“The longer these (measles) outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States.”

PART 1. April 30, 2019

PART 2. May 6, 2019. “We are getting very close to a tipping point. If (measles) cases continue to escalate, the U.S. could lose its elimination status…”

Assignment: Develop a continuum of evidenced based strategies for states focusing on avoiding measles cases (22 states are already “infected”)

New PART 2 after PART 1

PART 1. April 30, 2019

“The longer these (measles) outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States.”

“The number of measles cases in the United States has risen to 695, the highest annual number recorded since the disease was declared eliminated in this country in 2000, federal health officials said on Wednesday.

The total has now surpassed the previous high of 667 set in 2014, according to the Centers for Disease Control and Prevention. The virus has been detected in 22 states.

Most cases are linked to two large and apparently unrelated outbreaks. One is centered in Orthodox Jewish communities in New York City and its suburbs; that outbreak began in October and recently spread to Orthodox communities in Michigan.

The other outbreak began in Washington State…

The New York outbreak was set off by Americans who had visited Israel, where cases have been spreading in Orthodox communities since early last year. City officials have taken extraordinary measures to crack down on resistance to immunization.

Mayor Bill DeBlasio declared a state of emergency and threatened residents of four Brooklyn ZIP codes with $1,000 fines if they refused to vaccinate.

Twelve summonses have been issued so far, the city health department said; people who do not answer them can be fined $2,000. City officials closed a yeshiva preschool for violating vaccination orders.

Rockland County, N.Y., the center of another outbreak, initially barred unvaccinated children from all indoor public places, including schools, malls, supermarkets, restaurants and houses of worship.

After a court blocked that order, the county instead barred from public spaces anyone who had measles symptoms or who had recently been exposed to the disease, threatening them with fines of up to $2,000 a day.”  (A)

“More than 1,000 students and staff members at two Los Angeles universities were quarantined on campus or sent home this week in one of the most sweeping efforts yet by public health authorities to contain the spread of measles in the U.S., where cases have reached a 25-year high.

By Friday afternoon, two days after Los Angeles County ordered the precautions, about 325 of those affected had been cleared to return after proving their immunity to the disease, through either medical records or tests, health officials said.

The action at the University of University of California, Los Angeles, and California State University, Los Angeles — which together have more than 65,000 students — reflected the seriousness with which public health officials are taking the nation’s outbreak…

“This is a legally binding order,” the county’s public health director, Dr. Barbara Ferrer, told reporters.”

Anyone who violates it could be prosecuted, she said, but added that it appears everyone is cooperating so far. She didn’t describe what penalties those who don’t could face.  (B)

Measles is making a comeback in 2019.

“Since January of this year, 22 states have experienced a total of 695 cases of measles, an infectious disease that was supposed to be eradicated almost two decades ago following an outbreak of more than 30,000 cases and a push to get everyone vaccinated — twice…

“This year is the worst since 2000.” said Dr. Sean O’Leary, a pediatric infectious diseases specialist working with the American Academy of Pediatrics. “There are more pockets now of parents who have chosen not to immunize their kids. And when someone with measles comes into that community, it spreads.”” (C)

CDC Measles Tracking by State

https://www.cdc.gov/measles/cases-outbreaks.html

HISTORY (D)

Pre-vaccine Era

In the 9th century, a Persian doctor published one of the first written accounts of measles disease.

Francis Home, a Scottish physician, demonstrated in 1757 that measles is caused by an infectious agent in the blood of patients.

In 1912, measles became a nationally notifiable disease in the United States, requiring U.S. healthcare providers and laboratories to report all diagnosed cases. In the first decade of reporting, an average of 6,000 measles-related deaths were reported each year.

In the decade before 1963 when a vaccine became available, nearly all children got measles by the time they were 15 years of age. It is estimated 3 to 4 million people in the United States were infected each year. Also each year, among reported cases, an estimated 400 to 500 people died, 48,000 were hospitalized, and 1,000 suffered encephalitis (swelling of the brain) from measles.

Vaccine Development

In 1954, John F. Enders and Dr. Thomas C. Peebles collected blood samples from several ill students during a measles outbreak in Boston, Massachusetts. They wanted to isolate the measles virus in the student’s blood and create a measles vaccine. They succeeded in isolating measles in 13-year-old David Edmonston’s blood.

In 1963, John Enders and colleagues transformed their Edmonston-B strain of measles virus into a vaccine and licensed it in the United States. In 1968, an improved and even weaker measles vaccine, developed by Maurice Hilleman and colleagues, began to be distributed. This vaccine, called the Edmonston-Enders (formerly “Moraten”) strain has been the only measles vaccine used in the United States since 1968. Measles vaccine is usually combined with mumps and rubella (MMR), or combined with mumps, rubella and varicella (MMRV). Learn more about measles vaccine.

Measles Elimination

In 1978, CDC set a goal to eliminate measles from the United States by 1982. Although this goal was not met, widespread use of measles vaccine drastically reduced the disease rates. By 1981, the number of reported measles cases was 80% less compared with the previous year. However, a 1989 measles outbreaks among vaccinated school-aged children prompted the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) to recommend a second dose of MMR vaccine for all children. Following widespread implementation of this recommendation and improvements in first-dose MMR vaccine coverage, reported measles cases declined even more.

