The Virtual Immunization Communication (VIC) Network is a project of the National Public Health Information Coalition (NPHIC) and the California

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1 The Virtual Immunization Communication (VIC) Network is a project of the National Public Health Information Coalition (NPHIC) and the California Immunization Coalition, funded through a cooperative agreement with the Centers for Disease Control and Prevention 1

2 . Measles 2014 Update: Clinical Presentation, Outbreaks, Vaccination Recommendations and Patient Management Webinar Objectives Provide a brief background on measles, including a description of the disease, clinical presentation, and complications Outline the current status of measles outbreaks in the United States Review CDC vaccination recommendations for the general public and international travelers Explain the guidelines for evaluating, diagnosing and managing patients with measles Highlight communication resources for doctors and other healthcare professionals and the public 2

3 Frequently Asked Questions 1. Will I receive a copy of the slides after the webinar? Yes 2. Will I receive a copy of the webinar recording? Yes

4 Welcome to the Webcast! We Will Be Starting Momentarily. 4

5 Polling Question

6 A nationwide virtual immunization community of health educators, public health communicators and others who promote immunizations. 6

7 Polling Results

8 Amy Parker Fiebelkorn, MSN, MPH Epidemiologist, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention 8

9 Measles 2014 Update: Clinical Presentation, Outbreaks, Vaccination Recommendations, and Patient Management Virtual Immunization Communication Network Webinar June 19, 2014 Amy Parker Fiebelkorn, MSN, MPH Measles, Mumps, Rubella, Polio Team Jessica Allen, MPH, MSW Health Communications Specialist Epidemiology Branch, Division of Viral Diseases National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention

10 Acute febrile rash illness Description of Measles RNA virus with 1 serotype, classified as a member of the genus Morbillivirus The only natural hosts are humans Transmitted by direct contact with infectious droplets or airborne spread Most contagious of the vaccine preventable diseases

11 Clinical Presentation Prodromal symptoms of mild to moderate fever, sore throat, & 3 C s : Cough, Coryza, and/or Conjunctivitis Tiny white spots (Koplik s spots) may appear in the mouth Rash ~10-14 days after exposure (range 7-21 days) Fever may spike when rash appears (up to 105 o F)

12 Measles Rash Erythematous maculopapular eruption that spreads from head to trunk to extremities with initial blanching Fades in order of appearance

13 Measles Complications & Deaths Diarrhea 8% Otitis media 7-9% Pneumonia 1-6% Encephalitis Death Subacute Sclerosing Panencephalitis (SSPE) 1-2 per 1,000 cases 1-3 per 1,000 cases (2-15% in developing countries) 1 per 100,000 cases 7-10 years after measles

14 Global Burden of Measles Cases ~20 million cases/year 77% decrease in reported incidence from 2000 to 2012 Deaths Pre-vaccine era: 5-8 million deaths/year 78% decrease in deaths from (90% decrease since 1985) 122,000 deaths in 2012 (~14 deaths/hour) Remains a leading cause of vaccine preventable deaths in children <5 years of age

15 U.S. Annual Disease Burden in the Pre-Vaccine Era 3-4 million estimated cases (~500,000 reported cases) 48,000 hospitalizations 4,000 encephalitis cases deaths

16 Licensed in 1963 in the U.S. Measles Vaccine Combination measles-mumps-rubella (MMR) vaccine licensed in 1971 Vaccine Effectiveness: 1-dose: ~93% 2-doses: ~97% Excellent safety profile over past 50 years Low risk of febrile seizures in children aged months (1 in 3000 doses) Temporary pain/stiffness in joints (teenage or adult women) Temporary low platelet count (1 in 30,000 doses)

17 Number of cases Measles Cases, United States, * 600, , , , , , 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 June 13, 2014

18 Measles Elimination in the U.S. High two-dose vaccination coverage and improved measles control in the World Health Organization Region of the Americas resulted in the declaration of measles elimination* in the U.S. in 2000 Even in an elimination era, imported cases and limited spread still occur *Defined as interruption of continuous transmission lasting 12 months

19 Measles, United States, 1996-Present* 550 Imported cases (Data available since 2001) Spread cases 450 Number of Cases Measles elimination declared Year *2014 case count preliminary as of June 13, 2014

20 Measles, United States, * Importations by WHO Region Number of Cases Unknown Western Pacific(WPR) South East Asian(SEAR) European(EUR) Eastern Mediterranean(EMR) African(AFR) American(AMR) Year *2014 case count preliminary as of June 13, 2014

21 Measles, United States, * Age Specific Incidence 25 <6m 6-8m 9-11m 12-15m 16m-4y 5-9y 10-19y 20y 20 Cases per 1,000, *2014 case count preliminary as of June 13, 2014

