California Statewide Measles Call Feb 3, 2015. Measles Case Counts by Jurisdiction since December...
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California Statewide Measles Call Feb 3, 2015
Transcript of California Statewide Measles Call Feb 3, 2015. Measles Case Counts by Jurisdiction since December...
California StatewideMeasles Call
Feb 3, 2015
Measles Case Counts by Jurisdiction since December 2014
Total number of confirmed cases
CALIFORNIA 92ALAMEDA 6LOS ANGELES 16
City of Long Beach* 2City of Pasadena* 3
MARIN 2ORANGE 28RIVERSIDE 5SAN BERNARDINO 6SAN DIEGO 13SAN MATEO 2SANTA CLARA 2VENTURA 7*City health jurisdictions not included in county total
Vaccination Status Among Measles Cases with Vaccine Documentation (n=53)
Total* PercentUnvaccinated 41 77%
Vaccinated1 dose 4 8%2 doses 7 13%3 doses 1 2%
*15 cases self report vaccination; 24 have unknown status
Total* PercentMissed dose 1 3%PBE 26 74%Too Young 8 23%
*6 unvaccinated for unknown reasons
Age distribution of Confirmed Measles Cases
Age (years) Total* Percent<1 6 7%1-4 11 12%5-19 18 20%>20 56 62%
*1 case has missing age data
Measles Outbreak Epi Curve
• 39 cases primary Disney• 1 case who reports visiting Disney outside of initial time
period
Transmission setting N %
Disney primary case - Visited Disney from December 17th - December 20th
39 43
Household or close contact of a confirmed case
20 22
Community setting where confirmed case was known to be present*
3 3
Unknown 29 32
*All 3 transmission events occurred in an ED setting. Two of the three cases are linked to the same source patient, same ED incident.
Is Disneyland Still a Risk?
• Epidemiology of measles in Orange County, Matt Zahn, Orange County Public Health
Testing Recommendations
1. Test: Suspect cases with classic measles symptoms, regardless of vaccination history (or prior IgG seropositivity)• Cough, coryza, conjunctivitis• Descending rash that starts on face/head (if
no rash on face/head/neck or if rash starts on trunk – measles not likely)
2. Test: Contacts of measles cases who have fever and rash of varying severity regardless of vaccine history (or prior IgG seropositivity)
Testing Recommendations, cont.
3. At your discretion: Suspect cases who do not meet the clinical case definition (fever <101, or not all Cs) and have no known exposure (but have 2 MMRs or prior seropositivity). This may depend on:
• Epidemiology of measles in your community – are there many cases with an unknown source?
• Whether the suspect case potentially exposed others in sensitive settings (healthcare facility, childcare facility with infants), e.g., did the suspect visit an NICU while potentially infectious?
• International travel, international travelers
Testing Recommendations, cont.
• Other considerations
o Itchy rash? May be itchy from day 4-7, but not itchy immediately
o Rash on palms and soles? Measles rashes may be on palms and soles but not as prominent as on face and chest
o What is the rash distribution and spread look like? Even if disease is modified the order of appearance (face and head) and direction of spread is the same
o Timing of fever and rash
Measles Testing Guidance For Patients With Rash And No Epi Link And Intact Immune System
• Testing Algorithm developed by Alameda County
Maculopapular erythematous rash?
Fever ≥ 101 °F
Do Not Test
Got Measles Vaccine in 1963 to 1967 in US
Do Not Test
Test
Facial Involvement
Fever ≥ 101 °F
Monitor for 4 days from rash onset
Fever ≥ 101 °F
Do Not Test
Test
Test
Got Measles Vaccine in 1963 to 1967 in US
Fever ≥ 101 °F
Test
Do Not Test
Do Not Test
What do two dose cases look like?1. Fever to 101, no cough, conjunctivitis, but did report coryza. Rash
started on face and went to chest and part of arms. Did not descend to extremities. Case had traveled to China, had no known exposure
2. Reported subjective fever, cough, conjunctivitis, no coryza. Rash started on face and progressed to chest, arms then stomach; rash duration was 4 days. Case was exposed to measles in an urgent care waiting room
3. Fever to 101, no cough, no coryza, no conjunctivitis. Rash started on face and descended to body, arms, legs. Rash duration was 3 days. Exposed to measles by household contact.
4. Subjective fever, conjunctivitis, no cough, no coryza. Rash spread from head and descended, rash duration unknown. Exposed to measles by a CA measles case on a flight
Specimen Collection
• Throat swab (preferred over NP, but NP also acceptable) – Collect within 7 days of rash onset
• Urine – Collect within 10 days of rash onset; virus levels are generally lower, but is thought to be a better late PCR specimen
• PCR sensitivity likely varies over time and by vaccination status for best sensitivity collect both throat swab and urine within 7 days of rash onset VRDL and CDC validation studies yielded 100% sensitivity but
this is based on a small number of specimens
• Blood – Does not need to be collected for every suspect case; collect for measles testing when a case is identified late, and the timing of specimen collection is not appropriate for PCR testing
1. Email: [email protected]
• Patient Name• Rash onset date• Priority status (how urgent is testing?)• Have specimens been collected and when will
the specimens be shipped• Courier and tracking information
2. Complete the specimen submittal form and enclose in the package with the specimens
Notify CDPH When Specimens are Submitted to VRDL
3. Work with the local PHL to package specimens each in their own plastic bag with an absorbent pad when shipped
4. Weekend deliveries can be a challenge
Alert VRDL when specimens are to be arrived on a weekend
510-307-8585 After hours Dr. Xia or David Cottam Alert GSO that CDPH can accept Saturday
deliveries
Notify CDPH When Specimens are Submitted to VRDL, cont.
