Measles Outbreak Update: “It’s Heartbreaking”

I'm Holly Wehment, and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner.

Click on the link in this podcast for free credit that may include CME, MOC, or ethics credit, depending on our topic or podcast. Today, we're talking about something that is on a lot of pediatricians' minds, measles. Joining me here today, it's such an honor, Dr. Jason Bolling, Professor and Interim Chief, Division of Infectious Diseases, UT Health San Antonio and University Hospital. And he's also the Director of Hospital Epidemiology at University Health.

Dr. Bolling, thank you so much for being here today on Pediatrics Now. Thank you for having me. What is the state? The big question, if we look at our community and in Texas, What's the state of measles right now? We are still experiencing the largest outbreak in the United States, in Texas, up in the panhandle region of Texas, with Gaines County being the epicenter of that, just south of Lubbock.

The most recent numbers for that area are up to 717 confirmed cases, which, for context, there were 285 cases in the entire United States for all of 2024. So a large number of measles cases in Texas, that's our current state. And two children, as we know, have passed away from complications due to measles. That's right. Tragic deaths of two children, unfortunately, related to this outbreak, which again, largely centered up there.

There have been other cases in Texas imported from travel to other areas, which also shows kind of this dynamic state of measles in Texas, but also globally, because these other people have traveled internationally and brought back cases that just haven't led to the large outbreak that we're seeing right now in the Gaines County area. In Bexar County, here in the San Antonio area, there have not been any reported cases as of yet?

That's correct. Fortunately, we have not yet to date seen any confirmed cases in the Bexar County area. We're obviously keeping close track of that. Early on with the outbreak, there was somebody that was within their transmissible infectious window that traveled through the Bexar County region. And so there were some potential exposures. But fortunately,

we didn't see any conversions, no confirmed cases. The closest county with a confirmed case to us is one in Atascosa County, which is a neighboring county to the south of us. But that is not related to the outbreak. It is thought to be related to travel. So that was one of the questions we had when we saw that case pop up.

And we'll talk about the United States and the world where we have listeners around the world and throughout the United States.

But here in Bexar County, the vaccination rate, it's my understanding, it's still high enough to have that firewall. Or is that what it's called to protect against an outbreak? Yes, we often call it the firewall. It's really the amount of people that you need in a community to have herd immunity, right? So there are definitely a few people in the community that can't receive the vaccine because of health conditions or wouldn't be expected to respond to the vaccine.

Their immune system is suppressed. You can't give the vaccine to people that are on high-dose immunosuppressants. And so what you need is enough people in the community that have protection with antibodies so that if the disease is introduced, it doesn't spread from person to person. The ideal number for measles is really 95% or higher. So we are just under that, but we're above the national average,

which is around 92.7%. And that's drifted down over the last few years, which is one of the reasons why we're seeing more measles cases today.

Well, as we know, pediatricians, they often see 40 patients a day. And as we all know, kids get a lot of rashes for various reasons. Any insight you want to give regarding the measles, rash, measles symptoms? Yes. So rashes and fever can go together, particularly in the pediatric population. And so it can be tricky because there are other viral illnesses in particular that commonly cause it. So roseola is a really common one that could cause fever and a rash in very small children.

That's caused by human herpes virus 6. You could see a rash with erythema, infectiousism, parovirus B19. And those can be more commonly seen. We have not seen a lot of measles since it's been declared eliminated in 2000, but obviously with this increased number of cases this year, people are understandably and appropriately on alert to look for measles. And so part of.

Way to ferret that out or to tease that out when you're talking with a patient and the parents is to really ask them about recent travel, if they've been around, and particularly currently, if they've been in that outbreak area, that would be good to ask about from travel.

And right now, saying here, Bexar County, it's my understanding the Department of Health is the place to send a patient to get tested, but it can be tough because they can only accept, there has to be a certain criteria in order to be tested. Is that correct? So generally, the tests that we send are a throat swab or an asopharyngeal swab, and then that is held. You also send blood tests for antibodies.

