Most of you have heard of the recent measles outbreak mostly linked to Disneyland over the holidays. As of this writing, a total of 73 cases of measles have been confirmed in the state of California, 48 of which are linked to those who recently visited Disneyland. There are 9 confirmed cases in the Bay Area. Alameda County has 5 cases, 4 of which are probably linked to Disneyland. There are 2 cases each in San Mateo and Santa Clara counties, none of which are directly linked to Disneyland.
Since news of the outbreak, I have received numerous questions about measles and the MMR vaccine. My goal in writing this newsletter now is to hopefully shed some light on this measles epidemic, and to separate fact from the fear that is circulating in the media.
What is measles?
In order to understand what the fear is about, the first thing to understand is what exactly measles is. Measles, also called rubeola, is a highly-contagious viral infection. It is airborne, meaning that it is transmitted by droplets from an infected person’s nose and throat, such as during coughing and sneezing. These droplets can survive in the air and on objects and surfaces for up to 2 hours, but are rapidly killed by heat, light (UV and visible), detergents and organic solvents. Once exposed, the measles virus begins to multiply in the nasal cavity. Two to three days later, the virus continues to replicate and spread from the nasopharynx to the lymphatic system, and eventually to the respiratory tract and other organs. It typically takes 10-12 days for a person to develop symptoms after exposure to measles (the incubation period), but this may be as short as 7 or as long as 18 days.
Takeaway: If the viral replication can be stopped at the time of exposure, this may help prevent actual infection. Consider daily nasal irrigation with Xlear saline nasal spray, neti pot, Neilmed sinus rinse or equivalent. The measles virus is easily inactivated – wash your hands frequently and before you touch your face or eat.
Initial symptoms mimic influenza symptoms, with a fever which can rise as high as 103°F-105°F. This is followed by coryza (runny nose), cough, and conjunctivitis (pinkeye) – the 3 "C’s". With our concurrent flu season in full force, it can be very challenging to differentiate initial measles symptoms with flu symptoms. However, it is during these early stages of measles that we can see what are called "Koplik spots", which are considered definitive for measles. These are discrete white spots on a red base on the inner cheek that appear 1-2 days before, and last 1-2 days after the measles rash develops, and unfortunately are usually gone by the time patients present to a clinic with a rash. The measles rash will develop 2-4 days after upper respiratory symptoms appear and last for approximately 5-6 days. The rash is red and blotchy and some spots may merge, typically starting on the face and moving down the body to the hands and feet, and disappears in that same order. The rash is generally not itchy.
An infected person is contagious for about 4 days before symptoms start, and until 4 days after the rash develops. The secondary "attack rate", or the likelihood of an unprotected person actually getting the infection if they are exposed during this period, is over 90%. The attack rate is highest the younger you are – 94% for children 1 to 4 years of age, and 91% for children 5 to 14 years of age.
The prognosis for measles is generally good. Complications are more likely to occur in children younger than 5 years of age and adults over 20 years of age, and in individuals with vitamin A deficiency, malnutrition, and immunodeficiency. The risk of death is approximately 1-2 per 1,000 cases – with the highest fatality rates seen in children less than 5 years, and in particular those infants aged 4-12 months. Common relatively minor complications include diarrhea in 8%, ear infections in 7% and pneumonia in 6%. While rare, encephalitis (brain infection) can occur in about 1 per 1,000 cases of measles, with an approximately 15% fatality rate, and 25% who will continue to have some residual neurologic damage. While very rare, with anywhere from 1-22 per 100,000 cases, subacute sclerosing panencephalitis (SSPE) is a very serious complication of measles. This is a fatal, progressive degenerative neurologic disease that occurs unpredictably, 7-10 years after a seemingly full recovery from the initial measles infection, resulting eventually in behavioral and cognitive changes, seizures, coma, and death. The risk of SSPE may be higher for patients who contract measles before 2 years of age.
