How best to protect against measles 

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Because measles is such a contagious virus, it spreads and crosses borders easily. The New York State Department of Health recently issued a measles travel advisory, so I'm talking about that with Dr. Elizabeth Asiago-Reddy. She's chief of the division of infectious disease at Upstate.

Welcome back to "The Informed Patient," Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Thank you for having me, Amber.

Host Amber Smith: This travel advisory is international and domestic. Do I understand correctly?

Elizabeth Asiago-Reddy, MD: Yes. It's because of the recent outbreaks within the U.S. that the domestic portion was added.

Host Amber Smith: So is it all states, or are there particular states to be careful about, and countries, too?

Elizabeth Asiago-Reddy, MD: The recommendation was specifically for areas of the United States where there is a current outbreak going on, and they left it open-ended, knowing that there would be the possibility of more than one location.

So we've been hearing about Texas. Internationally, the recommendation is very broad because we see outbreaks occurring periodically in various locations.

Host Amber Smith: Now, what are people recommended to do to make sure that they and their family members are protected against measles?

Elizabeth Asiago-Reddy, MD: So the first thing is understanding your vaccination history and the vaccination history of your family members, and going back to 1957. In that era, pre-1957, people are considered to be naturally immune because this is such a contagious virus. We did not have a vaccine available in that era, and so people were routinely infected with measles, so those individuals would be considered to be immune.

Then there are some periods where there's a gray zone, in between, the period from 1957 up until 1967, reason being that that's a time where vaccines were evolving. So there was some coverage, but not with the optimal vaccines. So individuals born in those time periods, it would be recommended, if you can access your vaccine records, to see what you have had, but there's a higher chance that you have not had an adequate vaccine.

And what we consider to be adequate vaccination is two doses of the modern ... in our country, it's the measles-mumps-rubella or measles-mumps-rubella-varicella vaccine. So you would want to check and see if you've had two doses. And then moving forward after 1967, increasing numbers of people have been adequately vaccinated all the way up until 1989, when definitively getting two doses was recommended.

So a lot of people were actually getting two doses. Like I myself, unfortunately, I have a distinct memory of getting vaccinated in kindergarten because I remember telling my parents that I didn't want to get vaccinated, and they told me I had to, but that was pre-1989. So many people were vaccinated in that era, but they may not have received that second dose.

So it's checking your vaccine history, and what the current travel recommendation says is that if you are unsure, or you know that you have not received two doses, that you would receive at least one dose at least three weeks prior to your travel, if you don't have time to get the two doses. So two doses should be separated by a month in between.

Host Amber Smith: Well, what do you do if you are unsure whether you were vaccinated as a baby, or you don't have your records? Would your pediatrician still have them? Or how would you find out?

Elizabeth Asiago-Reddy, MD: This is a challenge with us not having a national health care system, right, is that a lot of people do not have access to their records. So some people can rely, I think, adequately on their parents saying, "We absolutely got every vaccine that was recommended. You had regular pediatric care."

The surrogate that we often use, and this is used for school, it's used for employment, is a blood test looking at antibody levels to measles. And so there are certain antibody levels that are considered to be adequate.

However, if you're not sure, a booster vaccine is the best option, and a booster vaccine is actually more optimal compared with checking on levels, if you're not sure, because those antibody levels don't give you the full picture of your immune status. And a booster vaccine is actually going to give you a better chance at becoming fully immune.

Host Amber Smith: But if you were born before 1957, you're considered immune, correct?

Elizabeth Asiago-Reddy, MD: Yes.

Host Amber Smith: If you were born between '57 and '67, that 10-year period, you need to consider whether you're going to need to get at least a booster, correct?

Elizabeth Asiago-Reddy, MD: Yep, and a lot of my patients have approached me and are taking that approach of going ahead and revaccinating and getting a booster vaccination, if they were born during that period of time.

Host Amber Smith: Now you mentioned MMR, so it's bundled together with mumps and rubella. Does it matter? I mean, we're not being told that we need mumps or rubella, but that's not a problem to go ahead and get, since it's bundled in the same shot?

Elizabeth Asiago-Reddy, MD: Correct.

And it has been bundled in the same shot ever since the modern measles era. It's been bundled for quite a long time. So, yes, that's the way to go.

