Measles 2015: Situational Updates, Clinical Guidance, and Vaccination Recommendations

Coordinator:
Welcome and thank you for standing by. At this time, all lines are in a listen-only mode. During the question and answer session, you may press star one on your touchtone phone if you would like to ask a question. Today’s conference is being recorded. If you have any objections, you may disconnect at this time. I would now like to turn our meeting over to Ms. Loretta Jackson Brown. Ms. Jackson Brown, you may begin.

Loretta Jackson-Brown:
Thank you, (Priscilla). Good afternoon. I’m Loretta Jackson-Brown and I’m representing the Clinician Outreach and Communication Activity -- COCA -- with the Division of Strategic National Stockpile at the Centers for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call -- Measles 2015: Situational Updates, Clinical Guidance, and Vaccination Recommendations. We are pleased to have with us today Dr. Jane Seward from CDC. She will provide information on the current measles situation in the US. There is no continuing education provided for this call.

The PowerPoint slide set and webinar link are available from our COCA Web page at emergency.cdc.gov/coca.

At the conclusion of today’s session, the participants will be able to describe the current measles situation in the United States, discuss the clinical presentation of measles and the clinical guidelines for patient assessment and management, identify CDC vaccination recommendations, and outline CDC measles resources available for clinicians.

At the end of the presentation, you will have the opportunity to ask the presenter questions. On the phone, dialing star one will put you in the queue for questions. On the webinar, you can submit your questions by clicking on the Q and A tab at the top of the webinar toolbar.

Today’s presenter, Dr. Jane Seward, is the Deputy Director of the Division of Viral Diseases in the National Center for Immunization and Respiratory Diseases at CDC. She obtained her medical degree from the University of Western Australia, her clinical training in pediatrics and infectious disease at Tulane University, and her Master’s Degree in public health and epidemiology from Emory University. Her public health career has spanned both domestic and international arenas in the fields of maternal and child health, birth defects, nutrition, and immunizations. Since 1996, Dr. Seward has worked at CDC in the field of immunizations. She is an internationally recognized expert in vaccine-preventable diseases including measles, mumps, rubella, varicella, and herpes zoster.

At this time, please welcome Dr. Seward.

Dr. Jane Seward:
Good afternoon and thanks for joining the measles update today. A reminder that @CDC_IZLearn is live-tweeting the event this afternoon. So we’ll go right into the update. I’ll start with - I’ll be covering measles and the disease, including complications. I’ll then be talking about the global situation for measles, covering measles epidemiology in the United States over the time since the vaccine was introduced, then focusing on measles epidemiology since measles elimination; and then with a focus on the last two years, and then updating you on MMR vaccine recommendations and clinical guidance.

So as you are all very well aware, I think, measles is a febrile rash illness caused by the measles virus. It’s very highly transmissible, transmitted by respiratory droplets and aerosols, so it can be spread easily by coughing and sneezing, especially. If anybody is in a room, you’re very likely to come down with measles if you are susceptible. It is contagious from four days before to four days after rash onset, with an r of zero - of twelve to sixteen. That means that in a susceptible population, you expect twelve to sixteen cases for every case of measles. So, one case can infect twelve to sixteen secondary cases. In households, the secondary attack rate in susceptible household contacts is 90% or higher. Measles has very distinct clinical course. It starts with a prodrome of fever which can be very high -- up to 105 or even higher degrees Fahrenheit. And then the hallmarks in the prodrome are the three “C”s -- cough, coryza, and conjunctivitis. Coryza is runny nose and conjunctivitis is runny eyes - red eyes - pink eyes. And then if people know to look for this and know how to recognize, there can be very characteristic enanthem, or spots on the mucous membranes inside the mouth called Koplik’s spots. Then, the prodrome is followed by a rash, or an exanthem, about fourteen days after exposure. That incubation period can range from seven to twenty-one days. The rash is maculopapular. It spreads from the head and trunk down to the extremities. In severe cases, it can become confluent and it lasts five to six days and fades in the order of appearance.

Measles can have some very severe complications, which is why the vaccine got developed; especially in children under five and in adults. So quite commonly, it can cause diarrhea, otitis media. It can cause viral and bacterial complicated pneumonia. Encephalitis occurs at a rate of about one per 1,000 cases and even now, in 2015 in developed countries, measles has a mortality of about one to three deaths per 1,000 cases. And then perhaps what’s not as well recognized is the late effect of measles in causing subacute sclerosing panenchephalitis at a rate of one in 100,000 cases seven to ten years after the measles infection. And often that’s hard to diagnose because people don’t think about it with measles cases acquired, you know, a decade before. That’s usually fatal. The measles disease burden is in the U.S. in the decade before the vaccine was licensed. We had 500,000 reported cases annually at that time, but there were three to four million estimated cases. Essentially every person got measles during their lifetime. Of the three to four million cases, 48,000 were hospitalized. There were 4,000 encephalitis cases and 450 to 500 deaths on average every year. Most of those were in healthy children. On a global scale, measles was a huge cause of death and disability, estimated to cause 2.6 million deaths a year in 1980 at the start of the expanded program on immunizations. Due to very accelerated programs, for measles control and elimination, there’s been seventy-five percent decrease in estimated deaths from 2000 to 2013; nevertheless there is still 400 deaths occurring a day around the world, just to give you an idea of the extent of measles mortality still. So, measles does remain a leading cause of vaccine-preventable deaths in children less than five. In those children, too, it can cause all the complications I discussed, including blindness often complicated by vitamin A deficiency. There is still a lot of measles in the world despite the tremendous advances in measles control and elimination. There are an estimated 20 million cases a year, and this is very relevant to us, as you’ll find out later in our post- elimination status in this country because those cases come into the U.S. on a regular basis. So this slide shows measles - reported measles cases, which is a growth underestimation of the amount of cases that actually occur; but gives you an idea of the measles cases reported from the different WHO regions --so the Afro region, Southeast Asian Region, American Region, EMRO -- or Eastern Mediterranean Region -- European Region in red and the Western Pacific Region is brown colored. This shows you that over the years there’s been a difference in when these all predominated around the globe. It has remained endemic in some countries, but there was a lot of measles in Europe back in 2010-2011. We had a big number - large number of importations of measles in 2011 into the U.S. and a lot of those were from Europe. You’ll see over the last twelve months, there’s been a huge number of reported cases from the Western Pacific Region, and last year we saw twenty- five separate importations from the large outbreak in the Philippines.