Measles was declared eliminated (absence of continuous disease transmission for greater than 12 months) from the United States in 2000. This was thanks to a highly effective vaccination program in the United States, as well as better measles control in the Americas region.

Photos reveal what it looks like to get the measles when there are no vaccines, by Hilary Brueck,

https://www.businessinsider.com/what-measles-looks-like-2019-4

Complications (E)

Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea.

Even in previously healthy children, measles can cause serious illness requiring hospitalization.

One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.

One or two out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.

Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection.

People at High Risk for Complications

People at high risk for severe illness and complications from measles include:

Infants and children aged <5 years

Adults aged >20 years

Pregnant women

People with compromised immune systems, such as from leukemia and HIV infection..

Healthcare personnel

Healthcare personnel should have documented evidence of immunity against measles, according to the recommendations of the Advisory Committee on Immunization Practices

“In asserting the constitutionality of vaccination mandates and coercive public health orders, public health lawyers generally look back to the Supreme Court’s 1905 case of Jacobson v. Massachusetts. In that case, the Supreme Court upheld a law mandating smallpox vaccination stating, “Upon the principle of self-defense, of paramount necessity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.”

The Jacobson case is still the starting point for any discussion of the constitutionality of public health emergency powers, and courts in the modern era have continued to cite it in upholding state vaccine mandates…

The reason Jacobson endures, while other cases and public health practices from its era have been cast aside, is that its central message — “there are manifold restraints to which every person is necessarily subject for the common good” — remains as relevant today as it was in 1905. Public health still requires some limitations on individual freedom. Still, exactly what limitations Jacobson countenances, and how its reasoning should be applied in our own, very different era, are deeply contested and will assuredly be debated as the New York litigation continues.

Even if the courts conclude, as they might, that Jacobson supports the Rockland County and New York City orders, that doesn’t mean Jacobson provides the most effective model for stopping contemporary outbreaks. After all, in what other areas do public officials rely upon approaches that were used in 1905?..

No compromise is likely to be perfect, or fully effective. Many will likely fail. But the return of measles suggests that our old, tried-and-true methods of mandates and emergency orders don’t seem to be solving the problem of vaccine resistance. New tools are needed before more dangerous outbreaks of even more lethal diseases occur. “ (F)

‘Ninety-nine times our legislative bodies have passed such legislation. And that’s gone to the governors that have represented the entire political spectrum in the United States that have signed that legislation all for the benefit of our children and healthier communities. Now think about that — 99 times. That’s the epitome of democracy. Nothing that I can think of has been so profound in affecting the health of children, because those laws have obliged most children to be vaccinated…

But measles has been reintroduced into the Western Hemisphere in two countries; in the United States and Venezuela. What? Two different reasons. In the United States, it’s because some parents, whether for cultural reasons, misunderstood religious reasons, or kind of libertarian reasons, have withheld many children from vaccination creating pockets and communities of susceptible children…

I think every child should be vaccinated and I will now make a bold statement. I think there ought to be valid — valid — medical reasons for exclusion from vaccination. I’m not a friend of either personal belief or religious exemptions. We have three states that have such tight laws now: West Virginia, Mississippi, and California. I think they’re leaders and the rest of us should follow. I wouldn’t want any child to suffer measles or its complications.

I’ll remind you of one thing before I come to a close. Before we had [a] measles vaccine, 400 to 500 children died in the United States annually because of measles and its complications. That number now is zero.”… (G)

“Measles, a virus that invades the nose and throat, causing fever, cough and phlegm, is one of the most contagious pathogens on the planet. Before 1963, it infected some four million people every year in the United States alone. Nearly 50,000 of them would land in the hospital with complications like severe diarrhea, pneumonia and brain inflammation that sometimes resulted in lifelong disability. Of the 500 or so patients who died from these complications each year, most were children younger than 5.

Until recently, those numbers were a matter of history. The measles vaccine, which was introduced to the United States in 1963, drove the annual case count from four million to zero inside of four decades. Measles was officially eradicated in America in 2000 and was largely wiped from our collective memory soon after.

But in the shadow of that memory lapse, a different virus has spread: anti-vaccine propaganda and vaccine misinformation. Both have persuaded a small but growing number of parents that vaccines designed to inoculate against infectious diseases pose a greater health risk than the diseases themselves. As a result, these parents are skipping crucial shots for their children. And as the number of unvaccinated children grows, some vaccine-preventable diseases are making a comeback.

The Centers for Disease Control and Prevention has logged at least six measles outbreaks so far this year, across five states, involving more than 100 patients. In recent weeks, as those numbers have ticked upward, both houses of Congress have held hearings to discuss the issue, while more states have considered limiting vaccine exemptions for school-age children and several prominent social media platforms have pledged to block anti-vaccine propaganda and vaccine misinformation from their sites…

But the new rash of outbreaks has made clear that even small pockets of vaccine hesitancy and refusal can have grave consequences. And health officials say that if left unchecked, this outbreak crisis will only worsen…” (H)

 “The outbreak of measles in the U.S. and around the world is due largely to inadequate vaccination rates in some communities, not illegal immigration, as one popular meme on Facebook claims.

