Report from Ground Zero: Public health crisis in New York

Contemporary Pediatrics recently spoke with Mary Koslap-Petraco, DNP, PNP-BC, CPNP, FAANP, a nationally known expert in immunization practice, about why measles infection rates have skyrocketed in her home state of New York, what’s in store for the rest of the United States during the current measles outbreak, and how physicians can engage with parents to boost immunization rates.

Dr Koslap-Petraco, pediatric nurse practitioner and community health specialist, is a nurse consultant on the staff of the Immunization Action Coalition (IAC) and CEO and primary care provider in her own private practice. She serves on the board and executive board of Vaccinate Your Family (VYF): The Next Generation of Every Child by Two, a national nonprofit organization founded in 1991 that is committed to reducing the burden of vaccine-preventable diseases in families and individuals. She is a nationally known expert in immunization practice and has been an advisor for the Centers for Disease Control and Prevention (CDC), serving on the CDC’s Advisory Board of the IAC and National Vaccine Advisory Committee. She is an adjunct clinical assistant professor at Stony Brook University School of Nursing, Stony Brook, New York, where she teaches in the Pediatric Nurse Practitioner Program. She has more than 25 years’ experience in public health and has advised local and state health departments on immunization public policies using her expertise as a public health nurse to influence system-level changes. Dr. Koslap-Petraco is a Fellow of the American Association of Nurse Practitioners.

Erin Johanek: All right Mary Beth, can you briefly explain the situation going on in New York State right now with this measles outbreak. 

Dr Koslap-Petraco: Well right now here in New York we have a very big and very dangerous measles outbreak. It basically concentrated in two communities, two Orthodox Jewish communities, one in Upstate New York and one right here in lower New York, in Brooklyn. There have been a couple of cases outside those communities. So it’s not as insular as we think it is. The big problem is measles is a horrendous illness. The big thing is trying to contain and stop this. We’re also in danger of losing our designation as measles-free here in the United States which was a very hard fought battle for us in public health over the last many, many years. As we approach a thousand cases, we’ll be pretty surprised if they allow the United States to keep that measles-free designation.

Erin Johanek: So you mentioned Upstate New York and Brooklyn, so is that where the outbreak originated or is there kind of like a ground zero for this measles outbreak?

Dr Koslap-Petraco: The ground zero are those two communities. What happened was a lot of their families, with their children, traveled to countries in Europe. This particular outbreak, there’s in Ukraine, there’s a huge Orthodox Jewish community there with a temple. It’s almost like a religious pilgrimage and several community members with their children traveled there and that was the original bringing measles back to the United States. It also is coming from Israel, it’s coming from England, it’s coming from Ireland, it’s coming from France, it’s coming from Spain, it’s coming from Italy. Whoever thought a travel medicine to Western Europe? Now the first thing that we health care providers say to people who say they’re going to Western Europe is, what’s your measles immunization status? Have you had two doses if you didn’t have real measles as a child? I’m one of the dinosaurs and I’m old enough to have had measles. So the outbreak we have here in the U.S. is from unvaccinated children and adults coming back into the United States but it’s also a result of parents who don’t want to vaccinate so everybody is at risk because we have these pockets, large pockets in these communities of children and adults who are not immune to measles.

Erin Johanek: Were there any risk factors present before the outbreak started? And were these anticipated or mitigated well by the public health community? Or what could they have done differently? 

Dr Koslap-Petraco: I spent 30 years working for a county health department and we have always pushed for a very high immunization rate. Unfortunately, there were providers who gave in to parent’s demands to slow up vaccinating children or to not give measles, mumps and rubella vaccine at all based on these unfounded fears that the vaccine causes autism. Honestly, I think this was an accident waiting to happen and as far as anticipating it, we in public health probably knew that something like this was going to happen because the numbers of children who are not vaccinated is growing rather than receding in these insular communities. And I can’t say that it’s just isolated to religious communities because there are other pockets of children who are not vaccinated on the East Coast, the West Coast, the South, they’re all over. Most of the time it’s middle to upper middle class white families who are not vaccinating their children based on the unfounded fears of what they’re seeing on the Internet. Could we have stopped it? Quite honestly, I don’t think so because when I look now and what the data are telling us about what it is that convinces parents to vaccinate, first hand stories of others who have suffered from measles and other vaccine preventable diseases are the key that seems to be turning parents around to then vaccinate their own children. Because nobody was afraid of measles, they kind of were like ah it’s not a really bad disease, we haven’t seen it in so long, I’m not going to worry about it and now it’s rearing its ugly head again and as parents hear from other parents whose children have suffered from this disease, that’s one of the biggest things that’s convincing parents to turnaround and change their minds and begin to vaccinate again.  So can we anticipate it? Yes. Could we have prevented it? Honestly, with all the junk that’s on the Internet, I don’t think so.

