John Jesitus

John Jesitus is a medical writer based in Westminster, CO.

	To reduce human papillomavirus (HPV)-related cancers, pediatricians must strongly recommend the underutilized HPV vaccine in preteens, said Joseph Bocchini Jr, MD, FAAP, in his session "Safe and effective: HPV vaccine-the pediatrician's critical role” at the American Academy of Pediatrics 2016 National Conference and Exhibition.

	Among vaccines recommended for 11- to 12-year-olds, over 80% of children receive the tetanus, diphtheria, and pertussis (Tdap) vaccine and the first dose of the meningococcal conjugate vaccine by age 17 years, according to the Centers for Disease Control and Prevention (CDC) 2015 National Immunization Survey (NIS)-Teen. However, with the 3-dose HPV vaccine that is also recommended at that age, the figures are significantly lower:

		62.8% of girls have started the series by age 17 years;

		49.8% of boys have started by age 17 years; and

		34.9% of 13- to 17-year-olds have completed the series.

	The FDA has recently licensed a 2-dose HPV vaccine series (0, 6 to 12 months) for 9- to 14-year-olds. In late October, the CDC Advisory Committee on Immunization Practices (ACIP) recommended using the 2-dose series for healthy persons who initiate the HPV vaccine series before their 15th birthday. This new recommendation should help improve vaccine series completion figures. 

	The HPV vaccine is designed to prevent HPV-related cancers that affect both men and women. About 30,000 cases are diagnosed annually in the United States-two-thirds of them in women.

	It is crucial to educate parents that this vaccine prevents cancer, and it is best given at age 11 to 12 years-before children are likely to be exposed to HPV. There is no way to estimate when an adolescent will become exposed to and infected with HPV. Modeling indicates that giving the vaccine at age 11 or 12 years has the best likelihood of preventing HPV-related cancers.

Rather than making as strong a recommendation for HPV vaccination as they do for the Tdap and meningococcal vaccines, some pediatricians are presenting the timing of the HPV vaccine as a choice. When parents ask questions about the HPV vaccine, pediatricians may feel that the parents are hesitant to give the vaccine, and so the pediatricians do not pursue the issue or provide the information to make parents aware of the importance of giving the vaccine at the recommended age. They are willing to defer the vaccine until the child is older. This creates the potential that the adolescent will be infected with an HPV type that could have been prevented.

	Evidence shows that a strong recommendation emphasizing that the vaccine is designed to prevent HPV-related cancers significantly increases the likelihood that parents will accept this vaccine in children.

 Pediatricians are in a unique position to protect their patients against HPV-related cancers by immunizing them before exposure to HPV is likely to occur.

	1. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years-United States, 2015. 

	2. Moss JL, Reiter PL, Rimer BK, Brewer NT. Collaborative patient-provider communication and uptake of adolescent vaccines. 

	Recently, the Centers for Disease Control and Prevention (CDC) recommended only 2 doses of the human papillomavirus (HPV) vaccine-as long as children start the series before age 15 years (versus 3 doses, starting at 11 or 12 years). If children start at age 15 years or older, 3 doses are still recommended.

	We do not know if the new CDC recommendation will have an impact on HPV vaccine usage, but we know that approximately 55% of adolescent females (aged between 13 and 18 years) have received 1 dose of HPV vaccine. Around 45% have received 2 doses, and around 35% have received 3 doses. The change should boost immunization rates, but we will not know for certain for a few years.

	Meanwhile, the Pap smear remains one of the most effective cancer-detection techniques ever developed. It has succeeded marvelously in the United States. The problem is, there are still some 12,000 cases of cervical cancer diagnosed in the United States yearly, and 4000 deaths occur. That is why use of the HPV vaccine is critical-Pap screens are not picking up all cervical cancers.

	Unfortunately, the HPV vaccine was introduced as a means of preventing sexually transmitted infections. Accordingly, parents typically think, "My child is not sexually active. He or she does not need the vaccine yet." Parents also believe that having had the vaccine will increase a child's likelihood of becoming sexually active sooner. Studies have proven that notion false.

