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Monday, November 11, 2013

Article Referenced in Loop Article Part 7

Measles --- United States, January--May 20, 2011
May 27, 2011 / 60(20);666-668

On May 24, this report was posted as an MMWR Early Release on the MMWR website (
Measles is a highly contagious, acute viral illness that can lead to serious complications and death. Endemic or sustained measles transmission has not occurred in the United States since the late 1990s, despite continued importations (1). During 2001--2008, a median of 56 (range: 37--140) measles cases were reported to CDC annually (2); during the first 19 weeks of 2011, 118 cases of measles were reported, the highest number reported for this period since 1996. Of the 118 cases, 105 (89%) were associated with importation from other countries, including 46 importations (34 among U.S. residents traveling abroad and 12 among foreign visitors). Among those 46 cases, 40 (87%) were importations from the World Health Organization (WHO) European and South-East Asia regions. Of the 118, 105 (89%) patients were unvaccinated. Forty-seven (40%) patients were hospitalized and nine had pneumonia. The increased number of measles importations into the United States this year underscores the importance of vaccination to prevent measles and its complications.
Measles cases are reported by state health departments to CDC, and confirmed cases are reported via the National Notifiable Disease Surveillance System (NNDSS) using standard case definitions (3). Cases are considered internationally imported if at least some of the exposure period (7--21 days before rash onset) occurred outside the United States and rash occurred within 21 days of entry into the United States, with no known exposure to measles in the United States during that time. Import-associated cases include 1) internationally imported cases; 2) cases that are related epidemiologically to imported cases; and 3) imported virus cases for which an epidemiologic link has not been identified but the viral genotype detected suggests recent importation.* Laboratory confirmation of measles is made by detection in serum of measles-specific immunoglobulin M antibodies, isolation of measles virus, or detection of measles virus RNA by nucleic acid amplification in an appropriate clinical specimen (e.g., nasopharyngeal/oropharyngeal swabs, nasal aspirates, throat washes, or urine). For this report, persons with reported unknown or undocumented vaccination status are considered unvaccinated. An outbreak of measles is defined as a chain of transmission with three or more confirmed cases.
During January 1--May 20, 2011, a total of 118 cases were reported from 23 states and New York City (Figure 1), the highest reported number for the same period since 1996 (Figure 2). Patients ranged in age from 3 months to 68 years; 18 (15%) were aged <12 months, 24 (20%) were aged 1--4 years, 23 (19%) were aged 5--19 years, and 53 (45%) were aged ≥20 years. Measles was laboratory-confirmed in 105 (89%) cases, and measles virus RNA was detected in 52 (44%) cases. Among the 118 cases, 105 (89%) were import-associated, of which 46 (44%) were importations from at least 15 countries (Table), 49 (47%) were import-linked, and 10 (10%) were imported virus cases. The source of 13 cases not import-associated could not be determined. Among the 46 imported cases, most were among persons who acquired the disease in the WHO European Region (20) or South-East Asia Region (20), and 34 (74%) occurred in U.S. residents traveling abroad.
Of the 118 cases, 47 (40%) resulted in hospitalization. Nine patients had pneumonia, but none had encephalitis and none died. All but one hospitalized patient were unvaccinated. The vaccinated patient reported having received 1 dose of measles-containing vaccine and was hospitalized for observation only. Hospitalization rates were highest among infants and children aged <5 years (52%), but rates also were high among children and adults aged ≥5 years (33%).
Unvaccinated persons accounted for 105 (89%) of the 118 cases. Among the 45 U.S. residents aged 12 months−19 years who acquired measles, 39 (87%) were unvaccinated, including 24 whose parents claimed a religious or personal exemption and eight who missed opportunities for vaccination. Among the 42 U.S. residents aged ≥20 years who acquired measles, 35 (83%) were unvaccinated, including six who declined vaccination because of philosophical objections to vaccination. Of the 33 U.S. residents who were vaccine-eligible and had traveled abroad, 30 were unvaccinated and one had received only 1 of the 2 recommended doses.
Nine outbreaks accounted for 58 (49%) of the 118 cases. The median outbreak size was four cases (range: 3--21). In six outbreaks, the index case acquired measles abroad; the source of the other three outbreaks could not be determined. Transmission occurred in households, child care centers, shelters, schools, emergency departments, and at a large community event. The largest outbreak occurred among 21 persons in a Minnesota population in which many children were unvaccinated because of parental concerns about the safety of measles, mumps, and rubella (MMR) vaccine. That outbreak resulted in exposure to many persons and infection of at least seven infants too young to receive MMR vaccine (4).
Reported by
Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Huong McLean,, 404-639-7714.
Editorial Note
As a result of high vaccination coverage, measles elimination (i.e., the absence of endemic transmission) was achieved in the United States in the late 1990s (1) and likely in the rest of the Americas since the early 2000s (5). However, as long as measles remains endemic in the rest of the world, importations into the Western Hemisphere will continue.
