Contraception must not be ignored in climate change debates

Wider distribution of contraceptives through investment in family planning programmes would have a profound effect on the climate and the environment, as well as on human welfare, experts have argued. They said population growth is fuelling greenhouse gas emissions and the environmental crisis and almost half of pregnancies globally are unintended, yet the climate debate has so far largely ignored the importance of improving access to effective contraception.

In their commentary* in today’s BMJ Sexual & Reproductive Health, Dr John Bongaarts and Dr Regine Sitruk-Ware of the Population Council in New York point out that contentious ongoing policy debate about potential interventions against global climate change focuses on switching to renewable energy sources and increasing energy use efficiency, but they say we must prioritise other approaches to limit greenhouse gas emissions given the urgency of the problem and the lack of political will. They recommend improving global access to effective contraception as one such policy, because: population growth is a key driver of climate change; higher and more effective use of contraception reduces unplanned pregnancies and hence population growth; and many more women and men would freely choose to use contraception if only it were available and acceptable.

They cite research that has found that women who want to avoid pregnancy might still not use contraceptives for a mixture of social, economic, health and service-related reasons. These include lack of access and high cost for women in poor areas, as well as myths about hormones, traditional social norms (particularly in traditional and/or patriarchal societies) and disapproval of husbands, noting: “Fear of side effects and dissatisfaction with available methods are often the dominant reasons women are reluctant to use (or continue to use) contraception.”

They call for culturally sensitive media campaigns developed in collaboration with community leaders, investment in men’s and women’s education and careful counselling, to change norms around women’s roles in society and expectations around their ability to exercise their reproductive preferences, and to address concerns and incorrect rumours about contraceptive methods and side effects. They add: “Access to a wide range of options is essential to maximise the chances that clients’ needs and concerns are satisfied at different times of their reproductive lives.”

They discuss methods still under development for both male and female contraception, noting that these will offer more choices to women and men, thus reducing unplanned births and abortions – but insisted we need not and must not wait for these innovations.

They conclude: “Wider distribution of contraceptives already on the market through greater investment in voluntary but underfunded family planning programmes is sufficient to raise contraceptive use substantially. This in turn would have a profound positive impact on human welfare, the climate and the environment.”

Patients, doctors may not share priorities for chronic diseases

Carolyn Crist

Patients and doctors often have different views about which chronic health conditions are their top priorities, suggests a study in France.

After separate surveys of patients and their physicians, researchers found that priorities matched up for some conditions, such as diabetes and hypothyroidism, but diverged on others, like anxiety and sleeping disorders.

“An increasing number of patients live with multiple chronic conditions, especially among younger cohorts,” said Dr. Stephanie Sidorkiewicz, a general practitioner in Paris and a researcher at Paris Descartes University, who led the study.

“Against this backdrop, physicians increasingly have difficulties understanding patient expectations and responding appropriately to their individual situations, especially given they at the same time face increased pressure on their time,” she told Reuters Health by email. “However, understanding patients’ perspectives is necessary to set realistic and shared treatment goals.”

As reported online September 9 in Annals of Family Medicine, Sidorkiewicz and colleagues surveyed 233 patients from 16 general practices in Paris in 2017. All patients had been seeing their doctor for at least a year. Patients and doctors checked off all of the patient’s current chronic conditions based on a list of 124 conditions and ranked the three top-priority conditions.

About 8 in 10 patients reported two or more chronic health conditions. The three most common were high blood pressure, osteoarthritis and chronic anxiety disorder.

Agreement between doctors and patients on the number of conditions a patient had was moderate, but agreement on specific chronic conditions ranged from poor to very good.

Among 153 patient-doctor pairs where each made a priority list, about 88% had at least one matching priority. However, 29% of patients’ first priorities didn’t appear anywhere on their doctors’ lists. In addition, 19 pairs, or about 12%, had no matching priorities.