	The most important reason we give the HPV vaccine is to prevent cancers. It will prevent almost all cases of cervical cancer in women and oropharyngeal cancers in men (the oropharynx is the most common location for HPV-induced cancers in men).

	As Dr Bocchini notes, people generally get the pertussis and meningococcal vaccines as recommended, but many more people die of HPV-related cancers than of these diseases.

	Mr Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

Articles

To reduce human papillomavirus (HPV)-related cancers, pediatricians must strongly recommend the underutilized HPV vaccine in preteens.

Push the HPV vaccine

coverage of the 2015 AAP Annual Conference. For more coverage, click 

	Many pediatricians believe that if they pay $30 for an immunization, as long as a payer reimburses them more than $30, they’re OK, said Chip Hart. The fact is, that’s not the case, he explained during his presentation “The Business of Immunization: Protecting Kids without Destroying Your Practice.” 

	Many physicians don’t realize they are not paid for carrying costs that make the vaccine’s true retail cost much higher than what they paid for it. Unreimbursed carrying costs include everything involved with getting the product into a refrigerator, into a child, and accurately accounted. Physicians are also not paid for any wasted vaccines. Practices have lost more than $50,000 worth of product because someone failed to close a refrigerator door. They’re not reimbursed for credit card handling fees; the time nurses spend entering the patient data into an immunization registry; or the manpower required to dispute an unpaid or improperly paid vaccine claim. All this overhead carries a cost, which the American Academy of Pediatrics (AAP) has estimated at 17% to 28% more than the actual vaccine cost.

	And until current procedural terminology codes 90460 and 90461 debuted in 2011, vaccine reimbursement had fallen as an increasing number of antigens were combined into multivalent vaccines. New vaccines such as Pentacel (diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus and Haemophilus b conjugate [tetanus toxoid conjugate] vaccine; Sanofi Pasteur) would reduce the number of administrations from 2 or 3 to a single administration, although the combined vaccine often costs a pediatrician as much in labor, counseling time, and carrying costs as it did to administer 3 separate vaccines. Fortunately, the AAP’s effort to recognize the number of antigens, rather than actual shots, has had a profound positive effect on pediatricians’ bottom lines.

	Further boosting one’s immunization business requires negotiating these payments with payers and understanding where one’s practice is efficient and inefficient. Frequently, physicians themselves spend a tremendous amount of time accounting for vaccines. However if a pediatrician spends 30 minutes daily doing immunization inventory, he or she could have seen a patient or 2 in that time. For that amount of revenue, one could easily pay someone to handle this function and still more than break even.

	1. American Academy of Pediatrics. The business case for pricing vaccines. 

www.aap.org/en-us/Documents/immunizations_thebusinesscase.pdf

. 2011. Revised March 2012. Accessed October 20, 2015.

Chip Hart is director of Pediatric Solutions (Physician’s Computer Company), a pediatrics-specific electronic health record and practice management system vendor, Winooski, Vermont.

	It’s reasonable for physicians to consider all costs associated with vaccinations, not just physician time. However even before this, physicians must make 2 decisions: will they provide any vaccinations, and if they’re providing some level of vaccinations, how much reimbursement do they need per vaccination to be profitable? Those are very different decisions.

Next: Spreading out the vaccine schedule in spite of concerns

	Much of the data Mr Hart presents address the first question: vaccinations, yes or no? Costs such as negotiating time, temperature control and monitoring, and exam table costs factor into this decision. However once the decision is made to provide vaccinations, one will spend that money whether undertaking 1 vaccination or 10,000 vaccinations. For the second question, consideration must be given to only the costs associated with giving the shot itself, which vary as one gives more shots; for example, the costs of sharps and waste management, gloves, paper, syringes, and nurse time for drawing and preparation.

	Costs associated with setting up the infrastructure for providing immunizations are fixed and do not vary based on how many shots are given. That money is spent. Then the question becomes, what’s the marginal cost of each shot, and is the payment covering the costs associated with actually giving the shot?

	Let’s say one has already spent $10,000 on fixed costs. If by providing immunizations one can make perhaps $2000 profit, the choice is between losing $10,000 and losing $8000. Long term, it’s probably wise to get out of the immunization business. Short term, it’s better to lose less money than more.