The unusually large number of importations into the United States in the first 19 weeks of 2011 is related to recent increases in measles in countries visited by U.S. travelers. The most frequent sources of importation in 2011 were countries in the WHO European Region, which has accounted for the majority of measles importations in the United States since 2005 (2), and the South-East Asia Region. This year, 33 countries in the WHO European Region have reported an increase in measles. France, the source of most of the importations from the European Region, is experiencing a large outbreak, with approximately 10,000 cases reported during the first 4 months of 2011, including 12 cases of encephalitis, a complication that often results in permanent neurologic sequelae, 360 cases of severe measles pneumonia, and six measles-related deaths (6).
Measles can be severe and is highly infectious; following exposure, up to 90% of susceptible persons develop measles. Measles can lead to life-threatening complications. During 1989--1991, a resurgence of measles in the United States resulted in >100 deaths among >55,000 cases reported, reminding U.S. residents of the potential severity of measles, even in the era of modern medical care (7). In the years that followed, the United States witnessed the return of subacute sclerosing panencephalitis among U.S. children, a rare, fatal neurologic complication of measles that had all but disappeared after measles vaccine was introduced in the 1960s (8).
Children and adults who remain unvaccinated and develop measles also put others in their community at risk. For infants too young for routine vaccination (age <12 months) and persons with medical conditions that contraindicate measles immunization, the risk for measles complications is particularly high. These persons depend on high MMR vaccination coverage among those around them to protect them from exposure. In the United States this year, infants aged <12 months accounted for 15% of cases and 15% of hospitalizations. In Europe in recent years, measles has been fatal for several children and adolescents, including some who could not be vaccinated because they were immune compromised.
Rapid control efforts by state and local public health agencies, which are both time intensive and costly, have been a key factor in limiting the size of outbreaks and preventing the spread of measles into communities with increased numbers of unvaccinated persons. Nonetheless, maintenance of high 2-dose MMR vaccination coverage is the most critical factor for sustaining elimination. For measles, even a small decrease in coverage can increase the risk for large outbreaks and endemic transmission, as occurred in the United Kingdom in the past decade (9).
Because of ongoing importations of measles to the United States, health-care providers should suspect measles in persons with a febrile rash illness and clinically compatible symptoms (e.g., cough, coryza, and/or conjunctivitis) who have recently traveled abroad or have had contact with travelers. Providers should isolate and report suspected measles cases immediately to their local health department and obtain specimens for measles testing, including viral specimens for confirmation and genotyping.
MMR vaccine is safe and highly effective in preventing measles and its complications. MMR vaccine is recommended routinely for all children at age 12--15 months, with a second dose at age 4--6 years. For adults with no evidence of immunity to measles, 1 dose of MMR vaccine is recommended unless the adult is in a high-risk group (i.e., health care personnel, international travelers, or students at post-high school educational institutions), in which case, 2 doses of MMR vaccine are recommended. Measles is endemic in many countries, and exposures might occur in airports and in countries of travel. All travelers aged ≥6 months are eligible to receive MMR vaccine and should be vaccinated before travel (10). Maintaining high immunization rates with MMR vaccine is the cornerstone of outbreak prevention.
The findings in this report are based, in part, on contributions by Mary McCauley and Paul Chenoweth, National Center for Immunization and Respiratory Diseases, CDC.
  1. Katz SL, Hinman AR. Summary and conclusions: measles elimination meeting, 16--17 March 2000. J Infect Dis 2004;189(Suppl 1):S43--7.
  2. Parker Fiebelkorn A, Redd SB, Gallagher K, et al. Measles in the United States during the postelimination era. J Infect Dis 2010;202:1520--8.
  3. CDC. Manual for the surveillance of vaccine-preventable diseases. 4th ed. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at Accessed May 20, 2011.
  1. CDC. Measles outbreak---Hennepin County, Minnesota, February--March 2011. MMWR 2011;60:421.
  1. World Health Organization. Global elimination of measles---report by the Secretariate, 16 April 2009. Available at pastedGraphic.pdfpastedGraphic_1.pdf. Accessed May 20, 2011.
  2. Institut de Veille Sanitaire. Epidémie de rougeole en France; Actualisation des données au 20 mai 2011. Available at pastedGraphic.pdfpastedGraphic_2.pdf. Accessed May 23, 2011.
  3. Gindler J, Tinker S, Markowitz L, et al. Acute measles mortality in the United States, 1987--2002. J Infect Dis 2004;189(Suppl 1):S69--77.
  4. Bellini WJ, Rota JS, Lowe LE, et al. Subacute sclerosing panencephalitis: more cases of this fatal disease are prevented by measles immunization than was previously recognized. J Infect Dis 2005;192:1686--93.
  5. Editorial team. Measles once again endemic in the United Kingdom. Eurosurveillance 2008;13. Available at Accessed May 20, 2011.
  1. Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Measles, mumps, and rubella--vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR-8).

