Measles Vaccination Q&A

Background
Since January 2019, approximately 700 cases of measles have been confirmed in 22 states, with large outbreaks in New York and Washington. This is the greatest number of cases reported in the U.S. since 1994. In the decade before the live measles vaccine was licensed in 1963, an average of 549,000 measles cases, 48,000 hospitalizations, 1000 cases of chronic disability from acute encephalitis and 495 deaths were reported annually in the U.S.

Why have there been more measles cases in the U.S. this year?
The increased number of cases has been attributed to:
  • measles outbreaks in countries to which Americans travel, and therefore more measles cases coming into the U.S., and/or
  • more spread of measles in U.S. communities with pockets of unvaccinated people.
Who Should Get the MMR Vaccine and How Many Doses Should They Get?Children
Children should get two doses of MMR vaccine, starting with the first dose at 12 to 15 months of age, and the second dose at 4 to 6 years of age.
Adults who do not have evidence of immunity should get at least one dose of MMR vaccine.
Some Adults who do not have evidence of immunity should get two doses of MMR vaccine (separated by at least 28 days):
  • College students and students at post-high school educational institutions.
  • Healthcare Workers.
  • People with HIV Infection who are >12 months of age and who do not have evidence of severe immunosuppression.
  • Household members and close contacts of immunocompromised persons.
International Travelers
Before any international travel:
  • Infants 6 to 11 months of age should receive one dose of MMR vaccine. Infants who get one dose of MMR vaccine before their first birthday should get two more doses (one dose at 12 through 15 months of age and another dose separated by at least 28 days).
  • Children > 12 months of age should receive two doses of MMR vaccine, separated by at least 28 days.
  • Teenagers and adults who do not have evidence of immunity against measlesshould get two doses of MMR vaccine separated by at least 28 days.
Women of Childbearing Age 
  • Women of childbearing age should make sure they are immune to measles before they get pregnant. Women of childbearing age who are not pregnant and do not have evidence of immunity should get at least one dose of MMR vaccine.
  • It is safe for breastfeeding women to receive MMR vaccination. The baby will not be affected by the vaccine through breast milk.
Who Does Not Need an MMR Vaccine?
A person is protected against measles and does not need an MMR vaccine if they meet any of these criteria for evidence of immunity:
  • Written documentation of adequate vaccination: o at least one dose of a MMR vaccine administered on or after the first birthday for preschool-age children and adults not at high risk for exposure and transmission o two doses of MMR vaccine for school-age children and adults at high risk for exposure and transmission, including college students, HCWs , international travelers, and groups at increased risk during outbreaks
  • Laboratory confirmation of measles at some point in their life. Laboratory confirmation of immunity to measles.
  • Born before 1957. (The majority of people born before 1957 are likely to have been infected naturally and therefore are presumed to be protected against measles. The exception is that HCWs born before 1957 should receive two doses of MMR vaccine).
If a person is unsure whether they’ve been vaccinated, they should first try to find their vaccination records. If they do not have written documentation of MMR vaccine, they should get vaccinated. The MMR vaccine is safe even if they are already immune tomeasles (or mumps or rubella).