Doctors and patients agreed the most on high blood pressure, hypothyroidism and diabetes, potentially because these have more concrete measurements and guidelines, the study team notes. They also agreed somewhat on asthma, obesity, osteoarthritis and eczema. However, patients tended to rate their chronic anxiety, sleeping and low-back pain conditions as higher priorities, likely due to the impact on their daily lives.
“We were somewhat expecting to find some discrepancies between patients’ and physicians’ priorities, but the extent of these discrepancies was much more severe than we had expected,” Sidorkiewicz said. “Patients and doctors even disagreed on the presence of certain diseases in patients.”

The results align with similar studies in other countries, including Switzerland, where doctors are unaware of patients’ priorities for about 1 in 4 patients, said Dr. Stefan Neuner-Jehle of the University of Zurich, who wasn’t involved in the current study.

“The patient has a role in this procedure as well, in terms of actively thinking about priorities of care before the encounter and openly talking during the encounter,” he told Reuters Health by email. “Standardized patient-centered approaches and tools may be helpful for both physicians and patients.”

Examples of such tools that are available online include the Mayo Clinic’s ICAN Discussion Aid ( and Patient Revolution’s Plan Your Conversation Cards (

“Clinicians have expertise in the guidelines, evidence and healthcare knowledge, and patients have expertise in their lived experience. We need both,” said Kasey Boehmer of the Mayo Clinic’s Knowledge and Evaluation Research Unit in Rochester, Minnesota, who also wasn’t involved in the study.

These two-way conversations can help especially with chronic conditions that are difficult to diagnose and treat and don’t fit under a traditional medical paradigm, such as chronic low back pain, fibromyalgia and autoimmune diseases, she said.
“That background knowledge that we may or may not be on the same page is helpful,” she told Reuters Health by phone. “Give yourself permission to share those experiences in your life and how your health and your healthcare is intertwined with your life.”

Omega-3 supplements ‘no benefit’ to type 2 diabetics

Mark Gould

Thursday, 22 August 2019

People with type 2 diabetes “should not be encouraged” to take omega-3 fish oil supplements, researchers from the University of East Anglia say.

Writing in the BMJ* the authors say they carried out the most extensive systematic review of trials to date to assess effects of polyunsaturated fats on newly diagnosed diabetes and glucose metabolism, including previously unpublished data. They reviewed 83 studies and found no evidence of that supplements were either harmful or beneficial.

They found that long chain omega-3 had little or no effect on likelihood of diagnosis of diabetes or measures of glucose metabolism such as HbA1c, plasma glucose or fasting insulin, or homoeostatic model assessment for insulin resistance.

Dr Lee Hooper, who led the research, told the BBC there had been concerns omega-3 supplements might make glucose control more difficult. However, people with diabetes or who are at risk of developing it, can also have high levels of triglycerides – a type of blood fat – which omega-3 has been shown to reduce.

She said: “We found neither harm nor benefit.”

She described fish oil supplements as “really expensive stuff”.

“If somebody’s at risk of diabetes, there are much better things to spend money on, like a physical activity – or oily fish,” she added.

Douglas Twenefour, deputy head of care at Diabetes UK, said: “Eating a healthy, varied diet is incredibly important, and we know that certain foods – including fruits, vegetables, wholegrains, yoghurt and cheese – can help to lower your risk of type 2 diabetes.

“While omega-3 fatty acids are crucial for our overall health, it’s generally better for people with type 2 diabetes to get their intake by eating at least two portions of oily fish a week, than by taking supplements.”

But Dr Carrie Ruxton, from the industry-funded Health and Food Supplements Information Service, said: “While I would prefer people to follow the government’s advice and eat more fish, this isn’t the reality and a daily omega-3 supplement – whether from fish oil or algae – can bridge the gap.”

Drug-resistant superbugs spreading in European hospitals

Ingrid Torjesen

Tuesday, 30 July 2019

Antibiotic-resistant strains of Klebsiella pneumoniae, an opportunistic pathogen that can cause respiratory and bloodstream infections in humans, are spreading through hospitals in Europe, research* published in Nature Microbiology has found.

Certain strains of K. pneumoniae are resistant to the carbapenem antibiotics that represent the last line of defence in treating infections and are therefore regarded as extremely drug resistant.

