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Infectious disease physician Janet A. Jokela discusses her article, “Measles is back: Why vaccination is more vital than ever.” Recounting her own experience diagnosing a case in the 1990s, Janet contrasts that contained incident with the current crisis in 2025, which has seen over 1000 cases and the first pediatric deaths in the U.S. in 22 years. The conversation covers the critical 95 percent vaccination rate required for herd immunity, a threshold the country is falling below, and explains why measles is one of the most contagious diseases known. Janet dismantles dangerous misinformation about the MMR vaccine and ineffective alternative treatments, emphasizing that the vaccine is 97 percent effective and has saved millions of lives. For listeners, the key takeaways are to understand the severe, and sometimes fatal, complications of measles—such as pneumonia and encephalitis—and to recognize that the benefits of the MMR vaccine far outweigh any risks.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Janet A. Jokela, former treasurer of the American College of Physicians and infectious disease physician, and we’re going to talk about measles: why vaccination is more vital than ever. Janet, welcome back to the show.

Janet A. Jokela: Thank you so much, Kevin. Delighted to be here.

Kevin Pho: All right, so as I was prepping for this episode, a convenient article appeared in The New York Times, which I’m sure that you’re aware of. Yesterday—we are speaking on July 10th—so yesterday, “Measles cases hit highest total since U.S. eliminated the disease.” There have now been more measles cases in 2025 than in any other year since the contagious virus was declared eliminated in the United States in 2000, according to new data released by the CDC. With that context, what is your article about?

Janet A. Jokela: Thank you, Kevin. It was a sobering article to see and sobering data to hear about with the measles cases that have been erupting this spring. It brought me back to my fellowship when I saw a case of measles and what was involved in all of that. As an infectious disease fellow in Boston, I was called in the middle of the night, and the nurses said, “I think we have a case of measles.” And I thought, “Oh my goodness,” because that was not on anybody’s radar. We weren’t talking about it; we weren’t really thinking about it. And I thought, “All right, I have to go in.” I was going into the hospital in the middle of the night to see this patient.

So that’s what I did. Before I left, I reviewed a little bit about measles because, again, it wasn’t something at my fingertips. I went in to see the patient. They put the patient in a respiratory negative pressure room, which is absolutely the right thing to do. This individual was a teenager visiting with their high school group from an adjacent country. They were part of a musical group, actually, and they were playing in venues across the city of Boston, including nursing homes. All right, so this is potentially a major infection-control-related issue.

At any rate, I went in to see the patient, and she had all the stigmata: she had a rash, but also her eyes were red, her nose was running, and she was coughing. I looked in her mouth, and she had Koplik spots. I had read about Koplik spots; I’d never seen them. As soon as I saw them, I thought, “Oh my goodness. That’s pathognomonic. This is measles.” So there we were.

Kevin Pho: I think that with measles, we always think it’s one of those cases that we only read about on board exams and in textbooks, but we’re seeing an increasing number here in the United States with the CDC data. To get everyone on the same page, give us a brief synopsis of the virus that causes measles and provide a little background.

Janet A. Jokela: Indeed, it was eliminated in the U.S. or declared eliminated in the U.S. in 2000, meaning that there were no ongoing episodes of transmission. And it’s been that way ever since, for 20-plus years. The virus is highly contagious; it’s one of the most, if not the most, contagious respiratory viruses that we know of. It can infect, say, nine out of 10 susceptible people if they are in the same room or same area and are exposed to it.

Even if a patient with measles has left the room, people within that room, say within the subsequent two hours, can be infected. The virus can essentially hang in the air. In many ways, you’d think, “All right, if it were a common cold, so be it.” But that’s not measles. Measles can cause disability and it can cause death, certainly in young children but also in adults. So it’s a really big deal that this is happening. We often hear about the death part, but there’s a big disability part as well.

Kevin Pho: Specifically, what disability complications can we be aware of?

Janet A. Jokela: Deafness can be one thing that can develop. There’s no treatment for measles, but if someone develops measles and complications of ear infections, deafness can result. Also, the neurologic things are, I think, what really scare people. Approximately one in a thousand people who are infected with measles can develop encephalitis. It could either be acute encephalitis or acute disseminated encephalitis, and that can lead to neurologic disability long-term.

Then there’s the scary subacute sclerosing panencephalitis, much more rare, but that can pop up out of nowhere, like seven to 10 years later. That often can lead to profound disability or death. So those are some of the scary things that can happen disability-wise.

Kevin Pho: So tell us, when was the vaccine—the MMR, measles, mumps, and rubella vaccine—first introduced, and what was life like before that vaccine?

Janet A. Jokela: Great question, Kevin. The vaccine was first introduced in 1963. Today we have an improved vaccine that’s been in existence and been in use since 1968. Before 1963, before the vaccine was developed, there were 400 to 500 deaths per year in the U.S. due to measles. Thousands of people and children were catching measles. It was just so contagious. Once it got into a population, in essence, it was really impossible to stop. So infections were common. Then the sequelae: pneumonia was the most common cause of hospitalization, and that could also lead to more progressive illness and death as well from respiratory failure. It was just a real scourge, particularly in the pediatric population.