Do people who got the killed measles vaccine in the 1960s need to be revaccinated with the current, live measles vaccine?
Yes, people who know they got the killed measles vaccine (an earlier formulation of measles vaccine that is no longer used) should get revaccinated with the current, live MMR vaccine. Not many people fall into this group; the killed vaccine was given to less than 1 million people between 1963 and 1968. If a person is unsure whether they fall into this group, they could ask their doctor to test their blood to determine whether they’re immune or they can just get a dose of MMR vaccine. There is no harm in getting another dose of MMR vaccine if they are already immune to measles (or mumps or rubella).
Who Should Not Receive the MMR Vaccine or Postpone Vaccination?
  • Persons who have any severe, life-threatening allergies to a previous dose or to a component of the vaccine.
  • Women who are pregnant. Pregnant women should wait to get MMR vaccine until after they are no longer pregnant. Women should avoid getting pregnant for at least one month after getting the MMR vaccine.
  • Persons who have a severely weakened immune system due to disease (such as cancer or HIV infection with evidence of severe immunosuppression) or medical treatments (such as radiation, immunotherapy, steroids, or chemotherapy).
  • Persons who have a parent, brother, or sister with a history of immune system problems should speak to their provider.
  • Persons who have a h/o thrombocytopenic purpura or thrombocytopenia.
  • Persons who have recently received a blood transfusion or other antibody containing blood products may be advised to postpone MMR vaccination for 3 months or more.
  • Persons who have gotten any other vaccines in the past 4 weeks. Live vaccines given too close together might not work as well.
  • Persons with moderate or severe acute illness.
Do people need a booster vaccine? No. People who received two doses of measlesvaccine as children according to the U.S. vaccination schedule are protected for life, and do not ever need a booster dose.
Do adults who only got one dose of measles vaccine as a child need a second dose? Most adults born after 1957 only need one dose of measles vaccine. Certain adults who are going to be in a setting that poses a high risk for measles transmission should get two doses separated by at least 28 days. These adults include:
  • students at college or other post-high school education institutions
  • HCWs
  • international travelers
  • people who public health authorities determine are at increased risk for getting measles during a measles outbreak
What should a person do if they are unsure whether they are immune to measles? The person should first try to find their vaccination records of measlesimmunity. If they do not have written documentation of measles immunity, they should either get vaccinated with MMR vaccine or have a doctor test their blood to determine whether they’re immune. There is no harm in getting another dose of MMR vaccine if they are already being immune to measles (or mumps or rubella).
How effective is the measles vaccine? The measles vaccine is very effective. Two doses of measles vaccine are about 97% effective at preventing measles if exposed to the virus. One dose is about 93% effective. About 3 out of 100 people who get two doses of MMR vaccine will get measles if exposed to the virus. However, they are more likely to have a milder illness, and are less likely to spread the disease to other people
How long does it take for the measles vaccine to work in your body? Detectable antibodies generally appear within just a few days after vaccination. People are usually fully protected after about 2 or 3 weeks. People traveling internationally should make sure to be fully vaccinated at least 2 weeks before you depart.
What should a person do if they’ve been exposed to someone who has measles?Promptly call their doctor and let them know that they have been exposed to someone who has measles. Their doctor can:
  • make special arrangements to evaluate them, if needed, without putting other patients and medical office staff at risk, and
  • determine if they are immune to measles based on their vaccination record, age, or laboratory evidence.
If a person is not immune to measles, MMR vaccine or a medicine called immune globulin may help reduce their risk developing measles. Their doctor can advise them, and monitor them for signs and symptoms of measles. If they are not immune and do not get MMR or immune globulin, they should stay away from settings where there are susceptible people (such as school, hospital, or childcare) until their doctor says it’s okay to return.

BHIP is back in business!

Kendra Koeplin, our founding BHIP social worker, is back from maternity leave, and BHIP is once again able to take new social work referrals (along with BHIP psychiatry referrals)! Thanks to everyone for your patience during this transitional period. We’re aware that (at least) a few referrals slipped through over the past couple months, and our BHIP team has been vigilant in seeking to triage/address them.

We wanted to take this opportunity to refresh everyone on the BHIP model – what’s in scope, what’s really beyond scope – and review the process for referring patients. The BHIP approach is essentially defined by goal directed, time limited intervention, focused on symptom reduction. Bottom line: the BHIP model is built around brief skills-based counseling interventions and brief psychiatry consultations. It’s not well-suited for patients in need of long-term mental healthcare, for patients in need of processing-based therapy (for example, grief counseling), or for urgent/crisis needs – Jan Eisenman should be consulted for patient with acute needs.

Where do I find the Medicare Annual Wellness Questionnaires?!

Option 1: In EPIC: Go to MISC Reports –>  MyChart –> Patient Message Review –> then scroll down to the “Messages sent from” section and finally click on the “Questionnaire Submission”. The answers should display.