We don't typically manufacture measles vaccines on their own, but many countries in the world do, just because some other countries have a situation more similar to our past measles situation, where mumps and rubella are acquired during childhood pretty universally. And so they're not necessarily required to have vaccination because mumps and rubella, the complications are actually worse in adults than they are in children. So natural infection, if you're going to be exposed to those as a child, is OK, so you may find that a broad only-measles vaccine by itself is available. In our country, we do bundle them, and that's fine.

For younger children, like I said, they're oftentimes being bundled as well with the varicella vaccine. Varicella vaccinates against chickenpox.

Host Amber Smith: So where do you go for the vaccine?

Elizabeth Asiago-Reddy, MD: If you have a primary care provider, that is your best bet, but there are now, especially recently with these advisories going out, there are more commercial pharmacies that are offering it as well.

So now, locally, we have Kinney's, Walgreen's are offering it, and you can make an appointment online. The health department offers the vaccine in some limited settings. So they offer it for children; basically, if they don't have a proper insurance option or a place to get it, they will provide it. There's a sliding-scale fee associated with that. That's a pretty nominal fee.

And then they also will offer it to adults who require it for admission to school. So for example, if you're going to Syracuse University, you are required to have either documentation of immunity or through the blood test that I was mentioning or an actual vaccine. So if you're a student who's greater than 19 years old, and you don't have a location to get it, you could get it at the health department.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Upstate's chief of infectious disease, Dr. Elizabeth Asiago-Reddy, about measles.

Who should not get an MMR vaccine?

Elizabeth Asiago-Reddy, MD: Very few people, fewer than what is often feared. The biggest one is people with severe immune compromise, and that's something that would need to be discussed with a physician provider because, what does that mean for somebody to be severely immune-compromised?

I think we became more aware of that during COVID, but still, that's something you'd want to discuss with your health care provider as to whether you are indeed severely immune-compromised. Pregnancy actually is a contraindication (reason to avoid) at this point for the MMR vaccine, again, unless there's a significant discussion that's happened with your health care provider in a limited set of circumstances.

And then the, other one would be severe allergy. So if you're known to have an allergy to any of the components of the vaccine, you got the vaccine, you had a severe allergic reaction as a child, for example, that would be another contraindication.

Host Amber Smith: Well, let me ask you also, can you get the shot if someone in your household is pregnant or severely immune-compromised?

Elizabeth Asiago-Reddy, MD: Yep.

Host Amber Smith: You can. OK, that's important to know as well. The vaccines are so effective for people who have been vaccinated, but there are, like we're talking about, a small number of people with medical conditions who could not be vaccinated.

So with so many cases of measles in different communities, what do those people do to stay safe? Do face masks work and hand washing?

Elizabeth Asiago-Reddy, MD: Yeah, I just want to say first that this is the main reason why we still have vaccine mandates in some locations. So New York state does have vaccine mandates. This was put back in place again after a significant outbreak in New York City. And this is because there are individuals who are unable to protect themselves, and so it becomes a matter of it being not fair to exclude those individuals from an environment where they could be exposed to someone else who does have the ability to get vaccinated.

And, it's important that vaccine rates reach 95% for it to be fully effective in protecting those individuals who are unable to be vaccinated. So really, the best protection for people who can't get a vaccine is that everyone around them is vaccinated. That's called herd immunity. So when you reach a certain point, you are diminishing the likelihood that somebody who is unable to be vaccinated or wouldn't respond to the vaccine, you're diminishing the likelihood that they would ever even come in contact with the virus.

Otherwise, measles has some similarities to COVID in that it's an aerosolized, airborne virus. So if you're going to try and prevent it by means other than vaccination, it really does require masking, isolation, optimally that would be masking isolation of the individual who's infected, right?

Masks, we know, do offer protection for the people who are not infected as well. And the level of protection is going to depend on the type of mask that you're wearing. Measles is a little bit different than COVID in that it is higher likelihood, we believe, of being transmitted through surface exposure as well.

So COVID, it looks like, really is very much primarily a respiratory virus, not so much one that you get by touching a surface and putting your hands to your mouth. Measles is both, so measles is all the above. It is really one of, if not the most, contagious virus known to humans. So you can get it by any of those means.

And so yes, you can, wash your hands, avoid contact with surfaces, wear a mask, but it can be difficult to avoid exposure due to the high level of contagiousness.

Host Amber Smith: So if people have already traveled, and now they're concerned about possible measles exposure, what are the symptoms to watch out for?

