Measles: Cough, Coryza, Conjunctivitis...Crud!

- [Dr. Amato] Hello, my name is Dr. Christopher Amato. I am here on behalf of ACEP. And today, we're gonna talk about measles, otherwise known as the three Cs, cough, coryza conjunctivitis, and if you wanna add the fourth C, crud. Okay, let's get into it and hopefully I'll be able to answer some questions that you might have about the current outbreak that we're dealing with. So, I know that I'm preaching to the converted when I come and talk to you about how vaccinations have been the greatest public health success of the last century plus. We have eradicated diseases that absolutely has significant morbidity and mortality, and we continue to go further down that ability to protect the public by doing so. As a reminder for those who are not necessarily peds savvy, we do have an updated vaccination schedule that we've got here, but today we're gonna focus on the measles, mumps, and rubella vaccination. So, this is really just for your own iteration. If we look at the measles, mumps, and rubella schedule, we recognize that the first vaccination really doesn't happen until about a year. Somewhere between 12 and 15 months, is typically where they're gonna start getting their first vaccination. And then, their second vaccination is gonna be more as a toddler age. So, we in the emergency department are potentially dealing with patients who are not vaccinated when they are younger than a year of age, okay? The reality though, is that you really aren't gonna be truly capable of fighting off an infection related to the vaccine until you've had at least two vaccinations. That's where you start getting more of a 90% protection related to that. Here's the good news, is that in general, vaccination rates nationally, there's only about a 3% complete refusal. There are about a 20% that have a delayed approach, or a delayed schedule to treating their children with vaccinations. That's gonna be significantly higher for your annual flu, or of course, in this current day and age, COVID vaccinations. But for the most part, most families are protecting their children. And those that are not fully vaccinated are being protected therefore, by herd immunity. That's not necessarily always the case because if they are a child, or a family in an area where there is a much higher non-vaccination rate in that community, then that's where we have these risks for outbreaks and rampant infections because these illnesses are generally considered extremely contagious, okay? And again, this is just a pie graph of the same thing. This is all information that you can obtain from the CDC website, and we'll go further into that here. So, as you can see, in general, our rates for these vaccine-preventable diseases are relatively good actually. And you can actually, with the color-coded chart there, again from the CDC, you can actually recognize where you are. And if you were on the CDC website and you're actually moving your cursor over your particular state, you would actually have a breakdown by area as to what is the vaccination rate and potentially illness rate in your particular location. I don't think that many of us need constant surveillance because we're the ones who are actually watching those patients coming through the door, be they children, or adults. So, when we're dealing with the full vaccine status, you know, most of those patients are getting more and more of those diptheria, tetanus, and acellular pertussis. Three, or more is gonna be polio with one measles, mumps, and rubella and one hemophilus influenza, okay? And so, you continue going down in terms of your own location as to what is the vaccination rate in your particular location. When we're dealing with vaccine-preventable outbreaks, again, this is actually about a year, or so old. But it's from 2014, looking at those areas that where, again, vaccine-preventable diseases had a huge breakout. And in that situation, it was a huge breakout, more on the West Coast, and even a little bit of the Midwest where we were dealing with pertussis, we were dealing with measles, we were dealing with a few other vaccine-preventable diseases. And again, those of you who work in those states don't need me to remind you of those horrible, horrible situations. This was just accessed today, by myself. And again, we're looking at the outbreak that we're dealing with now with measles. As of March 21st, there was 64 measles cases in 17 different jurisdictions. And you can read the states there. In my own particular state in New Jersey, I've had two cases, and both were actually in unvaccinated individuals. And you can see on the bar graph below that we are dealing with, you know, by season and by year, a increase of these numbers accordingly. In terms of by year, we again can see the outbreaks. And we had a much bigger outbreak in 2018 to 2020. And every time that we think that we have gotten things under control, unfortunately it seems like there is another round of an outbreak. And again, this is just a graphic interpretation of the different states that are being affected currently. And once again, you can just, on the CDC website, just go ahead and slide your cursor over it, and get more granular data. So, I think first and foremost, when we're dealing with the patients that are coming through our door, we do need to verify their vaccination status. And there are certain groups that, in general, have a lower vaccination rate, Amish, Mennonites, Dutch Reformed, Christian Scientists, Orthodox Jewish, et cetera. And you will know