Update on Measles

Transcription

1 Update on Measles Alan R. Hinman, MD, MPH (With thanks to Jim Goodson, Peter Strebel, and Greg Wallace) Texas Immunization Summit November 6, 2014

2 I do not have any relevant conflicts of interest to disclose.

3 Outline of presentation Background on measles US situation Global situation Conclusion

4 Background on measles Aerosol/airborne transmission Rash ~14 days (7-21) after exposure Infectious 4 days prior through 4 days after rash onset Complications in US Diarrhea 8% Otitis media 7-9% Pneumonia 1-6% Encephalitis % Death % SSPE 0.001%

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6 US annual burden before vaccine ~500,000 cases/yr reported (3-4M actual) 48,000 hospitalizations 4,000 cases encephalitis deaths

7 Evolution of US Measles Program 1962: Challenge to eradicate measles (Langmuir) 1963: 1-dose recommendation (age 9 mos) 1965: 1-dose recommendation (age 12 mos) 1966: 1 st measles elimination goal (Sencer et al) 1967: 1-dose recommendation (age 15 mos) 1978: 2 nd measles elimination goal (Hinman et al) 1989: 2-dose recommendation (age 15 mos & 4-6 yrs*) : measles resurgence 1993: 3 rd measles elimination goal (initiation of VFC) Outbreaks >1 yr ceased 1994: 2 doses (age mos & 4-6 yrs) 2000: Elimination declared * AAP recommended 2 nd dose before middle school entry

8 Number of cases 600, , , , , ,000 Measles Cases, United States 1963 Vaccine Licensed * 30,000 25,000 20,000 15,000 10,000 5, Resurgence nd Dose Recommended 1993 Vaccines for Children Program 2000 Elimination Declared Year *2014 case count preliminary as of August 29

9 Cases/ 100,000 Reported Measles Incidence United States, * Measles elimination declared 1 case/million *2014 case count preliminary as of August 20 Year

10 No of Cases Measles, United States, 2001-Present* Import Non-Import *2014 case count preliminary as of August 29

11 Number of Cases Measles, United States, * Importations by WHO Region Unknown Western Pacific(WPR) South East Asian(SEAR) European(EUR) Eastern Mediterranean(EMR) African(AFR) American(AMR) Year *2014 case count preliminary as of August 29

12 Measles Outbreaks with >20 Cases, United States, * Year Outbreak Name 2014 Knox County State OH (MO) # of Cases 378 Import Status Genotype Setting Imported (Philippines) 2013 Brooklyn NYC 58 Imported (UK) D KC Metro Tippecanoe County DuPage/Cook County MO/KS (TX/NE) IN 34 IL 30 D9 Community Household/ community 44 Imported-virus B3 Community Imported (Romania) Importedvirus D4 D4 Church/ household Homeschool 2014 Manhattan NYC 25 Imported-virus B3 Community Stokes/Orange County Tarrant/Denton County Hennepin County Brooklyn/ Kings County NC 23 Imported (India) D8 Community TX 21 MN 21 NYC 21 Imported (Indonesia) Imported (Kenya) Imported (Israel, Belgium) D9 B3 D4 Church Shelter Community 1st & last rash onsets 3/24/2014 7/23/2014 3/13/2013 6/9/2013 5/5/2014 7/18/2014 5/16/2005-6/24/2005 5/17/2008-7/3/2008 2/11/2014 3/24/2014 4/5/2013 5/7/2013 7/21/2013 8/21/2013 2/15/2011-4/24/2011 2/17/2008-4/25/2008 Duration 18 weeks 13 weeks Median Age 23 y (early) 13 y (late) 10 y (early) 19 mos (late) Age Range 2 wks 53 y 0 mos 32 y 11 weeks 21 y 2 wks 43 y 6 weeks 12 y 9 mos - 49 y 7 weeks 10 y 8 mos - 43 y 6 weeks 22 y 3 mos 63 y 5 weeks 14 y 12 mos -59 y 5 weeks 11 y 4 mos 44 y 10 weeks 23 m 3 mos - 51 y 10 weeks 15 m 5 mos - 11 y *as of August 29, 2014

13 Measles outbreak response has a high economic burden in the U.S. Year Location Number of cases (outbreaks) Estimated public health cost* 2011 US 107 (16) $ M 2011 Utah 13 (2) >$330, California 12 (1) $125, Arizona 14 (1) $800,000 (limited to cost for 2 hospitals to respond to 7 cases in their facilities) 2005 Indiana 34 (1) $168, Iowa 1 $142,000 *Public health and health care costs expended to control the spread of measles

