Call Transcript: Record High US Measles Cases: Patient Vaccination, Clinical Assessment and Management

Coordinator:
Welcome everyone and thank you for standing by. At this time all participant lines are in listen-only mode. Following today's presentation, we will provide an opportunity for a question and answer session; at that time press star 1 on your phone to ask a question. I would also like to remind all participants that the call is being recorded. If you have any objections you may disconnect. Now I'll turn the call over to our host for today, Miss Leticia Davila. Miss Davila, you may begin.

Leticia Davila:
Thank you, Sylvia. Good afternoon. I am Leticia Davila and I am representing the Clinician Outreach and Communication Activity, COCA, with the Healthcare Preparedness Activity at the Centers for Disease Control and Prevention.

I am delighted to welcome you to today's COCA Webinar, Record High US Measles Cases: Patient Vaccination, Clinical Assessment and Management.

We are pleased to have with us today Dr. Seward from CDC. She will discuss the status of measles in the US and CDC vaccination recommendations and guidelines for patient assessment and management.

You may participate in today's presentation by audio only, via Webinar, or you may download the slides if you are unable to access the Webinar. The PowerPoint slide set and the Webinar link can be found on our COCA Website at emergency.cdc.gov/coca. Click on COCA Calls. The Webinar link and slide set are located under the call-in number and call passcode.

At the conclusion of today's session the participant will be able to: discuss the current status of measles outbreaks in the United States; describe the clinical presentation of measles and the guidelines for patient assessment and management; outline CDC vaccination recommendations for the general public, international travelers and healthcare professionals; and identify CDC measles resources and training materials for clinicians.

In compliance with continuing education requirements, CDC, our planners, presenters and their spouses or partners wish to disclose that they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. Planners have reviewed the content to ensure there is no bias.

The presentation will not include any discussion of the unlabeled use of a product or a product under investigational use. CDC does not accept commercial support.

At the end of the presentation, you will have the opportunity to ask the presenter questions. On the phone dialing star 1 will put you in the queue for questions. You may submit questions through the Webinar system at any time during the presentation by selecting the Q&A tab at the top of the Webinar screen and typing in your question.

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 diseases at Tulane University and obtained her Master’s degree in public health in 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 she has worked at CDC in the fields of immunization. She is an internationally recognized expert in vaccine preventable diseases including measles, mumps, rubella, varicella and herpes zoster.

Again, the PowerPoint slide set and the webinar link are available from our COCA Webpage at emergency.cdc.gov/COCA. At this time, please welcome Dr. Seward.

Jane Seward:
Thank you very much. I'm delighted to be here this afternoon to update you on the record high measles cases reported to the Centers for Disease Control and Prevention this year and also patient vaccination, how to clinically assess and manage measles cases.

So let's start by discussing what is measles. Measles is a febrile rash illness caused by the measles virus. It's a very, very contagious infectious disease; one of the most contagious of all. It's preventable with a highly effective vaccine that's recommended in the routine immunization schedules for both children and adults.

Measles is transmitted via respiratory droplets and aerosol so that makes it very highly contagious. It's spread by coughing and sneezing, by close personal contact or direct contact with infected nasal or throat secretions.

Measles is contagious from 4 days before to 4 days after the rash onset. This makes recognition of measles cases very, very important because they can transmit before a rash onset.

And measles cases - being highly contagious, have a secondary attack rates in susceptible household contacts of about 90% and an R0 of 12-16. This means that if somebody with measles is exposed to a lot of susceptible people with measles, on average there'll be 12-16 cases for every measles case that occurs.

Measles presents clinically first with the prodrome. This precedes the rash. So typically, the first clinical presentation is a fever that can be very high, up to as high as 105-106 degrees. One or three of the Cs, typically cough, coryza and conjunctivitis. Coryza is runny nose and conjunctivitis is pink eye. These are very typical clinical presentations of measles in the prodrome.

And then an enanthem, which means a rash on the mucous membranes, as opposed to an exanthem which is a rash on the skin. The enanthem shows up as white spots on mucous membranes inside the mouth or also called Koplik spots. And those are visible before the rash is noticed on the skin.

The rash occurs typically about 2 weeks after exposure, but it can occur as soon as 7 days or as long as 21 days following exposure.

The measles rash looks like this. It's erythematous maculopapular rash. It starts on the face and spreads from the head and trunk, down to the trunk, and then to the extremities. It may become confluent if the rash is severe. It lasts for about 5 or 6 days and then it fades in order of appearance.

I was hoping here to be also - also be able to show a video of a child with measles, but wasn't able to do that. But look for the link to the video at the end of this presentation. It's very dramatic being able to see a child coughing with measles and see the runny - the coryza and conjunctivitis.