The meme shows a picture of a baby who appears to be infected with measles and says: “Thanks to a highly effective vaccination program the Measles virus was eliminated from the U.S. in 2000. Thanks to the immigrants who illegally cross the U.S. Mexican border, and the Democrats who refuse to stop them, the Measles virus has been declared a public health emergency in 2019.”

The first part of that claim is correct. Measles was eliminated in the United States in 2000 and it was eliminated across both North and South America in 2016…

The second part of the claim, however, is incorrect.

The virus has been brought into the U.S. by people who have traveled to places where there is an outbreak or where the disease is still common, such as parts of Europe, Africa, Asia, and the Pacific, according to the Centers for Disease Control and Prevention. From those travelers, the disease can then spread in U.S. communities that have unvaccinated people, according to the CDC.

For example, the New York City health department declared a public health emergency on April 9. That measles outbreak, which started in 2018 and spread in the Orthodox Jewish community, was brought on by travelers who had been in Israel, where a large outbreak is occurring, according to the Pan American Health Organization”… (I)

“The Washington state Senate narrowly passed a measure late Wednesday that would make it harder for parents to opt out of vaccinating their children against measles in response to the state’s worst outbreak in more than two decades.

The bill, which would eliminate personal or philosophical exemptions from the measles, mumps and rubella (MMR) vaccine, is a victory for public health advocates who had not expected it to make it to the floor…

The bill is expected to pass the House, where a nearly identical measure was approved last month, and be signed into law by Gov. Jay Inslee (D). It would be the first time in four years a state has removed personal exemptions in the face of growing anti-vaccine sentiment. California and Vermont removed personal exemptions in 2015. Other states have tightened vaccination requirements but have not removed exemptions…

The stricter rule would apply only to immunizations for measles, mumps and rubella. Parents would still be able to cite personal or philosophical exemptions to avoid other required school vaccinations for their children. Religious and medical exemptions will still be allowed for all vaccinations, including MMR.

Advocates and lawmakers were able to overcome strong lobbying by anti-vaccine groups, which are among the most vocal and organized in the country. Those groups mobilized hundreds of supporters, who telephoned and sent emails to lawmakers, turned out for public hearings and proposed poison-pill amendments, intended to weaken a bill or ruin its chances of passing…

Campaigns to toughen state requirements in Iowa, Colorado, Maine and Oregon also face strong opposition. Washington is one of 17 states that allow exemptions from required immunizations for personal or philosophical beliefs.”  (J)

California would give state public health officials instead of local doctors the power to decide which children can skip vaccinations before attending school under legislation proposed Tuesday to counter what advocates call bogus exemptions.

The measure would also let state and county health officials revoke medical exemptions granted by doctors if they are found to be fraudulent or contradict federal immunization standards. The proposal comes amid measles outbreaks in New York, Washington and elsewhere that are prompting states including Maine and Washington to consider ending non-medical exemptions.

California eliminated all non-medical immunization exemptions in 2016, as have Mississippi and West Virginia. The lawmakers want California to now follow West Virginia’s lead in having public health officials rather than doctors decide who qualifies for medical exemptions. Doctors would send the state health department the reason they are recommending the exemption and would have to certify that they examined the patient….(K)

“In a statement this week, U.S. Secretary of Health and Human Services Alex Azar reiterated a tactic that has proven ineffective at reaching skeptical populations in recent years: telling them what to do. “Vaccines are a safe, highly effective public-health solution that can prevent this disease,” he said. “The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken.”…

Research suggests that the reason informed people fall into conspiracy-theory mind-sets often has less to do with a lack of information than with social and emotional alignment. Facts are necessary, but not at all sufficient. Websites and YouTube videos where a federal employee in a suit states various statistics are unlikely to be effective against targeted disinformation campaigns that only need to plant the seed of doubt in the mind of people already skeptical of the medical establishment. The work of global inoculation requires first rebuilding a social contract, which means meeting people on the platforms where they now get their information, in the ways they now consume it.” (L)

“It was actually measles outbreaks in the 1960s that inspired a push to have states require children get inoculated before starting kindergarten. By the 1980s, all states had mandatory immunization laws in place. The idea behind these laws was simple: Near-universal vaccinations sustain herd immunity.

Still, there’s a lot of variation across the country when it comes to immunization requirements. Even though all 50 states have legislation requiring vaccines for students entering school, almost every state allows exemptions for people with religious beliefs against immunizations, and 17 states currently grant philosophical exemptions for those opposed to vaccines because of personal or moral beliefs. (The exceptions are Mississippi, California, and West Virginia, which have the strictest vaccine laws in the nation, allowing only medical exemptions.)

In these places, opting out can mean simply listening to a doctor or health official explain the benefits of vaccination or getting a signed statement about your religious beliefs notarized. It’s often harder for parents to sign their kids out of school for the day than to help them avoid vaccines.

In 45 states, even without an exemption, kids can be granted “conditional entrance” to school on the promise that they will be vaccinated, but schools don’t always bother to follow up…

California has made it tougher to opt out of vaccines — with mixed and instructive results

Some states have been moving to crack down on vaccine avoiders — most notably California — and the experience there is instructive for states that might want to close some of their loopholes…

There is indeed evidence from Mississippi and West Virginia that strict vaccine laws can work — but again, interpret it with caution.” (M)

“If the U.S. loses its “measles elimination” status, it will join Venezuela as the only other country in North and South America with this distinction. Measles was declared eliminated across the Americas in 2016, but within a year, an outbreak sparked in Venezuela that has persisted up to the current day.

