5/2/2019
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Measles: Right Here, Right Now
Noelle Bessette, MPH
Surveillance Specialist
Vaccine Preventable Disease Program
New Jersey Department of Health
71
Measles Case Update
Measles Around the World• Measles Incidence Rate per Million (12 month period), WHO
• United States measles cases, 2019
• Largest # of cases reported in the US since measles was declared eliminated in 2000
• Current United States measles outbreaks
• Rockland County, NY • Michigan
• New York City • New Jersey
• Washington • California (Butte, LA, Sacramento)
• Georgia • Maryland
2018 Ocean County Measles Outbreak
• Case Count: 33
• 30 Ocean County residents
• 3 Passaic County residents (one household with direct epi-link to Ocean County)
• Onset date range: 10/17-11/30
• Age Distribution
• Age range: 6 months-59 years (mean=11.5 years)
• Distribution
• Under 1: 1
• 1-5: 9
• 5-18: 19
• 19-29: 3
• 30+: 1
• 52% female
• Vaccination rates
• 0 MMR: 79%
• 1 MMR: 3%
• 2 MMR: 15%
• Unknown vaccine status: 3%
2019 New Jersey Measles Cases
• Total confirmed cases: 14*
• 1 Bergen County resident w/ contact with a community outside NJ experiencing an ongoing
outbreak
• 1 Essex County resident w/ international travel from a country experiencing an ongoing outbreak
• 12 outbreak-associated cases
• 2019 Ocean County measles outbreak update
*As of 4/24
Measles Contact Investigations
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NJ Residents are being exposed to measles:
• On airplanes
• In other states
• Medical facilities
• Private events
• Hotels
• In other NJ jurisdictions
• Notified by phone, email, fax, CDC Epi-X Notification
Measles Flight Notifications
• NJDOH alerted of NJ residents exposed to measles on airplanes via CDC Epi-X message
• CDC has a protocol to identify passengers who may have been exposed to measles on a flight based on the disease, how it spreads, and where a passenger was seated in relation to the index patient
Red=index patient
Teal=contact zone
• For measles, passengers in the same row as the patient and two rows in front of and
behind patient are the only passengers considered “at risk”
• Exceptions:
• All travel companions of the index patient on the same flight
• All children younger than 2 anywhere on the plane
Contact Investigation: Exposed Individuals
• Make initial contact with exposed individual to inform him/her of exposure
• Educate contacts on signs & symptoms/ what to do if they become symptomatic
• Call ahead before seeking medical attention to alert them of exposure and symptoms so arrangements can be made to
prevent exposures at the facility
• Inquire if anyone accompanied individual to the facility where exposure occurred/ if there was a babe-in-arms on the flight
• Assess and obtain documented evidence of immunity for all exposed individuals
• Consider post-exposure prophylaxis (PEP) if applicable
• Vaccine (within 72 hours from 1st exposure) or Immune globulin (IG -within 6 days from 1st exposure)
• Quarantine contacts without presumptive evidence of immunity
• Starting day 5 from 1st exposure through 21 days after last exposure
• Consult with NJDOH before recommending quarantine
• Provide “Exposed to Measles?” document
• Follow up at the end of the incubation period
• Return CDC form to NJDOH (not CDC) if flight notification
Measles Investigation
Considerations and Challenges
Challenges With Exposure Notifications
• Patients may or may not have been notified by the exposure facility
• Incomplete or incorrect locating information (e.g. no phone number)
• Some options include searching town tax records, Google search, NJIIS search, sending email,
sending a certified letter, conducting a home visit
• Concerns about period of time between exposure and notification
• Difficulties in obtaining documentation of immunity
• NJ school, college, military, OB records if woman who has been pregnant previously, other
states’ immunization registries, titer
• Request for documentation from LHD re: exposure for workplace
• Individuals without proof of immunity unwilling to abide by quarantine recommendations
IgM + Electronically Entered into CDRSS
• First call should be to ordering MD
• Inquire about symptoms
• Inquire why test was ordered
• If asymptomatic and test was ordered just to check immunity, case can be closed as “Not a Case” an MD should be educated on not ordering IgM unless suspecting disease (IgG should be specified)
• If symptomatic, investigate as suspect case
• Use Measles One Pager as an outline
• Request appropriate testing, etc.
