Measles — United States, January 4–April 2, 2015

Tuesday, 12th of April 2016

Measles — United States January 4–April 2 2015

URL for more graphical information  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a1.htm
 

Weekly

April 17 2015 / 64(14);373-376

Nakia S. Clemmons MPH¹ Paul A. Gastanaduy MD¹ Amy Parker Fiebelkorn MSN¹ Susan B. Redd¹ Gregory S. Wallace MD¹ (Author affiliations at end of text)

Measles is a highly contagious acute viral illness that can lead to complications such as pneumonia encephalitis and death. As a result of high 2-dose measles vaccination coverage in the United States and improved control of measles in the World Health Organizations Region of the Americas the United States declared measles elimination (defined as interruption of year-round endemic transmission) in 2000 (1). Importations from other countries where measles remains endemic continue to occur however which can lead to clusters of measles cases in the United States. To update surveillance data on current measles outbreaks CDC analyzed cases reported during January 4–April 2 2015. A total of 159 cases were reported during this period. Over 80% of the cases occurred among persons who were unvaccinated or had unknown vaccination status. Four outbreaks have occurred with one accounting for 70% of all measles cases this year. The continued risk for importation of measles into the United States and occurrence of measles cases and outbreaks in communities with high proportions of unvaccinated persons highlight the need for sustained high vaccination coverage across the country.

Confirmed measles cases in the United States are reported by state and local health departments to CDC using a standard case definition (2). A measles case is considered confirmed if it is laboratory-confirmed or meets the clinical case definition (an illness characterized by a generalized rash lasting ≥3 days a temperature of ≥101^°F [≥38.3^°C] and cough coryza or conjunctivitis) and is linked epidemiologically to a confirmed case. Measles cases are laboratory confirmed if there is detection in serum of measles-specific immunoglobulin M isolation of measles virus or detection of measles virus nucleic acid from a clinical specimen. Cases are considered imported if at least some of the exposure period (7–21 days before rash onset) occurred outside the United States and rash occurred within 21 days of entry into the United States with no known exposure to measles in the United States during that period. Import-associated cases include 1) imported cases 2) cases that are linked epidemiologically to imported cases and 3) cases for which an epidemiologic link has not been identified but the viral genotype detected suggests recent importation.* An outbreak of measles is defined as a chain of transmission of three or more linked cases.

During January 4–April 2 2015 a total of 159 measles cases (in 155 U.S. residents and four foreign visitors) from 18 states and the District of Columbia were reported to CDC (Figure 1). Patients ranged in age from 6 weeks to 70 years; 26 (16%) were aged <12 months 18 (12%) were aged 1–4 years 27 (17%) were aged 5–19 years 58 (36%) were aged 20–39 years and 30 (19%) were aged ≥40 years. Twenty-two patients (14%) were hospitalized including five with pneumonia. No other complications and no deaths have been reported.

A total of 111 cases (70%) have been associated with an outbreak that originated in late December 2014 in Disney theme parks in Orange County California. The source of the initial exposure has not been identified but measles cases associated with this outbreak have been reported in seven U.S. states Mexico and Canada (3). Measles was laboratory confirmed in 101 (91%) of these cases either by detection of measles-specific IgM or of measles virus RNA. The B3 genotype was identified in specimens from at least 40 patients associated with this outbreak. B3 is a common measles genotype that has been identified in multiple states and countries (4). Other smaller measles outbreaks in 2015 without a link to Disney theme parks have been reported in Illinois (15 cases) Nevada (nine) and Washington (five).

The majority of the 159 patients with reported measles in the 2015 outbreaks were either unvaccinated (71 [45%]) or had unknown vaccination status (60 [38%]); 28 (18%) had received measles vaccine. Among the 68 U.S. residents who had measles and were unvaccinated 29 (43%) cited philosophical or religious objections to vaccination 27 (40%) were ineligible because they were too young to receive vaccination (26 patients) or had a medical contraindication (one) three (4%) represented missed opportunities for vaccination and nine (13%) had other reasons for not being vaccinated (Figure 2).

Of the 159 measles cases 153 (96%) were import-associated. Ten cases were classified as direct importations (six among unvaccinated U.S. residents returning from overseas travel of whom three were aged 6–11 months and age-eligible for vaccination before departure and four among foreign visitors). Countries associated with direct importations included Azerbaijan China Germany India Indonesia Kyrgyzstan Pakistan Qatar Singapore and United Arab Emirates (one import each).

Discussion

High population immunity secondary to high measles vaccination coverage has maintained measles elimination in the United States since declaration of elimination in 2000 (5). Worldwide however approximately 20 million measles cases occur annually and importations to the U.S. will continue to place unvaccinated populations at risk for measles. Measles transmission in pockets of unvaccinated persons increases the risk for transmission to vulnerable groups such as those who cannot be vaccinated because of underlying medical conditions or infants too young to be vaccinated.