	And I’m not suggesting anyone should get out of the vaccination business. With the data presented, it’s hard to tell whether people are truly suffering economic losses from giving immunizations. A staff nurse would get paid whether she gives vaccinations or not. The question is, could that slot be filled with another type of visit that paid more? These are exactly the right types of questions to ask. Think about the total cost of vaccination, beyond the physician time, and whether or not the revenue covers these costs. Because every practice will have different components to that cost, it’s up to each practice to answer this question for itself.

Adam Atherly, PhD, is an associate professor and chair, Department of Health Systems Management and Policy, Colorado School of Public Health at the University of Colorado, Denver. 

Many pediatricians believe that if they pay $30 for an immunization, as long as a payer reimburses them more than $30, they’re OK, said Chip Hart. The fact is, that’s not the case, he explained during his presentation “The Business of Immunization: Protecting Kids without Destroying Your Practice.”

PRACTICE MANAGEMENT: The real cost of immunization

As complex as it is common, chronic cough in children presents diagnostic and treatment challenges that are complicated by a dearth of solid data and, often, the anxieties of well-meaning parents. 

	An important defense mechanism for clearing the airway and signaling the presence of an upper respiratory tract infection (URTI), coughing represents the most common reason for pediatrician visits in the United States.

 However, the search for an underlying etiology often proves fruitless, and in other cases multiple etiologies may overlap, making diagnosis and treatment difficult. However, a practical approach focuses on red-flag symptoms that help point the way toward appropriate management strategies regardless of diagnosis.

 reflex occurs when inhaled, aspirated, or locally produced objects activate sensory nerves located throughout the airway. These afferent nerves communicate with the brainstem, which signals motor nerves that activate respiratory muscles to produce the characteristic cough response.

	Often, coughing is normal. Healthy school-aged children typically cough between 10 and 34 times daily.

 Of concern, however, is chronic cough, which for practical purposes most experts define as cough lasting more than 4 weeks,

 based on the expected duration of acute URTIs, which represent the most common cause of coughing in adults and children. Coughing associated with a typical viral URTI lasts 14 to 21 days.

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	Because most acute (lasting longer than 3 weeks) and subacute (lasting 3 to 8 weeks) coughs in adults and children signal viral URTIs, they do not demand specific diagnostic evaluation. In otherwise healthy children, these coughs stem from transient situations that are likely to be self-limited.

	However, the aftermath of viral respiratory tract infections can include upregulation of cough reflex sensitivity (CRS), which can provoke coughing long after the infection has resolved.

	Other conditions associated with increased CRS include asthma, 

 (GERD, albeit weakly), and angiotensin-converting enzyme inhibitor therapy.

	Children in whom cough reflex hypersensitivity persists beyond 3 weeks may require evaluation. Additionally, all children with cough persisting beyond 8 weeks should be evaluated.

	Outside CRS and garden-variety URTIs, other forms of abnormal, persistent coughing in children can be associated with more severe, progressive underlying illnesses and/or structural abnormalities. Such cases require thorough evaluation to ensure that underlying problems are properly identified and, to the extent possible, addressed. The Table lists cough characteristics and associated symptoms that should raise these red flags.

	Although multiple etiologies can overlap, the following questions

 can help determine the etiology of a particular cough:

	·      Is the cough an isolated symptom; if not, what other symptoms exist?

	·      What is the cough's character or quality? How disruptive is it?

	·      At what time(s) does the cough occur?

	·      Is there a family history of respiratory, allergic, or infectious disease?

	·      Does the child (or do the parents) 

? Is there evidence of environmental pollutants in the home?

	·      What treatments have been tried, and what were their effects?

	·      What medications, if any, does the child take?

 for chronic pediatric cough is quite varied, the child's age can help narrow the investigation. In this regard, the top 3 causes of chronic cough in adults and older children-upper airway congestion syndrome (UACS, formerly called postnasal drip syndrome), asthma, and GERD-rarely afflict preschool-aged children.

	In 2 studies of children whose average ages were 9.2 years and 8.4 years, respectively, UACS, 

, and GERD accounted for a combined 83% and 69% of cases, respectively.

