Joey Wahler (Host): Cases are rising in the United States, so we're discussing the treatment of measles. Our guest is Dr. Norma Kreilein. She's a Pediatrician with the Carle Foundation Hospital. This is Expert Insights with the Carle Foundation Hospital. Thanks for joining us. I am Joey Wahler. Hi there Dr. Kreilein. Welcome.

Norma Kreilein, MD: Good afternoon.

Host: Thanks for hopping aboard. We appreciate the time. So first, for those who may need a quick reminder, what exactly is measles and who does it impact?

Norma Kreilein, MD: Measles is a viral infection that we used to see quite often until the vaccine was developed in the sixties. It was one of the five major childhood illnesses that included chicken pox, German measles and a couple of other ones. It's a rather severe virus that was deemed to be worth vaccination a long time ago because of how serious it is.

Host: Any reason in particular for the rise in cases of late?

Norma Kreilein, MD: Yes, the control of measles is really completely related to vaccination, in part because it is so contagious that without having immunity, it spreads really rapidly through a community. So outbreaks of measles are always, for the last several decades, related to the lack of vaccinations or vaccine hesitancy. It was no longer endemic in the United States because of the effectiveness of the vaccine. But over the last decade, with the emergence of vaccine hesitancy, we started with the introduction of foreign cases that have now developed into it being endemic in the United States again.

Host: Gotcha. So what age child do measles typically impact most? And how young can you be when you get it?

Norma Kreilein, MD: Any child can get measles if they don't have immunity. I think the cases that we've had so far in the United States this year have shown that any child can get seriously ill. Newborns obviously are some of the most vulnerable because they don't localize infection. But what we've seen so far in this country, from what I have read, is that the children that have died have actually been a bit older, school age and teenage.

So, it can produce serious complications in a child of any age. That's part of what makes it so scary. But the problem really is how contagious it is that that's the thing that, I remember from Los Angeles in the eighties, where I was in residency and we actually were treating the last big measles outbreak in this country.

Host: Wow. What do you remember most about that?

Norma Kreilein, MD: Well, the severity, just watching it can be. We obviously, intensive care has improved over the last 30 years, but we had electricity, we had all types of interventions back then, and these children were just sick. Their lungs were beyond what a ventilator could help. And, in fact, the child, I remember watching die was like a middle school aged child. The other thing that I absolutely remember is just how contagious it is. Because we had children that contracted it in our emergency room from other kids that were literally 20 feet away because, it was actively being followed. And that, we had children who were far away from a child with measles that caught it anyway. So the airborne contact is really quite striking in, in how, how contagious it is that you can catch it without close contact. You don't have to have close contact. You can just be 20 feet away from someone who left the room and contract measles.

So with that type of contagiousness, the control of it absolutely hinges upon vaccination and having immunity.

Host: Absolutely. I'm going to ask you more in further detail in a moment about that contagiousness factor, but first to back up sort of for just a moment, Doc, what are the symptoms of measles?

Norma Kreilein, MD: Well, the first thing that you see is a fever without the rash. The fever predates the rash, and that's what makes it sometimes difficult to pick up also, is that the symptoms are common to other illnesses, kind of pulling a needle out of a haystack when you're seeing the first few cases. I do not remember seeing K spots.

That's one of the, the rash inside of the mouth. I did not ever see that in the kids that had measles. The rash is pretty striking. It's very heavy on the, the head and the neck and it can be pretty confluent. But I think one of the problems is if you have partial immunity, you, may not see the classic situation that you expect to see. So one of the issues is similar to when you see a fever in the winter time, Almost all the diseases we see share the same symptoms and overlap quite a bit in how they present. So one of the issues is going to boil down to having an index of suspicion as well as erring on the side of testing so that you don't send one home.

Host: And you led me beautifully there, Doc, into my next question, a measles test, a PCR test is then administered. What does that entail?

Norma Kreilein, MD: That just entails a swab.

Host: And then

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Norma Kreilein, MD: And then it needs to be expedited. Most of the time the, the health boards are revved up to hopefully get results on those things right away, once the risk level is high,

Host: And because of that risk level, because of that contagiousness that you discussed a little bit earlier, what's job one for a doctor that suspects they have a measles patient on their hands, what do they do?

Norma Kreilein, MD: Get the test cooking and isolate them.

Host: And isolation in this case is pretty stringent, right? What do we mean exactly?

Norma Kreilein, MD: Well, if the child is stable, you send them home and hope they will quarantine. But it needs to be reported so that that is enforced and that contacts are immediately, tracked down because, they're contagious from before they break out. So they've essentially got several days or hours of places that the child has been that they you know, that's one of the challenges of controlling it as you inevitably have not just family members with close contact, but an entire school or an entire park or an entire Walmart. Trying to get it under control once it has established is really quite challenging.

Host: I'm sure it is. And because of that, the local health department has to also be notified of all measles cases. Yes?

