Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast Narrator - ? 00:11 is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Unknown Speaker 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 101 I'm your co host, Dr. Kane. Speaker 1 00:35 I'm Dr. Patel, and along with us, we have our returning guest, Dr. Lauren and Angelo. It's great to be here. Thank you. Thank you for joining us. And today we are diving into some of the most prominent clinical issues that we have seen in the vaccine world or infectious disease world. And the title of our episode is measles. We have a problem. Dr. Sean Kane 00:58 And really today we're talking about measles being an outbreak, especially this year compared to previous years, talking about, what is measles? How is it spread? Why are we seeing the outbreak, and what are we doing about it in terms of healthcare providers? So why don't we just start with, what is measles? It's something that many people have probably heard about, but maybe don't even know what it is, or what are some symptoms. Or how would you even know if a patient who presented to a clinic or your pharmacy had maybe measles or not? Speaker 2 01:26 Well, it is a highly contagious virus, and what we are most concerned about is the way that it is spread, usually through sneezing or coughing by an infected person, and it does live in the air for up to two hours. So that's a scary thought if we are around someone who has measles. Speaker 1 01:41 Yeah, and it's also known as rubeola, which is not to be confused with rubella, which is part of the measles vaccine, the MMR, which is measles, mumps and rubella. Dr. Sean Kane 01:52 And this is really, really contagious. So one of the problems with this virus is that a person who's infected is contagious four days before they really start having some of these symptoms, and then many patients will have a rash that develops and they're contagious four days after that appearance of the rash. So because the patient may not know that they have measles, they may not know that they need to kind of be isolated and things like that, and by that time, they've kind of already spread it so very highly contagious with this kind of prodromal period that makes it easy to spread before you really know what's going on, Speaker 2 02:23 and it's not as easy to diagnose because of that. And I think when the symptoms first come on, it's known as the three C's. So we've got cough, coryza, which is a runny nose or nasal congestion, and conjunctivitis, also known as pink eye. So we'll see inflammation in the conjunctiva, usually runny eyes. So it does make it difficult early on, because it looks like maybe cold symptoms or mild flu symptoms, and so until they see a provider for true diagnosis, they could be spreading the virus to others. Speaker 1 02:54 Yeah, and talking about just how contagious it is, going back to having it spread by sneezing or coughing. Let's say you have a person infected, they just think that they have a mild cough or cold and they're bygone but that virus can live up to in the air or the area where they have coughed or sneezed for up to two hours, and anybody who comes in contact with that surface where that person was either coughing or sneezing can become infected, especially when The uninfected person then touches their hands to their eyes or the nose or the mucosal membranes. That's how the transmission of the virus really occurs. And I Speaker 2 03:28 think it's important to note that for individuals who are immune, it really isn't a concern. It's for those who haven't been vaccinated or haven't been able to be vaccinated, where we do worry about transmission of the virus, Dr. Sean Kane 03:43 so I'm guessing then that prior to when we had a vaccine, this was probably something that lots of people got, because it sounds really contagious. And pre vaccine, this is something that you could be susceptible to if you hadn't already been exposed to the virus before. Yeah. Speaker 1 03:56 So the first ever vaccine available for measles was back in 1963 — they called it the Edmonston strain. But if you look at it, why they had the need to develop that first vaccine? Because in the decade prior to 1963 estimated three to 4 million US population was infected, and we looked at about 50,000 hospitalization and about 400 to 500 deaths and one of the severe complication of measles is encephalitis, which can produce deficits later in life after the infection, the acute infection period has resolved, and those numbers were about 1000 in the decade prior to that first vaccine. The vaccine was then improved in 1968 where another strain was combined, and so the combined strain was called edmonston Enders strain, and that's the vaccine that's been on the MMR component and on the CDC recommendation for schedules. Dr. Sean Kane 04:53 When you say MMR, you're referring to measles, mumps and rubella, which are three different things that we're vaccinating for with one shot. Yeah, right, correct. Speaker 1 05:00 And there is another combination available with the addition of the varicella in it. So we have the MMRV available as well, but it's either or not both to be vaccinated. Speaker 2 05:11 Yeah, the varicella component is a great addition, usually for children who need to be protected against