Documented receipt of 2 doses of live measles virus-containing vaccine, laboratory evidence of immunity, documentation of physician-diagnosed measles, or birth before 1957.

What is already known on this topic?
Measles, mumps, and rubella (MMR) vaccine is highly effective in preventing measles and its complications. Sustained measles transmission was eliminated from the United States in the late 1990s, but the disease remains common in many countries globally, and cases of measles are imported into the United States regularly.
What is added by this report?
During the first 19 weeks of 2011, 118 cases of measles were reported in the United States, the highest number for the same period in any year since 1996, and hospitalization rates were high (40%). Importations accounted for 46 (40%) cases, including 34 (74%) cases among U.S. residents who had recently traveled abroad, among 105 import-associated cases.
What are the implications for public health practice?
High 2-dose MMR vaccine coverage is critical for decreasing the risk for reestablishment of endemic measles transmission after importation of measles into the United States. Before any international travel, infants aged 6--11 months should receive 1 dose of MMR vaccine and persons aged ≥12 months should receive 2 doses of MMR vaccine at least 28 days apart or have other evidence of immunity to measles.

FIGURE 1. Distribution and origin of reported measles cases (N = 118) --- United States, January 1--May 20, 2011
Alternate Text: The figure above shows the distribution and origin of reported measles cases (N = 118) in the United States during January 1-May 20, 2011.

FIGURE 2. Cumulative number of measles cases reported, by month of rash onset --- United States, 2001--2011
Alternate Text: The figure above shows the cumulative number of measles cases reported, by month of rash onset, in the United States during 2001-2011. During January 1-May 20, 2011, a total of 118 cases were reported, the highest number reported for the same period since 1996.

TABLE. Countries where measles was acquired, by World Health Organization (WHO) region --- United States, January--May 20, 2011
WHO region
No. of cases
No. of cases

Eastern Mediterranean


France/United Kingdom






United Kingdom
Dominican Republic
South-East Asia



Western Pacific
* Patient had visited more than one country where measles are endemic during the incubation period, and exposure could have occurred in any of the countries listed.
Although the patient acquired measles in the Dominican Republic, the likely source of infection was a French tourist with measles who stayed in an adjacent room at the same resort at the same time as the patient. The genotype identified in this patient was D4, a genotype commonly circulating in France.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

Friday, November 8, 2013

A Community Conversation - Part 8

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 8:  Finding the 3rd Option

There’s something about two clear options that humans find appealing.  We write stories about good and evil with heroes to cheer for and villains to boo!  We go to sports events where one side must win.  Even in a debate, where the participants are bringing up really good points, we declare a winner and a loser.  Our legal system.  Enough said.  

It goes on.  Right and wrong.  Black and white.  Left and right.  Liberal and conservative.  Pro-vaccine and anti-vaccine.  Rich and poor.  All or nothing.  Us and them.  

These are examples of polarization.  And, a polarized world view is like looking at our planet and only seeing the north and south poles, while ignoring everything from Greenland to New Zealand.  With this approach, we are left with two options which both seem cold, hard, and lacking in diversity.