Measles complications are more common in children less than 5 years old and in adults. And, they include the conditions listed here. Of these, otitis is more common of course in children than adults, but adults can certainly get diarrhea, pneumonia and anyone with measles can get encephalitis, about 1 per 1000 cases.

And even now in the United States in the last 10 or 15 years, 1-3 people will die for every 1,000 measles cases that we have. So even with the best available medical treatment measles can still result in death. There were a number of deaths from measles in France a couple of years ago when they had a large outbreak.

And then, a rare late-developing, very serious complication of measles is subacute sclerosing panencephalitis that can occur 7-10 years after the measles case.

Globally, measles is still quite common. There's been tremendous advances and achievements in global measles control. Before widespread use of the measles vaccine throughout the world there were an estimated two and a half million deaths in 1980.

And since 2000, there's been almost an 80% decline in estimated deaths due to enhanced implementation of global measles strategies. But still, there were an estimated 122,000 deaths in 2012. That's 14 deaths every hour. Measles remains a leading cause of vaccine-preventable deaths in children under 5.

Other serious complications occur with measles which can include things like involvement of the eyes and blindness. So throughout the world there are still estimated 20 million cases of measles a year. There's been a big decrease in measles incidents over the last decade.

But the point of showing you these numbers is to say that there's lots of opportunities for travelers coming into the US to get - to have been exposed abroad and to bring measles back into the US.

So this slide shows measles case distribution by month and WHO region over the last 6 years. There are - the WHO regions is shown here on the top of the slide with the African region, the Southeast Asian region, etcetera. And these are different colors depending on the region.

You'll see that the European region, which is colored red, there were a lot of cases in the European region in 2011 - 2010, '11, '12 there was a big outbreak in Europe and we benefited in a way that we wouldn't like to see with a lot of importations coming in from that country.

And then recently you'll see that the WPR region, which is mainly the Philippines, has had a lot of measles cases. And this has affected our measles importations into the US this year.

And so, just in 2014 there's been a huge outbreak of measles in the Philippines and it's not only the US that suffered importations. Importations have gone into Australia, New Zealand, to Japan, many parts of the United States and Europe.

So let's go back to the measles annual disease burden that occurred in the United States before we had a vaccine to prevent measles. Measles being very contagious, affected essentially everybody in the community. So there were 3-4 million estimated cases every year. Of those 500,000 were reported to CDC annually.

The number went up and down depending; maybe 1 million in one year and 200,000 the next but on average about 500,000 reported cases a year. Those resulted in almost 50,000 hospitalizations, 4,000 encephalitis cases and 450-500 deaths on average every single year.

This is why a vaccine was developed to prevent measles and so the measles vaccine was developed and licensed first in the United States in 1963 and the combination, measles, mumps, rubella vaccine was licensed in 1971.

This is the only measles vaccine that's available now in the United States. So to protect against measles, mumps and rubella there's just the one combination product available now.

These vaccines have had an excellent safety profile. We've been using them for more than 50 years and so we've had a lot of experience with their use. There is a very low risk of febrile seizures in children 12-23 months of age when they receive the first dose of MMR vaccine. A febrile seizure will occur about 1 in 3,000 doses.

There can be temporary pain and stiffness in the joints, mostly in teenage or adult women from the rubella component. And then a temporary low platelet count, or ITP, occurring about 1 out of 30,000 doses.

The measles vaccine is very highly effective. It's one of the most effective of our vaccines. One dose is about on average 93% effective in preventing measles and two doses on the range of 97% effective. So it's a very, very good vaccine.

This slide shows measles cases in the United States from time the vaccine was licensed in 1963 on up to 2014. And, you can see that following licensure and recommendations measles reported cases plummeted down to much lower levels, between 50,000 and 100,000. There were a few little blips in 1970s with some outbreaks and then a resurgence in the United States from 1989 to '91.

But then following that there was implementation of the Vaccines For Children program which helped address gaps in cost and access to vaccines for children. And then in 2000 measles elimination was declared. I'll talk a little bit more about what that means in a couple of slides.

So this just shows from 1992 following the resurgence up through 2014 measles elimination, as I said, was declared in 2000. We have maintained measles reported incidence of around 1 case per million since 1997 but you'll see that in 2014 we're jumping above that level already.

So measles elimination, what that means was that in 2000 we declared that we had interrupted, as a country, ongoing year around endemic disease transmission of measles. The measles virus no longer circulated year around as an endemic disease in the country. We interrupted that transmission.

And so the only way now that measles can come into the United States is from overseas. Elimination doesn't mean that the disease is gone forever; it can occur here and it does occur here every year because of imported cases and limited spread that occur from these cases.