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Investigation Tips
• How to handle calls from non-healthcare providers re: “cases” and exposures
• Inquire about all symptoms/ symptom progression to help determine likelihood of measles
• Inquire about travel/ known exposure/ risk factors/ vaccination status
• Ask for picture of the rash (no face, no genitals)
• Work on timeline early
Timeline
• Timeline should be compiled over course of investigation before the lab result comes back for highly suspect cases of measles
• Often this is the step that holds up public health response and public notification
• Compile list of all places suspect case visited during infectious period (4 days before rash onset through 4 days after rash onset- total of 9 days)
• Patient should begin compiling timeline upon first LHD contact
• Will need minute-by-minute breakdown of the 9 days
• Important details to request: time arrived, time left, name of location, address, transportation
method to/from
Specimen Collection
• NP swab, urine, and blood should be collected on all suspect measles cases
• Viral specimens (NP swab and urine) can only be tested at CDC/CDC Reference Laboratory
• NJDOH approval is needed to send viral specimens to CDC for testing
• If specimen is approved for testing, many options for sending specimens
• FedEx, if available
• State courier
• Scheduled courier pickup sites
• Private courier
• LHDs to help medical facilities coordinate specimen transport
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New Resources Available
https://nj.gov/health/cd/documents/topics/measles/measles_travel_flyer.pdf https://nj.gov/health/cd/documents/topics/measles/measles_ob_guide.pdf
Resources Available
• NJDOH website: https://www.state.nj.us/health/cd/topics/measles.shtml
• “Exposed to Measles?” document: https://www.state.nj.us/health/cd/documents/topics/measles/measles_exposure_guidance_public.pdf
• CDC website: https://www.cdc.gov/measles/index.html
• CDC measles cases & outbreaks page: https://www.cdc.gov/measles/cases-outbreaks.html
Thank You!
Noelle Bessette
(609) 826-5964
LOCAL LENS
Neisseria meningitis serogroup B Rutgers University – New Brunswick
2019
Eric Adler, MPH Regional Epidemiologist NJDOH
Sherie Wolpert, MPH Epidemiologist Middlesex County Office of Health Services
Outline
• Meningococcal disease
• Overview
• Serogroup B
• Outbreaks
• University-based outbreaks of meningococcal
disease caused by serogroup B
• Middlesex County Office of Health Services
• Situation update
• Recommendations
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Meningococcal Disease
• Presentations
• Meningitis
• Bacteremia
• 10-15% case-fatality ration
• 11-19% permanent sequelae
Neisseria meningitis
• Bacteria
• 12 serogroups
• A, B, C, W, X, and Y primarily cause disease worldwide
• B, C, W, an Y cause most disease in United States
Meningococcal Transmission
• Humans are the only reservoir
• Asymptomatic nasopharyngeal carriage
• >5-10% of population are asymptomatic carriers
• Adolescents and adults have highest rates of carriage
• Carriage is an immunizing process that results in a systemic, serougroup-specific protective
antibody response
• Spread through close contact
• Respiratory or oral secretions
• Patients or asymptomatic carriers
Risk Factors for Meningococcal Disease
• Medical conditions
• Functional or anatomic asplenia
• Persistent complement component deficiency
• Treatment with Soliris (eculizumab)
• Recent viral respiratory infection
• Smoking
• Among college students
• Living in dormitories (freshmen in dormitories have 3-23X increase in risk)1
• Social mixing (Greek life membership, attend bars)1
Serogroup B Meningococcal Disease
• Meningococcal conjugate vaccine (MenACWY) does not protect against serogroup B
• Most common cause of meningococcal disease in persons aged 16 to 21 years
• Recent cause of university based clusters/outbreaks
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Meningococcal Disease Outbreaks
• <5% of meningococcal disease cases in the U.S.