Researchers at the Centre for Genomic Pathogen Surveillance, based at the Wellcome Sanger Institute, University of Freiburg and their partners, analysed the genomes of almost 2,000 K. pneumoniae samples taken from patients in 244 hospitals in 32 countries.

They identified a small number of genes that, when expressed, can cause resistance to carbapenem antibiotics. These genes produce enzymes called carbapenemases, which “chew up” the antibiotics, rendering them useless.

Of concern to public health is the recent emergence of a small number of “high-risk” clones carrying one or more carbapenemase genes, which have spread rapidly. It is thought that the heavy use of antibiotics in hospitals favours the spread of these highly-resistant bacteria, which outcompete other strains that are more easily treatable with antibiotics.

Dr Sophia David, based at the Centre for Genomic Pathogen Surveillance, said: “The ‘One Health’ approach to antibiotic resistance focuses on the spread of pathogens through humans, animals and the environment, including hospitals. But in the case of carbapenem-resistant Klebsiella pneumoniae, our findings imply hospitals are the key facilitator of transmission – over half of the samples carrying a carbapenemase gene were closely related to others collected from the same hospital, suggesting that the bacteria are spreading from person-to-person primarily within hospitals.”

Antibiotic-resistant bacteria samples were also much more likely to be closely related to samples from a different hospital in the same country rather than across countries – suggesting that national healthcare systems as a whole play an important role in the spread of these antibiotic-resistant bacteria.

Despite the clear threat that carbapenem-resistant K. pneumoniae pose to patients, more effective infection control in hospitals, including consideration of how patients move between hospitals and hygiene interventions, will have an impact.

Professor Hajo Grundmann, co-lead author and head of the Institute for Infection Prevention and Hospital Hygiene at the Medical Centre, University of Freiburg, said: “We are optimistic that with good hospital hygiene, which includes early identification and isolation of patients carrying these bacteria, we can not only delay the spread of these pathogens, but also successfully control them. This research emphasises the importance of infection control and ongoing genomic surveillance of antibiotic-resistant bacteria to ensure we detect new resistant strains early and act to combat the spread of antibiotic resistance.”

It is estimated that 341 deaths in Europe were caused by carbapenem-resistant K. pneumoniae in 2007; by 2015 the number of deaths had increased six-fold to 2,094. The high number of deaths is down to the fact that once carbapenems are no longer effective against antibiotic-resistant bacteria, there are few other options left. Infants, the elderly and immuno-compromised individuals are particularly at risk.

Over-75s stopping statins face increased heart attack risk

Ingrid Torjesen

Wednesday, 31 July 2019

Stopping statins after the age of 75 increases the risk of heart attack by almost half and the risk of stroke by around a quarter, a study* published in European Heart Journal has found.

For the study, which is the first to evaluate the impact of discontinuing statins taken for primary prevention in older people, the researchers analysed data from the French national health insurance claims database and information on hospital diagnoses and clinical procedures. They were able to get comprehensive information on statin use, as statins are available by prescription only in France.

They looked specifically at all patients who had turned 75 between 2012 and 2014, who had been taking statins for at least 80% of the time in the previous two years. They included only people with good cardiovascular health in the analysis and excluded all those who had been diagnosed with cardiovascular disease and anyone who was taking other medications to treat or prevent heart or blood vessel problems.

In total 120,173 people aged 75 between 2012 and 2014 who had been taking statins continuously for two years were enrolled and followed for a maximum of four years (average of 2.4 years). During this time 14.3% (17,204 people) stopped taking statins for at least three consecutive months, and 4.5% (5,396 people) were admitted to hospital for a cardiovascular problem.

Those who discontinued their statins had a 33% increased risk of any cardiovascular event. The association was stronger for admissions to hospital for heart problems; there was a 46% increased risk of a coronary event, while the increased risk of a blood vessel problem, such as stroke, was 26%.

Dr Philippe Giral, an endocrinologist specialist in prevention of cardiovascular disease at Pitié-Salpêtrière Hospital (part of Assistance Publique-Hôpitaux de Paris), Paris, France, who led the research said that although further, randomised studies are needed before guidelines can be updated, he would advise elderly people who are taking statins to prevent cardiovascular disease to continue taking them.