We achieved measles elimination because of high two-dose vaccine coverage, high-quality measles surveillance and response as well as improved measles control in the WHO region of the Americas that really reduced the number of cases of measles coming in here from those countries.

So following elimination in the immediate post-elimination era, and this pattern is still the case now, who is at the greatest risk of acquiring measles? And you'll see that it's the populations that you would consider the most susceptible which are children, infants 6-11 months. Babies less than 6 months have some protection from maternal antibodies. Children 6-11 months those antibodies are declining.

And then children 12-15 months that's the age that measles vaccine is recommended but they may not get the vaccine exactly at 12 months of age and so they're susceptible until they get that first dose.

You can see from these aggregated numbers from 2001-2008 that of the cases 6-11 months and 12-15 months 1/3 of the children 6-11 months and almost half the 12-15 month olds were unvaccinated and they traveled abroad.

So all these children and infants actually should have had at least one dose before they traveled and for the children 12 months or 13 months and older they should have had two doses. So these cases were directly preventable despite the fact that children 6-11 months old are usually not recommended a dose.

And we'll go over recommendations in more details later including the special recommendations for travel.

This slide shows measles cases in the United States from - reported from 2001 to the present time. Since 2001, we have separately counted importations and they're indicated here by the red bar. And you can see then on average we've had - we had about 20-50 importations in the US every year. So as I said before measles elimination doesn't mean it's gone; we have measles cases coming in all the time from overseas testing our population immunity.

And you can see that those cases spread, the yellow part of the bar means the cases that were acquired here. And so on average most of our importations in fact don't spread but the ones that do can result in some outbreaks. And you'll see that in 2008 there wasn't an increase number of importations but there was an increase in measles cases and that was because of spread and a few large outbreaks that occurred that year.

In 2011, we had 80 separate importations. That's more than the number of measles cases reported in many years in the preceding decade. And those cases, you know, on average had about 1 case for every importation. But you'll see in 2014 we've had 48 importations to date but a huge number of reported measles cases. And that's due to some - a lot of outbreaks and one particularly large outbreak that is occurring in Ohio and is ongoing.

This slide just shows where, again, where the importations come from in a little bit more detail for you to see showing that in 2011 that year we had a huge number of importations, almost half of them were from the European region.

So when patients are going overseas they may not think when they're going to Paris or London or Rome that they need to take note of measles vaccine recommendations for travel, but they do. In fact, those are the places you're very likely to get measles. In 2014, as I said before, most of the cases are coming from the WPR region due to the very large outbreak in the Philippines.

Now most of these importations are not from travelers coming in from those countries visiting the US, about 80% of them are US residents who travel abroad and then come back and bring measles back into the United States.

So here we have just a graphical representation of reported measles cases by month showing, again, the very unusual pattern and high number of cases early in the year in 2014 reflecting the cases from the Philippines.

The Philippines and the Southern Hemisphere, the measles season is over the, you know, November, December, January, February, March and so that's when the importation started occurring here whereas in the Northern Hemisphere measles is going to be more common in the spring. And so the importations from Europe mainly occur at that time.

So you can see some of these inflections - the huge inflection upward in April in reported cases reflects a particularly large outbreak that we're experiencing and that is ongoing.

So this year to date and these numbers are through June 20, 2014, we've had 514 measles cases reported to CDC from 20 states. That includes 16 different outbreaks. We've had 48 importations; almost half of those are from the Philippines and 90% of these importations have occurred in US residents.

Almost all the cases are import-associated, in fact 100% are, but we sometimes don't find the link for a very small percentage of cases. And this year 11% of cases have been hospitalized.

Of the cases in US residents, 81% of them are unvaccinated, 12% have unknown vaccination status; most of those cases are in adults. Adults don't do as good a job of maintaining their vaccination records so unfortunately we don't have an accurate account of whether they're (unvaccinated) or not.

And then 7% of cases are vaccinated so although, you know, the measles vaccine is highly effective it can occasionally fail and when you've got a large number of people being exposed you'll see some cases in vaccinated people.

Among the unvaccinated cases, 87% were people who were personal-belief exempters; that is they had refused vaccination for themselves or their children for religious or philosophical or personal belief reasons.

Three percent were travelers age 6 months to 2 years who did not have that travel dose and 7% were too young to be vaccinated so those were children less than 6 months that didn't travel abroad or children less than 12-15 months that didn't travel abroad. And those children got infected here through contact with somebody with measles.

This slide just shows the particular countries that the importations have come from really just to make the point that you can get measles absolutely anywhere you travel including right now in the United States.

So this slide shows outbreaks in the US for 20 or more cases since measles elimination was declared in 2001. And as you see, I mean, most of our outbreaks tend to be small and that's great; that's due to high population immunity and it's also due to very effective and rapid public health response by the medical and public health community.

