Bracing for Measles

The spots started on the back of his neck. Ariel Loop’s 4-month-old son, Mobius, was battling his first illness. His fever was 102 when Loop noticed the telltale rash—flat red spots that started on his head and gradually spread throughout his body.

“I thought I was crazy. There’s no way,” Loop said, laughing incredulously. Even two years later, the experience is surreal. Loop, a nurse, knew some of the signs of the measles, but they didn’t spend much time studying it in nursing school, she said. She never expected to see cases of an eliminated disease, let alone in her own child.

The Loops had taken their son to Disneyland a couple of weeks earlier, in mid-January 2015. Living in Pasadena, California, Disneyland was a regular destination. Ariel and Christopher Loop were married there. It’s where they announced they were expecting Mobius, and it was only a matter of time until they visited the park as a family.

As the spots spread and the fever wouldn’t break, reality sank in: Mobius had caught the measles at Disneyland. Knowing how contagious the disease is, the couple called ahead to warn the emergency department of their local hospital. They were ushered through a back door and whisked into a negative pressure room where their infant was treated by doctors and nurses in protective gear—medical experts who had never seen measles in person.

The hospital did bloodwork, warned them of complications and sent them home under quarantine. Four days later, the test came back positive for measles.

One of the most contagious diseases

Distill the threat of measles down to its quantitative essence and you’re left with a number between 12 and 18. That’s its R0, or basic reproduction number. On average, one person with the measles will infect 12 to 18 others. Each one of those people infects a dozen or more, and each one of them infects another dozen. That’s how an epidemic begins. One cough or sneeze sends the measles virus airborne. There it can linger, able to infect for up to two hours. The R0 of influenza? Two to three. The R0 of SARS, the respiratory illness that in 2003 infected more than 8,000 people worldwide? Two to five.

Measles is one of the most contagious of all infectious diseases, but the development of a vaccine in the 1960s led to dramatically decreased rates of infection. It was officially declared eliminated in the United States in 2000. In the years since, however, misinformation about the safety of vaccines has caused immunization rates to reach dangerous lows in a number of places throughout the country, including some areas in Texas. A recent outbreak among unvaccinated people in Minnesota has public health experts wondering if Texas could be next.

“We’ve got about 50,000 kids whose parents have opted them out of getting vaccinated for non-medical reasons, and this has accelerated precipitously,” said Peter Hotez, M.D., Ph.D., dean of the National School of Tropical Medicine at Baylor College of Medicine and president of the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development.

Non-medical reasons to forgo vaccinations—known as conscientious exemptions—are often based on religious or philosophical beliefs.

The key to preventing measles from spreading is “more than 95 percent immunity through a two-dose vaccination regimen,” the World Health Organization says. In the 2015-16 school year, 97.6 percent of Texas kindergarteners had received both doses of the measles, mumps and rubella vaccine (MMR), according to the Texas Department of State Health Services. While this is above the recommended rate, the number of exemptions still poses a threat, because unvaccinated children are not spread evenly throughout the state.

“They tend to be concentrated more in the Travis County, Austin area and around Denton, Texas,” Hotez said. “I think that’s where we’re going to start seeing measles outbreaks.”

When more people are immune to a disease through vaccination, it’s more difficult for the disease to spread. High vaccination rates protect those who can’t be vaccinated for health reasons, a concept called herd immunity. Low vaccination rates threaten herd immunity and put vulnerable communities—children too young to be vaccinated, individuals with compromised immune systems, people who are severely allergic to certain vaccines—at risk.

“It’s a global economy, and higher immunization rates are safeguards to keep us from being susceptible to these diseases,” said Brian Reed, M.D., director of disease control and clinical prevention at Harris County Public Health and Environmental Services. “Parents may be thinking they’re doing the right thing for their child, but they’re inadvertently harming the community.”

The consequences of reducing herd immunity can currently be seen in action in Minnesota, where a measles outbreak has been spreading since April.

Minnesota-Austin connection

Like all epidemics, the Minnesota measles outbreak started out small. In early April, Hennepin County reported three cases of the disease. Two months later, that number has grown to about 70—the worst outbreak the state has seen in 30 years. Like Texas, Minnesota’s vaccination rates are over 90 percent. The current outbreak can be traced to a Somali immigrant community in Minneapolis, where the vaccination rate in 2014 was reported to be 42 percent—a significant decrease since 2008, when the same community had some of the highest vaccination rates for two-year-olds in the state.

This swift decline is a result of targeting by anti-vaccine advocates. Most notable: Andrew Wakefield, the British doctor who rocked the medical community with his 1998 paper, published in The Lancet, claiming a link between autism and the MMR vaccine.

In 2010, the U.K. barred Wakefield from practicing medicine and The Lancet formally retracted his paper, but the damage had been done. Despite numerous studies debunking the link between autism and vaccines, the myth persists. Wakefield continues to campaign against vaccines and parents continue to listen. In 2008, he visited the Somali-American community in Minneapolis, and vaccination rates have been decreasing ever since.

When questioned by The Washington Post regarding the recent outbreak, Wakefield said he was simply providing information about vaccines and autism.

“The Somalis had decided themselves they were particularly concerned. I was responding to that,” he said. “I don’t feel responsible at all.”

What does an outbreak in Minnesota have to do with Texas? Although Wakefield travels the country promoting his anti-vaccine agenda, he lives in Austin. He speaks at anti-vaccine rallies on the steps of the state capitol building, and he holds screenings of his film, Vaxxed: From Cover-Up to Catastrophe, throughout the state. Meanwhile, non-medical vaccine exemptions have increased since 2003, when the state enacted some of the loosest vaccine exemption laws in the country. At least one private school in Austin has an exemption rate of more than 40 percent.

“In 2003, we had less than 5,000. In 2016 we had 45,000 to 50,000 exemptions,” said Richard Lyn-Cook, M.D., medical director of Harris Health School-Based Clinics and assistant professor at Baylor College of Medicine. “It just takes one person to come in contact with a traveler who was not vaccinated and can spread it to a child less than one, the most vulnerable population.”

A common refrain among vaccine critics is that the measles is not dangerous. Robert “Dr. Bob” Sears, M.D., a California pediatrician and high-profile proponent of “alternative” vaccine schedules, wrote in a Facebook post: “Ask any grandma or grandpa (well, older ones anyway), and they’ll say, ‘Measles? So what? We all had it. It’s like chicken pox.’”