Vaccine Preventable Diseases. Overview MEASLES 4/8/2015. Amy Schwartz, MPH Immunization Surveillance Coordinator North Dakota Department of Health

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1 Vaccine Preventable Diseases Amy Schwartz, MPH Immunization Surveillance Coordinator North Dakota Department of Health Measles Mumps Pertussis Meningococcal Disease Polio Rubella Hepatitis A Overview MEASLES 1

2 Measles Respiratory disease caused by a virus. Usually grows in cells at the back of the throat and lungs Spread through the air by breathing, coughing or sneezing Extremely contagious Can live for up to 2 hours outside the body Cases can spread the disease 4 days before symptoms appear Symptoms include fever, runny nose, cough and a rash that covers the body Can result in other complications 1/10 children get an ear infection 1/20 children get pneumonia 1/1000 children get encephalitis 1-2/1000 children die Laboratory Confirmation of Measles Confirmatory Labs: Detection of measles virus-specific nucleic acid by PCR Isolation of measles virus Detection of measles IgM Rise in measles IgG between convalescent and acute specimens Additionally: Testing for Rubella should always be ordered along with Measles testing and vice versa as the symptoms are sometimes clinically indistinguishable. Measles PCR Should always be used if possible Nasopharyngeal or throat swab Throat swab preferred More likely to be detected if collected within three days of rash onset but may be detected up to 10 days after rash onset Urine May be able to detect virus later on in illness if it is no longer present in throat/nasopharyngeal specimens 2

3 Measles IgM Often the first result available Should be done concurrently with PCR Serum required May be undetectable if serum collected within first 72 hours of rash onset Second serum specimen should be collected to rule out false negative Measles IgG Usually detectable a few days after IgM May be used to confirm diagnosis Seroconversion in unvaccinated individuals Rise in IgG between acute and convalescent serum Ordered along with measles IgM Measles in North Dakota The last case of measles in North Dakota was in 2011 Our first case of measles in over 23 years! Adult male in Cass County Was exposed to measles while traveling on an airplane Spent his infectious period in South Dakota His sister later developed measles from their time together in South Dakota. No other known cases associated 3

4 Epidemiology of 2015 Cases From January 1 to April 3, measles cases 18 states and the District of Columbia 117 (74 percent) are linked to an amusement park in California Most cases have been unvaccinated Recent Cases in Border States South Dakota Mitchell Outbreak First case reported on December 30 th, confirmed cases Cases were an extended family group All cases were unvaccinated Sioux Falls Case Reported on January 24 th, 2015 Not known to be connected to Mitchell outbreak Minnesota One case confirmed in a university student on January 30 th, 2015 Student was unvaccinated and recently returned from international travel 4

5 Vaccination Recommendations Recommended schedule is one dose at 12 through15 months with a second dose at 4 through 6 years. Adults with no evidence of immunity should receive 1 dose of MMR. If the adult is in a high risk group, he/she should receive 2 doses separated by at least 28 days. High risk includes Healthcare personnel International travelers Infants 6-11 months may be recommended to receive a dose if traveling Students at post-high school educational institutions People exposed to measles in an outbreak setting Those previously vaccinated with killed or unknown type vaccine during The Vaccination Situation Recommended coverage for MMR Vaccine is 95% to produce herd immunity North Dakota s Kindergarten vaccination rates for MMR vaccine were approximately 89.97% According the 2013 National Immunization Survey (NIS) 91.4% of month olds have received a dose of MMR in North Dakota. 96.1% of year olds have received 2 doses of MMR in North Dakota. MUMPS 5

