California Wants Physicians to “Think Measles.”

As a growing number of Californians exempt their children from required immunizations, public health departments statewide are launching campaigns to try to persuade them to vaccinate and legislators are trying to make it harder for them to get exemptions. Photo: @alviseni/Flickr
Photo: @alviseni/Flickr

Hoping to avoid a repeat of last year’s measles outbreak in California, public health officials have launched a campaign reminding doctors to consider the highly contagious virus as a possible diagnosis when patients or parents call or come in with a fever and rash.

While the virus simply runs its course in many patients, it can cause hearing loss, encephalitis and death.

Last year’s outbreak, believed to have been started by a foreign visitor to Disneyland, was over in April. But Dr. Karen Smith, director of the Department of Public Health and the state’s Health Officer, said more cases might arise during the current school year.

According to CDPH, measles begins with a fever that lasts for a couple of days along with a cough, runny nose, and red, watery eyes. The rash may appear 3-7 days after symptoms begin and the rash typically appears first on the face, along the hairline, and behind the ears and then spreads to the rest of the body.

Before 1963, when the measles vaccine was introduced in the United States, just about all doctors were able to recognize measles from the time they were medical students and saw cases during their hospital rotations.

But the vaccine drastically dropped the numbers of cases over the years, and in 2000 measles was declared essentially eliminated in the U.S.

In recent years, though, parents fearing side effects from the vaccine have been withholding it from their children, which leaves many vulnerable to the virus when a traveler brings it from one of the countries where it is still endemic or an unvaccinated Californian travels to those countries.

Health department officials went on high alert again a few weeks ago when a Berkeley college student, who had recently traveled, was diagnosed with measles, though no new cases have been announced.

In the aftermath of last year’s outbreak, a new California law was passed in July to take effect next summer that bars parents from claiming a religious exemption in order to keep form vaccinating their children. Parents may still be able to skirt the rule by home schooling children or trying to find a doctor to write a medical exemption such as an allergy to the vaccine or a previous serious side effect.

But the outbreak last year also brought attention to another group of kids missing vaccines–those that have had one but not both of the two recommended measles doses and are protected about 95 percent against the disease but are still vulnerable. (Two doses bring immunity up to about 97 percent according to the U.S. Centers for Disease Control and Prevention.)

Current national recommendations for the measles vaccine are for a first vaccine at 12-15 months and a second one at 4-6 years (babies who will be traveling to countries known to have measles can get a vaccine starting at six months, but should get the full two doses on the recommended schedule).

But while the California Department of Education requires at least one shot for kindergarten admittance, children without the second one can remain in school “conditionally” on the understanding that they will soon make it up. Nine of the patients who came down with measles in last year’s outbreak had documentation showing they’d had only one measles shot. (Half of those who caught the virus had no measles vaccine documentation whatsoever.)

Schools are supposed to remind parents whose kids remain conditionally unvaccinated that they need their outstanding shots until they‘re up to date, according to the rules of the California Department of Education.

But catching up with those children can be difficult, says Dr. James Watt, CDPH’s Chief of the Division of Communicable Disease Control. While records are supposed to be checked every thirty days, Watt says schools vary on how they keep track.

“Those who have an electronic filing system can have an easier time staying up to date than those who have to check records manually,” he said.

Budget cuts have resulted in fewer school nurses and clerks to check the records, says Watt, although during last year’s outbreak public schools in Los Angeles and other cities brought in extra nurses to vaccinate kids with parents’ permission.

James Cherry, MD, a former chief of the division of pediatric infectious diseases at Mattel Children’s Hospital UCLA, said that although there are no numbers to support it, anecdotally doctors believe that many children who lack the second vaccination are in low-income families with parents who often can’t take time off work to bring kids to the doctor’s office or a clinic during regular office hours.

That access is slowly changing.

Amy Simmons Farber, a spokeswoman for the Association of Community Health Centers, says the centers, which accept Medi-Cal and use sliding scale fees, offer more night and weekend hours than other providers.

Mike Witte, MD, chief medical officer of the California Primary Care Association, says insurers are adding incentives to providers who have convenient patient hours, which should help working parents stay up to date on kids’ vaccines.

In many California cities a call to 311 can find community health centers that hold free immunization clinics. People who live in cities without the 311 service can find clinic hours by looking at the California Cities website.

Carlos Villatoro, a spokesperson for CDPH. says doctors can help increase measles vaccination this year by:

  • Discussing the risks of measles and the benefits of immunizations with patients and their families
  • Offering immunizations on schedule at each clinic visit
  • Reminding patients (by email, text, phone and postcard) about upcoming or missed vaccinations
  • Using the California Immunization Registry and the electronic health records systems to indicate what vaccines are due.
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