22 Measles Outbreaks with 20 or more Cases, United States, * Year Outbreak Name 2014 Knox County OH 312* State Cases # Import Status Genotype Setting Imported (Philippines) 2013 Brooklyn NYC 58 Imported (UK) D Tippecanoe County DuPage/Cook County IN 34 IL 30 Imported (Romania) Importedvirus D9 D4 D4 Community Household/ community Church/ household Homeschool 2014 Manhattan NYC 25 Imported-virus B3 Community Stokes/Orange County Tarrant/Denton County Hennepin County NC 23 Imported (India) D8 Community TX 21 MN 21 Imported (Indonesia) Imported (Kenya) D9 B3 Church Shelter 1st & last rash onsets 3/24/2014 6/3/2014 3/13/2013 6/9/2013 5/16/2005-6/24/2005 5/17/2008-7/3/2008 2/16/2014 3/24/2014 4/5/2013 5/7/2013 7/21/2013 8/21/2013 2/15/2011-4/24/2011 Duration 12 weeks and counting 13 weeks Median Age Age Range 16 y 2 wks 52 y 10 y (early) 19 mos (late) 0 mos 32 y 6 weeks 12 y 9 mo - 49 y 7 weeks 10 y 8 mo - 43 y 6 weeks 22 y 3 mo 63 y 5 weeks 14 y 12 mo -59 y 5 weeks 11 y 4 mos 44 y 10 weeks 23 m 3 mo - 51 y 2008 Brooklyn/ Kings County NYC 21 Imported (Israel, Belgium) D4 Community 2/17/2008-4/25/ weeks 15 m 5 mo - 11 y *As of June 13, 2014

23 Measles outbreak response has a high economic burden in the U.S. Year Location Number of cases (outbreaks) 2011 US 107 (16) $ M 2011 Utah 13 (2) >$330, California 12 (1) $125,000 Estimated public health cost* 2008 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

24 No. of cases (cumulative) Measles, U.S., * Cumulative Number by Month of Rash Onset (excluding 2008) * 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month *As of June 13, 2014

25 Measles U.S. 2014* 477 cases reported from 20 states including 16 outbreaks 47 importations 22 from the Philippines 42 (89%) U.S. residents 470 (98%) cases import-associated 48 (10%) hospitalized Cases in U.S. residents (N=469) 381 (81%) unvaccinated 57 (12%) unknown vaccination status (of whom, 77% were adults) 32 (7%) vaccinated (9 had 1 dose, 19 had 2 doses and 4 had 3 doses) Among the 381 unvaccinated: 87% had personal belief exemptions 3% unvaccinated travelers aged 6 mos to 2 yrs 7% too young to be vaccinated * Provisional reports to CDC through June 13, 2014

26 Keys to Measles Prevention, Diagnosis, & Response Vaccine Vaccine recommendations Vaccine coverage rates Diagnostics Differential diagnosis History & Physical exam Lab testing Case Response Report suspect cases Begin contact investigations Establish who has presumptive evidence of immunity Isolation and quarantine Post-exposure prophylaxis CDC guidance available at:

27 Advisory Committee on Immunization Practices (ACIP) Vaccine Recommendations for Measles Routine recommendations (children): 1st dose: children aged mos 2 nd dose: children aged 4-6 yrs (but can be given up to 28 days after the 1 st dose) Routine recommendations (adults) Non-high risk adults born in 1957 or later: 1 dose (unless they have other evidence of immunity) High-risk adults (i.e., students at post-high school educational institutions, international travelers, and healthcare personnel) born in 1957 or later: 2 doses (unless they have other evidence of immunity) 2013 ACIP Recommendations at:

28 International Travel Recommendations for Measles Vaccine Persons aged 12 months should receive 2 doses* Includes providing a 2 nd dose to children prior to age 4-6 yrs Includes adults born during or after 1957 who have only received one routine dose in the past Children aged 6-11 months should receive 1 dose (Will still need 2 subsequent doses at age 12 months) * 2nd dose of MMR should be administered at least 28 days after the 1 st dose

29 MMR Vaccination Coverage National Immunization Survey, U.S. MMR 1+ (19-35 mo) MMR 2+ (13-17 yr) 90 Coverage (%) 0 NIS data available at :

30 Diagnosing Measles Many U.S. healthcare providers have never seen a case of measles Consider measles in differential diagnosis (e.g., Kawasaki s, Dengue) of febrile, rash illness particularly for patients: Recent travel history or exposure to recent travelers Unvaccinated Lab testing Serology for IgM Viral specimen (nasopharyngeal, oropharyngeal, or nasal swab) for PCR (and genotyping)

31 Public Health Response (for confirmed and suspect cases) Respiratory isolation of case-patients Infectious period 4 days prior through 4 days after date of rash onset Report to Health Department Immediately notifiable to CDC (within 24 hours) Contact CDC Quarantine Station if relevant travel Enhanced Surveillance Contact investigation

32 Contact Investigation for Exposure to Measles Persons exposed during patient s infectious period Includes exposure to area 2 hours after infectious person left Establish presumptive evidence of immunity for contacts Quarantine contacts without presumptive evidence of immunity (through 21 days after exposure) Post-exposure prophylaxis (PEP) Vaccine or Immune globulin (IG)

