Measles can be difficult for doctors to detect because the infection is so rare and the symptoms are easily confused with many other conditions.
That's one possible reason a Wake County patient visited hospitals in Raleigh and Durham and a doctor's office in Garner over the course of seven days before being diagnosed with measles last week.
The patient, who has not been identified, had recently returned from international travel and sought medical attention on five separate occasions before Wake County health officials were notified.
"It just looks like any other respiratory tract infection," said David Weber, an infectious disease specialist at UNC Health Care. "The average physician has probably never seen a case of measles."
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County public health officials wouldn't confirm whether the person was an adult or a child, but said the patient was not vaccinated for measles. The person is recovering at home and is no longer contagious, said state epidemiologist Zack Moore, who noted it is not unusual for a measles patient to go undiagnosed for days before the telltale rash leads medical professionals to the right answer.
"I can't speak to what took place at the hospitals, but I can tell you when people sometimes initially get to be sick and they're not sure of what is going on, they might go to different places just to see and as their symptoms might get (worse), they might go to different hospitals," said Ruth Lassiter, Wake County's communicable disease program manager.
WakeMed Health & Hospitals has contacted more than 250 patients in the past 24 hours who may have been exposed to the measles patient at WakeMed facilities, said Barb Bisset, executive director of WakeMed Emergency Services Institute. Those patients are being told to contact the N.C. Communicable Disease Branch so they can be assessed for immunity and monitored for measles symptoms, which typically start with fever and a runny nose.
WakeMed has also confirmed that 225 employees who could have been exposed to measles are at low risk because they have been vaccinated, a condition of their employment.
WakeMed identified potentially affected employees and patients by mapping air pathways of air conditioner ducts and vents through which the airborne measles virus particles could have traveled, Bisset said.
Are you at risk?
Two doses of the MMR (measles, mumps and rubella) vaccine is 97 percent effective at preventing a person from getting the disease, and people born before 1957 are considered protected from the virus for life. For those who are not protected, the airborne disease is highly contagious.
Most adults in this country are vaccinated and have immunity against measles. Those who are at greatest risk are infants under 12 months of age who haven't received the first of two recommended childhood vaccinations, and pregnant women who are not vaccinated and pose risk to themselves and their fetus, said Cameron Wolfe, an infectious disease specialist at Duke University Hospital.
Weber said measles is airborne, unlike the flu virus, which travels in droplets. A person infected with measles is expected to infect 15 to 20 people, while someone with the flu will infect three to four people, he said. But the measles vaccine is much more effective than a flu shot, which some years benefits fewer than half the people who get the vaccination.
People may have been exposed to measles at the following locations, dates and times.
- WakeMed Physician Practices in the WakeMed Garner Healthplex on Friday, June 8, from 11 a.m. through 3 p.m.
- WakeMed Raleigh Campus: Children’s Emergency Department, Adult Emergency Department (D-Bay), Chest Pain Unit and Imaging, June 8 from 11 p.m. through June 9 at 7 a.m.
- WakeMed Raleigh Campus: Children’s Emergency Department, Adult Emergency Department (D-Bay), Chest Pain Unit and Imaging, Sunday, June 10, from 8:30 p.m. through Monday, June 11, at 3 a.m.
- WakeMed Physician Practices in the WakeMed Garner Healthplex, Monday, June 11, from 1 p.m. through 5:30 p.m.
- Duke University Hospital Emergency Department, Durham, Wednesday, June 13, from 3:30 p.m. through Thursday, June 14, at 1 a.m.
If you have not been vaccinated against measles and were at one of these locations during the time frames listed above, call the North Carolina Communicable Disease Branch of the N.C. Division of Public Health at 919-733-3419 or your doctor right away.
No flight risk
The last reported case of measles in Wake County was in 2016, also due to international travel.
Moore, the state epidemiologist, said the patient was not contagious when flying back to this country, so the passengers and flight crew were not exposed to the measles virus. Moore said privacy constraints prohibit him from disclosing where the patient became infected with the measles, but he said the most commons sources are Western Europe and India.
Moore said the Wake County Health Department would typically identify all the places the patient had been and potentially exposed others, but in this case the patient was not feeling well and remained at home when not visiting hospitals and doctors. Moore said so far there have been no secondary cases but "the clock is still ticking" and won't run out until 21 days have passed from the time anyone was exposed to the patient.
There is no cure or specific treatment for measles. Patients are advised to rest and drink plenty of fluids. Measles can lead to complications, like meningitis, encephalitis or pneumonia.
According to the Centers for Disease Control, measles is still common in many parts of the world, with nearly 90,000 deaths reported worldwide each year. The infection is brought into the United States by people who are not vaccinated. Measles typically kills about one or two people out of a 1,000 infected; the last measles death in the United States was reported in 2015.
From Jan. 1 to April 21, 63 people from 16 states were reported to have measles. In 2014, the United States experienced a record number of measles cases, with 667 cases from 27 states, the greatest number of cases since measles elimination was documented in the U.S. in 2000, according to the CDC.
"Measles is more rare in the U.S., but we are a global society now," Lassiter said. "People are able to travel. Within 24 hours, we can be within other areas. Other areas that might have outbreaks of measles or where vaccines aren't, we do need to follow up. Though it's not as common for measles in the U.S., we do get them occasionally."
Measles will typically start with a fever and then rash, but people are most contagious four days before the rash appears and four days after. It can take a week from the moment of infection for a person to become contagious.
Wolfe, the infectious disease specialist at Duke University Hospital, said measles is tricky to detect for a number of reasons. Symptoms start out very general, and they can change quickly so that one person may not have all the symptoms at any given time.
"If someone coughs or sneezes, it can be passed through the air that way," Lassiter said. "We need to make sure we get up with people who might have been exposed to that person."