Update on Measles in the U.S. Update on Measles in the U.S. 20082008

National PerspectiveNational Perspective

Kathleen Gallagher, D.Sc, MPHKathleen Gallagher, D.Sc, MPHNCIRD, CDCNCIRD, CDC

Today’s PresentationToday’s Presentation

• Measles in the US in the pre- and post-Measles in the US in the pre- and post-elimination eraselimination eras

• What’s going on in 2008What’s going on in 2008

• Strategies to maintain eliminationStrategies to maintain elimination

• ChallengesChallenges

Annual Measles Disease BurdenAnnual Measles Disease BurdenUnited States, 1950sUnited States, 1950s

• 3-4 million cases3-4 million cases– ~ 500,000 reported cases~ 500,000 reported cases

• Severe complicationsSevere complications– 4,000 encephalitis cases4,000 encephalitis cases– 150,000 respiratory complications 150,000 respiratory complications

(pneumonia)(pneumonia)

• 48,000 hospitalizations48,000 hospitalizations• 450 deaths450 deaths

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

1962 1966 1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 20100

10

20

30

40

50

60

70

80

90

100

1963Vaccine Licensed1st Dose

Recommendation

19892nd Dose

Recommendation

2000 Elimination Declared

1-dosepreschool coverage

2-doseadolescent coverage

1989-91Resurgence

Reported Measles CasesReported Measles CasesUnited States, 1962 - 2007United States, 1962 - 2007

Mea

sles

Cas

es

% M

easles Vax C

overag

e

Year

0

10,000

20,000

30,000

1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

19892nd Dose

Recommendation

2000 Elimination Declared

Measles, United States, 1985 - 2007Measles, United States, 1985 - 2007R

epor

ted

Mea

sles

Cas

es

Year

Measles resurgence 1989-199155,622 reported cases123 reported deaths

Reported Measles IncidenceReported Measles IncidenceUnited States, 1992-2007United States, 1992-2007

0

0.2

0.4

0.6

0.8

1

92 94 96 98 2000 2002 2004 2006

Year

Cases/100,000

1 case/million

Measles elimination declared

Measles Epidemiology, Post EliminationMeasles Epidemiology, Post Elimination

• 63 cases reported each year (2000-2007)63 cases reported each year (2000-2007)• Cases are all related to imported cases including Cases are all related to imported cases including

from developed countries – Europe, Japanfrom developed countries – Europe, Japan• Outbreaks predominantly in unprotected Outbreaks predominantly in unprotected

populationspopulations– 20052005 Indiana, 34 cases in unvaccinated religious communityIndiana, 34 cases in unvaccinated religious community– 20062006 Boston,Boston, 18 cases in young adults mainly one dose 18 cases in young adults mainly one dose

vaccine recipients and foreign born adultsvaccine recipients and foreign born adults

Measles, US, 2008Measles, US, 2008

• Highest number of Highest number of reported cases year reported cases year to date (Jan-July) to date (Jan-July) since 1996since 1996

• No increase in No increase in imported casesimported cases

• Increase in spread Increase in spread within the U.S. within the U.S. – 7 “outbreaks”7 “outbreaks”

Measles, January – July 2008Measles, January – July 2008

• 131 cases from 15 states and DC131 cases from 15 states and DC• 15 (11%) cases hospitalized, no deaths15 (11%) cases hospitalized, no deaths• Importation status:Importation status:

– 17 importations17 importations• 8 foreign visitors (all unvaccinated)8 foreign visitors (all unvaccinated)• 9 US residents (all unvaccinated)9 US residents (all unvaccinated)

– 99 (76%) additional cases linked to importations or 99 (76%) additional cases linked to importations or virologic evidence of importationvirologic evidence of importation

– 15 cases unknown source15 cases unknown source• 123 cases in US residents123 cases in US residents

– 91% cases unvaccinated or unknown vaccination 91% cases unvaccinated or unknown vaccination statusstatus

Measles Cases Reported to CDC/NCIRD Measles Cases Reported to CDC/NCIRD January-July, 2008 (N= 131)January-July, 2008 (N= 131)

San Diego, CASan Diego, CAN=12N=12

Missaukee County, MI, Missaukee County, MI, N=4N=4

Pima County, AZ N=14Pima County, AZ N=14

Los Angeles, CA Los Angeles, CA N=1N=1

Fairfax, VA Fairfax, VA N=1N=1

Milwaukee County, WI Milwaukee County, WI N=6N=6 Nassau County, NY Nassau County, NY

