Recognizing & Managing Measles

– What is up ZPac? It’s your boy Z DoggMD. I am fired up today because this is gonna be the first in hopefully a series of many continuing medical education lectures. We all know how boring CME is or continuing education credits, whatever your specialty calls it. It’s like well, okay, item three, diagnosis, item four. We’re gonna try to make it fun and engaging and watch a Facebook live video a couple days later. I’m gonna repost the video with some disclosure material and a link to Physician’s Weekly’s Learning Management System website. They are our partners. They will have there you log in, you set up an account, supporters who’ve subscribed to Facebook for me for $4.99 a month get access to this on a private post section and the way it works is for supporters, we’ll do the show now for everyone because this is crucial information about measles we’re gonna talk about today that matters for everyone. Part of our mission here at ZDogg Industries is to make sure we educate and entertain not just patients but really, the people who are caring for them because if you teach a teacher then you can have a huge impact. So I would never put this behind a paywall, the teaching. What we are putting just for subscribers and people who support the show is the ability to get actual credits, continuing education credit and that’s anybody who can take ANCC or ACCME certified credit that includes all doctors, all nurses, nurse practitioners, PAs at the minimum and probably your specialty although people like pharmacists have very specific requirements that may not be covered by this so talk to your own board and see if you’re covered and if you’re a supporter; in a couple days, we’ll put out instructions on how you can log in, take a couple tests and a couple questions post tests and get credit for what I’m about to talk about.

Alright, that housekeeping out of the way. I put a link on how you can become a subscriber. By the way, think about that. It’s like the cheapest CME you’re gonna get, that’s short of free and we have fun for subscribers. Alright, that housekeeping out of the way, here’s the deal. ♪ Measles is back, alright ♪ Except it’s not alright. Because of increasing anti-vaccine thinking; particularly in certain hotspots for example the Orthodox Jewish community on the East Coast and basically anything on the West Coast so Oregon, Washington, California; what we’re starting to see are fairly emergent outbreaks. 30-31 cases near Portland, Oregon, Vancouver, Washington. The governor’s declared a state of emergency about resurgent measles. This was a disease that was practically wiped out in the United States.

Why does it matter that it’s coming back? Isn’t it just a normal natural part of childhood? After all, in the old days, 90% of Americans contracted measles before they became an adult. So pretty much everyone got it with a small exception and so why are we worried about it? Why are we treating it like it’s Ebola or something serious? Because it is. Measles, in the pre-vaccine era, killed, listen to me carefully now, killed 2.6 million people, most of them children under five. This is of plague proportions in the old days. Now why does it not, today, worldwide, it kills roughly 110,000 people, we think, in 2017; again, the data is tough because the places that are most hard-hit are the places that vaccinate least in the developing world; you have parts of India, Pakistan, Nigeria so Africa, Asia. These are places that are still catching up with vaccination regimens whereas in the West, we had mostly eradicated it because of the measles, mumps, rubella combination vaccination, two shots that were given.

And the way that this worked was a live attenuated virus, in other words, a virus that is still alive and can replicate and trigger an immune response but does not cause the symptoms or complications of measles is given in an injection and what they found is it after the first injection, maybe like 85-90% of people were immune but they were missing a few. So the second booster brought it up to close to 99% would then have long-term, practically lifetime immunity. Again, there’s a percentage of people who don’t and they are still at risk for getting something we call modified measles which is an attenuated form of measles if they’re exposed to measles; we’re gonna talk about that in the course of this.

In this lecture, what I wanna talk about is first of all, the prevention aspect, we’ll wrap back to that. I wanna talk about recognizing measles, the different forms that measles can take, including modified measles, atypical measles, severe measles in immunocompromised patients. We’re gonna talk about how do you diagnose it, first of all, clinically by looking at rash and fever and symptoms, something called Koplik spots which are very specific but not very sensitive for measles. So we’re gonna talk about that and again, why do I even have to talk about this? Because we’ve never seen measles, the younger generation. It was practically eradicated. Older docs have seen it, younger docs have not and they can miss it and it is one of the most contagious diseases known to humans. 90% of unimmunized people exposed to a patient with measles will get infected. The measles virus is transmitted by airborne coughing, by obviously close contact, fluids but in the air, it can remain in a room, airborne, for two hours after the patient has coughed in that room. You can imagine how the outbreaks we’ve seen in Disneyland and other places could have become more than an outbreak could have become an epidemic if people weren’t vaccinated. Why do we even have outbreaks now? Because there is a failure of what we call community immunity in places like Oregon say or Washington State because the rate of vaccination is only 70-80% because of this anti vaccine sentiment, thinking these vaccines cause autism which they don’t. So they save lives and you’re gonna see why measles is so horrible.

Part of my goal here is to get you angry at professional anti-vaccine activists who are harming children with their lies online. So back to this herd immunity, I call it community immunity. You need about 94% vaccinations in a community to prevent widespread outbreaks because that’s the critical mass to keep the virus from replicating around in a tribe of people. Well, in some cases, we’re down to 70% or 70 to 80% and so what happens is somebody gets infected, possibly from somebody coming from abroad where it’s more prevalent, where measles is still, there’s still a lot of cases yearly because of poor vaccination and they come here and then it starts to break out in unvaccinated communities. A good example is Orthodox Jewish communities on the East Coast, I was talking to Paul Offit about this. This is a big problem over there and on the West Coast, we’re talking about this stuff. So it’s a highly contagious disease, it’s easy to spread and it’s preventable with the two-shot series of measles vaccine as part of MMR.

