Emily was a beautiful 19-year-old honors student attending Barnard College in New York, New York, who contracted measles and developed post-measles encephalitis with resulting severe brain damage. I met Emily when visiting with a group of fellow pediatricians at Letchworth Village in Thiells, New York, a former residential institution for the physically and mentally disabled. We soon realized that, unfortunately, Emily was now barely able to function at the developmental level of a child aged 4 to 5 years.
That encounter made an indelible impression that has stayed with me to this day. The year was 1959, 60 years ago, and shortly before the measles vaccine was available. At that time, measles was one of the most common childhood illnesses.
Vaccine success story
Since the approval and licensing of the vaccine in 1963, we have seen a dramatic decrease in the prevalence of measles. The vaccine has been shown to be safe and effective. My office participated in the field trials in 1961. My son was an uncooperative, unwilling participant in the trial as I drew his blood, as were many of my other patients. In those days every practicing pediatrician was quite familiar with measles that was, along with chicken pox, seen very frequently.
The diagnosis of measles at times could be challenging. We learned about the 4 k’s: koplik spots, kough, koryza, and konjunctivitis. However, there were cases that did not present with all these features. Finding the koplik spots, which appeared before the rash, was not easy. Prying the mouth open of a sick and screaming toddler was hard enough. Locating these 1-mm to 3-mm blue white lesions with an erythematous base on the buccal mucosa opposite the first molar was even harder.
During the 1989-1991 outbreak, the mortality rate was 2.2 deaths per 1000 cases.1 Pneumonia was responsible for 60% of the deaths, mostly in children aged younger than 5 years.2 As illustrated by Emily, measles can also cause severe neurologic complications. Post-measles encephalitis is seen in 1 to 2 cases per 1000, usually developing several days after the rash. The hope at that time was for the vaccine to not only protect against measles, but more importantly to prevent the serious complications, which is exactly what has happened.
The vaccine had been an incredible success, so much so that in 2000 the Centers for Disease Control and Prevention (CDC) declared that measles was officially eliminated in the United States, as a result of so few reported cases in each of the previous few years.