Bob Underwood, MD: Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Bob Underwood. Before we introduce our guest, I'd like to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and then click on the claim CME button. Joining me today is Dr. Eddie Lyon from Children's Mercy, where he specializes in pediatric infectious diseases, and we'll be exploring the timely topic of measles assessment and treatment, and discussing concerns surrounding this recent increase in measles cases. Dr. Lyon, welcome to Pediatrics in Practice.

Eddie Lyon, DO: Thank you so much for having me. I'm really looking forward to talking today.

Host: Yeah. So this is a super timely topic right now in the United States, isn't it?

Eddie Lyon, DO: Unfortunately, uh, yes it is.

Host: Yeah. So given the current rise in cases in the region, what should providers know about these recent exposure sites? Are there transmission trends? What are the affected populations? Kinda what is this outbreak that we're seeing?

Eddie Lyon, DO: Yeah, so that's an excellent question. And as you mentioned, one that's unfortunately, rather timely for us at the moment. So the largest kind of settings of the outbreak that are still currently in play are those that are linked to that original Texas outbreak that started a little bit earlier this year. There have been kind of several other areas around the country where there have been other cases that have developed or been found, and a lot of them have been able to have been tied back to that particular kind of inciting event. The most affected population, are those that are either unvaccinated or undervaccinated with about 95% of cases happening in those individuals.

And nationally there's about 1200 cases so far as of the last time the CDC updated their numbers of measles in the United States. For kind of a more local context, there are about 80 in Kansas and I, haven't been able to find a whole lot of data, but it seems like there's less cases so far in Missouri, but there have been a few that have developed, and about 60% of those happen in people who are less than 19 years of age.

So it really kind of speaks to the population that we treat as pediatricians, are the ones that seem to be most primarily affected with it. And in terms of the trends, I mean, there definitely was kind of some spikes earlier towards the year and kind of the big uptrend in like that bell type curve if you think about it.

And it does seem like it's kind of starting to cool off a little bit. But I think it can always be a little bit surprising because measles is so highly transmissible among people who are either un or un undervaccinated.

Bob Underwood, MD: Absolutely. The statistics I've seen is unvaccinated and sometimes vaccine status unknown when I've been reading through those stats. And so as a fellowship trained pediatric infectious disease specialist, I'll assume you think that vaccines are important. So what are the updated recommendations for the MMR vaccine during the outbreak, especially if we're talking about infants that are under 12 months old. Because in the normal pattern, 12 months is the time you would get your first MMR. So how is that different?

Eddie Lyon, DO: Yeah, absolutely. So you are right in my, in your assumption. I am a very strong proponent of vaccines. I think they're an incredible piece of science that have vastly changed the trajectory of human history and public health. So the recommendations for less than 12 month olds really does hinge on whether or not you have what's classified as a local outbreak.

We tend to give the vaccine between six to 12 months, if there is an outbreak locally, meaning that there's at least three connected cases that aren't imported from somewhere else. So in that setting, the health department would declare a local outbreak, at which point in time they would have this recommendation to then proceed with immunization of infants who are between six to 12 months of age.

It can be a local discussion with local providers and practitioners. Because it is always this little bit of a balance. If you have somebody who's going to an endemic area, so traveling outside of the country perhaps, or going to those areas within the country that do have cases of measles, it is something to discuss and consider.

The reason that we don't do it kind of across the board is that the immune response that's generated from infants who are between six to 12 months is less than someone who is over 12 months of age, really secondary to maternal antibody. So the maternal antibodies are present, and so that impairs the response of the vaccine, which then makes it a less durable immune response. So you do get some protection, but it wouldn't be quite as long lived. So that's why if you get the vaccine between six to 12 months of age, it doesn't count towards your two dose series that you ultimately need to be counted up to date.

Bob Underwood, MD: Did not know that last piece, that it wouldn't be counted towards the entirety of the series, and I didn't know we were going to get into the overall health benefits of breast milk.

Eddie Lyon, DO: Yeah. Yeah. One is, so breast milk certainly does it, but also just generally maternal antibodies that are passed, like transplacentally in the IgG that's passed that way. Also has that same benefit, so that sticks around for a long time as well. And so it's really that impairment of the immune response generated by the vaccine that then makes the body generate less immunity that's less durable.