 Conversely, these diagnoses accounted for just 9% of cases in a similar review involving children whose average age was 2.6 years.

 In this study, persistent bacterial bronchitis (PBB), postinfectious causes, and bronchiectasis (irreparable structural damage to the airway wall) accounted for a combined 68% of cases. In the 2 reviews involving older children, the corresponding totals for these 3 diagnoses were 5% and 40% (the latter included PBB, 35%), respectively.

	Additionally, in infants and younger children, causes of coughing more likely include foreign-body aspiration and abnormalities of the upper respiratory, lower respiratory, and gastrointestinal tracts, versus the infectious agents and habit cough that predominate in older children and teenagers.

	Specific etiologies of cough that clinicians are likely to encounter include:

This syndrome encompasses various types of rhinosinus diseases, particularly allergic or nonallergic rhinitis and sinusitis, that can induce cough. Diagnostic criteria include postnasal drip, nasal discharge, and throat clearing caused by rhinosinusitis. Alone or with other entities, UACS is the most common cause of cough in adults and older children. It is particularly associated with nocturnal coughing. Regarding chronic sinusitis, chronic sinus inflammation doesn't always show up on routine x-rays.

The leading cause of emergency department visits in children, this condition provokes signs and symptoms including frequent, intermittent coughing, as well as wheezing or whistling upon exhaling, dyspnea, chest congestion, tightness, or pain.

 When considering asthma in children aged 2 to 4 years, the Modified Asthma Predictive Index

In this variant, which rarely occurs in infants, cough may be the main or sole symptom. In children without history of recurrent wheezing, the condition is frequently underdiagnosed. Because it rarely responds to asthma medications, accurate diagnosis is crucial.

Poorly characterized in medical literature, PBB is underdiagnosed, and frequently misdiagnosed as asthma. Key characteristics include an intense neutrophilic airway inflammatory response, revealed by bronchoscopy.

 Organisms most commonly responsible include 

Streptococcus pneumoniae, Haemophilus influenzae, 

. Children with PBB have normal adaptive immune function but heightened reactivity of the innate immune system.

 If untreated, some children with PBB will progress to chronic suppurative lung disease, the precursor of bronchiectasis.

Theoretically, intraesophageal reflux, laryngopharyngeal reflux, and microaspiration all may provoke cough. Moreover, GERD and 

 occur commonly in infants and, to a lesser degree in the case of aspiration, children. However, the link between reflux and cough in children, particularly younger children, is tenuous at best. There is little convincing evidence that GERD commonly causes isolated chronic cough in children.

Read more: Meeting the rising costs of vaccines

This harsh, dry, honking, repetitive cough usually appears after a trivial viral infection. Although adults may consider habit cough disruptive, affected children typically remain unperturbed. Habit cough disappears with distraction and during sleep.

Pertussis, pertussis-like, and mycoplasma infections-

A cough (with or without other symptoms) lasting more than 6 weeks may signal 1 of these entities, the 3 leading infectious causes of cough. Ruling them out, which is especially important with 

 that has been near epidemic for the past 2 decades, requires laboratory testing.

Collapse of the tracheal walls or the bronchi creates symptoms such as airflow obstruction and wheezing, stridor, or both.

Signs include breathing problems, persistent cough, wheezing, and lung infections, as well as developmental abnormalities such as finger clubbing, rectal prolapse, and nasal or sinus polyps.

Stemming from allergic reaction, this entity manifests as a corticosteroid-responsive chronic cough in nonsmokers, with evidence of airway inflammation but lacking airflow abnormalities characteristic of asthma.

	The concept of specific versus nonspecific cough underpins American College of Chest Physicians guidelines for diagnosing and treating chronic cough in children.

 If nonspecific, the typically dry cough is the sole or predominant symptom. The child exhibits no markers of more troublesome etiologies. Viral infections and increased CRS account for many cases of nonspecific cough.

	Fortunately, most cases of nonspecific cough resolve spontaneously.