Specimen testing
• Specimens are tested within one day of arrival
• Results will be reported back to the submitter (usually the PHL)
• CDPH epi also receives official results
Will call LHJ or send high priority email with positive results
Email with negative result
Weekend Measles Testing at VRDL
• Weekend testing at VRDL is considered on a case by case basis depending on the importance of testing results for public health actions
• Jurisdictions with measles PCR testing capability - please let Jennifer Zipprich and Kathy Harriman know:
if weekend testing is being performed if lab is willing to perform testing for other
jurisdictions, and if so, what is the weekend lab contact information?
Vaccine Reactions
• Rash that occurs days 5-12 post vaccination with MMR
• Patients can have symptoms comparable to those associated with wild type measles
• PCR on the patient’s urine and throat swab will likely be positive for measles
• Additional testing (genotyping) is needed to discriminate between vaccine strain and wild type strain Vaccine strain is genotype A Additional testing takes several days
• In some cases the level of virus is too low to successfully genotype
Vaccine Reactions, cont.
• No known transmission from a vaccine recipient experiencing rash, no reason to isolate the patient Different approach may be recommended if patient is
immunocompromised
• The dilemma is that some cases are clinically indistinguishable from wild type disease and will be PCR and IgM positive so only genotyping will provide a definitive answer (assuming it is successful)
• Approach to case differs depending on current situation - in an outbreak setting, the conservative approach is to start the investigation prior to receipt of laboratory results
• The epidemiology of measles in the case’s community should also be a consideration
CalREDIE
• Confirmed cases are reported officially to CDC through NETSS
• CDPH will enter basic information on all confirmed cases into CalREDIE
Percentage of measles IgG-antibody seropositivity in 6 birth cohorts, according to the National Health and Nutrition
Examination Survey conducted during 1999–2004
McQuillan G M et al. J Infect Dis. 2007;196:1459-1464© 2007 by the Infectious Diseases Society of America
Current age: 57-65 48-57 38-47 28-37 18-27 16-17
ACIP MMR Recommendations
• 2 doses for Children 1-18 years: Additional dose for infants 6-12 months prior to
international travel
• 2 doses for adults born after 1956 (=19-58 years of age) who: Work in a healthcare facility (also: if born before
1957 and no evidence of immunity) or Plan to travel internationally or Are postsecondary students or Who received inactivated (killed) measles
vaccine or measles vaccine of unknown type during 1963–1967
• 1 dose for other adults born after 1956
MMR Vaccine Supply at Local Health Jurisdictions
• LHJs receive publicly funded MMR doses from 2 funding sources:
Vaccines for Children (VFC-funded) MMR • Doses can only be used on VFC-eligible children
317-funded MMR• Doses can only be used on uninsured and under-
insured adults• During an outbreak situation, CDPH may
approve the use of 317 doses in children and adults, regardless of insurance status.
Temporary Authorization for Use of 317-funded MMR
• In response of the current outbreak of measles in the state, and in accordance with CDPH’s Vaccine Eligibility Guidelines, the Immunization Branch will temporarily authorize the use of Section 317 funded MMR doses in children and adults, regardless of insurance status, for the purposes of outbreak control and prevention efforts.
Temporary Authorization for Use of 317-funded MMR
• LHJs may use existing 317 MMR supply or order additional doses for outbreak control and prevention efforts:
• Post-exposure prophylaxis • LHJs with increased MMR vaccine demand at
local health department clinics form residents (even if not a susceptible exposed case)
• a jurisdiction may receive CDPH approval to transfer doses out to an organization dealing with direct outbreak response and control of susceptible cases.
317-Vaccine Transfers to Outside Providers
• In the event that approved doses are distributed to an outside provider, the local health jurisdiction is responsible for ensuring:
the overall vaccine management of distributed doses;
documentation of vaccine usage; reporting of administered doses; and inventory return/retrieval at the at the
conclusion of the response effort
• A “Provider Agreement for 317 Vaccine Use during Outbreak Response” and “317 Outbreak Response Vaccine Usage Log” must be completed by the outside provider and submitted to the local health jurisdiction.
Process for Requesting Vaccine Doses• Local health jurisdictions
complete a “LHD Request for 317 Vaccine Use during Outbreak Response” form and submit to your Sr. Immunization Branch Field Representative.
• Upon approval-317 order should be submitted through MYVFCVaccines.
• Urgent orders
must be submitted by 2pm Orders arrive within 1-2 days Priority for urgent orders- PEP
Documentation of Outbreak Response Doses
• Doses approved for use in this outbreak response effort must be documented and reported back to CDPH upon the conclusion of the response effort
• A summary report is currently being drafted
Number of doses approved Summary of doses administered Doses remaining after response efforts If dosses were distributed outside LHJs-outside provider
must submit administration log to health department• Documenting doses in CAIR or IIS
Developing guidance for documenting usage within CAIR instead of a manual log
MMR Vaccine Supply
• There are no current delays or vaccine supply issues with Merck’s MMR II vaccine.
Discussion: Daycare exposure
Measles exposure in a daycare setting with infants and toddlers
Administer PEP to infants and unvaccinated kids < 66 lbs and exclude through day 21?
Test one dose recipients for IgG and if negative exclude from setting?
Administer PEP to infants and unvaccinated kids < 66 lbs and allow to continue attending?
Questions/Contacts
Kathy [email protected]
Jennifer [email protected]
Immunization Branch Main Number510-620-3737
