After three years with no cases, 15 people in Hawaii came down with measles last year, and health officials worry that unvaccinated people are endangering themselves and others, including infants.
The largest outbreak of measles was on Kauai, where three unvaccinated adults brought the disease home in October after a trip to Bali, Indonesia, and infected four other people, according to Ron Balajadia, chief of the immunization branch at the state Department of Health.
"We’ve taken so many leaps forward in medicine and in our health, and now we’re in danger of backsliding dangerously," said Dr. Sarah Park, state epidemiologist. "The fact of the matter is we are seeing increased pockets of people who are not vaccinated, and that is eroding our protection in our communities."
Hawaii’s vaccination rate for measles remains high, with nearly 93 percent of children under age 3 having the recommended doses, slightly above the national average of 91 percent. But there are clusters of resistance to vaccination, and Kauai is high on the list.
Last year, 8 percent of children entering kindergarten on Kauai sought vaccination exemptions for "religious reasons," compared with less than 1 percent on Oahu and about 4 percent in Maui and Hawaii counties, according to Health Department data. Those rates have roughly doubled in the past 10 years. The figures don’t include home-schooled children.
Measles was eliminated domestically in 2000, but it has been making a comeback. Across the United States, 644 cases were reported last year, more than three times the previous year’s total and 11 times the 2012 total, according to the U.S. Centers for Disease Control and Prevention.
And the pace isn’t slowing. In January alone, 102 people in 14 states came down with measles, most of them related to the recent outbreak tied to Disneyland. Then last week, five babies under age 1 who attend a day care center in Chicago were diagnosed with measles.
The CDC recommends a first dose of the measles vaccine between 12 and 15 months old, and a second for children ages 4 to 6.
The virus poses a particular threat to babies too young to be vaccinated and to people who cannot receive vaccinations for medical reasons such as a compromised immune system.
"They have no choice in the matter," Balajadia said. "Those are the ones that are the most vulnerable."
Measles symptoms can include a blotchy red rash, fever, cough, runny nose and watery eyes. The disease sometimes leads to ear infections, pneumonia and brain swelling, and it can be life-threatening.
Sarah Zietz, a mother of two who lives in Kilauea, Kauai, has avoided vaccinations, but the recent measles outbreak has her thinking twice. She has a 4-year-old daughter who has no immunizations, and a 3-month-old baby.
"We are on an island, but some stuff is starting to reach here," Zietz said during a shift working at a local cafe. "Me and my brothers and sisters weren’t vaccinated. But my parents were just saying I should get my daughter vaccinated because it’s here now."
Balajadia said people who refuse vaccinations cite various reasons: Some don’t believe in government. Some don’t trust modern medicine. Some have heard a story of a bad outcome or have a relative who had a bad reaction.
Despite fears, researchers have concluded there is no scientific link between vaccination and autism. Symptoms of autism often appear in toddlers at about the same age that routine immunization starts, leading some people to mistakenly assume a causal relationship, according to the American Academy of Pediatrics.
A 2014 meta-analysis of studies involving more than a million children found no difference in autism rates among those who got the measles-mumps-and-rubella vaccine and those who did not.
"The MMR vaccine is incredibly efficacious — it’s very effective, very safe," said Dr. Michael Hamilton, president of the Hawaii chapter of the American Academy of Pediatrics. "It’s really one of our better vaccines that we have as far as the rate of protection that it gives the patient."
While the majority of people get immunized, a small percentage refuses, even after discussing the risks involved, said Hamilton, who practices at Kaiser Permanente but who was not speaking for the hospital.
"We are getting questions about measles since it’s been hitting the news," Hamilton said. "Hopefully, this will change some minds."
The 15 measles cases in Hawaii last year stemmed from four separate introductions of the disease to the islands. Along with the Kauai cases, measles cases were diagnosed on Oahu and Maui.
In February a baby under age 1 who had traveled from Oahu to the Philippines came down with the virus after returning home and passed it on to another child, Balajadia said. In October another mother and baby fell ill on Maui after returning from a trip to the Philippines, and infected one other adult.
Two adults on Oahu came down with measles in the fall, one of whom had traveled to Kauai and Maui, but it wasn’t clear how they got the disease.
The most recent case was a Maui resident who was diagnosed after a trip to Disneyland in October, but his case is not part of the current Disneyland outbreak, Balajadia said.
All 15 Hawaii residents recovered without serious complications, although two were briefly hospitalized. According to the World Health Organization, there were 145,700 deaths worldwide due to measles in 2013.
Park said the multiple outbreaks of measles in Hawaii and on the mainland show "how increasingly susceptible we’re becoming as the numbers of persons refusing vaccination increase."
"That really is an alarm bell in public health," Park said. "It makes me nervous to see 14 states and Mexico all involved."
In Hawaii, Department of Health investigators jumped into action as measles cases cropped up last year. They instructed patients to stay in isolation so they didn’t spread the disease, which is one of the most easily communicable. They painstakingly traced their contacts and researched travel patterns to try to warn others of the possibility of infection.
"It could have blown out even more … but we were trying to minimize the spread by identifying as many contacts as we could," Balajadia said.
Symptoms of measles appear about a week or two after exposure, and patients are infectious even before they develop a rash. The virus is spread through coughing and sneezing, and can live for up to two hours in the air or on a surface.
No cases have been reported so far this year in Hawaii. The Health Department has been urging clinicians to report any potential cases of measles immediately so state authorities can contain the disease.
"We all have to do our part to make sure these diseases don’t take a foothold in our community and cause more harm," Balajadia said. "Vaccinate your children and yourself. Make sure you’re protected."