This slide is just to highlight a large outbreak that occurred in France in - over the years of 2000 and mainly 2010-11; but just to show you there were very few cases being reported in France in 2008 and then suddenly there was this huge outbreak. And so I think we need to be very cautious that we maintain our high coverage so that we don’t get reestablished endemic disease transmission. France had more than 20,000 cases and ten deaths over this time period. In the United States, the measles vaccine was licensed in 1963 and you see there was a dramatic decline in cases after that with some peaks again in the 1970s - late ‘70s and then again around 1990 where we had large outbreaks of measles in inner city large urban areas in the U.S. In 1989 we had the second dose recommended routinely for children and in the year 2000 we had measles elimination declared in the U.S. This is the same data showed as an incidence slide, so just accounting for population changes and population numbers over time. And so you see that the number of cases we had in 2014 was well above the line that we like to see for measles elimination, a line of one case per million population. And this incidence rate was the highest incidence rate we’ve had since 1994.

So measles was declared eliminated in the year 2000 and it was - that status was achieved due to our very high two-dose vaccine coverage, high quality measles surveillance and response, and also to improve measles control in the WHO region of the Americas which resulted in us getting far fewer importations endemic countries that threaten to spread. And also, to highlight that elimination does not mean gone forever. It just means that it’s not endemically transmitted in this country year-round; but we can still get imported cases. We still expect to get imported cases every year and we get limited spread from some of those cases.

Just to highlight, this is a paper by somebody in our group, Amy Fiebelkorn, published in 2010 that summarized the first eight years after measles elimination in the U.S., showing that the highest incidence disease of the measles was in the infants six to eleven months, and then in children twelve to fifteen months. By far, they had the highest incidence and almost a third of the infants six to eleven months were unvaccinated and traveled abroad. So these children should have been vaccinated in accordance with our recommendations and almost half the twelve to fifteen month old cases were also unvaccinated and traveled abroad. So they didn’t get their first dose or they should have had two doses before they travelled.

So just - that is in keeping with the highest susceptibility. Babies less than six months may have some protection from maternal antibodies, so the greatest risks for susceptibility are in the age groups where we see the highest incidence. So this slide shows measles reported cases from 1966 to 2014. From 2001 on, we’re able to break the cases into those that are importations and those that are not in the yellow. So red imported cases have varied from year to year and you’ll see those summarized on the next two slides. You can notice that in the last few years, we’ve certainly seen a trend for an increased number of reported measles cases in this country, which is concerning.

Last year, because of - we did a COCA call a year ago and at that time put together or soon after that put together this infographic to remind people that measles can - when measles happens anywhere in the world, it can travel or spread to the United States. And so you need to be vaccinated before travel, but you can also acquire measles here if you get to exposed to a traveler or to an outbreak in your community. So, now I’ll summarize measles epidemiology in the first eleven years, actually, following declaration of elimination. We had a median of sixty cases reported a year with the range as you see there. We had thirty- three - so half of those cases or a bit more than half -- thirty-three a year -- were importations. Most of those were not people that traveled here form overseas. They were our own residents who traveled abroad and weren’t protected. So we can only blame ourselves for these importations. 25% of cases were hospitalized. We had two deaths in approximately 1000 cases -- so just in line with the risk that I quoted earlier. The incidence was less than one case per million except in that year - in every one of these years was less than one. Most of the cases were unvaccinated -- 65%. 20% did not know their vaccine status, and 15% were vaccinated. Most that did not know their vaccination status were adults. This is a call out to those adult providers to try to do your best to get adult vaccination records and get them in a registry if you have one. We had four outbreaks of measles a year ranging from two in the four years to twelve outbreaks in a large year. The outbreaks were small with a median number of cases of six. So going on to the next four years, 2011 to 2014, we had a much higher number of cases reported of 205, or a mean of 277; and the number of importations and outbreaks, is shown here. You can just read those, but we had more importations each year and a large number of outbreaks in 2011 and 2014. One of our very important tools for linking outbreaks or linking cases that occur is measles genotyping, and this is why it’s very important for physicians to get viral specimens for both PCR testing or virus isolation if possible, but also for genotyping. And so this is a slide showing the distribution of measles - the genotypes over the last twelve months around the world and, not surprisingly, the US gets lots of different genotypes because measles can come from lots of different places.

So this slide shows cumulative number of measles cases by month of rash onset from 1997 to 2014. And you can see that, again, this is just a different way of showing that the last few years -- 2008, then 2013, 2011, and then 2014 -- very dramatically had a lot more measles cases than previous years. And where are we for 2015? In the first month, we’ve far exceeded any of the years that are on this graph, which as I said is quite concerning.

So just to summarize briefly, measles cases last year in 2014 -- these are provisional reports to CDC through the end of the year. That number may change before final publication in the MMWR. We had 644 cases reported from twenty-seven states, and this included twenty-three outbreaks. We had sixty importations that we detected and a number that we missed because we had imported virus cases - cases where we could identify a genotype but no known link to an importation. So among those sixty importations, twenty-five were from the Philippines, nine were from India, and 91% of them were among U.S. residents. Almost all our cases were associated with known importations. We had quite a low rate of hospitalization last year and this was mainly due to a very large outbreak among the Amish population in Ohio where a smaller percentage of those cases were hospitalized.

