by Muntu Davis, MD, MPH, and Jeffrey Duchin, MD

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This post is published with permission from Big Cities Health Coalition. Visit Big Cities Health Coalition and the Front Lines Blog for more information about the work they’re doing to improve population health.

The US Centers for Disease Control and Prevention (CDC) has reported more than 1,200 confirmed cases of measles in 2019, the most in any year since 1992. Measles was declared eliminated in 2000; however, the US is now on the verge of losing that designation.                Measles Local Health Departments

Local health departments are on the front lines investigating possible measles cases and responding to outbreaks when they occur, and the large urban health departments that make up the membership of the Big Cities Health Coalition are no different. New York City, where there have been over 600 cases of measles, reports the department has deployed 400 staff during their response, with the local cost reaching more than $2 million. This is not unique to New York. Outbreaks result not only in severe illness, but also place significant pressure on already stretched financial and human resources in public health departments, and tight local budgets often have to find dollars to support this important on the ground work.                                        Measles Local Health Departments

The current outbreak has largely been linked back to a handful of travelers who were exposed to measles abroad prior to coming back to the US. Such exposures can lead to outbreaks if and when those who are ill – or don’t yet know they are ill – come in contact with pockets of unvaccinated people in a community. Measles is a highly contagious disease, and the majority of this year’s cases have occurred in people who were not vaccinated. In some communities, the spread of false information about vaccines has impacted overall immunization rates, contributing to the severity of some of the localized outbreaks.

Los Angeles County

In April 2019, Los Angeles County Department of Public Health (LACDPH) responded to five local cases associated with an outbreak – all were unvaccinated and could be traced to an index case infected during international travel. For all suspected and confirmed cases, regardless of jurisdiction, public health officials interview each case to establish where they were and with whom they had been in contact, determining who else might be at risk for contracting the illness, and then follow up with those people, the case contacts. For example, during this outbreak, one of the confirmed cases went to the UCLA campus for multiple days attending classes, and another visited Cal State University Library, leading to over 1,800 known contacts from just two measles cases.          Measles Local Health Departments

LACDPH worked with health services from both universities to assess the risk for the 1,800 contacts – important and valuable support – but the department also had to track down hundreds of people who were in public spaces visited by the confirmed cases when they were infectious. This included restaurants, ride shares, health care workers, and friends and family. Many members of the public self-identified as being in contact and made themselves known to officials, another great help to health officials. 

To prevent further spread of measles, quarantine orders were issued to university contacts (nearly 350 people) and all those who had visited Cal State’s Library (more than 700 people who could be identified) while determining whether or not they at risk for developing measles. This was a labor intensive process, taking approximately 4,500 staff hours and costing between $1,000 – $2,000 to investigate each person that was a contact. With nearly 3,000 contacts identified, the health department invested between $3 and $6 million, in addition to the unknown costs of lost wages due to quarantine and university staff costs.

LACDPH communicated with diverse audiences to ensure the local community had accurate, clear information on the outbreak, so people could understand if they were at risk and what to do if they were exposed. Telebriefings were organized and health notices put up in key locations, such as the airport.  Health information was translated into 11 foreign languages and the department worked with trusted local partners such as churches or community centers to help spread the word about measles.

Seattle & King County

A measles outbreak was also reported in Seattle & King County in April. One infected traveler passing through Sea-Tac airport resulted in nine cases over a two-month period, leading to at least 37 locations being identified by Public Health – Seattle & King County as places where people may have been exposed.                            Measles Local Health Departments

Detailed investigations were undertaken to reconstruct the activities and locations of cases during the infectious period. Ninety potential cases were investigated, leading to six confirmed cases of measles, and 397 close contacts were identified for active monitoring. This entailed a health official contacting the person on a daily basis to see if they had started to develop symptoms. Extensive messaging and materials were produced for health care facilities, schools, and businesses to try to limit the spread of disease. This has cost Seattle & King County over $280,000 to date, in addition to the costs borne by local businesses, service providers and to those who developed measles. The outbreak also strained staff resources, with some staff unable to maintain their routine responsibilities.