For most Americans, these outbreaks are a bittersweet wake-up call about the importance of the measles-mumps-rubella (MMR) vaccine. Thanks to the success of vaccination programs, most people are unfamiliar with measles itself — which means they may be unsure about how to approach these outbreaks and protect themselves.” (N)

“And although the majority of people getting the illness now were never vaccinated, the expanding outbreaks have raised new questions about whether some older adults — including many of those born before the mid-1960s — should be revaccinated, along with some younger people uncertain of their immunization status.

According to the Centers for Disease Control and Prevention, people who were vaccinated prior to 1968 with an early version of the vaccine, which was made from an inactivated (killed) virus, “should be revaccinated” with at least one dose of live attenuated measles vaccine.

Today’s recommended vaccine is known as MMR and protects against measles, mumps and rubella.

“This recommendation is intended to protect those who may have received killed measles vaccine, which was available in 1963-1967 and was not effective,” according to this Q & A on measles from the CDC…”  (O)

PART 2. May 6, 2019

“We are getting very close to a tipping point. If (measles) cases continue to escalate, the U.S. could lose its elimination status…”

“ON AN OTHERWISE normal Thursday in November 2018, the doors to the Lowell Community Health Center in Massachusetts opened at 8 a.m., as they always do, and the first of 802 patients who would walk through those doors began trickling in…

This routine — a seemingly banal choreography repeated hundreds of times each day — continued until around 12:50 p.m., when a mother arrived with her two-year-old daughter. The child had measles, and suddenly, this was no longer an ordinary day. For virtually anyone not immune to the virus who crossed paths with the toddler, infection was almost certain, and so all of those places the child had been and the rooms where she may have coughed or sneezed became critical evidentiary artifacts in a crisis that had all the potential to spin quickly out of control.

Indeed, the arrival of mother and child set off a chain of events and triggered longstanding but rarely tested protocols aimed at containing a measles outbreak. It involved hundreds of staff not just at the Lowell Community Health Center, but also the Massachusetts Department of Public Health (DPH), the City of Lowell Health Department, and the local hospital — with thousands of emails and a weeklong flurry of activity that strained the center’s capacities to the limit…

That the center managed to contain the highly-contagious measles virus is a testament to its modernized records system, its staff’s military-style precision, and its location in a resource-rich region. But even here there were occasional missteps, bouts of confusion, and administrative second-guessing and finger-pointing. There were also 179 exposed people with no evidence of vaccination — even though the center tried to reach them — suggesting that the fallout at a less-prepared facility could be disastrous…

ON NOVEMBER 7, the child’s mother called the center for an appointment. She said her daughter had a cough and a rash and some sores in her mouth, and asked if they could come in.

Here, the staffer on the phone made the first crucial mistake. Lowell is an old New England mill town with weathered red-brick buildings interconnected by canals, and as a large suburb of Boston, it is heavily populated these days by immigrants; nearly 40 percent of the center’s patients don’t speak English. Protocol would have dictated that center staff ask the mother about recent travel while she was still on the phone, but that didn’t happen. Had the question been asked, staff would have learned that the mother and child had just returned from a month-long trip to an African country where measles is endemic. Although the toddler had received one shot of the measles, mumps, and rubella (MMR) vaccine at the center when she was one, and a single dose is supposed to be 93 percent effective, it may have been no match for the heavy exposure.

Had the staffer asked, mother and daughter would likely have been directed straight to an isolation room, intended for anyone with a contagious illness, on the center’s ground floor. Instead, they came to the center and disclosed to a medical assistant upon arrival that the child had contracted measles abroad…

At approximately 2 p.m., they gathered in a conference room to strategize and to connect with other officials via conference call. Health care organizations are required to have an emergency plan in place, and the center’s chief information officer, Henry Och — an infantry officer in the National Guard, with stints in Kosovo and Afghanistan — would play the role of incident commander…

 “If this happened in a school and not a health center — who’s responding, and how is it being managed?” Vigroux asked. “I think our community is not ready for that.” (A)

“Incidence of measles in Europe spiked dramatically from 2016-2018 in a handful of countries, led by the Ukraine, researchers found…

The World Health Organization’s (WHO) European Region, which contains countries outside of what is traditionally thought of as Europe, went from a little under 5,300 reported cases of measles in 2016 to nearly 83,000 reported cases of measles in 2018 — a fourteen-fold increase, the authors wrote in the Morbidity and Mortality Weekly Report…

When citing reasons for ongoing measles transmission, the authors pointed to factors that appear to be playing a role in the U.S.’s ongoing measles outbreak — namely “an accumulation of susceptible young children in marginalized communities with suboptimal coverage.” Other reasons included persistent measles virus reservoirs in WHO European Region countries “with limited resources and weak immunization systems.”

The majority of measles cases were from the Ukraine — which was previously cited by CDC researchers as one of the top three countries exporting measles to the U.S. In 2018, there were over 53,000 cases in the Ukraine, comprising two-thirds of all measles cases in this region. Second was Serbia, with around 5,000 cases (6% of the total) followed by France and Israel with about 2,900 cases each (each 4% of the total)…”  (B)

“New Jersey’s growing measles outbreak appears to have roots in Israel, New York City and New York’s Rockland County, according to Garden State officials.