So considering cases in U.S. residents where we can check vaccination status more carefully, 77% were unvaccinated. 15% didn’t know their vaccinate status and some - a minority were vaccinated. And among the unvaccinated, almost 80% were people that chose not to be vaccinated because of personal belief exemptions. 8% were too young to be vaccinated. So where did the measles importations come from? Well, all over the place as you can see here. I’ve already mentioned the Philippines. You can see the Western Pacific region really on fire with measles last year. They had this huge outbreak in the Philippines. China’s had a resurgence of measles. There was an outbreak in Vietnam and an outbreak that we assisted the Federated States of Micronesia with; but it came from Europe and other parts of the world, including India. So now to 2015 -- we’ve had a very large multistate outbreak that started in California on December 28 and as of last week, since the 28 of December, 125 people from seven states were reported to be part of this outbreak, linked to amusement parks in California. For the year as a whole, we’ve had 141 cases and these dates start on January 1. So in addition to the seven states that I mentioned before, we’ve had ten additional states and Washington D.C. that have had measles outbreaks this year. And most of these cases are part of that large multistate outbreak, but a number are not. We’ve had six importations from a variety of different countries this year.

Some other highlights - while the six importations are shown here - the six countries, most of the cases this year are unvaccinated or a significant number -- again in adults -- have unknown vaccination status. Cases this year – we have a lot of adult cases as well as children and we’ve identified three different means of genotypes this year -- B3, D8, and D9. Many of you may have also seen in the recent couple of weeks in the media this child care center outbreak in Illinois where there are nine confirmed measles cases in babies less than twelve months and one case in an adult. And that investigation is ongoing. This slide highlights the largest outbreaks that we’ve had since measles elimination was declared - the ones that have greater than twenty cases. And you can see that in recent years since 2013, really, we’ve had a real jump in some large outbreaks with fifty-eight cases and an outbreak in Brooklyn in 2013, 383 cases in the outbreak in Ohio last year, and this year to date 125 from the outbreak that started last year. Just to mention that it’s a huge amount of work for public health departments to do all the follow-up on these measles cases and contacts, and also vaccine and all the things that they have to do to trace every single person that’s been in contact with the measles case to try to shut down these outbreaks. And so that’s been documented in some publications that you see here.

So, now on to measles and MMR vaccines. We have live viral vaccines, as you know. The measles single vaccine was licensed in 1963 and our combination MMR vaccine was licensed in 1971. We don’t have monovalent vaccines available anymore and we also have a multivalent MMRV vaccine available since 2006. Measles vaccine has an excellent safety profile with fifty plus years of use. There is a low risk of febrile seizures in children. You can get temporary pain and stiffness in joints, particularly in teenage or adult women, and there’s a known association with temporary low platelet count that can occur. This is one of our most effective vaccines, and so this is why you almost always see measles in unvaccinated people. Measles finds the unvaccinated susceptibles in the population. One dose is about 93% effective in preventing measles and two doses is about 97%. So just to highlight, the routine recommendations for two doses in children and adolescents at twelve to fifteen months and four to six years, with catchup vaccination as needed. Adults without evidence of measles immunity need two doses if they are in the high risk group for exposure and transmission, which includes healthcare workers, post-high school students, and travelers; other adults need one dose. And then there are specific travel recommendations; so, anyone twelve months of age or older without evidence of immunity should receive two doses. So this includes providing an early second dose to children prior to four to six years and includes adults who have only received one routine dose in the past. Additionally -- and this is an important recommendation that many physicians and pediatricians are not fully aware of -- that children aged six to eleven months should receive one dose before they go abroad and then that dose is not considered a valid dose. They’ll need two other doses after twelve months. So just to highlight here that we have achieved and maintained reasonably high vaccine coverage among children at age two years or nineteen to thirty-five months, and among our teenage children with two doses. So 92% of our two year-olds are vaccinated with one dose and about the same percent of adolescents. The other side of that is that eight children out of 100 are not vaccinated on time with their first dose and are susceptible to measles. So that’s at the national level. At the state level and at lower levels, you do get more granular data that can highlight some clustering of people that choose not to vaccinate. And this is the paper published in 2012. The data are now three years old and so these rates have undoubtedly continued to climb, especially showing here that although exemption rates remain fairly low overall at 2% for the country excluding the two states that don’t allow any nonmedical exemptions, these rates varied. They were much higher in states that allowed philosophical exemptions and states that had only religious exemptions. And then four states that allow exemptions - the exemption rate is much higher in states that have an easy exemption policy that can mean just signing a form for the parent. That can be easier than going and getting the records, as opposed to states that have a difficult exemption policy where the rates were very similar, actually, to religious exemption only rates. And so there has been some interest, I think, among in-states in looking at their policies, especially the ease or difficulty of getting these exemptions. So if measles is - it’s very important to suspect measles and to diagnose it as quickly as possible because a rapid public health response can help prevent spread. We’re aware that many US healthcare providers have never seen a case of measles because of the success of our vaccination program. And because of that, they may not recognize a case and delay in diagnosis can really contribute transmission. So we urge providers to consider measles in the differential diagnosis of febrile rash illness. If you’re thinking Kawasaki’s, you should be thinking measles, especially if somebody’s traveled abroad or have been in contact with somebody that’s traveled abroad, or hasn’t - is unvaccinated. So Kawasaki’s, scarlet fever, Dengue -- if somebody comes back from overseas, think measles before you think Dengue because that’s much more common. Take a travel history. Take a history if they haven’t traveled of exposure to somebody who’s traveled or ask if there’s measles in the local community. And be especially suspicious in an unvaccinated person. That is not to say, though, that measles cannot occur in vaccinated people -- it can. So don’t discard the diagnosis if you’ve got what looks like measles in somebody who is vaccinated. Still do the testing, et cetera.

