Measles: going, going, but not gone.

For those of us engaged in disease investigation and response at the state and local level, the report by Chen and colleagues [1] in this issue of the Journal makes for sobering reading. It describes an outbreak of measles in Arizona where virus transmission predominantly occurred in the health care setting, a scenario of great concern to us all. In reading through the report, I was repeatedly reminded of the adage ‘‘What a fool does in the end, the wise do in the beginning.’’ One hopes that a report of this nature will spur at least some health care systems, hospitals, and physicians’ offices to act wisely before they too are confronted with a case of measles in their facilities. The Tucson outbreak also highlights many of the challenges faced by public health departments around the country with respect to a disease that, vaccine controversies notwithstanding, has been receding in memory and importance for many health care practitioners, institutions, and the public In the United States, we entered the ‘‘postelimination’’ era in 2000 [2]. But in the context of measles, ‘‘elimination’’ does not mean that there are no cases occurring. This is because the disease continues to be still too common in other parts of the world, and international travels produce opportunities for continued introduction [3]. As a result, between 2000 and 2008, an average of 56 cases per year have been confirmed in the United States [3]. And paradoxically, the number of cases may actually be rising as segments of the population increasingly opt out of vaccination, producing uneven vaccination rates and pockets of susceptibility [4]. This raises concerns that sustained transmission can occur if measles is introduced into the wrong setting at the wrong time. Consequently, even a single case of measles sets off alarms in every health department around the country and often prompts an extensive investigation like the one described in Tucson. Such investigations usually involve tracking large numbers of contacts; hastily arranged mass vaccinations; isolation, quarantine, and exclusion; expensive laboratory testing; and an enormous drain on resources [5, 6]. These actions are geared toward rapid containment to minimize the potential for transmission and, especially, multigeneration outbreaks. A major take-home lesson from Tucson is that some of the actions taken, and certainly many of the costs, were avoidable had common-sense measures been in place beforehand, rather than after the fact. At least one hopes that that lesson was learned and that these common-sense measures were applied after the fact. First, as so well described by Chen and colleagues, case diagnosis and reporting were repeatedly delayed in Tucson. This happened even after the presence of measles was known, presumably the medical community had been alerted, and statewide active surveillance for measles was instituted. With the index case who was an international traveler, a full week elapsed between rash onset, establishment of a definitive diagnosis, and reporting of the case to the health department. Even while the patient was hospitalized, 3 days elapsed before the diagnosis of measles was even considered for this patient, followed by 2 more days before a lab test (which unfortunately had a negative result) was ordered. Only after a second test came back with a positive result was the case reported to health department investigators. With a highly transmissible infection such as measles, every day is crucial for successful containment. Even when the disease is only suspected, it should be immediately reported so that health authorities can get the jump on contact tracing (eg, the airline passengers on the patient’s flight and care providers and patients in the emergency department), identifying susceptible individuals, and Received and accepted 31 January 2011. Potential conflicts of interest: none reported. Correspondence: Stephen M. Ostroff, MD, Pennsylvania Department of Health, Rm 933, 625 Forster St, Harrisburg, PA 17120 ([email protected]). The Journal of Infectious Diseases 2011;203:1507–9 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected] 0022-1899 (print)/1537-6613 (online)/2011/20311-0001$14.00 DOI: 10.1093/infdis/jir125