chickenpox as well. But right now, as we go through our conversation today around measles we'll really be referring to the MMR vaccine. Dr. Sean Kane 05:24 So it's my understanding, when MMR came out in 1968 and probably even in 1963 this was a game changer in terms of its efficacy, its ability to prevent measles in patients who received a vaccine. Is that correct? Speaker 2 05:38 Sure was. And so even as early as 1981 it was able to reduce cases by about 80% greater than the year just prior to that. And moving along and to the year 2000 the US actually declared measles eliminated, which is heartbreaking for me to think about where we are now in 2019 versus 2000 when at that point in time, there were only, I believe, 86 cases reported, and all of those were associated with something that was imported. And so that's how they were able to declare measles eliminated. Dr. Sean Kane 06:13 And it sounds like 1989 we started seeing that children who had previously received one vaccine. We saw a little bit of breakthrough, if you will, meaning that even though they received the vaccine, they were not as immune as we would hope. So at that point, we decided, You know what, two doses of the measles vaccine is the right answer, and that's kind of where we've been since then. Speaker 1 06:33 Yep, exactly. So the first dose is given anywhere between 12 to 15 months of age, and then the second dose is given between the age four and six, and that's been the schedule since 1989 Speaker 2 06:44 and it is a live vaccine, and so it does work very well. But because of that, we usually don't start vaccinating until age one, just because those younger than 12 months of age tend to have maternal antibodies that are circulating, and so we wait until one year of age. Now there are exceptions to that rule, which we'll talk about as we get into some of the issues with the outbreaks and what we're doing about it, or around some of the international travel. But I do want to point out that second dose, which doesn't happen for several years later. So as Dr. Patel mentioned, between four and six years of age, is really considered an insurance dose. We look at efficacy. Even that first dose can be up to 95% efficacious for children. But because we saw, as Dr. Kane mentioned, some cases, even after one dose, adding that second dose really boosts that to about 97 to 98% just so we have really good coverage in our kids. Dr. Sean Kane 07:37 And I came across a statistic in a measles review article that I thought was fascinating. So more than 21 million deaths worldwide have been prevented between 2000 and 2017 by the measles vaccine. Just think about that for a second. That's more than a million deaths per year globally that we're preventing just by giving one or two doses of a vaccine. That's amazing, Speaker 2 08:00 but it is still a global problem. So when we look at some of the World Health Organization statistics as well as some of our travel health advisories, there are areas of the world that we do need to be concerned about for travel, and that's something obviously individuals who are traveling will need to do their research, meet with their travel health pharmacist to talk about what vaccines they need, and if Measles is a concern in the locations in which they're going, Speaker 1 08:25 we're going to talk about those, and then some other tools that they can use to find out if they qualify for those, for the additional measles vaccine or not, kind of going back to why this is a problem, right? Like 21 point 1 million deaths avoided, that's probably the extreme case, right, where it results into a death. But going back to, like, some of the common symptoms we see, we talked about the three C's, and then we see graduality of the symptoms, right? I mean, we talked about how the contagion period is, you know, four days before they see the rash, versus or up to four days after having the rash appear. So rash usually happens three to five days after the symptom starts, happens on the face and head, and then kind of progresses to the trunk and extremities, and usually it's gone within seven days. And like I mentioned, patients can be still contagious up to four days into having the rash. So it's kind of like the hallmark symptoms there. The other thing is to look for is these bluish-white plaques that happen on the mucosal membranes in the mouth in the buccal mucosa; we call them Koplik spots. They're seen two to three days after the symptom starts and occur in about 70% of measles cases. And if they occur, usually they're very visible — they're usually visible 1–2 days before the skin rash. Dr. Sean Kane 09:46 So if you think about it, you know something like runny nose, some cough prior to having that pretty significant rash, many patients will not know that they have measles. They'll think that they just have a common cold or something that's just kind of going around. Down, and unfortunately, again, by the time that they get a relatively full body rash and some of these other symptoms, it's kind of already too late where they've already missed the period to isolate themselves away from other people who may be at risk for getting measles. Speaker 1 10:12 Yeah, and apparently, this rash and the Koplik spots are so obvious that the literature kind of quotation