So how do you confirm a measles case? You use your clinical judgment according to the signs and symptoms that I mentioned earlier, but lab testing is available and is needed for confirmation. The serology testing for IgM - and then we highly encourage viral specimens as well to be tested for PCR and, as I mentioned, for genotyping. Acute and convalescent specimens for IgG may be useful, especially in vaccinated cases. So that first blood can be sent for IgM, can also be tested for IgG; and then if there’s any query about the diagnosis, convalescent sera can be obtained.

A reminder that suspected measles cases are considered a public health emergency and should be reported immediately to the local health department. The state health department needs to report a measles case to CDC within twenty-four hours. So it’s on the emergency list of reports to CDC that is put together by the Council for State and Territory Epidemiologists. The other thing a healthcare provider should do is to offer vaccine or immunoglobulin immediately to household members while they have them in the office. They should check their immunity and offer vaccine or immunoglobulin to those that don’t have acceptable evidence of immunity.

Now, acute measles cases that are severe -- that is those that are hospitalized -- should be treated with Vitamin A. We haven’t been highlighting this in the past, so I’m highlighting it today. This will be going up on the healthcare provider Web page. I don’t think it’s there now, but it should be there by tomorrow. If it’s not - and this is in line with WHO guidance that’s highlighted here at the bottom of the slide, and the AAP Red Book. The online version is available now -- the 2015 Red Book -- and that text will be updated to exactly match this text that - it’s always been in the Red Book, but they’re going to also add severe measles, hospitalized cases. And so, children get two doses of vitamin A on the day of admission and then on the next day -- twenty-four hours later. And the recommended dose is listed here according to age. Public health response, I mentioned previously. Cases must be isolated from - they won’t be seen until rash onset, typically. So they should be isolated until four days after rash onset. As I mentioned, these cases have to be immediately notified to CDC by phone. You have to contact the CDC quarantine station if there’s relevant travel. There’s a lot of contact tracing to be done on planes and at airports. States typically alert physicians statewide and ask for enhanced measles surveillance throughout the state to look for additional cases. And then the huge amount of work that the state health departments start immediately is contact investigation and response efforts. If your see measles in your clinic, in ER, or hospital setting – isolate that case immediately. The case should be put in an airborne isolation room; or if you’re in a hospital or in a private room with the door closed if you’re in a clinic. And you should mask the patient if that’s feasible. You should ensure that the healthcare person dealing with that case has evidence of immunity; and in hospital settings, respiratory precautions including N-95 masks or PAPRs are required even for those with evidence of immunity.

Contact investigations are done by the health department and those are everybody exposed during the cases’ infectious period, and that includes exposures in areas two hours after the case left. That’s a lot of work in hospitals and that’s very high priority. The health department has to get records of vaccination or evidence of immunity for all those contacts or draw blood to establish evidence of immunity if they can; or else just offer vaccine, which is often simpler. And then depending on that evidence, they may quarantine contacts who don’t have that evidence if those people choose not to be vaccinated or receive immunoglobulin, which are the two post-exposure prophylaxis options.

This table is in the ACIP recommendations - the Web link that’s shown here. I won’t go through it but it’s an excellent, very useful table that I highly recommend that you have taped to your wall to be able to check at any time who has evidence of immunity -- what things are acceptable evidence of immunity. And I would point out that history of disease is no longer considered evidence of immunity. It was but it was taken off the evidence table in 2013.

So MMR vaccine is - should be offered to exposed contacts without evidence of immunity within seventy-two hours of exposure. They may go back to normal activities except if they are in a healthcare setting, but they should still be monitored for symptoms. Babies six to eleven months can be vaccinated but be aware that there’s a possibility of vaccine rash. And then immunoglobulin can be given out to six days following exposure. The recommended dose is here, and please note that these doses are different from the doses that were in the 1998 ACIP recommendations. So make sure that if health departments are listening in that you have updated these recommendations on your Web site. Previously, the recommendation was for 0.25mL per kilogram for IgIM, and for 100mg per kilogram of IV. So these are higher and that’s because immunoglobulin now is mainly manufactured from people with vaccine-induced evidence of immunity and not diseased-induced. And so please take note of these changes. And so the recommended - these - immunoglobulin is recommended for people who can’t be vaccinated. So you can give it to infants less than twelve months. So six to eleven month olds can get either immunoglobulin or vaccine. Pregnant women should get this and they have to get IVIg -- it’s a large dose -- and also severely immunocompromised patients. So just to summarize, measles in the post-elimination era is due to failure to vaccinate. Measles elimination is a global problem. We should expect to see importations continuing despite tremendous advances in global measles control and elimination. There’s still a lot of measles around the world and a lot of people travel, and measles is just a plane ride away. So, measles occurs in the U.S. every year. We should expect it to occur in the U.S. every year. It’s eliminated but it’s not gone. Maintenance of elimination is a lot of work and effort. It takes smart, thoughtful healthcare providers to recognize a case. So we rely on you all and your offices to recognize these cases to think measles if you see a rash with fever in someone who’s traveled, to do your best to vaccinate all your patients and to be providing as much information as you can to parents who may have concerns about vaccination. And then offer - measles – maintaining elimination does need advanced laboratory techniques which we can offer here at CDC as well as at some state health departments. We have updated a lot of materials on our Web site. So we have updated outbreak and case information available - they’re updated weekly now at the Web site shown here with a map showing the measles cases that are linked to the California amusement park outbreak. We have updated resources for healthcare professionals shown at this Web site here. Updated - some more updated materials for healthcare providers -- a net conference, MedScape video, children with measles video for those of you that have never seen a case, more information and resources for healthcare providers, banners, fact sheets, information to use to have discussions with parents and patients about measles. So, some of those are just great tools for you to use. And then finally, resources for parents and caregivers -- we’ve got a great new infographic that you can see here. Measles isn’t just a little rash. We’ve got some other great materials that you can look at including materials in Spanish. I’d like to acknowledge a lot of people out there in the state and local health departments who are doing all the boots on the ground work and all the staff at CDC here that have helped.

