Spotting the Unicorn-Measles in 2019

Mr. Smith, Member-at-Large and Board Member for SPAP, received his Bachelor of Science in Biology from Georgia Southwestern College in Americus, Georgia, next attending the University of Georgia for master’s work in education and later Emory University Physician Assistant school from which he obtained his Master of Medical Science.

In addition to membership in SPAP, Mr. Smith is also a member of the Georgia Association of Physician Assistants, American Academy of Physician Assistants, and the American Academy of Pediatrics. He is credentialed at Piedmont Columbus Regional Hospital where he chairs the Pediatric Preparedness Committee. He also is a Co-Trainer for the Pediatric Readiness Quality Collaborative, a national program through the Emergency Medical Services for Children.

In December of 2014, Mr. Smith earned a Certificate of Added Qualifications in Pediatrics from the National Commission on Certifications of Physician Assistants (NCCPA). This certification is in addition to his certification from the NCCPA and demonstrates knowledge and skills specific to pediatrics. He is married to Renee Smith, also a Physician Assistant, and they have one child, Emma.

In the July 2019 edition of Contemporary Pediatrics, Pat F. Bass III, MD, MS, MPH, discusses measles and its hallmark signs and symptoms in his article “Measles makes a comeback: What to know, what to do.” For most of us practicing today, we have never seen the disease outside of a textbook or a website. A few years ago at the weekly meeting for providers at our practice, the subject of measles came up. Of the 10 practitioners at the meeting, only 3 had ever seen measles, and of those 3, none had seen it in the past 25 or more years. It made me wonder if I would be able to diagnosis it if the time came. As far as I know, I have never missed a case of measles, nor has anyone else in our office, but with numbers trending up, would that change?

Diagnosing the never-seen-before

We all probably remember the prodrome for measles consist of the 3 C’s, coryza, cough, and conjunctivitis from boards or school. The problem here is, during flu season, that could look like just about every child. I don’t think there are enough negative pressure rooms to go around. Even during the summer, we get plenty of children who fit this description. Speaking of boards, I think every time I have taken them, I get a question on Koplik spots, the pathognomonic sign for measles-or so we have been told for 50 or more years. Talking to providers who have seen real cases of measles, not one has ever seen a Koplik spot. Were they there and the providers missed them because they are a whopping 1mm to 3mm?  I don’t know, but from what I gather, it’s going to be fairly useless in helping to diagnose measles. 

Lessons Ebola taught

So, what can we do to improve our odds of correctly diagnosing measles?  I think Ebola helped us out here. We got into the habit of asking about travel, exposures, and immunizations, and that is a habit we can extend to measles. In general, most cases have been in unvaccinated or under-vaccinated individuals. Asking about or checking on immunization status for all visits will remind us about the risk and maybe catch a few patients who have fallen through the cracks. Washington state, Oregon, and New York have all had large outbreaks. Asking about travel to areas of known outbreaks, like we did with Ebola, can help keep measles on our radar. We also need to think about the measles, mumps, and rubella (MMR) vaccine as a travel vaccine for patients who are not fully vaccinated.  The MMR vaccine can be given to an infant as early as 6 months of age (remember you still give the normal dose at 12-15 months).  For travelers aged older than 1 year, a second dose can be given 28 days after the first. Titers can always be drawn when there is a question of immunity, but I would advocate that, when in doubt, give it. 

Acting after exposure

If you diagnosis a case of measles, you are probably going to have more help than you want. Between public health officials, the infectious disease department, and probably the Centers for Disease Control and Prevention, you will have plenty of people with their fingers in the pie. Dr. Bass’ article brings up many aspects of treatment that would be important if and when the case arises.  A more probable scenario would be if and when to start post-exposure prophylaxis. Do you wait on titers or a confirmatory test to come back? Or go ahead and treat? I would think that input from public health officials and maybe infectious disease specialists would be important in this situation, but there is a time concern to think about. Per the article, you can give the MMR vaccine to children aged 6 months and older when they are under 72 hours post-exposure, and intramuscular immune globulin when under 6 days post-exposure. 

I hope some good will come from the current outbreak and we will see less vaccine resistance, but that is covered in the next article!