Erica Finkelstein-Parker planned her daughter’s 8th birthday party with love.

Because Emmalee adored airplanes, Finkelstein-Parker chose the theme “Flying High with Emmalee.” Finkelstein-Parker filled nearly two dozen brightly colored goody bags for Emmalee’s friends — one for every child in her class, so no one would feel left out.

Months later, the treat bags remained unopened in Finkelstein-Parker’s bedroom, reminders of a birthday party that was never held.

Emmalee, who developed a rare complication of measles that can strike years after infection, spent her 8th birthday in hospice care at her family’s home. Her parents adopted Emmalee from an orphanage in India when she was 2 ½ years old. The orphanage staff didn’t tell them she had been infected with measles.

“There are some things that a parent should never have to do,” said Finkelstein-Parker, of Littlestown, Pennsylvania. “I had to call the birthday venue and explain that we were canceling the party because our daughter was dying.”

Emmalee died on Jan. 2, 2011.

“People think these diseases are ancient history, but they’re still around,” said Finkelstein-Parker. “Measles is a stealth virus. It may look like it has cleared your body, but it can hide in your nervous system.”

The massive resurgence of measles around the world — attributed to pandemic-related declines in immunizations and rising rates of vaccine hesitancy among parents — raises the risk of more serious complications and deaths, said Dr. James Cherry, a professor of pediatrics and an infectious disease expert at the David Geffen School of Medicine at UCLA.

In the past two months, doctors in the U.S. have diagnosed dozens of measles cases related to unvaccinated travelers who arrived at international airports, then exposed others at hospitals and day care centers. State health departments have reported measles cases in California, Georgia, Missouri, New Jersey, Pennsylvania, Washington, Ohio, Maryland and Minnesota. The Centers for Disease Control and Prevention has issued a warning to health providers, warning them to be on alert for more cases.

“All it takes is one infected traveler to spark an outbreak,” said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. “It’s coming from people who are getting off airplanes.”

Measles is so contagious that even one case is considered an outbreak. Each measles patient infects an average of 12 to 18 people who lack immunity from vaccines or natural infection. In comparison, each Covid-19 patient infects about two other people, said Dr. Paul Offit, the director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

“Measles is much, much more contagious than Covid or the flu,” Offit said.

Although two doses of the measles vaccine protect 97% of children, the airborne virus spreads so quickly that 95% of children in a community need to be vaccinated in order to stop outbreaks. About 93% of children were up to date on the measles vaccine in 2022-23, according to the CDC.

All states mandate vaccinations for children in public schools, but a growing number of families are taking advantage of exemptions for religious, philosophical or medical reasons. About 3% of students are now exempt from vaccine mandates. In 10 states, more than 5% of schoolchildren are exempt, a rate that makes it harder to contain outbreaks.

People who decline to vaccinate their children against measles are taking large and unnecessary risks, Dr. Peter Hotez, co-director of the Center for Vaccine Development at Texas Children’s Hospital, said. Measles vaccines have repeatedly been shown to be safe.

Long-term effects of measles

For every 10,000 children infected with measles, 2,000 will be hospitalized; 1,000 will develop ear infections with the potential for permanent hearing loss; 500 will develop pneumonia; and 10 to 30 will die, Hotez said.

Ariel Loop was shocked when her 4-month-old son, who had received all recommended vaccines, became sick with measles after visiting Disneyland in 2015. Babies are vulnerable to measles because they aren’t routinely vaccinated against the virus until age 12 to 15 months.

Loop took her son to the emergency room after he developed red spots, itchy eyes and a fever of 102 degrees that acetaminophen didn’t help. Loop, a nurse, was especially worried about her son because he was born prematurely and suffered a stroke while in utero.

“He was my first baby, and I didn’t know how dangerous measles was,” said Loop, who lives in Pasadena, California.

Measles often leaves patients vulnerable to secondary bacterial infections, such as pneumonia, one of the most common causes of death in measles patients, said Patricia Stinchfield, president of the National Foundation for Infectious Diseases.

Measles also causes “immune amnesia,” in which the immune system loses its ability to fight infections that a patient was previously immune to, Cherry said. The virus wipes out 11% to 73% of a person’s antibodies — both those acquired through infection and vaccination — which can leave patients at increased risk from viruses such as the flu and bacteria that cause pneumonia and skin infections.

Early symptoms of measles

In addition to the well-known red spots on the skin, measles usually causes white spots in the mouth, which can make it painful for children to eat or drink, Stinchfield said. Many kids with measles become dehydrated and malnourished during their illness.

About 20% of measles patients are hospitalized, often because they need intravenous fluids, she said.

“These kids come in, slung over their parents’ shoulders, barely able to hold the head up,” Stinchfield said. “They’re like little rag dolls. They won’t even take a popsicle.”

In the days before children develop a red measles rash, symptoms include:

• Cough
• Lethargy
• Runny nose
• Pink eye
• Fever  

Many become so sensitive to light that ordinary room lights hurt their eyes.

“It might look like the common cold except for the degree of misery they have,” Offit said.

People with measles can spread the virus for nine days — from four days before they develop spots until four days after, Stinchfield said.

Because the virus spreads through aerosols, it can infect people up to two hours after a sick person has left the room.

A fatal long-term complication

Although Emmalee was always tiny for her size — topping out at a weight of 39 pounds — she was otherwise healthy, Finkelstein-Parker said.

The first signs of serious illness occurred when Emmalee was 7 and began tripping over her feet, Finkelstein-Parker said. At first, her mother said she wondered if Emmalee’s new shoes were too big. The next day, Emmalee’s chin dropped onto her chest, as if she couldn’t hold up her head. While sitting in a chair, Emmalee listed to one side, without enough muscle control to remain upright.

A pediatrician at Children’s Hospital of Philadelphia who was trained in India quickly recognized the early signs of a devastating long-term complication of measles called subacute sclerosing panencephalitis, which is more common in countries where the virus remains endemic. The fatal condition can cause memory loss, irritability, disturbances in movement, seizures and blindness, and can develop six to eight years after a child has apparently recovered from measles. Although anti-seizure drugs can sometimes ease symptoms, they don’t cure the disease.

Recent research shows the complication is more common than previously believed, striking about 1 in 600 infants with measles.

Emmalee began having uncontrollable seizures. After four months, Emmalee slipped into a coma while at home, Finkelstein-Parker said.

“My father couldn’t understand why she wouldn’t wake up,” Finkelstein-Parker said. “He tried everything, including playing music from her favorite music box.”

Emmalee spent five weeks in home hospice, passing away five months after symptoms began, Finkelstein-Parker said.

After Emmalee died, Finkelstein-Parker took the goody bags to school as presents for her daughter’s classmates. The children, who were also grieving, shared their favorite stories about Emmalee, and made a hanging mobile decorated with drawings and notes.

“Their teacher said they needed closure,” Finkelstein-Parker said. “They handled that day a whole lot better than I did.”