Thank you and with that, I’ll take questions.

Loretta Jackson Brown:
Thank you, Dr. Seward, for providing our COCA audience with such a wealth of information. We do understand that some of today’s participants have experienced technical difficulty when attempting to access the audio portion of today’s webinar. Please note that the recorded webinar along with the transcript and an audio will be posted to the COCA call Web page for today’s call.

In addition, the PowerPoint slides are currently posted and the Web site is emergency.cdc.gov/coca. We will now open up the lines for the question and answer session. Joining us for the question and answer portion of today’s call are Sarah Foster and Allison Fisher with CDC. Operator, we are ready for the first question.

Coordinator:
If you would like to ask a question, please press star one form your touchtone phone. Please unmute your phone and record your first and last name as this information is needed to introduce your question. Once again, if you would like to ask a question, please press star one from your touchtone phone. If you wish to withdraw your question, please press star two. One moment for our first question.

Loretta Jackson Brown:
And while we’re waiting for the operator, we’ll go ahead and take a question through the webinar system. Dr. Seward, do you foresee that CDC will recommend that children six to eleven months in age in outbreak settings in the U.S. get vaccinated with one dose of MMR?

Dr. Jane Seward:
Yes. That’s an excellent question and CDC does recommend in specific outbreak settings where there’s ongoing community transmission affecting that age group with ongoing risk of exposure. So children - babies six to eleven months have to be measles cases in an ongoing way to make that recommendation, and so we have not seen epidemiology in the outbreaks this year that would indicate that that recommendation is needed. That recommendation is typically made at the local level where they understand the local epidemiology. So for example, the outbreak in the childcare center in Illinois -- that affected one childcare center. So it was very bad for those babies. All the babies who could have had Ig would have been given it, but I don’t think they knew in time to get that. But other babies exposed at emergency rooms, et cetera, were offered immunoglobulin. But there was no ongoing transmission in that age group, so even that was not a cause to recommend that early dose. So you really need ongoing large outbreak with ongoing transmission affecting that age group. And that recommendation is a recommendation in the ACIP guidance. And so physicians can look at that and health departments can look at that in the 2013 ACIP recommendations, and the wording that clarifies it’s not - we don’t - there are plusses and minuses to giving that early dose. You can affect the immune response to a later dose, so you don’t do it lightly.

Loretta Jackson Brown:
Thank you. Operator, do we have a question on the phone?

Coordinator:
Our first question is from (Allison). (Allison), your line is open.

(Allison Hagwood):
Hi, this is (Allison Hagwood) from the South Carolina State Health Department. What are the PPE recommendations for ambulatory provider that do not have access to the fitted N-95 mask? And are there any alternative options regarding PPE?

Dr. Jane Seward:
Well, if you don’t have access to N-95, the best thing you can do is just mask yourself and the patient if possible if the patient is able to tolerate a mask, and close the door. And avoid people coming in to the room who don’t have evidence of immunity or a mask on.

(Allison Hagwood):
Okay, thank you.

Coordinator:
Our next question is from (Diane). Your line is open.

(Diane Higgins):
Yes, hi there. This is (Diane Higgins) calling from a rural area in Western Nevada. Of the percentage of children in that recent Disneyland outbreak, what percent, roughly, had already been vaccinated against measles?

Dr. Jane Seward:
I don’t have the breakdown for the children. I have the breakdown overall for the multistate outbreak. So 13% of cases in that outbreak - 12% are vaccinated.

(Diane Higgins):
Okay. So only 12% had been vaccinated.

Dr. Jane Seward:
Yes, and that’s not a concerning number because most people in the population are vaccinated. So if you do the math of, say, 1,000 people in the population and maybe 900 of them are vaccinated and they may have a 3% failure rate and that’ll add up to twenty-seven people getting measles; and 100 people are unvaccinated and 90% of them will get measles if they’re exposed, you’re going to have ninety unvaccinated cases and twenty- seven vaccinated cases. So about a quarter of your cases, in that case, will be vaccinated. So it’s a function of high vaccine coverage and a low failure rate that gets us that proportion vaccinated.

(Diane Higgins):
Alright, and may I ask one more question? After placement of a purified protein derivative tuberculosis skin test, what’s the wait period for giving the MMR? Our public health - our county public health people have given us different answers. One said they can be given simultaneously, the other one says they have to wait for a week after they have the PPD to get their MMR vaccine. What’s the verdict on that, please?

Dr. Jane Seward:
I’ll have to get back with you on that. I don’t have that at the tip of my tongue. Well, hang on. Okay, wait a minute -- maybe I do. Okay. So it’s - MMR vaccine might interfere with the TB skin test and so if it is to be performed, it should be given either any time before -- so before the vaccine -- simultaneously with, or at least four to six weeks after MMR.

(Diane Higgins):
I get it. So they could - the PPD could be placed at ten in the morning with the MMR being given at two in the afternoon.

Dr. Jane Seward:
Yes.

(Diane Higgins):
Okay, alright. Well thank you so much for giving such an informative conference. We appreciate it.

Dr. Jane Seward:
Thank you for listening in.

(Diane Higgins):
Alright, bye-bye.

Coordinator:
(Mike), your line is now open.

(Mike):
Jane, can you comment on the utility and the - what types of serology you could use? Because this is obviously the alternative to immunizing people if in doubt.

Dr. Jane Seward:
Sorry, I don’t quite understand the question.

(Mike):
What specific serologic tests are readily available without long time delay? Because that’s the alternative to – when in doubt -- immunizing if you can.

Dr. Jane Seward:
Oh, if you don’t know evidence of immunity? So if you have people exposed to a case and you don’t have a vaccination record - so evidence of immunity can be age-appropriate vaccination. So if you’ve got a record, they’re fine. If you don’t have a record, then if they’re born before 1957 they’re fine. They’re considered to be immune, so you don’t need anything for them. And then others you can do a serological test if you are confident that you’ll get the result quickly and that that person will come back into your office for the results. And it’s just a commercially available IgG test. If there’s any question about whether the patient will come back, then it’s often easier - it might be more expensive to do a test and then have another office visit than just to give an extra MMR vaccine dose. It’s safe to give an extra dose and it may just be easier.

