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Update on Measles in the U.S. 2008 National Perspective

Update on Measles in the U.S. 2008 National Perspective. Kathleen Gallagher, D.Sc, MPH NCIRD, CDC. Today’s Presentation. Measles in the US in the pre- and post-elimination eras What’s going on in 2008 Strategies to maintain elimination Challenges.

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Update on Measles in the U.S. 2008 National Perspective

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  1. Update on Measles in the U.S. 2008National Perspective Kathleen Gallagher, D.Sc, MPH NCIRD, CDC

  2. Today’s Presentation • Measles in the US in the pre- and post-elimination eras • What’s going on in 2008 • Strategies to maintain elimination • Challenges

  3. Annual Measles Disease BurdenUnited States, 1950s • 3-4 million cases • ~ 500,000 reported cases • Severe complications • 4,000 encephalitis cases • 150,000 respiratory complications (pneumonia) • 48,000 hospitalizations • 450 deaths

  4. Reported Measles Cases United States, 1962 - 2007 1963 Vaccine Licensed 1st Dose Recommendation 1989 2nd Dose Recommendation 2000 Elimination Declared 1-dose preschool coverage 2-dose adolescent coverage Measles Cases % Measles Vax Coverage 1989-91 Resurgence Year

  5. 1989 2nd Dose Recommendation 2000 Elimination Declared Measles, United States, 1985 - 2007 Measles resurgence 1989-1991 55,622 reported cases 123 reported deaths Reported Measles Cases Year

  6. Measles elimination declared Reported Measles IncidenceUnited States, 1992-2007 1 case/million

  7. Measles Epidemiology, Post Elimination • 63 cases reported each year (2000-2007) • Cases are all related to imported cases including from developed countries – Europe, Japan • Outbreaks predominantly in unprotected populations • 2005 Indiana, 34 cases in unvaccinated religious community • 2006 Boston, 18 cases in young adults mainly one dose vaccine recipients and foreign born adults

  8. Highest number of reported cases year to date (Jan-July) since 1996 No increase in imported cases Increase in spread within the U.S. 7 “outbreaks” Measles, US, 2008

  9. Measles, January – July 2008 • 131 cases from 15 states and DC • 15 (11%) cases hospitalized, no deaths • Importation status: • 17 importations • 8 foreign visitors (all unvaccinated) • 9 US residents (all unvaccinated) • 99 (76%) additional cases linked to importations or virologic evidence of importation • 15 cases unknown source • 123 cases in US residents • 91% cases unvaccinated or unknown vaccination status

  10. Measles Cases Reported to CDC/NCIRD January-July, 2008 (N= 131) Chicago, IL Grant County, WA N=19 Vernon County, WI N=1 Milwaukee County, WI N=6 Nassau County, NY N=1 Missaukee County, MI, N=4 NM N=1, Unknown Pittsburgh, PA N=1 San Francisco, CA N=2, Sources: New York City, NY N=26 Los Angeles, CA N=1 San Diego, CA N=12 Fairfax, VA N=1 D.C. N=1 Baton Rouge , LA N=1, Cass Co, MO N=1 Honolulu, HI N=4 Du Page Co, I L N=31 Pima County, AZ N=14 Scott County, AR N=2 Fulton Co, GA N=1

  11. Reported Measles Cases, U.S. 1997-2008*, by Importation Status *Provisional data through July 31

  12. U.S. Residents with Measles, January 1 through July 31, 2008, by Age N = 123 80% cases < 20 years

  13. Reasons for not receiving Measles vaccine, U.S Residents with measles who were Eligible* for Vaccination, January 1 through July 31, 2008, N=95 * Excludes infants under 12 months old, persons born before 1957, foreign visitors, and persons who are vaccinated. † Includes children 16 months to 4 years old who have not been vaccinated. § Includes persons who are age eligible for vaccination but whose vaccination status is unknown or who are unvaccinated for unknown reasons. All case-patients in this category were between 20 and 50 years old. No persons cited medical reasons for not having been vaccinated

  14. Strategies for Achieving and Maintaining Measles Elimination • Maximize population immunity through vaccination • Assure adequate surveillance • Respond rapidly to outbreaks • Work to improve global control

  15. Maximize Population Immunity through Vaccination • Provide scientific evidence for vaccine policy decision making and communicate policy recommendations • Deliver recommended vaccinations on time • First dose 12-15 months • Second dose 4-6 years • Two dose MMR vaccine schedule for children, students, health care personnel and international travelers • At least one dose for other adults • Child care and school requirements • Evaluate vaccine coverage and population immunity • National Immunization Survey (19-35 months) • School entry assessments (≥ one dose) • Two dose coverage among school students (NHIS, adolescent NIS) • Health care personnel

  16. Estimated MMR Vaccine Coverage among children aged 19-35 months , NIS, US, 2003-2007 MMWR

  17. Nonmedical Exemptions for States With Religious Exemptions and With Personal Belief Exemptions -1991 - 2004 Only Religious Exemptions Permitted Personal Belief Exemptions Permitted Exemption Rate Exemption Rate Omer , Pan, Halsey et al., JAMA, 2006

  18. WA State Counties’ School Entry Exemption Rates2005-2006

  19. Assure Adequate Surveillance • Detect imported cases to prevent indigenous spread • Detect small chains of transmission • Timely reporting and notification of cases • Polio, measles, rubella recently made “immediately” reportable by CSTE • Monitor surveillance indicators • Assess completeness of reporting periodically

  20. Rapid Outbreak Response • Case finding and investigation • Active surveillance • Laboratory confirmation and genotyping • Isolation of cases • Contact tracing • Identify contacts • Vaccine, IG and/or voluntary home quarantine for those without evidence immunity • Assess community vaccine coverage and needs for additional community vaccination including infants 6-11 months

  21. Global Measles • Achievements in measles control and elimination • However, in 2006 (estimates) • 20 million cases • 242,000 deaths • In 2006, ~30 million U.S. residents traveled abroad and 51 million international visitors entered the U.S. • In 2008, measles endemic in many countries, outbreaks in Europe and UK declared re-establishment of endemic disease transmission • Ongoing risk of importations

  22. Measles Importations 2005-2008* 2005-2007, N = 84 2008, N = 20 * 2008, provisional data through Sept 12

  23. Global Threat of Measles, U.S. 2008 131 cases 17 importations 21 virologic evidence D4 (10), D5 (9), H1 (2) D5 D4 D4 D4 D5

  24. Demands/Challenges in Maintaining Measles Elimination in the US • Ongoing risk of importations • Lack of familiarity with measles among the public and health care providers • High level of investigative and public health response effort by local, state and national public health and laboratory staff • Maintaining high one and two dose vaccine coverage with increasing vaccine safety concerns in the population

  25. Thank you Kathleen Gallagher kxg7@cdec.gov

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