The measles outbreak that has reverberated from one infected person’s visit to Disneyland in December has now sickened 102 people in 14 states, including 99 in California, and has sparked a national conversation over vaccines, personal choice and community responsibility. It also has parents expressing concern over whether their children are protected from the highly contagious virus.

 “We are seeing more parents who have already immunized their children calling in to double check that their children are protected,” said Dr. Sunita Saini, a board certified pediatrician with Turlock Pediatric Medical Group.

The Stanislaus County Health Services Agency offers immunizations and has seen an uptick in the number of parents coming in to get vaccinations since the measles outbreak began, said Dr. John Walker, the agency’s Public Health Officer.

Measles begins with a fever that lasts for a couple of days, followed by a cough, runny nose, conjunctivitis (pink eye) and a rash. The rash typically appears first on the face, along the hairline, and behind the ears and then affects the rest of the body. Infected people are usually contagious from about four days before their rash starts to four days afterwards. The virus can linger in a room for a couple of hours after an exposed person has left and is so contagious that 90 percent of the people who come into contact with it will catch it if they are not vaccinated, according to the Centers for Disease Control.

Measles can also result in complications. In children they can develop pneumonia, lifelong brain damage or deafness. In 2013, about 145,700 people died of measles across the world, according to the CDC.

“Even in developed countries like the U.S., for every thousand children who get measles, one to three of them die despite the best treatment,” said Anne Schuchat, the assistant surgeon general of the United States Public Health Service and director of Center for Disease Control’s National Center for Immunization and Respiratory Diseases.

Measles vaccine eradicates disease in U.S., until now

Up to 1957, measles was considered epidemic in the United States, but an effective vaccine and a successful vaccination campaign led to decreases of occurrences of the virus in the Unites States to the point that it was declared eradicated in 2000. The number of cases remained low for several years until recently, when the number of cases began to rise steadily again.

Measles is still widespread in many parts of the world, including Europe, Africa and Asia and has entered the country through foreign travel. In 2014, the United States saw the highest number of measles cases in 20 years with more than 600. Most of the people who got measles last year were linked to travelers who picked up the virus in the Philippines, which saw more than 50,000 cases in 2014.  

Children routinely get their first dose of the MMR (measles, mumps, rubella) vaccine at 12 months old or later. The second dose of MMR is usually administered before the child begins kindergarten but may be given one month or more after the first dose.

The California Department of Public Health has confirmed 99 measles cases as of Wednesday. Of those, 39 cases resulted from a visit to Disneyland between Dec. 17 -20, when an infected individual was also at the theme park. Another 23 individuals were infected by being in close contact with one of the confirmed cases. Three people caught the virus in California after being exposed in some form of community setting, such as an emergency room, where a confirmed case was known to have been present. The remaining 34 cases have an unknown exposure source, the CDPH reported.

 “Measles is highly contagious and highly preventable through vaccinations. CDPH is urging caution to individuals who are not vaccinated, especially infants under 12 months,” said Dr. Gil Chavez, the state epidemiologist and deputy director for the Center for Infectious Diseases at CDPH. “Any place where large numbers of people congregate and there are a number of international visitors, like airports, shopping malls and tourist attractions, you may be more likely to find measles, which should be considered if you are not vaccinated. It is safe to visit these places, including the Disneyland Resort, if you are vaccinated.”

Chavez said that two doses of measles-containing vaccine are more than 99 percent effective in preventing measles.

Of the 99 cases in California, 8 percent are in children under the age of one year and 14 percent in children between the ages of one year to four years. Children and teens between the ages of five years to 19 years make up 18 percent of the cases. The largest number of cases, at 60 percent, are adults over the age of 20, the CDPH reported.

Stanislaus County does not have any reported measles cases so far this year, but that doesn’t mean health officials are not on alert.

“We are taking the posture that it is a real possibility,” Dr. Walker said. “There are more than 10 cases in the Bay Area and there is a lot of travel between here and there. We cannot assume that we are insulated in any way.”

The majority of the cases reported across the country are in individuals who are unvaccinated, reported the Centers for Disease Control and Prevention. On Thursday, five infants at a Chicago day care center were diagnosed with measles and officials are trying to determine if there is any link to the Disneyland outbreak.

“Although we aren't sure exactly how this year's outbreak began, we assume that someone got infected overseas, visited the Disneyland parks and spread the disease to others,” Schuchat stated. “Infected people in this outbreak here in the U.S. this year have exposed others in a variety of settings including school, day cares, emergency departments, outpatient clinics and airplanes.