N=1N=1

New York City, NYNew York City, NYN=26N=26

Honolulu, HIHonolulu, HIN=4N=4

Pittsburgh, PA Pittsburgh, PA N=1N=1

Chicago, ILChicago, ILGrant County, Grant County, WAWA

N=N=19Vernon County, WIVernon County, WI

N=1 N=1

Scott County, ARScott County, ARN=2N=2

San Francisco, CA San Francisco, CA N=2, Sources:N=2, Sources:

D.C. N=1D.C. N=1

NM N=1, NM N=1, UnknownUnknown

Baton Rouge , LA Baton Rouge , LA N=1, N=1,

Du Page Co, I L Du Page Co, I L N=31N=31

Fulton Co, GA Fulton Co, GA N=1N=1

Cass Co, MO N=1Cass Co, MO N=1

Reported Measles Cases, U.S. Reported Measles Cases, U.S. 1997-2008*, by Importation Status1997-2008*, by Importation Status

0

20

40

60

80

100

120

140

160

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Imports Import associated/other

*Provisional data through July 31*Provisional data through July 31

U.S. Residents with Measles, January 1 U.S. Residents with Measles, January 1 through July 31, 2008, by Agethrough July 31, 2008, by Age

<12 mo: 16 (13%)

12-15 mo: 9 (7%)

16 mo-4yr: 19 (15%)

20-49 yr: 22 (18%)

≥ 50 yr: 2 (2%)

5-19 yr: 55 (45%) N = 123N = 123

80% cases < 20 years80% cases < 20 years

Reasons for not receiving Measles vaccine, U.S Reasons for not receiving Measles vaccine, U.S Residents with measles who were Eligible* for Residents with measles who were Eligible* for Vaccination, January 1 through July 31, 2008,Vaccination, January 1 through July 31, 2008,

N=95 N=95

Philosophical or religious

beliefs against

vaccination: 63 (67%)

Delayed Vaccination:†

7 (7%)

Unknown:§ 16 (17%)

12-15 months old: 9 (9%)

* 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

Strategies for Achieving and Strategies for Achieving and Maintaining Measles EliminationMaintaining Measles Elimination

• Maximize population immunity through vaccinationMaximize population immunity through vaccination

• Assure adequate surveillanceAssure adequate surveillance

• Respond rapidly to outbreaksRespond rapidly to outbreaks

• Work to improve global control Work to improve global control

Maximize Population Immunity through Maximize Population Immunity through VaccinationVaccination

• Provide scientific evidence for vaccine policy decision making and Provide scientific evidence for vaccine policy decision making and communicate policy recommendationscommunicate policy recommendations

• Deliver recommended vaccinations on timeDeliver recommended vaccinations on time– First dose 12-15 monthsFirst dose 12-15 months– Second dose 4-6 yearsSecond dose 4-6 years– Two dose MMR vaccine schedule for children, students, health care Two dose MMR vaccine schedule for children, students, health care

personnel and international travelerspersonnel and international travelers– At least one dose for other adultsAt least one dose for other adults– Child care and school requirementsChild care and school requirements

• Evaluate vaccine coverage and population immunityEvaluate vaccine coverage and population immunity– National Immunization Survey (19-35 months)National Immunization Survey (19-35 months)– School entry assessments (School entry assessments (≥ one dose)≥ one dose)– Two dose coverage among school students (NHIS, adolescent NIS)Two dose coverage among school students (NHIS, adolescent NIS)– Health care personnelHealth care personnel

Estimated MMR Vaccine Coverage Estimated MMR Vaccine Coverage among children aged 19-35 months , NIS, among children aged 19-35 months , NIS,

US, 2003-2007US, 2003-2007

93 93 91.5 92.3 92.3

0

20

40

60

80

100

2003 2004 2005 2006 2007

Year

% r

ecei

vin

g 1

or

mo

re d

ose

s

MMWR

Nonmedical Exemptions for States With Religious Nonmedical Exemptions for States With Religious Exemptions and With Personal Belief Exemptions -Exemptions and With Personal Belief Exemptions -

1991 - 20041991 - 2004

Omer , Pan, Halsey et al., JAMA, 2006

Only Religious Exemptions Permitted Personal Belief Exemptions Permitted

0.0%

1.0%

2.0%

3.0%

4.0%

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

0.0%

1.0%

2.0%

3.0%

4.0%

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004E

xem

pti

on

WA State Counties’ School Entry WA State Counties’ School Entry Exemption RatesExemption Rates

