles outbreaks rise

Measles is very contagious. One person with measles, let loose in a community without immunity, will infect nine to 18 other people. In 2002,  the United States was declared free from ongoing measles transmission in 2000. But we’re vulnerable to cases imported from elsewhere. Occasional large outbreaks have occurred in recent years when measles has been unleashed in regions with low vaccination rates. In 2014, 383 people got measles in an Amish community in Ohio. In 2017, 79 people were infected in Minnesota, most of them unvaccinated Somali-American children. Since the beginning of 2019, more than 800 cases have been reported in a multistate outbreak. A large number of cases have occurred in Orthodox Jewish populations in New York City, and a smaller number among unvaccinated children in Washington State. No one has yet died as a result of these outbreaks, due to the capabilities of modern medicine and a good measure of dumb luck. But the intensity and scope of these outbreaks threatens to bring measles back as a full-time threat to American kids.

Vaccination rates for measles are falling because of anti-vaccine activists who have pushed a debunked connection between autism and the MMR vaccine. While most of the United States still has vaccination rates of 90% to 95% — adequate to prevent measles transmission — vaccine refusal has created islands of vulnerability. Large swaths of rural Idaho, Wisconsin, Utah, and Maine have plummeting measles vaccination rates. So do major metropolitan centers such as Seattle, Portland, Austin, Phoenix, Salt Lake City, Houston, Kansas City, Detroit, and Pittsburgh.

How can you protect yourself and people you care about from measles?

• Find out if you are immune to measles. Most adults who have had one dose of MMR vaccine or who were born before 1957 are immune. Some people born in the 1960s may not be immune because the killed measles vaccine did not provide sufficient protection.
• If you are not certain you are immune, ask your doctor to test whether you have an antibody to measles. Just thinking you had the measles is not sufficient. Many people who think they’ve had measles actually lack the measles antibody.
• If you do not have measles antibody, get the MMR vaccine. One dose of MMR vaccine provides 93% protection against measles. Two doses provide 97% protection. The 3% of people who get measles after vaccination have mild disease and are less likely to spread it to others. It’s especially important to get the vaccine before travel to a foreign country.
• Vitamin A deficiency is associated with higher mortality in measles. Vitamin A supplementation reduces deaths in children hospitalized with measles. Make sure you’re getting enough vitamin A from healthy dietary sources such as sweet potatoes, spinach, carrots, cantaloupe, and pumpkin.

If you have friends or family who are hesitant about vaccines, talk to them about their fears in a sympathetic and nonjudgmental way. Make sure they are aware of the serious risks that measles may pose to their children and provide them with information about vaccine safety.

Follow me on Twitter at@JohnRossMD

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