• Case-patients share common affiliation or area of residence but not
direct close contact
• Transmission within population via asymptomatic carriage
• Most outbreak cases in U.S. occur in persons <25 years of age1
• CDC recently updated outbreak definitions and guidelines available at
https://www.cdc.gov/vaccines/vpd/mening/index.html
• 10 university-based outbreaks occurred in 7 states during 2013-2018
• January 2013 – May 2018
• Total of 39 cases and 2 deaths
Case Characteristics
• Median patient age – 19 years
• 62% male
• 36 (92%) were undergraduate at 4-year university; 3 in close contact of undergrads
• 2-9 cases per outbreak (median 3 cases)
• Attack rate 10-34 cases/100,000 (median 35/100,000 (compared to baseline .11 cases/100,000 in 2017)
Response
• Chemoprophylaxis provided to all close contacts
• MenB vaccines were used in response to all 10 outbreaks
• 2 outbreaks (NJ and CA) before vaccine licensed
• 8 outbreaks following vaccine licensure
• 6 implemented after 2 cases
– 4 had no further cases; 2 had 1 additional case (one 6 days post vaccine)
1 after 3 cases
- 2 additional cases
1 after 4 cases
- 3 additional cases
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Current College Outbreaks
• Columbia University’s School of International and Public Affairs
• 2 cases
• San Diego State University
• 3 cases
• Five College Consortium
• Amherst College
• Hampshire College
• Mount Holyoke College
• Smith College
• UMass Amherst
Rutgers University – New BrunswickCase Description
• Case 1
• Undergraduate – 3rd year
• 1 dose Trumenba 2017
• Off-campus housing
• Member of Greek life
• Case 2
• Undergraduate – 2nd year
• No MenB vaccine
• On-campus housing
• Involvement with Greek life
• Following each case, close contacts were identified and recommended to receive antimicrobial prophylaxis
Neisseria meningitis serogroup B:Local Investigation
Two cases in February
• 1st case: onset Feb 3rd, HD notified Feb 5th
• Home address Union County, school address
Middlesex County
• Hospitalized Union County
• 2nd case: onset Feb 19, HD notified Feb 23rd
• Home address Monmouth County, school address
Middlesex County
• Hospitalized Monmouth County
Where do we start?
First Steps
• Receive call
• Make notifications
• Gather information (as much as you can)
• Begin investigation
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First RU CASE, Early Feb
• Who is primary investigator?
• Must get patient history for past 10 days.
• Identify close contacts back to 1/27
• PROBLEMS:
• Patients unable to speak due to illness.
Investigation
• Patient had many close contacts at RU. (Greek life )
• Patient traveled, by car, with 3 other friends to another
State for Superbowl party. That State was cooperative in
follow up for those exposed people.
• Patient well enough to be discharged after 3 days in
hospital.
• Result: serogroup B
Second RU Case, late Feb.
• Who is primary investigator?
• Must get patient history for past 10 days. (this patient was
unresponsive for first 2 days)
• How do you get information when patient can’t talk to you?
Investigation
• Mother and brother given prophylaxis
• Frequents Greek life events
• Attended parties, doesn’t remember which ones
• Discharged from hospital on 3/4/19
• Serogroup B
Prophylaxis and Vaccine
• After contacts were identified by HD and RU, all contacts were offered
prophylaxis.
• RU students were strongly recommended to receive Meningitis B
vaccine.
• No obvious link between cases.
THANK YOU
Board of Chosen Freeholders
Ronald G. Rios, Director
Charles E. Tomaro, Deputy Director
Kenneth Armwood, Charles Kenny, Leslie Koppel,
Shanti Narra, Blanquita B. Valenti
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