(Mike):
Comment - and it also has the advantage of providing a boost in immunity to mumps.

Dr. Jane Seward:
Absolutely. Good point.

Coordinator:
Our next question is from (Sarah). Your line is open.

(Sarah):
Yes, you kind of just answered this a little bit, but I just want to make sure because we were under the assumption that with this outbreak situation when you have a patient -- even somebody who is born before 1957, if they did not have evidence of immunity -- whether that would be the blood draw for that or having documented two doses because of the seventy year-old patient that was infected, we were still supposed to give them one booster. Is that not the case?

Dr. Jane Seward:
It’s only healthcare workers that we worry about that we do not accept evidence of birth before 1957 as evidence of immunity when exposed.

(Sarah):
Okay.

Dr. Jane Seward:
So very occasionally you’ll get a case in somebody who’s older, but it’s not very often. And in healthcare workers, we just don’t want to take any risk whatsoever.

(Sarah):
Okay. SO that’s the only case is the healthcare workers.

Dr. Jane Seward:
Mm-hmm.

(Sarah):
Okay, thank you.

Loretta Jackson-Brown:
Dr. Seaward, before we go onto the next question, can we stay on healthcare workers for a bit? We have quite a number of questions in the webinar related to that same particular topic. So some of the participants want to know a little bit more detail about what they need to do with their healthcare workers if they’ve already vaccinated them, they’re not showing signs of immunity, do they need to go ahead and give a third dose of MMWR? And also, that lack of documentation and if they have a negative rubeola titer with two documented MMWR’s, will that trump the titer? So they have some ongoing questions about what to do with healthcare workers and when they’re able to actually come back to work, and what’s considered immunized.

Dr. Jane Seward:
Right. Okay. So we do get this question quite a lot. Firstly, it’s very important to document your status of all your workers before you have a situation of exposure because it’s very difficult to go running around and find all the records -- especially if you don’t have electronic records -- once you have an exposure in a healthcare setting. So it saves you a lot of time and money to be well-prepared for that and have documented, easy to obtain -- either electronically or in any other fashion -- records. For healthcare personnel, documentation of vaccination is two doses of live measles virus containing vaccines or laboratory evidence of immunity and serological tests showing evidence of immunity in the past; or, rarely, lab confirmation of disease. That’s not common, but if a healthcare worker happened to have measles disease and had it confirmed by PCR two years ago, that would count.

And then birth before 1957, except in an outbreak setting. And so once you’ve got measles in your facility, if they have any of those things, the birth before 1957 doesn’t count anymore and so you’ve got to go and test people who were born before 1957. And that’s why we recommend being proactive and actually knowing the evidence of immunity for those people, whether they have serologic evidence or not so that you don’t have to do it during an outbreak.

Two doses trumps serology and so there’s no need to test after getting vaccinated. If you have any positive tests in the past, that counts for now. If you go and test now, you don’t need to test now; but if it’s negative, you actually can rely on the two doses in the past according to our formal recommendations. There’s no recommendation for an extra dose to people who are seronegative.

Loretta Jackson-Brown:
Thank you. Hopefully that helped to answer a lot of questions for today’s participants. Operator, do we have any more questions on the phone?

Coordinator:
We have several questions. (Liz), your line is open.

(Liz):
Yes, hi. Good afternoon. My question’s regarding an outpatient setting. If we have a patient that the physician suspects has measles, they collect a specimen and the patient is discharged home, what would be the instructions given to the patient? What type of isolation? How would we manage those patients at that point? What type of...

Dr. Jane Seward:
You should call your local health department. They’re the ones that will manage them form that point. So you tell your local health department before that patient leaves the office. You should call the health department and say I have a suspected measles case. I’ve drawn the blood. I’ve sent it to this lab. So they will work with you from that point on and they would - if it’s highly suspicious, especially if the person is unvaccinated and traveled abroad, the health department will consider that a measles case as far as starting contact tracing immediately. They won’t wait for the lab result. And so they’ll tell the patient...

(Liz):
Okay, so we don’t need to transfer the patient to the hospital at that point. They will give us further instructions.

Dr. Jane Seward:
Yes, you don’t need to put in the hospital unless they need to be put in the hospital for medical reasons. You hand - you’ll let the local health department know and they will work with you closely. They’ll take over the – telling the patient what to do as far as isolation and they’ll talk to the patient to track the contacts. And so the patient only needs to talk to you about their medical condition.

(Liz):
Okay, thank you.

Coordinator:
(Kimberly), your line is now open.

(Kimberly):
Yes. So in - I was just wondering. In a healthcare facility, if a measles patient were to present -- if there’s any – should be any consideration to the air circulation through the ventilation systems? Is that any risk to exposure?

Dr. Jane Seward:
Absolutely, so you need to talk to your engineers in the facility and they’ll tell you where that air - how widely that air might have circulated and any place that it has circulated in the last two hours is at risk for exposure.

(Kimberly):
Okay. So in the clinic setting that you had mentioned and you shut the door, you really should be evaluating also that air circulation.

Dr. Jane Seward:
Yes.

(Kimberly):
Where that might be. Thank you.

Dr. Jane Seward:
I was thinking clinic by outpatient - sort of private clinic for that. In a hospital, if it’s a clinic, yes, you should be talking to your - you would have an air isolation room, I would imagine, in that kind of setting.

(Kimberly):
Right. I was thinking if they come into the ER and that situation before we got them there.

