Measles on the Rise
Measles Outbreak
By CDR Michael Chuley, MSPAS, PA-C, CPH, USPHS
Abstract:
Shortly after being declared eradicated in 2000, measles cases and outbreaks have been on the rise in the United States in recent years. The measles outbreak in New York has lasted longer than any current outbreak nationwide and has infected the most people. In part, fears stoked by anti-vaccine activists have led to a higher incidence rate of measles over the past few years. Faced with a measles outbreak that had reached 194 cases, Rockland County made an emergency declaration; it barred unvaccinated children from schools and other public places. This decision was overturned by the courts and unvaccinated, asymptomatic children returned to school. This article looks at one of our most valuable health professionals and their influence on population health. A new strategy should start with nurses that work at schools, private offices, hospitals, community outpatient clinics, home health care, and nursing homes. Funding nursing teams that can go out to the community to educate on vaccinations would help tremendously.
Measles on the rise
Measles was declared eliminated from the United States in 2000. However, measles cases and outbreaks occur every year in the United States because it is still common in many parts of the world. Worldwide, 19 cases of measles per 1 million persons are reported each year; an estimated 89,780 die each year. In 2018, the U.S. experienced 17 outbreaks. Three outbreaks in New York State, New York City, and New Jersey, respectively, contributed to most of the cases.
Cases in those states occurred primarily among unvaccinated people in Orthodox Jewish communities. These outbreaks were associated with travelers who brought measles back from Israel. This has been the greatest number of imported cases since measles was eliminated from the U.S. in 2000. The number of new measles cases reported in 2019 is on pace to be the highest-reported number in the past 10 years (see chart below).
The intent of this article is to provide information and education to community nurses, as they are often our first line of defense against communicable diseases. In New York State, specifically Rockland County, has had the largest spike in active measles cases throughout the United States since 2018. Why are cases occurring among unvaccinated people in Orthodox Jewish communities? What can the health care community do to better curb the rise of this disease? Some insist vaccinations are against Jewish law, however, that is not correct. Rabbi Dr. Aaron Glatt, who is also chairman of the department of medicine at South Nassau Communities Hospital on Long Island stated that, “there’s not a single opinion that says vaccination is against Jewish law.”
Nurses as advocates
Population health is the alignment of various interventions that improve healthcare outcomes and lowers costs. The focus of the health care community must be on a targeted population or an entire disease state within a population versus one patient one at a time. Nurses are the largest health profession with over 3 million nurses in today’s healthcare workforce. In order to meet the demands of the Affordable Care Act (ACA), the nursing profession needs to be fully engaged in patient care policy. Community nurses are often the first line defense in the United States health care system. Nurses frequently spend the most time with patients in a community compared to other health care professionals.
In fact, research has shown nurses spend on average more time with their patients than physicians or hospital administrators. As such, nurses know exactly what patients need and what policies can improve patient care. When nurses have the policies in place to help their patients, satisfaction and health outcomes improve. A strong argument can be made that the nurse is the single most important member of the health care delivery team when targeting a sector of the population. A nurse acts as the care coordinator, informatics specialist, community-based facilitator, and primary care partner.
As the care coordinator, a nurse ensures the patient receives the necessary services from different disciplines and service sites. The nurse utilizes their skills in communication and electronic information management to organize and disseminate patient information to team members. As the community-based facilitator the nurse ensures the community adopts procedural and policy changes for the wellness of the patient. Finally, as we see a shortage in primary care physicians throughout the United States, the scope of a nurse is expanding to help alleviate the growing pressure that has been placed on our health care organizations.
The nurse in today’s health care system must be a strong advocate for the community in which they serve. Effective nurses establish collaborative relationships with community stakeholders and advance health care policies that will benefit the entire sector of the population. As they provide resources, care, education, and services, nurses communicate to promote health program initiatives. Adopting a community participatory approach has enabled nurses to develop strategies based on the communities’ culture which gives the perspective of community participants. This approach, which empowers the patient to take an active role in their health, has been shown to be quite beneficial in research. In fact, a number of studies involving Native Americans have shown how important cultural understanding is when attempting to change one’s influence on population health.
Current strategies
In an effort to contain New York’s outbreaks, the health commissioner for Rockland County initially prohibited 6,000 children at 60 mostly religious schools and day care centers in Rockland County from attending class because they hadn’t been vaccinated. As more children were vaccinated, the school vaccination rates reached 95 percent and about 3,800 students at 35 schools were still excluded from attending as of March 11, 2019. While this act seemed to slow the number of new cases reported, the emergency declaration was overturned by the New York State Supreme Court on April 19, 2019. At this time unvaccinated children have been allowed to go back to school and other public places.
The county is still enforcing the quarantine of individuals that have active disease. The counties policy, “Communicable Disease and Exposure Exclusion Order” carries a potential $2,000-a-day fines for anyone with or exposed to measles who goes out in public. The county’s offensive against the highly contagious virus has resulted in 19,015 people receiving the MMR (measles, mumps and rubella) vaccinations since the beginning of the outbreak late last year. A new strategy, deploying nurse task forces into neighborhoods with a high prevalence of measles to combat misinformation about the measles vaccine.
A group identified as PEACH (Parents Educating & Advocating for Children’s Health) has an anti-vaxxing propaganda handbook which provides non-evidence based material (below is an image from the handbook). Unfortunately, In 1998, The Lancet published a paper that alleged a link between the MMR vaccine and autism. Over the next several years MMR immunization rates plummeted. This one article published in a peer-reviewed journal cast doubt on one of the most effective methods to target disease in human history. Not only did scientists disprove the initial article, 17 studies have since been published to debunk the original claim linking immunizations and autism. This is valuable time, energy, and resources that could have been better spent preventing actual illnesses.
Nurses’ role is to educate
To continue and fight the rise of measles in New York State, nurses must understand the culture of their patients. Increasing the number of task forces led by a Jewish Nurse or a nurse that has extensive experience with such cultures should be the first step. Secondly, nurses must be educated on the signs and symptoms of measles, how the disease is transmitted, who is at the highest risk for disease complications, and how the diagnosis is made.
It is essential that the nurses are able to educate the patient on the effects of measles on the human body and the dangers that an unvaccinated individual may encounter. It is important that the nurses educates patients and their families that measles usually appears in 14 days after exposure. In addition, it is necessary to ensure the community understands that measles is one of the most contagious of all infectious diseases (see below). Therefore, we must spend more time understanding the targeted population, and becoming more involved in their community. This should be done with task forces, cultural awareness training, and involving the community as active participants in their health.
Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine
References
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CDC. (2013). Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: Summary recommendations of the advisory committee on immunization practices (ACIP). MMWR 2013;62
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