1. 1 Measles in Fraser Health Michelle Murti, MHO Fraser Health Authority, BC CPHA May 27, 2014

2. 2 2 Measles of known and unknown origin  Measles in Fraser over last year  Cluster of unknown origin  Issues and implications of unknown importations

3. 3 3 Measles 2010-present, BC

4. 4 4 Map of Fraser Valley

5. 5 5 FHA, as of May 8, 2014

6. 6 6 Recent measles 2014  Many suspect measles reported and investigated from across FHA  Good level of awareness and reporting  Large outbreak  Only 5 cases not affiliated with religious community (lived in the area)

7. 7 7 Dutch importations  22 genotypes available – all D8  Same strain circulating in Netherlands  Importations to Alberta and Ontario  2 other known clusters from importation in 2013  Netherlands outbreak  >2600 measles cases

8. 8 8 Measles 2013 D8 3 lab-confirmed B3 Secondary transmission B3

9. 9 9 Description of 3 B3 cases  32yoM – Fraser North  Hx 1 dose MMR, but was IgG Negative  Cdn-born, no travel history

10. 10 Description of 3 B3 cases  32yoM – Fraser North  Hx 1 dose MMR, but was IgG Negative  Cdn-born, no travel history  21yoM – Fraser South  Foreign-born, no documented imms hx, also IgG negative  No travel, no known exposure

11. 11 Description of 3 B3 cases  32yoM – Fraser North  Hx 1 dose MMR, but was IgG Negative  Cdn-born, no travel history  21yoM – Fraser South  Foreign-born, no documented imms hx, also IgG negative  No travel, no known exposure  9 month old male –Fraser South  Unimmunized by age  Resulted in transmission to 3yo unimmunized playmate

12. 12 Time to genotyping  Early indication that these were different due to H and N genes on PCR  Days-weeks to get genotyping  Was this wider spread of our original outbreak or a new cluster?  Implications for public health control measures

13. 13 Source?  Detailed exposure histories  NO connections identified  All exact same genotype of B3  After typing available weeks later  No known recent importations of B3  1 secondary transmission  304 contacts followed up  Significant public health work

14. 14 B3 Worldwide

15. 15 Heightened Surveillance

16. 16 Surveillance  Heightened surveillance due to outbreaks  Unusual detection?  Frequency of these importations and unrecognized disease?  Index case(s)?  Unrecognized importations  Unrecognized disease vs unreported disease?

17. 17 Implications  Limited spread in highly vaccinated populations  Risks for under-immunized populations  Significant risk in some pockets  Effectiveness and efficiency of follow-up required  Public Health interventions

18. 18 Acknowledgements  FHA team  BCCDC and BC Public Health Laboratory  Ahmed Hashim, PHPM resident