 Specific cough, on the other hand, is associated with underlying respiratory or systemic disease that requires further investigation, typically following the direction suggested by the coexisting symptoms, 

, and laboratory results. Among these markers, a frequent (daily) wet cough is the most reliable clinical hallmark of specific cough.

	In pediatric reports, a wet or moist (also called productive) cough has been associated with asthma, 

 exposure, and endobronchial bacterial infection.

 Similarly, a barking or brassy cough in infancy or childhood may signal croup (or, in infancy only, tracheomalacia or other anatomic abnormalities of the respiratory or gastrointestinal tract).

	Additional indicators of specific cough in children based on history and physical examination include auscultatory findings (wheezing or crackling), cardiac abnormalities (including murmurs), and immune deficiencies.

	A previously published algorithm (Figure 1 and Figure 2) for evaluating children with chronic cough relies on signs, symptoms, and history to guide the investigation toward either a specific or nonspecific cause and, wherever possible, appropriate treatment.

	Regarding diagnostic strategies and procedures, all children with chronic cough should undergo the following measures:

	·      A careful, systematic examination, including a thorough history, seeking possible causes of allergy or chronic infection;

	·      A chest x-ray to check for abnormalities of the heart, lungs, and other structures.

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	The following tests also may be indicated, at the pediatrician's discretion:

If one suspects bronchiectasis or interstitial lung disease, supporting either diagnosis requires a chest CT without contrast. For patients with persistent upper airway symptoms, a limited CT scan of the sinuses, if normal, is most helpful to rule out intrinsic sinus disease. Interpret results carefully, however, because abnormal sinus scans routinely occur in asymptomatic children.

Most children aged 6 years and older-and some as young as 3 years-can successfully undergo spirometry.

 When performed with a bronchodilator, spirometry showing reversible airway obstruction (at least 12% improvement in forced expiratory volume in 1 second) suggests asthma. Conversely, patients with normal spirometry require more advanced testing such as the methacholine challenge, which is most helpful when negative. If patients with abnormal pulmonary function fail to respond to a bronchodilator or inhaled corticosteroids (ICS), consider the following etiologies:

	·      Structural airway abnormalities;

Findings of more than 2% eosinophils per high-power field (using induced sputum samples for most reliable results) can support a diagnosis of asthma and predict response to ICS.

 Conversely, children without history of wheezing, reversible airflow obstruction, or elevated markers of airway inflammation probably do not have asthma.

Experts consider laboratory studies useful in ruling out infectious causes, immunodeficiency, and CF in pediatric chronic cough. One should measure quantitative immunoglobulins in all children with persistent cough secondary to recurrent bacterial infections. Conversely, a pH probe study may help diagnose gastroesophageal reflux (with or without aspiration), and impedance studies are increasingly recommended to evaluate non–acid reflux. Flexible bronchoscopy may help highlight airway abnormalities, chronic infection, or aspiration (with or without retained foreign body) in children. Finally, always investigate children with chronic productive purulent cough for bronchiectasis, and to identify treatable underlying causes such as CF and immune deficiency.

	Wherever possible, treating pediatric cough requires addressing the underlying etiology. For chronic nonspecific cough, however, physicians frequently try empiric therapies.

Unlike in adults, antihistamines (alone or combined with decongestants, 

, or codeine) have little if any effect on pediatric cough or sleep disturbances associated with nocturnal cough. In allergic rhinitis, however, pediatric reports have revealed significant improvements from use of oral cetirizine, terfenadine, and mometasone nasal spray.

 If a patient with chronic sinusitis responds to oral antibiotics but symptoms return after treatment stops, consider a 3-week to 4-week dose rather than the typical 10 days.

Therapy for asthma-associated cough mirrors age-based therapeutic guidelines for asthma.

 No data support empiric use of beta-adrenergic 

, anticholinergics, theophylline, or leukotriene modifiers for chronic, nonspecific cough in children. Therefore, establishing the diagnosis of asthma is crucial. For children with isolated, dry cough suspicious for asthma, experts recommend an empiric trial of ICS (fluticasone, 200 µg/d to 400 µg/d; or budesonide or equivalent, 400 µg/d to 800 µg/d) lasting from 2 to 12 weeks. With proper inhalation technique, most patients respond within 4 weeks. The presence of multiple cough etiologies may delay response to therapy if all causes are not treated appropriately. Additionally, one must periodically reassess therapy and discontinue it in nonresponsive patients.