So let’s say now we have failed this prevention, community immunity is not there and you are looking to diagnose this in somebody so you’re concerned. What are you looking for in terms of measles and let’s go through this very carefully because this is something that again, we just don’t see. It can mimic other diseases and if you miss it, it’s so contagious that it can spread. Here’s the thing, there are children younger than 12-months-old who, or even six months and younger who cannot be vaccinated, who are relying on maternal immunity through antibodies that wane over time and they are at risk. There are people who are immunocompromised, who cannot be vaccinated or who are at risk so you cannot protect them.

How do you protect them? With community immunity from a mass vaccination campaign where everybody who can be vaccinated is vaccinated on time. I’m gonna emphasize that again. This is entirely preventable to keep our most vulnerable patients safe. Now let’s say we fail this because we have, why? A ton of videos we’ve done on why. Alright, let’s talk about measles itself. So we’ve talked about how contagious it is and actually, the period of contagiousness is quite long. So it can be anytime from five days before you see a rash and you could be asymptomatic, have no symptoms at all, to up to four days after the rash appears and you start to get better. So this is particularly dangerous because you can have no symptoms and be contagious or you can have what they call a prodrome. So the measles virus tends, in typical hosts, to evolve in this series; there’s an incubation period and that can be anywhere from six to 21 days.

Now in people who’ve been vaccinated but didn’t develop full immunity or people who were exposed to measles as a child or little young kids who just have maternal antibodies to protect them and they haven’t been vaccinated yet, you can get something called modified measles where it’s an attenuated measles where the incubation period can last much longer so it can start 17-day minimum incubation period. So it’s harder to diagnose in those patients which is yet another reason that we need just full vaccination so there’s a few susceptible individuals as possible.

So that being said, you have the six to 21 day so that the median’s around 13 days incubation period and that’s when the virus is entered and it enters through the mucosa, through the eyes, through the nasal mucosa, through the respiratory tract, through those mucous membranes and starts replicating in the epithelial, it gets into the endothelial cells, it gets into the reticulo-endothelial system, the lymph nodes and starts crazy replicating. During this period, you have something called viremia so the virus is really spreading. It can spread through the blood and disseminate everywhere. At this point, after this incubation period, you start to get what they call a prodrome.

Prodrome is a fancy way of saying get ready, stuff’s about, I can’t curse on CMEs, stuff’s about to get real. They told me I can’t which makes me want to. They were like, “Hey, Z Dogg, don’t say that S-word.” I’m like, “Oh, yeah, here it is.” I can’t, I’m trying to keep it real. So the prodrome usually lasts around two to four days and again, this is modified in certain situations but it’s typically, and it can last as long as eight days. What it really is defined by is fever, malaise, feeling like, like I look typically because I just got off a bike ride with my kids because today’s screen free Sunday where we ditch our phones but I told them look, I just have to do do one thing with my phone. I’m gonna talk to the ZPac, it’s urgent because measles is a thing and they’re like alright, we’re gonna sit in the hot tub, you’re gonna teach your thing and don’t you dare go in and start answering comments today. You do it tomorrow. So if you don’t see me online that’s why.

The prodrome, the malaise, fever, anorexia. So feeling like you don’t wanna eat and in kids, this is very easy, some of it is not easy to recognize. The fever is pretty easy but the other stuff, they’re just being punky. And then it’s followed by the three Cs: conjunctivitis, which is a fancy way of saying redness of the eyes, coryza, which is the fancy way of saying snotty runny nose, inflamed mucous membranes and cough and it’s typically a dry cough. And so this is the prodrome and it’s very nonspecific. A flu can do this, rhinovirus cold can do this, parrot influenza can do this, there’s a ton of things in the differential diagnosis right here that can look like this. Any viral or bacterial infection can look like this so it’s very vague but during this time, you can be highly contagious. So it’s a problem.

So your index of suspicion has to be high in communities where maybe vaccination isn’t prevalent like any rich affluent over-educated community where they suffer from something called the Dunning-Kruger effect. Dunning-Kruger effect means you know very little about something so much so that you don’t have the capacity to understand how little you know and you overestimate your knowledge. So hyper-educated well-intentioned parents feel like they know everything about immunology because they read a couple articles on Google and they’re generally smart people and they know stuff about other stuff but, mm-mm, they don’t know what they don’t know whereas doctors are always equivocating. Oh, I don’t know, it may be measles, it may be something else, we’re not always sure. They can say that because they know enough to know that they don’t know everything. They have metacognition.

So your index of suspicion should be high in communities where you’re worried about vaccination levels being low or there’s a travel history to an endemic area, parts of Asia, parts of Africa, developing world, et cetera. So the prodrome, this conjunctivitis, one thing I should say, it could lead to a lot of tearing, photophobia, which is a fancy way of saying light bothers your eyes. They go with the conjunctivitis. The respiratory symptoms are due to actual viral infection of the respiratory tract so it’s direct viral toxicity and there’s often fever during this time in the prodrome and that fever can reach 40 degrees Celsius. I mean it can be a very, very, very high fever and there’s different patterns of fever but the bottom line you know is that this is the prodrome. Now what is the prodrome leading to? The next phase of the disease which is the exanthem, let me unpack that word for a second. So exanthem is a fancy way of saying rash on the skin, ex meaning outsides, anthem, I don’t know what it means, who cares? The bottom line is it’s a rash on the outside.