If the antibodies are positive, then that swab gets sent through the health department to the state, and they send that for PCR to confirm that it's a true case of measles. So the blood tests generally get run with our labs here, and the health department requires that those be run and that they have a positive before they send the swab for the PCR test. So here locally, but is it still for that initial blood test?

Is that done in the pediatrician's office and then sent to you at University Hospital? Or what's the process just to make sure? So it depends on the clinic. I think many clinics will send those tests out. The measles test gets sent out. And University Health is able to do an IgG test, but you send both an IgM and IgG antibody test. So at least one of those is a send out. And depending on your clinic setting,

both of those may be sent out. And so there's a few days of waiting to see those results. And then that would trigger sending the swab for the PCR through the health department to the state lab. And so do the test in the clinic and then send it to University Hospital? Is that right? I, I, I, it will depend on the lab setup for, for the clinic that you're using. I'm so I, I guess I would, this is definitely something to look at now.

It's unfortunately somewhat of a hassle that it's not something that we have, you know, available where you can get quick turnaround time. Cause every, obviously everybody would want to know the answer right away. I think there's some research ahead about where you would send serology testing and the swab would be held, would be good to check with your clinics that you would know in advance if you don't know already. Okay. And for the doctor listeners for clinics...

They probably have a process in place, but if there's any specifics for here in Bexar County, you want to send me, you know, how to get, what's the best way to get a test? Or if there's anything you want to say here, let me know about that. Yeah, so I guess, yeah, I guess each clinic is a little bit different what labs they use. A lot of them you send out labs. So I don't know, like university health clinics would use the university health lab.

And so they have a process, but other clinics are going to have different processes. It's kind of a hassle too, because it's two different tests, right? It's the blood test for the two different antibodies in the swab. But if people had questions, they could always call the MetroHealth to ask. Okay. So call, yeah, call MetroHealth.

Anything else you want to say about, so is something that for you, you know, with your 15 years of experience in infectious disease, that you would really raise a red flag about, well, this really could be measles. Or could it look like something else until you get that test result?

Yeah, and did you want to talk about complications from measles or why do we worry about measles or the numbers nationally? Yes, I would love to talk about that. I was just wondering for the pediatric practitioner, is there anything else you want to say about identifying measles? They don't want to have the family go through the alarm or having to go through the testing unnecessarily. necessarily. And then, of course, at the same time, of course, you don't want to miss it.

You know, so is there anything else you want to say there regarding identifying who needs to be tested? Or is your advice like, better to be safe and sorry, go ahead and test if you suspect it? Yeah, sure. So I think it's important to kind of review the clinical course of measles because, again, it's not something that we've seen a lot of cases of until this big outbreak.

Since it was declared eliminated in 2000, we've been fortunate to not have to worry a lot about what the clinical course looks like. And it's important because it can help to distinguish measles from other viral rash syndromes. Most people tend to have their symptoms initially start about 10 to 12 days after their exposure. So really within the one to two weeks after their exposure can be as far out as three weeks from exposure.

But the point is there's a delay from the potential exposure to when someone will start to first have symptoms. And the first symptoms are really nonspecific, which can make it really challenging. People start off with a fever, a cough, runny nose, and then itchy, watery eyes. And just that description alone is really nonspecific, right? That's what we see with a lot of people with viral upper respiratory infections,

which are still circulating, right? We're moving out of respiratory virus season. You don't see the rash, the characteristic rash, develop until about three to four days after those nonspecific symptoms. And that is a little bit tricky. The rash is pretty characteristic. It usually starts with the face near the hairline as these flat brown or red spots. It then kind of moves down the face to the trunk of the arms and legs. So it moves from top to bottom.