2005-20062005-2006

Assure Adequate SurveillanceAssure Adequate Surveillance

• Detect imported cases to prevent indigenous Detect imported cases to prevent indigenous spreadspread

• Detect small chains of transmissionDetect small chains of transmission• Timely reporting and notification of casesTimely reporting and notification of cases

– Polio, measles, rubella recently made “immediately” Polio, measles, rubella recently made “immediately” reportable by CSTEreportable by CSTE

• Monitor surveillance indicators Monitor surveillance indicators • Assess completeness of reporting periodicallyAssess completeness of reporting periodically

Rapid Outbreak ResponseRapid Outbreak Response• Case finding and investigationCase finding and investigation

– Active surveillanceActive surveillance– Laboratory confirmation and genotypingLaboratory confirmation and genotyping– Isolation of casesIsolation of cases

• Contact tracingContact tracing– Identify contactsIdentify contacts– Vaccine, IG and/or voluntary home quarantine for those Vaccine, IG and/or voluntary home quarantine for those

without evidence immunitywithout evidence immunity

• Assess community vaccine coverage and needs for Assess community vaccine coverage and needs for additional community vaccination including infants 6-additional community vaccination including infants 6-11 months11 months

Global MeaslesGlobal Measles

• Achievements in measles control and elimination Achievements in measles control and elimination • However, in 2006 (estimates)However, in 2006 (estimates)

– 20 million cases20 million cases– 242,000 deaths242,000 deaths

• In 2006, ~30 million U.S. residents traveled abroad In 2006, ~30 million U.S. residents traveled abroad and 51 million international visitors entered the U.S.and 51 million international visitors entered the U.S.

• In 2008, measles endemic in many countries, In 2008, measles endemic in many countries, outbreaks in Europe and UK declared re-outbreaks in Europe and UK declared re-establishment of endemic disease transmissionestablishment of endemic disease transmission

• Ongoing risk of importations Ongoing risk of importations

Measles Importations 2005-2008*Measles Importations 2005-2008*

CountriesCountries

1717 IndiaIndia

1010 JapanJapan

77 ChinaChina

66 UkraineUkraine

44 U.K, ThailandU.K, Thailand

33 Pakistan, Mexico, SwitzerlandPakistan, Mexico, Switzerland

22 Germany, Belgium, Hong Kong, Germany, Belgium, Hong Kong, Romania, Saudi Arabia, Kenya, Israel, Romania, Saudi Arabia, Kenya, Israel, Australia, YemenAustralia, Yemen

11 Ghana, Ethiopia, Italy, Uganda, Armenia Ghana, Ethiopia, Italy, Uganda, Armenia Bangladesh, France, Indonesia, NigeriaBangladesh, France, Indonesia, Nigeria

2005-2007, N = 842005-2007, N = 84

* 2008, provisional data through Sept 12

CountriesCountries

55 ItalyItaly

33 SwitzerlandSwitzerland

22 Israel, Belgium, IndiaIsrael, Belgium, India

11 Germany, China, Pakistan, Germany, China, Pakistan,

PhilippinesPhilippines, , Japan, RussiaJapan, Russia

2008, N = 202008, N = 20

D5

D5D4

D4

D4

Global Threat of Measles, U.S. 2008Global Threat of Measles, U.S. 2008

131 cases131 cases 17 importations17 importations 21 virologic evidence21 virologic evidence D4 (10), D5 (9), H1 (2) D4 (10), D5 (9), H1 (2)

Demands/Challenges in Maintaining Demands/Challenges in Maintaining Measles Elimination in the USMeasles Elimination in the US

• Ongoing risk of importationsOngoing risk of importations• Lack of familiarity with measles among the Lack of familiarity with measles among the

public and health care providerspublic and health care providers• High level of investigative and public health High level of investigative and public health

response effort by local, state and national response effort by local, state and national public health and laboratory staffpublic health and laboratory staff

• Maintaining high one and two dose vaccine Maintaining high one and two dose vaccine coverage with increasing vaccine safety coverage with increasing vaccine safety concerns in the populationconcerns in the population

Thank youThank you

Kathleen GallagherKathleen Gallagher

kxg7@cdec.govkxg7@cdec.gov