Now contrast that with another thing that becomes relevant here which is enanthem, enanthem is a rash on the mucus or are lesions on the mucous membranes, the inside like this. And it’s interesting because prior to the exanthem, the rash of measles that everybody knows about which we’ll talk about, you can get 48 hours prior to that roughly, you can get an enanthem and it turns out this is important because the type of lesion you see, typically on the mucous membrane, sometimes you go off the mouth, the buccal mucosa right next to these molars, right here, is right here is the classic place but you can see it on the hard palate, on the other mucus membranes in the mouth and in girls on the labia because those are also mucous membranes and you can get this lesion called a Koplik spot and I don’t even know if I’m pronouncing that right. It’s K-O-P-L-I-K because I’ve never diagnosed one directly because we don’t see measles because we thought we’d gotten rid of it so a Koplik spot turns out to be very specific for measles. If you see one classically, it used to be considered pathognomonic. That’s a fancy way of saying if you see it, it pretty much means measles so it’s very specific for measles. You don’t see it in a lot of other things. There are other things that look like it but not quite. Now let me show you a picture of this so you can see for yourself, here we go. Okay, bear with me. This is the CDC website and here is a Koplik spot. Now it’s very hard to see. Do you see that white there on a red background. The way that it’s described is a erythematous background, that’s the red and these little white grains of sand and they can be white, they can be blueish, they can be gray, they can be different colors other than white. They don’t necessarily have to look like that but the key thing is they’re on a red background. So there are other little white things and yellow things you can get in your mouth but if you see it with fever and the prodrome symptoms on a red background, these little white millimeter dots and sometimes they can get confluent so you have like a red background and a bunch of these little grains of rice, these little white bits, those are Koplik spots, very, very high suspicion in the right setting of measles. So it can help, there’s data that shows, they looked at this and what they saw was if you combine that with the other findings of like fever and runny nose and the three Cs of cough and coryza and conjunctivitis, your diagnostic accuracy for measles is much higher.

Why does it matter? Because you want to, in the developed world, you wanna quarantine that person, you wanna put them in respiratory isolation and keep other people out of the room they’ve been in. Even if they leave the room, you wanna stay out of that room for hours because of how contagious measles is and then you wanna watch them for complications and you wanna treat them a certain way which we’re gonna talk about. After the enanthem, the Koplik spot, it’s doesn’t always occur so it’s specific for measles, generally but it’s not very sensitive. So if you’re relying on Koplik spots, you’re gonna miss the diagnosis because a lot of people just don’t have it or you’re just not good enough to see it because it can be very subtle.

So the next phase is the exanthem, the rash. Now the rash is, I’m gonna pull it up here, is a fairly… It’s not classic in the sense that there are a lot of viral illnesses, drug eruptions, other things that can look like this and when we talk about full differential diagnosis, we’ll get into some of that but what’s interesting about typical measles is that it starts often on the face and the neck and it spreads outward. So it goes in what they call, for the nerds, a cranial caudal spread, so from cranium from head down to caudal which is tail. So it goes this way and it ends up on the trunk and so on so that’s the classic spread of the measles rash. It’s a maculopapular rash which means there’s these flat red lesions that blanche initially so what blanching means you squeeze on them with your finger and they turn white and then they refill with red. Now later, as the rash evolves, they stop blanching and often they become light brown except in African-Americans, people with different skin tones, it can look different. So that’s important and then it starts to slough off and resolves in the reverse distribution. So the same way it appeared actually. So if it starts on the face and spreads this way, it resolves starting on the face and spreads out, sequentially. Let me show you some images of what those measles rashes look like. So here’s the classic maculopapular facial rash. Here’s a truncal rash where you know it’s very, very subtle, not subtle, it’s very classic but other things can look like it. For example, take a look at chickenpox over here. So some things can mimic it although you can tell the difference with the chickenpox lesions, they’re more raised, they tend to be much more itchy but again, there can be overlap and in fact, here’s probably a good time to talk about the other things that can fake measles because this rash, you think oh yeah, I nailed it. It’s measles; well, not so fast ace.

So here are the things and I have to look at this list because there’s so many of them. So first of all, in the prodrome, it could be anything like any respiratory virus, adenovirus, RSV, particularly the time of year in the winter but typically, the fever in the measles prodrome can be more pronounced but it’s not always the case. And again, when we talk about diagnosis, you’ll see how to differentiate it. The viral causes of rash in kids, varicella which is chickenpox, roseola which is herpesvirus 6, Parvovirus B19, the classic slaps, ow! God, don’t let me do that again. The slap cheek syndrome that can cause anemia and things like that, that can cause a rash like this. Enterovirus, toxic shock syndrome, streptococcal infections, scarlet fever, there’s a lot of things including drug eruptions so certain antibiotics can cause this kind of rash and a fever. So starts to look similar, meningococcus, meningococcal bacterial infection, Rocky Mountain spotted fever, mono, mycoplasma pneumoniae, vasculitis, Henoch-Schonlein purpura purpura, all these different things including Kawasaki disease. You can look this stuff up. What’s important is there’s other stuff that causes it.

How do you differentiate it? Through the diagnostic regimen we’re gonna talk about. Now let’s get back. We talked about the rash. Now that rash can start about two to four days after the onset of fever and then it takes some days to unwind and then clinical improvement really starts about two days after it starts. So the rash appears, then 48 hours, it’s a little better. Then three to four days, the rash is dark and brown, especially in Caucasians, not so much in African-Americans and it begins to fade and then it can desquamate, meaning it can start to peel like a sunburn in the more severe areas. So typically, you’re talking six to seven days and fading in the order that it appeared. So going centrifugally out.