But you'll see that in 2013 we had an outbreak in New York City with 58 cases and then this year we're experiencing the largest outbreak that's occurred in the United States since 1994 in Ohio. And that outbreak is ongoing.

Measles outbreak response has a very high economic burden. It's expensive to respond to these outbreaks, the public health and healthcare costs can be really high. I collaborated with the state of Arizona in investigating an outbreak there in 2008 and two different hospitals spent a total of $800,000 to respond to seven cases in their facilities.

The biggest cost in that case and that's the case in many of the other outbreaks as well is healthcare providers didn't have evidence of immunity and so when exposure occurred, hospitals had to check 4,000 records of their employees to know whether or not they had measles vaccination or serologic evidence of immunity and they had to furlough a lot of people that didn't have those records. And so, this exacts a toll both for hospitals, for pediatric clinics, for private clinics and for public health officials.

Keys to measles prevention diagnosis and response or maintaining high measles vaccine coverage, diagnosing measles and then effective case response. And we'll go through this in a little bit more detail now.

So the recommendations for MMR vaccine in the United States, routine recommendations as I'm sure most of you know, for two doses in children and adolescents at 12-15 months and 4-6 years or at least 28 days after the first dose. And catch-up vaccination is needed so if a child comes in at 8 years and they've never had a dose they should be vaccinated with two doses.

Adults without evidence of measles immunity need two doses if they're a healthcare worker, post high school student and any sort of college or institutional setting and if they're a traveler going abroad and one dose for all other adults.

As mentioned, we're up to Slide 30. I was asked at the beginning to sort of give slide numbers every now and again, so we're now on Slide 30.

The MMR vaccine travel recommendations are persons aged greater than or equal to 12 months without other evidence of immunity should receive 2 doses. So this means providing a second dose to children prior to age 4-6 if they're traveling abroad and giving an extra dose for adults who only have received one dose in the past.

And then infants age 6-11 months should receive 1 dose. This is an early dose and it won't count as a valid dose for their 2 MMR doses so these children need two subsequent doses at age greater than or equal to 12 months.

We need to maintain high vaccine coverage for maintaining high population immunity. You'll see here that we're doing a reasonably good job with one and two-dose coverage. About 90% for both means that 1 child in 10 and 1 teen in 10 haven't received their needed age-appropriate MMR vaccine doses on time.

So the - one success of our vaccination program is an unfortunate one in a way, because we don't see much measles anymore most healthcare providers have never seen a case now because measles is uncommon relatively speaking and so delays in diagnosis can occur that contribute to transmission.

So we urge physicians to keep measles on their radar and consider measles in the differential diagnosis of febrile rash illnesses. Just this year we've had measles cases misdiagnosed as Kawasaki's Disease, Scarlet fever, Dengue and some of those people continued to circulate and weren't isolated because of those diagnoses.

Consider measles especially if there's a travel history, travel history abroad or exposure to recent travelers or measles is occurring in a local community as it is now in Ohio, in Kansas, Missouri and in Washington State.

And don't forget that occasionally measles can occur in people with a documented vaccine history. Don't take it off the radar if you see somebody that has a history of vaccination. We've had some cases this year in healthcare providers with two doses.

If you suspect a measles case, laboratory testing is needed for confirmation using serology. Also the - we need to get viral specimens in order to genotype and confirm through those rapid tests. And then sometimes acute and convalescent specimens for IgG can be useful. So the first specimen can be tested for IgM and also IgG.

Report a case immediately to the local health department if you suspect measles. Don't wait for confirmation, pick up the phone and call your local health department. And then offer vaccine or immune globulin immediately to household members who don't have evidence of immunity.

Public health response for confirmed and suspect cases is to isolate the case for 4 days after the rash onset. Usually we don't diagnose a case before rash onset. And then immediately notify CDC. Measles cases are notifiable to CDC within 24 hours of confirmation.

CDC will contact a quarantine station if there was relevant travel. State health departments will typically alert physicians statewide following confirmation of a measles case and then they'll enhance measles surveillance throughout the state or local area to put physicians on high alert. And then they will initiate contact investigations and response efforts.

If measles is suspected in a clinic, an emergency room or a hospital setting isolate the patient immediately. Take them out of the waiting room, put them in an airborne isolation room if you have one or in a private room with the door closed and put a mask on the patient if that's feasible. It might not be feasible in a child, but it should be in an adult.

Ensure that healthcare personnel who are coming into that room have evidence of measles immunity. In a hospital setting respiratory precautions - or airborne precautions, including N95 masks or PAPR are needed even for those healthcare workers with evidence of immunity.