Option 2: If you want to see the patient’s answers right in the “This Visit” tab on the right side of the screen during an encounter, you can add a “Conversation” button to the toolbar in the “This Visit” tab. Here is how: Open the encounter –> click on the wrench in the top right of the “This Visit” tab, which will open a box that allows you to modify the toolbar –> type “conversation” into an empty cell in the “Report” column on the left of this box and click the default box on the right of this box, then click Accept. You should now have a “Conversation” button permanently part of your “This Visit” toolbar, and patient answers will populate there when they are submitted.

We are working with IT to fix this workflow ASAP. One proposal is to create a “Questionnaires” button that would live by default in the “Rooming” tab, where it would link directly to patient answers.

A few notes:

– The questionnaire (electronic or paper) does not include the PHQ-2. This is because a separate tool has been developed in EPIC to enable all patients (not only Medicare AWV patients) to complete the PHQ-2 electronically such that it would populate in flowsheets in EPIC. This tool has not yet rolled out across all clinics, so for now, our protocol is for our MAs to complete/review the PHQ-2 electronically annually with all patients during the rooming process. We recognize that this has not yet been happening consistently, but we are actively working toward this. We are also adjusting our paper intake forms for wellness/preventive health visits to include the PHQ-2 (see below).

– We are revising the annual health history form that is given to non-Medicare patients for return preventive health visits and is given out as a supplement to the questionnaire for Medicare patients for return annual wellness visits. These revisions include adding sections on social/substance use history and sexual history, which are generally pertinent but currently not included in the Medicare questionnare, as well as adding the PHQ-2. This should enable our paper intake forms for AWVs to capture all the information needed, and the electronic intake process should catch up over time. Once our intake forms have been fully revised, Jake will send out copies for comment and reference.

BHIP Update

As many of you know, Kendra Koeplin will be returning from her parental leave in March, and we are looking forward to welcoming her back to GIMC. We are working with Jo Knott, who has been doing an exceptional job covering BHIP in Kendra’s absence, on a plan to ensure a smooth transition.  Given a few constraints, we are currently facing an acute crunch in BHIP access. For the time being, BHIP will not be able to take on any new referrals. Additionally, there are a number of referrals that have been made over the past few weeks that may be beyond BHIP’s capacity and have not been processed or scheduled. We will work on reviewing these referrals and ensuring that each of these patients has a follow up plan. Apologies for the disruption to what we know is a valuable service for our patients.

Jake will update us all as we work through the specifics of BHIP access/continuity over the coming weeks, and will certainly notify everyone once BHIP is again able to take new referrals.

Retina Scanning is live at GIMC!

Retina scanning is live at GIMC! Screening for diabetic retinopathy saves patients’ vision, and we can now do it right in clinic. Barak sent an email this week with the how-to, here’s a quick review:

– Enter an order in Epic by typing “Retina.” Choose either:

              1. Screening (if no known retinopathy), or

              2. Monitoring (if  known retinopathy)

– MA walks the patient to the camera near the south hallway (next to exam rooms 1-3)

– Results are reported to the ordering provider’s Epic InBasket with clear instructions for next steps

A few reminders: 

– Retina screening should happen once every 1-2 years

– Retina screening at GIMC (without eye dilation!) is recommended if your patient:

                — doesn’t have eye symptoms of any kind

                — doesn’t have other eye conditions (ex. glaucoma, macular degeneration

– If your patient has any eye symptoms, or your patient has a chronic eye condition which needs eye clinic management:  then DO NOT order retina screen at GIMC.  Instead send a referral for the patient to have an in-person  evaluation in the Eye Center.

Quick primer on the stages of diabetic retinopathy:

1. Non-proliferative – this is the early stage. Non-proliferative can be mild, moderate, or severe.

2. Proliferative – this is vision-threatening (ischemia present) – Needs treatment.

3. Macular edema – can be present with either Non-prolif or Prolif. Needs treatment.

Typical follow-up recommendations by type of finding:

– If no retinopathy or mild/moderate-non-proliferative retinopathy: repeat scan in 1 year.

– If macular edema or severe non-proliferative or proliferative retinopathy: refer to Eye Clinic