Alright, so after the rash phase, the next phase is recovery and the building of immunity to the disease. So you can have a cough for up to one to two weeks after measles but that fever should start to go away, once that rash appears, in 48 hours, the fever should start to go away. If you’re still having fever several days after that rash, you should start thinking about complications that might be arising; secondary infections, et cetera. So in the recovery phase, you start to clear the virus, produce antibodies to the virus, IgM, IgG, immunoglobulin start to be made and you start to get better. Now here’s the rub, this is why measles is such a nasty, nasty, nasty, nasty disease and anti-vaxxers need to be stopped and parents on the fence need to be educated about how bad this disease is. This is not a natural disease of childhood. You don’t go have a measles party and the reason is measles suppresses the very immune system that fights it. It suppresses T cell-mediated and cellular immunity. Potentially, they don’t exactly know how but they’ve noticed T cell deficiencies and damage to the cellular mediated immune system for weeks to months to sometimes years after the infection. Why does this matter? Because that’s when your little kid or your adult can get a secondary pneumonia, bacterial or viral pneumonia or another type of infection. And so by suppressing the immune system, you end up setting yourself up for some of the potentially deadly complications of measles.

And those complications include severe diarrhea, which in the developing world can be a cause of death because you get malnutrition, dehydration and death, less so in the US but the big cause of death is respiratory infections. So secondary bacterial and viral pneumonia, direct cellular damage, giant cell pneumonia from the measles itself and again, this effect on the immune system that can last for some time after the initial infection. That’s why measles is so particularly nasty. So let’s talk about some variants. What can be some things that’ll throw us for a loop in diagnosing this and one of them is modified measles. Modified measles, I’m gonna read this specifically because I want you to have no doubt about what this is. Modified measles is an attenuated infection that occurs in patients with pre-existing measles immunity; either through getting infected in the wild or through vaccination and it’s similar to classic measles except the manifestations are generally milder and the incubation period is longer so 17 to 21 days. It’s a longer incubation period than classic measles. Individuals with modified measles are not highly contagious but they are still contagious.

So again, this is another reason why mass community vaccination works because you decrease the amount of contagiousness even if someone does get infected, very important. So how can that happen? Well, you can be vaccinated and not really have a full response and again, we said that 1% of people, even after the two series or maybe they just got one and didn’t get revaccinated or maybe they got, they were exposed to measles as a child and it didn’t create lifelong immunity and they never got MMR because really, it’s only health care workers who tend to get revaccinated and get titers checked because they need to for their jobs. And sometimes little kids who have maternal antibodies and they wane away and so they have partial immunity, so they can get this modified measles.

So recognize modified measles and understand that it may not look as severe as the standard measles. Sometimes you don’t even get a rash, which is why our index of suspicion has to be high; particularly in affected communities with travel histories, things like that because you wanna test for it and we’ll talk about that. So there’s something called, that’s very rare now that’s called atypical measles. Atypical measles is fascinating because it happened typically in patients who were immunized between 1963 and 1967 with an early killed version of the vaccine so in other words, it was just inactivated viral antigen. Now we use a live attenuated vaccine, why? Because the inactivated viral antigen in those early formulations led to a kind of immunity where the body made antibodies against parts of measles but it wasn’t enough to stop the disease from progressing much. It was enough to stop it from being contagious so in other words, you couldn’t spread it once you got infected but what would happen is you would make antibodies to these particles but they would clump. The theory is in these immune complexes which would deposit and cause severe vasculitis and pneumonia and pretty bad disease. Now the reason I mention atypical measles is that again, it’s exceedingly rare but if you see a patient who may be got that vaccine between 63 and 67, it can be on the radar. It’s just gonna be really unusual. You get a dry cough, pleuritic chest pain, bad pneumonitis, the chest x-ray could show all these nodules and you know hilar lymph nodes and this kind of thing and it usually results in pretty severe illness. A lot of patients get this respiratory distress type syndrome, they develop peripheral edema, hepatosplenomegaly and it’s presumably due this immune response. Liver function tests are abnormal, et cetera. So again, you’re not gonna likely see this but it’s something to think about just academically at least and then maybe, who knows, there may be one ZPacer who diagnoses a case in an outbreak zone of somebody who gets this and saves a life by recognizing it and managing it aggressively.

So what do you see on and essentially because those atypical patients don’t transmit the virus which is again, a probably a function of their partial immunity due to the vaccinations.

All right, what do you see on lab tests? What lab tests are you gonna do? Well you’re gonna need your standard CBC Chem-7, those kind of things and this is what you’d see on those: thrombocytopenia so low platelets, often a low white count, slightly low white count, suppressed white count, so-called leukopenia, you can see T cell cytopenia so low T cell count if you’re looking for that during measles infection. The chest x-ray, you can sometimes see interstitial pneumonitis, so it’s very nonspecific inflammation. If you biopsy lymph nodes, you might see these giant cells which are something you see with measles where a bunch of cells merge and you have a bunch of nuclei in this big giant cell and it’s presumed to be a viral effect, cytotoxic viral effect. So if you actually do a biopsy, you might see those things and the same goes with the conjunctiva and the nasopharynx and those kind of things. You guys wanna see, let me show you what these giant cells look like just because it’s fun. Here you go, this is this courtesy of up-to-date. So here are typical cells and here is a giant cell. All the nuclei are crammed up in the center in this one big cell, see that? The arrow helps, doesn’t it, see that? And pathologists tell me where I’m wrong but I see three little doohickeys there which I presume. Let’s see, medium power view of a lung biopsy from a patient with measles pneumonia shows a nodular pattern with acute and chronic inflammation and areas of necrosis. Multinucleated giant cells with inclusions are shown. There it is and there’s the inflammation in the lung. All right. I’m gonna stop pretending to be a pathologist and keep going here.