Erin Johanek: Do you see an end to this? When it this going to be over?

Dr Koslap-Petraco: Oh brother, honestly, at this point, I really don’t see an end to it. We just have to get a lot more children vaccinated and then a lot of young adults vaccinated as well. Wakefield came out with that horrible paper in the early 90s.  That means there’s a lot of young adults who are having children who were never vaccinated as well because their parents bought into those unfounded fears. So we have to get all those people vaccinated. We have to have between 90 and 95% and the closer you are to 95% vaccinated in the community to keep measles out of the community. And to protect those who cannot be vaccinated because of true medical contraindications. So we’ve got a long road to hoe here. It’s not going to happen overnight. This outbreak is going on for two years already. In fact, we’re into the third year and look what happened with the Somali community in Minnesota because the anti-vaxxers got into that community and convinced the families that measles vaccine was going to make their children autistic. And quite frankly, I don’t think the public realizes how much money this organized anti-vax community makes off parents who don’t know what to do and are looking for good information. They’re making a fortune.  Wakefield alone has become a multi-millionaire.                 

Erin Johanek: That’s sad.

Dr Koslap-Petraco: He lives here in the United States under the cover of being a proponent of protecting children down in some big mansion in Texas while children are suffering. And we’re approaching a thousand children now, if we didn’t hit it already. So before the week is out, I can almost guarantee you we’re going to be hitting a thousand. Once we hit a thousand, that’s when the risk for children dying starts to begin.  Unfortunately, I am really worried we are going to lose a child and not in the too distant future.

Erin Johanek: In your opinion, what are the key takeaways, what lessons can be learned so our readers can use those to take action in their own communities?

Dr Koslap-Petraco: Well what we need to do is, even though it takes a lot of time, we have to build that trust with our patients and their families. So they trust us as healthcare providers more than they trust Google or the University of Google. Honestly, the biggest thing that we need to do is build the trust. We also need to share the stories of parents whose children have been sickened by this horrible disease. The problem is, measles is another one of those gifts that keeps on giving because even after you recover from measles and the younger you are the more chance you have of getting this. There’s a condition called subacute sclerosing panencephalitis and it’s a complication of measles that can occur at any time after an infection with measles. It’s most likely to occur if children get measles before two years of age. And what it does is it literally liquefies the brain.  There’s no cure and the children or whoever else develops it, dies within three months to a year. And they lose their coordination, they lose their ability to speak and slowly but surely they lose all their facilities and capabilities until they die. If you vaccinate, there’s no risk for that. If you don’t vaccinate, there is a risk because the kill virus doesn’t work like that. 

Erin Johanek: So we need to build the trust and kind of scare people in to what could really happen if they’re not vaccinating their children.

Dr Koslap-Petraco: Well I don’t really like to scare for it.  What I feel that we need to do is educate them to what can happen to their children if they develop measles that this is not a benign disease. My own sister had measles when we were children. I can see her face right now. I was 4 and she was probably a little over 2 when she had measles. I mean she looked like a lint rag doll in my mother’s arm. We lived in a cold water flat in a tenement building and here’s my mother sitting on the bed and rocking my sister who looked like this limp rag doll. Her vision was damaged from measles. That’s probably the least thing that could have happened to her. I don’t think she had measles encephalitis because I don’t know whether she would have survived that in the early 50s. She sure as heck was very, very sick. I remember very high fevers. I remember her face being very flushed and I remember my mother almost tearing up as she was trying to bring the fevers down and just sitting on the bed rocking my sister. And I’m sure she was doing a lot of praying that might sister would survive.

Erin Johanek: Absolutely. So any final thoughts for our listeners?

Dr Koslap-Petraco: Well I think my final thoughts are, we pro-vaccine folks can’t be afraid to engage with parents and we need to take the time to speak with them. Always respectfully, always listening to them first, usually the way that I start out the conversation is tell me what you’ve heard and let’s discuss this point by point. Addressing every one of their concerns. There’s plenty of website where we could direct parents that has good information. We need to put the personal faith on it. I think we do too much Googling, texting and all of that other stuff. And I think if we pediatric and adult providers as well because this is an issue for adults, I think we need to put that personal faith on it, establish the trust, ask parents what their concerns are, don’t talk down to them, answer their questions honestly and be there for those parents.

Erin Johanek: Thank you so much for speaking with me today.

Dr Koslap-Petraco: Well thank you very much for inviting me, I’m really grateful to have this opportunity because honestly, I don’t want to see any other families go through what my family has gone through.