Here's where the JoCo measles outbreak started, and why health pros fear future cases

As the director of health services for Olathe Public Schools, it's Sharon Morris' job to keep the Johnson County measles outbreak from spreading to students.

But it's also personal.

Morris had measles when she was 4 or 5, and it made enough of an impression that she can still recall it decades later.

“I remember a dim room, sick in bed — and I do mean sick in bed — shades drawn to keep the room dark because of the danger to your eyes and doctors making house calls to check on me," Morris said. "And just the fear and the misery because the measles is not fun.”

When Morris got measles, it was routine. Lots of kids got it and most recovered, but some ended up with lifelong complications and some even died. Thanks to widespread vaccination, this year's outbreak is not routine.

Health officials say they think it's winding down now, but not before sickening 15 people: 12 in Johnson County, two in Linn County and one in Miami County.

It's the biggest measles outbreak Kansas has seen since 1990, topping one in 2014 that sickened 13 people in Johnson County and Sedgwick County.

There were only 118 cases of measles in the entire United States last year.

So why here and why now?

In interviews with the Star, health officials provided more information about how this outbreak started, how it spread and how the increasing use of the state's religious exemption from vaccine requirements could make the next one worse.

International sources

Once the measles came to Johnson County, it landed in perhaps the worst possible spot.

Greg Lakin, the chief medical officer for the Kansas Department of Health and Environment, said the current outbreak started when an infant who was too young to be vaccinated picked up the virus in Asia.

That infant then returned to a Johnson County day care.

Children don't usually get vaccinated for measles until they're more than 12 months old, so measles is particularly dangerous in places where infants gather.

County and state health officials have declined to name the day care for privacy reasons. They told the Star they're confident they were able to track who went in and out and notify them of the measles exposure risk, so there was no reason to alert the general public, as they have with more than a dozen other sites where people may have been exposed.

Lakin said most of the 15 Kansans who have gotten measles so far are infants, too young to be vaccinated. Another was a child who had one dose, which is 93 percent effective against measles, but had not reached kindergarten age, when children traditionally get a second dose that increases that to 97 percent.

Two cases were in adults, one of whom was fully vaccinated.

“They could have just had an incomplete (immune) response, or it’s possible they just had a bad batch (of vaccine),” Lakin said.

So far, none has had serious complications.

Lakin said testing had confirmed the source of the virus.

“It was brought back from overseas,” Lakin said.

That's usually how outbreaks happen.

The Centers for Disease Control declared measles eliminated from the U.S. in 2000.

But there are still sporadic cases, because people bring it to the U.S. and spread it to unvaccinated people.

Immigrants who are applying for permanent residency have to be vaccinated against measles and a host of other diseases, and most people who enter the U.S. illegally come from countries that have high measles vaccination rates.

Mexico's rate of 96 percent is higher than the United States' 92 percent, according to the World Health Organization and UNICEF.

But there are 38 nations where citizens require no visa to visit the United States, and that list includes several European nations where measles is resurgent amid rising vaccine skepticism.

U.S. residents who aren't vaccinated and travel to countries where measles is prevalent can also bring it back.

Health officials have confirmed that a person treated for measles last month at the University of Kansas Hospital — a case separate from the Johnson County outbreak — contracted it through international travel.

The 2014 outbreak, which eventually sickened 28 people in Kansas and Missouri, started and spread within a community from Micronesia, which has a vaccination rate of just 70 percent.

Johnson County has a diverse population with personal ties to other nations, businesses executives who routinely travel overseas and families with the means to take European vacations.

Nancy Tausz, the director of disease containment for the Johnson County Department of Health and Environment, said all that mobility makes the county vulnerable.

“A disease is a plane ride away,” Tausz said.

A vulnerable population

Eldonna Chestnut, the director of Johnson County's child care division, said the best way to prevent measles in day care centers is to immunize as many people as possible around the infants who are too young. That protects them through "herd immunity."