So on the laboratory findings, we’ve gone through that. Now so the question is we’ll talk about diagnosis in a second because I wanna first talk about, actually now let’s talk about diagnosis, I wanna talk about diagnosis then we’ll talk about complications so the way you diagnose this, it depends on, first of all, there’s the clinical exam which we just talked about. So your index of suspicion has to be high then you have to go am I in an area that has a high prevalence of measles; for example, parts of Africa, Asia, developing world, in which case the WHO says you know what, you should probably just do a serum IgM for measles. In other words, see if the body is responding with an acute phase IgM antibody response to measles because it should. Now often, there can be false negatives and false positives but if you’re already in an outbreak epidemic zone where it’s all over the place anyways and you see the symptoms of it and the rash and this and that, that’s probably all you need because you’re like well, it’s measles and it’s not like there’s already a big epidemic. So that’s the, I think the rationale for you, you can just do that test.

Now if you’re somewhere like the US and the prevalence is quite low, the first thing you to do is hit the local public health authorities. Your ID guy, the Public Health Service in your city or CDC, whoever you wanna call, call an authority because they’ll tell you what the best specimen is. Because typically, they’ll say you want three specimens. You want some kind of nasopharyngeal swab. You want a serum test for the IgM and a throat nasopharyngeal for a viral culture and a urine sample for a viral culture. So you get three. So two different viral culture sites because the culture is hard to do and the IgM. The other thing you can do, if it’s available and it’s not this massive send out is a reverse transcriptase PCR. So we’ve had guests on the show talking about point-of-care PCR, this is a great example. You could probably do a quick PCR once they develop it up right there on the spot and say yeah, this is measles because it’s so sensitive and specific PCR. So PCR, it’s useful when it’s available. It may not be available. The other thing you can do is you can start and get a set of IgG antibodies. Now what do I mean by this? Here’s how the immune response typically works on the humoral side, on the antibody side: you start with this IgM just acutely against measles and IgG which is the longer term immunity starts building and it will generally go up while you’re convalescing and then you get this lifelong immunity. So what you can do is you can measure IgG at the beginning of the illness when you first see the patient and at the end and that will help confirm because you go, oh, it went up by fourfold which I think is their diagnostic criteria. Let me just confirm that because I don’t wanna lie to you. But typically, what will happen is a fourfold increase in anti measles antibody is indicative of infection. So that’s another way of just confirming yeah, this is what it is. So those are the ways you can typically test for it and again, that IgM serology is key.

So going back to now complications. So you’ve diagnosed it, now what are you worried about? This is another reason why measles is such a pain in the butt and why we really, really, really have to take it deadly serious, is the complication, sorry I’m just trying to keep an eye on the clock here. Turn up the light on this if I can, I can’t! Too bad. The complications, first of all, 30% of measles cases have complications and some of those can be severe. In pregnant women, it’s a huge rate of complications both for the mother and the unborn child. But let’s say it’s 30% of complications for any measles case; diarrhea is the most common and it can be debilitating in the developing world. Here we can manage it but it can be a serious problem. Most of the deaths are due to respiratory infections or encephalitis and that’s swelling of the brain. Let’s talk about that in a second. Ear infections, otitis media occur in about 5-10% of patients and it’s more common in young people. That makes sense because you’re all swollen and inflamed in the mucous membranes. You have blockage and you end up with ear infections.

Maybe there’s a direct viral effect. I don’t know the answer to that so it turns out these complications are more common in the developing world where a case fatality rate is somewhere between four and 10%. So between four and 10% of patients who are diagnosed with measles in the developing world die. This is still a huge problem which is why they would love to have the vaccines that we’re too snotty to give our kids because we think we know better because we’re affected with the Dunning-Kruger effect and we’re listening to celebrities like Jenny McCarthy instead of vaccine scientists like Paul Offit and we’ve forgotten collectively how terrible these diseases are and now there are 31 cases near Portland of this disease that has a complication rate of 30% and used to kill 2.6 million people in the old days. I’m not supposed to get so riled up for CME but I still do. All right, I hate anti-vaxxers. So one of the big problems is secondary infection.

So measles leads to systemic immune suppression, you end up with these severe secondary infections, whether it’s diarrhea, whether it’s pneumonia. We talked about the direct T cell suppressive effect as well as this effect on other cell mediated immunity. It’s actually interesting because in HIV-positive patients, there’s actually suppression of viral replication of HIV, they think by some effect of the measles virus, it’s really quite fascinating except we just don’t wanna see it. And so this measles immunity, associated immune suppression may be responsible for the long term complications that we see. Up to three years after infection is the outer limit of that immune suppression. So we talked about diarrhea, about 8% of patients. You can get these stomatitis, these sores that make it difficult to absorb and can lead to reduced nutritional status, mostly in kids. Pneumonia and that’s the most common cause of death in people younger than five and older than 20. A lot of times, it’s just, so they looked in South Africa, 85% of the cases of death were due to pneumonia due to either viral or bacterial infection. So they looked at 182 cases of measles-associated-pneumonia, it was strep pneumo, strep pyogenes, H flu, your standard actors. So it’s probably because your immune system’s suppressed, there’s bronchiectasis, damage to the lungs from inflammation and secondary infection. That’s how people die, most commonly of measles. There are other ways. It’s a great fun virus to kill people.

