Rita Espinoza, MPH

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Vaccine-Preventable DiseasesUpdate

• Rita Espinoza, MPH
• Epidemiologist
• Emerging and Acute Infectious Disease Branch
• Infectious Disease Control Unit
• January 9, 2009

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Overview

• Incidents
• Mumps
• Measles
• Texas Data
• Pertussis
• Varicella

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Comparison of 20th Century Annual Morbidity and
Current Morbidity, Vaccine-Preventable Diseases,
Texas
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Epidemiology of Mumps and Multistate Mumps
Outbreak United States 2006
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Mumps Epidemiology

• Reservoir Human
• Transmission Respiratory drop nuclei
• Subclinical infections may transmit
• Temporal pattern Peak in late winter and spring
• Communicability Three days before to four
• days after onset of active
• disease

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• Mumps United States, 1968- 2005

2005 provisional data
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• Mumps United States, 1980- 2005

2-dose schedule
2005 provisional data
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U.S. Mumps Cases

• 2005 265 cases
• 2004 258 cases
• 2002 270 cases
• 1996 751 cases
• 1993 1,692 cases
• 2010 Health Objective is to eliminate indigenous
  mumps by 2010

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Mumps Outbreak NY State, 2005
MMWR Feb 24, 2006
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• Mumps Outbreak United States 2006

Total reported cases 4,602
4
193
1
650
1,921
85
349
501
3
134
782
1
2
In PA, 14 of the 85 cases are considered
outbreak-associated.

• Provisional Number of Cases by State as of June
  20, 2006

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Incidence of Mumps/100,000, 8 Outbreak-Associated
States, NNDSS (Provisional) January 1 June 20
2006

• Iowa 65.3
• Kansas 28.0
• South Dakota 24.1
• Nebraska 17.1
• Wisconsin 4.9
• Missouri 3.1
• Illinois 1.1
• Pennsylvania 0.7

States with delayed reporting through NNDSS,
rates likely to increase
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Incidence of Mumps by Age Group in the Eight
Outbreak States, NNDSS (Provisional), 1 January
20 June 2006 (n3860)
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Multistate Mumps Outbreak 2006

• College students especially in Iowa
• Cases in health care workers
• Few outbreaks reported in schools or child care
  centers
• Transmission remained fairly focal
• Little or no spread to vaccine refuser
  populations and very few cases in infants
• Vaccination status cases
• 7 unvaccinated
• 14 1 dose
• 50 2 doses
• 30 unknown vaccination status (majority adults)

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Clinical Summary of Reported Mumps Cases, NNDSS
(Provisional), January 1-June 20, 2006 (n3860)
Number () 2215 (80.8) 10 (0.4) 5 (0.2) 59
(4.4) 6 (0.2) 43 (1.6) 0
Clinical Feature (n)1 Parotitis (2741) Meningitis
(2542) Encephalitis (2530) Orchitis
(1333)2 Deafness (2536) Hospitalization
(2745) Death (2745)
1 Number with Yes or No in data field
included. Cases with Unknown or missing data
excluded. 2 Data collected among males only.
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Hospitalizations

• Two data sources for hospitalization (1 January
  20 June 2006)
• NNDSS 43 hospitalizations
• Biweekly Report 66 hospitalizations
• Data source for reason for hospitalization
  Biweekly Report only
• 11 of 66 hospitalizations likely NOT to be
  mumps-related
• Hospitalized for another reason (e.g., colitis,
  pneumonia) and found to have mumps
• Reason for hospitalization (n55)1

1 Not mutually exclusive (ie., may have gt1 reason)
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Epidemiological and Laboratory InvestigationsPrel
iminary Data

• Attack rates in 2 highly affected college
  campuses Iowa
• 2.0 (97 college students 2 vaccine doses)
• 3.8 (77 college students 2 vaccine doses)
• Vaccine failure rate (college room mate contact
  study Iowa)
• 2 dose recipients 8

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Mumps Vaccine

• Composition Live virus (Jeryl Lynn strain)
• Efficacy 95 (Range, 90 - 97)
• Duration ofImmunity Lifelong
• Schedule 2 Doses (as MMR)
• Should be administered with measles and rubella
  (MMR)

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Mumps Vaccine (MMR) Indications

