Current Measles Outbreak

Updated 2/6/19

We have understandably been receiving many questions and concerns about the current measles outbreak that originated in Vancouver. While the outbreak has continued to spread to some degree, recommendations have not changed at this time. The short answer is that no further action is needed if your child is following the recommended vaccination schedule unless they have had direct contact with a measles case within the past 72 hours or have classic symptoms. If so, please call our office to confirm if any management might be needed. As of now the cases have been almost exclusively among unvaccinated individuals, but sometimes outbreaks can extend into vaccinated communities especially when herd immunity is not high enough. We will be watching this closely, and are anxiously waiting for this outbreak to blow over and hope that no further children are harmed.

Here are our recommendations and answers to common questions, based on age range of the child:

  1. Infants 0 - 6 months: no change to vaccine schedule recommended; first MMR at 12 months. Maternal antibody is still present and offers good protection, but reasonable precautions* won’t hurt.

  2. Infants 6 - 12 months: no change to vaccine schedule is recommended; first MMR at 12 months (but there could be some exceptions in specific cases). Maternal antibody is fading, but may still be present in variable amounts. It is ideal to wait until 12 months for the first MMR to prevent maternal antibody from interfering with the long term effectiveness of the vaccine. You can actually do the MMR early (between 6-12 months), and it can offer some additional short term protection, however it won’t count towards your vaccine schedule because of the maternal antibody. As of now public health officials are NOT recommending families get this additional dose of MMR unless the outbreak worsens substantially, and we agree with this recommendation. We prefer to do the vaccine at the age we know it works best unless we are starting to see measles cases and complications in infants while waiting until 12 months to get this dose, and as of this writing we have not. However, if you live in or frequently visit a community with many developing cases or unusually low vaccination rates, this is an optional measure that may be reasonable - just call our office to schedule and let us know that you are aware of these recommendations but wish to proceed with early MMR anyway as a special case scenario. Otherwise, for routine exposures here in Portland, reasonable precautions* are what we recommend.

  3. Children 1 - 3 years old: If your child has not yet had their first MMR (normally given at the 12 month well check), call our office right away to schedule. Otherwise, no change to vaccine schedule is recommended, with first MMR at 12 months and second MMR at 4 years. While it is acceptable to do the second MMR early (as early as 28 days after the first MMR), and it would actually count towards completing your child’s immunization status, as of now public health officials are NOT routinely recommending families get this dose of MMR early unless the outbreak worsens substantially, and we agree with this recommendation. Here’s why: the first dose provides excellent protection for most kids, and the second (“booster”) dose makes sure they have lasting immunity. That long term protection is believed to be better when the booster is received at age four than if given early, so we prefer to stick to that schedule for best long term immunity unless the short term risks are exceedingly high. As of this writing there has only been one case of measles among those with a single MMR dose. I don’t at this time have further details about that case (age, severity of disease, etc), but typically if cases do occur they are substantially more mild and without complication. So as of yet there has not been any urgency to go out and change the schedule for all these children to something that might benefit them less. With that said, if you live in or frequently visit a community with many developing cases or unusually low vaccination rates, this is an optional measure that you may choose to do - just call our office to schedule and let us know that you are aware of these recommendations but wish to proceed with early MMR booster anyway as a special case scenario. Otherwise, for routine exposures here in Portland, reasonable precautions* are advised, with second MMR booster at age 4.

  4. Children ages 4 and up: If your child has not yet had their second MMR (normally given at the 4 or sometimes 5 year well check), call our office right away to schedule. Otherwise, if your child has had both MMR doses, no further action is needed - your child is fully protected.