14 Measles U.S. 2014* 594 cases reported from 22 states 50 importations 23 from the Philippines 46 (92%) US residents 98% cases import-associated 66 cases (11%) hospitalized 18 Outbreaks (defined as 3 or more linked cases) Largest outbreak accounts for 2/3 of cases Top 3 outbreaks account for 3/4 of cases Cases in US residents (N=587) 76% unvaccinated 16% unknown vaccination status (mostly adults) 7% vaccinated (including 5% with 2 or more doses) Among unvaccinated 82% were personal belief exemptors 2% unvaccinated travelers age 6 mos 4 yrs 8% too young to be vaccinated * Provisional reports to CDC through September 19, 2014

15 Measles Outbreaks, USA, st onset latest rash 2014 OUTBREAKS State(s) cases Source Genotype PBE 6/11/2014 6/21/2014 New Haven, CT CT 3 Philippines B3 No 5/30/2014 7/3/2014 King Co., WA WA 16 FSM B3 No Clay Co. MO, Johnson Co., KS Sedgwick Co., MO 26, KS 14,TX 2, IV (imp 5/5/2014 7/14/2014 KC Metro NE 1 43 virus) B3 No 4/25/2014 5/11/2014 Hardeman Co. TN 5 Philippines B3 No 3/22/2014 7/23/2014 Knox/Ashland/Holmes/Ric hland,coschocton Cos. OH 376 MO Philippines D9 Yes 3/25/2014 4/9/2014 San Juan Co. WA 7 SE Asia B3 Yes BC 3/15/2014 3/31/2014 Whatcom Co. WA 6 Canada D8 Yes 3/13/2014 3/28/2014 San Mateo Co. CA 3 Philippines B3 No 3/2/2014 3/17/2014 Orange Co. #2 CA 3 IV (imp virus) B3 2/24/2014 3/15/2014 Orange Co. #3 CA 3 IV (imp virus) B3 Yes 2/18/2014 3/7/2014 San Diego CA 4 Philippines B3 No IV (imp 2/11/2014 3/24/2014 Manhattan NYC 25 virus) B3 2/11/2014 3/20/2014 Orange CA #1 CA 11 IV (imp virus) B3 Yes IV (imp 2/4/2014 3/3/2014 Riverside CA 5 virus) B3 Yes 2/8/2014 2/24/2014 Contra Costa CA 3 Philippines B3 Yes 1/24/2014 1/29/2014 (LAX) WI,NYS,TX 3 LAX (1/17) B3 Yes 1/17/2014 2/1/2014 Los Angeles CA 5 Philippines B3 Yes 12/27/2013 1/10/2014 Marion Co. OR 5 China H1 Yes

16 Measles, United States, Jan Sep 19, 2014 Source of Importations (N=50) WHO Region # of cases Countries of travel African 0 Eastern Mediterranean 1 Pakistan European 6 Dubai/Germany/London (1), Republic of Georgia (1), Netherlands (1), France/Belgium (1), Greece (1), Barcelona/Paris (1) Americas 3 Brazil (1), Canada (1), Chile (1) South-East Asia 9 India (7), Indonesia (1), Thailand/South Korea (1) Western Pacific 31 China (4), Philippines (22), Singapore (1), Saipan (1), Vietnam (1), SE Asia/Philippines (1), FSM (1)

17 Ohio Outbreak 2014 Index cases returned from relief work in Philippines Initially worked up for Dengue 377 reported cases (+ 1 case in MO resident) Affected 9 counties (+ 1 MO resident) Largest and longest outbreak in US since resurgence >10,000 vaccine doses administered in response Limited spread outside Knox County Including large Holmes County community (~30,000) No spread to larger Amish community (~275,000 people) No spread outside Amish community

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19 Global Burden of Measles Prior to Vaccine: 5-8 million deaths/year 77% decrease in incidence from 2000 to % decrease in deaths from 2000 to 2012 (90% since 1985) 122,000 deaths in 2012 (~14 deaths/hour) Remains a leading cause of vaccine preventable deaths in young children Most deaths in children under 5 years old

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23 MCV1 coverage among infants by country, 2013 Source: WHO/UNICEF coverage estimates 2013 revision, July WHO Member States. Map production: Immunization Vaccines and Biologicals, (IVB). World Health Organization Date of slide: 16 July 2014 <50% (4 countries or 2%) 50-79% (33 countries or 17%) 80-89% (28 countries or 14%) >= 90% (129 countries or 66%) Not available Not applicable The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO All rights reserved

