1. Update on Measles in the U.S. 2008 National Perspective Kathleen Gallagher, D.Sc, MPH NCIRD, CDC

2. Today’s Presentation Measles in the US in the pre- and post- elimination erasMeasles in the US in the pre- and post- elimination eras What’s going on in 2008What’s going on in 2008 Strategies to maintain eliminationStrategies to maintain elimination ChallengesChallenges

3. Annual Measles Disease Burden United States, 1950s 3-4 million cases3-4 million cases –~ 500,000 reported cases Severe complicationsSevere complications –4,000 encephalitis cases –150,000 respiratory complications (pneumonia) 48,000 hospitalizations48,000 hospitalizations 450 deaths450 deaths

4. 1963 Vaccine Licensed 1 st Dose Recommendation 1989 2 nd Dose Recommendation 2000 Elimination Declared 1-dose preschool coverage 2-dose adolescent coverage 1989-91 Resurgence Reported Measles Cases United States, 1962 - 2007 Measles Cases % Measles Vax Coverage Year

5. 1989 2 nd Dose Recommendation 2000 Elimination Declared Measles, United States, 1985 - 2007 Reported Measles Cases Year Measles resurgence 1989-1991 55,622 reported cases 123 reported deaths

6. Reported Measles Incidence United States, 1992-2007 1 case/million Measles elimination declared

7. Measles Epidemiology, Post Elimination 63 cases reported each year (2000-2007)63 cases reported each year (2000-2007) Cases are all related to imported cases including from developed countries – Europe, JapanCases are all related to imported cases including from developed countries – Europe, Japan Outbreaks predominantly in unprotected populationsOutbreaks predominantly in unprotected populations –2005Indiana, 34 cases in unvaccinated religious community –2006Boston,18 cases in young adults mainly one dose vaccine recipients and foreign born adults

8. Measles, US, 2008 Highest number of reported cases year to date (Jan-July) since 1996Highest number of reported cases year to date (Jan-July) since 1996 No increase in imported casesNo increase in imported cases Increase in spread within the U.S.Increase in spread within the U.S. –7 “outbreaks”

9. Measles, January – July 2008 131 cases from 15 states and DC131 cases from 15 states and DC 15 (11%) cases hospitalized, no deaths15 (11%) cases hospitalized, no deaths Importation status:Importation status: –17 importations 8 foreign visitors (all unvaccinated)8 foreign visitors (all unvaccinated) 9 US residents (all unvaccinated)9 US residents (all unvaccinated) –99 (76%) additional cases linked to importations or virologic evidence of importation –15 cases unknown source 123 cases in US residents123 cases in US residents –91% cases unvaccinated or unknown vaccination status

10. Measles Cases Reported to CDC/NCIRD January-July, 2008 (N= 131) San Diego, CA N=12 Missaukee County, MI, N=4 Pima County, AZ N=14 Los Angeles, CA N=1 Fairfax, VA N=1 Milwaukee County, WI N=6 Nassau County, NY N=1 New York City, NY N=26 Honolulu, HI N=4 Pittsburgh, PA N=1 Chicago, IL Grant County, WA N= N=19 Vernon County, WI N=1 N=1 Scott County, AR N=2 San Francisco, CA N=2, Sources: D.C. N=1 NM N=1, Unknown Baton Rouge, LA N=1, Du Page Co, I L N=31 Fulton Co, GA N=1 Cass Co, MO N=1

11. Reported Measles Cases, U.S. 1997-2008*, by Importation Status *Provisional data through July 31

12. U.S. Residents with Measles, January 1 through July 31, 2008, by Age N = 123 80% cases < 20 years

13. Reasons for not receiving Measles vaccine, U.S Residents with measles who were Eligible* for Vaccination, January 1 through July 31, 2008, N=95 * Excludes infants under 12 months old, persons born before 1957, foreign visitors, and persons who are vaccinated. † Includes children 16 months to 4 years old who have not been vaccinated. § Includes persons who are age eligible for vaccination but whose vaccination status is unknown or who are unvaccinated for unknown reasons. All case-patients in this category were between 20 and 50 years old. No persons cited medical reasons for not having been vaccinated

