Doctors Discuss the Columbus Measles Outbreak and Potential for More
Back in January, a friend in Philadelphia sent me a photo from one of his local hospitals. Inside an examination room, a computer screen displayed an alert with a big, red stop sign and two questions:
“Have you visited Columbus, Ohio, in the last three weeks?”
“Have you been in contact with anyone with measles?”
I explained to him that Columbus had been battling a measles outbreak for a couple of months. “Maybe someday they’ll have a vaccine,” he said, tongue firmly in cheek.
Columbus, it seems, was finally on the map, but not for reasons any city booster would celebrate. Despite 50 years of widespread access to a safe, effective measles vaccine in the United States, the virus infiltrated a local child care center last fall, eventually leading to 85 confirmed measles cases, most of whom were 5 years old and younger. Of the 85 minors, none were fully vaccinated: four were partially vaccinated, 80 were unvaccinated and one child’s status was unknown. No one died, but 36 of the kids were hospitalized during the outbreak, which was the largest in the country last year. Columbus Public Health didn’t declare the episode officially over until February, when 42 days—two incubation periods—had passed since the last rash onset of a measles case.
Our city has company. Even though measles was eliminated in the United States in 2000, the Centers for Disease Control and Prevention reported 1,300 measles cases in 31 states in 2019—the highest case number since 1992. Those outbreaks were related to travelers who visited countries where measles isn’t eliminated and where health systems are weaker. As the CDC likes to say: Measles anywhere is a threat everywhere. Globally, India ranked first for measles outbreaks as of June, with more than 73,000 cases—nearly four times the cases in Yemen, the second-place country.
Comparatively, the U.S. is in better shape. But in April of 2022, about six months before the Columbus outbreak, the World Health Organization warned of possible large outbreaks based on a nearly 80 percent increase in global measles cases in January and February of 2022 compared to the same period in 2021. Central Ohio saw its first measles case since 2019 in June of last year after a 17-month-old Franklin County girl traveled to a country with confirmed measles cases. Before 2022, the last Ohio measles outbreak occurred in 2014, when an unvaccinated traveler returned with measles from the Philippines and spread the virus to the Amish community, where many others were unvaccinated, leading to 382 confirmed cases.
As measles cases began to climb in October and November of last year, Dr. Mysheika Roberts, the director of Columbus Public Health, worried about a repeat of the 2014 outbreak. “We had one case initially that had measles, was not vaccinated and had no travel history. Having measles after you’ve traveled to a measles-endemic country is not unusual here in the United States. But what is unusual is to have a measles case when someone has not traveled,” Roberts says. “I was very concerned that we would identify more cases and that our case count would explode. … It absolutely felt like a crisis.”
➽ At one time, measles was a ubiquitous respiratory infection. Epidemics would hit every few years, leading to a devastating 2.6 million deaths per year globally, according to the WHO. The first measles vaccine was licensed for public use in 1963, and later improved in 1968 by Dr. Maurice Hilleman, who, in 1971, combined the measles vaccine with other recently developed vaccines for mumps and rubella. The resulting MMR vaccine is administered as a single shot followed by a booster dose. (The MMRV vaccine also protects against varicella, or chicken pox.) Experts recommend children get the first dose between 12 and 15 months and the second dose between the ages of 4 and 6. Infants as young as 6 months can get the first dose if traveling to another country.
Over the decades, the MMR vaccine has proven to be safe and highly effective. According to the CDC, two doses are about 97 percent effective at preventing measles, and one dose is about 93 percent effective. Thanks to the success of the vaccine, younger generations of health care providers have never even seen a measles case. Likewise, many Americans don’t know what measles can do to bodies that aren’t immunized against it. “With these vaccine-preventable illnesses, we’ve forgotten how serious they can be,” says Dr. Bruce Vanderhoff, director of the Ohio Department of Health. “There are a number of things about measles, in particular, that really make it concerning.”
