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3 Fitzgerald Health Education Associates, Inc., March 2015 fhea.com The Problem of Falling Vaccination Rates Widespread vaccination is essential because it con- fers herd immunity and protects those who are un- able to be vaccinated, such as children under 12 months of age and those with weakened immune systems. A recent outbreak in New York involving 9 children and 11 adults provides insight into who is affected during an outbreak. Of the children, 4 were too young to receive MMR (<1 year), 3 were less than 4 years old and therefore received only 1 MMR dose (which highlights the reason a second MMR dose is given), and 2 were not vaccinated by parental choice. 4 To exploit herd immunity as a means for preventing transmission of measles, ap- proximately 95% of the herd must be immunized against measles. An analysis of publicly available data from the amusement park outbreak in Califor- nia noted that "MMR vaccination rates among the exposed population in which secondary cases may have occurred might be as low as 50% and likely no higher than 86%." 5 There are several reasons people do not get vac- cinated, including lack of access to healthcare, but in the most recent outbreaks, much attention has focused on vaccine-hesitant parents who wish to delay or forgo vaccinations for their children out of safety concerns. This is an area where NPs can in- tervene. By listening to parents' concerns and pro- viding education about the safety of immuniza- tion, NPs can help parents understand the benefits of vaccination. The Immunization Action Coalition has developed an excellent resource on strategies for communicating with parents who are consider- ing not vaccinating their children and responding to their questions and concerns ( Quick Answers to Tough Questions ). Recognizing Measles Clinicians should suspect measles in patients who present with fever and rash and clinically compati- ble measles symptoms, and should ask if these pa- tients have recently traveled abroad, had contact with a person with fever and rash, or had contact with an international traveler. 6 Patients with measles usually present to acute care with prodro- mal symptoms 7 to 21 days after exposure (incuba- tion period). Symptoms include fever, cough, coryza, and conjunctivitis (copious clear discharge), as well as generalized lymphadenopathy. Pharyngi- tis is usually mild without exudate. Measles is often missed because the early illness looks like a variety of other viral illnesses that man- ifest with nasal discharge, fever, and watery eyes. Koplik spots, which can be observed in some pa- tients, are a potential means for making an earlier diagnosis. 7 Considered pathognomonic for measles, Koplik spots are white spots with blue rings held within red spots on the buccal mucosa that appear about 2 days pri- or to the onset of rash (Figure 1). The characteris- tic maculopapu- lar rash appears 3 to 4 days after the onset of the prodromal symp- toms; it begins on the head and spreads downward, and often coalesces to general- ized erythema (Figure 2). Immunocompromised patients sometimes do not develop the rash. Pa- tients are considered to be contagious from 4 days before to 4 days after the rash appears. 6 When measles is suspected, it is essential to isolate the patient promptly and implement air- borne precautions to avoid disease transmission; immediately report the suspected measles case to the health department; and obtain specimens for testing, including viral specimens for geno - typing. Clinical Update: Measles Figure 1. Koplik spots. Image courtesy of CDC/Heinz F. Eichenwald, MD Continued on page 5 C ontinued from page 1