Episode 5: The Monster That is Measles

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For informational purposes only, please discuss measles, and your personal risk if infected, with your physician. Feel free to show them this podcast.

Update: Since recording this episode, a second child has died from measles in Texas.

What is Measles?

Measles, also called rubeola, is a preventable, highly contagious, acute febrile viral illness. When someone says acute febrile illness, that means it's a non-specific illness that comes on all of a sudden with a fever. Measles is caused by the measles virus (the virus is actually called the measles virus) and it kills a lot of people in Africa and Southeast Asia, An estimated 107,500 people died from measles in 2023 – mostly children under the age of five years, despite the availability of a safe and cost-effective vaccine. Now don't confuse measles/rubeola with rubella. Rubella—also called German measles—is a different disease caused by a different virus.

Back to measles.

Epidemiology

Epidemiology is the study of the distribution, determinants, and control of health and disease in populations. The distribution and control of measles varies worldwide and depends on a region's immunization levels. Before implementing widespread vaccination programs, measles accounted for ~2.6 million deaths each year. According the CDC's 2024 report, Progress Toward Measles Elimination, coordinated international vaccination programs prevented an estimated 60 million measles deaths between 2000–2023; from 800,062 in 2000 to 107,500 in 2022. An effective vaccine has been available since the 1960s, and all countries offer measles-containing vaccine (MCV) in their immunization programs. Measles kills more children than any other vaccine-preventable disease. Predominantly in areas with low vaccination rates, particularly resource-limited settings. And of course now this is happening in America, resource rich but overrun with antivax disinformation.

Measles is a reportable disease in most nations, including the US, which means it must be reported to public health authorities when it is diagnosed. This allows health officials to track the spread of the disease, identify outbreaks, and take necessary measures to prevent further transmission. Unfortunately the current administration is firing the people who handle this so who the fuck knows how long we'll have access to this information. Now, 25 years ago, in 2000, public health officials declared the elimination of measles from the US because we had gone one year without continuous measles transmission. However, outbreaks continue to occur through imported disease and transmission among unvaccinated groups of children as we can see all over the country right now but especially in West Texas. Which has 279 cases with 36 people hospitalized, one confirmed death of an unvaccinated 6 year old child, and another suspected death under investigation. Antivax movements have resulted in decreased vaccination rates and each year we see bigger outbreaks and more of them. Unless we can stop the disinformation campaign by antivaxxers, Americans are going find out exactly how bad measles can be.

How is Measles Spread?

The measles virus occurs only in humans and has no animal reservoir. The virus is highly contagious, with each case capable of causing 12 to 18 secondary cases among susceptible populations. Epidemiologists call this number R0 – the reproduction number – pronounced "R naught" and it refers to the average number of secondary cases of an infectious disease that arise from a typical case in a totally susceptible population. R0 describes the intensity of an infectious disease outbreak. The higher the R0, the more contagious a virus is. So the reproduction number of measles, the R0, is 12-18. The R0 of Ebola is between 1.5 and 2.0. The R0 of the Omicron variant of SARS-CoV-2 is 9.5. You think SARS2 is really contagious and you're right, but just look at how much more contagious measles is. Measles is no joke.

OK, so it's really contagious and it's transmitted from person to person and is truly airborne,

meaning it spreads through the air when an infected person coughs, sneezes, breathes, or speaks and the virus can remain infectious in the air for up to two hours. The incubation period is 10 to 14 days, although longer periods have been reported. Unvaccinated young children and pregnant women are at high risk for contracting measles. An infected person is most contagious in the four days before and four days after the rash develops.

What Are the Symptoms of Measles?

• High fever (up to 104°F (40°C) or higher

• Runny nose

• Cough

• Pink eye

• Tiny white spots inside the mouth

• Feeling crappy in general (malaise)

• Red rash appears after other symptoms

Measles is characterized by the three “Cs”: cough, coryza (a head cold), and conjunctivitis (inflammation of the clear membrane covering the white part of the eye; AKA pink eye). Measles is also known for Koplik spots, small white papules on the lining of the inner cheeks that appear a day or two before the red rash, although they are not always seen. The fever precedes the rash and usually gets worse when rash appears. The rash appears first on the face and spreads down over the body. Uncomplicated measles typically resolves a week after the rash onset.