Kansas law doesn't have any vaccine requirements for day care workers, but Chestnut said parents should feel free to ask about the policies at individual businesses.

“If facilities want to go above and beyond (the regulations), if they want to require vaccines for their staff, that’s fabulous,” Chestnut said.

A few states, like Illinois and California, require vaccinations for workers.

Lakin said it's something Kansas should consider, even though the current outbreak wasn't caused by an unvaccinated worker.

Kansas Rep. John Eplee, a Republican from Atchison, agreed.

“It’s certainly something we need to look at," said Eplee, who is also a physician.

But Eplee said that wouldn't happen this year and possibly not even next year. This year's session is almost over and he said more lawmakers would have to be educated about the issue before anything is proposed, because attempts to change the law would certainly draw opposition from people who are anti-vaccine.

“When you talk about vaccinations and requirements, it opens up a bit of a hornet’s nest,” Eplee said.

Vaccine skepticism on the rise

From the day care, the measles threat spread into the community: to a YMCA, to a movie theater, to Children's Mercy Hospital in Overland Park to a Mexican restaurant in Paola and a pharmacy in Mound City.

Lakin said KDHE and local health departments have tracked where infected people might have exposed others and contained the outbreak. KDHE recently removed 10 businesses from its list of potential exposure sites because it had been more than three weeks since any cases were connected to them.

Those off the list are Children's Mercy, an AMC in Olathe, two businesses in the Legends in Kansas City, a laundry in Gardner, the Mexican restaurant in Paola, Payless Discount Foods in Olathe, Orange Leaf in Overland Park, ALDI in Olathe and a pharmacy in Mound City.

Lakin said he believes the outbreak is nearing an end, but it could have been a lot worse.

KDHE tracks kindergarten immunization rates by county. Its most recent report, from the 2016-17 school year, found that 94 percent of kindergartners in Johnson County and Linn County had received two doses of the measles-mumps-rubella shot and only 85 percent had in Miami County.

That's below the 90 to 95 percent threshold for herd immunity from measles, and dozens of other Kansas counties also fell short of that mark.

The report found that the rates of parents opting out of vaccines had been rising steadily for several years.

“We don't want this non-immunization trend to continue," Lakin said. "We just don't. ... It reaches a point where the herd immunity is not effective and the spread (of disease) can not be controlled."

In Kansas there are only two ways to get a vaccine exemption for kids entering day care or accredited schools: medical reasons or religious reasons. The medical exemption requires a doctor's signature. Opting out for religious reasons only requires the parents to sign.

Rates of medical exemptions remain the same, according to KDHE. It's the religious exemptions that are on the rise.

The CDC has observed that trend in about a dozen other states as well and health officials believe it has more to do with vaccine skepticism than religious teachings.

Morris, the Olathe schools health director, said that may be true. But she doesn't think Kansas should go the way of states like California, which ended its religious exemption after a 2014 measles outbreak linked to Disneyland.

“I stand by that right, even though that challenges the nurse part of me," Morris said. "I’m also a religious person and in America we have that freedom and that is precious to me.”

Johnson County's three main school districts — Olathe, Blue Valley and Shawnee Mission — all have religious exemption rates close to the state average of 1.8 percent. If the trend KDHE observed in 2016-2017 continue, that number will rise.

Morris said she polled her district's nurses and none had seen evidence that the current outbreak of measles has made any families change their minds about opting out.

She said measles is not generally considered frightening. But that could change if complications crop up — like encephalitis, pneumonia and hearing loss, which marked the era when she had measles return.

“The experience of those diseases that are considered, quote-unquote, 'normal childhood illnesses,' they do not come without a cost," Morris said. "They do not come without complications and they do not come without a mortality rate."

This story was originally published April 6, 2018 at 5:24 PM with the headline "Here's where the JoCo measles outbreak started, and why health pros fear future cases."