Contact investigations are very important following exposures to measles. And so this is a lot of work that's done by the state - local and state health departments. So people who are exposed to measles cases during the infectious period includes anybody in the area up to 2 hours after a case left.

Have to check anybody that's been in contact in the - during the infectious period that's 4 days before the rash onset. And then contact all those people and establish whether they have evidence of measles immunity either vaccination records or serologic evidence.

Quarantine contacts without presumptive evidence of immunity for 21 days after exposure and then offer postexposure prophylaxis to those that will accept it, either vaccine or immune globulin.

This is a very busy chart but at the bottom you can see - we're on Slide 37 - where this slide is available or chart in the 2013 ACIP recommendations. This just goes through evidence of immunity, routine, children, adolescents and adults, for students, for healthcare personnel and international travelers.

After exposure you can use MMR vaccine or immune globulin for postexposure prophylaxis. MMR vaccine needs to be administered within 72 hours of exposure. The person may return to normal activities except if they are in a healthcare setting. They need to be monitored for symptoms. MMR vaccine can be given if there is a close exposure to an infant at age 6 months or older. And be aware of the possibility of a vaccine rash.

For immunoglobulin, this needs to be administered within six days of exposure. The recommended doses for IM and IG are stated there. And it's recommended for the following groups that are at risk of severe disease and complications: infants less than 12 months, pregnant women without evidence of immunity and severely immunocompromised patients irrespective of their evidence of immunity.

Measles in the post-elimination era: So we are now 14 years into the post-elimination era in the United States. We're on Slide 40. Measles is due to failure to vaccinate. That means it pretty much only occurs in people - not only but almost only occurs in people that aren't vaccinated.

Measles elimination is a global problem and so until there is global elimination or finally eradication we're going to continue to have measles importations into the United States. So don't forget that measles occurs in the United States even in the post-elimination era.

Maintaining elimination is resource intensive. We need to maintain high vaccine coverage by offering vaccine on time routinely and especially paying attention to travel recommendations, through maintaining intensive case/contact investigations, healthcare workers diagnostic skills so that people remember measles when somebody with a febrile rash illness presents in the office, and then takes appropriate tests and measures to assess and manage those patients and then use of advanced laboratory techniques to confirm measles cases.

We have a lot of great resources many of which we've updated and some new ones that we've created this year and so please look at these on the CDC Website. We have special resource page now for healthcare professionals that provides clinical information, information on measles disease complications, transmission, guidelines for how to diagnose, lab test, isolate and treat; all the vaccine recommendations are there for routine use and for international travelers.

There are great images of measles. There is the video that I mentioned. And outbreak statistics including, as you can see here, the week to week case count. As of this week actually, our case count is up to 539 with 17 outbreaks so it's continuing to climb.

Additional resources for healthcare professionals is shown here, webinars, apart from this one, that can be accessed and looked at, a NetConference, we've got banners and buttons, fact sheets, resources, things that you can use to put on your Website through syndicating CDC's measles information. And, as I mentioned now the third time, you need to look at this measles video in children.

Special resources for the public you can see here that are measles Website with the statistics on the weekly case counts, on why it's important to be vaccinated if you travel abroad, that measles can occur here. We've got infographics, videos, podcast, features, you name it we have it including resources in Spanish.

So with that I'd like to end and thank – and acknowledge state and local health departments and the huge number of staff here at CDC in measles and rubella epi, labs, health economics and communications. Thank you and I’m happy to take any questions.

Leticia Davila:
Thank you, Dr. Seward, for providing our COCA audience with such a wealth of information. We will now open up the lines for the question and answer session. And also remember, you can submit questions through the webinar system. Operator.

Coordinator:
Yes, and to ask a question press star 1 on your phone, please remember to unmute your phone before asking your question. And record your name clearly when prompted. Please stand by for the first question.

Leticia Davila:
Thank you. And as we queue up for the questions on the phone, we do have a question that has come through the webinar system. And it states, "Will immunization against measles," well actually let me start over. "The immunization against measles is that sufficient for prevention as nowadays patients of measles are not children but adults?"

Jane Seward:
So I think the question relates to whether protection wanes over time and whether people become susceptible to measles if they're adults. We don't have good evidence that that's occurring. We do get cases in all age groups. But most of those people, both children and adult cases, are unvaccinated. That's the main reason that measles cases of our occurring across the age spectrum. We occasionally do get vaccine failure cases in both children and adults. And I think this is despite the fact that measles vaccine is highly effective; no vaccine is 100% effective. And so if you have a very high rate of vaccine coverage in your community you're going to get more - a lot of vaccinated people exposed as well as unvaccinated and you will get occasionally some cases in vaccinated persons.

Leticia Davila:
Thank you. Operator.