Little kids are most vulnerable and what are we doing? We’re fooling around with not vaccinating our kids. Just stop it, vaccinate your kids. If you’re a muggle watching this or you’re a parent on the fence. This is a reason to vaccinate your kids without screwing around. Encephalitis, one in 1,000 cases of measles get brain swelling and this is not a joke. So it usually happens a few days after the rash; typically, about day five and you start getting this fever again so if you get another fever, you should start thinking there’s a complication here. This isn’t just straight measles because the fever should be gone by now, typically. So fever, headache, vomiting, stiff neck, it hurts when you bend the neck, they’re drowsy, they’re somnolent, having seizures, going into a coma, those are signs of acute measles encephalitis and it can also occur without a rash. So your index of suspicion has to be high.

If you look at the CSF, if you do a lumbar puncture what you’re gonna do in these kids or adults, you’re gonna see pleocytosis, a lot of lymphocytes, some elevated protein, it almost looks like a viral meningitis and a normal glucose because it’s not bacterial meningitis where it’s eating up all the glucose. 25% of children who get measles encephalitis will go on to have bad sequelae, whether it’s mental delay, physical disability, et cetera.

This is not a joke and in 15% of people with encephalitis, it will rapidly progress to death. Vaccinate your kids! God! Aargh, what is wrong with you? And professional anti-vaxxers spreading these lies. I understand why parents are scared. Vaccinate your kids! Alright, it gets worse.

Acute disseminated encephalomyelitis is another dreaded complication. Remember we talked about Guillain-Barre disease in a previous show, often associated with infection, with flu, can sometimes be associated with vaccination, it’s an immune response. Acute disseminated encephalomyelitis, ADEM, occurs in one in 1,000 cases of measles, it is also felt to be a post infectious immune response and it can be caused by other things but in the case of measles; again, fever, headache, neck stiffness, seizures, mental status changes, somnolence, ataxia, myoclonus, signs of myelitis like paraplegia, quadriplegia, sensory loss, bladder and bowel control loss. So again, not good. It’s associated with a 10 to 20% death rate mortality and it’s higher than if you get this same syndrome from another infection or another cause. So all that being said again, residual neurologic abnormalities are common including behavior disorders, mental retardation, epilepsy. Alright, now here’s the worst, are you ready? It’s rare but it happens.

Subacute sclerosing panencephalitis. What is that? SSPE, we’ll call it. It’s a fatal progressive neurodegenerative disorder that happens seven to 10 years after measles. The rate of this disease is difficult to calculate because we’ve suppressed measles but one of the estimates says that if you are infected before 12 months of age which is a risk factor to get this, seven to 10 years later about 1,640 out of every million infections will develop this. So it’s not trivial, it’s low but it’s not trivial. What is it? Basically a four-stage debilitating, ultimately fatal neurodegenerative disorder. So it starts with just personality changes, lethargy, difficult in school, you’re having trouble in school, strange behavior, basically me on a good day and that can last weeks to years then think how hard this is to diagnose. Stage two; myoclonus dementia, sensory and motor disease then you have stage three and four which is further deterioration, autonomic dysfunction, vegetative state. Stage four: death. How do you diagnose that? It’s tough but serum anti measles antibody concentration is up so there’s a thought that there’s residual measles somewhere triggering this antibody response or some other immune trigger and CSF shows that you have high protein and detectable anti measles antibody in the CSF. That’s why we think it’s related to measles directly, very, very, very bad.

So this is all very depressing and yet, totally preventable! If everybody were vaccinated, there’d be enough community immunity. It’d be like smallpox. We would eradicate it. We were close to doing that until our friend Jenny McCarthy and Andrew Wakefield committed fraud and put us in a situation now where people are questioning everything that they thought they knew about vaccines. And it is just horrible. Let’s keep going. Who is at risk for complications in the worst situation? Let me just check on the time here. Okay, oh good, we’re gonna get an hour of CME out of this because it’s gonna go for an hour so this is great. So when supporters click through in a couple days when I set up the link, you’ll be able to get an hour of continuing education credit for this hour-long show and I’ll take some comments towards the end. All right, because I wanna get through this material because it’s important. So immunocompromised patients, so people with immunocompromise, whether they have immune disorders, HIV, et cetera, very young can get severe measles and that can include giant cell pneumonia. Remember I showed you that little picture of the funky cells in the lung. Imagine that everywhere, pneumonia, potentially death. And sometimes you don’t even get a rash in immune-compromised patients so it can fool you. You may even need a lung biopsy to make the diagnosis.

Measles inclusion body encephalitis is another crazy complication you can get with immune-compromised people, kids with HIV and the serology; in other words, doing that IgM may not be useful in patients who have immune-compromise because they don’t make antibodies. So what you may have to do there is another approach like PCR, tissue biopsy, looking for those giant cells, things like that, call it the new viral culture. Pregnant women, so it turns out, so they looked at 55 pregnant women with measles in Namibia. Measles related complications were diarrhea in 60%. 40% got pneumonia, 5% got encephalitis, that’s a lot, you guys. Like that’s serious and of the 42% pregnancies that they followed to conclusion, 60% had at least one adverse maternal, fetal or neonatal outcome and 12% of those pregnant women died, not a joke and here’s the thing, you cannot immunize a pregnant woman with MMR because it’s a live attenuated virus, to my knowledge, double-check that.