33 Post-exposure Prophylaxis (PEP) MMR Vaccine Administer within 72 hours of exposure May return to regular activities (except health care settings) Still monitor for symptoms Can be given to children as young as 6 months of age Be aware of possibility of vaccine rash If outside the 72 hour window for PEP, vaccine should still be administered to prevent infection from future exposures

34 Post-exposure Prophylaxis (PEP) Immune Globulin Administer within 6 days of exposure Recommended Dose Intramuscular (IGIM): 0.5 ml/kg (max = 15 ml) Intravenous (IGIV): 400 mg/kg Recommended for the following groups (risk of severe disease and complications) Infants aged <12 months (IGIM) Pregnant women without evidence of immunity (IGIV) Severely immunocompromised patients (IGIV)

35 Keys to Maintaining Elimination in the U.S. High 2-dose MMR vaccine coverage High quality surveillance Rapid identification of and response to measles cases Report within 24 hours per Council of State and Territorial Epidemiologists (CSTE) guidelines Rapid and aggressive outbreak control measures Information sharing tools (Epi-X, HAN)

36 Challenges in the Elimination Era Aggressive public health response (i.e., contact tracing, vaccination clinics) is resource intensive Continued global threat because of importations Highly contagious Today, in the relative absence of disease, public attention is focused on perceived vaccine adverse advents Clustering, accumulation, and aging of susceptibles

37 Keep Sight of the Successes Outbreaks are limited (size & number of generations) High overall vaccine coverage Rapid/aggressive public health response to suspect cases Elimination achieved & maintained for 14 years The vaccine works and the disease is recognizable Eradication possible & achievable

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39 Measles Resources for Healthcare Providers

40 Measles Resources for Healthcare Providers Currently available Clinical Information- CDC Measles Website Why Measles Matters- Current Issues in Immunization NetConference Fact Sheets and Resources Upcoming products and opportunities Medscape Expert Commentary Clinician Outreach and Communication Activity (COCA) Tuesday July 1, 2-3 pm ET Banner and Button that link to Clinical Information

41 Measles Resources for the Public

42 Measles Resources for the Public Measles Feature Measles Website Disease Overview Vaccination Information National Outbreak Information Fact Sheet Infographics, Videos & Podcasts Publications Morbidity & Mortality Weekly Reports (MMWR)

43 Measles Resources for the Media

44 Measles Resources for the Media Cases and Outbreak Information Press Releases

45 Measles and Social Media

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47 Back-Up Slides

48 Cases/ 100, Reported Measles Incidence United States, * Measles elimination declared 1 case/million *2014 case count preliminary as of June 13, 2014 Year

49 Advisory Committee on Immunization Practices (ACIP) Measles Vaccine Recommendation History 1963: Age 9 mos 1965: Age 12 mos 1967: Age 15 mos 1989: 2 doses (as age 15 mos & 4-6 yrs 1994: 2 doses (12-15 mos & 4-6 yrs)

50 Does the Vaccine Really Work? 1,000 exposed (90% vaccine coverage) 900 Vaccinated (97% VE) 100 Unvaccinated (90% attack rate) 27 vaccinated cases 90 unvaccinated cases 23% of cases vaccinated

51 Presumptive Evidence of Immunity for Measles Routine Students at post-high school educational institutions Health-care personnel International travelers (1) Documentation of age-appropriate vaccination with a live measles virus-containing vaccine: preschool-aged children: 1 dose school-aged children (grades K-12): 2 doses adults not at high risk: 1 dose, or (1) Documentation of vaccination with 2 doses of live measles viruscontaining vaccine, or (2) Laboratory evidence of immunity, or (3) Laboratory confirmation of disease, or (4) Born before 1957 (1) Documentation of vaccination with 2 doses of live measles viruscontaining vaccine, or (2) Laboratory evidence of immunity, or (3) Laboratory confirmation of disease, or (4) Born before 1957 (1) Documentation of age-appropriate vaccination with a live measles virus-containing vaccine: infants aged 6 11 months: 1 dose persons aged 12 months: 2 doses, or (2) Laboratory evidence of immunity, or (2) Laboratory evidence of immunity, or (3) Laboratory confirmation of disease, or - should consider 2 doses (3) Laboratory confirmation of disease, or (4) Born before 1957 (4) Born before ACIP Recommendations at:

52 Q & A Session 52

53 National Immunization Awareness Month Communications Toolkit Work group members: Nancy Erickson, Vermont Department of Health Catherine Martin, California Immunization Coalition Kathleen Horton, Vermont Department of Health Edgar Ednacot, California Department of Public Health Amy Callis, CDC John Stieger, NPHIC Making Public Health Public

54 2 Making Public Health Public

55 3 Making Public Health Public

56 4 Making Public Health Public

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58 6 Making Public Health Public

59 7 Making Public Health Public

60 8 Making Public Health Public

61 9 Making Public Health Public

62 10 Making Public Health Public

63 11 Making Public Health Public

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66 Resources Centers for Disease Control and Prevention National Public Health Information Coalition 66

67 Resources Immunization Action Coalition 67

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