Coordinator:
We have three questions in the queue at the moment. Our first question is from (Kathy) from Indiana.

(Kathy):
Hi. This is (Kathy). And I was just wondering at one point that you had said sometimes nowadays that measles are being misdiagnosed with different - with other diagnoses like the Kawasaki Disease. How is - I guess what are the major differences between those two?

Jane Seward:
Well, I mean, Kawasaki's typically doesn't have cough, coryza and conjunctivitis. And I don't think a fever quite as high. I think that, you know, people - physicians have, to a large extent, taken measles off their radar screen because they're not seeing it commonly like they did in the 50s, 60s and 70s or during the resurgence. And so, there's a whole generation of physicians that have never seen a case.

So they just don't think about it. And they think about other causes of rash illness that they've seen more commonly like scarlet fever, Kawasaki's, dengue. We had patients that came back from the Philippines so sometimes international travel stimulates thought about rare diseases that occur overseas that don't occur in the United States very often like malaria or dengue but it's more common to acquire measles overseas.

(Kathy):
Okay.

Jane Seward:
And so I think measles has a very typical presentation with, you know, the cough, coryza and conjunctivitis as well as the rash. And I think this helps. I think we want physicians to just consider it. You know, it may be appropriate to have Kawasaki as part of the differential. But if there's a question just don't forget about measles and think about it especially in people who travel abroad.

(Kathy):
Right.

Well and I brought that up because I have a very good friend with a child that just was diagnosed with a partial possible Kawasaki. And I kept thinking it sounds like measles.

Jane Seward:
Well, I mean, if the child didn't travel abroad and wasn't in contact with somebody who traveled abroad it may well be Kawasaki in this case. But we just want people to remember and have a very high index of suspicion and children who have traveled abroad and just come back or their families have traveled abroad and they’re unvaccinated. Often these things go together.

I mean, you know, you can acquire - or if measles was occurring in the community as this large outbreak is now in Ohio.

(Kathy):
Yes. Okay well thank you so much.

Jane Seward:
You're welcome.

Coordinator:
And our next question is from Dr. (Anan) from Connecticut.

(Anan):
Hi. Thank you for the very nice presentation. Can you hear me?

Jane Seward:
I can.

(Anan):
Wonderful. We just had a case and we did a postexposure investigation so I have two questions related to that from your presentation. One, what was the experience in other exposed immunized healthcare workers in the cases you've seen across the US in general?

And then the second was related to the time intensity of everything. When we have an exposure there's a 72 hour window to round up everyone and give them a vaccine if they're not immune and the diagnostic test, whether it's the IgM antibody or the PCRs we send to the CDC just takes so long right now that if it's a clear-cut case that's fine, but if it's going to be a borderline case it makes the whole logistics very challenging.

Jane Seward:
Well, I mean, you've raised a number of important questions. I mean, if a measles case is suspected, I mean, contact the local health department and they should be able to help get lab specimens routed as quickly as possible to the state lab. Or there are now some regional labs or vaccine preventable disease reference center labs that CDC is collaborating with to help with rapid diagnosis throughout the country. And they have very fast turnaround.

You know, the question of other physicians around the country and whether they are coming down with measles, we don't have exact numbers for how many people - how many physicians are getting exposed to measles. We suspect it's quite a few because most measles cases are going to physicians sometimes multiple times before they're diagnosed correctly.

So we don't have an absolutely correct estimate of the denominator or the number of exposures that have occurred. But this year we do know that we've had I think five healthcare worker cases. And, you know, I mean, that's going to occur when there's been a lot of exposures around.

We continue to look at our data and try to assess whether there's any greater risk of vaccine failure by age or things like that, as I answered with the first question. And right now we don't see any evidence of that but we'll certainly continue to look.

Regarding the timing and postexposure prophylaxis, you know, if somebody who is exposed doesn't have evidence of immunity that means they need vaccine, and if it can be given within three days that's the best thing in preventing that immediate case.

But they also truly may not have had an exposure that resulted in disease so it's always a good idea to vaccinate anybody who hasn't had - doesn't have evidence of immunity even if it's four, five, six, seven, any number of days after. It's just that that vaccine may not work for that exposure but it may work for the next one and that person may get multiple exposures within a family or within a setting.

And so we just advise everybody to, you know, make the best judgment calls they can depending on the situation they’re confronted with and call their local health department if help is needed with investigating and responding to a suspected measles case.

(Anan):
Thank you.

Leticia Davila:
I do have a question that has come through the Webinar system. Dr. Seward, "Can you talk a little bit about the challenges with the IG supply? IG efficacy is now made from vaccinated adults and not adults with naturally acquired immunity?"