A lab blood test called complete blood count may show low white blood cell (WBC) count called leukopenia. White blood cells including lymphocytes (mainly B cells and T cells) are important in fighting infections and in measles lymphocyte count may be especially low (lymphopenia). The complete blood count may also show abnormally low platelet levels (thrombocytopenia). Platelets, also called thrombocytes, are small blood cells that help stop bleeding by forming clots. Low levels of these can indicate infection. Children with measles may also exhibit electrolyte imbalance from dehydration.

How is Measles Diagnosed?

When not suspected it's hard to diagnose until after the rash shows up because it starts off like a lot of other illnesses. This is also when the person is most infectious so it's very easy to spread before you know you have it.

When suspected early because of possible exposure during an outbreak, a lab test called PCR—polymerase chain reaction—is usually used to diagnose measles as antibody tests can give false negatives if done too early. If there is viral RNA in your system, PCR can takes what's in your sample and amplify it enough to be detectable. The diagnostic test with the highest sensitivity is the plaque reduction neutralization assay (PRNT), but it is labor intensive and not practical. When viruses infect a layer of cells in a dish, they cause something called plaques - a hole in the otherwise continuous monolayer of cells. Antibodies against the virus can prevent this. PRNT utilizes the ability of a specific antibody to neutralize a virus, in turn, preventing the virus from forming plaques in the cell monolayer.

Measles Disease Development

The inhaled virus from the exposed droplets initially infects the respiratory tract’s lymphocytes (B and T cells), dendritic cells (specialized antigen-presenting cells that play a crucial role in initiating and regulating immune system), and alveolar macrophages (specialized immune cells found in the alveoli (tiny air sacs) of the lungs). Infected lymphocytes, macrophages, and dendritic cells then spread the virus to multiple organs and eventually the virus enters the blood. During this 10–14-day period of virus replication and systemic spread, interferon is suppressed and the infection is clinically silent. This is the incubation period. During this time, the virus that's in the dendritic cells and lymphocytes in the respiratory tract, moves to the lung's epithelial cells, which are shed and expelled during coughing and sneezing, but also during breathing and talking. This is how the infections spreads. As I mentioned before, you are infectious four days before the rash appears and you remain infectious for four days after. This means you are infectious before you have any symptoms at all (2-3 days depending on time from first symptoms to rash). Then symptoms begin with the initial inflammation response that leads to coryza, conjunctivitis, and cough. The appearance of fever coincides with the appearance of virus in the bloodstream (viremia). The skin rash occurs after the virus has spread systemically and is due to an accumulation of lymphocytes around blood vessels (perivascular lymphocytic infiltrates). Clearance of viral RNA from blood and infected tissues is slow and occurs over weeks to months after resolution of the rash

During the early, non-specific symptoms (prodromal phase), the measles virus reduces your immunity by suppressing interferon production. Continued and increasing viral replication then triggers both adaptive immunity in which B cells produce antibodies (AKA humoral immunity) and cellular immunity involving activation of phagocytes, antigen-specific cytotoxic T-cells, and the release of cytokines. The initial antibody response consists of IgM antibodies, which are detectable 3 to 4 days after the rash appears and can persist for 6 to 8 weeks. Ig stands for immunoglobulin and immunoglobulin M is the first antibody produced in response to a new infection. After that, IgG antibodies are produced and are the most long-lasting and protective antibodies produced in response to a vaccine or infection. The measles diagnostic antibody test looks for IgM. The test to determine if you are still immune after vaccination looks for IgG.

One nasty thing the measles virus does is to suppress your immune responses and that can last 2-3 years. This causes increased susceptibility to secondary bacterial and other infections and has been shown to increase the number of infection-related deaths in children during, and after they've recovered from, measles. The mechanisms causing this are unclear and require further study. The result, though, is clear: increased susceptibility to secondary infections, leading to most of the morbidity and mortality associated with measles as well as increased mortality from other infectious agents.

The neutralizing IgG antibodies against hemagglutinin from natural infection are responsible for lifelong immunity as they block host cell receptors from binding to the virus. Vaccine-induced immunity is not lifelong so get your boosters or get revaccinated people!

Let's Talk About Complications from Measles

Most children get better with no lasting effects. But measles can lead to serious complications or even death and there's no predicting who will come down with any of these.