Here, the drug of choice is either amoxicillin and clavulanate-90 mg/kg/d of the amoxicillin component-or a 

 (dosing depends on the product). Because of a high incidence of bacterial reemergence requiring a second course of therapy, initial therapy should last at least 3 weeks.

Helpful therapies in children include proton pump inhibitors, prokinetic agents, and H2 antagonists.

 However, data regarding the efficacy of treating chronic nonspecific cough in children with empiric GERD therapy remain inconclusive.

Although a different entity from psychogenic cough and cough tic, habit cough commonly responds to behavioral therapies such as self-hypnosis, biofeedback, or suggestion therapy. It is also important to halt any unnecessary medications for asthma, for which habit cough is often mistaken.

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Laboratory tests involving cultures, serology, and polymerase chain reaction methods can confirm the diagnosis of 

. In infants, and for others with highly suggestive clinical histories, strongly consider treating while awaiting results. Recommended agents include azithromycin, clarithromycin, and erythromycin. Trimethoprim sulfamethoxazole also can be used.

Most children outgrow tracheomalacia. Most cases require only conservative management: air humidification, physical therapy, slow feedings, and antibiotics to control infections.

This condition requires lifelong, multidisciplinary management to address respiratory, digestive, and 

This cough generally responds to ICS, however, occasionally patients may need long-term prednisone.

	If history or examination reveals the presence of exacerbating factors such as allergens or smoking, patients' families should eliminate or minimize these factors wherever possible. Likewise, over-the-counter cough medicines have shown little, if any, benefit beyond the placebo effect in children. Because dextromethorphan and codeine have been linked with significant morbidity and, rarely, mortality, the American Academy of Pediatrics advises against treating any type of cough with these drugs. Often, clinicians also must educate parents about the need for patience. Even with appropriate therapies, some patients with chronic cough require up to 12 weeks' treatment to experience relief.

	Common in children, coughing usually reflects a self-limited respiratory infection. However, cough that lasts beyond 8 weeks or that perhaps points to a serious underlying diagnosis requires thorough evaluation including, at the very least, a thorough history and physical examination, chest x-ray, and (in able children) spirometry.

	When a specific diagnosis emerges, this etiology should drive treatment decisions. For nonspecific cough, let available evidence guide an empiric trial. In such cases, it may help to characterize the cough as wet (suggesting antibiotics for possible PBB or sinusitis) or dry (suggesting ICS for possible asthma). With any chronic cough, one also must consider and, if necessary, address the impact of environmental factors and 

	1. Goldsobel AB, Chipps BE. Cough in the pediatric population. 

	2. Munyard P, Bush A. How much coughing is normal? 

	3. Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. 

	4. Khoshoo V, Edell D, Mohnot S, Haydel R Jr, Saturno E, Kobernick A. Associated factors in children with chronic cough. 

	5. Asilsoy S, Bayram E, Agin H, et al. Evaluation of chronic cough in children. 

	6. Marchant JM, Masters IB, Taylor SM, Cox NC, Seymour GJ, Chang AB. Evaluation and outcome of young children with chronic cough. 

	7. Mayo Clinic. Childhood asthma. Available at: 

http://www.mayoclinic.org/diseases-conditions/childhood-asthma/basics/symptoms/con-20028628

. Published March 5, 2013. Accessed February 13, 2015.

As complex as it is common, chronic cough in children presents diagnostic and treatment challenges that are complicated by a dearth of solid data and, often, the anxieties of well-meaning parents.

Chronic cough: Watch for "red flags"

 outbreak underscores the importance of childhood vaccines-opponents of vaccination notwithstanding, say experts.

	Drawing heavy traffic from visitors around the world, Disneyland makes an ideal incubator for a major infectious outbreak, says Sheila Fallon Friedlander, MD. She is professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

	“And that’s just what happened. It is believed that in December, unvaccinated individuals who had traveled to the Philippines and contracted measles there then visited Disneyland. That led to an outbreak of measles, which has now extended to more than 100 people” in 14 states including California and Arizona.

