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Measles

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Measles: What You Might Not Know
Amy Cobb
Western Governors University

Abstract
For years measles claimed the lives of many people throughout the world. Although mostly eradicated in the United States, measles outbreaks still occur in developing third world countries. This paper will analyze one such outbreak that occurred in 2011 and the epidemiological data and indicators that surrounded it.

What is measles? Measles is a highly contagious viral disease that can be fatal. Although an uncommon disease in the United States of America, in 2008, measles killed 164,000 children worldwide ("Measles symptoms," 2012). The disease measles and the virus that causes it share the same name. The disease is also called rubeola. Measles virus normally grows in the cells that line the back of the throat and lungs ("Meales: Rubeola," 2012). In 2000, measles were declared eliminated from the United States. However with the increase in foreign travel, outbreaks are still reported to the CDC annually ("Meales: Rubeola," 2012).
One such outbreak occurred on June 20, 2011. An emergency room physician reported five epidemiologically linked measles cases to the Indiana State Department of Health. The subsequent investigation identified a total of 14 confirmed cases in northeast Indiana (Brown, 2011). Of the 14 cases, 13 were unvaccinated people in the same extended family. The remaining patient was a 23 month old child who had received one dose of the measles, mumps and rubella vaccine 4 months prior to illness onset (Brown, 2011). Four of the 14 patients were males; median age was 11.5 years (range 15 months-27 years). The remaining patient was 32 weeks pregnant and hospitalized for pneumonia (Brown, 2011).
The source of the outbreak was traced back to a 24 year old unvaccinated U.S citizen. The traveler first noticed a rash during their return flight from Indonesia on June 3, 2011. The traveler was admitted to an Indiana hospital but was misdiagnosed and discharged. The outbreak went unrecognized till June 20th, when five family members visited the local emergency room with the onset of measles symptoms. Measles were confirmed through nasal swabs obtained from two of the patients. The strain identified was measles genotype D9, endemic in Indonesia (Brown0, 2011).
This definite diagnosis of measles, led to a follow up investigation involving 780 people. This investigation included follow ups at a church, a factory and in a bus ridden by school-aged children who traveled out of state. Health-care facility exposures included two general practice offices, one obstetrics office, two emergency departments, one urgent care facility and two hospitals (Brown, 2011). Outbreak control measures were instituted, including media releases that that informed the local public of the outbreak and steps to take. Community testing and vaccination clinics were conducted. Preliminary estimates of the impact of the measles outbreak on the state health department are as follows: 660 personal hours, 1,510 miles logged, and $6,243 in testing cost (Brown, 2011). Fortunately no deaths resulted from this outbreak.
Although such outbreaks are becoming increasingly uncommon, they do still occur. The current incidence rate for measles is 1 in 747,252 or 0.00% of 364 people in the USA ("Prevalence and incidence," 2011). Measles is still common in developing countries such as parts of Asia and Africa. Measles outbreaks can be particularly deadly in countries experiencing or recovering from a natural disaster or conflict. In 2010, there were 139,300 measles deaths globally-nearly 380 deaths every day or 15 deaths every hour ("Measles," 2012). Accelerated immunization activities have had a major impact on reducing measles deaths. From 2001 to 2011 more than one billion children aged 9 months to 14 years who live in high risk countries were vaccinated against the disease. Global measles deaths have decreased by 74% from 535,300 in 2000 to 139,300 in 2010 ("Measles," 2012).
The measles shot known as MMR vaccine, is an immunization shot against measles, mumps and rubella. It was first developed in the 1960’s and is a mixture of three live attenuated viruses administered via injection ("Mmr vaccine," 2012). The shot is generally administered to children around the age of one year, with a second dose before starting school. These vaccinations are offered in pediatric doctor offices as well as local health departments. The MMR vaccination is currently used in over 90 countries around the world ("Mmr vaccine," 2012).
The outbreak mentioned earlier may have been prevented had the traveler simply had the MMR vaccination. It is recommended that anyone traveling to a third world country should receive the MMR vaccination. If the traveler had been vaccinated properly he would not have carried the disease back into the United States and spread it to his family members. Same rule applies to the family members of the traveler. In order to completely eradicate measles it is important to educate families on the importance of taking accountability and vaccinating themselves and their children. The traveler encountered someone during his travel, who had an active case of measles, since the traveler was unaware of the exposure he put not only himself but the lives of his entire family at risk.
Measles is transmitted by direct contact with infectious droplets or, less commonly by airborne spread. The most infectious stage of the disease is associated with sneezing and coughing. The incubation period is generally eight to 12 days from exposure to onset of symptoms. The appearance of the measles rash can take up to 14 days to appear ("Meales: Rubeola," 2012). The traveler in the outbreak mentioned above, did not develop a rash until his return flight home. Depending on his length of stay in Indonesia, the traveler may have affected many other people during the incubation period. Once the traveler arrived home he was still considered contagious and infected the other unvaccinated family members as well as exposed the people at all the other places he visited. By being misdiagnosed the hospital workers as well as their families and everyone they came into contact with was also at risk of developing measles. Below is a graphic illustration of the mode of transmission of this particular outbreak.

Measles outbreak June, 2011
Measles outbreak June, 2011
Unvaccinated Indiana man travels to Indonesia
Unvaccinated Indiana man travels to Indonesia Measles identified on June 20th, proper control measures started.
Measles identified on June 20th, proper control measures started.

On June 20th 5 family members show up in local ER with measles symptoms
On June 20th 5 family members show up in local ER with measles symptoms

Gets misdiagnosed and sent home.
Gets misdiagnosed and sent home.
Presents to Indiana hospital on June 3rd with measles rash.
Presents to Indiana hospital on June 3rd with measles rash.

An outbreak such as the one analyzed above could very easily happen in my very own community. Luckily, many school systems and local health care facilities have made it mandatory for children and health care workers to receive this vaccination. However there are still select families who chose not to get their children vaccinated. These children are usually home schooled but still pose a great risk of being exposed to measles. In our community we have a large population of foreign doctors who often travel to third world countries. We currently offer several pediatric offices and a local health department where MMR vaccinations can be received. I do feel like our community would be able to handle a measles outbreak if one should occur.

SARS In this scenario I will assume the role of a community health nurse. A family that I am familiar with has recently returned from traveling overseas and has contracted SARS. Now several other members in our community are showing SARS symptoms. As a suspecting community health nurse the first place I would contact would be the local health dept. If a local health department was not open I would immediately contact the center for disease control. I would ask the suspected family to please remain isolated from the rest of the community. I would also make an attempt to contact the other residence who are showing signs and ask them to remain in isolation also. I would question the families regarding where their travels took place, the length of time they have had symptoms and whom else they have had contact with. I would provide education to the families about SARS and what they can expect during the next couple of weeks.

Poor Air Quality As a community health nurse I would have several patients suffering from asthma and other respiratory related disorders. I have just heard on the local news that the current air quality index in our community is very poor. This condition is very dangerous for everyone in the community. The people who are at the greatest risk are people with asthma, cardiovascular disease, diabetes, adults who are active outdoors, children and people over age 65 ("Air quality index," 2012). I would encourage my patients to avoid outdoor activities, avoid exercising that can cause deep, rapid breathing. I would encourage them to stay away from high-traffic areas, and do not exercise near those areas. I would encourage them to stay cool and hydrated and keep asthma inhalers on hand. If the patient most venture outside I would encourage them to wear a mask at all times and once they return home they should shower immediately.

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