for Prevention

Measles in LA County: Communicating with Parents and Patients about Immunizations

May 2019

Julia Heinzerling, MPH

Sharon Balter, MD

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With news of measles cases throughout the world and locally, parents and patients may be uncertain about their risk for disease, their immunization history, and whether outbreak- or situation-specific recommendations apply to them. Healthcare providers remain the most trusted source of information regarding immunizations. This is the case even for vaccine-hesitant parents and those who are considering delaying vaccine doses.1 By making a strong recommendation and actively listening to and discussing questions or concerns, healthcare providers can help patients understand the importance of both routine and outbreak- or situation-specific immunization recommendations.

This article provides information that providers can use to help promote the measles, mumps, and rubella (MMR) vaccine during the current measles situation, as well as a brief summary of vaccine communication tips from the Centers for Disease Control and Prevention (CDC). It also includes links to resources that can help providers discuss immunization recommendations and address concerns, including conversational techniques, video vignettes, and educational materials for patients and staff.

 

Current Situation: Measles in Los Angeles County

The Los Angeles County Department of Public Health (LAC DPH) is investigating multiple reports of measles in Los Angeles County residents. As of May 1, 2019, these include a local outbreak of four confirmed measles cases linked to one another after one of the individuals was infected with measles during international travel and an additional two unlinked cases of measles occurring in individuals infected during international travel.

During the current situation and with the continuing threat of measles importation, the risk of measles virus circulation in Los Angeles County may be increased. LAC DPH is encouraging providers to review vaccination status with all children and adults during routine patient visits and to immunize unvaccinated and under-vaccinated patients with the MMR vaccine. Please see the health update from the Los Angeles Health Alert Network (LAHAN) on measles prevention in LA County for recommendations and requested actions. Providers are encouraged to join LAHAN to receive further notifications via email regarding measles or other disease outbreaks or emerging health risks.

 

  Measles Outbreak
 
 
 

Visit the DPH Measles webpage for the latest resources including posters, FAQs, list of exposure locations, and information for schools.

Join the Los Angeles Health Alert Network (LAHAN) to receive email updates for health care professionals on measles, other disease outbreaks, and emerging health risks.

 

Promoting Measles Vaccination

Since measles was declared eliminated in the United States in 2000, most parents have never seen measles and its complications. The public health and medical communities are working to keep it that way, even as the disease is on the rise abroad. Parents considering immunizations want to do what is best for their children and adult patients want to make the safest and best choices for themselves. Locally, LAC DPH is encouraging residents to talk to a trusted healthcare provider about the measles vaccine, emphasizing that the risks associated with measles infection vastly outweigh the risks of the immunization. Healthcare providers may wish to consider the following points when discussing the MMR vaccine and the current measles situation with parents and patients. Since there are nuances to vaccine communication and patients’ questions, concerns, and vaccine confidence vary, providers are encouraged to tailor their approach.

  • We know that parents care deeply about their children and want to make the right choice. Adults considering immunizations also want to make the safest and best choice for themselves. As a result of misinformation in the community, some people have become anxious or hesitant about immunizations in general and measles immunizations in particular.
  • Measles vaccine has been extensively studied and found to be safe and effective. Serious adverse reactions from MMR are rare and reputable scientific studies have found no relationship between MMR vaccine and autism.2 Providers may wish to refer patients to the CDC’s “Understanding MMR Vaccine Safety,” which addresses common questions regarding MMR vaccine and provides links to research studies regarding autism and MMR vaccines.
  • At a time when sustained measles transmission has been eliminated in the U.S., some parents may have calculated that it was safer not to vaccinate. However, the risk of measles exposure is ongoing and is elevated during the current situation in LA County and internationally. There are measles outbreaks occurring throughout the world with thousands of cases abroad. With international travel being far more common than it once was, cases of measles regularly occur in people exposed during international travel. In some areas, including in pockets in California, immunization rates have fallen to a level that can't always prevent disease spread. For this reason, LAC DPH has encouraged families and individuals to speak with a healthcare provider who they trust about measles immunization.
  • The risks of measles infection vastly outweigh the risks of the immunization.
    • One to two out of a thousand people with measles infection die of respiratory or neurologic complications, and an additional one out of a thousand persons will develop brain swelling, which can lead to permanent damage.3
    • Additionally, there is a form of usually fatal degenerative brain disease that occurs six to ten years later in people who have been infected with measles.3 Although rare (i.e., it occurs in four to eleven of 100,000 infections), it cannot be treated. The only prevention for this complication is prevention of infection through vaccination.
    • The MMR vaccine protects against measles, mumps, and rubella, all of which can cause serious illness.
    • The MMR vaccine has been in use in the U.S. for decades and has a strong safety record. Some people receiving the vaccine may experience mild problems such as fever, mild rash, swelling in the glands in the cheek or neck, which are much less serious than the disease itself. Serious and moderate adverse reactions are rare.2
  • California law requires that children attending a pre-kindergarten facility (i.e., child care center, day nursery, nursery school, family day care home, or development center) and TK/K-12 school (transitional kindergarten/kindergarten through 12th grade) who do not have a valid exemption on file be vaccinated against measles.4 This requirement protects individual students, including those who cannot be vaccinated, and prevents disease outbreaks. For more information, healthcare providers are encouraged to read the Rx for Prevention article “Understanding California’s Child Care and School Immunization Requirements and Medical Exemptions.”
  • After an exposure to an identified or suspect case of measles, unimmunized children and adults may be quarantined or excluded from childcare, school, group activities, and work, for days or weeks until they are no longer at risk of developing measles and spreading the disease to others.