	The park draws an estimated 16 million visitors annually. On any given day, Friedlander says, “People are standing in line, jammed together for an hour or more.” In such an environment, the index patient or patients could easily have spread the extremely infectious measles virus via sneezing and coughing. “The people around him then inhaled or touched a surface where the droplets landed.”

	Measles is the world’s most infectious agent, says Stephen K. Tyring, MD, PhD, clinical professor of dermatology, microbiology/molecular genetics, and internal medicine at the University of Texas Health Science Center, and medical director of the Center for Clinical Studies in Houston.

	Not only can the measles virus survive up to 2 hours on a surface or in the air, he explains, but it also takes less of it to cause disease than any other infectious agent. “If you were in a room that a patient with Ebola was in 2 hours ago, you’d have to actually touch the patient’s bodily secretions to get infected-the Ebola virus is not airborne.” However, after a patient with measles coughs or sneezes, “The virus is still at high enough concentration 2 hours later that the next person who hasn’t had measles or been vaccinated has a 90% chance of catching it.”

	At Disneyland, says Friedlander, at least half of the reported cases occurred in 

	Measles was eradicated in the United States in 2000, say Friedlander and Tyring. However, Friedlander points out, Americans don’t always choose to have their children vaccinated (19 states allow parents to opt out of vaccinations for personal beliefs). If these children travel abroad, she says, “They may become exposed to people who have measles.”

NEXT: The legacy of the Andrew Wakefield 

	The current measles outbreak is particularly alarming, says Tyring, because the purported link between vaccines and 

 that initially caused parents to abandon vaccines has been discredited. It originated with a publication

 by Andrew Wakefield, who was paid by lawyers to advance the fraudulent claim so they could sue vaccine makers. Subsequently, “Investigators reexamined all these children that Wakefield said got autism after being vaccinated, and they found that it was all a lie,”

 for which he lost his British medical license. Several years later, “We still have people believing the big lie.”

	More recently, some parents-and even the occasional physician-oppose vaccination out of concern for potential 

 including aluminum, mercury, antibiotics, and fetal proteins used in various vaccines.

	Paradise Valley, Arizona-based cardiologist Jack Wolfson, DO, said on CNN in early 2015, “We cannot sterilize our society. Our children have the right to get infections. We have immune systems for that purpose.” Ultimately, he added, measles is “a benign childhood infection” that most victims survive.

	Friedlander and Tyring counter that measles is anything but benign.

	Before the measles vaccine became widely used in the United States in the 1960s, says Tyring, measles killed more than 1 million persons globally and permanently injured 4000 in the United States annually. Friedlander adds that the disease can cause pneumonia, 

, and ocular complications, particularly in younger children. Other complications can include ear infections that may cause permanent 

. Rarely, says the Centers for Disease Control and Prevention (CDC), patients who survive measles can develop subacute sclerosing panencephalitis, a fatal disease of the central nervous system, approximately 7 to 10 years later.

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	“In 2014,” says Tyring, “there were 644 cases of measles in the United States. We’ve already had more than 100 this year” nationally.

	Worldwide, he adds, measles killed more than 1 million children annually at the end of the 20th century. Even now, more than 150,000 children worldwide die annually of measles. Even in the healthiest nations, Tyring says, it’s impossible to predict which patients will develop encephalitis or die from measles.

	Most fatalities occur in children too young to undergo vaccination, or living in areas where the vaccine is unavailable. Because of malnutrition, says Tyring, infected children in the Third World are likely to contract bacterial infections atop the measles, leading to viral or bacterial pneumonia and death.

	Babies, toddlers, and pregnant women suffer the most serious infections, says Friedlander. “Mortality can be as high as 1 to 2 in 1000 cases, and severe morbidity including encephalitis can occur in 1 in 1000.”

	“Since you don’t know who’s going to suffer serious consequences,” says Tyring, “why not vaccinate everybody?”