Fortunately, there are choices beyond penguins versus polar bears!  There is always a 3rd option to every situation, and many times a 4th, 5th and 99th...if we are willing to look for it.  

So, what gets in the way?  How do we find ourselves so split?  There are many forces which push us towards polarization.  

First let’s talk about the types of polarization that are deliberate manipulation.  There’s the Straw Man fallacy, in which someone exaggerates or misrepresents someone else’s argument in order to make it easier to defeat them.  We see this all the time in politics.  There’s also the philosophy of “just pick the lesser of two evils,” also frequently seen in politics.  There’s also the use of trigger words such as “conspiracy theorist,” as a way to discount and shut down an opponent.  None of these manipulative tactics have anything to do with finding the best solution, respecting the other person, or even having a real conversation.  They’re all about winning.

Such manipulation is designed to prevent you from questioning why you can’t have a third option.  The polar bears and the penguins like feeling important.  But what about bananas?  And kangaroos?  And all the other interesting stuff in the middle? 

Of course, not all polarization is deliberate.  Sometimes we spend so much time talking to polar bears and penguins that we genuinely forget about the tropics.  For example, when March Twisdale was interviewed for a Beachcomber article about her participation in the film, Everybody’s Business, the reporter assumed that anyone involved in the film must hold a polarized view.  Without asking, it was reported that March Twisdale & her husband had not vaccinated their children.  Apparently, anyone involved in medical choice advocacy must be “anti-vaccine.”  In fact, March has high regard for the role of vaccines in healthcare and her children are vaccinated against tetanus, polio, measles, mumps, rubella, and diphtheria.  

Polarization is also incredibly contagious.  As we become more polarized, we perceive more polarization in others.  With each issue that we see in a polarized way, it increases the chances we will approach the next issue in a polarized way as well.  Polarization breeds polarization, as we feel the need to defend ourselves from “the other side.”  Parent-child transmission of polarization is also quite common.  Perhaps we need a vaccine against polarization? 

It’s time to back up and see the bigger picture.

First, let’s acknowledge why polarization is so seductive.  Our emotional state can impact how we approach a problem.  For example, when we are under stress, we seek the comfort of joining the “winning side.”  When we are frightened, we want the safety of a “right answer.”  When we are tired, we want the simplicity of a “quick and easy answer.”  When we are insecure, we want to know that we are part of a group of “like-minded people.”
It takes time to deeply explore and evaluate an issue.  It takes even more time to explore possible solutions.  And sometimes it can feel like this effort is a luxury we cannot afford.

But finding the third option is worth the effort.  Non-polarized attitudes allow us to see all the options and come up with creative solutions that better meet everyone’s highest needs.  Polarized “solutions” may be quick and easy, but they tend to be inherently destructive.  In the long run, it is worth investing the time to find true solutions.
But how can we find it, if no one is talking about it?  What are the habits that help us find non-polarized solutions?

Let’s start with humility.  I don’t know everything and neither do you.  So let’s share our knowledge and work together.

Self-knowledge matters.  Why do you believe what you believe?  What’s behind that?  And what’s behind that?  Check your assumptions.

Ask genuine questions.  Encourage others to share their core assumptions and world view.  They might surprise you.

Seek the future.  We can’t progress without constantly challenging ourselves to learn something better.  Progress takes time, effort, imagination, and a few mistakes.  But there is nothing more depressing than deciding that we are at the pinnacle of human evolution and it’s all downhill from here.  There is still much to learn.

Long story short - if you’re looking at any issue in a polarized way, consider inviting your fellow penguins or polar bears to go on a trip to the equatorial regions of the world and learn something new while you’re there!

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.  BLOG:   Email:  

A Community Conversation - Part 7

A Community Conversation About Health and Responsibility: Vaccines and Beyond

Part 7:  Keeping Things In Perspective 

Fall is upon us. The school year has begun. Once again, we are subjected to a constant series of public health messages and editorials claiming that making an informed choice about your health care is immoral and selfish. If you want to be a good person, these sources claim, you must follow directions.

Okay, it usually isn't phrased that way. It's usually phrased as “the threat of vaccine refusers” or “the danger of vaccine free-riders.”  But the core message is still the same: the right to medical choice endangers public safety.  This message is tiresome, it's polarizing, and it's false. But it's also pretty pervasive. So, with a deep sigh, we address this issue again.