Measles is a respiratory disease that usually starts with a high fever and then adds a cough, runny nose and red, watery eyes. After several days, a signature rash often appears on the face and upper neck, then advances over a few days to reach hands and feet. Serious complications can arise, particularly in babies and young children. These include pneumonia, brain damage, blindness, severe diarrhea (and related dehydration), ear infections and hearing loss. About one in four people infected require hospitalization, though it’s often higher for infants and toddlers. In rare cases, the virus leads to death.
Measles also happens to be one of the world’s most contagious diseases, compounding its seriousness. Nine out of 10 unvaccinated people exposed to a person with measles will become infected. The virus spreads through breathing, sneezing or coughing, and it can remain in the air for up to two hours. And while the rash is the most recognizable characteristic of measles, infected persons are contagious up to four days prior to the rash—often before anyone realizes their relatively common symptoms are related to measles.
Last fall and winter, the presence of COVID complicated things further in Columbus. “Measles can mimic a lot of diseases, but most importantly, it can mimic an upper respiratory viral condition,” Roberts says. “We were still seeing a fair amount of COVID, as well as a lot of RSV in our community, particularly in the pediatric population. So I think a lot of parents, and maybe even some providers, mistook measles for just a mild respiratory virus and didn’t make that connection initially.”
Roberts’ team at Columbus Public Health informed her of the first case in late October, and it didn’t take long for the numbers to rise. Multiple parents from the local child care facility at the center of the outbreak (the name and location of which CPH will not disclose) told health officials their children had similar symptoms. “It became very clear, very quickly, that there had been quite a number of people who were initially impacted by this,” Vanderhoff says.
While CPH took lead on the outbreak, ODH worked alongside the city’s health department, providing testing support and extending lab hours to process samples. The state also helped with contact tracing and case investigations, as did the CDC. At the time of the outbreak, Columbus had an Epidemic Intelligence Service officer from the CDC on hand, and a CDC team also came from its federal headquarters in Atlanta for about two weeks to help conduct the investigation.
Right away, Roberts also relied on the expertise of Dr. Matthew Washam, a pediatric infectious disease doctor and the medical director of Nationwide Children’s Hospital’s infection control program. Washam and his team helped with the first two identified measles patients in early November, then worked with the local health department to identify retrospective and current patients.
Thanks to the COVID-19 pandemic, these health care collaborations across departments and health systems were nothing new. “The initial response is always the most challenging and most labor intensive,” Washam says, “but a lot of the systems that have been either established or refined and further developed over the last three years with the pandemic really paid dividends.”
Case investigation involved calling every household with a lab-confirmed result and asking the child’s guardian a series of questions: Where does your child go to school? Who else lives in the house? Are they vaccinated? What symptoms did your child have? When did they start? Are there other people in the house who had similar symptoms? If so, when did those begin?
“Depending on where they tell us they go to school, or what special activities they go to, or where they go to church—particularly where they went while their child was ill—that’s where the contact tracing comes in,” Roberts says. “We have to contact those venues and say, ‘You had a participant who was at your location on this day with these symptoms. Who was there at that same time?’ ”
On Nov. 9, with four cases confirmed in unvaccinated children with no travel history, Columbus Public Health issued a statement about the outbreak. “That’s when our case count really started to increase, as more people had a heightened sense of awareness,” Roberts says. “More providers were testing for it. More parents were bringing their child to health care [centers] because they had some of those symptoms.” By Nov. 15, CPH reported 15 measles cases at five local child care facilities. A couple of days later, the health agency reported 24 cases at seven child care centers and two schools. By the end of the month, CPH also announced public venues that had been exposed: a Meijer on Sawmill Road; a church on Cleveland Avenue; department stores at Polaris; a Dollar Tree on Westerville Road.
Roberts also had to steer the city’s measles response in accordance with the Ohio Statehouse’s passage of Senate Bill 22, a pandemic-related law that took effect in 2021 and stripped certain powers from local and state health departments. “I couldn’t tell all daycares to close. I couldn’t even tell one daycare with one, two or three cases to close. I could only ask them if they would close and help us,” Roberts says. “We got cooperation from every daycare that we worked with, but that was the luck of the draw.”