“To patients, we would say that if you are regularly take statins for high cholesterol, we would recommend you don’t stop the treatment when you are 75. To doctors, we would recommend not stopping statin treatment given for primary prevention of cardiovascular diseases in your patients aged 75,” he said.

The researchers found an unexpectedly low statin discontinuation rate (14.3%) among the people they studied, but believe this is probably due to the fact that they included only people who had been taking statins continuously for the previous two years. A recent meta-analysis** of data from 40 countries found a 40% non-adherence rate among statin users aged 65 years and older, and the overall French population of 75-year-olds, from which the people in this study were derived, had a similar rate of non-adherence among statin users: 44% had not taken statins for at least 80% of the time in at least one of the preceding two years.

Commenting on the study, Professor Kausik Ray, chair in public health, Imperial College London, said: “A previous analysis, from a collaboration called the Cholesterol Treatment Triallists Collaboration and published in the Lancet earlier this year, suggests that in randomised trials older patients taking statins derive similar relative benefits to younger patients taking the medication.”

He added: “A specific randomised trial called STAREE, in Australia, is evaluating this from a trial perspective.”

“Old age itself – particularly reaching the age of 75 and above – puts people at increased risk of a heart attack or stroke,” Professor Sir Nilesh Samani, medical director, British Heart Foundation, said.

“Age should not be a barrier to prescribing these potentially life-saving drugs to those people who are likely to benefit.”

Is Caffeine Fueling Your Anxieties?

By Robert Preidt
HealthDay Reporter

FRIDAY, July 19, 2019 (HealthDay News) — If you struggle with anxiety, you might want to skip that second cup of coffee, new research suggests.

For some people, caffeine may help with concentration and provide an energy boost, but it can cause problems for those with general anxiety disorder, said Dr. Julie Radico, a clinical psychologist with Penn State Health.

“Caffeine is not the enemy,” she said in a university news release. “But I encourage people to know healthy limits and consume it strategically because it is activating and can mimic or exacerbate the symptoms of anxiety.”

Low doses of caffeine are in the range of 50 to 200 milligrams (mg). Consuming more than 400 mg at once may lead to feeling overstimulated and anxious, and bring on symptoms such as racing heart, nausea or abdominal pain.
Anxiety is a common problem, but many patients and their doctors don’t think about caffeine as a potential contributing factor, said Dr. Matthew Silvis, vice chair of clinical operations in the division of family medicine at Penn State Health.

“We want people to consider whether there may be a connection between their caffeine consumption and anxiety,” he said.

As well as being a potential problem for people with anxiety, caffeine can interact negatively with medications for seizure disorders, liver disease, chronic kidney disease, certain heart conditions or thyroid disease, Silvis noted.

“Medical disorders that a patient may already have can become more difficult to control,” he said.

In terms of amounts of caffeine, an average cup of home-brewed coffee has about 100 mg, compared with 250 mg in a tall Starbucks coffee and as much as 400 mg in energy drinks. A can of Mountain Dew has 55 mg while a can of Coca-Cola has 35 mg.

Many vitamin and sports or nutritional supplements also contain caffeine, but many people don’t think to check the labels of those products, Silvis added.

Diabetes drug cuts cardiovascular and kidney problems

By Jo Carlowe

A large international trial has linked the use of the drug dulaglutide with a reduction in cardiovascular events in middle-aged and older people with type 2 diabetes.

The clinical trial* followed more than 9,900 people in 24 countries. During more than five years of follow-up, cardiovascular events like heart attacks and strokes were reduced by 12% in people taking dulaglutide compared to people taking a placebo.

This effect was seen in both men and women with or without previous cardiovascular disease. In addition, during the same period, the drug reduced the development of kidney disease by 15%.

The trial was led by the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences, Canada. Two papers describing the cardiovascular and kidney results of the trial were published in the journal The Lancet from the study called the Researching Cardiovascular Events with a Weekly Incretin in Diabetes (REWIND) trial.

