The baby had been brought into our clinic to rule out measles. That is, the baby, who was living in a shelter, had developed a rash, and the mother was concerned because she thought there had been some cases of measles in the shelter.
The resident, or doctor in training, thought that the baby looked good. As I was going into the exam room with her to see the baby myself, the resident spoke to me thoughtfully, reviewing some recent patients with measles she had cared for in the hospital, including a young child in the intensive care unit, and comparing them to the baby we were about to examine.
And as I examined the baby myself, my mind was still reeling because a pediatrician in training in New York City in the year 2019 had matter-of-factly reviewed several hospitalized children with measles, children she had seen herself over the past few months as part of the current outbreak of more than 400 cases reported in New York since October, mostly among ultra-Orthodox Jews.
I never diagnosed or even saw a case of measles during my own training in Boston in the 1980s, just as I never diagnosed a case of polio, or diphtheria or smallpox. They were the diseases of the past, at least in Boston.
“I learned about measles for the most part from books and from journal articles,” said Dr. Adam Ratner, the chief of pediatric infectious diseases at New York University School of Medicine and Hassenfeld Children’s Hospital. He had seen measles before, he said, because he was practicing in northern Manhattan in 2014, when there was a small outbreak.
That he had seen measles at all probably put him in the minority for pediatricians of his generation, trained in the United States, and he said the experience was useful when he talked to the first-year medical students about important viruses.
But in the current outbreak, Dr. Ratner said, he has seen many more cases of measles in the last six months than in his entire life, and has come to understand it as a far more varied disease. “There are little pieces of understanding a disease that you just know when you take care of a whole bunch of kids,” he said. For example, he has been seeing children with “these insane dry cracked lips,” he said.
Dr. Jennifer Lighter, a pediatric epidemiologist at N.Y.U. Medical Center, said that she and her colleagues have made tremendous efforts to keep other patients safe from measles, which she called “the most contagious germ there is.” (If one person in a room has measles, she said, of the people in the room who are not protected by vaccination, 90 percent will be infected.)
“It’s scary, especially for our oncology patients and premature infants, there’s been a lot of effort to make sure that they are not exposed to anyone with measles,” she said. “We have a large population from the outbreak areas.”
All the pediatric rooms in the hospital except those used for patients with damaged immune systems have been converted to negative pressure, she said, with the airflow directed out of the hospital. Visitation to the newborn intensive care unit has been restricted to parents, since premature infants are particularly vulnerable, and parents who live in one of the high-risk ZIP codes have to show immunity in order to visit.
“There’s almost this guilty feeling because I recognize the real suffering that measles inflicts, these children who are truly sick and are in the intensive care unit with pneumonia and without that support would certainly be in danger of dying,” Dr. Ratner said. And yet, “this is an incredible chance to learn for our trainees and for me,” he said. “I will never forget what I’m seeing now.”
The baby in our clinic had no evidence of measles, and in fact, the original rash was almost gone. The resident was able to get in touch with the shelter and verify that there were not in fact any cases of measles there, and we were therefore able to reassure the mother.
But we talked all afternoon, on and off, about what to do to keep children safe. Dr. Arthur Fierman, chief of pediatric ambulatory care at Bellevue and a professor of pediatrics at N.Y.U., said that may mean reviewing all the children cared for in the clinic who live in the four ZIP codes of the outbreak.
“I have a spreadsheet on my desktop right now with the names, addresses, phone numbers, of about 700 kids less than 4,” he said. It may be necessary to contact them all, offering protection through early initial or second vaccination and also telling them how to get help if they think they’ve been exposed (come in but call ahead so they don’t expose everyone in the waiting room).
The first MMR vaccine is usually due at the age of a year, but we can give it as early as 6 months if children are in danger of being exposed. That means giving an extra dose of vaccine, since they’ll need to get it again at a year. And there’s also the possibility of moving the usual second dose forward; we normally give it at 4, but could do it earlier. Babies under 6 months who are exposed and are too young for vaccine can be given immune globulin as protection.
The New York Department of Health has advised medical providers serving the Orthodox community in those ZIP codes that all babies 6 to 11 months should be given the first dose of vaccine early, and that children under 4 can receive the second dose early as well.
The outbreak in New York is centered in the ultra-Orthodox Jewish and Hasidic community, and children might be exposed to infected relatives at family gatherings for the holiday of Passover, which starts Friday night. Pediatricians may advise parents of babies too young to be fully protected not to celebrate with relatives in the area of the outbreak.
Dr. Lighter referenced the Jewish laws around not harming other people. “By not vaccinating an individual, you could be harming the most vulnerable, very young babies and immunocompromised individuals,” she said.
“There’s a piece of this of course that is incredibly frustrating because there are so few things we know how to prevent,” Dr. Ratner said.
“The larger this outbreak gets, the more rare complications like encephalitis, seizures, deaths we’re going to see,” he said. “When you look at the child in the hospital bed and you know that this, out of all the range of things we see, this one is preventable.”
As we count down the days toward Passover, there is a recurring sense of unreality in spending the afternoon in clinic worrying about measles. And, if you will excuse a holiday reference, a certain hovering sense of plague.