Sometimes it sucks to be right.
March was a busy month at the Montana State Capitol. MT ACEP showed up in force; naturally, testifying in state legislature committee hearings on topics ranging from opposition to a bill that would require emergency physicians to report patients’ immigration status to support for a home grown MT ACEP bill that would allow the use of naloxone past its bogus “expiration date”. My head was swirling a bit on the drive home from Helena. As immediate past president of MT ACEP, I was representing our organization by testifying against MT SB475, a dangerous bill that would have prohibited the use and sale of vaccines containing aluminum in Montana. The bill was based on claims that aluminum in vaccines can potentially induce allergies and cause hyper-reactive immune responses in children. There is no credible scientific evidence to support this claim, of course, and we consume more aluminum in one day through our daily diet than is contained in any vaccine. Nevertheless, the anti-science fringe dominated the debate with hours of anecdotal and tangential testimony. One legislator claimed his wife had seasonal allergies because a physician “forced” an MMR vaccine upon her. Another claimed that “no Montanan has ever successfully secured a medical or religious vaccine exemption” despite Montana having one of the most lax standards for vaccine exemptions in the country.
Bobby Redwood, MD, MPH, FACEP
Driving past the Missouri Headwaters on my way home from Helena, it struck me just how easy it is to make outrageous claims and spread misinformation unchecked…even in the hallowed halls of the peoples’ Capitol. Maybe I should not be surprised anymore with the amount of misinformation going around on social media, but this was real…local…important. We are talking about a law that would ban a life-saving therapy and endanger the lives of our children; not for any benefit, but for a false, pseudo-benefit. A “benefit” invented by conspiracy theorists, but trumpeted by our lawmakers, despite reems of scientific evidence to the contrary. Was I just being alarmist, though? I mean, vaccines are one of the biggest wins in human medicine…they are here to stay, right? Right?
One month after that drive back from Helena, Bozeman—my home town—reported its first cluster of measles cases since 1990. Measles is, of course, a vaccine-preventable disease and the MMR vaccine is one of those villainized aluminum-containing vaccines that would have been banned in Montana by SB475. That long afternoon that my ED group spent waiting to see if the department of public health could confirm the measles outbreak was an eyeopener for me. Those theoretical fears that we conveyed to our legislators in Helena were starting to feel very real, very quickly. Besides the obvious human suffering that SB475 would have unleashed on our patients, the law would wreak professional havoc on our emergency departments and the physicians who staff them. Off-hours staff meetings, N95 fittings, measles trainings, outbreak drills, viral syndrome visits to rule out measles, panicked calls to our unit clerk at 2am…this has been our professional reality in Bozeman since the outbreak on April 17th. Sure, we may be used to this after COVID, desensitized even; but COVID-19 was a novel disease. This is Measles…we were supposed to have had this one beat.
SB475 never made it out of committee. Science won the day, not by default, but because MT ACEP and many other physician and citizen organizations showed up to provide a measured, reasoned counterfactual to the bluster and blather of the anti-vaccine activists. The eight patients in Bozeman have all recovered and I went to get my 4-year-old her kindergarten MMR vaccine a little bit early just in case some unforeseen policy-decision came up that could compromise her ability to get one. We seem to have dodged a major bullet this legislative session, but the simple fact remains that advocacy truly matters. Thank you for being a member of MT ACEP. Thank you for showing up for science and physician wellbeing. Thank you for putting yourself out there every shift, for every patient, even the anti-vaxxer…who has a new rash.
Here are some helpful Measles Tips, brought to you by MT ACEP member Eric Lowe MD
Clinical features of measles:
- Consider measles in a patient of any age who has an acute rash and fever
- Incubation period is 7-21 days but usually ~10 days
- Prodrome of high fever, cough, coryza lasts ~3 days
- Koplik’s spots appear ~day 2-3 – a pathognomonic enanthem.Tiny bluish-white spots on an erythematous base, cluster on the mucosa of the cheek or palate.
- Rash begins day 4 – lasts to day 7. Red, blotchy, and maculopapular; rapidly progresses to confluence. Usually starts on the face (hairline and behind the ears). Rapidly spreads to the chest, back, and finally the legs and feet.
- Treatment is isolation and supportive care. Vitamin A can be considered for patients ages 6 mo – 2 yrs who are hospitalized, or those who are immunocompromised
For patients presenting to the ED, the most important steps are:
- Assess risk of potential measles
- If patient screens at risk, mask and isolate in negative pressure ASAP, then dive further into assessing risk.
- Involve infectious disease for decision making about testing, isolation, shutting down the waiting room or other areas patients were before they were isolated, etc. You do NOT need to make these decisions alone. Let our ED / ID leaders know if a concern arises.
Protection:
- Airborne precautions. This means N-95 or PAPR along with gown/gloves even if you are immunized and feel you are immune. Watch your staff and make sure they remain vigilant with PPE too.
- If you feel at high personal risk and are concerned about personal safety/risk, please reach out to your ED director for a risk mitigation plan
- Negative pressure rooms typically take 25-30 mins to clear after the patient leaves. A non-negative pressure room (ie: waiting room) can take 2 hours to clear.
- Surface cleaning for measles does not require anything special. The purple-top germicidal wipes used routinely and/or UV light are fine. It is the air exposure that is the different concern with Measles.
A few helpful tips:
- Immunizations are really good but not 100%. One MMR dose has 93% efficacy and 2 doses has a 97% efficacy rate. A fully immunized person should be considered at very low risk but not zero risk if their symptoms and exposure are convincing.
- The primary testing is a PCR test that should be positive during the time the patient is symptomatic. There is NO utility in testing asymptomatic people who have been exposed.
- Testing is a send-out to the state with ~24 hour turnaround. It is a nasopharyngeal swab or throat swab.
- Incubation period can be 7-21 days.
- Infectious period is considered to be 4 days prior to rash until 4 days after rash appears.
- If someone is exposed, they cannot go home and expose someone else right away.
Manifestations of Measles in Children (from NEJM)