Kevin Pho: The vaccine was fabulously successful. Measles was considered eradicated for a period of time. Is that correct?

Janet A. Jokela: Not eradicated, but eliminated from the U.S. There are still pockets around, and certainly around the world there are pockets of measles as well, just because of varying levels of uptake of the vaccine. So it was eliminated in the U.S.; it wasn’t eradicated. The only virus that’s been truly eradicated is smallpox, and there have been efforts for a long time to eliminate polio, for instance. There are efforts in those directions, but it was eliminated in the U.S.

Kevin Pho: You also talk about the concept of herd immunity. It’s not just the shot itself, but the community receiving the shot. Talk more about the percentage of the community that needs to be immune in order for the whole vaccine to be effective.

Janet A. Jokela: Thank you, Kevin, for asking that question. The level of herd immunity that’s understood to be effective for containing a measles outbreak is 95 percent, which means that 95 percent of the persons within a given community must be immunized to prevent ongoing spread of measles.

If you look at the CDC’s website, there are some really nice maps there that show the level of MMR vaccination in kindergartners across the U.S. by state over the last 10 to 15 years. Those levels have dropped in various states, in large part due to the fact that there have been non-medical exemptions, which have been approved by state legislatures. In many ways, the vaccination rates have ended up dropping below that 95 percent, and now we’re in the situation where we are today, where there are pockets where the vaccination rate is less than 95 percent in certain areas in various states. And here we are.

Kevin Pho: And how much less than 95 percent are we talking about? The low nineties, high eighties? What number are we talking about in order to get these outbreaks?

Janet A. Jokela: That’s a really important question. When you look at the maps at the CDC, they have maps where 95 percent or higher are blue states. Then there’s light orange from 90 to 95 percent, and that’s light orange. Below that, it’s a darker orange color. That said, it’s highly variable, and there are pockets in any state that may be highly vaccinated and other areas which may be less vaccinated. Because it’s so contagious and can linger in the air in a room, if someone who’s unvaccinated is in that same room, they may be infected and may contract measles as well.

In terms of the values, it’s highly variable. In Illinois, the rates overall are, say, between 90 and 95 percent in that region. But also in Illinois, we even have data down to the individual schools and the individual counties, and there’s high variability within the vaccination rates in the schools. So it’s highly variable.

Kevin Pho: From your understanding and what you’ve heard, what are some of the major reasons why people are hesitant or resist receiving the vaccine?

Janet A. Jokela: I think people have been confused. They’ve been confused, and there have been concerns raised by a number of people in very prominent positions that have sent out confusing messages about vaccines and vaccinations. I think the situation with the COVID vaccine has made people more hesitant about other vaccines. I think that’s been problematic and a challenge for us in health care to try to mitigate and to address and correct any mis- or disinformation.

The MMR vaccine does not cause autism. Unfortunately, there had been a paper published in Lancet, which has since been retracted, that addressed that issue, and that caused confusion all over the world. We’re still dealing with the repercussions of that. Then there have been some very well-funded, well-organized entities that have been sowing confusion about vaccines. I think people have just been confused, and it has bled over into this very safe vaccine, which the MMR vaccine is.

Kevin Pho: You mentioned that the MMR vaccine does not cause autism. What specific misconceptions can you also refute?

Janet A. Jokela: The immunity from the MMR vaccine is durable. OK. It’s durable. It does not cause autism. It does not cause death. Those are some very key, fundamental points that I think it’s important for patients, parents, and all of us to know. Those are some key ones which I think are really important.

Kevin Pho: Are there any alternative treatments that are valid? I know some anti-vaccine proponents also tout alternative treatments other than the vaccines that can address measles. Are there any, as far as you know, that have any validity?

Janet A. Jokela: No. OK, here’s the issue. There’s been a lot of discussion about vitamin A this spring and early summer, and in fact, unfortunately, we’ve seen children develop signs of vitamin A toxicity, I think on the part of well-intended but misguided parents. The issue around vitamin A is that there has been some data reported, more from the developing world, that children who have been malnourished, who have developed measles, and then receive vitamin A have done better. So that said, there’s data that supports doing that in malnourished children. That’s it.

What the CDC is recommending now, if someone is diagnosed with measles, is that two doses of vitamin A would be appropriate. But again, that should be done under the guidance of a health care professional. I would advise against parents going out and administering vitamin A on their own because vitamin A toxicity can be a real problem and can cause liver issues and other things. The vitamin A could be used just as a kind of supportive, adjunctive treatment, if you will, but it doesn’t treat measles itself.

Kevin Pho: Now, I think just as important as the science and just as important as refuting some of this misinformation is communication. You obviously have a lot of experience with that. You are with the American College of Physicians. So, what are some obstacles that we have in terms of communicating some of this science to the country? What have you learned over your years with the American College of Physicians and your work with public health in terms of the obstacles in communicating science, and how can we overcome those obstacles?