[bctt tweet=”The experiences of @lapublichealth and @KCPubHealth demonstrate the local impact that even a handful of measles cases can have. We must support local health departments & ensure they have funds and resources ready for future outbreaks. @LAHealthOfficer @DocJeffD @BigCitiesHealth” username=”@JPHMPDirect”]

Policy Response

Washington state was home to a legislative response, with the state passing legislation to remove philosophical or personal objection exemption for the measles, mumps and rubella vaccine. Further, at the federal level, local Congresswoman Kim Shrier (WA-08) introduced the VACCINES Act (Vaccine Awareness Campaign to Champion Immunization Nationally and Enhance Safety) to fund research on vaccine hesitancy.                          Measles Local Health Departments

The federal government is a key partner to local and state officials in any response, policy and monetary resources are crucial components to combating these measles outbreaks. The US Congress each year appropriates dollars for the 317 immunization program, which provides funds health department infrastructure to provide vaccines for those most in need. The budget passed by the US House includes a $39 million increase for FY20 (which starts Oct 1) to ensure high vaccination coverage levels in response to the measles outbreak.                        Measles Local Health Departments

In recent weeks, a number of bills have been introduced in the Congress related to vaccines hesitancy and surveillance that would help move us more towards the prevention rather than response end of the spectrum. In addition to the VACCINES Act, the Lower Health Care Costs Act authorizes a national campaign to increase awareness of vaccines and combat misinformation, and the Vaccines and Promotions Act directs the Department of Health & Human Services to assess the impact of social media in accelerating or mitigating public health crises.

These bills propose meaningful activities, and should they be enacted, federal dollars will need to be appropriated to support them. The experiences of Los Angeles County and Seattle & King County demonstrate the local impact that even a handful of measles cases can have – we must support local health departments and ensure they have the funds and resources to stand ready for future outbreaks.

Follow along with the work of Public Health – Seattle & King County on their Public Health Insider blog.

Related Reading in the Journal of Public Health Management and Practice:

• Health Departments’ Experience With Mumps Outbreak Response and Use of a Third Dose of Measles, Mumps, and Rubella Vaccine
• Cost Analysis of 3 Concurrent Public Health Response Events: Financial Impact of Measles Outbreak, Super Bowl Surveillance, and Ebola Surveillance in Maricopa County
• CDC Guidance for Use of a Third Dose of MMR Vaccine During Mumps Outbreaks
• Effects of California Assembly Bill 2109 in Low Vaccination Rate Counties: Are We Looking at the Right Variables?

More from Big Cities Health Coalition:

• Investing Early to Prevent Hepatitis A Outbreaks Among People Living Homeless
• Improving Health for African American Women in Columbus, Ohio: Interview with Dr. Mysheika Roberts
• A Standardized Approach is Needed to Address Social Determinants of Health
• Now Is the Time to Tell Policymakers that Trauma Matters to Our Health
• Wrapping Up the Highs and Lows of Urban Public Health in 2018
• New Report: Shortage of “Disease Detectives” in Local Health Departments Puts Cities at Risk
• Let Schools Be Places for Learning—Not “JUULing”
• Child Development-Community Policing: How One Local Health Department Joins Local Police on the Front Line in the War on ACEs 

You Might Also Enjoy These Posts:

• Measles in New York: The Outbreak, the Response, and the Potential Unintended Consequences
• Anti-Vaxxers: A Threat to Our Future
• We R-Naught Ready for an Epidemic

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Muntu Davis, MD, MPH, serves as the Los Angeles County Health Officer. With a specialty in Family Medicine, Dr. Davis practiced extensively in urban and rural primary care and urgent care clinics in Northern and Southern California. He has served as Alameda County Health Officer since 2009 and as the public health director for the past six years. Prior to working at the ACPHD, he worked in the Immunization Branch of the California Department of Health Services on pandemic planning and education on febrile rash evaluation.

 

Jeffrey Duchin, MD, is the Health Officer for Public Health — Seattle & King County. He served for over 15 years as Chief of the Public Health’s Communicable Disease Epidemiology & Immunization Section. Dr. Tuchin is trained as a Medical Epidemiologist in the Centers for Disease Control and Prevention’s (CDC) Epidemic Intelligence Service (EIS) after which he completed the CDC’s Preventive Medicine Residency program. He worked for the CDC in the National Center for Infectious Diseases, the Division of Tuberculosis Elimination, and the Division of HIV/AIDS Prevention before joining Public Health – Seattle & King County.