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When a case is suspected, public health employees launch an exhaustive investigative process that one official called "real gumshoe work."
Employees at the Clark County Department of Public Health have assumed hybrid roles as they attempt to keep tabs an ongoing measles outbreak: part detective and part health monitor.
Their goal is to contain the contagion.
“This is a real gumshoe work,” said Dr. Alan Melnick, public health director of the southern Washington county. “Every time we get a new case, we have to repeat the process—find out where the infected person might have been and who they might have exposed, and then track those folks down. There’s a lot of investigative work that goes into this.”
County officials first became aware of the resurgence of measles in early January, after a patient presented with an active case of the illness at an urgent-care center. (Measles is a “notifiable disease” in Washington state, meaning that doctors and health professionals are required by law to report confirmed active cases to the local health department.)
Since January 1, health workers in Clark County have confirmed 53 cases of measles, 51 of them in children. There has been one other case in Washington state during that period, in Seattle, while there have been four confirmed cases in nearby Oregon.
The county health department's work goes far beyond simply examining test results from patients. Once a measles case is suspected, public health employees launch an exhaustive investigative process that begins by interviewing the patient (or, in many cases, the patient’s parents) to find out where the infected person may have gone while he or she was contagious.
That part of the investigation can be tricky, Melnick said, because the first symptoms of measles mimic the flu or the common cold—meaning most people have no idea they’ve contracted the virus and thus are unlikely to restrict their movements at the time they’re most likely to pass it on to others.
“You become contagious from measles with the first symptoms, while the rash takes several days to develop,” he said. “So you’re contagious when you have the runny nose, the cough, a fever or pink, red eyes, which are all really common this time of year. We interview the family to find out when the child developed those symptoms and when the rash followed, because you’re also contagious up to four days after the rash appears. That total period can be up to eight days.”
The next step depends on where the patient traveled during that contagious period. If it’s a public place—confirmed measles patients in the county have been to Costco, Trader Joe’s, a Portland Trail Blazers’ basketball game and the Portland International Airport—the department will launch an informational campaign to let visitors know that they may have been exposed.
“If it’s a school, we will exclude all unimmunized children as well as unimmunized susceptible staff from school for 21 days, which is the end of the incubation period,” Melnick said. “We will also look to see what bus routes the child may have been on, because a bus route can include kids from different schools.”
If the infected patient visited a health clinic, officials will get a list of patients who were in the waiting room and follow up with each of them. If any are susceptible to the virus—including pregnant women, unvaccinated children, or infants—antibodies can be administered within a certain time period. If it’s too late for that, health workers will place the exposed people on “active monitoring” and stay in contact with them for the full three-week incubation period.
At its peak, the health department was actively monitoring more than 200 people, Melnick said, though the number has dropped since then. It’s an exhaustive process but one that’s necessary to contain a highly contagious illness in a county where less than 85 percent of kindergartners received the recommended slate of shots before starting school last year. That practice is legal in Washington, where state law allows parents to abstain from vaccinations for religious as well as personal and philosophical reasons. (Proposed legislation would remove those exemptions from the measles vaccine.)
“This disease is so contagious. If we don’t control it and people go in public with symptoms, we’d have a lot more than 53 cases right now,” he said. “One person surrounded by 10 unimmunized folks will infect nine of them. You can be contagious with measles and leave a room, and susceptible people who go into that room two hours later will get the disease. We have large populations of unimmunized folks here. This stuff keeps me up at night.”
Both the county and the state declared a state of emergency in January, allowing the public health department to summon help from other jurisdictions. Melnick said the county currently is receiving help from health officials from Idaho, the federal Centers for Disease Control and Prevention, the state’s medical reserve corps and the Washington State Department of Health, among others. So far, the containment operation has cost the county almost $400,000, and has diverted dozens of county health employees from their normal duties, including restaurant inspections and water and septic tank testing.
“Other communicable diseases aren’t taking a holiday while we’re dealing with measles, and we’ve got people pulled from their work on those things,” Melnick said. “It’s kind of all hands on deck.”
The bright spot, if there is one, is skyrocketing vaccination rates among both children and adults in Clark County. Last year in the second week of February, 219 children and 25 adults received the measles vaccine; this year, 1,002 children and 638 adults got the shot.
But “this is a lousy way to get vaccination rates up,” Melnick said. “We should have controlled this years ago.”
For now, exposure sites are dropping, and Melnick is “cautiously optimistic” that the outbreak is contained. Addressing the situation is a complex and collaborative process, he added, which would have been easier with additional funding.
“The public should know that the response to this, and the work to prevent it, takes funding. We need to have an adequate public health system,” he said. “The staff I have been working with, both from here and from neighboring jurisdictions, are missing their families and doing a lot of work. It’s a privilege to work with the staff here.”
Kate Elizabeth Queram is a Staff Correspondent for Route Fifty and is based in Washington, D.C.