Dr. Jane Seward:
Right. It’s a lot of work in a hospital. It’s a lot of work. The priorities for contact tracing is the - who’s the most likely to be truly exposed, right? Have a very high chance of being sick if they come into contact with a case, and it’s the people in the household and it’s the- you worry about people in healthcare settings because you’ve got children under one in doctor’s offices. You’ve got leukemic and cancer children in pediatric hospitals who can’t be vaccinated. And that’s the priority for contact tracing, those two groups right there.

(Kimberly):
We’ve had a lot of discussions, too, in our clinic setting, especially where there’s - for pediatrics and so on as well.

Dr. Jane Seward:
Right. Yes, it’s a lot of work. We have many anecdotal - anecdotes of children being infected in doctors’ offices.

(Kimberly):
Okay, thank you.

Loretta Jackson-Brown:
Dr. Seward, can you - while we’re on, again, hospital settings or healthcare settings, can you re-emphasize some of the points you made earlier in the slide to clarify? We’ve got questions about that in general. When do healthcare workers need to put on an N-95 or PAPR? When do we need to identify those healthcare workers who are immunized? That versus a hospital setting versus any other type of healthcare setting. There’s confusion about clinics, doctor offices, and what they need to do.

Dr. Jane Seward:
Well the recommendation is N-95 masks or PAPR. We realize that that’s unlikely to be available in a private doctor’s setting, but in any hospital where those are available they should be used the minute you suspect a measles case. So you may not suspect a case until you walk into the room, examine the case, and here’s a child sitting with a high fever, a maculopapular rash, cough, coryza, conjunctivitis, and they traveled to the Philippines two weeks ago. So you should go on high alert if you see that kind of patient. You should walk out of the room, get on an N-95 mask or a PAPR before you go back in, notify the person in the clinic or in the emergency room that you’ve got a suspected measles case. And so everybody who goes into the room should be appropriately protected and ideally, also, have evidence of immunity - be appropriately vaccinated, which they should be anyway. But in addition, it’s recommended because measles vaccine is not 100% effective. It’s very effective but not 100% and there’s - healthcare workers are at risk of exposing people who could get seriously ill with measles -- compromised patients. And that’s the reason we have such high standards of infection control in addition for healthcare workers.

In a private clinic, if you’re in a doctor’s office and you’ve got five exam rooms, if somebody walks into your waiting room, look - the nurse should be trying to triage people that look acutely sick and getting them into a waiting room and not having them sit in a general waiting room for very long but if somebody has a febrile rash they should be, again, taken out of the general waiting room as soon as possible and put in a room with the door closed and in a doctor’s office, do whatever you can. Put on a mask, get the patient out of the general waiting room and advise your patients especially unvaccinated patients. If you've got people that refuse vaccines, they should be told - if they travel and come back with a febrile rash, they need to call you. Not just show up. They should call you and warn you that they'll be coming in and you should try to see them at the beginning of the day or the end of the day, bring them in a different entrance and do whatever you can to minimize exposure to other people in your waiting room.

Loretta Jackson Brown
Thank you. Operator, do we have more questions on the phone?

Coordinator:
We do. (Shegar), your line is now open.

(Shegar):
Hi. What if someone was born before 1957 and wants to travel, do we need to give the vaccine to the patient or not?

Dr. Jane Seward:
No. You don't need to be vaccinated if you were born before 1957.

((Crosstalk))

Loretta Jackson Brown:
Dr. (Seaward), talk about that in a little bit more detail. You have about four questions on the webinar system and folks are still a little confused about why...

((Crosstalk))

Dr. Jane Seward:
Why that's here? Okay. So measles is a very highly infectious disease and so before the vaccine was used, most children got measles before they were 10. Many, many got it before they were five so there were hardly any adults who were susceptible and so the measles vaccine was licensed in 1963 but it didn't really start to get used to a great extent for a few more years than that and so, basically they went back to six years before the vaccine program started or about 10 years before the vaccine got used to any large extent and figured that anybody born before that had already had measles before the vaccine was used widely in the country and were already immune.

Later, theological studies verified that showing that more than 95% of those people were immune and so those people, we consider them immune, they don't need to be vaccinated. If they're a healthcare worker, we do have additional recommendations for - we say in our ACIP recommendations that unvaccinated personnel born before 1957 who lack lab evidence of immunity for measles, mumps or rubella, healthcare facilities should consider vaccinating people at the appropriate interval and that's because in an outbreak, you'll have to vaccinate them. So it may be easier to do it before an exposure occurs. You don't have to. That's why it says you should consider but in an outbreak, it's recommended and so if you weigh out is it easier to just hope you won't get exposed in your facility for those people or is it easier to have on record whether they've got lab evidence, theologic evidence of immunity.

Loretta Jackson Brown:
Thank you. Hopefully that helped a lot of our listeners today. Operator, do we have another question on the phone?

Coordinator:
(Cyndi), your line is now open.

(Cyndi):
Hi. My question is do you know what percent of the population needs to be immunized to have herd immunity when it comes to measles? We're trying to look at that in our community here in Waukesha, Wisconsin.

Dr. Jane Seward:
Yes. You need a population immunity level of 92 to 94% to interrupt transmission in the community and that requires 95% or more of all your children and adolescents at least having two doses of MMR vaccine. So you need very high coverage in the community to interrupt transmission. That needs to be in every community and so if you have - if you have a state coverage of 95% but in a local county or some schools it's much lower than that, those schools are not going to be protected if measles comes in there. The community - the herd can't protect them.

(Cyndi):
Thank you very much. That was just the answer we wanted.

Dr. Jane Seward:
Okay.

Coordinator:
(Ellen), your line is now open.

(Ellen):
Yes. I’m the state epidemiologist in Utah and one of the - we had one of these case - a couple of these cases and we're looking at our philosophical exemption rule and whether we should make it more difficult or actually get rid of philosophical exemptions and wondered if other states have tried to do that, what are the consequences of trying to do that are?