So that being said, you want community immunity, you want them immunized prior to pregnancy, you want everybody just immunized. So we talked about the diagnostic algorithms, we talked about some of the differential diagnosis. Now we’re gonna talk about treatment. How do you treat measles? There is no specific treatment for measles. There is supportive care. So it’s a viral syndrome. There’s some thought about giving ribavirin which is an antiviral to people with immune-compromise or very young, very sick kids. You can talk to your infectious disease fellow, talk to your public health department about that. The measles virus is susceptible to it in vitro, we don’t know what’s going on in vivo because the clinical data is hardly anything and in one trial, they looked at like 100 kids with measles, they got supportive care with or without ribavirin and those that got the ribavirin had a slightly shorter duration of fever and symptoms. And then with adults with bad pneumonitis from measles, they got IV ribavirin, there were only five patients and they recovered whereas the patient treated later, too late, did not recover. I mean, again, we have no, it doesn’t say much. It is not great data.

So that being all said, what do you do? Well, the first thing you do is you give supportive care, you need an isolation room and it’s airborne isolation. So they say in an inpatient setting, airborne transmission precautions are indicated for four days after the onset of their rash in an otherwise healthy patient and for the duration of illness and immunocompromised patients because they can spread it constantly. Susceptible individuals should not enter the room of patients with suspected or confirmed measles. Exposed susceptible individuals should be excluded from work so you don’t have antibodies, are not vaccinated, from day five through 21 of the exposure. If the case is confirmed, even those who were vaccinated within 72 hours after the fact should be excluded. And in the outpatient setting, patients with the febrile rash should be escorted to a separate waiting area, they should be placed immediately in a private room, preferably at negative pressure relative to the other patient care areas. Everyone should wear masks and respirators; masks for patients so that they’re not putting droplets everywhere and respirators for staff to filter airborne particles regardless of immunity status because immunity can fail. We talked about modified measles. If not admitted, the patient should be told to remain in isolation at home through four days after the rash starts then they’re gonna be less contagious. Measles virus can remain suspended in air for up to two hours and so if you have a room, you shouldn’t use it for two hours after the patient’s departure. So this is important actionable stuff for doctors, nurses, health care providers in institutions.

Now one thing I failed to mention, the WHO recommends everybody, including in the US, every patient with measles gets doses of vitamin A. And you can look up those doses, it’s like for infants less than six months, it’s 50,000 IU, from six to 11 months, it’s 100,000 international units and children greater than 12, it’s 200,000 international units, why? Because another complication of measles that I failed to mention earlier, a dreaded complication is blindness, keratitis and diseases of the eye that are associated with the measles infection can cause blindness. It is a big cause of blindness in the developing world. You can attenuate the effects by giving vitamin A which may not eliminate them. So again blindness, add it to the list of terrible things that this virus has done to scourge mankind for millennia until we practically eradicated it and we’ll again, ZPac, eradicate it. So definitely, the vitamin A, we talked about the ribavirin, the supportive care.

Let’s just summarize then we’re gonna read some comments. Highly contagious disease. Preventable with vaccine. Fever, malaise, cough, coryza, conjunctivitis, enanthem Koplik spots, rash, exanthem, starts in the face, goes out unless you have the very rare atypical measles where it actually starts out here and moves in but you’re never gonna see that. So worry about it less but we did talk about it. You have an incubation period; six to 21 days. You have a prodrome period; two to four days, fever, malaise, anorexia and all that red, the Cs, the cough, coryza, conjunctivitis, Koplik spots, then you have the rash that usually resolves in five to six days and the recovery period of a couple weeks where you’re coughing. If you start getting fever again, you could have some of these complications; encephalitis, pneumonia, diarrhea, blindness, long-term complication of subacute sclerosing panencephalitis which is thankfully rare but still does happen and the treatment is largely supportive. So let’s read comments which means I’m gonna pull up your comments on Disgracebook right now as we’re 50 minutes in.