And then that characteristic rash can make it a little bit easier to identify that someone has measles. And that rash lasts for about a week before it goes. And it's usually accompanied with very high fever. And usually with our upper respiratory illnesses, we may see some fever. But fever with measles can be as high as 104 degrees. So it can be pretty high. People are considered infectious from four days before the rash, which is tricky, right?

Because that's when they're having those nonspecific symptoms to four days after the rash. So if someone develops that rash, if one of your patients develops that rash, you'd want them to be seen, but you'd want them to contact the clinic first if possible.

So you can make arrangements to move them into a private room, put a mask on them, and then make sure whichever people on the health care team are seeing this patient, even if they're fully immunized, should still wear a respirator, an N95 respirator, to make sure that they're protected. Because could they be contagious with the virus if they're vaccinated, kind of like with COVID?

The patient or the healthcare provider? The patient who's vaccinated against, or were you saying even if the healthcare provider is vaccinated, he or she should wear a mask? Correct. So if the healthcare provider, even if the healthcare provider is fully immunized, and most healthcare providers are fully immunized, which is great, it's still recommended to wear an N95 respirator, even though the measles vaccine is very, very protective, 97% protective if you've had two doses.

There's obviously a 3% chance, right? And so you don't want to take any risks. And so wearing an N95 respirator for the healthcare provider, in addition to being vaccinated, is the way to protect yourself while you're examining the patient, testing the patient, interacting with the patient, the family members. And as we know, the measles, it can float in the air for some time, right?

That's absolutely right. So one of the challenges with measles, it's one of the most transmissible pathogens we know. It's one we use as an example when we're looking at outbreak models. Up to 90% of people that are susceptible to measles, meaning they haven't been immunized or had measles, if they're exposed, will develop disease. That's a really high infection rate. And it lingers in the air in these tiny little droplets. And they can linger in the air up to two hours, as you mentioned.

It's been tested up to two hours after someone that's infected with measles leaves a room. They leave this plume of infectious particles that sits there for up to two hours. And the other challenging part is, again, you're considered infectious for up to four days before that rash starts, where you're having those nonspecific symptoms that sound a lot like an upper respiratory infection. So it has some elements to it that make it very easy to transmit to others,

transmitting before you would suspect that it's measles. And then it has this really high attack rate. It just sounds scary. It's a very, very concerning disease, which is why it's so heartbreaking to see us lose some of the ground that we've made from being declared eliminated to 2000 to where we're sitting at here in 2025. That's a great way to put it, Jason. Would you recommend, so say if there was a patient, you don't know yet if he or she actually has the measles.

Whoever's been helping that patient in the exam room has an N95 on. After that, not have anyone in that room for the rest of the day? Or what would you recommend there in the pediatric practitioner setting where they're seeing a high volume of patients? Sure. Yeah, that's a tricky issue, right? Because you don't want to mess with the workflow too much. You don't want to expose patients either.

Uh, so they need to be, that room needs to be left empty for at least two hours after this suspected measles patients with suspected measles has left the room. So there's enough time for ventilation to change that out. Some people will let it sit for a bit longer and be conservative. And can it go through the vents to other rooms? Well, in a hospital setting, so the answer is yes. So ideally, in the hospital setting, we have prolonged stays of these patients.

We place them in an airborne infection isolation room, and that has dedicated exhaust that goes directly outside. It doesn't connect to the air conditioning for all of the other vents. In the outpatient setting, most outpatient settings don't have that type of room, but they're also not seeing the patient for such a prolonged time period.

And so really the recommendation in the outpatient setting or where you don't have an airborne infection isolation room is to put them in a private room and then again let that room air out, as we talked about, ventilate after that patient has left the room. There's less risk for transmission through the ventilation system if they're there for a shorter period of time. In the inpatient setting where they're sitting for days potentially, you have a higher risk.

Like we saw with COVID, a lot of clinics were testing patients outside. I mean, it's really hot right now in San Antonio, but is that something, if a clinic is set up to do that, is that something that you would recommend? If we started seeing confirmed cases, we may have to start looking at something similar, yes, to try and help reduce the risk of other patients in the clinic being exposed.