Common complications:

• Middle ear infection that can cause hearing loss

• Pneumonia

• Infection of the upper airway with trouble breathing and cough (croup)

• Diarrhea

Hospitalization. You will see everywhere you look, this statistic: About 1 in 5 unvaccinated people in the U.S. who get measles is hospitalized. That is 20%. Fun fact! In 2024, 285 people became sick with measles in the US and 40% (4 in 10) required hospitalization. That's twice as many as expected. I don't put much stock in the "1 in 5" stat I keep seeing but let's see how the outbreak in Texas turns out. Also, most of the people who developed measles had not been vaccinated against the disease, or did not report being vaccinated.

Pneumonia. As many as 1 out of every 20 children with measles gets pneumonia, the most common cause of death from measles in young children.

Encephalitis. About 1 child out of every 1,000 who get measles will develop encephalitis (swelling of the brain). This can lead to convulsions and leave the child deaf or with intellectual disability.

Death. Nearly 1 to 3 of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.

Complications during pregnancy. Pregnant women are at increased risk of serious complications, including pneumonia and hospitalization, and their babies face potential risks like miscarriage, stillbirth, premature birth, and low birth weight.

Long-term complications

Subacute sclerosing panencephalitis (SSPE) is a very rare, but fatal disease of the central nervous system. It results from a measles virus infection but doesn't show up until 7-10 years after a person fully recovers from measles. Those who get measles before they are two years old are at higher risk of SSPE.

• Since measles was eliminated in 2000, SSPE is rarely reported in the United States. Yeah, so that's not true anymore, thanks antivaxxers.

How Do You Treat Measles?

There is no antiviral therapy for measles; treatment is supportive, meaning you just try to keep the person alive while their body fights the infection. The good news with measles is that the incubation period is so long, our bodies have a lot of time to fight it before we start getting sick, and that helps. That's why for a lot of people measles is no big deal. Unfortunately that doesn't mean the immune suppression that happens won't result in a different infection killing someone who has a mild case of the measles, especially children and pregnant women.

Supportive care includes controlling the fever, prevention, and correction of dehydration, and infection control measures including appropriate isolation.

Measles complications should be identified early and appropriate therapy initiated.[14]

You've heard RFK spewing loads of misinformation about vaccines and measles in general and one of the things he's said is that vitamin A, MAHA fries, and cod liver oil treat measles. I will not link him here. No fucking way he gets views from my page. You can google it if you need evidence that he speaks in public about measles. It'll come up. And funny thing...he never produces any evidence for the bullshit he spews. No he doesn't. That's because there isn't any. Now, let's clear this up, please. Beef tallow does not treat measles. Not even a little bit. Zero truth there. As for vitamin A, that I have to clarify because it's not just total bullshit. I think he heard about something that is recommended in places where vitamin A deficiency is a problem and without any understanding decided to tell everyone to take Vitamin A for measles. He clearly doesn't understand what's happening and everyone then runs out in Texas and buys all the vitamin A and cod liver oil. Cod liver oil is a source of vitamin A, but please hear me when I say, vitamin A does not treat measles. Giving a malnourished child vitamin A, in countries where that is a serious health issue is important to improve the child's health so their body can fight the infection, but it does not treat measles. If you have a vitamin A deficiency, taking vitamin A when you have measles can help your body fight the measles, as will upping your other vitamins and minerals if you are malnourished. But vitamin A does not treat measles. In fact you can get sick from too much vitamin as we now see in children in Texas with vitamin A toxicity from trying to treat measles.

This is analogous to someone claiming antibiotics treat measles because they don't understand what's happening when someone with measles is prescribed antibiotics. Antibiotics do not kill viruses. They do NO GOOD at all against viruses, they work against bacteria. However, if you have measles and get a secondary infection with a bacteria, say for example in your lungs, you will be prescribed antibiotics to treat that secondary infection!! And you should take them for that secondary infection because they could save your life. That doesn't mean the antibiotics are treating the measles. They aren't. They are treating the bacteria you have on top of your measles. Are we all on the same page here?

Excellent. Let's move on to the vaccine.

Is the Measles Vaccine Safe and Effective?

The FDA, specifically, The Center for Biologics Evaluation and Research (CBER) regulates vaccine products. They undergo a rigorous review of laboratory and clinical data to ensure their safety, efficacy, purity, and potency. Vaccines approved for marketing may also be required to undergo additional studies to further evaluate the vaccine or address specific questions about the vaccine's safety, effectiveness, or possible side effects. Licensed vaccines have been through rigorous testing. We might want to keep funding these agencies. Just sayin'.

