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Opinion The Checkup With Dr. Wen: Key lessons from recent measles and Marburg outbreaks

A measles, mumps and rubella (MMR) vaccine on a countertop at a pediatric clinic in Greenbrae, Calif., in 2015. (Eric Risberg/AP)

You’re reading The Checkup With Dr. Wen, a newsletter on how to navigate covid-19 and other public health challenges. Click here to get it in your inbox.

Most reader questions continue to focus on covid-19, as reflected in my recent newsletters addressing masking, long covid and whether some need a second bivalent booster shot. But the coronavirus is far from the only pathogen worthy of attention.

In central Ohio, for example, a measles outbreak that began in November has sickened at least 85 children. Most were younger than 5, and all those who were infected were either unvaccinated or not yet fully vaccinated.

Measles is one of the most contagious respiratory viruses — even more so than the highly transmissible coronavirus variants. An unvaccinated person has a 90 percent chance of contracting measles if they are around someone infected with it. The virus is airborne and can still be contagious to others two hours after the infected person has left the room.

The extreme transmissibility makes containment challenging. What makes it possible is that there is a highly effective vaccine: Two doses of the measles, mumps and rubella (MMR) vaccine are 97 percent effective at preventing measles infection.

Then there is the Marburg virus, which is raising alarm in Equatorial Guinea. Marburg is in the same family of viruses as Ebola. Like Ebola, it causes a deadly hemorrhagic fever characterized by bleeding in a person’s organs and through their mouth, eyes, rectum and other mucosal surfaces. Fatality is estimated to be between 24 and 88 percent.

In Equatorial Guinea, at least nine people have already died from Marburg. The true toll might be higher due to people dying at home. A neighboring country, Cameroon, is investigating two suspected cases.

Unlike measles and the coronavirus, which are airborne, Marburg requires direct contact with an infected individual or their bodily fluids to infect you. You won’t catch the virus from simply being in the same room as an infected person; however, you are at high risk if you come into contact with their blood or vomit as a health-care professional or family caregiver.

The World Health Organization met in emergency session last week and emphasized the danger of Marburg. Of particular concern was the lack of vaccines or treatments. Plus, given the threat to health-care workers and the already short supply of doctors and nurses in the region, Marburg could cause major disruptions to West Africa’s health-care systems for years to come.

These two outbreaks point to three key lessons. First, it is possible to contain infectious diseases. Less than three months after the measles outbreak first struck, state health officials in Ohio declared that their outbreak was over. The success can be credited to coordinated efforts among local, state and federal health agencies and the use of effective vaccines to stem further spread.

Second, despite many scientific advances, diseases continue to emerge and reemerge. Neither measles nor Marburg is a new disease. In 2000, measles was thought to be eliminated in the United States, yet it made a comeback because of low community vaccination rates.

Similarly, Marburg was first recognized in 1967. As with Ebola, there have been outbreaks in the past, but each successive surge in cases raises alarm because of the severity of disease and the need to contain it early and aggressively.

Third, while the emergence of novel diseases might be out of our control, it’s particularly tragic when they wreak havoc as a direct result of human behavior. We should all be deeply concerned about the decline in routine childhood immunizations in the United States. The proportion of kindergartners fully vaccinated against measles has fallen to 93 percent — below the 95 percent needed to prevent spread. Rates of polio, chickenpox and pertussis immunizations are declining, too, largely fueled by growing vaccine hesitancy.

The world must prepare for reemergence of old diseases while anticipating new ones. That means having surveillance capabilities to detect outbreaks as they occur and investing in the development of vaccines and treatments. It also requires ongoing education and outreach to counter misinformation, because the success of public health interventions hinges on public trust.

Ask Dr. Wen

Newsletter subscribers are invited to submit questions to Dr. Wen. Not a subscriber yet? Click here to sign up.

