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Status of Measles Outbreak

Protecting the Public with Vaccines

Anne Schuchat, MD
RADM, US Public Health Service
Assistant Surgeon General
Director, National Center for Immunization and Respiratory
Diseases

National Press Foundation


Washington, DC
February 23, 2015
National Center for Immunization and Respiratory Diseases

Provisional data as of February 20, 2015

Measles Cases, United States, 1962-2014*


600,000
500,000

1963
Vaccine
Licensed

30,000

1989-1991
Resurgence

25,000

400,000of cases
Number

20,000
15,000

300,000
200,000

10,000

1993
Vaccines for
Children
Program

2000
Elimination
Declared

5,000
0

100,000
1989 2nd Dose
Recommended

*2014 provisional total as of Dec 31st 2014

Year

Measles Elimination* in the


U.S.

Declared in 2000 and achieved due to:

High two-dose vaccine coverage


High quality measles surveillance and response
Improved measles control in the World Health
Organization Region of the Americas

Elimination does not mean gone forever


- imported cases and limited spread occur
every year

* Defined as interruption of continuous measles transmission for


lasting > 12 months

Measles, United States, 2001-2014*


(Importations indicated by red bar, available since
2001) 700
600
500
400
No of Cases 300
200
100
0

*2014 provisional total through Dec 31st

Measles Epidemiology US, 20012011

Median 60 cases/year (range 37 to 220)


Importations ~ 33/year, majority in US
residents
~ 25 % cases hospitalized
2 deaths in approximately 1,000 cases
Incidence < 1 case/million population
Highest age-specific incidence in infants, lowest in adults

Vaccination status
65% unvaccinated
20% unknown vaccination status
15% vaccinated

4 outbreaks/year (range 2-12)


Median size 6 cases (3-34 cases)

DC US National Report: to PAHO on Documentation and verification of measles, rubella and CRS
mination in the Americas

Measles 2011 - 2014

Reported cases 220, 55, 189, 644


Median 205
Mean 277

Importations and Outbreaks

2011
2012
2013
2014

80
21
54
60

importations
importations
importations
importations

14 outbreaks
4 outbreaks
11 outbreaks
23 outbreaks

3
3
3
3

21 cases
- 14 cases
- 58 cases
383 cases

Measles, U.S., 2001-Feb 20, 2015*


Cumulative Number by Month of Rash Onset
Number of Cases (Cumulative)

700
600
500
400
300
200

Feb 20, 2015

100
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

* Provisional total 2014


* 2015 data to Feb 20, 2015

20
01
20
02
20
03
20
04
20
05
20
06
20
07

Measles U.S. 2014*


644 cases reported from 27 states including
23 outbreaks
60 importations
25 from the Philippines and 9 from India
54 (91%) among US residents

98% cases import-associated


78 cases (12%) hospitalized

Cases in US residents (N=635)


77% unvaccinated
15% unknown vaccination status (most are adults)
8% vaccinated
Among unvaccinated

79% were personal belief exemptors


3% travelers age 6 months to 4 years
8% were too young to be vaccinated
10% unknown/misc
* Provisional reports to CDC through Dec 31 2014

Incidence/million
U.S., 2014
25
20
15
10
5
0

11

Measles, U.S., 1997-2015*


Cumulative Number by Month of Rash Onset
1997-2001
min1
600
2008
2011
500
2012
No. of cases (cumulative)
2013
2014
400
2015
2002-2010
300
(excluding 2008)

200
Jan 2015

100
0
Jan

Feb

Mar

Apr

* Provisional total 2014


* 2015 data through Jan

May

Jun

Jul

Month

Aug

Sep

Oct

Nov

Dec

Provisional data as of February 20, 2015

Every Measles Case Requires


Public Health Follow-up

Childcare
centers
Hospital
Transportatio
n

Widely
attended
gatherings

ER
Family

14

Measles 2015

Most cases unvaccinated or


with unknown vaccination
status
7 importations from
Azerbaijan, Indonesia, Qatar,
Pakistan, Dubai/India,
Singapore/Indonesia,
Afghanistan
Adult and child cases
Measles genotypes B3 , D8
and D9
Child care center cases IL
2 outbreaks
Amusement park-associated

15

Measles outbreak response has a high


economic burden in the U.S.