6 Mumps Disease caused by the mumps virus Symptoms include fever, headache, muscle aches, tiredness, loss of appetite and swelling of salivary glands Disease is spread by droplets of saliva or mucus Occasionally, complications can occur The most common complication is orchitis(inflammation of the testicles.) Other more rare complications include Encephalitis or meningitis Oophoritis(inflammation of the ovaries) and/or mastitis. Deafness Laboratory Confirmation of Mumps Confirmatory Labs: Detection of mumps virus-specific nucleic acid by PCR Isolation of mumps virus Detection of mumps IgM Rise in measles IgG between convalescent and acute specimens Mumps PCR Should always be used if possible Fluid collected from the buccal/parotid duct, the throat or other affected salivary glad ducts Best when the salivary gland area is massaged approximately 30 seconds Should be collected as soon as possible. Within three days of parotitisonset and not more than eight days. Urine Less likely to contain sufficient virus for detection 6

7 Mumps IgM Often the first result available Should be done concurrently with PCR Serum required Usually detectable within 5 days after symptom onset If specimen collected 3 days or less after parotitis onset, a Second serum specimen should be collected 5-7 days after symptom onset to rule out false negative Mumps IgG Usually detectable a few days after IgM May be used to confirm diagnosis Seroconversion in unvaccinated individuals Rise in IgG between acute and convalescent serum Test should be done at the same time using the same test Ordered along with measles IgM Mumps in the United States and North Dakota North Dakota: The last confirmed cases of mumps in North Dakota was in 2011 Three cases linked to an outbreak occurring in the UK One probable case in 2013 and 2014 A few suspect cases each year Nationally: 81 cases so far cases in

8 PERTUSSIS Pertussis/Whooping Cough Coughing illness caused by bacteria Bordetella pertussis Symptoms can include cold-like symptoms, coughing fits, posttussive vomiting, whoop, apnea. Cough will persist for at least 14 days May result in certain complications. The most common complication is pneumonia. Infants may also suffer from seizures and encephalopathy. Death is rare but does occur. Most deaths are in unvaccinated infants. Pertussis Lab Culture is gold standard PCR Nasopharyngeal swab Most common method of testing Serology is not confirmatory for pertussis. 8

9 Pertussis in North Dakota Only 4 cases so far in Pertussis in North Dakota The number of pertussis cases peak every few years. Some peak years in North Dakota were 2012(214 cases) and 2004 (757 cases). In 2015 there have been 6 total cases so far. 5 confirmed 1 probable Ages range from under 1 year to Pertussis in the US Pertussis Cases in the US No. of Cases

10 Vaccination Recommendations DTaPvaccination is routinely recommended at ages 2 months, 4 months, 6 months, 15 through 18 months with a booster at 4 through 6 years. Tdapvaccination is routinely recommended at age 11 through 12 years. Under vaccinated children over age 7 can be caught up using Tdapfollowed by Td. Pregnant women are recommended to receive a dose of Tdap during each pregnancy between 27 and 36 weeks gestation. Protective antibodies passed to baby The Vaccination Situation According to the 2012 NIS 92.9% of 24 month year olds have received 3+ doses of DTaPin North Dakota. Only 81.1% of 24 month year olds have received 4+ doses of DTaP in North Dakota % 95.00% 90.00% 85.00% 80.00% 75.00% 70.00% 4 DTaPCoverage Before Months of Age (2013 NIS) 94.10% 94.10% 78.60% 83.10% DTaP 3+ DTaP 4+ ND US The Vaccination Situation According to the 2013 NIS, 95.0% of adolescents received at least one dose of Tdapin North Dakota. National coverage rate was 89.1% Adult Tdapvaccination coverage was collected in 2012 via the National Health Interview Survey (NHIS.) 14.2 % of adults over 19 years were vaccinated with Tdap. 25.9% Adults living with a child under 1 year were vaccinated with Tdap. 8.0% of adults over age 65 were vaccinated with Tdap. 10

11 MENINGOCOCCAL DISEASE Meningococcal Disease Caused by the bacteria Neisseria meningitidis. The bacteria can result in meningitis, blood stream infection or other invasive infections. Symptoms may include fever, headache, nausea, vomiting, stiff neck, petechial rash, photophobia, mental confusion. Secondary cases are rare. Bacteria can be transmitted via respiratory and throat secretions. Confirmatory Testing for Meningococcal Confirmatory Testing: Culture PCR Should be reported as soon as a gram negative diplococci are identified 11