If we were to start to see an outbreak here, we would need to look at what would be the most effective way to do screening and testing of people that we're presenting with symptoms.

And this is even more infectious than COVID, right? Yes, much more infectious than COVID. So we talked about that 90% infection rate. So 9 out of 10 people that are susceptible that are exposed will get infected. With COVID, that number is much lower. It kind of depends depending on immune status. If you've been vaccinated or had COVID, which most people at this point have, most people are protected. But the attack rate for COVID is closer to like 40% to 60%. So much, much lower than measles.

How worried are you about the current state of things? I'm very concerned that we could potentially move to where we have to worry about measles on a regular basis. Part of that is because of this large outbreak, but more concerned by the fact that we have now 31 jurisdictions in the United States. So that's 30 states, and then New York City is listed as its own jurisdiction that have reported cases. And so it's over half of the states in the U.S. now have confirmed cases.

And most of those started off with an imported case because globally, measles is really high right now. We have had some decrease in our firewalls we talked about before, the number of people that are fully immunized. We were about 95% in 2019, so right before the pandemic. But we have drifted down to the national average being around 93%. So that decrease is worrisome because that increases the chances that one of these imported cases could lead to another outbreak.

And if you look at the map, the CDC has a nice map where they show percentage vaccine rate in different states. There are some states like Idaho, which is all the way down at 79%. And so they're at much higher risk for an outbreak occurring there if they get an imported case.

So those things are what concern me that we're going to see ongoing activity for a while, not just this huge outbreak, obviously, that's worrisome in the Panhandle region, but the number of cases throughout the U.S. right now. For our listeners in Idaho and in the Texas Panhandle, those are the two real hotspots right now, it sounds like. They don't have any ongoing cases in Idaho, but just looking at areas of vulnerability based on where that vaccine uptake rate is.

And they basically use the data from kids that are entering kindergarten, school-age children, and they have a lower percentage uptake compared to some of the other states. It almost sounds like it's like the tsunami or hurricane warning. That's right. There are different risks depending on where you're at and then, you know, how much influx of travelers you have and where your vaccine firewall immunization rate is at.

Is there one thing with, you know, pediatric practitioners are so busy as are family practitioners and seeing 40 patients a day. Given the state of things, is there one line you would hope that could be said in between, I mean, asking are you vaccinated or any thoughts there if we could have a crystal ball and everybody say something to help the situation? I know a lot of doctors feel pretty helpless right now regarding this. Sure. Yeah, I understand that too.

It's discouraging. There is an overall increase in some vaccine hesitancy.

But what I would say I look at, it's optimistic, and it is the silver lining, is that when patients are polled and surveyed, they do look to their pediatrician as a source of truth, a credible source of information. And so I think starting that conversation about vaccines is really important. Understandable that people might have questions. But I think starting a conversation is the best thing. And pediatricians are great about this, about talking with families.

I would encourage everyone to continue having those conversations with their patients and families so that they can get those questions answered because they do listen. Even if it doesn't seem like they may be listening, they do listen. There's good published data showing that doctors are still considered an excellent, consistent source of truth. That's great reassurance, Jason. And we do have in this Pediatrics Now newsfeed our previous, two previous episodes on motivational interviewing.

And our expert in the Department of Psychiatry addresses specifically how to utilize motivational interviewing to talk about vaccines. So hopefully that's helpful. And is your hope for it to be mentioned in each visit if you haven't seen a patient in a couple of months or anything you want to say there?

Yeah, I think motivational interviewing and finding out ways, some scripting that you can use when you're busy to engage in these conversations is really helpful, and it's good to know that there's resources for that available.