Elizabeth Asiago-Reddy, MD: Yes, measles has a couple of different stages that we refer to. The first one is the incubation period. Incubation means that the virus is inside somebody's body, it's replicating, but you actually don't have any symptoms, so you don't realize.

And that is about two weeks for measles, which is long and can make it difficult, right? Because two weeks after your vacation, you're on and about your life. You're not even thinking about your vacation anymore, probably, right? But it could be harboring inside of you.

Then we have the prodrome. So the prodrome is that phase where you have started to develop symptoms, but you don't yet have the classic rash, OK? So the symptoms could easily be confused with other types of illnesses, but there are some kind of classic features. And, in measles, it's considered to be the three C's, so that is cough, coryza and conjunctivitis. Cough, we know what that is. Coryza is a runny nose, just so that you can get it into the three C's, and then conjunctivitis is redness of the eye. So those three things together are kind of a classic part of that prodrome.

And that prodrome lasts for about three to five days before the rash appears. You may get a rash inside your mouth, which can show up actually before the generalized rash does, that consists of white spots inside the mouth. And then the generalized rash appears. And what we always learned in school when looking at the different types of rashes is that measles classically appears like somebody dumped a bucket of paint over the individual who was infected, so it tends to start from the face, going down.

Host Amber Smith: Are you contagious during incubation and all the way through?

Elizabeth Asiago-Reddy, MD: You're contagious about a day before the prodrome appears, so about four days or five days before the rash appears, and then for four days after the rash is present.

For people who are severely immune-compromised or who have ongoing symptoms, where normally about four days after the rash comes out, you expect your fevers to be going away. If the fever is continuing, the patient's not getting better, then we also worry that those individuals may continue to be contagious.

Host Amber Smith: Well, let's talk about the treatment for measles. Since the virus is so contagious, I'm assuming people who are infected need to be isolated. Is that right?

Elizabeth Asiago-Reddy, MD: Yes. Isolation is critical.

If they're in a hospital environment, they need to go into an airborne isolation room. That's the highest level of isolation in the hospital, typically, and then if they're at home, then what you would want is, ideally, the individual would self-isolate. If this is a child who requires a caregiver, then, ideally, that caregiver would be vaccinated. Otherwise, they would certainly be at extremely high risk of also contracting measles.

Host Amber Smith: Is there any medication or anything that you can give the person to help them get through measles?

Elizabeth Asiago-Reddy, MD: So vitamin A is the one that we've been hearing a lot about, as per the recommendations that have come out recently.

Vitamin A: It is especially important for young children, and especially young children living in environments where they actually may be deficient in vitamin A. The data are somewhat controversial. This is not a slam dunk. There have been some studies that have shown vitamin A to be efficacious in promoting recovery from measles, so not dying from measles in resource-limited settings in children less than 2 years of age. But not all studies have shown that. But those are really the people who are going to benefit the most from vitamin A.

Vitamin A for older children and adults, there's really very little evidence that it is particularly helpful. As long as it's given in a reasonable dose, it's unlikely to be harmful, but some people can take it to an extreme and give too much Vitamin A, which has its own sets of risks associated with it.

Aside from that, treatment for measles is largely supportive. So just like any febrile illness caused by a virus, it is "tincture of time" (letting it run its course), anti-fever agents like Tylenol, and then, after that, if the patient is extremely ill and hospitalized with pneumonia, there is an antiviral called Ribavirin, which can be used, but that would not be used outside of very severe cases.

Host Amber Smith: We've heard of children dying from measles during these outbreaks recently. Is it pneumonia that they die from? What makes measles become deadly?

Elizabeth Asiago-Reddy, MD: Yeah, it did appear from the available information about the two cases where children have died in Texas recently, that those children did die of pneumonia.

So the three major complications that you could see after a typical course of measles would be diarrhea, pneumonia and encephalitis, with pneumonia and encephalitis being the most likely to be deadly. And encephalitis is inflammation of the brain. So that would present more like confusion, headaches, that type of a picture.

Host Amber Smith: Well, this is really important information, and I thank you for making time to share it.

Elizabeth Asiago-Reddy, MD: Absolutely. Thank you for having me.

Host Amber Smith: My guest has been Dr. Elizabeth Asiago-Reddy, the chief of infectious disease at Upstate Medical University.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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