Vaccine-Preventable Diseases: Situations Requiring Immediate Action

1. Vaccine-Preventable Diseases: Situations Requiring Immediate Action Carrie A. Thomas, PhD Epidemiologist (VPD/IBD) Division of Infectious Disease Epidemiology West Virginia Bureau for Public Health www.dide.wv.gov (304) 558-5358

2. Objectives • Overview of vaccine-preventable diseases that require rapid response & why it is important • Consequences of non-response or untimely response • Populations for special consideration • Highlight key steps in the investigation

3. Measles – Why is it an Emergency? • Endemic measles declared eliminated in the US in 2000 • Almost 30% of cases experience complications • Inflammation of the middle ear (7%) • Pneumonia (6%) • Encephalitis (0.1%) • Hospitalization (19%) • Death (0.3%) • Susceptible populations at higher risk for disease and complications

4. Measles – Populations for Special Consideration • Children < 1 year of age • Susceptible immunocompromised patients • Healthcare workers (HCWs) • Increased risk of exposure and transmission through patient care • Pregnant women • High risk for pregnancy complications • People travelling to places where measles are endemic

5. Measles – What to Do • Immediately isolate suspect cases with airborne transmission precautions • 4 days after rash onset in otherwise healthy individuals • duration of illness in immunocompromised patients • Confirm/rule out suspect cases rapidly through lab results • Work with DIDE to submit sample to CDC • High false positive rate of results in commercial labs

6. Measles – What to Do (cont.) • Confirm immune status of exposed individuals • Need written confirmation (verbal indication is not acceptable) • Acceptable evidence of immunity • Evidence of physician-diagnosed natural measles infection • Documentation of two doses of measles containing vaccine, or • A positive IgG antibody test for measles

7. Measles – What to Do (cont.) • Post-exposure prophylaxis (PEP) for susceptible contacts, including HCWs • Vaccination within 72 hours of exposure* • Immune globulin, given within 6 days of exposure for • Susceptible household or other close contacts • Contacts < 1 year of age • Pregnant women† • Immunocompromised patients† *preferred method of PEP † vaccination contraindicated in these populations

8. Measles – What to Do (cont.) • Susceptible persons do not receive PEP should be excluded for 21 days after rash onset in last case of measles • Furlough susceptible HCWs from 5th-21st day after exposure, regardless of PEP • Furlough ill HCWs for 4 days after development of rash

9. Rubella – Why is it an Emergency? • Endemic rubella declared eliminated in the US in 1994 • Complications are rare, occurring more frequently in adults than children • However, arthralgia or arthritis may occur in up to 70% of adult women • Encephalitis or hemorrhagic manifestations are rare • Urgency comes from desire to prevent Congenital Rubella Syndrome

10. Rubella – Populations for Special Consideration • Susceptible immunocompromised patients • Children < 1 year of age • Healthcare workers (HCWs) • Pregnant women • High risk for pregnancy complications • Congenital Rubella Syndrome – affects up to 85% of infants infected during 1st trimester

11. Rubella – Congenital Rubella Syndrome (CRS) • Can affect all organ systems; manifestations include • Deafness - most common • Cataracts & other eye defects • Heart defects including holes in the walls or blood vessels; malformations of heart valves or blood vessels • Microcephaly and/or mental retardation • Bone alterations • Liver and spleen damage • Diabetes mellitus, progressive encephalopathy and autism have also been observed in children with CRS

12. Rubella – What to Do • Immediately isolate suspect cases with contact precautions for 7 days after rash onset • Confirm/rule out suspect cases rapidly through lab results • Work with DIDE to submit sample to CDC for confirmation • False positive IgM results seen in persons with parvovirus B19 infections, infectious mononucleosis, or a positive rheumatoid factor

13. Rubella – What to Do (cont.) • Confirm immune status of exposed individuals • Documentation of at least 1 dose of rubella-containing vaccine • Positive IgG antibody test • Born before 1957 • Note: clinical diagnosis is unreliable and should not be considered when assessing immune status • Confirm pregnancy status of exposed women

14. Rubella – What to Do (cont.) • PEP for susceptible contacts, including HCWs • Vaccination ASAP after exposure to prevent spread of disease, especially in settings where pregnant women may be exposed • Vaccination is contraindicated 4 weeks prior to and during pregnancy and in immunocompromised individuals • If pregnant woman is exposed • Assess immune status

15. Diphtheria– Why is it an Emergency? • Endemic in many parts of the developing world • Approximately 50% of US adults are susceptible • Formation of pseudomembrane over tonsils, pharynx or larynx can cause airway obstruction • Complications include • Inflammation of the heart muscle (myocarditis) • Paralysis • Inflammation of the middle ear • Respiratory insufficiency

16. Diphtheria – Populations for Special Consideration • Susceptible HCWs • HCWs who are not up-to-date on Td boosters may become infected and spread disease to susceptible populations • People travelling to places where diphtheria is endemic • Immunocompromised patients and those with existing history of respiratory and/or heart conditions

17. Diphtheria – What to Do • Isolate suspect cases with droplet precautions for 48 hours after beginning antibiotics • Confirm diagnosis through lab results • Work with DIDE to submit sample to CDC • Do not wait for lab confirmation to treat those meeting clinical case definition with antibiotics & diphtheria antitoxin (only available from CDC since 1997)

