Her first symptoms around March 7 seemed like a cold. By the time the telltale measles rash appeared a few days later, she had exposed her family and scores of other people in public settings, according to health officials in Washtenaw County, near Detroit.
The Michigan outbreak is one of 17 new outbreaks nationwide reported to the Centers for Disease Control and Prevention since January. There have been 1,671 confirmed cases of measles reported this year across 32 states, according to CDC data.
Most of this year’s cases (94%) have involved outbreaks. Some — like those in Texas and Florida — involve more than 100 infections. In a few, cases have surged into the hundreds, as is the case in the outbreak in Utah, which is still growing, and the outbreak in South Carolina, which appears to be ending.
Many of the outbreaks are small — just a few cases. But as public health officials in Washtenaw County, Michigan, are learning, the resources required to keep them that way can be enormous.
“We’re still at seven cases,” Beth Ann Hamilton, communications coordinator for the Washtenaw County Health Department, told Healthbeat this week. “We’re definitely not out of the woods yet.”
Meanwhile, another measles case announced on April 2 in neighboring Monroe County has state health officials concerned that measles may be silently spreading in the community. No definitive link has been established to the cases in Washtenaw County, but the timing and location of the new case are concerning, officials at the state health department said.
Because of this risk, the Michigan Department of Health and Human Services is recommending young children receive their first measles shot early — at 6 to 11 months of age.
Yet even with just a handful of known measles cases, the containment workload is already taking its toll.
At the Washtenaw County Health Department, measles control is taking priority over many other health department services as staff have been needed to help track down and counsel hundreds of exposed people, test them for immunity to measles when they don’t have vaccination records, and monitor those in quarantine.
“Seven cases may not seem like a lot, but it is, and it’s hundreds and hundreds of contacts that our staff have to follow up on and monitor,” Jimena Loveluck, the department’s health officer, told the Washtenaw County Board of Health on March 27.
“We’re not able to get other work done,” she said. “We just don’t have the capacity to respond and then continue all our regular level of services. The expense also is tremendous.”
Exposures have occurred at a popular mall in Ann Arbor, a community college, a hospital, urgent care clinics, several stores, and a restaurant.
Investigating and managing the exposures of just the initial three or four cases cost $45,000 in staff time, Ruth Kraut, the department’s deputy health officer, told the board. Other health department staff noted that $100,000 in funding from the state to help with the outbreak had been largely spent.
“It’s been a huge effort,” Dr. Juan Luis Marquez, the department’s medical director, told the board. “We get lists of students or patients or whatnot. We don’t have much information to go by other than their name and date of birth. So that basically means our team of nurses and other folks calling everybody to verify their immunization status.”
Because two doses of measles-mumps-rubella vaccine is 97% effective at preventing the disease, public health officials are mostly trying to identify those who aren’t protected so they can be advised to quarantine at home and not spread the disease to others.
But people often don’t remember whether they’ve been vaccinated or don’t have access to their immunization records, Marquez said. So then they need to come to the health department clinic to have a blood test to check to see if they have measles immunity from past vaccination or infection.
The result is that the health department’s clinic is largely focused on measles and vaccine response, he said, and communicable disease efforts are being limited to measles and other high-risk cases.
A significant challenge for public health officials is that it’s difficult to know which small measles outbreaks can be quickly and easily contained, and which ones will spread to hundreds of people.
Dr. William Moss, a professor at the Johns Hopkins Bloomberg School of Public Health and director of the school’s International Vaccine Access Center, compared the measles landscape across the United States to a map of forest fires.
“You’ve got these bigger outbreaks, they’re kind of sending out sparks,” Moss said. “If that spark lands in a county or a community with high vaccine coverage, you don’t get much spread. And so you see one of these small outbreaks. But if it does land in a community with a large number of individuals who are under vaccinated or unvaccinated, then you get these larger outbreaks.”
It would be helpful to overlay measles cases onto maps with detailed vaccination coverage data, he said. But sources of vaccination data are limited and fragmented, and while school vaccination data can be helpful, it doesn’t include information about adults in the community.
“We and many other groups have been trying to develop ways to predict or forecast, as best we can, where the hotspots are. It’s just very difficult with measles,” Moss said.
Moss said that to know how easily measles will spread requires having detailed information about the coverage levels of vaccination and immunity within very localized communities where people socialize. But such data isn’t readily available, he said.
The places Moss and his team are watching closely are those where cases have been increasing the most in the past few weeks. That includes Hudspeth County, Texas, where the Johns Hopkins U.S. Measles Tracker has tallied 31 cases in recent weeks, and several counties in Utah, which are in the midst of a surge in their outbreak. Many of the cases in Hudspeth County, Texas, involve a federal detention facility.
Since it began last year, Utah’s measles outbreak has sickened 559 people, 362 since January. South Carolina’s measles outbreak, the largest in the United States in decades, has had 997 known cases since October — more than 660 of them since January.
The good news: South Carolina health officials haven’t had a measles case reported to them in more than two weeks. If that trend continues for 42 consecutive days — which is two incubation cycles for the measles virus — that outbreak will be declared over after April 26.
As of early March, the South Carolina Department of Public Health told Healthbeat it had spent $1.6 million on its response to the outbreak.
This story was produced by Healthbeat and reviewed and distributed by Stacker.