14. Strategies for Achieving and Maintaining Measles Elimination Maximize population immunity through vaccinationMaximize population immunity through vaccination Assure adequate surveillanceAssure adequate surveillance Respond rapidly to outbreaksRespond rapidly to outbreaks Work to improve global controlWork to improve global control

15. Maximize Population Immunity through Vaccination Provide scientific evidence for vaccine policy decision making and communicate policy recommendationsProvide scientific evidence for vaccine policy decision making and communicate policy recommendations Deliver recommended vaccinations on timeDeliver recommended vaccinations on time –First dose 12-15 months –Second dose 4-6 years –Two dose MMR vaccine schedule for children, students, health care personnel and international travelers –At least one dose for other adults –Child care and school requirements Evaluate vaccine coverage and population immunityEvaluate vaccine coverage and population immunity –National Immunization Survey (19-35 months) –School entry assessments (≥ one dose) –Two dose coverage among school students (NHIS, adolescent NIS) –Health care personnel

16. Estimated MMR Vaccine Coverage among children aged 19-35 months, NIS, US, 2003-2007 MMWR

17. Nonmedical Exemptions for States With Religious Exemptions and With Personal Belief Exemptions - 1991 - 2004 Omer, Pan, Halsey et al., JAMA, 2006 Only Religious Exemptions PermittedPersonal Belief Exemptions Permitted Exemption Rate

18. WA State Counties’ School Entry Exemption Rates 2005-2006

19. Assure Adequate Surveillance Detect imported cases to prevent indigenous spreadDetect imported cases to prevent indigenous spread Detect small chains of transmissionDetect small chains of transmission Timely reporting and notification of casesTimely reporting and notification of cases –Polio, measles, rubella recently made “immediately” reportable by CSTE Monitor surveillance indicatorsMonitor surveillance indicators Assess completeness of reporting periodicallyAssess completeness of reporting periodically

20. Rapid Outbreak Response Case finding and investigationCase finding and investigation –Active surveillance –Laboratory confirmation and genotyping –Isolation of cases Contact tracingContact tracing –Identify contacts –Vaccine, IG and/or voluntary home quarantine for those without evidence immunity Assess community vaccine coverage and needs for additional community vaccination including infants 6- 11 monthsAssess community vaccine coverage and needs for additional community vaccination including infants 6- 11 months

21. Global Measles Achievements in measles control and eliminationAchievements in measles control and elimination However, in 2006 (estimates)However, in 2006 (estimates) –20 million cases –242,000 deaths In 2006, ~30 million U.S. residents traveled abroad and 51 million international visitors entered the U.S.In 2006, ~30 million U.S. residents traveled abroad and 51 million international visitors entered the U.S. In 2008, measles endemic in many countries, outbreaks in Europe and UK declared re- establishment of endemic disease transmissionIn 2008, measles endemic in many countries, outbreaks in Europe and UK declared re- establishment of endemic disease transmission Ongoing risk of importationsOngoing risk of importations

22. Measles Importations 2005-2008* Countries 17India 10Japan 7China 6Ukraine 4 U.K, Thailand 3 Pakistan, Mexico, Switzerland 2 Germany, Belgium, Hong Kong, Romania, Saudi Arabia, Kenya, Israel, Australia, Yemen 1 Ghana, Ethiopia, Italy, Uganda, Armenia Bangladesh, France, Indonesia, Nigeria 2005-2007, N = 84 * 2008, provisional data through Sept 12Countries5Italy 3Switzerland 2 Israel, Belgium, India 1 Germany, China, Pakistan, Philippines, Japan, Russia 2008, N = 20

23. D5 D4 Global Threat of Measles, U.S. 2008 131 cases 17 importations 17 importations 21 virologic evidence 21 virologic evidence D4 (10), D5 (9), H1 (2) D4 (10), D5 (9), H1 (2)

24. Demands/Challenges in Maintaining Measles Elimination in the US Ongoing risk of importationsOngoing risk of importations Lack of familiarity with measles among the public and health care providersLack of familiarity with measles among the public and health care providers High level of investigative and public health response effort by local, state and national public health and laboratory staffHigh level of investigative and public health response effort by local, state and national public health and laboratory staff Maintaining high one and two dose vaccine coverage with increasing vaccine safety concerns in the populationMaintaining high one and two dose vaccine coverage with increasing vaccine safety concerns in the population

25. Thank you Kathleen Gallagher kxg7@cdec.gov