It is something that needs to be talked about. There's strategies such as when a patient is there saying, well, today we have your vaccine scheduled, as opposed to asking if you want a vaccine, because that kind of highlights that you're endorsing it as an important part of their care, and they can, of course, decline it if they don't want it, but knowing that you're recommending it, I think is also something that helps.

It's a positive nudge towards what we would want them to do, which is take the vaccine. Jason, do you have anything you want to say to our pediatric practitioner listeners worldwide? We have listeners in Ukraine. We have listeners in Israel, in Africa. Anything you want to say there? I would encourage everybody to keep up the good work. It's really important for people to continue the physician-patient relationship and dialogue.

Everybody is really busy, but it's really important that we continue this conversation and endorsement of vaccines. They're the most effective public health strategy we have for reducing infections. So we deal with infections when they come up, but the more that we can prevent, the better off that we are and we can avoid unnecessary morbidity and try to take deaths from vaccine-preventable illness.

And maybe it's more important now than ever for the doctor listeners to take care of themselves, do something fun on their time off work, like you were mentioning, and it just, it can be so frustrating because it just feels like an uphill battle. Yes, I think it is important for people to reach out to colleagues, talk to each other, Look for other sources of reassurance and then, you know, keeping tabs on what's going on as well is important.

One pediatric practitioner, she was wondering about incidents, clinic presentation, and infectivity of measles from vaccination. She says, I know it's super rare for them to have a reaction, but she had a nine-month-old patient have a reaction. There can be some reactions from measles vaccines. So overall, it's very well tolerated, right? The measles vaccine has been out since 1963. So we have decades of experience with it, which is great.

Some patients have very little side effects or no side effects at all. The most common side effect we see is soreness and redness at the injection site in the arm, right, which is similar to other vaccines. And then some children will develop some stiffness in their joints and they can have some fever.

It is also possible, it's much less common, but it's possible a few days after the vaccine to develop a rash, similar to the measles rash, but children that develop that are not contagious to others. It's not true measles, but it looks very much like measles and it can be associated with a fever. Serious side effects from the vaccine are very rare. They should be reported if they occur, but overall the vaccine is very well tolerated.

That's great to know and that's reassuring. Have you heard of there's some parents requesting and some parents are getting their baby vaccinated sooner? Yes, it is recommended. So a lot of people are asking about getting extra doses of measles vaccine, and that's not recommended.

But what is recommended is if you're planning to travel and you have a child that is less than 12 months of age, so the routine vaccine schedule is you get the first dose at 12 months of age or one year, and then the second dose of age is four to six years of age.

But if you have a child that's between six to 12 months, so six to 11 months, and you're going to be traveling internationally, it is recommended that you give a dose of the MMR to that child so that they'll be protected when you're traveling internationally, since we are seeing increased cases of measles globally. Now, they'll still need to get their two doses when they return, you know, one year of age and between four to six years of age.

It doesn't count as early credit for that, but it's a way that you can protect a child between six and 11 months of age from that risk of measles if they're traveling internationally. So really, they would get some kids, babies are getting an extra dose, and that's okay, but they still would need to stay on the, in addition to that, stay on the regular schedule. That's right. Yes, that's the nice way to summarize it.

Okay, because then I think pediatricians are getting asked a lot about getting an early dose. Yes. Anything else, anything else, Jason, you want to say to pediatric practitioners or family practice doctors in general? Yeah, it's also important for any adults that are unclear, if they're up to speed on their vaccine, to talk with their provider as well.

So they're around the children, they could get sick themselves, and so they should make sure that they're also up to speed and they've received the two doses of vaccine. The way that you're analyzing things, do you see this summer places where there's not any sort of, there's not been a reported case, things really amping up this summer or anything you want to say there? It's always tricky to predict, right? But, you know, at this rate, we are still seeing a number of cases.

And we're seeing with the widespread nature of these, the concern is always that you're going to see an active case in an area with much lower rates of infection. So a little pocket of infection. This outbreak in Gaines County is largely associated with an area of under-vaccinated community, a Mennonite community that had a much lower vaccine rate. And so if you were to see an active case in another area with a lower vaccine uptake rate, you could see another outbreak.