*Reasonable precautions = over the next ~ 4 weeks while this is expected to be going on, it is reasonable to avoid places that have higher risk for transmitting measles to your child if they have not yet had their first or second MMR dose. The age of highest concern would be 6-12 months because they have the least protection. For example, avoiding crowded indoor public venues especially where higher percentages of unvaccinated children might be found. By “reasonable”, we mean as an example, if feasible, going shopping for example at less busy times of day, but if not feasible, don’t avoid shopping - your family needs groceries, etc., and we are not at a “stay home and lock your doors” kind of level at this time. Don’t keep your child out of all activities, but consider prioritizing activities where fewer children at a time are playing together, playing with other kids who you know/know their vaccination status, and/or at venues that tend to have pretty standard vaccination rates and keep their area and toys clean. Measles can be airborne, so there is not foolproof way to prevent it in these settings, but it can also be spread by contact so keeping surfaces clean and washing hands is also good practice.

For more questions about Measles and this current outbreak, please view this FAQ page maintained by the OHA.

We've moved!

We are excited to announce our clinic’s new location, offering some nicer features and a bit more space. Here is the new address:

5231 NE MLK Jr Blvd
Portland, OR 97211

We are located in the Vanport Square building, one block north of Alberta on the west side of MLK. There is a parking lot behind the building, and there are two rows of parking - you may park in either row. The entrance is from the parking lot at the back of the building. If you prefer to use the door on the street side/front of the building instead, simply ring the bell.

Our phone and fax numbers are the same. Our clinic hours will be mostly the same, open daily M-F, although each doctor’s schedule may adjust slightly as the space affords us more flexibility.

Current schedule:

  • M:      J*   M
  • Tu:        M*
  • W:      J  M
  • Thu:      M
  • Fri:        J

(J = Dr. Joel, M = Dr. Meri, * = late day, where the doctor starts a couple hours later in the morning and stays a couple hours later in the evening for patients who need later appointments.)

Starting Jan 1st:

  • M:      J*   M
  • Tu:        M*
  • W:         J
  • Thu:      M
  • Fri:     J   M

We are excited to have a little place of our own, and can’t wait to share it with you! We have worked hard to make our space fun, inviting, functional, and designed around the unique needs of a smaller, more personal pediatric practice. There are still a few finals touches of course, so forgive any mess as we get settled over the next few weeks. 

We plan to schedule an open house as soon as we are settled, and would love to see you all there!

Time to change the 15-minute doctor visit?

Here's a great article that appeared in Forbes about the archaic and arbitrary 15 minute doctor visit. It's a nice validation for why our clinic schedules 30-60 minutes per patient as standard.

To take things further, the article doesn't even mention that the problem even goes beyond this: it is common practice in actuality to spend only 10 minutes with the patient during a "15 minute" visit!

(If you want to know how/why, it's a bit complicated, but here's the gist: doctors are not actually required to spend the whole 15 minutes to bill that amount - completing all the necessary components during a visit will also qualify for that amount (eg. a certain number of questions, physical exam findings, etc.). In offices that are very streamlined, doctors can hit all those requirements in 10 minutes or less.)

Sayward Canoe Route

Portaging the canoe into a tricky put-in spot on Surprise Lake

Portaging the canoe into a tricky put-in spot on Surprise Lake

We're back from summer vacation! I had a lovely excursion into the wilderness this summer on the Sayward Canoe Circuit on Vancouver Island, BC. Rustic camping on tiny islands far from civilization, listening to the echoing whale of the loon, eating wild huckleberries, thimbleberries, salmonberries and blueberries. It was exactly the yearly rejuvenation I needed, and I can't wait to go back! It was about 40 miles of canoeing and portaging, and well worth it to find such peace and solitude. I highly recommend the natural beauty of Vancouver Island, BC, if you've never been there. There are several family-friendly access spots to some of the lakes on the circuit, such as Morton Lake Provincial Park, as well as deeper access into the wilderness for those with older children up for an adventure. Here are some photos of my trip:

Want to get your kids out into the wilderness more but don't know where to start? That's easy! Go to Trackers Pdx - an awesome program that offers camps and outdoor programs for all ages. It's never to early for kids to learn about wilderness safety, survival, wild plants and protecting our natural world.