So that's why at 12 months of age you get another vaccine and then at least 28 days later, you would then proceed with the second dose. Typically it's, right now it's around four to six years of age.

Bob Underwood, MD: So what about those patients who may have been exposed, like they have been told they have a known exposure to measles and they are unvaccinated, how would you manage a patient like that?

Eddie Lyon, DO: Yeah, so it's also an excellent question. It's a little bit nuanced overall. So there's a couple different ways that you could get the MMR vaccine. So if you've been exposed, if it's within 72 hours, you could get it if you're between six months, 12 months of age. If you're unimmunized in general, it'd be the same timeframe within 72 hours.

And then really, when you're past that three day mark, your choices for post-exposure prophylaxis do shift a little bit. If you're a healthy individual, you may not necessarily need post-exposure prophylaxis at that point. But if you are certainly less than six months, if you're between that six to 12 months, if you're a pregnant individual or you have severe immunocompromise, then you would be eligible for either intramuscular immunoglobulin or intravenous immunoglobulin.

Host: Got it. Now let's talk about the disease itself. What are some of the key clinical features that distinguish measles from other similar presenting illnesses? What are some of the other similar presenting illnesses and, how do I tell them apart, especially early on after the uptake of the virus.

Eddie Lyon, DO: Yeah, so that's a kind of a tricky question because ultimately it's very similar and as it starts, it's a very like classical syndrome that we see in tons of different viral infections. So you'll have fever, you'll have cough, you'll have conjunctivitis, pl usor minus conjunctivitis. And then you'll also have what's called coryza, which is basically like a runny nose.

So if that doesn't sound like every other viral illness in existence, I don't know what does. But what happens from that point is what ultimately will distinguish it. So if you're seeing someone early on in their course of illness, you might not know. So that's where it would be important to start having these questions of checking people's immune status to see if they've received their vaccines, and then asking those exposure questions about, have you traveled anywhere that has measles? Or do you know anybody who's had measles? And have you been around them? Because that would then obviously raise that suspicion in your mind a little bit. But after the first couple of days, typically within the first four to five days, sometimes up to a week, that's when the rash starts and the rash classically starts on your head behind the ears and then moves downward.

So it's a descending rash, which is fairly characteristics of measles. One thing that I will mention that you can potentially see before then, a couple of days before the rash is what are called those Koplik spots. So those are kind of like those light blue, tiny little dots that are happening on the inside of the buccal mucosa.

Those are there before the rash does. So if you see that, then that give does give you the opportunity to say, okay, this might be measles. And then you can go through the public health stuff of isolation and quarantine and testing. But that's really the only like hallmark feature before the rash starts that would clue you into that this is measles. But then once the rash starts and you have that descending rash that's fairly classic for measles. And so that would be at that point in time, it'd be like, okay, yes, this is, what it is. But I mean, other mimikers could be adenovirus, it could be COVID-19, rhino, enterovirus, hand, foot, mouth disease, parvovirus, all of those things can have high fevers, can have rashes, conjunctivitis.

So it's really hard initially to distinguish without that exposure history. And then coupling that with your vaccine status. Because if you're up to date on your immunizations, it would make it less likely, not impossible, but it does make it less likely for you to then have measles.

Host: Like you said it, it starts off as just kind of a generic viral exanthum or viral presentation. So the Koplik spots, I think, important. I think we all learned that in our training, but I've actually never seen it. Now it becomes important to pay attention to that.

Eddie Lyon, DO: Yeah, and it might be something where you kind of, as you're working through patients, trying to get in the habit of whenever you see someone with fevers and all this stuff looking in their mouth, we do it a lot, especially in, the times of the year when we're thinking about hand, foot and mouth disease or herpingina or some of those other things, but getting in that habit of not just looking at the back of the throat and the palate, which we do for group A strep and other things, but looking at more of the buccal mucosa. Because that can be an insightful thing that you might find.

Bob Underwood, MD: So we're going to advance some of the questions. Okay. So I'm in my clinic, I've seen this patient. There's an outbreak. Now I'm suspicious that this might be a measles case. How do I address that in my clinic to prevent further transmission?

Eddie Lyon, DO: Yeah, so I'll take a couple steps back from that. So when we're thinking about, entering into this world where this might be part of kind of more something we see commonly is that it's important from a kind of occupational health standpoint to make sure that every, all the clinicians are up to date on their immunizations.