12 Gram Stain Often the first result indicative of N. meningitis Start investigating and recommending chemoprophylaxis upon identification of gram negative diplococci from a sterile site PCR North Dakota can send specimen to reference laboratory in Minnesota Specimen from affected site should be submitted Chemoprophylaxis Close contacts of case may be recommended to receive antibiotics. Household contacts Those who had contact with case s saliva Antibiotics should be given within 24 hours of identifying case After 14 days post-exposure, unlikely prophylaxis will be effective 12

13 Meningococcal Disease in North Dakota Number of Cases Meningococcal Cases in North Dakota N. meningitidis Serogroups in North Dakota Unknown, 1 B, 4 Z, 1 C, 2 Y, 3 Z Y C B Unknown Meningococcal Disease in the US 88 cases so far in Unknown Serogroup 4 Other Serogroup 20 SerogroupB 11 SerogroupsA, C, Y, W total cases in 2014 Meningococcal Serogroupsfor 2014 Cases B 32% Other 4% Unknown 44% A,C, Y, W % Vaccination Recommendations Meningococcal vaccination (MCV4) is routinely recommended at age 11 through 12 with a booster dose at age 16. Protects against serogroups A,C, Y and W-135 One dose required for Middle School Entry Also required to reside in campus housing at North Dakota Universities Two doses at age 10 or older at least 8 weeks apart or one dose within the last 5 years 13

14 The Vaccination Situation According to the 2013 National Immunization Survey: North Dakota s coverage rate for adolescents aged years for 1 or more doses of MenACWYwas 93.7(±3.2)% The United States coverage rate for adolescents aged years for 1 or more doses of MenACWYwas 77.8(±1.1)% POLIO Polio Highly contagious disease caused by poliovirus Most infections are asymptomatic or result in nonspecific febrile illness. A small portion of patients will experience meningitis and/or paralytic disease. The proportion of individuals who experience paralytic disease ranges from 100:1 to 1000:1 or more. Viral replication occurs in the oropharynx and the intestinal tract. Can be transmitted via the respiratory route or fecal contamination. 14

15 Polio Lab Poliovirus isolation Stool specimens High likelihood of isolation At least 2 specimens 24 hours apart Pharyngeal swabs Intermediate likelihood of isolation At least 2 specimens 24 hours apart Blood or Cerebrospinal Fluid Low likelihood of isolation If isolated from CSF, diagnostic Several specimens should be collected to increase likelihood of isolation Should be collected within 14 days of paralytic disease onset Polio in the US and North Dakota The last imported case of wild type polio in the US was in Prior to that case the last case was in The last cases of naturally occurring paralytic polio in the US occurred in 1979 among an Amish community. The last case of paralytic polio in North Dakota was in Polio In The World Polio virus has been eradicated from most of the world. Currently only 10 countries infected with Polio Afghanistan, Equatorial Guinea, Ethiopia, Iraq, Israel, Somalia and Nigeria, Pakistan, Syria, Cameroon On May 5 th, the World Health Organization (WHO) declared an international public health emergency. A coordinated international response is necessary to stop the spread of polio. The virus is being spread from three countries: Pakistan, Syria and Cameroon. 15

16 Vaccination Recommendations IPV or Inactivated polio vaccine is the only polio vaccine available in the United States. Routinely recommended at age 2 months, 4 months, 6 through 18 months, and 4 through 6 years. Unvaccinated individuals traveling to high risk areas should be vaccinated before leaving. 3 doses First two doses given 1-2 months apart Third dose 6-12 months after the second Newer Polio Vaccination Recommendations On May 5, 2014 the World Health Organization declared the international spread of polio to be a public health emergency of international concern. This declaration has led to some new vaccine requirements for residents and long term visitors to countries with active polio transmission. CDC released a Health Alert on June 2, Alerted clinicians of possible vaccination requirements for patients planning to travel to countries with ongoing polio transmission for more than 4 weeks. Adults should receive a booster dose of IPV 4 weeks to 12 months prior to departure. U.S. citizens who plan to travel to any of the polio infected countries should have documentation of a polio booster in their yellow International Certificate of Vaccination. RUBELLA 16