Department of Health Commissioner Dr. Shereef Elnahal said a combination of travelers returning from countries where measles is rampant, and individuals crossing back and forth between neighboring states, is largely responsible for the situation in New Jersey. Fourteen Garden State residents have been diagnosed with the virus this year, in addition to the 33 infections detected last fall. Another case is expected to be confirmed this week.

But with New York City experiencing a more severe outbreak, with at least 420 cases, and another 200-plus diagnosed in nearby Rockland County, the threat of cross-border contamination is significant, Elnahal said. Most of the infections have been found within Orthodox Jewish communities in both states, including Ocean County’s Lakewood.

Since community members often travel back and forth for family visits, work or worship, Elnahal said “the transit between New York and New Jersey is the biggest concern now. And the collaboration with (local and state health officials in New York) has been critical.” International travelers have long been the source of viral infections in the United States, Elnahal said, but with more people refusing the vaccine there is a greater chance that infected voyagers can transmit the disease, which spreads quickly in communities with low immunization rates…

Exemptions are permitted for medical reasons (those with compromised immune systems are at risk) and also for religious reasons, although lawmakers in New Jersey and several other states are looking to eliminate the religious opt-out. Elnahal said all the religious leaders he has encountered, including prominent Jewish officials, have urged their followers to comply with vaccination laws.” (C)

“The country is experiencing the worst year for measles in a quarter century, according to the Centers for Disease Control and Prevention (CDC), with 704 reported cases. And New Jersey is right in the middle of an outbreak…

While it’s unlikely New Jersey would ever see hundreds or thousands of cases at once, the state could see localized epidemics with “pockets of people with low vaccination rates getting many infections,” Dr. David Cennimo, an infectious disease expert at Rutgers New Jersey Medical School, said via text

Cennimo said the state is already seeing a “disruption in medicine because of concern for measles.” Treating a measles patient is often tedious and cumbersome, he said.

“Measles is airborne, so people need to stay in special negative-pressure rooms. … These rooms aren’t plentiful,” Cennimo said in an email. “You cannot have a patient walking into a waiting room with measles without a mask on because they can infect everyone.”

Measles is so contagious that 90% of susceptible people exposed to an infected person will become infected, according to the CDC. If outbreaks continue, experts worry about measles patients walking among the public or in hospitals, potentially spreading the disease to vulnerable populations, like babies who’ve yet to receive the vaccine. Those with weakened immune systems, like cancer patients undergoing treatment, would also be at-risk.

Medical personnel may have to ramp up protocols for dealing with patients reporting vague symptoms like a rash or fever. They may have to meet potentially infected patients in the parking lot with masks, diverting staff from other serious health matters.

“All of this is cumbersome and, if it delays care, potentially dangerous,” Cennimo said. “It is difficult for your average primary care doctor or pediatrician to do all of this in a busy office. The measles rash is not very specific and can be confused with other viral rashes.”

He added, “This can really slow down the flow in an (emergency department).” “ (D)

“If you visited the South Plainfield Sky Zone Trampoline Park at 600 Hadley Road on the afternoon of April 22 or the River 978 Banquet Hall at 978 River Ave. in Lakewood on the night of April 23 you may have been exposed to measles, according to the state Department of Health.

A New Yorker with a confirmed case of the virus visited both locations, according to the DOH. The department is warning anyone who visited Sky Zone from noon to 5 p.m. April 22 or the banquet hall from 6 p.m. April 23 to 1 a.m. April 24 that they may have been exposed.

“Anyone who suspects an exposure is urged to call a health care provider before going to a medical office or emergency department,” the department’s statement read. “Special arrangements can be made for evaluation while also protecting other patients and medical staff from possible infection.”

Anyone who may have contracted the virus in this most recent incident may not develop symptoms until as late as May 14, according to the DOH.

On April 22, the DOH announced that a Middlesex County resident with “a highly suspect case of measles” had visited Rosalita’s Roadside Cantina on Route 9 in Marlboro on April 19. The DOH later issued an update, advising that the possible carrier had also visited a Manalapan LabCorp diagnostic center on April 17 and 19.” (E)

‘The return of measles may be an early warning sign of a resurgences of other vaccine-preventable diseases such as rubella, chickenpox and bacterial meningitis, some experts say…

The use of quarantines and other orders are driven in part by a growing concern that outbreaks of measles and other diseases could get worse, despite the availability of effective vaccines, some health experts said.

“I think there’s a sense of anxiety and even a little panic in the public health community” as officials see high levels of mistrust of government and science from a surprising number of people, said Lawrence Gostin, a Georgetown University public health law expert.

That anxiety has led to what Gostin believes are missteps by officials.

It’s one thing to isolate someone with measles or to quarantine someone who has been exposed, he said. Those people are infection risks, and short-term limitations of where they can go and who they can meet are legally and medically appropriate, Gostin said.

But it’s another thing to take the kind of step Rockland County initially did, in which unvaccinated kids were placed under house arrest — not because they were infection risks, but because their parents weren’t listening to public health officials, he said.

