Mickey the Measles

I only hope that we never lose sight of one thing — that it all started with a mouse. –Walt Disney (1954)

An outbreak of highly infectious measles starting at Disneyland in Anaheim, California, has spread to eight U.S. states and Mexico. Arizona, one state hit, is presently monitoring 1000 people linked to Disneyland visitors and subsequent exposures.

With good reason, much attention has been placed on the role the anti-vax movement has played in both the initial outbreak and its subsequent spread. In 2014, before the outbreak, U.S. measles clocked in at three times the cases (644) than any of the ten years previous.

The outbreak may represent a second scandal.

Five years ago Disney objected to suggestions the theme park and resort, drawing 15 million visitors a year from around the world, was a potential amplifier for infectious diseases.

In late 2009, with swine flu H1N1 still circulating, a colleague and I produced a report on the occupational epidemiology of influenza for a union representing Disneyland employees.

We placed Disneyland within the geography of global disease,

Disney’s park draw may have epidemiological implications. Each year millions of visitors from around the world visit Disney parks, some for as long as a week. Given such traffic, a reasonable inference is that at least some of the pathogens that annually emerge elsewhere in the world, influenza included, find their way into Disney venues…

As a major destination site the resort has the potential to amplify the geographic spread of the virus. Any Disney pandemic plan should account for the possibility the company’s parks may contribute to the spread of influenza both locally and abroad…

The draw may produce a funnel-like effect, in which sick individuals from numerous geographically diffuse locations are brought to a specific location, in this case a resort at which thousands of employees work.

There were already apparent precedents,

Long-distance travel also offers a primary mechanism by which newly evolved variants of a pandemic strain, characterized by shifts in inherent virulence, can geographically spread. Maria Koliou and her colleagues reported some of the first H1N1 cases in Cyprus were in younger people who had visited tourist resorts. Similarly many of the first cases in the United States were reported among young adults returning from their spring break vacations in Mexico.

Indeed, there is anecdotal evidence from media reports that Disney parks and hotels, including at Disneyland, have already served as hubs through which swine flu H1N1 (2009) has been both brought in from abroad and transmitted locally. In mid-May three Melbourne siblings tested positive for swine flu on their return from a family holiday to Disneyland. Victorian health authorities subsequently quarantined and administered anti-viral medication to their classmates. In mid-July a group of Mississippi tourists who had stayed at Disney’s Pop Century Hotel were treated at a Celebration, Florida hospital for flulike symptoms thought to be caused by H1N1.

Of the mechanisms by which a pathogen can be amplified once on Disney properties, we wrote,

If one person, whether a customer or employee, becomes infected, there is a real potential that he or she could spread it to others, given the large number of people with whom he or she might come in contact…

Customer behavior may augment risk. Guests may not realize that they are ill until they have already traveled a long distance to visit Disneyland. Many may be unwilling to stay out of public after they have already paid for their vacations. This places employees at such sites in a position where they may be exposed to visitors who are ill with influenza, even as the level of influenza infection in the surrounding community may be comparatively low…

In effect, hotel workers are being asked to act as public health workers, commensurate with medium-risk exposure. Should the pandemic turn severe they could be asked to expose themselves still further. If public health authorities were to quarantine a hotel with severely sick guests, a scenario for which the [American Hospitality and Lodging Association] asks its members to prepare, the hotel’s employees, preparing and attending an isolation ward for guests and coworkers, could be shifted into high-risk exposure commensurate with hospital professionals.

We projected beyond influenza to other pathogens,

In preparing for a pandemic today, public and private organizations–employees and management—can better organize their operations to withstand outbreaks and other public health emergencies that may emerge in the near and extended future.

We capped our review with a list of detailed recommendations. These included employee-employer collaborative pandemic planning, an off-site employee response team, and, as employees’ lives extend beyond the park gates, regional planning.

We concluded by alluding to the responsibility Disneyland bears to its employees and customers both,

In bringing over 15 million people through its park gates and thousands into its hotels each year, the Disneyland Resort takes on enormous responsibilities. These obligations, however, extend beyond the health and safety of its employees and customers day-to-day and on to acting responsibly under even the worst of community and public health threats. The company is not indemnified by the severity of an emergency. As one of Southern California’s largest employers, Disneyland can and should act to assure its employees and their families are protected to the fullest extent possible. By doing so, the company will also help protect its customers from near and far, as well as the surrounding community.

Catching wind of the draft report, Disney trotted out CDC’s Phyllis Kozarsky to preempt calls for long-term pandemic preparations.

Kozarsky, of the CDC’s Travelers’ Health Branch, emailed the New York Times,

To single out Disneyland and Disney World is not appropriate with regard to transmission of H1N1. There are too numerous to count opportunities for people to be in close spaces together, whether in movie theaters, in crowded shopping malls, on public transportation as well as during most individuals’ daily activities.

In other words, Disneyland is like anywhere else, so, against OSHA, Homeland Security, and yes, CDC recommendations, don’t bother with special preparations.

And yet, at the same time, CDC researchers offered very different conclusions for another global attraction.

Shahul Ebrahim and colleagues reviewed the epidemiological implications of the annual Hajj, when two and a half million Muslim pilgrims converge on Mecca, Saudi Arabia from around the world. According to Ebrahim’s team,

Hajj-related exportation of H1N1 virus by returning pilgrims could potentially initiate waves of outbreaks worldwide…[P]ilgrims originating from North America (more than 15,000) and Europe (more than 45,000) pass through major airline hubs of the world on their journey, which increases the risk of international spread of the virus.

The authors offered control recommendations for the Hajj under the principle that those administrating mass gatherings, including, for instance, Disneyland, should act in as cautious a way as possible in case such places or the events they host are in fact instrumental in the virus’s spread. In short, it is better to be safe than sorry.

The difference here is that unlike the travel industry, Hajj organizers do not deploy the kinds of ruffian lobbyists and envelopes of PAC money we see from Mickey the Measles.

Five years later and this outbreak wave is now followed by a wake of post-hoc rationalization.

The California Department of Public Health reports,

Measles has been eliminated in the United States since 2000. However, large measles outbreaks have occurred in many countries, particularly in Western Europe, Pakistan, Vietnam and the Philippines in recent years. Travelers to areas where measles circulates can bring measles back to the U.S., resulting in limited domestic transmission of measles. California has many international attractions and visitors come from many parts of the world.

“This is the ideal scenario [for an outbreak],” pediatric infectious diseases expert James Cherry told the Los Angeles Times. “People go to Disneyland ‘from all different counties and all different states.'”

We always knew what we refused previously to acknowledge.

UPDATE. Five Disneyland employees have been confirmed infected with measles. Other employees who may have been in contact with them have been sent home on paid leave while awaiting test results.

Disneyland employees meanwhile have observed an apparent decline in attendance to the park. Disney Chair and CEO Bob Iger denies the observation, claiming attendance and bookings are up.