17 Rubella A viral illness caused by a togavirusof the genus rubivirus Spread by contact with respiratory secretions of an infected person Symptoms include a mild, maculopapularrash, fever, general ill feeling and swelling behind ears or back of neck. Complications result when a pregnant woman becomes infected. These complications can include deafness, cataracts, heart defects, mental retardation, liver damage, and spleen damage. 20% likelihood of a birth defect if the woman is infected in early pregnancy Rubella Labs Confirmatory Labs: Detection of rubella virus-specific nucleic acid by PCR Detection of rubella IgM Rise in rubella IgG between convalescent and acute specimens Rubella PCR Should always be used if possible Nasopharyngeal or throat swab Throat swab preferred More likely to be detected if collected within four days of rash onset but may be detected 1 week before to 2 weeks after rash onset Urine and blood may also contain virus 17

18 Rubella IgM Often the first result available Should be done concurrently with PCR Serum required May be undetectable if serum collected within first five days of rash onset Second serum specimen should be collected to rule out false negative after day five Rubella IgG Usually detectable eight days after rash onset May be used to confirm diagnosis Seroconversion in unvaccinated individuals Rise in IgG between acute and convalescent serum Second specimen should be collected 7-21 days after first specimen Ordered along with rubella IgM Rubella in the US and North Dakota So far this year, there has been one case of rubella in the US. North Dakota had a rubella case in Associated with travel to India Before that hadn t had a case since

19 HEPATITIS A Hepatitis A Viral disease transmitted via the fecal-oral route Cases in children under 6 years are often asymptomatic (70%) Symptoms usually include nausea, vomiting, abdominal discomfort, pale stools, dark urine, jaundice and elevated serum ALT or AST levels. The average incubation period is days with a range of days. Often contracted during international travel. Exposed individuals may be recommended to receive prophylaxis. Individuals between 12 months and 40 years should receive Hepatitis A vaccine. Individuals younger than 12 months and older than 40 years should receive Hepatitis A immune globulin. Confirmatory Testing for Hepatitis A Hepatitis A IgM Indicates recent infection Hepatitis A Total Antibody does not confirm Hepatitis A infection Could indicate past infection, current infection or past vaccination 19

20 Hepatitis A in the US and North Dakota North Dakota Three confirmed cases in North Dakota this year All case reported travel outside of the US Eight confirmed cases in North Dakota in 2014 One case reported travel outside of the US Nationally 206 cases reported in the US this year 1123 cases reported in the US in 2014 Vaccination Recommendations Hepatitis A vaccine is routinely recommended for children at 12 months of age. Two doses separated by 6 months Unvaccinated children can be caught up at any time Also recommended for people at high risk: 12 years or older who are traveling to high risk areas Men who have sex with men Users of illegal drugs Previously unvaccinated individuals who anticipate having close contact with an international adoptee from a country where hepatitis A is prevalent People who have blood clotting disorders People who may have occupational exposure (i.e. lab setting, working with infected primates) People with chronic liver disease People who wish to be immune to hepatitis A Mandatory Reportable Vaccine Preventable Diseases All mandatory reportable diseases should be reported to Disease Control within 7 days. Certain diseases should be reported immediately. Reporting can be done by: Calling 1(800) or (701) Reporting online: 20

21 Mandatory Reportable Vaccine Preventable Diseases Pertussis/Whooping Cough* Chickenpox Meningococcal disease* Influenza Measles* Mumps* Rubella* Diphtheria* Tetanus Invasive Streptococcus pneumoniae Invasive Haemophilus influenzae Hepatitis A Hepatitis B Polio* *Report Immediately Thank You! Questions? amschwartz@nd.gov 21