Janet A. Jokela: Kevin, you are the master of communication. That said, this issue is one that I personally have been grappling with, and I think many, many people have been grappling with. I think it’s the issue of our time. How do we do this? How do we as informed physicians, scientists, and biomedical scientists do this better to communicate the value of what we do and the knowledge that we have that we know can save lives and can really help people?

There are a few things that come to mind, and I know the ACP has been working on this and has addressed this. There’s a gazillion things on the website that address all of that as well. But I think it is about meeting patients where they are, meeting them in the exam room. If they’re hesitant, that doesn’t necessarily mean that they’re refusing the vaccine, but it’s more that they have questions. They want to know what we would recommend if we were in their shoes, what we would do, and why. I think also it’s critical for us to be curious.

In the same vein, we need to try to explore more. Why is the patient hesitant? Why do they not want the vaccine? And we must try to address those concerns as best as possible. I think it has to start there. In addition, I’ll say there was a lovely New York Times article by Dr. Craig Spencer just the other day as well, talking about the key ingredient of empathy. We have to be empathetic with our patients and not shame them or embarrass them, but truly try to meet them where they are so we can help impart what we know could be life-saving information.

Kevin Pho: As you know, everything is so politicized. For someone on the opposite end of the political spectrum, sometimes it’s hard to have that empathy in today’s society. So talk to us about some tips on how we can do that, especially in the exam room.

Janet A. Jokela: Again, that’s a really important question, Kevin. As I reflect on this, fully expecting that we’d be talking about this today, it seems that we have to dig deep. It’s a personal thing. We have to dig deep within ourselves and find that strength to do that. If we need to count to 10—we may not feel like we have time to count to 10—but count to five, count to 10, and just gather ourselves and try to do that. Perhaps schedule another appointment if more time is needed to talk about these things.

Also, I think we need to work together with our teams. We want to make sure that our teams—our nurses, the people checking patients in when they come in—that we’re all on the same page. We don’t want any people amongst our teams conveying an alternative message. The fact is we can’t do this on our own, but we have to ensure that our teams are unified in what we’re trying to do and why we’re trying to do it. If our teams aren’t unified, then we must try to find out why and work with them. Again, I think it just requires digging deep within ourselves to find that patience and that core of empathy that is really needed in this moment.

Kevin Pho: I talk to a lot of physicians who are getting discouraged because science and what they try to do in the exam room is so politicized. Maybe you could inspire us. Do you have a success story, or a story from your colleagues, of a constructive conversation with someone who had reservations and hesitancy about the vaccines? A time when you may not have changed their mind, but you felt you moved the needle in the conversation. What would be an example of a constructive conversation that you’ve had?

Janet A. Jokela: Thanks, Kevin. The one that comes to mind most strongly for me was one that I had with an HIV-infected patient of mine who was very hesitant about the flu shot. I had developed a relationship with him over a number of years, and that helped. He continued to come back to see me. I would broach the topic of the flu shot, and he’d say, “No, not today.” I said, “OK.” But I told him, “Look, I’m going to continue to ask you about this. If you don’t want it today, that’s fine. If I were in your shoes, I’d want to get it.”

We would continue to discuss this as we discussed everything else, like his viral load and adherence to his medications, and he was good with all that. So he continued to come back to see me. Eventually, one day he said, “I’ll get the flu shot today.” And Kevin, I nearly fell out of my chair. It’s like, “What? Did I hear you correctly?” I think I even joked with him about it, like, “Really?” And he said, “Yes, it’s fine. I’m ready. You’ve talked to me about it. You’ve been persistent. You’ve respected me. You respected my opinion, and that’s important to me. And I’m going to get it today because I trust you.”

Kevin Pho: I think that really resonates with me because sometimes, in order to change minds, it isn’t necessarily something that you read in a newspaper. It isn’t necessarily an advocacy campaign or an influencer online. It’s really the relationships that physicians specifically have in the exam room with that patient, and that has to be developed over time.

Janet A. Jokela: That’s exactly right. In some of the reading I’ve been doing recently, Paul Farmer had some wonderful, beautiful things to say about this. One quote of his was that trust must be built one patient at a time. I think what he did globally in organizing all these big organizations and all this—that was his take on trust.

Kevin Pho: We’re talking to Janet A. Jokela, infectious disease physician and former treasurer of the American College of Physicians. Today’s KevinMD article is, “Measles is back. Why vaccination is more vital than ever.” Janet, as always, we’ll end with some take-home messages that you want to leave with the KevinMD audience.

Janet A. Jokela: Thank you, Kevin. I think it’s important for us as clinicians to be aware that measles is out there and to be familiar with how it presents, what the symptoms are, and how we can address this. In essence: vaccinate. And to do that, I think we must meet our patients where they are, be empathetic, really listen to them, and work with them to try to understand whatever hesitations they may or may not have.

Kevin Pho: Thank you, Janet. As always, thank you so much for sharing your expertise and perspective, and thanks again for coming back on the show.

Janet A. Jokela: Thank you, Kevin. I was delighted to be here.