“My sister is 74 and hypertensive. She received her bivalent booster in September. Since a second booster is not available, she is interested in Paxlovid. Her concern is that she is 4-foot-10, 130 pounds and very sensitive to medications generally. Should the dose of Paxlovid be reduced given her size and age?” — Ralph from Louisiana

Your sister should take Paxlovid if she contracts covid-19. Her age alone is a significant risk factor, and unless she has a specific contraindication such as medication interactions, she would benefit from the reduction in severe illness that this antiviral treatment provides.

Paxlovid comes in one standard dose. It is a combination of two antiviral medicines, nirmatrelvir and ritonavir. It is authorized for people 12 and older who weigh at least 88 pounds. The dosage is not altered based on height or weight.

“My husband and I are in our 70s. We have avoided getting covid by being extremely cautious, until our recent first vacation in three years. We came home from a small ship expedition (100 people) with covid. We began Paxlovid on Day 1 of symptoms. On Days 7 and 9, we both tested negative. On Day 11 we tested positive. I am now on Day 9 of rebound covid. My doctor said the protocol for rebound covid is to isolate for five days and then mask for five days, with no more testing needed. Since I still have symptoms, I tested and I am positive. Assuming I stay positive past the 10 days, do you agree that it is OK for me to go out and not be concerned that I am going to give someone else covid?” — Debbie from North Carolina

The Centers for Disease Control and Prevention says you need to isolate for five days after you are first diagnosed with covid and then for the five days after that, you can go out in public but must mask the entire time. If you experience rebound, as in your case, the isolation clock starts over again.

The CDC guidance does not require testing to exit isolation. That means that 10 days after your rebound, you could be in public without a mask. But if you are still symptomatic, and especially if you are still testing positive, you should still mask and remain careful around people who are vulnerable to severe illness.

This is not the time to have dinner with an elderly relative or to visit a friend who resides in a nursing home. Be sure that you are testing negative before you see them, even if you could already technically exit isolation.

“I’ve seen several news reports recently that pegylated interferon lambda is a potentially effective coronavirus treatment that is not likely to make it to FDA approval. Can you comment on the reasons why? This is the kind of news that conspiracy theorists like to enhance to support their own world view!” — Seth from Illinois

New research, published in the New England Journal of Medicine, found that in patients infected with the coronavirus, a single injection with this interferon medication reduced their likelihood of hospitalization by about half. This is promising; we need far more treatment options, especially for those ineligible for Paxlovid.

The New York Times reports that the Food and Drug Administration informed the manufacturer that it is not yet prepared to authorize it for emergency use. The reasons cited include that the studies were done in Brazil and Canada rather than the United States and that the research wasn’t by the company itself but by an academic institution. These reasons might be standard practice for regulators, but given the urgent need to develop better treatments for covid, I hope the FDA will work with the manufacturer to lay out an expedited pathway for further research leading to authorization.

The Post has also compiled Q&As from my previous newsletters. You can read them here.

What I’m reading

In this very well-designed New England Journal of Medicine study, researchers randomized covid patients to receive three experimental treatments: metformin, ivermectin and fluvoxamine. These treatments are all approved to treat other ailments, and some earlier studies suggested that they could be promising as outpatient treatment for covid to prevent progression to more severe disease. Unfortunately, all three failed to meet the study endpoints. None prevented low oxygen levels, emergency department visit, hospitalization or death.

Young children who test positive for both covid and another respiratory virus are more likely to become sicker and to develop severe disease compared with those with covid alone, a recent study published in the journal Pediatrics found. Among hospitalized children younger than 5 , co-detection of both covid and another virus such as the common adenovirus or rhinovirus was associated with twice the likelihood of severe respiratory illness than those who tested positive only for covid. This study has implications for clinical care, including the need for closer monitoring in those with multiple concurrent respiratory viruses.

Three members of the Global Virus Network in an exceptional op-ed in STAT News suggest pivoting from an “avoid exposure” paradigm to an “accept exposure, live with the virus” approach. These scientists advocate for more practical public education, including tailoring guidance “for how low-risk people (such as children) can protect high-risk people (such as their grandparents) in close-contact scenarios.” As the national emergency for covid ends, I expect the Biden administration to shift to the kind of strategy proposed by the authors.