OK, so YES the MMR vaccines in use are SAFE! The current triple virus vaccine has been used for over 40 years and we know it's safe and effective. We know for a fact it doesn't cause autism. Please listen to my series on vaccine safety, there is an episode on vaccines and autism and an episode on Andrew Wakefield whose fraudulent science started this whole vaccine/autism bullshit. It will infuriate you. It was all bullshit and a disciplinary panel found Wakefield guilty of serious professional misconduct on 30 charges and he lost his medical license. Then he fled to Texas. You can't make this shit up.

So I know the vaccine is safe and effective, let's talk about what you need to know.

The WHO has a great page on the history of measles and the measles vaccine if you're interested. Long story short, a measles outbreak at a boarding school near Boston In 1954 gave doctors at Boston Children’s Hospital a chance to isolate the measles virus from infected students' throat swabs and blood samples. Physician Thomas Peebles took a sample from 11-year-old David Edmonston and was able to culture measles from it. That means he could grow it in cell culture then isolate it. Known as the Edmonston-B strain, this virus was then cultivated to become the measles vaccine by Peebles's boss, John Franklin Enders, often called the father of modern vaccines. This strain is still the basis of most modern measles vaccines. To become a vaccine scientists had to attenuate the virus by repeated culture in cells until they got some that lost its ability to make people sick. Then they used that one to make the vaccine. This is why it's called a live attenuated virus vaccine. Attenuated means it won't make you sick.

Individual measles vaccines were licensed in the US in 1963, mumps in 1967, and rubella in 1969. The combination measles, mumps and rubella vaccine M-M-R™ was licensed in 1971, with a modified vaccine containing the more immunogenic rubella strain RA 27/3 (M-M-R II) licensed in 1978.

Sidebar about mutations: Now, you might be thinking that the virus is going to mutate and make the vaccine ineffective like what happened and will continue to happen with the SARS-CoV-2 virus and vaccines, but that's actually not the case with the measles virus. A 2021 study published in Cell Reports Medicine shows that for the virus to escape vaccine-induced immunity it would have to experience a whole bunch of very specific mutations all at the same time. That's really unlikely and it makes sense considering measles has been replicating freely in humans for years in lots of places that don't have the resources for mass vaccination efforts and we have not seen any measles mutations that render our vaccines ineffective. So this at least is not something we need to worry about.

What's in the MMR Vaccines?

MMR vaccines contain a combination of live attenuated measles, mumps, and rubella virus vaccines. There are two MMR vaccines available in the United States: M-M-R II and PRIORIX and they are considered interchangeable. M-M-R II has been licensed in the US since 1978 and has been used extensively in >75 other countries, with >803 million doses distributed globally as of May 2021, we don't have newer stats on its use. M-M-R II is licensed as M-M-RVaxPro, in the UK (since 1997) and in the EU (since 2005). PRIORIX was licensed in the EU in 1997, in the UK in 2006, and in the US in 2022. Those can be given to people of all ages.

MMRV vaccine contains a combination of live attenuated measles, mumps, rubella, and varicella (chickenpox) virus vaccines. Known as ProQuad, this vaccine was licensed for use in children 12 months through 12 years of age in the US in 2005 and in the EU in 2006. Varicella is not on the UKs routine childhood immunization list so this has not been licensed yet in the UK. The Joint Committee on Vaccination and Immunization (JCVI) has recommended a vaccine against varicella to be added but the Department of Health and Social Care (DHSC) will make the final decision at some point. Just as an aside...ProQuad was only licensed for use in children who are 12 months through 12 years of age because it hasn't been studied in older kids yet. This is how this works. We don't license vaccines for use in people unless we have studied it. Our system works guys. It does.

OK, so globally, the most common MMR vaccines used today are M-M-R II (aka M-M-RVaxPro) and PRIORIX.

Now let's talk about what's actually in these MMR vaccines. My episode on What's in Vaccines goes in-depth on vaccine components so here I'll keep it short. Possible vaccine components include:

• An Antigen—the pathogen or part of the pathogen—in this case three viruses—that elicits the immune response. All vaccines need this.

  • M-M-R II (aka M-M-RVaxPro) contains a live attenuated strain of measles virus, derived from Enders' attenuated Edmonston strain; the Jeryl Lynn™ (B level) strain of mumps virus; and the Wistar RA 27/3 strain of live attenuated rubella virus.

  • PRIORIX contains the attenuated Schwarz strain of measles; the RIT 4385 strain of mumps (derived from Jeryl Lynn strain); and Wistar RA 27/3 strain of rubella.