mark used around, is it the measles rash. It's very particular to the measles infection. So if you're ever interested, go on the CDC website or immunize.org you'll probably see some examples of what we are talking about here. Dr. Sean Kane 10:33 So Dr. Angelo, if we have a patient where we suspect that they may have measles, obviously we're going to do a lot of different stuff, but one question is going to be, how do you know that they actually got measles? What is a confirmatory test? As opposed to looking at their rash and getting their mouth and kind of getting a good patient history? What is the confirmatory test that is done for these patients? Speaker 2 10:54 Well, they'll need to have a blood test done, and they're looking for a specific antibody for measles, and so making sure, obviously, if a rash is seen in conjunction with other symptoms, that we are moving forward with that, and contacting the health department as well once a measles case is diagnosed, that does need to be reported. Also, timing is important with respect to testing blood levels, and so it could be a false negative too early on in the course of the disease, but usually after about four days that rash, the positive test should be evident. You're referring to an IgM antibody, correct specific for measles, okay. Dr. Sean Kane 11:32 And in addition to that, I would assume it's not as common, but there is PCR testing for the RNA of the measles virus, and this PCR testing will detect the presence of the RNA of the virus, and obviously, if that's there, then it's clearly positive that that patient has measles, and that is going to be positive earlier than the IgM antibody will be. However, testing is going to vary based on where you're at and the resources that you have and things like that. Speaker 1 11:58 So we talked about the acute infection. But what are really the complications of measles? Right? That being one of them, but we can prevent it. Some of the acute complications, in addition to the symptoms we talked about, include ear infections, and that has happened in one out of 10 children infected with measles. This actually can result into permanent hearing loss, which is pretty significant, it can cause diarrhea as well, although this happens in less than one patient out of the 10 people who are infected. Dr. Sean Kane 12:30 Just to clarify that ear infection is actually a secondary bacterial infection, where, after the virus hits, you're at an increased risk for bacteria to cause an infection, we actually see the same type of problem with influenza. Oftentimes, when patients go into the ICU post having an influenza infection, a lot of these patients will get secondary bacterial infections like MRSA pneumonia, where they normally wouldn't have been predisposed to that had they not had influenza to begin with, Speaker 2 12:59 we do see pneumonia as well with measles cases, especially in those who are hospitalized. Speaker 1 13:04 Yeah, and that leads to, you know, those hospitalization or having measles pneumonia, or consider some of those acute complications. The other ones include encephalitis, as we mentioned earlier, too, that was a big issue, and that that results from either having this encephalitis or having this pneumonia and leading further neurologic or respiratory complications and things like that in certain other population, especially pregnant population, if they are infected with measles, the risk of miscarriage or premature birth or even low birth rate can can be resulted Speaker 2 13:36 and I think we talked about this being a live vaccine. So for that reason, women who are pregnant should not be getting vaccinated with MMR, which, again, is pretty scary, because if a pregnant woman gets Measles, the outcomes, especially for the unborn child, can be very severe. So making sure women of child bearing age are vaccinated before obviously becoming pregnant. If she's not vaccinated and she's pregnant, immediately after birth, she would get that vaccine. So as we Dr. Sean Kane 14:05 kind of alluded to, there are certain patient groups that are going to be at higher risk for some of these measles complications. So if you're younger, kids, less than five years of age, if you're pregnant, we just mentioned that. And in addition to the young anyone above 20 years of age is also at risk for some of these complications. And you might be asking yourself, Wait, less than five, greater than 20, so the teenagers apparently have the golden ticket here to fewer complications, but still, basically, anyone less than five, more than 20 years of age, and then obviously immunocompromised patients, they're going to be at a very high risk as well for more complications caused by measles. Speaker 1 14:40 So what's the what's the treatment? How do we treat either this, acute symptoms or complications? Speaker 2 14:46 Well, I would say we need to prevent this, so we don't have to treat it well, that's the best of action Unknown Speaker 14:50 treatment, right? Prevention is the best treatment. Speaker 2 14:52 But if they didn't get vaccinated, or weren't able to be vaccinated due to some of their medical conditions. Or age, then obviously we would need to look at options for treatment. As we mentioned earlier, this is a viral illness, and unfortunately we do not