Dr. David Taylor (Host): Hello. This is David Taylor for the Riverwood Healthcare Center On-Call Podcast. Thanks for joining us today. Today, we're going to talk about measles. It's been in the news lately. It's a hot topic for a lot of families. We've seen the outbreak that started in Texas and New Mexico and now has spread to many states. And I think it's important for us just to get some basic information about what measles is, what kind of effects it has, why it's important to prevent measles, and just a good overview for everybody that's as fact-based as possible.

So in that vein, I'd like to start out just with, well, what is measles? Many people have heard about it through vaccinations. But usually, nobody has had it or you don't know people that have had it other than if you see outbreaks in the news that happen every year in various parts of the country. It's a single-stranded RNA virus. It's in the Paramyxoviridae-- if I'm saying that correctly-- family. And probably more importantly, it's a virus that's related to RSV, which is respiratory syncytial virus that people are hearing about more, and then parainfluenza virus and mumps.

Why is it a concern? Well, it's one of the most contagious viruses that we know of. It causes an acute respiratory illness in most of the people that are susceptible to it. And before the age of vaccination, that was most people because it was so contagious. The symptoms that go with it are a high fever, and this is a really high fever. It can be up to 105, which is not something you'll typically see with other febrile illnesses like influenza or RSV or COVID. And then, it has the classic three Cs, which include cough, choryza, and conjunctivitis. And the choryza anyway is an old-time term. It's really just the crud that you get with almost any virus. And that doesn't really help separate things out that well, the cough, the choryza, and the conjunctivitis, because that's really common symptoms for many viruses. The conjunctivitis might be one that we don't see as much with other viruses, and that's a fancy way of saying the inflammation of your eye and the outer kind of membrane area of your eye.

There's something specific to measles that is really more important for healthcare providers to know about than it is for the general public or patients to know about, and that is, it can have these spots in your mouth called Koplik spots, and they're basically just a rash inside your mouth that has a particular appearance and can be used to diagnose measles without actually having laboratory tests.

The thing is, because we don't really see measles anymore across the United States in most situations for most healthcare providers. It's not something that any of us have seen. I've never seen them in my entire medical career, which is now going on 30 years. And so, I think doctors back in the 1800s and early 1900s would've been very familiar with these spots, but we aren't now. So, that's different than the rash that people think of with measles that is on your body, and that develops 10 to 14 days after exposure. So, measles tends to start with more of an acute, high fever, the typical upper respiratory crud, and then we'll develop into a rash after that.

So, one of the concerns about measles is how it's spread. It's airborne and droplets. And this airborne spread and droplet spread has become more of a thing that people are aware of ever since COVID. And when we were trying to talk about whether masks work for covid, whether they don't work, how covid is spread. Airborne spread is aerosols that just go up into whatever atmosphere you're in, whether that's a room, whether that's outside, and float around and are teeny particles or teeny droplets that you can then inhale into your nose or into your mouth and then get into your nasal passages or into your lungs and can cause infection. Droplets is more what you think about if somebody were to cough or sneeze on you and you see actual or can feel actual moisture from that. Or if somebody coughed on their hand and then grabbed a door handle and you touch that, that's more droplet spread.

So, measles is both airborne and droplet. Almost everything that's airborne is also droplet, but that's why it's so contagious. COVID is the same way in that there's airborne spread, but it's covid is not as contagious as measles. So, a person who has measles is actually contagious four days before their rash develops, and then four days after the rash appears, that's a commonly accepted timeframe. So roughly, you know, a little over a week where a person is contagious. And it's so contagious, nine out of 10 susceptible people were estimated to catch measles if they were exposed. That's a really high rate relative to other viruses. And of course, this is an estimation because, ever since there's been vaccination for measles, we don't have the rates of measles to know if this is actually still the case or not. But that's what is a commonly accepted estimate because of how contagious it is. Measles can float in the air for about two hours after somebody has left whatever space they're in. So if you're in a room, somebody's there with measles, just breathing, the measles virus particles can still be in the air roughly two hours afterwards, before, and you could still catch measles even though somebody had left the room.

So, to understand how impactful measles used to be, we can talk about pre-vaccination and post-vaccination. So in the 1950s and '60, right before we started having widespread vaccination, 48,000 people were hospitalized annually on average, and about 1000 people developed chronic disability due to the acute encephalitis, which is inflammation of the brain. And we'll talk about that a little more when we talk about the complications of measles.

So, that 48,000 people hospitalized, to put it in context, is a lot of people, but it is less than we hospitalize for influenza every year. A thousand people developing chronic disability though is different. And these are estimates with 1950s and 1960s population, which I looked up and was in the 170 million to 180 million range, and now we're 330 to 340 million people. So, you could roughly double those numbers if you wanted an idea of what that would be like today if we didn't have measles vaccinations.