As in previous years a sizeable proportion of U.S. residents who became infected with measles had an unknown vaccination status (6). This occurred primarily among adults and reflects the lack of immunization data in registries on adults in the United States. Among the U.S.-resident patients who were confirmed as unvaccinated the numbers who were ineligible for vaccination and who cited philosophical or religious beliefs as the reason they declined vaccination were similar. Exemptions from mandated immunizations have been shown to increase risk for acquiring disease as well as increasing the risk of a disease outbreak at the community level. Exemption rates are higher in jurisdictions where exemption requirements are procedurally easier to meet (7).^†

Health care providers should encourage vaccination of all eligible patients who do not have other evidence of measles immunity. Children without contraindications should receive their first dose of measles mumps and rubella (MMR) vaccine at age 12–15 months and a second dose at age 4–6 years. Before international travel infants aged 6-11 months should receive one dose of MMR and children aged 12 months and older should receive two doses of MMR vaccine separated by at least 28 days. Adults born during or after 1957 who are at high risk for measles (i.e. health care personnel international travelers and students at postsecondary educational institutions) and who do not have other evidence of measles immunity should also receive 2 doses of MMR vaccine. Other adults without evidence of measles immunity should receive at least 1 dose of MMR vaccine. 1 dose of MMR vaccine administered to those aged ≥12 months is approximately 93% effective at preventing measles and 2 doses approximately 97% effective (8).

Measles should be considered in the differential diagnosis of patients with febrile illness and rash. Patients with clinical symptoms compatible with measles should be asked about recent travel abroad or contact with travelers and their vaccination status should be verified. Patients with suspected measles should be promptly screened before entering waiting rooms and appropriately isolated (i.e. in an airborne isolation room or if not available in a separate room with the door closed) or have their doctors office appointments scheduled at the end of the day to prevent exposure of other patients (9). Serology as well as viral specimens should be collected for laboratory testing. Viral genetic sequencing can be used to detect the genotype of the infection which can be used to suggest the source of an imported virus and track global transmission patterns (10). To assist state and local public health departments with rapid investigation and control efforts to limit the spread of disease suspected measles cases should be reported to local health departments immediately. State health departments are required to notify cases of measles to CDC within 24 hours of detection.^§

Maintenance of high 2-dose MMR vaccine coverage has been crucial in limiting measles spread from importations in the United States. Most measles importations occur when U.S. citizens travel abroad and have not been appropriately vaccinated. Therefore it is important to encourage timely delivery of measles vaccination for U.S. residents before overseas travel. In addition early detection of cases and rapid public health response to outbreaks can serve to limit the spread of illness.

Acknowledgments

William Bellini PhD Paul Rota PhD Jennifer Rota MPH Division of Viral Diseases; Melinda Wharton MD Immunization Services Division; Kristin Pope MEd; Office of Policy National Center for Immunization and Respiratory Diseases CDC.

¹Division of Viral Diseases National Center for Immunization and Respiratory Disease CDC (Corresponding author: Nakia Clemmons nclemmons@cdc.gov 404.639.2553)

References

1. Katz SL Hinman AR. Summary and conclusions: measles elimination meeting 16-17 March 2000. J Infect Dis 2004;189(Suppl 1):S43–7.
2. CDC. Manual for the surveillance of vaccine-preventable diseases. Chapter 7: measles. Atlanta GA: US Department of Health and Human Services CDC; 2013. Available at http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.pdf .
3. Zipprich J Winter K Hacker J Xia D Watt J Harriman K; CDC. Measles outbreak—California December 2014-February 2015. MMWR Morb Mortal Wkly Rep 2015;64:153–4.
4. CDC. CDC health advisory: U.S. multi-state measles outbreak December 2014–January 2015. Atlanta GA: US Department of Health and Human Services CDC; 2015. Available at http://emergency.cdc.gov/han/han00376.asp.
5. Papania MJ Wallace GS Rota PA et al. Elimination of endemic measles rubella and congenital rubella syndrome from the Western hemisphere: the US experience. JAMA Pediatr 2014;168:148–55.
6. Gastañaduy PA Redd SB Fiebelkorn AP et al.. Measles—United States January 1–May 23 2014. MMWR Morb Mortal Wkly Rep 2014;
   63:496–9.
7. Wang E Clymer J Davis-Hayes C Buttenheim A. Nonmedical exemptions from school immunization requirements: a systematic review. Am J Public Health 2014;104:e62–84.
8. McLean HQ Fiebelkorn AP Temte JL Wallace GS. Prevention of measles rubella congenital rubella syndrome and mumps 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013;62(No. RR-4):1–34.
9. CDC. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Atlanta GA: US Department of Health and Human Services CDC; 2007. Available athttp://www.cdc.gov/hicpac/2007ip/2007isolationprecautions.html.

10.  Rota PA Brown K Mankertz A et al. Global distribution of measles genotypes and measles molecular epidemiology. J Infect Dis 2011;204(Suppl 1):S514–23.

 

* Additional information available at http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html.

^† Additional information available at http://www.cdc.gov/vaccines/imz-managers/laws/state-reqs.html and athttp://www.cdc.gov/phlp/publications/topic/vaccinations.html.

^§ Additional information available at http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/pdfs/cstenotifiableconditionlista.pdf .