One community had success without taking such measures. Officials in Vancouver, Washington, declared an end Monday to a measles outbreak that began in January but apparently stopped at 71 cases a month ago. It was a much smaller community than New York City or Los Angeles and was tamed by an intense investigation and vaccination campaign that involved 230 health workers tracking down infected people and those they had contact with, at a cost of about $865,000.”  (F)

“California public health officials are warning moviegoers who went to see “Avengers: Endgame” and other films at an Orange County movie theater last Thursday that they may have been exposed to measles by a woman in the audience.

The woman attended a midnight screening of the “Avengers” blockbuster at the AMC Dine-In Fullerton 20 on Thursday from 11 p.m. to 4 a.m, the Orange County Health Care Agency said.

Everyone who was in the building may have been exposed, not just at that particular screening room, the agency said.

The warning also applies to people who went to buildings at 5 Hutton Centre Drive in Santa Ana from last Wednesday through Friday.

The woman, who is in her 20s, reported having recently traveled to a country with widespread measles activity, the agency added.” (G)

“A cruise ship was quarantined Tuesday in Saint Lucia after the island nation’s chief medical officer cited concerns that crew members and passengers possibly infected with measles might spread the highly contagious virus, causing an outbreak…

Quarantines are one of many measures used by public health officials to limit the spread of disease, especially to vulnerable populations, such as pregnant women, unvaccinated children, and those with weak immune systems.

According to the Centers for Disease Control and Prevention, a quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. This is different than isolation in which sick people are identified and separated from people who are not sick.

“Isolation is used to separate ill persons who have a communicable disease from those who are healthy. The most important thing is that a distance is created between the respiratory secretions of the infected person and others. The person on the cruise ship has to stay in their room and not come into contact with others, especially those who are not vaccinated,” said Dr. Mirella Salvatore, a travel medicine and infectious diseases expert at Weill Cornell Medicine and New York-Presbyterian…

Quarantine times vary, but typically last for at least 21 days — the typical the time from the moment of measles exposure to the time when signs and symptoms of the disease disappear — or until public health officials can prove that everyone is immune and safe.” (H)

“The cruise ship that was placed under quarantine by St. Lucia because of a confirmed case of measles onboard is bound for Curaçao. It’s not clear what will happen when the vessel, called the Freewinds, arrives there…

Health authorities in St. Lucia made the decision to quarantine the Freewinds after a female crew member was confirmed to have measles. There was concern that others onboard might have been infected and that measles could spread to the Caribbean island, which has been free of local transmission of the disease since 1990. St. Lucia’s Ministry of Health and Wellness said on Thursday it had provided 100 doses of measles vaccine to people on the ship…

As we reported Thursday, the Church of Scientology says its members rely on the advice and treatment of medical doctors, but several high-profile Scientologists have spoken out against vaccination.

Curaçao’s vaccination rate is 97% in children born since 2007, according to the Pan American Health Organization.” (I)

“Authorities in Curacao on Saturday boarded a ship that arrived in the Dutch Caribbean island under quarantine, to start vaccinating people to prevent a measles outbreak.

Health officials said only those who already have been vaccinated or have previously had measles will be free to leave the 440-foot (134-meter) ship Freewinds, which reportedly belongs to the Church of Scientology.

Curacao epidemiologist Dr. Izzy Gerstenbluth told The Associated Press that a small team is assessing more than 300 people aboard the ship, and that the process might take more than a day.

“We will go on board and do our job,” he said, adding that authorities have an international obligation to avoid spreading the disease. “If we allow that to happen, measles spreads in places where the risk of severe complications is much bigger, especially when we’re talking about poor countries where people have a lower level of resistance.” (J)

“New York City saw its first and only patient with the deadly Ebola virus 4½ years ago. Since then, emergency and health-care workers have been training for the next patient.

To test their preparedness for treating a patient with Ebola or another similar deadly infectious disease, fire, police, city and medical workers ran a drill, acting out the steps, over two days late last week, while nurses and doctors evaluated them.” (K)

“In order to prepare for viral outbreaks occurring in other parts of the world, New York City and State partnered with first responders in New Jersey to conduct an emergency exercise last week to transport a person pretending to be an Ebola patient to NYC Health + Hospitals / Bellevue. Agencies that participated in the drill included the Health Department, NYC Health + Hospitals, the Fire Department of the City of New York, New York State Department of Health, the Robert Wood Johnson University Hospital, and health and law enforcement agencies from New Jersey. The exercise entailed the transfer of a person pretending to be an Ebola patient from Robert Wood Johnson University Hospital in New Jersey to the Regional Ebola and Other Special Pathogen Treatment Center at NYC Health + Hospitals / Bellevue in New York City…

This exercise – the first of its kind between New York City and New Jersey – tested the health care system’s ability to safely move a patient to a clinical setting where Ebola can be most effectively treated. In particular, the exercise assessed the ability of participants to coordinate patient transportation to NYC Health + Hospitals / Bellevue, safely use biocontainment devices and personal protective equipment while caring for the patient, and appropriately decontaminate and dispose of equipment after transportation. Today’s unprecedented exercise involved over 70 staff from participating health care facilities and state and local agencies.”(L)

“Nearly 70 of the city fire department’s emergency medical techs and paramedics are not vaccinated for measles, according to sources…

The FDNY’s Bureau of Health Services went through all the immunization records after the outbreak, and realized that they had a population of unvaccinated members who were vulnerable to the disease.

