Costs of a Measles Outbreak

Measles Outbreaks are Expensive to Contain

A measles alert posted on a home of a child with measles by the health department.
A warning notice put on homes of children with measles to show that they were quarantined because of a measles infection. Photo by Buyenlarge/Getty Images

Measles Outbreaks

The endemic spread of measles was eliminated in the United States in 2000, but unfortunately, that hasn't stopped us from having outbreaks of measles each year. The difference now is that instead of being widespread in the United States, almost all cases are linked to travel outside of the country.

And instead of occurring in people who didn't have access to vaccines, most cases now are in people who choose to not vaccinate themselves and their kids.

These continued cases do make it very easy to see that being in the post-elimination era doesn't mean that measles has been eradicated. In fact, since reaching a record low of just 37 cases of measles in 2004, other milestones in the measles timeline we should all know about include that there were:

  • 220 measles cases in 2011 - a 15 year record and the highest number of cases since 1996 - at least until 2014, when we had at least 644 cases
  • 58 cases in the 2013 New York City measles outbreak - and for a short time, the largest outbreak since the endemic spread of measles was eliminated in the United States
  • 377 cases in a measles outbreak in Ohio - and now the largest outbreak since the endemic spread of measles was eliminated in the United States
  • 170 measles cases in the first few months of 2015, including a large outbreak in California that was linked to Disneyland.

That's still far below where we used to be though, especially when you consider that before the first measles vaccine was licensed, there were an average of about 549,000 measles cases and 495 measles deaths in the United States each year.

And after the first measles vaccines began to be used in the 1960s, we quickly went from 503,282 measles cases and 432 measles deaths in 1962 to 47,351 measles cases and 89 measles deaths in 1972.

Measles cases fell even further after 1990, once kids began to routinely got a booster dose of the MMR vaccine.

There were 27,786 measles cases in the U.S. that year, but just ten years later, the endemic spread of measles was eliminated.

Falling immunization rates have helped fuel a rise in measles in recent years though.

Containing a Measles Outbreak

If immunization rates are falling, why aren't these outbreaks even larger?

Why isn't the United States seeing the very large outbreaks that they have been seeing in Europe in recent years?

Several factors help to limit the outbreaks of measles in the United States. Most important is that fact that despite the talk of personal belief vaccine exemptions and anti-vaccine parents not getting their kids vaccinated, we still have high population immunity.

In the United States, 90.8% of children get at least one dose of the MMR vaccine by the time they are 35 months old and 91.1% of teens have two doses. While not perfect, that is still far higher than the 81% immunization rates the UK saw from 2002 to 2004, when Andrew Wakefield started the scare about the MMR vaccine.

Instead of overall low immunization rates, in the U.S., we have "clusters of intentionally undervaccinated children."

It also helps that the measles vaccine is highly effective. One dose of a measles vaccine provides about 95% protection against measles infection. A second, booster dose helps to improve the effectiveness of the measles vaccine to over 99%.

To further help limit the spread of measles, in addition to these preventative steps, there are a lot of immediate control measures that go into effect once a case of measles has been suspected, which include:

  • the local health department initiating a case and contact investigation
  • a quick confirmation that the patient actually has measles, including testing
  • getting immunization records for confirmed cases
  • identifying the source of the measles infection, which might include contact with someone while traveling overseas, with a visitor from out of the country, at a doctor's office or hospital, etc.
  • assessing the potential for further spread, identifying contacts who aren't immune to measles and are at risk for getting measles, especially those who are at the highest risk
  • offering postexposure prophylaxis to household contacts if they likely aren't immune to measles
  • isolation of people with measles and quarantine of contacts who likely aren't immune to measles for at least 21 days after the start of the measles rash in the last case of measles in the area
  • offering postexposure vaccination, a dose of the MMR vaccine within 72 hours of exposure to contacts who are not fully immune so that they can get some protection and don't have to be quarantined
  • having targeted immunization clinics in the affected population, such as a school or church, to get as many people vaccinated as possible, even after 72 hours, so they have can be protected in the future

That's an awful lot of work. A 2013 measles outbreak in Texas required 1,122 staff hours and 222 volunteer hours from the local health department to contain.

Costs of a Measles Outbreak

In addition to requiring a lot of work, containing a measles outbreak is expensive. A study reviewing the impact of 16 outbreaks in the United States in 2011 concluded that "investigating and responding to measles outbreaks imposes a significant economic burden on local and state health institutions. Such impact is compounded by the duration of the outbreak and the number of potentially susceptible contacts."

