A stubborn measles outbreak that has plagued Southern California for two years has flared this summer in Riverside and San Bernardino Counties, causing two deaths and prompting concern that the disease could spread still faster with the start of the school year next month.
More than 500 cases of rubeola, or "10-day measles," have been reported in San Bernardino County alone since October.
In San Diego County, the number of cases of measles has dramatically increased but the outbreak has not approached the epidemic stage, said Nancy Bowen, acting health officer for San Diego County.
"We have had a definite increase so far this year," Bowen said last week. "We've had 159 reported cases so far in 1989, and last year . . . we had just 35." The outbreak has not caused any deaths, Bowen said.
Number of Cases Slowing
Despite the outbreak to the north and the fact that San Diego's case count is far above last year's, "the rate of reports has actually slowed down in recent months," Bowen said. "If it were increasing and increasing, and we couldn't get a handle on it, then I'd be tempted to say it's an epidemic. But we feel it's pretty well contained in San Diego."
The epidemic was especially evident at three San Bernardino County jails as well as the California Institution for Men in Chino, claiming the lives of two inmates and prompting mass inoculations of those who work and are housed in the detention facilities.
Gary Euler, a San Bernardino County epidemiologist tracking the outbreak, said the disease has struck residents in 18 widely scattered cities, from San Bernardino to Big Bear, and has so far defied efforts to stop its spread.
Although San Bernardino recorded about 32 cases annually over the past decade, the county has been struck by an average of 100 new cases a month since June. An unusually high rate of one in three patients has required hospitalization.
"We're doing what we can to get people immunized, but so far we don't have a handle on it," Euler said. "I don't think anyone has the answer as to why this has just taken off here."
Neighboring Riverside County has fared somewhat better, with 93 people contracting measles since the first reported case April 11.
Taking Outbreak Seriously
There have been no fatalities in Riverside County, but health authorities are taking the outbreak seriously nonetheless. After an inmate in the county jail system came down with the disease and quickly infected two others, officials launched a mandatory immunization program, inoculating 1,500 inmates and staff members. Transfers within the jail system also were limited to control exposure to the highly contagious rubeola virus.
Riverside County epidemiologist Randy Regester said Riverside's outbreak was initially concentrated in the region's eastern reaches, near Indio, but quickly spread west. He said public health nurses have interviewed all of the victims and have alerted anyone with whom they had contact.
"We've been real aggressive on the case investigation end of things in hopes of keeping control of it," Regester said.
Rubeola, or red measles, is a highly infectious viral disease characterized by a rash that covers the entire body. Its symptoms typically last 10 days, unlike those of rubella, or German measles, which persist about three days.
State health officials say Riverside and San Bernardino counties have been caught up in a rubeola epidemic that began in August, 1987. Initially, the outbreak was centered in Los Angeles, but it has fanned out to include the the two large counties to the east as well as Orange County to the south.
San Diego County health officials are using "aggressive public health measures" to maintain control over measles, Bowen said. The county regularly tracks down those who have come in contact with an infected person. Health officers can also administer immunizations and require that those with measles remain isolated until they are no longer infectious.
"These measures do work," Bowen said. "Even though measles is highly infectious, we've got a fairly high level of immunization in the county."
Measles cases reported in San Diego County have been evenly divided into three age groups: preschoolers, school-age children and adults.
Measles usually begins with a fever, itchy eyes, a runny nose and a cough, Bowen said. "By the third to seventh day, you get the red, blotchy rash on the face and all over the body," Bowen said.
Dr. Loring Dales, chief of the immunization unit for the state Department of Health Services, said the Southland epidemic is the most serious to strike California since 1977. More than 2,000 cases have been recorded so far, the majority occurring in 1989. Eleven deaths have been linked to the epidemic, and at least six other fatalities may be related.
Dales said most of the victims have been preschool-aged children in poor, inner-city neighborhoods, where public education about immunization is often deficient. Children under age 3 are particularly vulnerable to the high fever and bronchial infection associated with the disease.
"This has been a very difficult outbreak to contain," Dales said. "Unlike a school outbreak, where you have it confined, this has been very diffuse. It's not like we can target one area and go door to door."
Unusually Severe Symptoms
The disease has also caused an abnormally high number of fatalities and has brought unusually severe symptoms, with 20% of the victims suffering pneumonia and the same ratio requiring hospitalization. Typically, 5% of measles victims need hospital care, Dales said.
Although rubeola usually surfaces among elementary schoolchildren, this outbreak has also taken its toll on adults, who, like infants, are much more vulnerable.
In San Bernardino, half of the victims have been of preschool age, while one-quarter were 19 and older. Many of the adult cases have been among jail inmates, a particularly dangerous situation because of the crowded confines.
While about 85% to 90% of the young adult population is immune to measles, "when you have barracks-type living, like in a jail, measles will find the 10 to 15% who aren't protected and you've got trouble," Dales said.
Euler said the county instituted a mandatory inoculation program in the jails and have had no new cases since it concluded Tuesday.
'Keeping Fingers Crossed'
"It's been 15 days since our last case left the jail, so we're keeping our fingers crossed," Euler said. There was a case at the county's Juvenile Hall last week, however, so authorities immunized nearly all of the 340 youths at that facility.
With the first day of school not far off, health officials face a new challenge: how to protect the thousands of pupils ready to flood back to class.
"Obviously with school back in and large numbers of children congregating together, it increases the risk," said Barbara Cole, supervising public health nurse for Riverside County.
Cole said the health department will offer low-cost vaccinations at a special back-to-school clinic later this month and will repeat the service on opening day of the school year.
In San Bernardino, where hundreds of students lacking proper immunization records were barred from school at the end of last year, a similar campaign is under way.
"We've had 46 schools involved since this thing began, so we've sent lots of notices home," Euler said. "Any student who isn't properly vaccinated will be excluded until we see proof that they are."