We’ll do 10 minutes of comments, how’s that? Let’s pull it up. All right, I took notes and as a patient advocate, I do think even I can get CME, Chelsea Corbett, who’s a supporter, yes. And to remind you guys, the CME, in a couple of days, I’ll post a link on how to get that for supporters only so sign up using the link I’ve given you, it’s only $4.99 a month and you get the CME. Let’s see, oh I see there’s some anti-vaxxers here. Don’t worry, I’ll go through and ban them later. I can’t do it today because today is screen-free Sunday for the Dogg. Elizabeth Smith, I have Hashimoto’s disease… Okay, hold on, let’s read some. Is it possible to contract measles if vaccinated? Denise Daniels Haisa Rodik, that’s a lot of names, Denise. Yes, it absolutely is. It is something called modified measles where you have an attenuated version. You usually manage better, you’re less contagious and it is unusual. Most people have lifelong immunity. However, there are some who don’t and they tend to be people have trouble making those antibodies. We don’t really understand it but we understand this, if the whole community is immunized, the virus never has a way to get a foothold because even if it infects these partial responders, it’s less contagious. However, if you have 20% of the population who is absolutely unvaccinated, you are going to spread this disease like wildfire because 90% of unvaccinateds exposed to measles will get an incubation period of prodrome and exanthem and hopefully, a recovery period if they don’t have a complication. Let me pull up your comments on the big computer because my iPad is giving me grief. It only shows me the last few comments and I suspect there are some good ones here. Why does it say I only have eight comments? That’s just not true. Hang on, give me a second people. We’re going to make this happen. Click for more, there it is. Alright, I suspect there’s some anti-vaxxers all over this. Close the southern US border! Check everyone! That’s not gonna work, it is not gonna work because you can get, listen, borders are porous no matter what you do and people are coming on planes from anywhere in the world and they’re upstanding American citizens and they come back with measles because as I mentioned, the prodrome, you may not even have symptoms, you may have a mild nonspecific fever, you’re highly infectious, you’re coughing all over the plane, there are people aren’t vaccinated because they’re not doing that anymore and what happens? You spread it so you can’t blame the border on this and if you do, you’re shunting blame from where it should be which is our own freakin’ people are doing this to us. You can blame immigrants for a bunch of stuff, that’s all day long you can do that. Fine, no problem. You blame them for measles, you’re just plain wrong. Because the one thing that the developing world wants is our vaccines. That triggers me. So let’s see here. So Mexico is known to be more compliant with vaccines, Sandra Oxtoah, that’s the thing! Only in the US and in Europe in highly advanced societies are we advanced enough to have the Dunning-Kruger effect where we think we know more than we do and we question our authority figures so much that we stop vaccinating and we end up with a pool of at-risk individuals. Now you’re exposed to someone who couldn’t get vaccinated or worse yet, you’re a baby or someone with immune-compromise who cannot be vaccinated and you’re exposed and you get sick. We need that community immunity to protect us and I would argue, go back and watch the show I did with Paul Offit, he is a fantastic explainer of how and why we do this and he does it with a lot more empathy and compassion than I do because I get mad, all right. Can we build an anti-vaxxer wall? April Peter, now I’m down for that. I’m down for that wall. That and a wall against Canada because they’re musical terrorists, okay, Justin Bieber, that’s an act of war. Alanis Morissette, ♪ Well, all I really want ♪ is you never to sing again. I agree we need community immunity, June Peach. 20 years ago my son broke out from head to toe with red bumps and whelps and it was after his first MMR, the doctor gave Benadryl to help clear it up, TYLENOL for the fever until it cleared. I still vaccinated both my brood of boys. What would the treatment be now for a case like my son had? It’s the same thing. You can get these mal-vaccine reactions. They are vastly better and you can have serious side effects from vaccines, they’re very, very rare. What’s increasingly not rare is measles coming back. The hope is one day we vaccinate so well that we don’t need to vaccinate anymore because we have, look at smallpox, it’s gone. This is theoretically possible. That should be our goal. Angela Smith, thank you. Bieber is an act of war, you’re right. ♪ Because I said baby, baby, baby, oh ♪ Hey, you just used the Barenaked Ladies in your new video, says Anna McCuiqwa. I know they are not musical terrorists. They are spies the Americans sent to Canada to elevate their musical game. ♪ This is me in grade nine, baby, yeah ♪ ♪ This is me grade nine ♪ ♪ This is me in grade nine. ♪ Sandra Oxtoah, my titers show I don’t convert after multiple vaccines of measles. So that’s interesting and some people do not seroconvert. Like I said 99% do after the two and so again, it’s for your sake Sandra that we need a community immunity. Let’s see, tissues now they’re selling with viruses, Kaylie Medina, yeah, I saw that they’re selling pre-flud snot rags. If you want a day off work, you can infect yourself with a flu; first of all, I don’t know enough details about it. Second of all, that is the cardinal sign of the end of America. We’re just done, civilization as we know it is over when you start selling snot rags. We’re finished. I don’t really believe that. I think we’re too smart to go buy snot rags and if you aren’t that’s called Darwinism. If you don’t convert, does that mean you for sure aren’t immune? Dana Velenje. I don’t know the answer to that Dana because there is a humoral response and there’s a cell mediated response and I’m not smart enough of an immunologist to answer that question wisely. Again, the Dunning-Kruger effect. I know a little therefore I know everything if I had Dunning-Kruger I’d say, well, I waive some hand answer and make something up but I know what I don’t know and I don’t know the answer to that. Let’s see, people get mad about this stuff. I can’t believe how stupid people have gotten, Catherine George; these are smart people. It’s just they’re misled by stupid people. They’re misled by professional stupid people that are activists about this stuff. Let’s see, there’s no complete eradication. There are stores of smallpox for biological warfare. Well Robin Johnson, that’s the thing. You can eventually destroy those but Russians probably have some up their pocket and so you wanna keep some too to be able to make a vaccine, I think. It might be a good reason to keep it. All right, I think let’s see where we’re at in terms of time here because I don’t wanna exceed an hour or else the CME people get mad. Okay, we have a couple more minutes. Let’s read some more comments. “He pronounced my last name correctly,” says Kaylee Woodino. What can I say with a name like Damania, not gonna be hard.

Alright, couple calls to action here. In a couple days you’ll be able to get CME for this if you’re a supporter. So sign up as a supporter now. A couple posts ago on the supporter page on Facebook, which you get access to when you sign up, I told you how to register at Physician’s Weekly to get an account that then will host my video, you can then click the video, review any parts you want, take the post-test which will be straightforward if you watched any of this and get your credit and that credit you’ll be able to get a certificate emailed to you, anyway, store it there, whatever you want. What a great way to get your learn on while fighting evil, while improving people’s health, while teaching the teachers around the country, others how to recognize and manage measles in a resurgent era and I think we are nearly out. I wanna thank all the supporters for making this possible. I wanna thank my kids and family for letting me broadcast on screen-free Sunday. I’m gonna go back and sit in a hot tub with them because I promised them this, which we’ve been doing all day but I wanted to get this out of myself before it made me crazy because the more I read about this stuff happening in Washington and Oregon and on the East Coast, aargh! I would just hate for a case to be missed and another outbreak occur. All right, we are out, peace. Actually let me double check that. Yeah, we’re out, one hour!