have antiviral medications available. So we're looking at really supportive care for measles. Dr. Sean Kane 15:15 And supportive care is going to include things like preventing dehydration, making sure that nutrition is kept up for these patients, if they potentially are at risk for these secondary bacterial infections, that we can identify those quicker and treat those quicker, so otitis media, ear infections, pneumonia, things like that. And another option that you may or may not read about or see is vitamin A, and basically in developing countries where vitamin A deficiency is more common. There is some data that supplementing with vitamin A in these areas where vitamin A levels tend to be low, that supplementation can help in patients who have more severe cases of measles, so those that are requiring hospitalization or those that are immunocompromised. Now it is difficult to extrapolate some of that data to a US based patient population where vitamin A deficiency is not common, I can tell you that without having treated a measles patient in the past, if you had a very, very sick four year old, we probably would be willing to give them vitamin A based on this other data, knowing that it's a relatively safe drug to give, and there's some data in other patient populations, but it may not be externally valid to our patient population, Speaker 1 16:24 and another way to perhaps mitigate some of these issues is to prevent transmission. So if you know that your child has measles or you have measles, you should know that you could be contagious within that time period, and you should probably avoid contact with other individuals to prevent the spread from occurring. Dr. Sean Kane 16:43 So don't take them to the McDonald's playground play place when they have Speaker 2 16:47 measles or the Super Bowl. There was an outbreak at the Super Bowl several years back, so Unknown Speaker 16:52 or do not consider traveling. Dr. Sean Kane 16:54 And of course, if they're hospitalized, we see plenty of patients with airborne precautions anyway, but these are the patients, where you can't go into the room without a full mask on, because, again, those droplets in the air are going to last for hours, and if you walk in with no mask, you're going to expose yourself to that virus. Speaker 1 17:10 If you look at the healthcare provider recommendations from CDC on this measles outbreak and how to contain it, there's actually a lot of detailed guidelines on how to prep the room, when to see the patient, how to see the patient, what are the isolation precautions and things like that. So there are detailed guidelines available on CDC for this too, Speaker 2 17:28 and the CDC is a great resource for all of the things we are talking about today. Speaker 1 17:32 So we talked about where we were back in the days. You know what? What are some facts about measles and how we treat it, and things like that. But let's talk about what's been going on lately, right? This outbreak? What's the magnitude of this outbreak? Speaker 2 17:46 Seems like every few days to a few weeks, I open my email and there's more reports of cases spreading across the US. We are now up to, as of I think this month, 1169 cases spread across 30 states so far. So pretty significant impact. New York's been hit pretty hard, in fact, so hard that the governor recently issued a ban on all non medical exemptions for vaccination. And so now that brings us up to four states total — California, Mississippi, West Virginia, and New York — as our only states with such non-medical exemption laws in place. Dr. Sean Kane 18:24 Just to put that number to perspective, 1169 cases just this year, and we're seven months into the year. Last year in total, we were at 372 so we have plenty of months left, and we're already about three to four times where we were last year for the entire year. So this is something that is getting worse, not Speaker 2 18:43 better, and the majority of individuals who are infected or transmitting the infection are unvaccinated, just sad. Speaker 1 18:51 Some of the local measures that have been put in place to contain the spread is, you know, take an example of the New York City Health Department. They said that they will actually issue fines to patients who are living in certain ZIP codes within Brooklyn if they are found to be unvaccinated. So they have to take to the measure of extreme and mandate the vaccination for these patients who have not been previously vaccinated. Dr. Sean Kane 19:15 So I want to just step back for a second. Dr. Angelo, in the year 2000 you told us that it effectively was not an issue anymore with measles. What is it about the last 19 years that this has gone from it's eradicated from the United States to the point of now we're seeing an expansion of the number of cases by three to four times more than what it was previously? Speaker 2 19:35 Well, there are several factors, I think, over the years that have unfortunately spread, unvalidated and untrue messages around the MMR vaccine. I think I don't know that we have time today to get into some of those debates, but autism has been at one point in time linked to this vaccine, which we know was not true. It was false data reported in The Lancet that physician who reported. Did that data obviously had the