The city’s health department also asked infected children to quarantine for three weeks to avoid exposing others. In addition to these containment efforts, CPH, ODH, Franklin County Public Health and local health systems communicated a clear, unified message about how to stop this measles outbreak and avoid future outbreaks. “With vaccine-preventable illnesses, that really comes down to how well vaccinated are the people in the impacted area,” Vanderhoff says. “We had a substantial number of people who simply were not vaccinated, and that became a major call to action for us.”
Messages went out on all platforms encouraging and reminding parents to vaccinate their age-eligible children against measles. In an effort to boost immunization rates, Columbus Public Health held several vaccine clinics in Columbus City Schools buildings. According to the CCS Office of Health Services, “quite a few students who had prior immunization exemptions received the MMR vaccine at those clinics.” (None of the confirmed 85 measles cases were identified as CCS students.)
By mid-December, the outbreak tapered off, with only four cases appearing in the last couple of weeks of 2022. Those turned out to be the final measles cases of the outbreak before Columbus Public Health deemed the outbreak over on Feb. 4. In the end, 42 percent of the infected kids were hospitalized. “We had a higher hospitalization rate than is typically seen in a measles outbreak,” Roberts says. “Most of them were hospitalized for things like dehydration, nausea, vomiting, diarrhea. Some were even in the intensive care unit for a short period of time.”
Even though it had been several years since the last measles outbreak in Ohio, Roberts, Washam, Vanderhoff and others in the health care industry weren’t shocked to see it recur. “With immunization rates below 100 percent,” Washam says, “there’s always a risk of introduction of measles into a community.”
➽ Some parents’ fear over measles immunization stems from a 1998 study that suggested a link between the MMR vaccine and autism. The report in medical journal The Lancet was later retracted, and the primary author was found guilty of ethical violations, including falsification of data. Subsequent studies have consistently found no evidence of a link between the MMR vaccine and autism. But 25 years later, the damage from the debunked study endures. “That myth continues to persist in our community and other communities and has established a foothold,” says Washam, noting it has become “very hard to overcome with information.”
Vaccine skepticism, though, isn’t new. Maria Gallo, an epidemiology professor and associate dean of research at Ohio State University’s College of Public Health, traces it back to the very beginning of immunizations. “In the United States, there’s been a fear of vaccines ever since vaccines were introduced,” she says. “You can find it in literature, people talking about [their] concerns … and religious figures referring to [vaccines] as ‘the devil’s work.’ ”
Today, those fears have been stoked by two modern phenomena: social media and the COVID-19 pandemic.
While the pandemic helped the health care industry prepare for future outbreaks by establishing and improving systems for dealing with infectious diseases, it also amplified the voices of vaccine skeptics, whose messages spread far and wide through social media. The Center for Countering Digital Hate found that just 12 people, whom the nonprofit refers to as “The Disinformation Dozen,” were responsible for 65 percent of false and misleading claims about vaccines on social media and up to 73 percent of shares on Facebook. One of those 12, Robert F. Kennedy Jr., belongs to a famous political family and is running for president. Another, Ohio physician Sherri Tenpenny, testified during a House Health Committee hearing at the Ohio Statehouse in 2021 that COVID-19 vaccines magnetize people and react with 5G towers. (They don’t.)
“The Disinformation Dozen are doing this because they’re making a lot of money doing it. They’re selling supplements. They’re selling books,” Gallo says, noting that RFK Jr. “greatly increased the number of his followers at the start of the pandemic by doing this, and he’s building off of this for his presidential run.”
The false claims tend to find a foothold by preying on deeply held convictions of liberty and purity. “A lot of these anti-vaccination messages are framed around, ‘These are assaults on your individual freedom,’ ” Gallo says. “And there’s a lot about being unnatural—associating that with vaccines. And then also saying that vaccines contain contaminants.”