Because if you haven't been up to date or have received your vaccines, I would recommend talking with your physician about that to see if that's something that you would be interested in and would strongly recommend that you receive that in order to protect yourself so that you can care for everybody else as well as take care of your family.

So I think that's the first step. And then having a plan in place that like if you have patients that you're concerned about measles, how you might move them through your office or clinic setting, because how that happens greatly influences exposure and transmissibility. So in a perfect setting, the family would call ahead and say, Hey, we have fevers, we have a rash. We were around someone that has measles, we think we might need to be tested so they could call ahead, and then that way you could plan like, okay, they're going to come in this door, we're going to take them to this room. All of that stuff. Obviously that's like an ideal scenario, which happens rarely. Um, if someone comes in that's like, Hey, you find that out during your examination, I would recommend that you move them to a negative pressure room if you have one. If you don't have that, a door that, a room with a door that closes will be fine. So just in a room that has a door that will close and then all clinicians that are going in there need to have either an N95 or a PAPR and an N95, if you've been fit tested for it would be the ultimate recommendation because that would protect you even if you've been immunized, would protect you from the potential infection that you're dealing with.

So say you meet someone, you do their exam, now you have this worry would make sure that the door is closed at that point in time, you gown up, you wear your respirator, all that stuff. And then you can go through the testing and stuff like that, which a lot of times involves reaching out to the health department.

And then at the end of the visit, what you ultimately do would have them exit quickly and ideally not through the waiting room, if at all possible. Tell them that the health department will be in contact with them and tell them to isolate at home until they hear from the health department. And then lastly, the room that they were in needs to be shut down for two hours, and that gives a chance for the viral particles that get suspended in the air to then come out of the air so that it's no longer infectious and also gives it a chance for the air circulations to occur to, again, remove it from the air, so that either any additional clinicians that go in that room or future patients that go in that room then would get exposed or have the chance of developing measles.

Host: And like you said, it's incredibly infectious.

One of the hallmarks, unfortunately, of measles. Now you mentioned the health department. Now what is the health department's role? Because a big one in measles cases.

Eddie Lyon, DO: Yeah, so the health department has a crucial role in working with individuals that are exposed to or have measles. And it really comes down to a few things. So one, they can facilitate testing, and testing a lot of times will happen faster, through them as opposed to a private laboratory setting. And there would be no cost to the family to have the testing occur. So having like the nasal swab that you run a PCR off of doing the IGM IgG Serologies. And then sometimes you can even do a PCR from the urine to detect it a little bit after the nasopharyngeal area might no longer have the viral, viral nucleic acids present.

So they have a role in the testing of it. But then even more so, they have a role in kind of tracking cases and ensuring that people stay quarantined or isolated as long as they need to in trying to have contact tracing to try and quell an outbreak before it really spreads. Because as you alluded to, measles is the most infectious virus that we know about at this point in time. It is more infectious than influenza, Ebola, the original COVID-19 virus. It's more infectious than all of those. So it's one that we have to be really cautious about, especially in an environment where vaccines have become a little bit more of a point topic to discuss. And there's been less vaccination overall because that makes it easier for the virus to spread amongst the population.

Host: So once the measles has been diagnosed, what are our treatment options? I mean, there's been advances in some other viral illnesses. How about measles? Supportive care, or are there other options?

Eddie Lyon, DO: So it's going to ultimately be what like nearly every other viral infection is for the most part, unfortunately, which is supportive care and trying to prevent dehydration, because dehydration with the high fevers that you get and all of that stuff are one of the hallmarks of it. The other kind of non-specific treatment that we recommend is vitamin A therapy.

So it's two days of vitamin A, that's appropriately dosed based on weight. And I will just mention that Vitamin A is not a way to prevent measles infection. The only way that we know of preventing measles infection is with the vaccine. And that there is really the evidence for use of vitamin A is in nutritionally deficient individuals.

So that's not most of the people in the United States. Most of the people in the United States or other resource, high resource countries, aren't nutritionally deficient in vitamin A. However, we still recommend that you do it where it's just those two days because there is a mortality decrease, at least in nutritionally deficient individuals, against pneumonia and just mortality overall with the use of vitamin A.

