There are now 13 measles cases in three counties across Montana as of May 29 and health agencies are preparing their emergency response plans.

All 13 cases are Montana residents and newly identified cases are isolating, according to the Montana Department of Public Health and Human Services.

Two cases have been reported in Flathead County, one in Hill County and 10 in Gallatin County.

The case in Hill County case is a child who attended a private party that included unvaccinated children so health officials there are anticipating more cases, Abigail Hill, Cascade County health officer told the County Commission during a May 28 discussion.

Last week, the Hill County Health Department issued enhanced MMR vaccine recommendations for all residents and travelers to Hill County due to the potential for community spread, according to DPHHS.

The recommendations include early and accelerated vaccination for children and an additional MMR dose for adults who have received one dose.

First measles cases confirmed in Montana

Early and accelerated vaccination is not recommended for residents or travelers to other Montana counties currently, according to DPHHS.

The Cascade City-County Health Department is now recommending that infants ages 6-11 months receive an early dose of MMR before travel to Hill County, including Havre. Anyone with questions should call 406-791-9242.

During the May 28 meeting, Hill, the Cascade County health officer, said a question had been raised at the state level about rules for quarantines of those exposed to measles.

She said that she wanted to keep the county commissioners in the loop and get their guidance on the communicable disease response and enforcement. They were joined by two deputy county attorneys.

She said that health boards have the authority to isolate those who are confirmed cases of a communicable disease and they’ve been able to quarantine those exposed.

Hill said that the rise of measles cases in Montana.

Measles is highly contagious and lingers in the air for two hours after an infected person has left the room, she said.

CCHD recommending measles vaccines while local agencies preparing for potential cases

According to the U.S. Centers for Disease Control, if one person has measles, up to 9 out of 10 people nearby will become infected if they are not protected.

For those infected, health professionals recommend isolation for 21 days. It’s also recommended that those exposed quarantine for 21 days if they don’t have immunity.

In 2021, the Montana Legislature passed House Bill 702, which is now part of the Montana Human Rights Act, that prohibits discrimination based on vaccine status, but it carves out an exception so that the law doesn’t apply to vaccine requirements for schools, daycares and healthcare facilities.

Hill said a question was raised if health departments could exclude children in schools and daycares based on their vaccine status if they’re exposed to measles.

The state asked local health departments to look at it and Hill said she got the county legal department involved.

She said that the Cascade City-County Health Department has plans for response measures, as do many other counties, which include isolation and quarantine for communicable diseases.

Hill said that at a daycare, anyone under one year old doesn’t have immunity to measles because they don’t typically administer the MMR vaccine until 12 months.

It’s highly likely that unvaccinated children would contract measles and continue spreading the virus, she said, and in schools, they assume the entire school is exposed if one student contracts measles since students move around and the virus lingers in the air for so long and schools lack filtration systems.

If a measles case is confirmed in a school, Hill said her staff would get a list from the school nurse of those without immunity and order those students to quarantine for 21 days.

The question raised, Hill said, was whether that was discrimination.

Otherwise, they’d have to quarantine the entire school to avoid discrimination or says it’s the honor system for those without immunity to stay home for 21 days and risk further spread.

Public health officials will have a verbal understanding from those with confirmed illness or exposure, Hill said, and wanted commissioners to be aware of enforcement measures if people don’t comply with those rules.

If CCHD issues an order for isolation or quarantine that someone doesn’t follow, CCHD will send a letter of violation and the county attorney’s office gets involved.

The health officer has the ability to request the sheriff’s assistance in enforcing those orders.

She said it wouldn’t be realistic to send those letters to every student in a school during an outbreak to avoid discrimination related to vaccines.

Carey Ann Haight and Michele Levine from the county attorney’s office said that in daycare settings they know children younger than a year aren’t immunized and would be very vulnerable to measles.

Haight said she was on a statewide conference call on May 14 regarding the vaccine rules and said there wasn’t really a consensus on the interpretation.

She said the state recently removed language from the Administrative Rules of Montana related to vaccines and daycares without any explanation. That rule specified that anyone exposed to a communicable disease without immunity could be excluded from a daycare until the outbreak was over.

Levine said the administrative rules are now silent on the issue, but state law under HB 702 is specific.

She said those facilities can require vaccines and exclude children during an outbreak.

That won’t apply to the adults, such as staff at those facilities, she said.

Hill said she wanted to talk about the interpretation of the law as CCHD and other local agencies are preparing in case of a measles case in Cascade County.

She said she wanted to ensure CCHD had the ability and authority to exclude unvaccinated children from schools and daycares to prevent the spread of measles, because, “if not, the options aren’t great.”

Levine said she talked to Riverstone Health, the public health agency in Yellowstone County, where officials said that the law didn’t change with the removal of the administrative rules, so there was no need to change their interpretation.

Commissioner Joe Briggs said that legislative intent is notoriously difficult to ascertain but remembered the vaccine exemption for schools and daycares was intensely debated and he didn’t think the bill would have passed without it.

At the time, lawmakers were responding to the COVID pandemic but they considered the potential for a measles or mumps outbreak.

He said that since the state removed the administrative rule and didn’t give further guidance, “they’re basically telling us the law speaks for itself.”

Under state law, the county health officer has the authority to enforce rules set by the health board.

The health board approved their isolation and quarantine measures in 2023 and will be reviewing them again during their June 4 meeting.

Hill said the question remains as to what enforcement will look like over the summer as school’s out but there are camps and programs that aren’t necessarily associated with schools or daycares.

Haight said that in terms of enforcement, “this is going to have a lot of parallels to what we saw in COVID,” with orders from the governor and health departments.

The sheriff has the authority to arrest people for violating health officer orders, but Haight said that was unlikely.

She said there are strong words in state statute, but in reality, a lot of resistance to public health enforcement.

“Measles is just particularly challenging, because it’s 21 days,” Hill said of the quarantine and isolation required for the virus.

That’s hard for families and employers, but so far in the counties with measles cases, those infected or exposed self isolated and quarantined so health departments there didn’t have to issue orders.

It would be tough in daycares, she said, telling people they can’t come due to measles exposure, but those are some of the most vulnerable populations to the virus.

In most of those cases, the cases were largely contained within families and didn’t lead to community spread.