Please post what you're doing this summer, and if you recommend it to other families!

Alternative vaccine schedules finally evaluated

While alternative vaccination schedules have become increasingly popular, up until now there has been little data evaluating whether any of the claimed benefits of an alternative schedule are actually real. As many of you know, I’m not the type of doctor to dismiss something out of hand just because it goes against the grain, or because it’s different. I challenge the status quo and embrace the alternative when it’s the right thing to do. But the difference is I would never do or recommend something just because it’s the in thing, I would only recommend it if it were actually better for my patients. And in order to understand this, we need to start collecting information and stop collecting opinions - we need to actually look at kids who delay or skip vaccines and compare them to those that get them on time, and see how they’re doing several years later. At long last, that’s been done. Let’s review what they found.

The long-awaited study was just published this year in Pediatrics from the Division of Pediatric Infectious Diseases at the University of Louisville School of Medicine. The study tracked 1,047 children who received various different vaccine schedules in their infancy. Some had all the vaccines on time, some delayed by various amounts, and some had no vaccines at all.  The children were then evaluated at 7-10 years of age to see if there were any differences. The 7-10 year evaluation was very in-depth, with 42 specific neuropsychological tests (!) including assessments of speech and language, verbal memory, achievement, fine motor coordination, visuospatial ability, attention and executive functioning tasks, behavior regulation, tics, and general intellectual functioning. Whew!! In other words, very, very thorough, with a good, long follow-up period.

What did they find? Interestingly enough, those that delayed their vaccines the most did the worst on many of the tests. In fact, those that got all their vaccines on time showed better performance on 12 of the 42 outcomes, and those that skipped or delayed did better on none of them. Now, you would be correct if you said “wait a minute - what about confounding variables?” Fortunately, the researchers thought about that, too. They adjusted for a long list of confounding variables, including education level, income level, breastfeeding rates, maternal IQ...even tuna and nicotine exposure were among many more variables analyzed. And even after adjusting for these variables, those that got their vaccines on time still did better on a couple of the outcomes, and those that delayed their vaccines still didn't do better on any of them. How could it be that the neurodevelopmental outcomes might be better in those that receive all the vaccines on time? Easy! Don’t forget that most of the infant vaccinations specifically protect babies against things that cause brain damage: pertussis, meningitis, sepsis, encephalitis, etc... 

In summary, there are few important points to take home here:

  1. Delaying or skipping vaccines does not improve neurologic, psychologic, behavioral or developmental outcomes, as the proponents of alternate schedules claim, but it does increase risks.

  2. All the people in this study live within a population that has herd immunity. This means the people without timely vaccination are still benefitting from the herd immunity gained from those with timely vaccination. Even with this being the case, they still do worse by delaying vaccines, albeit subtly so. Imagine if you took this benefit away? If you compared entire populations with and without timely vaccination, you would see a much more massive benefit to timely vaccination, and massive risk to delaying or skipping vaccines - the true risk. This study merely proves there is no benefit to delaying; that doing all of the vaccines on time does not cause any neurologic, psychologic, behavioral or developmental problems when compared to spreading them out or skipping them. 

  3. On a side note, it was interesting from a social perspective that those who delayed vaccines tended to have lower education and income levels. It's frustrating to the community advocate in me that those with less education or money should receive less accurate information, and ultimately receive worse health care. I am passionate about providing equal time, equal healthcare and equal information to all families, and hope to bridge that gap! I think part of this is about trust as well; those less fortunate may have been hurt by the medical system and are less likely to trust their doctors. I hope to bring trust back into the relationship as well, and want all my patients to know that my care comes from a place of love, compassion, and equality.

Citation:  “On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes.” Michael J. Smith, MD, MSCE and Charles R. Woods, MD, MS.

Pediatrics 2010;125;1134-1141