When Measles Comes To Town, What’s a Doc To Do?

Measles outbreaks around the world are becoming commonplace. Young physicians are seeing the disease for the first time in their careers.  Public health officials are managing outbreaks that haven’t been seen for decades. There is definitely a palpable fear mounting all over the world for what our immediate future holds in terms of the spread of vaccine-preventable infectious diseases.

There are a number of theories for why measles is making such a comeback, and by far the most plausible explanation is that too many parents are choosing, despite consensus medical recommendations, to not immunize their children.  As the number of unvaccinated children rises, so too will the rates of measles along with its hideous complications: pneumonia, blindness, meningitis, encephalitis, and death.

Yesterday, a colleague of mine asked me what our office policy is regarding managing patients with suspected measles infections in the clinic. The honest answer is that we don’t have one.  Until recently, there hasn’t really been a need for such a policy.  But, as measles rates rise in North American big cities, so too does the chance that someone contagious will walk through my clinic doors. The reality is that the moment someone with measles walks into a building, everyone in that building has been potentially exposed.  What if that building was a medical building? What if there was a pediatrics practice in that building with a waiting room crammed full of babies too young to get immunized? It’s a horrifying thought.

Physicians are beginning to plan for this in the hopes of mitigating this risk.  Many clinics have implemented the “fire all vaccine-refusing patients” policy.  I have previously shared my thoughts about this. But how does the situation change when there is a measles outbreak in my city? How would I feel about a non-immunized patient coming to my practice during a local measles outbreak?  In the absence of an outbreak, the risk of that patient bringing measles into the office is trivial.  But when measles is spreading through the community, that risk increases dramatically. One becomes contagious before knowing that one has measles.

On a regular basis, there are patients with cancer, patients on chemo, patients with immune deficiency, and babies too young to receive their measles vaccine sitting in my waiting room.  Providing a venue for the spread of measles (and other vaccine-preventable infectious diseases) to these patients is not only unfair to them, but a liability for me. It is my responsibility to keep my patients safe.

On the other hand, an unimmunized child (whether because she is not able to receive vaccines or her parents made the decision against immunization) has the right to receive medical care.

I decided to share this dilemma with my social media community as a Twitter/Facebook Poll.

I asked:

7 folks responded with a simple “Yes”.

Below is a sample of other insightful responses I received:

“So then how would unvaccinated patients ever get a vaccine or hear more about it if they aren’t allowed to your clinic?”

“Yes. They should pay for a house call.”

“I respect parents’ choices, but I wouldn’t take my fully vaccinated child to you if you didn’t. Certainly not a newborn.”

“Absolutely justified. They must understand it’s for their PROTECTION. They chose not to protect themselves, you do it for them.”

“My gut reaction is yes…but how do you turn away sick kids? not an easy question for doctors.”

“Yikes! Those poor kids still need care but they put your infant patients at risk.”

“Only if it isn’t going to stop them getting access to health care. Up to and including you doing a home visit. Otherwise wouldn’t that be contrary to the Hypocratic Oath?”

“Isolate? Book at end of day after clinic closed?”

“Quarantine them in a separate area. If not you’re punishing the kid for parents poor judgement…”

“A febrile/symptomatic unvaccinated person should not be in the vicinity of other patients. With respiratory virus season still in effect, that’s at least 3-5 feet. For measles (or suspected), it’s airborne precautions. Basic rules of infection control/precautions. Since you’re not able to implement those, you should (and are probably in the medico-legal right to) exclude those patients from your clinic space. Of course, it would be defensible because of it would be based on infection control/public health reasons, and not because of a personal opinion that anti-vax people are negligent.”

“You are entitled to defend the health of all your patients.”

“Wow!!! No! absolutely not!”

“I’m appalled a doctor would be asking such a question.”

“If there are cases of Measles in [town], the children should remain home and that doctors should be coming to their homes to treat them, this way the spread of the virus can be contained”

“Please do. Unless they are coming in to be vaccinated, or they can’t be vaccinated for medical reasons.”

Not unexpectedly, there were opinions from all over the map.  What resonated most with me was the notion that as a physician and clinic director, I am responsible for the safety of any/all patients who come to clinic. If the spread of measles becomes a clear and present threat, it is justifiable to take measures that will protect my patients, especially the sickest, youngest, and frailest among them.

I hope to never be faced with this dilemma.

If you have any thoughts, recommendations, or experience making these sorts of challenging ethical decisions, please share your thoughts below in the comments section.