The obvious danger was that they could contract the illness, officials said. But they could spread it as well.” (M)

“Maine could soon prohibit parents from citing religious or personal beliefs to avoid vaccinating their children, making the U.S. state one of a half dozen cracking down during the nation’s largest measles outbreak in 25 years.

State legislatures in New York, New Jersey, Oregon, Vermont, Minnesota and Iowa are looking at similar bills that would only allow exemptions from vaccinations for medical reasons as determined by the child’s doctor…

Maine has one of the lowest vaccination rates in the country, with 5 percent of kindergartners holding a non-medical exemption from vaccination, compared to a national average of 2 percent, according to CDC data.

The World Health Organization has said at least 95 percent of a community must be immunized against measles to achieve the “herd immunity” needed to protect those unable to get the vaccine such as infants and people with compromised immune systems.

No measles cases have been recorded in largely rural Maine since 2017, but state officials have been worried by outbreaks of whooping cough, another childhood disease that can be prevented by vaccination.” (N)

“The measles vaccines are among the most extensively studied medical products. The safety of both vaccines has been firmly established over many years in some of the largest vaccine studies ever undertaken. Before the vaccines’ approval, clinical data developed through animal studies and human clinical trials were evaluated by FDA scientists and clinicians.

In addition, the FDA pays careful attention in reviewing the quality of raw materials and other ingredients used to make vaccines, the production process, and the procedure for assessing their safety and efficacy. Like many medical products, measles vaccines have known potential side effects, but they are generally mild and short-lived, such as rash and fever.

The bottom line is that there are safe and effective vaccines that provide lasting protection against the measles virus. Both contain live, but weakened versions of the measles virus, which causes your immune system to produce antibodies against the virus without causing you to contract the illness. Should you be exposed to actual measles, those antibodies will protect you against the disease.” (O)

“The U.S. is experiencing the greatest spike in measles cases in 25 years, but Merck, the sole producer of the measles vaccine for the U.S., says it has production in hand…

“In response to the measles outbreak that has occurred this year, Merck has taken steps to increase U.S. supply of our MMR-II vaccine so availability of the vaccine is maintained,” the company said in an emailed statement today. The statement emphasized the safety and effectiveness of the vaccine has been scientifically affirmed over decades of use against the highly contagious and sometimes fatal disease…

Merck Chief Marketing Officer Mike Nally told Reuters in an interview that the company has upped production but that there has not been a big boost in orders in the U.S., even from the Centers for Disease Control and Prevention. The CDC provides vaccines through the government’s Vaccines for Children program…

 “As measles outbreaks have occurred in different parts of the world over the last few decades, we’ve always been able to surge capacity, and we feel confident about our ability to do so in the U.S,” Nally told the news service.” (P)

“In New York, which has seen hundreds of measles cases since last fall, the state’s Department of Health has given doctors the go-ahead to lower the vaccination age to six months in areas with ongoing outbreaks, according to Erin Silk, a spokesperson for the department. New York City Mayor Bill de Blasio has ordered that everyone — including babies as young as six months old — get their measles vaccinations. The measles vaccine is safe and effective, despite the thoroughly debunked myth that vaccines cause autism. An extra measles vaccine at six months is very safe, too, according to Peter Hotez, dean for the National School of Tropical Medicine at Baylor College of Medicine. It just isn’t the norm because, under typical, non-outbreak circumstances, the vaccine may not be as effective for babies that young. “However, some babies could still benefit from early immunization during a true measles outbreak,” he says in an email to The Verge.” (Q)

“After a measles outbreak in Brooklyn and Rockland County and amid growing concerns about the anti-vaccine movement, a pair of state legislators are proposing allowing minors to receive vaccinations without permission from their parents.

The bill would allow any child 14 years or older to be vaccinated and given booster shots for a range of diseases including mumps, diphtheria, whooping cough, tetanus, influenza, hepatitis B and measles, which seemed to be the primary reason for alarm after the recent outbreaks.

“We are on the verge of a public health crisis,” said one of the bill’s sponsors, Assemblywoman Patricia Fahy, a Democrat from Albany, citing lower-than-recommended inoculation rates in some communities, spurred by unconfirmed suspicions about vaccines causing autism. “We’ve become complacent over the last couple of decades.”

That sentiment was amplified recently by the World Health Organization, which listed “vaccine hesitancy” as one of the Top 10 global threats. In Rockland County, officials are reporting 145 confirmed cases of measles, with the vast majority of those afflicted aged 18 and under. Of those, four out of five have received no vaccinations for measles, mumps and rubella.. “ (R)

“U.S. doctors are tapping into their electronic medical records to identify unvaccinated patients and potentially infected individuals to help contain the worst U.S. measles outbreak in 25 years.

New York’s NYU Langone Health network of hospitals and medical offices treats patients from both Rockland County and Brooklyn, two epicenters of the outbreak. It has built alerts into its electronic medical records system to notify doctors and nurses that a patient lives in an outbreak area, based on their Zip code.

“It identifies incoming patients who may have been exposed to measles and need to be assessed,” said Dr. Michael Phillips, chief epidemiologist at NYU Langone Health.