18. Diphtheria – What to Do (cont.) • Assess vaccination history in case/contacts. • Administer appropriate dose(s) of DTaP/DTP/DT/Td/Tdap • Submit samples for culture for and administer prophylactic antibiotics to close contacts • These recommendations apply to respiratory diphtheria • Cutaneous diphtheria is not a reportable condition • Transmitted through contact with skin lesions

19. Meningococcal Meningitis – Why is it an Emergency? • Infection can progress rapidly and result in death • 10-14% case-fatality rate • Approx 40% meningococcal disease cases present as bacteremia, • Of those surviving invasive disease, 10-20% experience sequelae, including limb loss from gangrene, extensive skin scarring or cerebral infarction • 70% of secondary cases occur within 7 days

20. Meningococcal Meningitis – Populations for Special Consideration • College freshman living in dorms • Military recruits • People travelling to countries where meningococcal disease is hyperendemic or epidemic • Persons with conditions leading to decrease immune system functions, including • terminal complement component deficiencies • anatomic or functional asplenia

21. Meningococcal Meningitis – What to Do • Trace patient contacts within 7 days of symptom onset in index patient • Close contacts defined as • Household members (including dormitory room and barrack roommates) • Childcare center contacts • Persons directly exposed to patient’s oral secretions by kissing, mouth-to-mouth resuscitation, or endotracheal intubation/tube management

22. Meningococcal Meningitis – What to Do (cont.) • Offer PEP as soon as possible (preferably within 24 hours) • If given more that 14 days after symptom onset in index patient, PEP is probably of limited or no benefit • Offer PEP to exposed HCWs, but think before you offer PEP • You probably don’t need to provide PEP to the receptionist who checked the patient in

23. Invasive Haemophilus Influenzae b (Hib) – Why is it an Emergency? • Before vaccine, 15-30% of survivors experienced serious complications • Hearing impairment • Severe permanent neurologic consequences • Mental retardation • Seizure disorder • Cognitive & developmental delay • Paralysis • Rapid identification important for early vaccination and chemoprophylaxis of susceptible contacts

24. Hib – Populations for Special Consideration • Children under 5 years of age • Immunocompromised children • Older children and adults who were not vaccinated in childhood and have the following conditions • Functional or anatomical asplenia • Immunodeficiency from IgG2 subclass deficiency • Immunosuppression from cancer chemotherapy • HIV • Hematopoietic stem cell transplant

25. Hib – What to Do • Isolate suspected cases with droplet precautions until 24 hours after starting antibiotics • Confirm diagnosis and have isolate serotyped (OLS) • Offer PEP for all household contacts as soon as possible • With at least 1 contact < 4 years old who is unimmunized or incompletely immunized • With a child younger than 12 months who has not received the primary series • With an immunocompromised child (regardless of immunization status

26. Hib – What to Do (cont.) • PEP should also be provided for • Nursery school/childcare center contacts when > 2 cases occur within 60 days • PEP is NOT recommended for • Contacts in households with no children < 4 years old except index case • Contacts in households where • Members 12-48 months old are fully vaccinated • Members <12 months old have received primary series of Hib immunizations • Nursery school/childcare center contacts of 1 index case • Pregnant women

27. Mumps – Why is it an Emergency? • 20-40% infections asymptomatic • Major cause of sensorineural deafness in children • Complications more common in adults • Meningoencephalitis • Orchitis , oophoritis, mastitis • Permanent consequences are rare • Susceptible HCW are who you need to be concerned about

28. Mumps – What to Do • Isolate cases with droplet precautions for 5 days after onset of parotitis • Evaluate immune state of exposed contacts • Written documentation of vaccination • Positive mumps IgG • Lab confirmation of disease • Birth before 1957 (except in healthcare setting)

29. Mumps – What to Do (cont.) • Susceptible children should receive 2 doses MMR • Susceptible children should be excluded from school until the 26th day after onset of parotitis in the last case • HCWs without evidence of immunity should be furloughed from the 9th-25th day after exposure • All HCW should be alert for symptoms of mumps 12-25 days after exposure, regardless of vaccination status

30. Pertussis during Pregnancy • Pertussis can cause severe illness and death in infants • Any woman who might become pregnant is encouraged to receive a single dose of Tdap • Women who have not received Tdap should receive a single dose in the immediate postpartum period

31. Pertussis during Pregnancy (cont.) • Pregnant women should receive a single dose of Tdap during an outbreak • Preferably in the 2nd or 3rd trimester to avoid coincidental association of vaccination and spontaneous termination of a pregnancy, which is more common in the 1st trimester • Vaccination during pregnancy can provide some protection for newborns

32. Varicella during Pregnancy • VZV infection of the fetus • Low birth weight • Skin scarring • Malformed limbs • Mental retardation • Vision problems • Primary infection with VZV in pregnant women is rare • Varicella in pregnancy is associated with

33. Varicella during Pregnancy (cont.) • Vaccination contraindicated during pregnancy • Women should be vaccinated before they attempt to become pregnant • If not immune pre-pregnancy, should be vaccinated immediately post-partum • Immune globulin can prevent or reduce severity of disease if given within 96 hours of exposure

34. Summary • Isolate case patient • Inform appropriate agencies – DIDE, CDC • Confirm diagnosis with appropriate lab testing • Trace contacts and assess immunity • Provide appropriate PEP

35. References • Manual for the Surveillance of Vaccine-Preventable Diseases, 4th edition, CDC, 2008 • Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book), 12th edition, CDC, 2011 • Red Book: 2009 Report of the Committee on Infectious Diseases, 28th edition, American Academy of Pediatrics, 2009 • www.mayoclinic.com