Yea Locatio
r
n

Number
of cases
(outbrea
ks)

Estimated public health


cost*

201
1

US

107 (16)

$2.7-5.3M

201
1

Utah

13 (2)

>$330,000

200
8

Californi 12 (1)
a

$125,000

200
8

Arizona

$800,000

14 (1)

(limited to cost for 2 hospitals to respond


to 7 cases in their facilities)

200 health
Indiana
34 care
(1) costs expended
$168,000
*Public
and health
to control the spread of

Keys to Maintaining Measles


Elimination in the U.S.
High 2-dose MMR vaccination coverage
High quality surveillance system
Thinking
beyond
our to measles
Rapid
identification
of and response
cases
borders
Measles is reportable within 24 hours per Council
of State and Territorial Epidemiologists guidelines
Aggressive outbreak control measures
Access to reliable laboratory testing capabilities
Genotyping can give clues to source in some
instances
Information sharing tools (Epi-X, HAN)
17

Infographic on travel and cases

MMR Vaccine Routine


Recommendations*
Children and adolescents

Two doses at 12-15 months and 4-6 years or at least 28


days after the first dose
Catch up vaccination as needed

Adults without evidence of measles


immunity
Two doses (healthcare personnel, post high school
students, travelers)
One dose (others)

2013 ACIP Recommendations at http://www.cdc.gov/mmwr/pdf/rr/rr6204.pdf


*ACIP, AAP/COID, AAFP, ACOG, ACP, ACNM available at http://
www.cdc.gov/vaccines/schedules/hcp/adult.html

MMR Vaccine Travel


Recommendations

Persons aged 12 months without other


evidence of immunity should receive 2 doses*
Includes providing a 2nd dose to children prior to age 4-6 yrs
Includes adults** who have only received one routine dose in
the past

Children aged 6-11 months should receive 1


dose
If vaccinated at age 6-11 months, still need 2 subsequent
doses at age 12 months
2013 ACIP Recommendations
2nd dose of MMR vaccine should be administered at least 28 days after the 1 st dose
** Born in 1957 or later

Est. % of children enrolled in kindergarten


exempted from receiving one or more
vaccines and with <90% coverage with 2
doses of MMR vaccine
United States, 201314 school year

Data Source: MMWR, October 17, 2014 / 63(41);913-920

21

Source: Immunization Action Coalition

22

Very few toddlers have


received no vaccines at all

HP2020 Goal:
<1%

1
0.8
0.7

% zero dose children

0.6

0.8
0.7

0.6

2008 2009 2010 2011 2012 2013

National Immunization Survey, 19-35 month old children, US, 2008 2013
MMWR 63(34); 741-748, August 29, 2014

Comparison of 20th Century Annual Morbidity and


Current Morbidity: Vaccine-Preventable Diseases
Disease

20th Century
Annual Morbidity

2014
Reported Cases

Percent
Decrease

Smallpox

29,005

100%

Diphtheria

21,053

> 99%

Measles

530,217

628

> 99%

Mumps

162,344

1,151

99%

Pertussis

200,752

28,660

86%

Polio (paralytic)

16,316

100%

Rubella

47,745

> 99%

Congenital Rubella Syndrome

152

100%

Tetanus

580

21

96%

20,000

27*

> 99%

Haemophilus influenzae

JAMA. 2007;298(18):2155-2163
CDC. MMWR January 9, 2015 / 63(53);ND-733-ND-746. (MMWR 2014 provisional week 53 data)
* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 12 cases of Hib are estimated to have occurred among the 226
reports of Hi (< 5 years of age) with unknown serotype.

Historical Comparisons of Vaccine-Preventable Disease Morbidity in the U.S.


1/9/2015

Measles In the Postelimination Era


Measles is due to Failure to Vaccinate
Measles Elimination is a Global Problem
Continued threat of importations

Measles occurs in the U.S.


Maintenance of elimination is challenging and
resource intensive
Maintaining vaccine coverage increasing vaccine exemption
Intensive case/contact investigations
Healthcare workers diagnostic skills
Advanced laboratory techniques

Whats a journalist to do

Covering stories vs. numbers


Problems with numbers
People involved
Affected, isolated, inconvenienced
Institutional impacts

Myths vs. facts


Avoid the traps associated with equal
time
Skewing impressions vs. recognizing social
norms

27

www.cdc.gov/measle

Acknowledgements
State and local health departments
CDC staff : measles epidemiology, laboratory,
health economics, communications, policy

Jane Seward
Greg Wallace
Amy Fiebelkorn
Paul Gastanaduy
Susan Redd
Nakia Clements
Mark Papania
Susan Reef
William Bellini
Michelle Basket
Teresa Smith
Natarsha Thompson

Paul Rota
Jennifer Rota
Ismael Ortega-Sanchez
Jeanette St Pierre
Sarah Poser
Jessica Allen
Mark Pallansch
Karen Mason
Candice Swartwood
Kristin Pope
Nancy Messonnier