For example, it cost:

  • as much as $200,000 to contain an outbreak in Clallam County, Washington - high rates of unvaccinated school children in area schools likely complicated the work of containing the outbreak and the high cost
  • $130,000 to contain a 2011 measles outbreak in Utah
  • $24,569 to contain a 2010 measles outbreak in Kentucky
  • $800,000 to contain a measles outbreak at two hospitals in Arizona
  • $176,980 to contain a 2008 measles outbreak in California
  • $167,685 to contain a 2005 measles outbreak in Indiana - unvaccinated 17-year-old catches measles on church mission trip to Romania, leading to 34 people getting sick, including an undervaccinated hospital worker who ends up on a ventilator for 6 days
  • $181,679 (state and local health department costs) to contain a 2004 measles outbreak in Iowa triggered by a unvaccinated college student's trip to India

The 2013 Texas outbreak cost $50,758.93 to contain. With 16 cases of measles in that outbreak, that comes to about $3,100 for each case of measles. And while that may seem like a bargain when you look at some of the other outbreaks, that was only for the direct public health costs to the county health department, including staff hours, the value of volunteer hours, and 240 syringes.

Additional costs that come with a measles outbreak can also include direct medical charges to care for sick and exposed people, direct and indirect costs for quarantined families, and outbreak–response costs to schools and hospitals, etc.

We should also consider what happens when our state and local health departments have to divert so much time and resources to deal with these types of vaccine-preventable diseases instead of other public health matters in the community. Do other public health matters take a back seat as they spend a few months responding to a measles outbreak?

There were 220 cases of measles in the United States in 2011. To contain just 107 of those cases in 16 outbreaks, "the corresponding total estimated costs for the public response accrued to local and state public health departments ranged from $2.7 million to $5.3 million US dollars."

In contrast, the MMR vaccine only costs about $56.

Costs of the 2015 Measles Outbreaks

How much have the 2015 measles outbreaks cost?

  • An outbreak in Cook County, Illinois has already been estimated to cost at least $150,000 to contain (13 cases).
  • Another outbreak in Clallam County, Washington cost at least $223,223 to contain (5 cases, almost all unvaccinated), and was linked to the death of an immunocompromised women.
  • In Alameda County with 6 cases and >700 contacts, it is estimated that over 56 staff spent at least 3,770 hours working to contain the outbreak, resulting in personnel costs of more than $190,000.

We don't have reports on the costs for rest of this year's outbreaks yet.

Anatomy of a Measles Outbreak

A closer look at the measles outbreak in San Diego, California in 2008 can help parents understand even better what happens during one of these outbreaks.

A 7-year-old who is unvaccinated because his parents have a personal belief vaccine exemption travels to Switzerland with his family. A week after returning home from the trip, he gets sick, but returns to school after a few days. He then develops a rash and sees his family physician, followed by his pediatrician, and then makes a trip to the emergency room because he continues to have a high fever and rash (classic measles symptoms).

He is eventually diagnosed with measles, but not before eleven other children are infected with measles, too. This includes two of his siblings, five children in his school, and four children who were exposed at his pediatrician's office.

It is not as simple as that though. During this measles outbreak:

  • Three of the children who became infected were younger than 12 months of age, and therefore too young to have been vaccinated
  • Eight of the nine children who were at least 12 months old were unvaccinated because they had personal belief vaccine exemptions
  • About 70 children were placed under voluntary quarantine for 21 days after their last exposure because they were exposed to one of the measles cases and either didn't want to be vaccinated or were too young
  • One of the infants with measles traveled to Hawaii, raising fears that the measles outbreak could spread there too

All together, 839 people were exposed to the measles virus.

At least one of them was a 10-month-old infant who got infected at his well child checkup, was too young to have gotten the MMR vaccine yet, and ended up spending three days in the hospital - time his parents spent "fearing we might lose our baby boy."

The parents of this 10-month-old weren't looking for a vaccine exemption and didn't want their child to catch measles, a life-threatening, vaccine-preventable infection. Instead, they were counting on herd immunity to protect them until their child could be protected with an MMR vaccine. They were one of "those who come into contact with them" that got caught up in a decision of some other parents to not vaccinate their child.

The kids who get a vaccine-preventable disease because they are too young to get vaccinated, have an immune system problem that prevents them from getting immunized or their vaccine from working, and the kids who simply didn't get protected from a vaccine are the hidden costs of these measles outbreaks that we don't hear about often enough.

Sources:

Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition Second Printing (May 2012).

Manual for the Surveillance of Vaccine-Preventable Diseases. 6th Edition 2013 (Jul 2013)

National and State Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2012. August 30, 2013 / 62(34);685-693.

National and State Vaccination Coverage Among Children Aged 19--35 Months -- United States, 2012. MMWR. September 13, 2013 / 62(36);733-740.

Ortega-Sanchez, Ismael R.The economic burden of sixteen measles outbreaks on United States public health departments in 2011. Vaccine, Available online 14 October 2013.

Sugerman, David E. Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated. Pediatrics 2010; 125:4 747-755.

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