Alerts in a patient’s medical record also prompt conversations with their visitors – who may also have been exposed to the virus – about their own health, prior exposure to measles and vaccination history.

Mount Sinai Health System in New York rolled out a similar program last week, said Dr. Bruce Darrow, its chief medical information officer.

Darrow said it was important because although a patient who comes from a measles-affected Zip code may have passed the screening, family members who visit may have been exposed.”

He said the alert system raises awareness for doctors and nurses “to be on lookout not just for our patients, but anybody who comes into the building.” (S)

“At first, the virus moved slowly through Orthodox communities in Jerusalem and Tel Aviv. Then in September, Dr. O’Connor said, a major outbreak in Ukraine supercharged Israel’s modest one — and probably led, indirectly, to outbreaks in Britain and in the United States.

Ukraine is suffering through a measles outbreak that began in 2017. The country has had almost 70,000 cases — more than any other country in recent years…

But the real problem appears to have begun at Rosh Hashana.

Each year on the holiday, tens of thousands of Orthodox men travel to Uman, a Ukrainian city where the grave of Rabbi Nachman of Breslov, founder of one branch of Hasidism, has become a popular pilgrimage site. (The festivities have been called the “Hasidic Burning Man.”)

Last year, Rosh Hashana fell in early September. Later that month, measles cases exploded in Israel, rising to a peak of 949 in October. The cause? Numerous pilgrims came back from Ukraine with the virus, experts believe.

New York’s outbreak began in October; the first patient was a child in the Bensonhurst section of Brooklyn who had visited Israel. At the same time, a measles outbreak began among Orthodox Jews in London.” (T)

“In 2000, the Pan-American Health Organization announced a monumental public health achievement: Widespread vaccination efforts, overseen by the Centers for Disease Control and Prevention, had effectively eliminated measles from the United States.

The disease, which before the vaccination era affected 3 to 4 million people in the U.S. each year, was now isolated to small, contained outbreaks connected to international travel.

This year’s record-setting outbreak threatens that achievement.

Since January, over 700 cases of measles have been reported in 22 states. Most of the affected have never been vaccinated. Sixty people have been hospitalized, and the case numbers continue to climb, although in some regions, like the Pacific Northwest, outbreaks have subsided.

Though the current numbers are dwarfed by the scale of cases in the first half of the 20th century, they’re still meaningful, says Rene Najera, an epidemiologist and editor of the vaccine education website History of Vaccines.

“We are getting very close to a tipping point. If cases continue to escalate, the U.S. could lose its elimination status,” says Najera.

A disease is considered eliminated from a country when it can no longer be contracted within its borders, though cases tied to international travel — like those that have happened since 2000 — can still occur.

Losing elimination status would mark a failure of one of the biggest public health achievements in our history.” (U)

“Why is handwashing so important?

Put simply, your hands are dirty. As they come into contact with various people, animals, foods, and surfaces, they pick up thousands of germs, bacteria, viruses and other assorted nastiness that can make you sick if they enter your body. “We touch our eyes, noses, and mouths with our hands more than we think, and this can allow direct inoculation of germs into our mucous membranes,” explains Janet Haas, PhD, RN, Director of Epidemiology at Lenox Hill Hospital. “We also use our hands to prepare and eat foods, so hands that are not clean can contaminate foods that we and others will eat.” But washing your hands has the power to minimize or even eliminate those risks—for you and those around you. For example, teaching people about handwashing can reduce diarrheal illnesses in immunocompromised people by up to 58 percent, according to the CDC. Another FYI: You should wash your hands immediately after touching these 10 things.

You’re probably washing your hands wrong

Believe it or not, only 5 percent of people wash their hands in a way that actually gets them clean, according to a study in the Journal of Environmental Health. Haas says the trick is to rub soap onto every part of your hands, since the friction is what removes the germs from skin, and to wash for a long enough period of time. “Keep rubbing for 20 seconds, making sure to get soap between fingers and on the backs of hands—and don’t forget the thumbs!” she advises. “Avoid turning off the tap with your clean hands: A towel, a wrist or elbow is preferred to keep your hands clean.” .. (V)

“U.S. health officials are increasingly relying on an informal network of community groups, religious leaders, and local medical practitioners in their efforts to fight the biggest measles outbreak in the nation in more than 25 years. Standard public-health tools are falling short in the face of an aggressive antivaccination campaign, growing exposure to measles in countries such as Israel, and a longstanding distrust of government or other outside sources of information. Grassroots approaches are becoming more important in public health, with infectious-disease outbreaks around the world increasingly erupting in remote or insular communities, conflict zones, and other areas where disease fighters have to grapple with economic, cultural, or security challenges. CDC has formed a work group to seek new ways to counter an increasingly vocal antivaccine movement. Trusted sources within a community’s own networks “can be more effective than we can” in educating people about vaccination, says Nancy Messonnier, an expert on immunization and respiratory diseases at the agency.” (W)

Prequel: Project Management. The hardest part of getting started….is getting started

Preparing “Raw” Contemporaneous Cases  http://doctordidyouwashyourhands.com/2019/03/method-of-preparing-raw-contemporaneous-cases/

To see more cases go to Doctor, Did You Wash Your Hands?™   http://doctordidyouwashyourhands.com/

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