“Compared to others, people with diabetes have twice the rate of cardiovascular events like heart attacks and strokes, and up to 40% of people with diabetes develop kidney disease,” said Hertzel Gerstein, principal investigator for the study, professor of medicine at McMaster and deputy director of the PHRI.

“The REWIND trial shows that dulaglutide can safely reduce these events while improving diabetes control and modestly lowering weight and blood pressure in middle-aged people with type 2 diabetes.”

Dulaglutide is a glucagon-like peptide-1 receptor agonist that is injected once per week.

The drug was well tolerated, modestly reduced weight, low-density lipoprotein (LDL) cholesterol and blood pressure, and modestly increased heart rate.

Oral Novo Nordisk diabetes drug poses no more heart risk than placebo: study

(Reuters) – An experimental oral form of a Novo Nordisk drug for type 2 diabetes posed no greater risk of serious heart problems or death than a placebo in patients at high risk for such complications, according to data from a large study presented on Tuesday.
Patients with type 2 diabetics and either heart disease or at high risk for heart problems who received the drug semaglutide in pill form had a combined rate of heart attack, stroke or heart-related death of 3.8% compared with 4.8% for placebo, successfully demonstrating non-inferiority.

Death from any cause occurred in 1.4% of semaglutide patients and 2.8% for placebo, according to data from the 3,183-patient trial presented at the American Diabetes Association meeting in San Francisco and published online by the New England Journal of Medicine.

While the drug led to a lower rate of death and other heart problems, the trial was not designed to show statistically significant superiority, only that semaglutide was as safe as, or non-inferior to, placebo. Similar drugs have also shown an ability to cut the risk of cardiovascular problems.

“The drug is safe,” Dr. Mansoor Husain, director of the Toronto General Hospital Research Institute who led the study, told Reuters Health in a phone interview.

“This is the first orally-available GLP-1 (glucagon-like peptide-1) receptor agonist and that’s a pretty big deal,” Husain said, noting the fear many patients have for injections. “Just being able to take a pill every day makes it much more accessible.”

Semaglutide, which stimulates insulin production, is seen as an important growth driver for Novo Nordisk, which funded the study known as Pioneer 6.
The Danish drugmaker already sells an injectable once-weekly version of the drug under the brand name Ozempic at a cost of about $800 per month, according to the website The oral version is a once-a-day tablet.

Novo filed for U.S. approval for oral semaglutide in March. It is seeking priority review in hopes of getting approval within six months.

All trial participants were at high risk of cardiovascular problems because they were at least 50 years old with established heart disease or chronic kidney disease, or at least age 60 with cardiovascular risk factors. They were followed for a median of 15.9 months. The trial was designed to end after a combination of at least 122 heart attacks, strokes and deaths had accrued.

Individual cardiovascular events in the composite also showed no significant differences.

The rate of non-fatal heart attack was 2.3% with semaglutide versus 1.9% with placebo, while the rate of non-fatal stroke was 0.8% with the drug and 1.0% for placebo. The odds of death from any cardiovascular cause were 0.9% in the semaglutide group and 1.9% in the placebo group.

“We did see a 50% reduction in cardiovascular death and all-cause mortality, but these were secondary endpoints,” Husain said. The main goal of the study “was just to demonstrate safety,” he said.

He cautioned people should not to read too much into the apparent reduction in the death risk. “We urge caution because they’re small numbers and it’s a relatively short-duration study.”

The rate of patients dropping out of the trial was higher for those who received semaglutide – 11.6% compared with 6.5% for placebo – with gastrointestinal problems such as nausea and vomiting being the driving force. Those are common side effects for the GLP-1 class of diabetes medicines.

Do Adults Need a Measles Booster Shot?

By Dennis Thompson
HealthDay Reporter

WEDNESDAY, May 8, 2019 (HealthDay News) — New York’s ongoing measles epidemic alarmed midtown Manhattan resident Deb Ivanhoe, who couldn’t remember whether she’d ever been vaccinated as a child.

So Ivanhoe, 60, sought out her long-time primary care doctor, who performed an antibody test to see whether she had any protection against measles.