your own specific populations based on your own locations where you're treating them, okay? The reality though, is that those groups that have a generally lower vaccination rate, do have almost a three times relative risk for hospitalization for vaccine-preventable diseases. So, those patients in and of themselves, will be somebody that we should be looking at a little bit more carefully and thinking about those things that we generally don't think about with the general population, but we do need to verify their vaccination status first and foremost. So, let's move on to our case. We have a five-year-old male who comes in for cough. They are from Rockland County, New York. And I'm bringing that up just because I'm an East Coast kinda guy, so cough county. So in January to October in 2019, we had 1200 individual cases of measles confirmed in 31 states. It was the highest case we've had since 1992. And we actually thought that we had declared measles as completely eliminated at the turn of this new century, in 2000. The reality though, was that New York was the highest area of breakouts in that Rockland County area. So again, when we're talking about, thinking about rubella, rubeola, excuse me, rubella is a completely different disease, we're talking about those three Cs, right, cough, conjunctivitis, coryza, and almost invariably, they're associated with fever. The problem is, is that depending on when they present to us in the emergency department, or in the office, or in your urgent care center, wherever you care for patients clinically, the examination is going to vary. So, the classic thing we talk about is Koplik spots, which are these kinda little grains of salt that we can see mostly on the buccal mucosa. But you can also see them on the lips, on the gums, you can see them in the lower conjunctiva, and in females, we can also see them in the vaginal mucosa, okay? They typically will show up about 24 to 48 hours prior to the onset of this morbilliform, which is the Latin term for measles kind of rash, and they will disappear within 12 to 72 hours. So if we miss that window, we are missing one of the most common, and I would say classic, even pathognomonic clinical findings that we've got for our measles patients. So generally, when we're dealing with that morbilliform rash or that measles rash, it is typically going from the head all the way down to the toe. And back in the '90s when I trained, we actually knew the prognosis, or how long that child was going to be ill for based on how far that rash spread, okay? So the problem is, is that there can be actually different stages of that rash as they progress. So, it is extremely contagious. Measles is extremely contagious. In the '70s and '80s, you would have either a varicella party where someone had varicella, and everyone would come over and try and get varicella because it was just better to get it over with when they were younger. The same thing was true for rubeola, or measles. You can have illness, and more importantly, they can be infectious five days before the onset of the fever, the Koplik spots, and then ultimately the rash, okay? And it has a mortality rate of 1 in 1000. Most of the times, again, they're getting that first vaccine at a year, but there is up to 7% that don't respond to that first vaccine. So inherently, even though that first vaccine should provide some type of protection for that patient, upwards of 7% will not actually get that. And there's a myriad of complications that we are dealing with. The classic one is that subacute sclerosing panencephalitis, but that doesn't show up immediately. That shows up almost a decade later. So, that's not something that we should be looking for in the acute phase. That is much, much later on. The biggest issue we'll deal with is bacterial superinfection. It is also the leading preventable cause of blindness worldwide. And if, either in a vitamin A-deficient area, or there's a nutritional issue, or a malnutrition issue, then vitamin A can absolutely decrease morbidity and mortality. So, let's start taking some look at the pictures themselves. So, I think you can clearly see these kinda salt crystals, or little white nodules that you can see in the buccal mucosa. It typically will show up in the area right around that first, or second lower molar. They can actually be bluish-white as opposed to just pure white. And those will be gone by 72 hours, and the rash is starting to show up. So, if we haven't seen them in that timeframe, we will potentially have missed that clinical finding. When it comes to the Koplik spots, again, two to three days before they show up that. So, we have the prodromal stage, or the catarrhal stage. It begins 10 days after infection, and it will last up to two weeks from the illness' onset, okay? Again, cough, coryza, and we're dealing with those Koplik spots as well, okay? You can actually have GI symptoms. Now, the rash that we typically see is rarely, rarely itchy, but it can be fulminate. It can be coalescent over the entire body, and again, starting from the forehead and working its way down to the torso, and even to the lower extremities. The eruptive phase starts about three to five days after the onset of fever, but it usually starts most commonly about day four. It is a red, almost a ruddy, almost purple, maculopapular rash, confluent, like I said, blotchy. It begins on the face area, oftentimes behind the ear, along the hairline, then goes towards the face, the neck, and starts working its way down, okay? It will include the palms and