Jane Seward:
Yes, I mean, that's the case that the levels of immune - of antibody and immune globulin is tracked closely by the FDA. And there was a big meeting about this a couple of years ago to look at that. And so - I'm not aware right now that there's any problem in supply. There have been, you know, certain shortages from time to time but I'm not aware of one at the current time.

And so the immune globulin - the doses that I presented on Slide 39 those doses are the currently recommended adjusted doses for the immune globulin that we have now - that is manufactured, as you say, mainly from people with vaccine induced immunity. That provides enough antibody for protection.

Leticia Davila:
Thank you. Operator.

Coordinator:
Yes ma'am, our next question is from (Len Rummel).

(Len Rummel):
Hi, I have a question regarding data supporting reduced transmission of measles from a masked individual with measles. I was unable to find the PubMed search data. We had a suspect case here that was ruled out but the patient was masked. And we were uncertain if the person had measles how much that would reduce transmission if they wore a mask say while in a hospital emergency department.

Jane Seward:
I'm not, I mean, I can't quote you definite references off the top of my head. I mean, it's just - if somebody is acutely symptomatic the symptom that is most applicable to transmission is cough. And, you know, you look at a video of a cough and you see how the droplets just spray out from somebody with coughing. You can look on our influenza Website and see that.

Then there's, just logically a mask is going to reduce that tremendously. I think most of the data for this, for measles, is indirect from other diseases like influenza.

Leticia Davila:
We do have another question that has come through the webinar system. It says "Having had measles as a child do adults need to have the MMR?"

Jane Seward:
No, they don't. But you need to have evidence of immunity that's acceptable now. And history of disease isn't evidence of immunity unless you have a serological test. And so if we look back at Slide 37 you can see the evidence of immunity is either documentation of age-appropriate vaccination, lab evidence of immunity, lab confirmation of disease, which isn't going to occur very much except for current cases or somebody who was born before 1957.

And so if somebody is an adult, knows they had disease in the past, they'll need to go and have a lab test that will show they have antibodies to measles for acceptable evidence of immunity.

It used to be, I mean, before these 2013 ACIP recommendations -- physician documented history of disease was considered acceptable evidence of immunity but in the last 15 years there's been a lot fewer measles cases and so, you know, this wasn't considered valid evidence of immunity anymore to have historical evidence of disease. And so now such a person would have to go and have a lab test.

Leticia Davila:
Thank you. We have another question. It says, "Can you talk a little bit about the transmissibility of measles from rash occurring as a result of MMR vaccination?"

Jane Seward:
That's a great question. Is measles vaccine transmissible? I - being a live viral vaccine it would be theoretically, and it may not be from the rash but it may be from, you know, replication in that nasopharynx. I'm just trying to think of cases where that's occurred though and I'm not able to think of any.

If that - if the person with that question would like to send it in I'll research and get a more accurate answer. But I'm not remembering any case of transmission.

Leticia Davila:
Thank you. And for that person who sent their question if you can please send a question to coca@cdc.gov. Operator.

Coordinator:
Yes, ma'am. We have one question remaining in the queue and that's from (Gail Skowron).

(Gail Skowron):
Hi. We just had a recent diagnosed case with an IgM positive; the patient had a high fever and a typical rash but no cough, coryza and no epidemiologic or travel link. So I was wondering if you could discuss causes of a false positive IgM and whether there's a automatic retesting of that serum with plaque neutralization by CDC? And then I have another follow-up question if you answer that one.

Jane Seward:
Sure, yeah no, that's a really good question. I mean, the - a lot of the predictive value of a positive IgM in an era of the very low measles prevalence - or incidents is very low in fact. I mean, we're having a - what we consider a high number of measles cases this year and have occurred in 20 states, but that said, measles false positive cases - results are going to occur not uncommonly.

And that's, you know, due to a variety of reasons, interference, you know, with other circulating antibodies from another acute febrile illness, etcetera. So a patient like that you should contact your health department and they will send the serology test and retest it at CDC not using plaque reduction but using our capture IgM assay. And we would consider that that, I mean, we do that not uncommonly to rule out a case that doesn't seem to be a case.

Now that said, we sometimes miss the original importation and people can acquire measles here and not have a link because the link was missed. They might have been at an airport or they might have been in a library and somebody came in who was infectious before rash onset. But if there's any question and an absence of travel history - was this person vaccinated?

(Gail Skowron):
Two documented MMRs at the appropriate time.

Jane Seward:
Yes, right. So the index of suspicion would be low, as you say and so this is a case where a false positive would be highly suspected and getting it retested at CDC would be advised. And that can be done through the state health department.

(Gail Skowron):
Great. My second question is regarding the Arizona outbreak in 2008. If I recall correctly from the publication in 2011 that 4% of those healthcare workers born before 1957 were non-immune. And I'm wondering is CDC considering requiring two doses of MMR for all healthcare workers?