articles retracted, and a lot of time research and energy has been put into disproving some of those issues that had come up several years back. The other layer to this is there are countries, especially in Europe, that have had a huge problem with unvaccinated individuals again, around just fears of being vaccinated. France has had some issues as well, and so we talked about importation of measles. And so I think our job as healthcare providers, our job as pharmacists, is to help educate our communities, our individuals, on the importance of this vaccine and the safety data that we have to support its use in our kids as well as unvaccinated adults. Speaker 1 20:47 And one thing we need to think about is, you know, we talked about the efficacy of one dose versus the two dose and why, you know, this is part of the regular vaccine recommendation in the schedule and stuff, is that think about those who are unable to be vaccinated. Think about those young kids who are less than 12, or those who have immunocompromised status, or who are pregnant by vaccinating. Those who are able to get the vaccine, we're creating this herd immunity. So now those who are able to get the vaccine, who are denying to get the vaccine, we are actually reducing the herd immunity for those who are unable to get vaccinated. Speaker 2 21:21 It is important in any community that we do our jobs and get our get the vaccines that we can for that reason alone, and to help protect those who can't be vaccinated because, again, of age or medical conditions. Dr. Sean Kane 21:33 Well, why don't we jump into that? So what are the actual recommendations right now with respect to who gets vaccinated? What if you don't know if you've been vaccinated or not? What are some of the recommendations around that? Speaker 1 21:44 Yeah, so as the schedule have always said, according to CDC, for individuals within United States, you know your kids, the first dose should occur between 12 to 15 months, and the second dose should occur between four to six years. And this this recommendation is including travel within United States, not just if you're staying versus traveling within the pockets of those outbreaks in United States as well. And then when we are looking at teens and adults who don't have any evidence for immunity against measles, they're recommending one dose as soon as possible, and Speaker 2 22:18 certain individuals might get two doses healthcare providers, definitely, if you do not have immunity as a healthcare provider, you should be getting two doses. The other cut off we tend to look at is whether or not you were born before 1957 so a lot of individuals were exposed at some point in time they were born before 1957 so they are considered immune. The exception would be again, healthcare providers, if they were born before 1957 It is suggested that they consider getting vaccinated and getting at least two doses. Dr. Sean Kane 22:50 I can actually say that I've been asked this question by multiple people who are born prior to 1957 they read in a newspaper, hey, measles is an outbreak right now, and when they were young, maybe they had viral illnesses that they don't know for sure, was measles or not? And they are asking me, should I get a measles vaccine or not? Because I never got it, and I was told I don't need it right now. The recommendation is, if you're born before 1957 you don't need to get a vaccination, unless you're a healthcare provider, then in that case, you should get your two dose regimen. Speaker 2 23:24 Think Dr. Patel had mentioned traveling. So that's the other thing we might look at too. Or for individuals traveling out of country where there are measles outbreaks, we do need to look at again, their immunity and their age. And it is suggested that if they are we mentioned this starts at 12 months of age, but we can actually vaccinate kids between the ages of six months and 12 months if they're going to a high risk area outside of the US. The other layer to all this is there are some communities where there are outbreaks in the US, where they are recommending that these young kids get one vaccine, or one dose of the vaccine, between six months and 12 months of age. So if you're going there and that is the age of your infant, then it is recommended that they be vaccinated, and then, because they are less than 12 months of age, once the child hits 12 months of age, we'll vaccinate again and get back on our routine series. Speaker 1 24:21 So if you're considering international travel, though, just like any vaccination takes about two weeks to build up that immunity, make sure you have that two weeks for the time to plan the travel and get the vaccination and get the immunity built before you embark on that flight. So as Dr. Angelo said, you know if the child is less than one year of age and parents want to decide they should get an early dose between six to 11 months, and then follow the routine schedule thereafter. If the kid is over one year, make sure they have gotten their first dose. But if they are between that 12 to 15 months, if not, get that first dose immediately, and there needs to be at least 28 day separation between the first and the second dose, so second dose can be received 28 Days after that first dose, and then, like we said, teens