Host: So generally we consider it benign, but there are potential complications associated with measles. What are these and how? How can these impact treatment?

Eddie Lyon, DO: Yeah. So yes, all viral infections, there are certainly complications that can occur. Measles has some that are quite severe. So the most common would be kind of a post viral bacterial infection, so that would include otitis media as well as pneumonia. And pneumonia is actually one of the most common causes of death and hospitalization is with pneumonia secondary to measles.

So you can have a post viral measles, or you can have a viral pneumonia from measles itself. But then you can also have other complications such as hearing loss. You can have encephalitis. You can have diarrhea. There's even been cases of blindness. And then ultimately the more severe and feared consequences are ones that happen later on.

 And that is SSPE or the Subacute Sclerosing Panencephalitis, which is anywhere from seven to 10 years after infection, which is ultimately an invariable fatal condition, and a progressive neurologic disease that kind of starts with alteration in mentation without fevers, some personality changes, stuff like that.

And once you diagnose that, it's invariably fatal within a couple of years. So that's the most feared one. And you know, I have some colleagues that have seen that around the country. It's pretty uncommon, thankfully. But it is something that can happen. And I think one of the most feared complications long term, in addition to hospitalization with the acute infection and even death from the acute infection, as there has been three deaths in the United States, which is the first in a long time, secondary to measles, this time around.

And then there's this really fascinating bit of immune amnesia where the viral, the virus itself infects some of your T cells and your B cells and causes a loss of some of the memory that you have developed in your immune system, to protect you moving forward.

So that's a really fascinating thing about measles as well, that it not just makes you sick now, but it decreases your ability to respond to and fight other infections in the future for a little bit of time.

Host: So we talked about vaccines and some hesitancy around vaccines. So how can we as clinicians, providers, respond effectively to families who are hesitant about getting the vaccine?

Eddie Lyon, DO: Yeah, so this is a really challenging subject and one that I want to just say, express some gratitude to all the primary clinicians that are listening. Because I mean, they're on the front lines of all these conversations. When people come into my world of infectious diseases, a lot of times they've seen their pediatrician plenty of times, and so these are typically more longitudinal discussions, with individuals who are vaccine hesitant, and there's really a spectrum of it. So there could be someone who is not opposed to vaccines but just has questions. There could be someone who kind of invariably accepts every vaccine that you have, and there's some people that have a, just a flat out refusal or don't want any vaccine or discussion at all.

And so really it's a nuanced discussion of finding out what concerns there are about vaccines, and then trying to address those. And I think being transparent in your perspective of, I support vaccines and I want to answer your questions. So understanding and meeting people where they are is an important first step.

Host: I think that that's really great information, because we have those patients that we have those discussions with. So anything else that you'd like to add as we kind of come to a close here on the CME?

Eddie Lyon, DO: Yeah, so I think the last thing I want to say is, you know, this is a scary time and a time at which it's a little bit nerve wracking to be thinking about measles when it had been eradicated from the United States, in the year 2000. So it's kind of a weird time to be thinking about it now.

But just like with the COVID-19 pandemic, I think it is certainly possible for us to learn how to assess these patients safely, to triage them, to treat them, to get as many people better as we can. And then just to again, really highlight the importance of vaccines and the longitudinal relationships that people build with their patients to have those conversations.

Because that is the way to prevent things like this from happening in the future, in that there are several different resources that are available, whether it's the CDC, the local health department from whatever state listeners are from, as well as any academic institutions that have infectious diseases that are accessible to providers, that are more than happy to answer questions as well.

Host: Oh, that's awesome. Thank you so much. I would say that I have learned a lot in this conversation, and I really feel that Children's Mercy has just got a great benefit of having an expert like you on the staff.

Eddie Lyon, DO: Well, I appreciate that. It's been quite a journey and a lot of learning, but happy to share what I know and continue to learn from all those around me.

Host: Yeah, absolutely. And to our listeners, as a reminder, claim your CME credits after listening to this fascinating episode today. You can do so by visiting CMKC.Link/CMEpodcast and click the claim CME button. And for more information and for other topics that might be of interest to you, you can visit the same site, cmkc.link/cme podcast. I'm your host, Dr. Bob Underwood, and this is Pediatrics in Practice, a CME Podcast.