Treatment for measles is supportive. Several studies have shown that high-dose vitamin A may be useful in reducing complications and death from measles, especially in those patients who are deficient in vitamin A. The World Health Organization recommends high-dose vitamin A for all children with acute measles, regardless of vitamin A status. High doses of vitamin A for prolonged periods may have associated toxicity. However, this 2-day protocol is very unlikely to lead to toxicity in the short term. The protocol is as follows – Vitamin A is administered once daily for 2 days at the following doses:
Antipyretics (fever reducers such as Tylenol and Motrin) have been found in many studies to prolong the course of viral illnesses, like chickenpox and measles. Studies have linked the use of antipyretics for the fever with measles to a significantly higher risk of prolonged illness, complications, and mortality. In fact, one study of children in Ghana during a measles outbreak found higher survival rates in children who had higher fevers and more severe rashes.
Takeaway: Fever is the body’s natural and useful response to infection. Do not succumb to fever phobia. In general, limit antipyretics for when your child is uncomfortable enough that it interferes with staying hydrated or getting adequate sleep. There are many homeopathic medicines that can be used to help the body naturally regulate its fever response. Please consult with your doctor for the most appropriate natural and/or conventional medicines to use should your child develop a fever.
What about the MMR vaccine?
The only vaccination against measles that is currently available is the MMR (measles-mumps-rubella) vaccine, and MMRV (MMR plus chickenpox) vaccine. The measles vaccine is no longer available as a separate single-strain vaccine. The MMR vaccine is a "live-virus" vaccine, which means that you are receiving a live, but weakened version of the viruses to create a mild infection with subsequent antibody response and protection. MMR is typically first given between 12-18 months of age, with a second MMR given between 4-6 years of age. After the first dose, approximately 95% of children vaccinated at 12 months of age, and approximately 98% of children vaccinated at 15 months of age will develop protective measles antibodies. Even one dose can be highly effective in preventing measles. But a second dose (technically not a booster) at 4-6 years of age is recommended to capture the 2-5% of children who did not respond to the first vaccine. This second dose may be administered as soon as 4 weeks after the first dose should there be a question as to efficacy. For children who have had their first MMR but are not yet at the recommended age for their second dose, options include receiving their second MMR before they are 4-6 years of age, or doing bloodwork to check for protective antibody levels (measles titers). Adults do not need a booster if they received a measles vaccine after 1968. For adults who are not sure that they’ve been vaccinated, options include checking measles titers or receiving an MMR vaccine. In outbreaks, the CDC may recommend that children as young as 6 months of age receive the MMR. Children between 6-12 months of age are less likely to respond to the vaccine and make appropriate antibodies, and are still recommended to receive the recommended 2 doses at 12-18 months and 4-6 years. There is evidence that vaccination within 72 hours of exposure to measles may prevent disease in those who are unprotected.
The vaccination status is known for 39 of the California patients who have contracted measles. Of these 39 patients, 32 were unvaccinated and 7 were fully vaccinated.
Takeaway: Even one dose of the MMR appears to be very effective in providing immunity against measles. However, no vaccine is 100% effective. A second dose may be required for some patients, especially those who received their first vaccine at less than 12 months of age. Post-exposure vaccination within 72 hours may be effective. Ensuring adequate nutrition and vitamin A as above continue to be important for all individuals regardless of vaccination status.
Because it is a live-virus vaccine, the MMR is not to be given to pregnant women or to individuals who are immunocompromised or are receiving immunosuppressant therapies. It is also contraindicated in individuals with a history of severe allergic reaction to gelatin, neomycin or any other component of the vaccine. Precautions should be taken in patients with moderate or severe illness with or without fever, or a personal or family history of febrile seizures. The measles virus used in the vaccine is grown in chicken embryo culture, but anaphylactic egg allergy is not considered a contraindication to the vaccine.
Takeaway: There are individuals for whom the MMR vaccine is not an option. Unprotected individuals who cannot receive the MMR vaccine (infants, pregnant women, immunocompromised individuals) may rely on "herd immunity", or high vaccination rates in the community, for their protection.
