No cough, no measles. that was one of the many mantras and memory aids I learned in medical school. Most were designed to reduce tomes like Gray’s Anatomy to a few rules. Much of the time, it was easy to miss the point, especially when the subject seemed to be an obscure disease.
Five years into a typical Western medical education, none of us had ever seen measles. Nor were we bothered. Apart from HIV, microbes like measles seemed prehistoric. Still, I remembered this particular rule, offered by a revered professor, even as I wondered why he was so focused on a cough instead of “Koplik spots,” the little white dots in the mouth that are specific to measles.
Then I spent ten weeks in a pediatric infectious-disease ward in Cape Town. I thought I would see “African diseases” like hemorrhagic fever and HIV, which I did. But I also saw measles, rubella, scarlet fever, syphilis, rheumatic fever, typhoid, tuberculosis and many other causes of rash and fever. Suddenly, I could see the point of my professor’s rule. The very first signs of measles are a fever and cough, followed by a runny nose and red eyes. The appearance of a rash three or four days later is usually what prompts parents to bring their child to the emergency room. The problem is that, at any given time, half the preschool children in the ER have a fever, rash or both. The differential diagnosis—which can range from mild roseola to devastating meningococcal sepsis—is hard enough in immunized children. In an unimmunized child, the ailment might also be rubella—harmless for the child, but catastrophic for unimmunized pregnant patients—or chicken pox.
Or it might be measles, in which case you need to know—fast—because measles is the most contagious disease on earth. Among unimmunized people exposed to the virus, 90 percent will contract the disease. And each of these people will spread it to twelve to eighteen others in an unvaccinated community. Complications like pneumonia and meningitis can be permanent, deadly or both, especially for immune-compromised patients such as those with cancer. And, in the ER, one of these kids might be in the next bed.
Older Americans remember measles as a common childhood disease that just had to be suffered through, but it is still frequently deadly in low- and middle-income countries. In 2014, an average of 400 kids died each day of measles, most under the age of 5. In the current US outbreak, 20 percent of patients were hospitalized in California during the first six weeks of the year. And one in fifteen kids will develop more serious complications, such as severe pneumonia, otitis media with the possibility of permanent deafness, and acute encephalitis. The cruel, late complication of subacute sclerosing panencephalitis (SSPE), a progressive brain disease, is inevitably fatal. In Germany, which has seen an explosion of measles for reasons similar to those in the United States, twenty-seven children died of SSPE between 2005 and 2010. One teenager died of SSPE just last year.