So, the complications that we talked about, like the in acute encephalitis, the complications of measles are otitis media, which is a fancy way of saying Infection of the middle ear. You have an outer ear, a middle ear, and an inner ear, and the middle ear is the part that can be infected. You can get pneumonia, bronchitis, diarrhea, encephalitis. And then, a rare problem that you can have that's an encephalopathic process, it's a progressive brain problem and nervous system problem that they abbreviate SSPE, which I'll talk about in just a second.

So, the otitis media part, prior to vaccination, 5-10% of all hearing loss in the United States was attributable to measles. That's, you know, one in 10 people with hearing loss is because of measles or one in 10 to one in 20. That's pretty significant and not something that we think about and is still a problem with acute measles infection. Encephalitis is more rare. One in 1000 cases of measles will develop this brain inflammation. And the problem with that is there's oftentimes permanent brain damage to some degree or another.

Pneumonia and bronchitis, this is two to three in every thousand cases of measles. And this is why people end up dying from an acute measles infection, is oftentimes they will get this pneumonia. They'll be very sick. They'll end up, you know, in the ICU, and then die. And it's rare. But when we have seen the cases, like in this recent outbreak that have died, it is because of that. It's because of the pneumonia.

And then this SSPE, this progressive brain and nervous system condition, which is really rare, but also pretty scary in that it shows up seven to 10 years after measles infection. It's just a progressive fatal disease where your brain and your nervous system essentially quit working. Luckily, we don't see that hardly at all anymore. It's not something I even remember from medical school. But when I was looking into an overview of measles, it's something that was widely reported, even though rare, back in the day when we used to have measles and now it's not something we see luckily.

So, are there any treatments for measles? There's no specific treatment. There's no equivalent of like Tamiflu that you can give for influenza. There isn't a medication in that regard. Vitamin A is something that is recommended. And I believe, HHS, the Department of Health and Human Services is recommending vitamin A for treatment of measles. This has been studied in undernourished populations and does have benefit. The reason it's important to talk about is it's now being discussed for treatment of measles. It's given in two doses. It may or may not help a population like the United States population where there's not a lot of malnourishment, but also isn't going to hurt as long as you don't take too much of it. That's the problem, is sometimes people think, "Well, I should just be taking a lot of vitamin A" or "My kids should have a lot of vitamin A." And then, you can get toxicity from too much vitamin A, and that's called hypervitaminosis A. So, it's really only two doses. If it's just two doses, which are based on age and your healthcare provider can tell you how much that is, then there's not a downside to taking vitamin A, and it might actually help, at least it's shown to be helpful in these developing countries.

The real way to prevent measles is vaccination. And measles vaccination, we'll get into concerns about autism in a second, but measles vaccination is part of the MMR vaccination. And measles vaccination is what we had all hoped COVID vaccination would be. It's a vaccination that's called that gives you sterilizing immunity. And what is meant by that is if you get vaccinated for measles, you do not get measles. Those of you who've been part of the Riverwood community and have followed town halls that we did during COVID, you may recall that we talked about briefly in the spring of 2021, that if you got the COVID vaccine, you weren't going to get COVID. And during the alpha strain, there was a brief period of time that that seemed to be true. It didn't take long into the summer of 2021 to realize that was not the case.

And people who knew vaccines like vaccine experts in the nation and virologists really knew that that was never going to be the case, even though that wasn't necessarily widely reported. Well, I'm bringing that context up to say that measles vaccination is exactly what we had hoped. It is the kind of vaccine where if you take it, you're not going to get measles. One dose in childhood is 93% effective for life, and two doses is 97% effective. There is no vaccine or treatment that's a 100% effective in anything. So, 97% is really excellent, and it's the kind of immunity that is what we always hope for, which is sterilizing. You don't get it if you get the vaccine.

Now, the reason that that works this way is that the measles incubation time is, I believe, 10 to 14 days, or it's at least a week, I believe, and that gives your immune system, time to spool up, meaning your immune system can rev itself up when it knows it's there while the virus is trying to make copies of itself and trying to become prevalent enough in your system to create the disease. That's not the case with other viruses. They have a much shorter incubation period, like COVID has a two to three-day incubation period, and there's no way for your immune system to get itself revved up and ready to go in that timeframe, even if it has memory of that virus. It just takes multiple days for your immune system to produce enough antibodies and to bring in enough of its components, like both the T cells and then the B cells that make the antibodies to get going to then combat the virus.

But that's why in measles, it works. The measles incubation time's long enough that your immune system can get going, kick out antibodies, it brings in T cells, and it's able to essentially shut the measles down before it can get a foothold and cause disease. That's really remarkable in terms of how well a vaccine can work. And then, this vaccine's combined with the mumps and rubella portions to get in the MMR, which is again, two doses in childhood.

So, one of the concerns that's happened over the years that people are aware of to varying degrees and has come back into light more recently is the concern about the MMR vaccine causing autism. And this all started with a British or English doctor named Dr. Andrew Wakefield. I believe he was an Ear, Nose and Throat specialist, or a gastroenterologist, one of the two. He was a subspecialist. He had produced a paper about this, and ever since then there's been questions as to whether the vaccine causes autism or not.