Norma Kreilein, MD: Yes. And that's, I think where it, it's so challenging until you're sure that's what it is, because you have to have this heightened surveillance in order to catch it in an appropriate time. And that heightened surveillance is in and of itself, expensive and time consuming.

Host: And by contacting the health department, that's helping to spread the word publicly, right? Because if someone's not aware that their child may have been exposed to this in another way, that would tip them off, perhaps. Hopefully, right?

Norma Kreilein, MD: The fundamental prevention is hopefully knowing that your immunization rate is high to begin with. When the immunization rate is above 95%, it will generally abort a severe outbreak. But there are always children that perhaps their vaccine didn't work or they're under a year old or under six months old and don't have the immunity. So there's always potentially going to be vulnerable children. One of the other aspects is to add on an earlier immunization and pre vaccinate that extra population between six and 12 months to strengthen the overall herd immunity that you have that ultimately controls the outbreak.

Host: Gotcha. So going back for a moment to isolation. When a measles patient is isolated, doctors should be warning parents to do what with their children.

Norma Kreilein, MD: Well, that's basically airborne isolation as tighter than what we did in COVID.

Host: And so detail for us a few of the finer points of that in terms of where and how they need to be kept and for how long, et cetera.

Norma Kreilein, MD: They're basically isolated for on the order of over two weeks because it takes time after potential exposure for that to come out. And so they're, basically, at home and hopefully they will stay there. And that, seems to be an issue as well where, there's, compared to the eighties when there was this universal drive to control it, now there appears to be families and people that are not committed to controlling it, thinking it as a minor illness. I'm not sure where that is at right now. In Texas, for example, and, until you have that in a community just like COVID, you don't know how people are going to respond to the type of control measures that are necessary.

Host: And so along those lines, Doctor, because of that, what would you advise doctors to tell parents about the importance of the measles vaccine?

Norma Kreilein, MD: What I tell my parents has a lot to do with my personal experience. I tell them that I have seen children die of measles in a situation where it was not a lack of care. It was actually aggressive care. That it is a viral infection. And I specifically tell them, you know, that means the virus is replicating in their cells.

Antibiotics don't work for that. And one of the cells that measles proliferates in is the lung, the brain, the skin. And that it is an in, it is an Encephalopathic virus. When I talk to parents I say, this is a brain eating virus. It affects the brain. And that's one of the severe complications of measles, that I think parents are not aware of. It could cause severe complications in normal children and it also wipes out their immunity compared to the vaccine that we know is safe and I've watched the measles vaccine for 40 years and I've also seen measles and there's absolutely no comparison. So I think the biggest thing is to try to get that community buy-in as you see patients even if you haven't seen measles, the the talking points of we give vaccines for a reason. And, we also know that places like Samoa a few years ago that fell through on vaccinations had just a, basically a catastrophic event with measles and they had on the order of 80 deaths. So it, despite the disinformation, I think going straight at the heart of what a parent thinks that is wrong and trying to get them to understand that what they've heard is not correct. I think that's still the challenge we're going to face on a lot of levels. And so I basically kind of invite parents, please tell me where your concerns are because I don't want you worried about something you don't need to worry about.

But I do want you to worry about the things that you need to, and, most of the time I've been very pleased in the last few weeks that when I tell parents this is a high risk situation, now. I think your six month old needs an extra vaccine. Is that okay? And I've actually been very pleased in this community that literally every parent I've said that to, and it's been about five so far, they've taken up the early vaccine.

And so just that alone, countering the disinformation within the community as a medical community is so key right now because the disinformation is what is driving the outbreak. If we can get kids to immunize, see, that wasn't a question in in 1989. Everybody did what they were supposed to do in the community.

Otherwise the risk is, especially in a rural community, that the number of cases are going to rapidly exceed since they're, some of them are pretty sick and we don't necessarily have that many people in public health or that many hospital beds. It's going to rapidly exceed what we could potentially take care of and it's preventable.

So I think, the biggest thing as a medical community is to really try to approach the disinformation that parents perceive and invite them to talk until they're convinced. And the indication of understanding is yes, I want that vaccine. That's kind of the litmus test for me, is parents saying, yes, I'll take that vaccine. Okay, we're good. And I think I would encourage providers to do that in the community because that's what's going to give them the best indication of the mess they're going to have if measles comes into their community. What is your vaccination rate and how does your community feel about it? Are there schools or populations in the town that are potentially going to be hot sources and to work with your county health department or your facility to try to proactively break that down because with the contagiousness of measles, it will rapidly, as we've seen in Texas, it's rapidly going to prove that it has the upper hand.

Host: Well, great crucial advice indeed. Folks, we trust you're now more familiar with measles prevention. Dr. Kreilein, hopefully we've saved some lives here today, literally. Thanks so much again.

Norma Kreilein, MD: Thank you.

Host: And for more information, please visit carle.org. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks so much again for being part of Expert Insights with the Carle Foundation Hospital.