And so each time we see more cases in more states, you always worry you're going to see that intersection of a transmissible person with a susceptible population. So I think we're going to have to keep a close eye on it. And it doesn't sound like the summer travel season is going to help. That's right. The more travel we have, the more mixing we have, and the more chances we have for that intersection of a transmissible person to a susceptible host.

Would you be surprised if we don't get a case in Bexar County where we are? I wouldn't be surprised if we had a case, I guess is the way I would say it. I'm hopeful that we don't, but with cases that we've seen in Travis County, Harris County, and then the one in Atascosa, I would not at all be surprised if we have a case. This is so helpful, Dr. Bolling. Before we wrap up for the practitioners, anything else you want to mention about measles that we did not cover?

We covered a lot of the important points. I think it's really important to, again, stress the importance of vaccine. We don't have antivirals for treatment after someone gets sick. Children bear the brunt of the real problems of severe illness, hospitalizations, pneumonia, which can lead to death, the most common cause of death with measles. Kids can also have bacterial infections afterwards, too, when children have a case of measles.

It suppresses their immune system temporarily, and so they're at higher risk of bacterial infections following that, which is another problem that parents of children should know about. There's multiple risks if you do develop measles. It's not something that just happens and goes away. The more people that we have that have measles, unfortunately, the more chances we have of having another severe case and potentially even another tragic death.

Yeah. So we know that measles causes fever, causes itchy, watery eyes, cough, runny nose, and a rash. Other complications, I think, are sometimes not as well known, especially to parents of kids that are considering vaccines. About 1 in 10 people with measles will develop diarrhea. That's probably the most common complication. Children, about 1 in 10 will get otitis media, which is obviously problematic for them. Ear infections, exactly. 1 in 20 will develop pneumonia.

And that viral pneumonia can be very serious. 1 in 5 kids gets hospitalized with measles, a lot of them with respiratory complications. 1 out of 20 can get a viral pneumonia. We don't have a treatment for that. It's the most common cause of death with measles. The death rate for measles is about 1 to 3 out of 1,000. And then about 1 in 1,000 kids can get encephalitis or swelling in the brain. They can have seizures.

And they can have long-term complications like deafness or delays in cognitive challenges from inflammation from the encephalitis. So there's some serious consequences that can happen from measles. It's more than just a viral rash that goes away that people used to get in the past. So long-term brain damage can occur. Long-term brain damage can occur. There's even a condition called, the letters are SSPE or subacute sclerosing panencephalitis.

It's pretty rare, so we don't have a lot of data on it. Back when we used to have more measles, about 7 to 11 kids out of 100,000 could develop this. This is a neurologic condition that happens about 7 to 10 years after the measles. So the kids have recovered from measles, they're doing better, and then they develop this debilitating, progressive, and universally fatal neurologic condition called SSPE. PE. But so that's something we saw when we had more cases of measles.

It doesn't happen very often. It starts to be either delayed immunologic response or a variant of the virus, but it happened so infrequently. We don't have a lot of data on it, but it's obviously extremely concerning, severe consequence that can occur rarely with measles infection. Awful. Kids who get pneumonia from measles, is it otherwise healthy kids or is it mostly kids who have an underlying lung condition?

Great question. It can happen in healthy kids that don't have underlying lung conditions. So underlying lung conditions can increase the chances of infections, but a measles viral pneumonia can occur in children with no health problems.

They can also develop bacterial supra-infections, again, from that temporary suppression of the immune system, and that can cause, you can get a bacterial pneumonia, bacterial otitis on top of the viral otitis, but you can see a viral pneumonia at a completely healthy child.

Dr. Bolling, thank you so much for doing this interview. It's really been insightful. And thank you so much for being here on Pediatrics Now. Thank you so much.