• All infants gt12 months of age
• Susceptible adolescents and adults without
  documented evidence of immunity

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Mumps Immunity

• Born before 1957
• Documentation of physician-diagnosed mumps
• Serologic evidence of mumps immunity
• Documentation of adequate vaccination

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Updated ACIP Recommendations

• Changes in evidence of immunity through
  vaccination
• 1 dose children 1-4 years and low risk adults
• 2 doses school aged children, students in post
  high school educational facilities, international
  travelers and workers in health care facilities
• Health facility workers without other evidence of
  immunity
• 2 doses routinely
• Birth before 1957 consider one dose in non
  outbreak setting and strongly consider 2 doses
  during outbreak
• Outbreak control recommendations
• 2nd dose for children 1-4 years and low risk
  adults if affected by outbreak

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Reported Cases of Mumps in Texas 1946-2007
Mumps Vaccine Licensed in 1950
Provisional as of 05/03/05
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Mumps in Texas, 2000-2007
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Percentage of Mumps Cases by Age Group, 2007
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Percentage of Mumps cases by Race/Ethnicity
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Measles Epidemiology

• Reservoir Humans
• Transmission Respiratory
• Communicability 4 days before rash onset to
  4 days after rash appearance
• Temporal Pattern Late winter-spring
• Incubation Period 14 days
• (range 7-18 days)

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Reported Cases of Measles in Texas 1920-2007
Measles Vaccine Licensed in 1963
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2005 Measles

• Family reunion in Cabo San Lucas, Mexico
• 48 individuals attended
• Houston, Dallas, Austin, and Los Angeles
• Travel dates 11/22-11/27/05
• Stayed in villas
• 3 addl members reported to have rash illness

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Case C

• 38 year old female
• Vaccinated
• Symptoms
• fever onset 12/5 (104.5oF)
• rash onset 12/10 (X days)
• cough
• coryza
• conjunctivitis
• light sensitivity
• ER visits 1X
• Office visits 2X
• Hospitalized with double pneumonia 12/12
• IgM positive for measles 12/12

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DSHS/CDC Measles Laboratory Results
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Additional Lab Results
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US Genotyping Results 2005
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Geographic distribution of measles virus
genotypes for regions that have not yet
eliminated measles transmission, 19952005
The countries in the western hemisphere and
Australia have eliminated measles and are not
shown. In western Europe, genotype D7 was the
most commonly reported genotype. Australia,
Spain, the United Kingdom, and the countries of
the western hemisphere have reported multiple
genotypes attributed to importation.
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International Youth Sporting Event

• Held annually in Williamsport, Pennsylvania
• August 1726, 2007
• 8 US and 8 international teams
• 200 boys aged 10 13 years
• Residential compound
• Estimated attendance 265,000

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Index Case
Suspected measles case reported
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Aug 2007
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Index Case
Japanese male, aged 12 years International youth
sporting event
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Aug 2007
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Index Case
Isolation
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Aug 2007
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Index Case
Isolation
Measles IgM detected
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17
Aug 2007
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Index Case
Exposed to ill sibling
Isolation
Measles IgM detected
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17
Aug 2007
Jul 2007
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Index Case
Tokyo ? Detroit
Isolation
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13
Aug 2007
Jul 2007
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Index Case
Tokyo ? Detroit
Detroit ? Baltimore
Isolation
16
13
Aug 2007
Jul 2007
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Index Case
Tokyo ? Detroit
Detroit ? Baltimore
Baltimore ? Williamsport
Isolation
16
13
Aug 2007
Jul 2007
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Contact Tracing

• Persons exposed during August 1320
• Residential compound attendees
• Airline passengers
• Airport workers
• Criteria for measles immunity
• Birth before 1957
• History of measles disease
• 2 doses of measles-containing vaccine
• Detection of measles IgG antibodies

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Laboratory Diagnostic Methods

• Serology
• IgM antibodies
• IgG antibodies
• Real-time reverse transcriptionpolymerase chain
  reaction (RT-PCR)
• Conventional RT-PCR
• Viral culture

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Genotyping

• Determine likely source
• Confirm epidemiologic association
• Detection of multiple genotypes in previous US
  outbreaks suggests importation

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Notifications

• Media
• Health Alert Network
• Epi-X
• WHO Revised International Health Regulations