	The vaccine is overwhelmingly safer than the virus, Tyring says. With a serious 

 (AE) rate of less than 1 per billion recipients, “The vaccine was proven in study after study to be extremely safe.” Independent bodies including the CDC, the Institute of Medicine, and European experts using databases going back to the 1980s have analyzed tens of millions of vaccine records and found no hint of increased risks of serious AEs. Tyring adds, “In 30 years of practice, I’ve never seen or heard of anyone who ever developed serious complications from the vaccine. Those people that say they have are unable to prove the vaccine caused it.”

	Even if serious post-measles sequelae were truly the exception, he says, “What parent would want their child sick, home from school, and miserable for 2 weeks?” Actually, public health officials advise parents to keep children with measles home for 3 weeks to reduce the risk of transmission. Meanwhile, says Tyring, the kids can’t do much because light hurts their eyes, and their parents miss work.

NEXT: How does the media contribute to the problem?

 recommend administering it at 1 year of age, followed by a booster at age 4 to 6 years. The first shot confers around 90% protection; the second raises it to 99%, says Tyring.

	However, he says, the fact that the vaccine requires 2 shots for maximum protection has led to miscommunication in the media, with some outlets reporting that anyone who has had 1 measles shot doesn’t need a booster. Rather, “The second shot is imperative. The 100-plus cases at Disneyland included a handful of children who had gotten the first shot, but not the second.”

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	These children didn’t get as sick as unvaccinated children, says Friedlander, but they can also serve as a source of infection for others. “Even fully vaccinated people can get disease, but it is uncommon. No vaccine is 100% effective, but the measles vaccine comes close.”

	Patients can be contagious for 4 days before and 4 days after rash onset, says Friedlander. Often, she says, “People are out coughing and spewing before they even have a rash and know what’s happening.” Other early symptoms include lethargy and coryza.

	A few days after the fever, which Tyring says he’s seen as high as 104°F, small white spots called Koplik’s spots, which are pathognomonic for measles, can develop within the mouth. They’re difficult to pick up, says Friedlander, and they don’t last long, fading right before the rash occurs, says Tyring.

	With the nonspecific early symptoms of measles, Tyring notes, “Hardly anybody ever looks in the patient’s mouth. It’s only when the rash appears, starting behind the ears, and starts progressing down to the trunk and extremities that most people would recognize measles.” Younger doctors may not recognize measles, he adds, because those trained in the 21st century have never seen a case.

	Among the lay public, he says, “The ignorance about vaccination may not stop with measles.” Any disease that vaccines have rendered rare in America could resurge because it’s still common elsewhere. Also, many parents are complacent because “they grew up without seeing anyone get very sick or die of these diseases.”

	Skipping the measles vaccine instantly raises the risk of mumps and rubella, the 2 other vaccines that come with it, says Tyring. 

 rates also may decline, he adds. Over the past 2 years, he says, “Thousands of West Coast children have contracted whooping cough [

] because their parents refused the vaccine.” According to the California Department of Public Health, 3 infants died from pertussis contracted in 2014, and 1 infant has died from pertussis contracted in 2015.

	Addressing such challenges will require physicians and media members to stick meticulously to the facts regarding vaccine-related matters in the future, says Tyring. “Vaccines have been the greatest breakthrough in the history of medicine. They have saved more lives than any other intervention. The ignorance about vaccination is a tragedy.”

	To prevent many deaths and serious injuries from measles, Tyring tells parents, “Don’t just get vaccinated for yourself or your child. Do it to protect the millions of children under 12 months and immunocompromised people who can’t get vaccinated.”

	To clinicians, Friedlander says that when one suspects measles, “Get a vaccination history and involve your state public health agency if you need further help in evaluating the patient.” Because there’s no antiviral medication for measles, adds Tyring, “Treat the fever, and the rash if it causes itching as it heals.”

Drs. Friedlander and Tyring report no relevant financial interests.

	1. Wakefield AJ, Murch SH, Anthony A, et al. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. 

	2. Godlee F, Smith J, Marcovitch H. Wakefield’s article linking MMR vaccine and autism was fraudulent. 

The ongoing US measles outbreak underscores the importance of childhood vaccines-opponents of vaccination notwithstanding, say experts.

Author | John Jesitus

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