On Sunday, public health officials in two Michigan counties warned their residents that they may have been exposed to measles. In Wayne County, an adult who had contracted the virus abroad had been in health-related settings in Dearborn on two days last week — two urgent care clinics, a CVS pharmacy, and a hospital emergency department. Health officials in neighboring Washtenaw County issued a similar alert about a different case — also an adult, also infected abroad — who was in the emergency department of a hospital in Ypsilanti on March 1.
Both counties urged unvaccinated people who had been in the listed locations at the listed times to contact public health or their health care provider, warning them to phone ahead if they needed to seek in-person care.
These kinds of notices are standard public health practice during measles outbreaks. Alerts of this sort may also warn that someone with measles had been in a crowded public location — an airport, a shopping mall, a theme park.
But in Florida, where 10 residents and at least four non-residents have been diagnosed with measles in the past month or so, the Department of Health has released scant information about those cases. The seeming reticence to speak openly about measles leaves in the dark anyone in the public who might be concerned about whether they may have had an exposure. Likewise, people considering spring break vacations to Florida who want to avoid measles exposures have almost no information on which to plan their trips.
There has been measles activity in at least three Florida counties — Broward, Polk, and Orange — in the past month. Yet the state Department of Health’s website homepage has a single measles alert. The 105-word advisory, which is dated Feb. 23, mentions an unspecified number of cases in Broward County and a travel-related case in “Central Florida.” The alert does not mention Polk County by name and makes no reference to the cases seen at Orlando-area health facilities.
(A Health Department spokeswoman told the Orlando Sentinel that the Orange County cases are not included on the list of Florida measles cases because the individuals were not residents of the state. That suggests these individuals were from other parts of the country. The guidelines for reporting to the National Notifiable Diseases Surveillance System — which is operated by the Centers for Disease Control and Prevention — say that a case should be reported by the jurisdiction of the individual’s usual residence. If they were non-U.S. residents, the state handling the investigation — in this case, Florida — should report them.)
While it’s known seven of the nine Broward County cases are students of Manatee Bay Elementary School, the two other infected children are too young to have been in school. Are they part of the school outbreak, infected perhaps by a school-aged sibling or neighbor? Can a line be drawn from these children to the Manatee Bay cases or could they have caught the virus from an undetected case? Were any of the four cases seen in Orlando hospitals in the city to visit Disney World? If yes, did they actually visit the theme park? These questions can’t be answered given the information that is in the public domain.
STAT contacted the Broward and Orlando health departments. Both declined to comment, directing questions to the state Department of Health. To date that office has not responded to STAT’s requests for interviews or acknowledged receipt of the questions.
Public health experts elsewhere see all this as of a piece and worry that the state’s approach could fuel spread of the virus. Part of that approach involved Florida’s surgeon general, Joseph Ladapo, telling parents of unvaccinated children that they could choose whether to send their kids to school or not during the ongoing outbreak at Manatee Bay Elementary — a move that has drawn widespread criticism within the public health sphere.
“Very little information is available,” Scott Rivkees, Florida’s former surgeon general, told STAT by email, adding it is “very unusual to have such sparse information for the public, especially when the onus is being put on parents to make decisions.”
Rivkees resigned in September 2021 after battling with Florida Gov. Ron DeSantis over Covid control measures; he is now interim chair of health service, policy, and practice in Brown University’s School of Public Health.
Michael Mina, an infectious diseases epidemiologist who has studied measles extensively, said the state’s approach defies common sense.
“What’s happening in Florida is sort of breaking all the global conventions around measles,” said Mina, who formerly taught at the Harvard T.H. Chan School of Public Health. “One of the first things that anyone would normally do, whether it be in Europe or the United States, is be extremely — almost overly — transparent.”
“They very well might get lucky. The outbreaks might subside. But if it’s not now, it’s next time,” Mina said, warning that if Florida mishandles its cases, other states could suffer. “It can light fires across the whole country.”
The primary price paid when measles transmission isn’t contained is unnecessary illness. Measles is, at best, a very unpleasant experience. At worst, it can kill. Though deaths are blessedly rare, the U.S. recorded a measles death in 2015, in a 28-year-old woman who was on immunosuppression drugs to treat another medical condition.