and adults who don't have evidence for immunity, they should get their first dose immediately, and second dose 28 days after that first dose. So the recommendation for the International travels are a little bit different than United States travel. Dr. Sean Kane 25:16 So what about the patient who, let's say they're in their mid 20s and they don't know their vaccination history. They don't have any records. And you ask them, Did you get your MMR vaccine when you were little? And they gave you the teenager answer of, Oh no. What is the right approach to that patient where there's no documented immunization history for the patient for MMR, we often Speaker 2 25:38 say, when in doubt, vaccinate. However. We could test for antibodies if we wanted to to see if immunity exists. I think, Dr. Patel, you had noted maybe some cost concerns, right? How you evaluate which is better just vaccinate or start testing to see? Speaker 1 25:56 Yeah, there's some debate about, you know, drawing the titers and having the cost of the titers versus drawing the titers occurring that cost and then the results having, well, you don't have enough titers, so you need to get a vaccination. So do we go through the titer and then get the dose, or do we just go ahead and give the dose and not worry about the titer? And so that's a decision that maybe the doctor and the person needs to make it individually. But in a lot of the cases, they have opted out of doing the titer and then just receiving that first dose vaccine or one dose vaccine. Dr. Sean Kane 26:25 And just to clarify, the titer is an IgG antibody titer, as opposed to IgM, which is the titer that we use for someone where we suspect they currently have measles. The IgG is what sticks around and provides that long-term immunity for you. Speaker 1 26:40 Yep, and then we have that one dose population that was dosed between 1957 and 1989 when the CDC schedule was updated with the two MMR doses. So there's a lot of questions from those individuals, like, do I need to get revaccinated? Well, no, most people would have the immunity even with that one we remember we talked about one dose can give you up to 95% immunity. However, one of the recent cases in the outbreak that occurred is was a lady who actually had that one dose and still acquired measles infection. So they were saying, if you're traveling in an endemic region, even if you've gotten that one dose, you might be able to get the second dose, or you should get the second dose. Speaker 2 27:24 And another interesting cut off would be if you got vaccinated before 1968 so as you recall, we mentioned, in 1968 the vaccine was improved and different strain was added to it, and prior to that, there was an inactivated vaccine available that really didn't work. And so someone was vaccinated before 1968 and they don't know if they got the live vaccine or don't know what vaccine they got at all. Is recommended that you be vaccinated with current MMR. Dr. Sean Kane 27:56 So let's say I would like to travel to New York City, and it turns out that that particular area of New York City that I'm traveling to happens to be one of these areas that has a measles endemic population. What are some considerations that I might think about prior to traveling? Speaker 1 28:11 Well, knowing you, Dr. Kane, I'm sure you got your measles vaccine so you all save there is nothing to be worried about. Nothing extra needs to be taking place. Awesome, okay, but let's say in a remote, remote or maybe a very horrible parallel universe. Dr. Kane lived and he did not receive a measles vaccine, then the recommendation would be for you to get a single dose vaccine, but Speaker 2 28:33 he is a healthcare provider, so I might tack on a second dose 28 days later, just to make sure you are protected as a healthcare provider, and the reason we do that is to protect our patients, right? It is our job as healthcare providers to make sure we are not causing undue harm. Speaker 1 28:48 Yeah, and I think Dr. Angelo, you alluded to this fact earlier, so follow CDC recommendations as they exist for US travel, which is pretty much similar to what the current recommendations are. However, if the local public health department has issued extra guidance you mentioned earlier, if the kids within that community, the resident community, are asked to be vaccinated prior to their indicated age, then the kids traveling within those endemic regions should also be vaccinated prior to their indicated age. Dr. Sean Kane 29:19 Now let's say I want to be a little bit more of a world traveler, and I don't want to just go to New York City, but I want to go to another country. What are some resources that I can look at to ascertain whether that country is a higher risk country or not? Speaker 1 29:33 Yeah, and I want to tie it back to the reasons behind the outbreak that we are seeing in 2019 a lot has to be tied to overseas travel patients who have not received measles vaccine and they've traveled to some endemic countries, mainly for this outbreak, we are aiming at Israel, Ukraine and Philippines, but other countries besides that, like Thailand, Vietnam, Japan and many more are experiencing outbreaks currently. So if you're worried about your international travels, there are actually online checkers available on