To her surprise, the test revealed that Ivanhoe had no immunity to measles. Her doctor quickly gave her a measles booster shot.

“I’m a New Yorker. I’m out and about. I take the subway every day,” Ivanhoe said of her concerns. “One of the outbreak areas is in Williamsburg, Brooklyn. I have friends in Williamsburg. I go to there to visit, for dinner. It all becomes local.”

Ivanhoe is one of a growing number of adults who are worried that their immunity against measles might have lapsed, if they even received a vaccination.

The U.S. Centers for Disease Control and Prevention has downplayed these concerns, saying that only adults in high-risk groups should talk with their doctor about a measles vaccination.

But experts are divided on whether the CDC is underestimating the threat posed by possibly waning immunity in adults.

New outbreaks, new dangers

There’s good reason adults are worried. At least 764 cases of measles across 23 states have been reported so far this year, the CDC says. Most cases have occurred in unvaccinated groups living in communities located on either side of the nation, in the areas surrounding New York City and Portland, Ore.

The high-risk groups of adults who should discuss measles vaccination with their doctor include international travelers, health care workers, and folks living in communities that are in the throes of an outbreak, Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, said in a media briefing last week.

“Most adults are protected against measles. That’s what the science says,” Messonnier said. “That includes people who were born before measles vaccine was recommended, and even folks who only got a single dose.”

Ivanhoe’s physician, Dr. Len Horovitz, said her antibody test “clearly proves that is not the case.”

Horovitz recommends his adult patients get a blood test that shows the level of antibodies they have against measles and other infectious diseases.

“By the time you reach your [childhood] pediatrician it’ll be weeks, if he’s still even alive and hasn’t retired or moved,” said Horovitz, an internist with Lenox Hill Hospital in New York City. “It’s impossible to get vaccination records for my patients. They’re tearing their hair out.”

But, Horovitz noted, “In a 24-hour turn-around time, I can offer them a blood test and have an answer.”

Waning effectiveness of early vaccine

Besides people at high risk due to their circumstances, there’s only one group of adults that really should talk with their doctor about getting the measles shot, the CDC says.

One of the first measles vaccines used a killed version of virus, and was administered between 1963 and 1967. That vaccine did not provide lasting immunity, and for decades the CDC has urged that generation of folks to undergo vaccination with the better live version of the measles vaccine.

“If you happen to be someone 50 years ago that got this killed measles vaccine, then you’d have to get re-vaccinated with the live virus vaccine,” said Dr. Sandra Fryhofer, an internal medicine specialist in Atlanta.

People born in the United States earlier than 1957 are presumed to be immune to measles because the virus is so contagious everyone caught measles in those days.

Pediatric infectious disease specialist Dr. Matthew Zahn says the CDC is right that most adults are protected against measles.

“Our experience overwhelmingly has been that it becomes a numbers game,” said Zahn, who is on staff at the Children’s Hospital Orange County in Orange, Calif. “The vaccine seems to be about 99% effective in keeping you from getting sick, but if you have hundreds and hundreds of people who are exposed, then you will see occasional cases of persons who’ve been vaccinated previously who are getting sick anyway.”

Best use of resources

Zahn figures people who are worried about the status of their measles immunity should just go ahead and get the vaccine, rather than go through an antibody test.

“If you’re not sure you’ve had your two doses before and you want to be up to date, there’s nothing wrong with getting that additional dose,” Zahn said, noting that a person who undergoes the antibody test pays extra and faces getting stuck with a needle twice.

There’s plenty of measles vaccine on hand so there’s no concern about shortages, Zahn said. Doctors are simply trying to focus their attention on the most critical weaknesses in America’s immune protection, and waning adult immunity doesn’t seem to be contributing to the ongoing outbreaks.

“It’s more of an issue where you want to best use everybody’s time and resources,” Zahn said. “We certainly are seeing outbreaks, but those outbreaks are so weighted towards unvaccinated persons, that’s where the community is by far at risk.”

2019 Measles Outbreak: What You Should Know

Note: This story was updated April 22, 2019, with additional cases reported and April 18, 2019, with statistics on reported measles cases worldwide.