Jane Seward:
That's a great question. I didn't remember that 4% but I take your word for it. This was discussed quite a lot in 2013 when we updated the ACIP recommendations. And the decision was made, if you look at the ACIP recommendations, you know, birth before 1957 is considered evidence of immunity. But it was suggested that healthcare – that in healthcare settings healthcare workers of this age be tested for serologic evidence. And those who aren't - who don't have serologic evidence be vaccinated.

If a measles case occurs, then you'll be required to test and vaccinate anybody in that age group who doesn't have evidence of immunity. And so,..

((Crosstalk))

(Gail Skowron):
...if an outbreak occurs.

Jane Seward:
If one case occurs - if one case - is considered an outbreak for the purpose of a healthcare exposure. If it's any case in a hospital, then every healthcare worker born before 1957 will have to be tested. And having to do that during an outbreak is very disruptive and costly. And so, it might be more efficient to do that ahead of any exposure occurring.

There was, you know, there have not been enough cases occurring in healthcare workers born before 1957 to justify a routine recommendation to test and vaccinate everybody throughout the country.

(Gail Skowron):
And then if I can have just one follow-up to that and that is the vaccine failure issue is really concerning when what we are requiring for healthcare workers are two MMRs. So if we require two MMRs and there is a vaccine failure rate of even 3% then you have the potential to have susceptible health-care workers who are in the hospital caring for patients.

Jane Seward:
Well, that's why currently the recommendation for such people is to wear an N95 mask or higher.

(Gail Skowron):
Right.

((Crosstalk))

(Gail Skowron):
...measles.

Jane Seward:
Sorry?

(Gail Skowron):
After you suspect measles?

Jane Seward:
Yes.

(Gail Skowron):
But not during the four days of the prodrome, when you don't know what they have.

Jane Seward:
Yeah, no, I mean, a lot of transmission can occur before you know what they have. I mean, we have seen these failures this year. We don't see them very often and so, you know, measles vaccine is highly effective. I mean, occasionally with very high exposures or whatever the combination of exposure and host interaction might be we'll get failure.

We don't - we can't - we don't say never but our limited experience in transmission from vaccinated cases, especially two dose cases, is that there's very little evidence of transmissibility because they tend to mount incredibly rapid animistic IgG responses that are just sky high and they don't tend to transmit onwards.

(Gail Skowron):
Excellent. Thank you so much.

Jane Seward:
You're welcome.

Leticia Davila:
Thank you. Operator, how many questions do we have in the queue?

Coordinator:
And that was actually our last question in the queue.

Leticia Davila:
Okay, we will take two more from the webinar system. The first one is "How long should immunocompromised children with measles be isolated? Are they contagious for more than four days after rash onset?"

Jane Seward:
Not that I'm aware of. I don't - I'd have to, no - I'm sorry, I have to look that one up. We don't get asked that question very often. I'm sure somebody in my group can answer it immediately but I can't. I think it's just - it's four days but if the rash is - I mean, rash can last longer than that in healthy people as well but the greatest period of infectiousness is right before rash onset and immediately afterwards.

So I would say right now it's four to four but I will - if you sent me in your email address I'll make sure that that answer is correct.

Leticia Davila:
Thank you. And for that participant please send your question to coca@cdc.gov.

The next question from the Webinar system, "How many complications from measles vaccine have been reported?"

Jane Seward:
Oh I don't have those - all those statistics at my fingertips. But there's a summary of the vaccine - MMR vaccine safety in the 2013 MMR ACIP recommendations. I mean, we’ve used how many millions of doses of this vaccine in 50 years, millions and millions and millions, you know, probably hundreds of millions.

And so the rates that I gave for complications apart from, I mean, fever and rash is not too uncommon occurring in maybe 1 in 100 or 2 in 100 people. And febrile seizures, as I said, in children 12-15 months - 12-23 months about 1 in 3,000 vaccinated children. But for measles disease, febrile seizures are much, much, much more common than that.

And so, I would just recommend that you look at the 2013 ACIP statement for an update there on the experience with MMR vaccine safety.

Leticia Davila:
Thank you. On behalf of COCA, I would like to thank everyone for joining us for today with a special thank you to Dr. Seward. We invite you to communicate to our presenter after the webinar. If you have additional questions for today's presenter please email us at coca@cdc.gov. Put July 1, COCA call in the subject line of your email and we will ensure that your question is forwarded to her for a response. Again that email address is coca@cdc.gov.

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Thank you again for being a part of today's COCA Webinar. Have a great day.

Coordinator:
This concludes today's conference. Participants may disconnect at this time.

END