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After decades of progress and the elimination of domestic transmission in 2000, measles is once again becoming a threat in the United States. Primary and urgent care facilities are the front line of detection and response in measles outbreaks, but most are insufficiently prepared.
Will measles become endemic in the United States?
A study published in JAMA confirmed what many of us in public health began fearing after childhood vaccine rates declined, and the anti-vaccine movement grew stronger during the peak of the Covid-19 pandemic: Measles is poised to return to endemic levels in the United States.
Even at current vaccination rates, the study estimates that over 850,000 measles cases could occur over the next 25 years. With just a 10% decline in measles vaccine coverage, that number climbs to over 11 million. And, if vaccination rates were to fall by 50%, the model predicts over 50 million cases and nearly 160,000 deaths.
No other vaccine-preventable disease examined in the study — rubella, diphtheria, or poliovirus — was projected to become endemic under current coverage levels.
Whenever an infectious disease emerges in the United States — such as Ebola, Zika, or Covid-19 — health care facilities need to implement new protocols for screening, case management, and infection control. Given the extreme contagiousness of measles and absence of effective treatments, the challenges are enormous.
Recognizing measles symptoms: Are today’s doctors prepared?
For decades, clinicians trained in the United States have not needed to worry about measles. When I trained in the 1990s, I never saw a single case, and I suspect most physicians practicing today would say the same.
The initial symptoms — fever, cough, conjunctivitis, and congestion — are similar to many other infections. Clinicians, therefore, need to learn how to detect Koplik’s spots, which are small white marks that often appear on the inside of the cheeks before the onset of the measles rash.
While examining patients with a rash, clinicians need to consider that it may not appear the same as in their textbooks. Most pictures I learned from only showed the appearance of the rash on light-colored skin, a documented problem with medical instructional material. A measles patient with light-colored skin will have a rash composed of bright red spots that can be so numerous that that they coalesce together. In contrast, a measles patient with darker skin tones may have spots that appear purple or that may only be identifiable as small, raised bumps without any distinguishing color.
Clinicians also need to consider that measles can cause illness long after the acute infection has resolved. First, measles patients may develop encephalitis months to years after infection. Second, measles causes immune amnesia, suppressing the immune system and leaving patients susceptible to bacterial and viral infections, including ones that were previously vaccinated against, for years. It is unclear whether patients who recover from measles should get repeat dosages of other childhood vaccines that they received before they had measles.
Front office staff and medical assistants also need updated training. These team members are often the first to interact with patients — checking them in, collecting vitals, and assigning them to rooms. They need clear protocols for identifying patients with febrile rash illnesses and for initiating airborne precautions immediately. In most clinics, this means putting a high-quality respirator on the patient and quickly moving them to an area with better ventilation or isolation capacity.
How can measles infection control be improved in outpatient clinics?
During the Covid-19 pandemic, many primary care offices upgraded their infection control procedures, screening patients for respiratory symptoms, and mandating mask usage by patients and providers.
For anyone working in an outpatient facility, now is the time to revisit Covid-19 infection control policies. Before they arrive, patients need to be asked about symptoms that could be measles, and high-quality respirators should be readily available and used for any patient with a suspected airborne respiratory infection. Clinics should improve indoor air quality by using portable HEPA filtration units for all exam rooms unless the facility has a heating ventilation and air-conditioning system with MERV-13 filters.
Providers must ensure that all staff in their facilities are up to date on the measles vaccination. While most will have received the measles, mumps, rubella shots in childhood, documentation may be lacking. Some may have incomplete series, or immunity may have waned.
Office staff need to ensure meticulous record keeping about which patients, family members, and staff are in the facility at all times. If an infectious case comes to the clinic, anyone in that clinic from the time of the visit to several hours afterward will need to be notified, given the ability of the measles virus to stay suspended in the air.
Do clinics have the supplies to diagnose, manage, and prevent measles?
Most outpatient facilities are used to ordering vaccines based on the number of children they expect to see for routine care. That typically includes 1-year-olds for the first measles vaccine dose, and 4- to 6-year-olds for the second.
In an outbreak, clinics will face demand from other groups, including: infants 6-11 months old who may benefit from an early measles vaccine dose; teenagers who never got their second dose; unvaccinated adults and parents concerned they may have been exposed.
In the United States, the supply chain for the MMR vaccine is not designed for surges. While manufacturers generally keep some buffer inventory, providers may find themselves waiting days or weeks for new shipments.
The same goes for measles diagnostic testing supplies and immune globulin for post-exposure prevention. People running pediatric practices and urgent care clinics need to know which labs will perform PCR or serologic testing for measles on short notice and be prepared to offer or refer people (including the parents of measles patients) for post-exposure prevention.
Planning for these contingencies now will save time and, possibly lives, later.
How should clinics handle unvaccinated families?
Few issues are as polarizing in medicine today as vaccine refusal. While the ethical considerations are nuanced, clinicians are permitted to discharge families from care if they refuse vaccines after repeated counseling.
To do so, clinics must develop clear, written policies for how to manage patients and families who refuse measles vaccines. These should be communicated to families in a respectful, culturally sensitive manner. Policies should also account for exceptions, such as those who can’t take the vaccines for medical reasons, or temporary delays due to illness or access issues.
The goal, of course, is not to punish families who refuse to vaccinate, but to protect patients and staff from preventable harm.
Are there federal funds to help with primary care clinic measles preparedness?
Emergency preparedness has most often been treated as a large hospital issue, even though primary care facilities are the first to identify patients, the first to report cases, and often the first to provide treatment or post-exposure prevention.
Unfortunately, even investment in large facilities is at risk. Covid-19 funding that was allocated for other infectious disease responses has been cut from states, and federal grants for health care system preparedness are at risk. That means fewer resources for training, fewer rapid response teams, and fewer dollars to support clinic upgrades.
Will clinics be ready for measles and other emerging infectious diseases?
We are entering a new phase in American public health in which diseases once considered eliminated are returning, and the systems we built to protect against them are under threat. For primary care and urgent care facilities, this will require making new investments in measles infection prevention and control.
Dr. Jay K. Varma is a physician and epidemiologist. An expert in the prevention and control of infectious diseases, he has led epidemic responses, developed global and national policies, and implemented large-scale programs that saved hundreds of thousands of lives in Asia, Africa, and the United States.