24 Global and Regional MCV2 Coverage New WHO-UNICEF Estimates 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Global Coverage: 53% Source: WHO/UNICEF coverage estimates 2013 revision. July 2014 Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of Slide: 17 July 2014 Global AFR AMR EMR EUR SEAR WPR 24

25 Reported Measles Incidence Rate* May 2013 to Apr 2014 (12M period) <1 (83 countries or 43%) 1 - <5 (28 countries or 14%) 5 - <10 (11 countries or 6%) 10 - <50 (43 countries or 22%) 50 (14 countries or 7%) No data reported to WHO HQ Not applicable!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! (15 countries or 8%)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! *Rate per 1'000'000 population Data source: surveillance DEF file Data in HQ as of 10 June 2014

26 Four strategies to reduce measles mortality improve coverage & quality of routine immunization services ensure a second opportunity for measles immunization (supplemental or routine) establish effective surveillance for measles disease and monitoring of vaccine coverage improve case management including Vitamin A supplementation

27 Global Measles and Rubella Laboratory Network: 711 Laboratories in Sub-National Labs N= 690 labs 34 Prov. Labs Prefect. Labs 191/194 countries served by proficient labs National Laboratories Regional Reference Labs Global Specialised Labs Provincial Labs China Sub-National Labs

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29 Global progress in preventing measles deaths During , 12.7 M measles deaths were averted globally as a result of immunization activities 8.4 M (66%) averted by maintaining routine immunization coverage at 2000 level 4.3 M (33%) averted as a result of Increases in routine immunization coverage Implementation of measles SIAs

30 Estimated Deaths (1000s) 90% Reduction in Estimated Measles Deaths, ,200 1, During % decrease in incidence 78% decline in deaths 13.8 million deaths averted Source: WHO/IVB estimates, February 2014

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32 No. of deaths "Global Measles Deaths Drop by 78% but Resurgence likely" Estimated number of measles deaths worldwide, and projections of possible resurgence in measles deaths worldwide, Year Estimates* Projected worst case Projected status quo Worst case: MCV1 level, no follow-up SIAs in 47 priority countries Status quo: MCV1 increases and follow-up SIAs continue, no SIAs in India Wkly Epid Rec, 4 december 2009 No. 49, 2009, 84,

33 No. of reported cases (millions) MCV1 Coverage* (%) % Reduction in reported measles cases Measles global annual reported cases and MCV1 coverage*, Number of cases MCV1 Coverage* * MCV1 coverage: coverage with first dose of measles-containing vaccine as estimated by WHO and UNICEF

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35 44 Measles Campaigns in 33 Countries in million children reached 24 (55%) achieved 95% coverage 36 of 44 SIAs integrated 1 or more other interventions Measles (10) Measles and OPV (11) Measles and Rubella (10) Measles, Rubella and OPV (2) Vitamin A 14 Not Available De-worming 12 Other interventions 5 Not Applicable Updated on 13 March 2014

36 Measles cases by month and year, WHO European Region, Source: MR reporting to WHO European region Update Date : 25-Aug-2014

37 Measles outbreaks in under-vaccinated groups, WHO European Region, Roma and Sinti communities Croatia Bosnia & Herzegovina Bulgaria Greece Italy Poland Romania Spain Followers of Anthroposophy Austria Germany Netherlands Switzerland Sweden Orthodox Protestant communities Netherlands Traveller communities Ireland Norway Spain United Kingdom Ultra-Orthodox Jewish communities Israel Belgium United Kingdom

38 Public settings for reported measles outbreaks, WHO European Region, Schools and educational facilities Health care settings Austria France Germany Ireland Italy Spain Switzerland UK Bulgaria Croatia Czech Republic Denmark France Greece Latvia Italy Netherlands Spain Switzerland

39 Measles Virus (genotype B3) Spread From Philippines to other countries, Confirmed importation Suspected importation MR campaign 9-59m Sept, 2014

40 Too many children still miss out on measles vaccination Iraq, 0.36 Afghanistan, 0.37 USA, 0.38 Philippines, 0.38 Rest of the world, 7.13 DRC, 0.68 Pakistan, 0.74 Indonesia, 1.11 India, 6.37 Nigeria, 2.66 Ethiopia, million infants unimmunized (MCV1), million infants missed MCV1 in % live in India Nigeria Ethiopia Indonesia Pakistan DRC

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42 Conclusions Measles has been and still is a major killer of children We have effective strategies to prevent measles We just need to implement them fully Measles eradication is inevitable The only question is WHEN we will do it