• An Adjuvant—a substance that enhances the body's immune response to an antigen—might be needed to increase the effectiveness of the antigen.

  • Measles vaccines don't need an adjuvant so they don't contain any.

• One or more stabilizers to help the vaccine maintain its effectiveness while the vaccine is made, stored, and moved. MMR vaccines do need stabilizers:

  • M-M-R II (aka M-M-RVaxPro) contains sorbitol, sucrose, and hydrolyzed gelatin.

  • PRIORIX contains lactose, mannitol, and sorbitol.

• A Preservative to protect the vaccine from outside bacteria or fungus.

  • Lyophilized MMR vaccines do not need preservatives so they don't contain any.

• Excipients: Excipients are byproducts of manufacturing with no medicinal properties and are taken out after production. The very small amounts of these ingredients that remain in the final product are so small there's no way they could be harmful. These can include antibiotics to prevent bacterial contamination (e.g., neomycin); egg proteins if viruses are grown in chicken eggs; cell culture medium—the liquid cells are grown in—if viruses are gown in cells; and killing or inactivating ingredients—something to kill or inactivate viruses making them unable to replicate (these are not live).

  • M-M-R II (aka M-M-RVaxPro) contains minute levels of recombinant human albumin (≤0.3 mg), fetal bovine serum (<1 ppm), approximately 25 mcg of neomycin and other buffer and medium ingredients.

  • PRIORIX contains minute amounts of neomycin.

• Both lyophilized vaccines are reconstituted in sterile water.

• vaccines never contain: aborted fetus parts, cow hearts, pig ligaments, worm ovaries, or anything else not listed here.

Package inserts for both vaccines:

Package-Insert-MMRII.pdf

Download PDF • 392KB

Package-Insert-PRIORIX.pdf

Download PDF • 333KB

 Some things to note about measles vaccination:

• There have been a tiny number of cases of allergic reaction to vaccines containing gelatin (about one case for every 2 million doses of vaccine). People with a known allergy to gelatin should talk to their doctor about receiving vaccines containing gelatin. And that goes for any components listed that you have an allergy to, like eggs. Talk to your doctor if you have any allergies at all to see if a specific vaccine is safe for you.

• Young infants born to mothers with acquired immunity are protected from measles due to passive antibody transfer, but as these antibodies wane, they become susceptible.

• Under certain conditions, the vaccine may be recommended for children < 1 year of age when at high risk of exposure for measles or travelling to an area where measles is common, measles vaccine alone or as MMR may be given as early as 6 months of age. However, if the vaccine is given before the child's first birthday, such children should receive the regular two dose MMR series (as normally scheduled) after the first birthday because immunity from the first dose will be short lived.

• Right now measles is resurging all across the country so unlike before, when it was basically eradicated, we now need to talk about getting boosted or revaccinated completely depending on how long it's been since we were vaccinated against measles.

• You can get the levels of anti-measles IgG antibodies in your blood tested (determine antibody titer) to see if you're immune still, and that might be covered by your insurance. If it's not covered or if you just don't want to do it because you hate needles and blood draws are way worse than vaccines to you like they are to my son, you can skip getting the titer done and get a booster or the two shot series depending on how long it's been since you got the last shot. If you can get vaccines, getting it again won't hurt you! TALK TO YOUR DOCTOR.

• Studies show that vaccine-induced immunity to measles starts to wane after 15 years, especially in places where measles isn't regularly circulating. That would be America. I skipped the titer and got the two dose series. If you can get the vaccine, it's not going to hurt you to get it again. Measles can have terrible long term health problems and will suppress your immune system for a long time. You don't want it.

• MMR vaccines contain live weakened virus and studies show that this virus is not transmitted between people. So you can't "transmit" vaccination to someone nor can you give them measles by "infecting" them with the vaccine strain. Won't happen.

• And finally, there are people in your community who cannot get vaccinated including pregnant women, who are especially vulnerable to complications, and those with compromised immunity like those going through cancer or other immune depressing diseases. Don't be a dick. Honor the social contract that is implicit in being part of a community and get vaccinated. When unvaccinated people are surrounded by vaccinated people they are very well protected. Those around you might save your life sometime by honoring their social contract in other ways.

Thanks for listening! Don't forget to check out my series on vaccine safety including an episode on vaccines and autism and one all about Andrew Wakefield.

Until next time, stay healthy, stay informed, and spread knowledge not diseases.