CDC. Speaker 2 30:06 The CDC, as you mentioned, Dr. Patel, has great travel resources. And if you just look into your search engine and type CDC yellow book, it will take you right to the links for all the different travel information. And there are some great assessment tools where you can tell this feature where you're going, and it will spit out what vaccines you need based on your area of travel, which is a pretty neat tool that we can use. Speaker 1 30:32 So talking about who should be getting regular vaccine, who should be getting the extra dose if they're traveling outside of the US and the endemic regions in the US, are there any individuals who shouldn't be vaccinated, and wouldn't they be at higher risk of the disease if they are not able to get the vaccine? Speaker 2 30:50 That is correct, and as we mentioned, this is a live vaccine, so when we are working with live vaccines, there are certain individuals where we do need to be cautious about vaccinating pregnant women, as we talked about earlier, those who are immunocompromised. Interesting, though, Dr. Patel's brought up the CDC vaccine schedule — it specifically mentions HIV and CD4 counts: people with CD4 counts >200 can be vaccinated, whereas CD4 <200 are a contraindication. Speaker 1 31:28 And I think the other examples of immunosuppression would be having certain type of cancers, leukemias and lymphomas, or being on medication that can make them immunocompromised, such as, you know, a chronic use of corticosteroids. Example: prednisone more than 20 milligrams per day, or 2 mg/kg/day. So I Dr. Sean Kane 31:47 think it would be nice to kind of wrap up this episode talking about how we actually give the vaccine. So we've talked about who gets it, who doesn't get it, what it looks like when you do have the measles infection, anything from a pharmacist perspective, about administration of the vaccine or storage of vaccine that would be helpful for the audience to know about, Speaker 2 32:06 again, because it's a live vaccine. A lot of times with our live vaccines, we're giving them in different ways. And so one common area for live vaccine to be injected is subcutaneously. And so this is how the MMR is given. It's a subcutaneous injection for our adults and goes on the back of the upper arm, and in younger kids, especially, it can also be in the back of the arm or into the thigh using a much smaller needle. So in this case, we use a 5/8-inch needle to make sure that we are in the subcutaneous space. Speaker 1 32:40 As we mentioned earlier, if they're receiving two doses because they're traveling internationally or whatnot, right away, we need minimum of 28 day separation between the two doses, as it is a live vaccine, we know that reconstitution is also required using a diluent that's provided with the vaccine. You don't want to use a diluent that has preservative in it, because it kills the live vaccine in itself. So make sure that their pharmacies or the providers offices are using the diluent that's provided with the vaccine. Dr. Sean Kane 33:15 So then, how do we keep those little viral particles all happy in storage, to make sure that they don't die off and then don't do their job when we inject it into a patient. Speaker 1 33:23 So when it comes to storing, the vaccine, can be stored either at freezer temperatures or refrigerator temperatures, but however, before reconstituting, it needs to be at refrigerator temperatures. And after recon, they can it can stay in the refrigerator temperatures, but has to be discarded after eight hours, because we cannot use it thereafter. Speaker 2 33:42 So if you're going to mix the vaccine, make sure you have an arm or a leg to put it in, Speaker 1 33:47 right but you don't have to store the diluent in the refrigerator. It can stay at the room temperature, so it saves some room space. Dr. Sean Kane 33:53 So Dr. Angelo, if you had one piece of advice to leave our listeners with, what would it be regarding the current measles outbreak that we're having. Speaker 2 34:01 The outbreaks are scary, and I think what we are seeing right now, we don't know where it's headed, and so for our jobs as healthcare providers is to make sure that individuals are vaccinated, especially those who are able to be vaccinated, to protect those who cannot be vaccinated. That's the only way we're going to really get a handle on this and help control the spread of measles throughout the US and even globally, yep. Speaker 1 34:27 And all I would add is knowledge is power and CDC your best friend. So please check out some of the links that we are going to be posting about measles and the recent outbreak that belongs to CDC and immunize.org Dr. Sean Kane 34:39 and those notes for us are available at HelixTalk.com this is episode 101 we're also on Twitter, if you want to see some clinical pearls from previous episodes or announcements of new episodes as they come out. So with that, I'm Dr. Kane, I'm Unknown Speaker 34:52 Dr. Patel, and I'm Dr. Angelo. Thank Speaker 1 34:55 you so much for being here. Dr. Angelo. We appreciate your expertise and time. And with that, I'm going to say. Vaccinate hard. Narrator - Dr. Abel 35:02 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there to Narrator - ? 35:13 suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.