 

Vaccine Communication Tips from the Centers for Disease Control and Prevention

The CDC’s “Provider Resources for Vaccine Conversations with Parents” offers practical guidance and messages that providers can consider when promoting routine and outbreak or situation specific recommendations. While the site is targeted toward conversations with parents about their children's immunizations, the recommended approach could also be considered when discussing immunizations with adult patients. The CDC’s guidance includes the following tips:1

  • Use a presumptive approach that assumes that parents/patients will vaccinate. Parents may be more likely to express concerns when providers use language that asks about immunization plans.5 CDC recommends that providers state that they will be providing the recommended vaccines during the visit, assuming that the parent/patient will accept the recommendation. Language such as “You/your child need(s) X vaccines today” is recommended rather than a tentative approach such as “Have you thought about the shots you/your child need(s) today?”
  • Make a strong recommendation when parents/patients are not yet ready to accept recommended immunizations. CDC recommends that providers clearly state a strong recommendation and if appropriate, add a brief supporting statement. Providers can use a mix of science and anecdote or personal stories, based on what they expect will resonate. The message should demonstrate the importance of vaccines and can describe why the provider personally recommends immunizations. For instance, CDC recommends statements such as: “These shots are very important to protect you/your child from serious diseases”, “I believe in vaccines so strongly that I vaccinated my own children on schedule.”, and “This office has given thousands of doses of vaccines, and we have never seen a serious reaction.”
  • Actively listen to and address concerns. Continue to work with parents/patients who are not yet convinced. CDC notes that questioning a provider’s recommendation does not necessarily mean that a parent/patient will refuse the recommended immunizations. CDC recommends that providers listen carefully, try to understand concerns, and address specific questions. If the parent/patient still declines, CDC recommends continuing to remind them about the importance of the recommended doses and scheduling a follow-up visit to revisit recommendations.

The CDC’s "Provider Resources for Vaccine Conversations" website has research-based resources including a video explaining 5 research-based strategies to improve vaccine conversations with parents and the following educational materials: “Understanding MMR Vaccine Safety” and “Preparing for Questions Parents May Ask About Vaccines.”  Additional resources that can help providers when discussing vaccines with parents and adult patients are listed below, along with additional information regarding the measles outbreak in Los Angeles County.

 

Resources

Measles Immunizations and Outbreak Information

Communicating with Parents and Caregivers about Immunizations

 

References

  1. Provider Resources for Vaccine Conversations with Parents. Centers for Disease Control and Prevention website. https://www.cdc.gov/vaccines/hcp/conversations/index.html. Accessed April 28, 2019.
  2. Centers for Disease Control, American Academy of Family Physicians, and American Academy of Pediatrics. Understanding MMR Vaccine Safety. https://www.cdc.gov/vaccines/hcp/conversations/downloads/vacsafe-mmr-color-office.pdf. Accessed April 28, 2019.
  3. McLean, HQ, Fiebelkorn AP, Tempte JL, Wallace GS. Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2013. MMWR Recomm Report. 2013;62(RR04):1-34.
  4. California Code of Regulations Title 17, Division 1, Chapter 4, Subchapter 8. California Department of Public Health, Vaccines for Children Program website. http://eziz.org/assets/docs/shotsforschool/IMM-1080.pdf. Accessed April 29, 2019.
  5. Opel DJ, Mangione-Smith R, Robinson JD et al.  The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience. Am J Public Health, 2015 Oct;105(10):1998-2004. doi: 10.2105/AJPH.2014.302425
 

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Author Information:

Julia Heinzerling, MPH
Special Assistant to the Chief Medical Officer,
Bureau of Disease Control

Sharon Balter, MD 
Director,
Communicable Disease Control Division

County of Los Angeles
Department of Public Health

ip@ph.lacounty.gov

www.publichealth.lacounty.gov/ip

Rx for Prevention, 2019
May;9(1).

Published: May 1, 2019