April 11, 2019 — Measles cases have been skyrocketing in the U.S. this year, with 626 reported so far, according to the CDC. Worldwide, the number of reported cases jumped 300% in the first three months of 2019 compared to the same time period in 2018, according to the World Health Organization. Learn why it’s happening and how to protect your family from this potentially deadly disease.

What is measles?

Measles is a contagious disease spread by a virus. It’s so contagious that when someone has measles, 90% of the people around them who aren’t immune will also catch it. And it’s so serious that one in four people who get measles will need to be hospitalized.

What are the symptoms of measles?

Seven to 14 days after exposure, symptoms begin with a high fever, cough, runny nose, and red, watery eyes. Several days after that, the measles rash appears.

Why has measles come back?

Measles was declared eliminated in the U.S. in 2000, 3 decades after the vaccine was introduced. But in recent years, “A critical number of parents have chosen not to vaccinate their children,” says Paul Offit, MD, director of the Vaccine Education Center at Children’s Hospital of Philadelphia. “When that happens, measles — the most contagious of vaccine-preventable illnesses — is often the first to come back.”

Where have there been measles outbreaks 2019?

The CDC defines an outbreak as three or more cases . The largest outbreak this year has been in New York City, with nearly 300 cases concentrated in an Orthodox Jewish community in the Williamsburg area of Brooklyn. New York City Mayor Bill de Blasio declared a public health emergency April 9 and said unvaccinated residents living in certain ZIP codes that had been exposed to the virus must get the vaccine to help prevent further spread of the disease. Residents who refuse may face a violation and possible fine of $1,000. A group of parents is suing the city’s public health department to block the order.

Rockland County, north of the city, also had a sizable outbreak, as did counties in Washington state, Michigan, New Jersey, and California. Individual cases have been confirmed in 14 other states.

How dangerous is it?

For some people, measles brings far more than just a fever and a rash. There is no treatment, and it can cause serious health complications, especially in small children. Currently, five patients in New York City have been admitted to the intensive care unit. In general, one out of every 10 children with measles get an ear infection, which can lead to permanent hearing loss. And one or two out of every 1,000 will die.

Who’s most at risk of measles?

About 500,000 people in the U.S. can’t be vaccinated because of severe allergies or a weakened immune system, says. Offit. Those people rely on everyone else’s vaccinations to protect them, in a concept known as community (or herd) immunity. Community immunity also keeps infants safe, since the vaccine isn’t given until a child is a year old.

How is measles spread?

People with measles can spread the disease up to 4 days before their symptoms appear. When an infected person coughs or sneezes, the virus sprays into the air, where it lingers or lands on surfaces. The virus can live outside a human body for up to 2 hours — so even if you enter an empty room, if you don’t have immunity, you can become infected.

What is the chance that measles will spread more widely?

If more parents refuse to vaccinate their children, the disease could become a constant threat.

When is the measles vaccine given?

The vaccine is usually given to children between the ages of 1 and 6. To be most effective, they’ll get two doses: the first at 12 to 15 months, and the second between ages 4 and 6. That second dose can be given as soon as 28 days after the first dose, if necessary.

If every unvaccinated person got vaccinated, would it stop the spread?

Absolutely, says Offit. “Measles is back because we haven’t learned from history. And it’s the children who suffer for our ignorance.”

Are measles parties safe?

Before there was a vaccine for chickenpox, parents would bring children to the home of a child who had the pox to expose them on purpose. (Chickenpox can become more serious in adults.) Now, some parents who refuse vaccinations for their children are doing the same with measles. Offit says this is extremely dangerous. “Why risk a natural infection, knowing it could mean your life?”

Does the vaccination I got as a child still protect me?

In most cases, yes. Only about three people out of every 100 who get both doses of the vaccine will still get measles after exposure. One caveat: If you received the vaccine in its early days, between 1963 and 1967, you may need to be re-vaccinated. Certain vaccines given in those years were not effective.

What should you do if you think your child has been exposed?

Call your pediatrician right away, Offit says. The risk will depend on several things, which your doctor will assess. Do not wait for symptoms.