Why does it matter whether public health officials warn the public when measles exposures have occurred? Knowing that measles poses a present risk can change thinking about vaccination, said Jane Zucker, who retired from the New York City Department of Health last July. The former assistant commissioner in the department’s bureau of immunization, Zucker has worked on measles outbreak responses, including the 2018-2019 outbreak that almost cost the United States its measles-free status.
Measles vaccination typically goes up during measles outbreaks, Zucker said. “Parents want to protect their children. They want to do what’s best for their children,” she said.
Giving people the information with which to make decisions like that is an important part of containing measles, said William Moss, executive director of the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health. “It is very important for public health officials to be very proactive about one, promoting vaccination, which we’re not seeing in Florida, and …. two, in the event of a potential exposure, to make people aware of that, so that individuals have an opportunity to protect themselves and their children,” he said.
Informing the public of sites where measles exposures could have taken place is especially critical when it comes to events in health care settings, which have the capacity to turbocharge both the size of an outbreak and the amount of work that curtailing it will entail.
When people infected with measles visit doctors offices, clinics, or hospitals, they can expose large numbers of people to the highly contagious virus. Some of those people may be infants too young to be vaccinated; the first shot in the two-dose measles regimen is given at between 12 and 15 months. Some may be people who are immunocompromised. Some may be among the rare group of vaccinated people for whom the vaccine didn’t induce protection.
A 2014 outbreak in Orange County, Calif., illustrates how bad the combination of undiagnosed measles cases and unsuspecting hospitals can be. In that outbreak, several cases went to hospital; five health care workers became infected. At least four were vaccinated (the vaccination status of the fifth was unclear); those health workers were still working when they started to feel the unspecific symptoms seen at the start of a measles infection. Between them, the health workers exposed about 1,000 people to the virus. One alone was responsible for 853 exposures. In that entire outbreak, there were nearly 2,250 exposed people that public health had to track down; nearly 2,000 of those exposures took place in a health care setting.
Fortunately in that outbreak, none of the people exposed to measles by the health workers went on to develop the disease. Still, any time there is measles spreading in a health care setting, the risk exists that someone who could become seriously ill from measles will encounter the virus.
“That’s what we would really like to try to avoid,” Moss said. “And without knowing where the cases are or where potential exposures occurred, you just increase the risk of that happening.”
One of measles’ devious tricks — one of the reasons it spreads so well — is that infected people are contagious in the four days before the telltale measles rash develops. During that period they can become quite sick, so they may seek medical care. But their symptoms could be caused by a range of conditions. And in countries where measles have been largely quelled by use of the highly effective measles vaccine, health professionals often do not recognize what they are dealing with. Some would never have seen a measles case.
“Unless you really know something’s going on with measles, or you have some reason to suspect measles, those are just not going to be recognized very often, and that often leads to lots of exposures in health care facilities,” said Kathleen Harriman, who retired from the California Department of Public Health, but continues to work with the department as a consultant.
During a long career in public health, Harriman worked on multiple measles outbreaks, including one in 2014-2015 that started at Disneyland. That outbreak resulted in 131 cases in California alone; cases from the outbreak were also detected in six other states, Mexico, and the Canadian province of Quebec, where a single child infected at Disneyland triggered an outbreak that resulted in 159 cases.
Telling the public of possible measles exposure events, in the way the Michigan health departments have, can get parents of unvaccinated children or adults who are unvaccinated to think “Maybe this is measles” if their children or they themselves become ill. It also alerts medical providers that they should think about measles and to be on the lookout for the triad of symptoms known as the three C’s — cough, coryza (a stuffed up or runny nose) and conjunctivitis or pink eye — which along with fever can signal measles.
All of this doesn’t merely prevent unnecessary illness. It can also save a great deal of money. The health department costs of containing the Disneyland outbreak were between $1.5 million and $4 million, Harriman has said. In an account of New York City’s efforts to stop the 2018-2019 outbreak that was published in the New England Journal of Medicine, Zucker and colleagues estimated that the cost to their department alone of responding to that outbreak was $8.4 million.
“You need to stop transmission. You just have to stop transmission,” Zucker said. But “it’s very labor intensive.”