1. Measles in New York City, 2008 and the use of an Immunization Information System in Outbreak Control Activities
C Zimmerman*, M Asfaw*, K Cummings*,
V Papadouka, M* Mickle-Hope*, A Metroka*, J Zucker*¶
*Bureau of Immunization (BOI)
New York City Department of Health and Mental Hygiene (NYC DOHMH)
¶Immunization Services Division, Program Operations Branch, Centers for Disease Control and Prevention

2. Overview Epidemiology of Measles in NYC
How we used our immunization information system (IIS) in outbreak response and control activities
How the IIS provided important information to understand why the outbreak may have occurred

3. NYC Measles,
Year
# of Measles Cases
# of Measles Cases
Year

4. Measles in 2008 29 cases (28 confirmed, 1 probable)
Most cases since 1992
Complex outbreak with multiple importations
Several generations of local transmission
Large numbers of contacts ~2,000 contact were identified and contacted about exposure

5. Complex Outbreak Sporadic Cases Cluster #1 Cluster #2 Cluster #3
Hatched pattern represents direct importations

6. Age Distribution
34%
28%
24%
14%

7. Pediatric Cases 66% of cases were children (range 5-42 months)
37% (7/19) <12 months of age
42% (8/19) months of age
6 were14-15 months)
4 (21%) >15 months of age
4 cases >15 months of age and unvaccinated
Reasons for non-vaccination
1 personal belief (42 month old)
2 missed opportunities (16 months & 20 months old)
1 unknown reason (24 months old)
2 Hospitalizations for pneumonia
1 possible nosocomial transmission from adult to child in a providers office

8. Adult Cases 10/29 cases adults Age range 20-41 years
All imported cases were adults (Israel, Belgium, Italy)
Immunization status
5 reported no previous measles vaccination
4 reported unknown measles vaccination status
1 had two well documented measles vaccinations >20 years earlier but was IgM positive

9. Molecular Epidemiology
38% (11/29) of cases had culture/PCR testing for measles
54% (6/11) were PCR\culture positive all were D4 genotype
D4 know to be circulating in Belgium, UK, and Israel at that time

10. Geography
90% of all the 2008 cases occurred in Borough of Brooklyn (Kings County)
2000 census population for Brooklyn 3.5 million
Birth cohort ~40,000
Of pediatric cases 79%(15/19) occurred in Borough Park neighborhood of Brooklyn
Population 2000 census of 185,046 (51,399/square mile*)
Birth cohort ~ 5,300 *

11. Outbreak Response
Issued alerts to medical community through local Health Alert Network (HAN)
Press release to media (TV, radio, print)
Outreach to community and religious leaders
Fliers distributed in Borough Park
Used school immunization compliance information to review public and private school Immunization coverage
Used IIS to target interventions

12. Use of the IIS in Outbreak Response Activities

13. NYC IIS- The Citywide Immunization Registry (CIR)
Initiated in 1997
Populated with vital records data
~ 125,000 births per year
Over 1,900 providers
~70% of population <19 years of age are VFC eligible
96% of VFC doses distributed are now accounted by the CIR
Need to talk to Amy about this slide what is correct and what to add

14. Using the IIS for Response I
IIS used to generate list of all (114) practices in 7 zip codes within Brooklyn, centered around Borough Park, and assessed their MMR coverage on children months of age
Providers with “large” numbers of unvaccinated were contacted by phone (10 practices)
Outbreak was discussed, strongly encouraged to recall children not UTD

15. Using the IIS for Response II
A list of all practices (72) reporting immunizations in Borough Park were generated from the IIS
A provider at each practice was contacted directly by phone by BOI physician
Items discussed included, infection control, post-exposure prophylaxis, disease reporting, recommendation for first MMR to be given at 12 months of age

16. Use of IIS for Response III
IIS used to generate a list of all children in Borough Park, months of age with an immunization but no measles vaccine
7,312 letters generated and mailed
Letter informed parents of outbreak, and of child’s status of being not up-to-date, encouraged to follow-up with child’s provider, and encouraged MMR at 12 months of age

17. Use of IIS for Response IV
Use IIS to compile lists of children not UTD for measles ages months for practices in Borough Park regardless of whether child live in Borough Park or not
69 Facilities were faxed a list of not UTD children for their practice for recall for vaccination

18. Why Borough Park? More travel between neighborhood and Israel?
Traditional measures of coverage in Borough Park consistent with the rest of NYC
No higher proportion of refusal or exemption in Borough Park
Anecdotal reports of preference for delaying MMR although not refusing MMR
Notable given disease in month age group

19. Timing of 1st MMR
Cumulative % of cohort with MMR at give age
Vicki I need to words to explain this. We are looking at cohort of children 36 months of age and the cumulative proportion receiving their first MMR dose at any age? Difference between CIR Coverage and that NIS
Age in Months when 1st MMR dose give to children born in 2005

20. Timing of MMR Doses by Month
Pre-Outbreak (1/07-1/08)
NYC 60.2%
Rest of Brooklyn 57.4%
Borough Park 38.7%
Post-Outbreak (6/08-12/08)
NYC 60.9%
Rest of Brooklyn 57.5%
Borough Park 45.4%
%of MMR doses at 13 months of all MMR <4 years
In each month what proportion of all MMR doses given to children <4 years of age were given at months of age

21. Limitations of the IIS Incomplete reporting of immunizations
Duplicate records, unmerged records
Unable to identify who moves out of the area
Children reported to no longer be affiliated with a given practice when recall lists distributed
Missing immunization data due to children moving in and past records not being entered
Keeping address data current
~1,000 letters returned

22. Conclusions
The risk of measles remains high in NYC and throughout the U.S. due to imported disease
A quality IIS can provide important tools for outbreak response and for understanding areas of increased risk transmission
Children months who are not yet immunized are at considerable risk during an outbreak
In addition to getting vaccinated, getting vaccinated on-time matters, particularly in outbreak situations

23. Recommendations
NYC recommends that the 1st dose of MMR be given at 12 months of age
ACIP should review its recommendations with respect to the first dose of MMR being given at months of age, in light of the events in NYC in 2008

24. Acknowledgements BOI Surveillance Unit NYC CIR
Francis Megafu
Mohammed Mannan
Gamal Sihly
Vanessa Collado
Luis Baez
George Robinson
Yvelouse Tannis
Grace Reyes
Renee Stewart
Antonine Jean
NYC CIR
Paul Schaeffer
Rezaul Kabir
Angel Aponte
Michael Hansen
Provider Quality Assurance Unit
Karen Fernandez
Paul McNamee
Cassandra Deas
Vaccine Management Unit
Angel La Paz
Jack Rodriguez
Program Support Unit
Betty Sanchez
Gracia Caines
Paulette Kentish
Nancy Villaneuva
Reva Thomas
Sharon Spence
Mirleine Joseph
Irene Burks
Jane Tubridy
Natalie Black
Emily Le
Osayuki Oshodin
NYC Public Health Laboratory
CDC Measles, Mumps Rubella Laboratory