“This is not a problem with the measles vaccine not working; this is a problem of the measles vaccine not being used,” Schuchat said in a teleconference. 

The more people who are vaccinated against a virus like measles, the greater protection an entire community has against the virus. It’s known as “herd immunity” and it helps protect those individuals who are unable to get a vaccine like infants, chemotherapy patients and those with HIV or other conditions that have left them with a weakened immune system. When a contagion spreads in a community with immunization rates below 90 percent, the protection provided by ‘'herd immunity" can be at risk.

“Very young children have the highest rate of morbidity, which is why it’s especially important to keep the herd immunity high,” said Dr. Walker.

Stanislaus County does have a high rate of vaccinations, Dr. Walker said.

Anti-vaccine backlash

The outbreak of measles has sparked a national debate about the anti-vaccine movement. Some parents have chosen not to vaccinate for a multitude of reasons, including the belief that children will develop a stronger immune system naturally and that it is linked to autism. The claim that the measles vaccine causes autism was reported in 1998 by Dr. A.J. Wakefield. He claimed he found evidence the vaccine had caused autism in 12 children. But in the years that followed his report, no other researcher was able to replicate his results. It was later revealed that he was funded by lawyers seeking to file a class action lawsuit against vaccine makers and his report was debunked and retracted.

Currently in California a child cannot enter kindergarten without the required immunizations. Some children are given a Permanent Medical Exemption because of their health. Others are allowed in without the immunizations because their parents have claimed a Personal Beliefs Exemption. Under California’s Personal Belief Exemption, a parent may choose to opt their child out of school vaccine requirements, but they must first talk with a licensed health care practitioner about the impacts to their child and community.

For the 2014-15 school year, the CDPH reported 90.4 percent of the 535,332 students enrolled in reporting kindergartens received all required immunizations. The percentage of students with permanent medical exemptions stayed the same at 0.19 percent, while there was a 0.61 percent decrease in the number of students with PBEs compared to the previous school year.

Of Stanislaus County’s 128 schools, 122 reported kindergarten vaccination rates representing 8,921 students. Of those, 8,335 or 93.43 percent entered kindergarten with all the required immunizations. Another 3.16 percent or 282 were registered into kindergarten with the condition that the immunizations would be filled within the year. The number of kindergarteners in Stanislaus County with a PME is 14 amounting to 0.16 percent. The number of students entering kindergarten with a PBE in Stanislaus County in 2014-15 was 290 students, amounting to 3.25 percent of the total number of kindergarteners, the CDPH reported. The number of parents using PBEs has decreased since last year by 0.83 percent. In the 2013-14 school year, Stanislaus County had 4.08 percent of kindergartners entering with PBEs.

Of the 290 kindergartners entered with PBEs, 41 were enrolled prior to the 2014 law requiring parents to prove they have spoken to a health care practitioner about vaccines, while 211 were granted PBEs after speaking to a doctor or health care practitioner. Another 38 were granted PBEs on religious grounds.

In the first year the state law was implemented, 20 percent fewer parents used the personal belief exemption.  However, in many communities across the state, over 10 percent of parents are using California’s personal belief exemption.

“When I have a parent claim a PBE, I respectfully challenge them and ask them what their basis is for their decision,” said Dr. Saini. “I present them with all the science and data and I am usually met with silence. I respect that it is their choice, but it’s my job to educate them.”

The outbreak has prompted two California legislators to introduce a bill seeking to change the vaccination law in California.

Dr. Richard Pan, a pediatrician and Senator representing Sacramento and Senator Ben Allen, the former board president of the Santa Monica-Malibu Unified School District, will introduce legislation that will repeal the personal belief exemption.

“As a pediatrician, I’ve been worried about the anti-vaccination trend for a long time,” said Dr. Pan. “I’ve personally witnessed the suffering caused by these preventable diseases and I am very grateful to the many parents that are now speaking up and letting us know that our current laws don’t protect their kids.”

“The high number of unvaccinated students is jeopardizing public health not only in schools but in the broader community.  We need to take steps to keep our schools safe and our students healthy,” said Allen.

If this legislation is passed, California will join 32 other states that don’t allow parents to opt out of vaccination requirements using a personal belief exemption.

To view vaccination rates for area child care centers and schools, visit: http://www.cdph.ca.gov/HealthInfo/discond/Pages/Measles.aspx