Domestic Measles Update

Gregory S Wallace, MD, MS, MPH Lead, Measles/Mumps/Rubella/Polio Team

Epidemiology Branch, Division of Viral Diseases National Center for Immunization and Respiratory Diseases

Centers for Disease Control and Prevention

Advisory Committee on Immunization Practices June 26, 2014

Global transmission patterns of measles viruses from the Philippines, 2014

B3 D9

Measles, United States, Jan – June 20, 2014 Source of Importations (N=48)

WHO Region # of cases Countries of travel

African 0

Eastern Mediterranean

1 Pakistan

European 5 Dubai/Germany/London (1), Republic of Georgia (1), Netherlands (1), France/Belgium (1), Greece (1)

Americas 3 Brazil (1), Canada (1), Chile (1)

South-East Asia 8 India (6), Indonesia (1), Thailand/South Korea (1)

Western Pacific 31 China (3), Philippines (23), Singapore (1), Saipan (1), Vietnam (1), SE Asia/Philippines (1), FSM (1)

Measles, U.S., 1997-2014* Cumulative Number by Month of Rash Onset

0

100

200

300

400

500

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

No.

of c

ases

(cum

ulat

ive)

Month

1997-20012002-2010 (excluding 2008)20082011201220132014*

*As of June 20, 2014

Measles U.S. 2014* • 514 cases reported from 20 states including 16 outbreaks

–

––

––––

48 importations • 23 from the Philippines • 43 (90%) US residents

98% cases import-associated 56 cases (11%) hospitalized

• Cases in US residents (N=506)

81% unvaccinated 12% unknown vaccination status (78% of those adults) 7% vaccinated (including 5% with 2 or more doses) Among unvaccinated

• 87% were personal belief exemptors • 3% unvaccinated travelers age 6 mos – 2 yrs • 5% too young to be vaccinated

* Provisional reports to CDC through June 20, 2014

Measles Outbreaks with >20 Cases, United States, 2001-2014*

Year Outbreak

Name State

# of Cases

Import Status Genotype Setting 1st & last rash

onsets Duration Median Age

Age Range

2014 Knox County OH 340* Imported

(Philippines) D9 Community 3/22/2014 –

13 weeks and

counting

23 y (early) 13 y (late)

2 wks – 52 y

2013 Brooklyn NYC 58 Imported (UK) D8 Household/ community

3/13/2013 – 6/9/2013

13 weeks 10 y (early)

19 mos (late) 0 mos – 32 y

2005 Tippecanoe

County IN 34

Imported (Romania)

D4 Church/

household 5/16/2005 - 6/24/2005

6 weeks 12 y 9 mos - 49 y

2008 DuPage/Cook

County IL 30

Imported- virus

D4 Homeschool 5/17/2008 -

7/3/2008 7 weeks 10 y 8 mos - 43 y

2014 Manhattan NYC 25 Imported-virus B3 Community 2/11/2014 – 3/24/2014

6 weeks 22 y 3 mos – 63 y

2013 Stokes/Orange

County NC 23 Imported (India) D8 Community

4/5/2013 – 5/7/2013

5 weeks 14 y 12 mos -59 y

2014 KC Metro MO/KS 22* Imported-virus B3 Community 5/5/2014 – 7 weeks and

counting 5 y 2 wks – 37 y

2013 Tarrant/Denton

County TX 21

Imported (Indonesia)

D9 Church 7/21/2013 – 8/21/2013

5 weeks 11 y 4 mos – 44 y

2011 Hennepin

County MN 21

Imported (Kenya)

B3 Shelter 2/15/2011 - 4/24/2011

10 weeks 23 m 3 mos - 51 y

2008 Brooklyn/

Kings County NYC 21

Imported (Israel, Belgium)

D4 Community 2/17/2008 - 4/25/2008

10 weeks 15 m 5 mos - 11 y

*as of June 20, 2014

US Annual Disease Burden Prior to Vaccine

• 3-4 million estimated and ~ 500,000 reported cases • 48,000 hospitalizations • 4,000 encephalitis cases • 450-500 deaths

Measles Cases, United States, 1962-2014*

0

100,000

200,000

300,000

400,000

500,000

600,000

1960 1970 1980 1990 2000 2010

Num

ber o

f cas

es

1989 – 2nd Dose Recommended

0

5,000

10,000

15,000

20,000

25,000

30,000

1985 1990 1995 2000 2005 2010

1963 Vaccine

Licensed 1989-1991

Resurgence

1993 Vaccines for

Children Program

2000 Elimination

Declared

Year

*2014 case count preliminary as of June 20

Measles, United States, 2001-2014* Importations by WHO Region

0

10

20

30

40

50

60

70

80

90

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Num

ber o

f Cas

es

Year

UnknownWestern Pacific(WPR)South East Asian(SEAR)European(EUR)Eastern Mediterranean(EMR)African(AFR)American(AMR)

*2014 case count preliminary as of June 20

Measles, United States, 1993-Present*

0

100

200

300

400

500

600

700

800

900

1000

No

of C

ases

*2014 case count preliminary as of June 20

Measles, United States, 2001-Present*

0

50

100

150

200

250

300

350

400

450

No

of C

ases

Import Non-Import

*2014 case count preliminary as of June 20

Most Measles Cases Result in Limited Transmission

2014: 76% with 1 or 2 chains of transmission, 6% with 10 or more

Measles, United States, 2001-2014* Age Specific Incidence

0

2

4

6

8

10

12

14

16

18

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Case

s per

1,0

00,0

00

<6m 6-8m 9-11m 12-15m 16m-4y 5-9y 10-19y ≥20y

*2014 case count preliminary as of June 20

What Works

• National vaccine coverage remains high

• Aggressive public health response can limit transmission

• Improved implementation of healthcare worker recommendations

Challenges

• Heterogeneity – Outbreaks reveal groups of accumulating and aging susceptibility

• Global arena –

–

–

Importations continue

• Early diagnosis of initial cases Including obtaining proper specimens

• Implementing travel recommendations Early dose for infants; 2 doses for everyone else

• Resource intensive public health response ––

Diverts resources Mission fatigue

Key Messages

• Measles in the U.S. is a global issue –

–

––––

–

Most importations are U.S. travelers

• Measles does exploit pockets of unvaccinated Highly contagious

• Keep measles in the differential diagnosis Febrile rash illness (Dengue, Kawasaki’s) Travel history or exposure to travelers Vaccine history Viral specimens

• Variety of susceptible groups in the U.S. Challenge to identify and intervene prior to exposures

DISCUSSION