What are the possible adverse reactions to the MMR? Just as no vaccine is 100% effective, no vaccine is 100% risk-free. The most common adverse reaction is typically due to the replication of the measles vaccine virus to induce a mild illness. This typically occurs 5-12 days after receiving the vaccine, and can include fever for 1-2 days and a rash. Joint pains are seen in 25% of susceptible adult women, due to the rubella component. The risk of febrile seizures increases 3-fold 8-14 days after the MMR vaccine, but is still relatively low. Anaphylaxis and thrombocytopenia (low platelet count) are other rare complications. There may be a link between the measles vaccine and SSPE of about 1 case per million vaccine doses, which is significantly lower than the risk of SSPE from a primary measles infection.
Of biggest concern for many parents is the proposed link between vaccines and autism, and in particular between the MMR vaccine and autism. While the media and common public opinion are quick to say that the link between vaccines and autism has been absolutely disproved, they have not done their due diligence research. The National Vaccine Injury Compensation Program (VICP, also called “vaccine court”), established by Congress in 1986, was created to provide a “no-fault” mechanism to compensate individuals found to be injured by vaccines. By 2010, the VICP had awarded nearly $2 billion to individuals who had suffered vaccine injuries. It has awarded at least 4 families millions of dollars after finding that their children had suffered from brain damage (encephalitis) caused by the MMR and other vaccines, which then resulted in regressive autistic symptoms. Since its inception, the vaccine court has awarded money judgments, often to the tune of millions of taxpayer dollars, to 1,322 families whose children were found to have suffered brain damage from vaccines. In August of 2014, a top research scientist whistleblower at the CDC released information that the CDC had manipulated data in an MMR and autism study to obscure the higher incidence of autism found in African-American boys who received the MMR vaccine before 36 months of age.
That being said, it remains that most children will not develop significant adverse reactions to the MMR vaccine. Is there any way to predict which children may be more vulnerable to vaccine reactions, or any way to prevent these reactions from occurring? In taking a closer look at the cases that were won in vaccine court, one case was won on the grounds that the MMR caused autism by aggravating an underlying mitochondrial disorder, and another case was won on the grounds that the MMR caused autism by triggering an autoimmune reaction called Acute Disseminated Encephalomyelitis (ADEM) which caused irreparable brain inflammation. One might conjecture then, that a child who has a suspected mitochondrial dysfunction, or who has a strong family history of autoimmune illness, may be more at risk for these rare, albeit devastating, reactions. What are possible signs of mitochondrial dysfunction – low muscle tone, easy fatigue/poor endurance, delayed developmental milestones, regressions with illness, and lab evidence (including high serum lactate, high serum CK, high AST, low serum carnitine).
A possible mitochondrial dysfunction and/or family history of autoimmune illness are not absolute contraindications to the MMR vaccine. They are, however, precautions. The risk of adverse vaccine reactions must be weighed against the risk of actual disease. In 2000, measles was thought to be mostly eliminated in the US. Measles is now on the rise, and hopefully will not reach the epidemic proportions it has in Europe. Now that the measles infection rate may potentially be climbing, this risk must be taken into account. Likewise, the community benefit of herd protection for infants and immunocompromised individuals must also be considered. These are all considerations that each parent must take into account for their own children. For children who may have mitochondrial dysfunction, or a family history of autoimmune illness, there are supplements that may help to reduce and prevent potential adverse reactions from the MMR vaccine while still enabling the measles protection that it can afford.
Takeaway: Most children will not experience adverse reactions to the MMR vaccine. Given the increasing prevalence of measles, consideration should be given to getting vaccinated, either now or within 72 hours of known exposure. However, if there is a possibility of mitochondrial dysfunction, or strong family history of autoimmune illness or neurodegenerative disease, Dr. Song and Dr. Ruiz are available to consult with you on supplements to help reduce the risk of adverse reactions. These may include carnitine, coQ10, milk thistle, vitamin A, homeopathic Thuja, and others.
We at Whole Family Wellness are here to help you make the safest and healthiest decisions for your child. Please do not hesitate to make an in-person or telephone consultation to discuss any of these issues further.
In good health,