And part of the reason this is questioned is autism rates, they seemingly have risen anyway over the past few decades. Nobody knows exactly why that is. There's some suggestion that we just have better methods of detecting autism. Others think there's evidence that there's a genetic predisposition to autism, and maybe there's an environmental aspect to this. And one of the environmental concerns was is it the vaccination that's caused this? This has become more of a problem for people. If I say problem, I mean more of a concern for people in recent years. And I think loss of trust in public health and loss of trust in vaccines, especially during COVID, has contributed to declining vaccination rates, which is part of why we are seeing a measles outbreak right now.

That measles outbreak is, I believe, at almost a thousand people, 700, 800 people across multiple states right now. There's been two children who've died, one adult, and there's probably many more people than the number of actual confirmed cases, and they're almost all unvaccinated persons who have either not had their family vaccinated or haven't been vaccinated themselves in these communities where it's spreading.

There have been multiple studies that have looked at the relationship between MMR vaccine and autism. And to this date, none of the high quality studies have found a link between MMR and autism. Is it possible this link still exists? I suppose it is. At this point, almost every credible expert who's not a contrarian does not think there's a relationship between MMR and autism.

RFK Junior is our secretary of HHS right now. He has proposed that there's going to be some randomized controlled trials looking into this. He's appointed somebody to determine the cause of autism I believe by September was what I had read. It's been studied for years. We haven't found a cause yet. I'm a little skeptical we'll have a cause by September, but if we do, that's great.

If we find out with high quality studies that there is a relationship to autism, then we're going to have to rethink our medical thinking. But thus far, there isn't an established link, and we know there's great benefits to getting the measles vaccine. So, I still recommend-- I work in the emergency room for those of you who follow Riverwood or follow the podcast-- I'm not in a position typically to be recommending vaccines. But were I still to be in a primary care setting, I would be recommending the measles vaccine because of how effective it is and the potential complications of measles. And the lack of any high quality evidence that suggests there's a link between measles vaccine and autism or other serious side effects that are high frequency. There's really no question when you look at just statistics, the risk of complications of measles versus the risk of complications from the vaccine. You're taking a much riskier position to get measles than you are to get the vaccine, even if there are side effects to the vaccine.

So, that's I think all that we can really solidly say about the importance of the vaccine. I can tell you about some of the side effects of it that are common. And just like most vaccines, you're going to get redness at the site of the injection, soreness, and mild fever. Rare are febrile seizures and a low platelet count, which is called thrombocytopenia. Those are rare established side effects, and these kind of side effects are common with many vaccines, but they're also very rare. So, almost always the risk-benefit ratio favors taking the vaccine in the vaccines we have established.

So, I want to talk a little bit about natural immunity and then I think we'll wrap it up. There's a push for natural immunity, and this came to light, at least for me, during COVID, where natural immunity wasn't necessarily counted as immunity as there was policy and across our states during COVID. What people mean by natural immunity typically is it means you get infected with an illness and then you survive the illness and now you have good immunity either temporarily or permanently against that illness. Well, measles is an example of this, where if you do get measles and survive it, you're going to have natural immunity to measles, most likely lifelong. Smallpox is another example of this. If you get immunity to smallpox, you're immune to it for a long period of time. If you get immunity to COVID, you have good long-term immunity to it because of your T cell immunity and your B cells remember and create antibodies. The problem is they don't create those fast enough to not just get the initial phase of COVID, but they help keep you out of the hospital, help keep you from dying. That's what long-term immunity you get.

Well, going back to the natural immunity component, natural immunity and vaccine-mediated immunity in my mind-- and this is how I urge people to think about it-- they're really the same thing. It's just your immune system responding to a threat. The question is, what is the threat? So in the case of measles or COVID or smallpox, a virus is coming into your system, your body recognizes it as a threat and it creates an immune response to that threat. The question is, how quickly can your body respond and what potential damage is done to your body while your body is responding?

With a vaccine, a threat is being injected into your arm or your thigh if you're a kid and your body is responding to that threat. The difference is the threat is much less risky because, as long as the vaccine is formulated right, it poses very little risk of either side effects or disease. And over time, we found that sometimes that's the case or not with polio. We had to switch from an oral poliovirus to an inactivated one because people were getting disease from the oral polio virus.

So as time goes on, we're able to establish where the safety concerns are, but I encourage everyone listening to think of immunity you get from a vaccine and immunity you get from getting infected and recovering as really all natural immunity. It's your body's natural immune system fighting off an invader. It's just how is that invader introduced to you? Is it introduced through your lungs or is it introduced? Through an injection into your arm. But either way, it's an invader that your body is fighting off. It's just one is much more risky than the other, in most cases, almost all cases.

So I think that wraps up our overview of measles. If people have questions, please submit them. We can try to address them as an update at the beginning of a future podcast. We can kind of expand on any of these topics, because I tried to keep it just an overview and touching the surface of a lot of this. But if there's any other concepts or other vaccinations people would like, we can do a future podcast for it.

So, thanks for joining us today. Really appreciate your time, and we'll see you at the next podcast.