Some parents might not have vaccinated their children due to gaps in medical care during the pandemic. Perhaps other caregivers haven’t prioritized vaccines amid the general busyness of family life. But anti-vaccination messages seem to resonate with a portion of Americans considering whether to give their children the MMR vaccine. In November of last year, the CDC issued a statement saying that measles vaccination coverage has steadily declined since the beginning of the pandemic. In January, the CDC analyzed nationwide vaccination data for kindergarteners and found that during the 2020–21 school year, national coverage with state-required vaccines declined from 95 percent to 94 percent; in the 2021-22 school year, it dropped another point to 93 percent.
In the few years leading up to the pandemic, Ohio Department of Health data indicates about 92 percent of Ohio kindergarteners were covered by the MMR vaccine; that dipped to 88 percent in the 2021-22 school year, then increased a bit to 89 percent in the 2022-23 school year. About 86.5 percent of Ohio kindergarteners were covered by all required vaccines last school year, with a six-year high 3.6 percent claiming a reason of conscience or religious exemption; a far greater number of kindergarteners had incomplete immunizations with no exemption on file—nearly 10 percent, meaning unvaccinated or partially vaccinated students without documented objections are slipping through the cracks.
In response to a public records request, Columbus City Schools’ Office of Health Services said 2 to 5 percent of the district’s students typically have immunization exemptions for medical reasons or religious or personal beliefs. CCS spokesperson Jacqueline Bryant says that without an exemption form, students have 14 days to provide vaccination proof after enrollment. “If a student is not up to date on their vaccinations and has not signed an exemption form, then they cannot attend school until that is corrected,” she says.
According to the National Conference of State Legislatures, all states allow medical exemptions for immunizations, and 44 states allow religious exemptions. Ohio, though, is one of 15 states that also allows philosophical exemptions for vaccine requirements. The new exemption category arrived in 2005, when public health advocates in Ohio proposed adding the chicken pox vaccine to the list of required immunizations for schools. State Rep. Lynn Wachtmann, a far-right Republican who was part of the so-called “Caveman Caucus” and chaired the House Health Committee, said chicken pox could be added only if Ohio law was updated to include a “reasons of conscience” exemption. “My intention was to make it a big enough loophole you could drive a truck through,” Wachtmann told The Columbus Dispatch last year.
Data from the American Academy of Pediatrics does not show a clear difference in vaccination rates among states with and without the personal belief exemption, but Roberts believes Ohio is more at risk because of it.
In an emailed statement, the Ohio Association of Child Care Providers said all licensed child care centers are regulated by the Ohio Department of Job and Family Services, which requires a medical statement for each child noting the immunizations the child has completed (or is in the process of completing). Measles is on the list of diseases that require immunization, though, given the origin and spread of last year’s outbreak in child care centers, the requirement is not uniformly enforced.
Roberts says that during the Columbus outbreak, she and her team talked to many parents who regretted not getting their child vaccinated. “They made comments like, ‘I made a mistake. I should have done it,’ ” she says. “They acknowledged they were concerned about autism. They acknowledged that that concern had not come from a medical provider; it had come from lay people that they trusted. But seeing their child now in the hospital, being very sick, made them regret making that decision.”
All of it could happen again. Summer, a popular time for travel, is a season particularly susceptible to outbreaks. “All the factors continue to be in place for increased measles cases globally,” Washam says.
“We, as a country, are one case away from any outbreak related to measles, mumps and rubella,” Roberts says. “Anything that has been eradicated in our country was the result of an effective vaccine campaign. And we have a very global [society]. You can move easily from one country to another. And there aren’t vaccine requirements to come back into this country, particularly if you live here. So if we don’t go back to the basics of getting people the required vaccines—the ones we know are effective and work—we’re going to see more outbreaks of things like measles.”
This story is from the August 2023 issue of Columbus Monthly.
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