soles. Fever rise is continuous and can be accompanied by toxic symptoms, okay? And the biggest thing that we need to worry about is again, bacterial superinfection on these patients. So, this is a pretty classic example of that rash. You can see it anywhere. And even in neonates, you can have this as one of the torch infections. This is just a typical, again, a picture of a child. These are all from the CDC. Again, you can visualize these on the CDC website. So, they are uncomfortable for a few reasons. The body aches, the fever, just the general discomfort of being ill. After measles has started working its way out, just like any viral illness, they can have weight loss, they will have a general malaise, or a weakness associated with this. It beats them up pretty, pretty well. You can actually have growth retardation. You can have GI symptoms. You can have superinfections, both bacterial, or fungal. You can actually, if for some reason that child has a history of tuberculosis, it can reactivate that tuberculosis because of that immunosuppression. And again, superinfection is what we're really concerned about, okay? Peak illness is gonna be about two to four days after the onset of rash, but remember that they have been contagious at that point, for seven to nine days. So, they've been at school, they've been around other children, so we are actually having, you know, a wildfire start with a small spark. Generally, the resolution is pretty rapid. They get better pretty much after about a week, or so, and they can actually have complete recovery and return to baseline in about 10 to 14 days. Now that rash though, can persist for weeks on end. And that is not something necessarily, that's gonna disappear in that 10 to 14 days. When we're dealing with diagnosis, if the clinical examination is there and you're able to see the Koplik spots and maybe the onset of that facial rash, that'll certainly help, but when it's considered basically standard, is gonna be the ELISA testing, looking for the IgM antibodies of measles, okay, of rubeola. So, we are looking at this test, but you have to give them a few days. Just like we know that any antibody requires typically about 7 to 10 days, you need about 4 to 28 days of illness before you obtain that test because it is very sensitive, but we need time for the body to create that IgM antibody, okay? A single serum sample within the first 28 days of illness after the onset, is considered pathognomonic for measles. So, all we need is one positive test, and we are good to go. Again, we talked about complications, we talked about superinfections being the most common. Corneal scarring, again, keratitis is the most commonly preventable cause of worldwide blindness. Pneumonia, diarrhea, and then the acute encephalitis, that we are dealing with with these children. Again, can happen acutely, but when we're dealing with that classic association, that is not happening for about a half to a decade later. I do wanna just bring up quickly, varicella, just because we can differentiate between the two. It is also extremely highly infectious. It also can be prevented with vaccinations. Those children who are vaccinated, can have a much milder course and overall a shorter duration of illness. In general, there are less than 200,000 cases per year of varicella. Most of the times, this is a clinical diagnosis. And again, I guess I'm old, but I have seen varicella many times, and this is something that you can tell. Again, we have that itchy rash that's in multiple stages, and it's basically everywhere on the body. So, let's just kind of look at the varicella quickly. Again, when we're dealing with chickenpox, or varicella, it is a symptomatic care. If they have presented within that first 24 to 72 hours, I do consider acyclovir. Certainly if there is a concern about their ability to fight off illness and I'm concerned that they're immunocompromised, those are the patients that should be admitted for IV acyclovir. Neonates, and again, immunosuppressed patients, or if they've got any kinda cancer illness, or transplantation, they should also get varicella immunoglobulin as well. And probably the vast majority of the audience that's listening to me has never seen Reyes syndrome. I've only seen one case in the early, early '90s. And we generally do not give any kind of aspirin for any kind of febrile illness for children because of the concerns for Reyes syndrome, okay? When we compare chicken pox and measles, please remember that we have different causes. The transmission is relatively similar, that it's direct person-to-person contact, although measles is more of a droplet cause. For chickenpox, it incubates for about 10 to 21 days, whereas measles is a little bit faster. And then the rash is typically more itchy, and will have various stages with chickenpox, whereas the measles is gonna be, again, morbilliform, that ruddy red, and it's gonna start more on the face and then work its way down, okay? When we're looking at, again, the rash itself, again, it is not confluent when you're dealing with chickenpox. You're dealing with a completely different-looking kind of rash. I hope that this mini-clinic about measles helped you. And if there's anything that can else be done, I know that ACEP is gonna be holding a webinar about measles as well as, there's a myriad of sources that are available to you as ACEP members on our website. Thank you so much. I appreciate your time. And I certainly hope that you guys continue to do the exceptional work that you do every single day. Thank you.