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Contact Tracing Results

• Follow-up of gt1,300 potentially exposed persons
• 186 persons vaccinated
• 3 received immunoglobulin
• 6 additional measles cases identified

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Case 3 Male, 25 No documented vaccination Exposed
Aug 13 Detroit Airport officer Aug 27 Rash
Japan
U.S.
2
PA
3
MI
1
PA
12 13
August 2007
Exposure Date
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Case 4 Female, 53 No documented
vaccination Exposed Aug 13 Detroit ?
Baltimore Passenger Aug 28 Rash
Japan
U.S.
2
PA
3
MI
1
4
PA
MI
12 13 14
August 2007
Exposure Date
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1
Index Case
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Case 4
Occupied Seat within 1 row of Index Case
4
1
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Case 5 Male, 40 No documented vaccination Exposed
Aug 14 PA Corporate representative Aug 28
Rash Aug 29 T 105.7F, seizure, pneumonia,
hospitalized
Japan
U.S.
2
PA
3
MI
1
4
PA
MI
5
TX
12 13 14
August 2007
Exposure Date
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Rash Onset Dates
No. cases
Aug
Sep
Date
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Laboratory Confirmation
Laboratory Results
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Genotyping Results
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VaricellaEpidemiology

• Reservoir Humans
• Transmission Respiratory or contact with
  lesions
• Communicability 1-2 days before and 4-5 days
  after rash onset
• Temporal Pattern Winter, early spring
• Incubation Period 14-16 days
• (range 2-3 weeks)

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Reported Cases of Varicella in Texas 1972-2007
Varicella Vaccine Licensed in 1995
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Reported Cases of Varicella 2000-2007
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Varicella Cases by Age GroupTexas, 2002-2007
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Varicella Cases and Vaccination Coverage
reported in Texas
Among children 19-35 months of age, National
Immunization Survey (NIS) By 2005, K-5 and 7-11
grades covered by school entry laws
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2007 Percent of Varicella Cases by Gender
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Percentage of Varicella cases by Race/Ethnicity
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Pertussis Epidemiology

• Reservoir Human (Adolescents/Adults)
• Transmission Respiratory droplets
• Communicability Maximum in catarrhal stage,
  may transmit in paroxysmal stage,
  secondary attack rate up to 80
• Temporal pattern No distinct season, may
  increase in summer-fall

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Reported Cases of Pertussis in Texas 1920-2007
Pertussis Toxoid Licensed in 1949
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Pertussis Trends 2000-2007
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Deaths due to Pertussis in Texas
Provisional as of 11/12/08
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Percentage of Pertussis cases by Race/Ethnicity
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Percentage of Texas Pertussis Cases by Age
Group, 2007
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2005 Incidence of Pertussis
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How can ED help?

• Vaccination policies
• Employees
• Patients
• Collecting specimens
• Prior to antibiotic treatment
• Viral and serologic
• Send to state lab for confirmation
• Reporting suspects to LHD

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Specimen Collection Shipping Guidelines
(Measles, Mumps, Rubella)

• Serology
• Collect a minimum of 6-8 mL of blood in a red-top
  tube or tiger top tube
• Within 8 hrs of collection may be transported at
  room temperature in the original blood collection
  tube
• Within 48 hours of collection, sera must be
  separated from the blood and shipped on cold
  packs, between 20 and 80C
• gt 48 hours of collection, then the samples must
  be frozen at 200C or lower and shipped on dry
  ice
• Do not freeze whole blood

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Specimen Collection Shipping Guidelines (contd)

• Virology
• Specimen should be collected within four (4) days
  of rash onset
• Urine Collect 50-100 mL of urine (first morning
  voided urine is ideal)
• Transport cold on ice packs within 48 hours of
  collection
• gt 48 hours, freeze and ship on dry ice

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Resources

• DSHS
• TXVPD Guidelines
• http//www.dshs.state.tx.us/idcu/health/vaccine_p
  reventable_diseases/resources/vpd_guide.pdf
• Laboratory Website
• http//www.dshs.state.tx.us/lab/default.shtm
• Centers for Disease Control and Prevention
• Vaccine Information
• www.cdc.gov/vaccines
• ACIP Recommendations Guidelines
• www.cdc.gov/vaccines/recs/default.htm