Dr. Jane Seward:
Well, we could put you in touch with some other states that have done that. I mean, California actually made an effort to tighten up their philosophical exemption and some other states are considering it right now and different ways that have done it. Things like requiring a notarized statement that you've read educational information, that you're informed about the seriousness of measles disease and the safety and effectiveness of MMR vaccine. Some states require watching a video and signing that you realize that you're putting other people at risk in the community. There are lots of different approaches that states have taken. So we'd be happy to put you in touch with some particular states if you'd like. If you could just send - yes. I know. I've got your email address. So I can - we can follow-up with you after the call.

(Ellen):
Thank you.

Coordinator:
Our next question is from (Michelle). Your line is open.

(Michelle):
Thank you. Should adults in their 30's who were vaccinated once with the MMR at 15 months of age receive a second dose of the MMR?

Dr. Jane Seward:
Not unless they're in a high risk group. So the high risk groups in adults are who have a greater risk of being exposed or having serious consequences if they become a case. Healthcare workers, students in post high school educational facilities and international travelers. Other adults just need one dose.

(Michelle):
Thank you very much. That exactly answers my question. Thank you.

Dr. Jane Seward:
You're welcome.

Coordinator:
(Gene), your line is open.

(Gene):
Hi. I was going to ask a question in regards to a quote from the CDC where it has people without evidence of immunity have been exempted from measles vaccination for medical, religious or other reasons and who did not receive appropriate PEP within the appropriate timeframe should be excluded from affected institutions in the outbreak area until 21 days after the onset of last and last case of measles. So having heard that, the recommendations, would that be if you just had one case of measles, you have a healthcare worker that's just in the building but we haven't confirmed their immune status, that they would have to be off work for 21 days or if we have confirmed their immune status and they've refused the vaccine because of medical or religious reasons, we would have to keep them off work for 21 days no matter where they work in the institution?

Dr. Jane Seward:
Yes. That's correct and if you want details, the ACIP recommendations for healthcare workers is online on the CDC ACIP website. It summarizes all those recommendations in quite a lot of detail.

(Gene):
And just to tag onto that, we have a paper record so we're going to be going through the process of prioritizing the areas to first go in and do titers if we don't have documentation or the vaccine status. Has there been anything written about any work restrictions or safe places to put these employees if you don't have their immune status? Do you go through this process? For example, to exclude them from patient care.

Dr. Jane Seward:
I mean, those decisions can be made at the local level. I mean, we defer to local state health departments and hospitals to make those tough decisions. I mean, we don't go into that level of detail. I think if people are excluded from patient care, that would seem a reasonable compromise if you're sure they are but we don't go into that level of detail I don't think in the healthcare worker recommendations.

(Gene):
Okay. Thank you very much.

Coordinator:
(Jeff), your line is now open.

(Jeff):
Okay. So this question is concerning just adults in the general population, not healthcare or other high risk persons. The summary of recommendations for adult immunization state that for adults born after 1957 that they should receive at least one dose of MMR if they have no laboratory evidence of immunity, but if a patient, an adult patient, states they've had measles, mumps and rubella but they don't have laboratory evidence, should they be vaccinated?

Dr. Jane Seward:
I'm sorry. I apologize. Why don't you finish?

(Jeff):
Okay. So it's an important question for health departments because they operate under standing orders and they have to interpret this and should they take that literally and say, well, if you don't have the laboratory evidence, you're indicated for a dose of MMR even though they have, in their minds at least, reliable history of all three diseases.

Dr. Jane Seward:
Reliable history of all three diseases no longer counts as evidence of immunity for us per the 2013 MMR vaccine recommendations, the table on Page 19 and those recommendations. That was removed from the evidence of immunity guidance because physicians don't remember what measles looks like now. Over the last 20, 30 years there's been so few cases and we don't necessarily trust. We've heard a lot of anecdotal stories about healthcare workers in particular saying, oh, I had it when I was a child and you just can't be wrong with healthcare workers. We need a very high level of evidence for immunity for healthcare workers and so, disease no longer counts as evidence of immunity.

(Jeff):
No. Okay. So, but...

Dr. Jane Seward:
That's for the general population neither.

(Jeff):
Okay. Great. Thank you.

Coordinator:
(Sue), your line is now open. (Sue), your line is now open. (Grace), your line is now open.

(Grace):
Good afternoon. We were wondering if in the vaccinated adults that you've seen in this most recent outbreak if their clinical presentation is attenuated at all or if it's a classical presentation.

Dr. Jane Seward:
Yes. That's a great question. I don't know the details in this particular outbreak but over the last decade, we have seen a vaccine modified measles in vaccinated persons. Not always but it can be modified and I think it could be missed if you're not in an outbreak setting. So it can be a much more transient rash, the rash may not last for three days which is part of the WHO case definition for measles, the fever may not be as high and they may not have all the three C's. So high index of suspicion for vaccinated people if they're exposed to a case.

Loretta Jackson Brown:
Thank you. On behalf of COCA, I would like to thank everyone for joining us today with a special thank you to (Dr. Seaward). We invite you to communicate to our presenter after the call. If you have questions for today's presenter, please email us at coca@cdc.gov. Put February 19 COCA Call in the subject line of your email and we will ensure that your question is forwarded for a response. Again, that email address is coca@cdc.gov.

The recording of this call and the transcript will be posted to the COCA website at emergency.cdc.gov/coca within the next week. There were no continued education credits for this call. Resources for clinicians related to measles are available on the COCA Call webpage. Go to emergency.cdc.gov/coca, click COCA Calls and then follow the link for today's call. To receive information on upcoming COCA Calls, you can subscribe to COCA by sending us an email at coca@cdc.gov and write subscribe in the subject line. Also, CDC launched a Facebook page for health partners. Like our page at facebook.com/cdchealthpartnersoutreach to receive COCA updates. Thank you again for being a part of today's COCA Call. Have a great day.

Coordinator:
Thank you for joining. This concludes the conference call. All parties may disconnect at this time.

END