As is frequently quoted in alarmist articles, Washington state has one of the nation's highest vaccine exemption rates: 4.5%. Is this a problem? Maybe not. The Pacific Northwest also has an unusually high rate of autoimmune diseases, some of which are a medical contraindication for certain vaccines. We also have an unusually high level of education and access to health care. The relatively high vaccine exemption rates may be a healthy indication of well-informed parents making careful decisions for their unusually vulnerable children.

Perspective is important.  How is it that 95.5% vaccination rates could be considered a cause for alarm?  After all, it indicates that we are successfully providing vaccines to all children, even those living in severe poverty.  Given the state of our overall health care system, this is quite an accomplishment.  

But what about those exemptors?  Can't they cause devastating epidemics of measles that endanger us all?

Sigh. No.

First, unvaccinated children do not compromise the immunity of children around them. Kids who are immune to measles will not lose that immunity by playing with children who are not immune to measles. Being unvaccinated is not contagious. If your vaccination worked and provided you with immunity, you are safe from infection.

To see evidence of this, look carefully at the statistics on all the recent US measles outbreaks. Measles is a highly contagious disease, yet all the outbreaks are small and localized. This pattern is revealed in a CDC document analyzing 9 outbreaks of measles in 2011, with a total of 118 cases. The median size of the outbreak was 4. The largest outbreak was 21. Everyone made a full recovery. This is not a devastating outbreak of disease. This is strong herd immunity.  (For a link to the full document, see our blog.)

What about the babies? Well, one outbreak in Washington was started by a baby too young to be vaccinated. The baby traveled to a nation where measles is endemic, then returned home and shared measles with an unvaccinated child. All subsequent infections in that outbreak were unvaccinated children and teens who had accepted the risk of measles when they declined the vaccine. And once again, everyone made a full recovery. Even the baby who started the whole thing.

The current approach to measles vaccination is working, including the part where people are allowed to refuse. The simple fact is that people want safe and effective vaccines. There is no coercion required. Greater than 95% of our state’s population will happily and willingly choose any vaccine that is safe, effective, and offers a genuine health benefit. That is plenty to achieve herd immunity against measles...because the vaccine has a very high efficacy rate and longevity of protection.

Which brings us to pertussis.  If herd immunity is working well for measles, why do we have epidemics of pertussis?  After all, the vaccination rates are fairly similar.

The unfortunate reality is, the measles vaccine has an efficacy rate of over 98% and offers lifelong immunity.  The pertussis vaccine has an efficacy rate of only 60-70% and wears off in 3-5 years.  Because of these differences in the vaccine, we have achieved herd immunity for measles.  We have not achieved herd immunity for pertussis...and we will never do so with the current vaccine. 

Medical choice doesn’t endanger public safety.  In truth, medical choice protects us all.  When a safe, effective, appropriate vaccine is available, most parents choose it for themselves and their children.  If significant percentages of people are refusing a vaccine, there's a reason. Perhaps the vaccine isn't very effective. Perhaps the complication rate is too high. Perhaps the rising rates of allergies have made certain vaccines contraindicated for too many people.

The important concept here is that when we accept a poor vaccine, vaccine manufacturers have no financial incentive to improve it. If everyone finds it acceptable, why should they waste their money making it better? When large numbers of people start refusing a vaccine, there's suddenly a profit motive to put forth better research and offer a better vaccine.

Coercing people into vaccinating does not improve the safety or efficacy of vaccines. It doesn't make concerns go away. If anything, coercion heightens anxiety and suspicion and feeds into conspiracy theories. Name-calling just distracts from the real questions about safety and efficacy.

We deserve access to safe, effective vaccines. We deserve the right to decline vaccines that do not meet our standards for safety and efficacy. How can we work together to make that happen?

Have ideas?  Suggestions?  Please visit our blog, and share your comments.  Also, we invite all readers to review Part #3, Individual Power in Community Health Dynamics.  As we start another school year, it is important to remember the many tools available which empower us to protect our own health and the health of others.

“A Community Conversation About Health and Responsibility: Vaccines and Beyond” is an ongoing series written by two close friends with a passion for improving community cohesion and building respectful relationships in a diverse world.  This article was co-created by Karen Crisalli Winter and March Twisdale.   BLOG:   Email: