Vaccine-Preventable Diseases 1 2/16/15 I have nothing to disclose - PDF document

◆ 2/16/15 Emerging Issues in Pediatric Infections (focus on Vaccine Preventable Diseases) C A R O L G L A S E R , D V M , M P V M , M D PEDIATRIC INFECTIOUS DISEASES KAISER PERMANENTE OAKLAND & DEPARTMENT OF PEDIATRICS DIVISION OF PEDIATRIC INFECTIOUS DISEASES UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Emerging Issues in Pediatric Infections with an emphasis on Vaccine-Preventable Diseases ◆ 1

◆ 2/16/15 I have nothing to disclose � Resurgence of VPDs due to failure to immunize and what it means to the United States � Measles � No indigenous transmission in the U.S., but continued transmission in many parts of the world, including Europe, means it’s still an issue in the U.S. � The Pertussis Problem � Why has the incidence been increasing in the U.S.? � Mumps � Why are there still cases in the U.S. even though immunization rates are high? � Other vaccine-preventable diseases ◆ 2

◆ 2/16/15 About vaccines � Childhood vaccination rates plummeted in Europe following a 1998 study that falsely claimed MMR was linked to autism � Although results of the 1998 study have been shown to be false, fears about vaccine safety have remained � In some parts of Europe, MMR vaccination rates are <80% Case 1 ◆ 3

◆ 2/16/15 Case 1 3 year old female with � 6/28: Onset of fever � 6/29 runny nose � 7/2 rash around mouth � 7/3 erythematous mp rash spread from face to whole body Case 1 Exam � Irritable child in mothers arms with prominent cough � + Conjunctivitis, +/- cervical LN � Erythematous MP rash whole body, most pronounced on trunk. � No palmar erythema, no puffy hands/feet Labs; � CRP=2, ESR=36 � CBC unremarkable � AST slight increase, ALT nl � U/A with pyuria ◆ 4

◆ 2/16/15 Case 1 Social History � This child comes from a family with several children—the 5 oldest have had vaccines , this child and 5 y/o sibling have not been vaccinated Exposure � Just returned from the Philippines (became ill on plane) Case 1 � Exam � Irritable child in mothers arms with prominent cough � + Conjunctivitis, +/- cervical LN � Erythematous MP rash whole body, most pronounced on trunk. � No palmar erythema, no puffy hands/feet � Labs; � CRP=2, ESR=36 � CBC unremarkable � AST slight increase, ALT nl � U/A with pyuria ◆ 5

◆ 2/16/15 Lab testing � Measles PCR throat positive � ◆ 6

◆ 2/16/15 Measles Background & Epidemiology ◆ 7

◆ 2/16/15 Measles � Highly contagious viral illness � Near universal infection of childhood in pre- vaccination era � Frequent and often fatal in developing areas � Humans are only natural host � Potential for eradication (by 2020?) � Several factors work in favor of measles eradication: humans are the only hosts, measles vaccine is highly efficacious, and immunity resulting from infection and/or vaccination is very durable Measles in the Prevaccine Era – United States, 1950s Annually: � 3-4 million cases � ~ 500,000 reported cases � Severe complications � 4,000 encephalitis cases � 150,000 respiratory complications (PNA) � 48,000 hospitalizations � 450 deaths ◆ 8

◆ 2/16/15 Measles – United States, 1950-200o Vaccine Licensed 1963 Resurgence Measles US 1989-1991 � 55,000 cases nationally � 11,000 hospitalizations � 123 deaths ◆ 9

◆ 2/16/15 Measles Resurgence California - 1989-1991 18,000 reported cases (30% national cases) • 3,500 hospital admissions • 70 deaths • Because of resurgence measles (late 80s-early 90s) United States � Introduction of 2 nd dose of vaccine in 1989 and federal “Vaccines for Children” program in 1993 � 2000: “Measles is no longer endemic in the United States” � Record low annual total in 2004 (37 total cases in US) � Elimination of endemic measles in North and South America was achieved in 2002 ◆ 10

◆ 2/16/15 Measles – United States, 1950-2005 2 nd dose 1989 Endemic Measles Vaccine transmission declared Licensed interrupted eliminated 1963 Global epidemiology 2000-current Currently, most U.S. measles cases are related to international travel or contact with ill travelers � Africa, Asia, Pacific Rim countries and… � Europe � Several different countries with large outbreaks including 15,000 cases in France in 2011 � Romania, Ireland, the UK, France, Italy, and Spain also with outbreaks ◆ 11

◆ 2/16/15 ◆ D ◆ D 5 4 ◆ D 4 ◆ D 4 ◆ D 5 Measles Importations, U.S. 2008 Measles Transmission � Highly contagious viral illness – 90% of susceptible persons who are exposed to measles will become ill � Measles is transmitted via the airborne route � Measles patients are infectious 4 days prior to rash onset and 4 days after rash onset � Persons who share the same air space at the same time or up to two hours* after an infectious person leaves a setting are considered exposed (*for contact tracing CDPH-one hour) ◆ 12

◆ 2/16/15 Measles Ro vs. other diseases Measles Airborne and probably the most infectious communicable disease: R 0 =12-18 1. Fine P. Herd Immunity: History, Theory, Practice. Epidemiologic Reviews 1993;15(2): 265-302. 2. Anderson RM and May RM. Vaccination and Herd Immunity to Infectious Diseases. Nature 1985;318:323-9. 3. Anderson RM and May RM. Immunization and Herd Immunity. Lancet 1990;335:341-45. Measles Transmission � Measles transmission has been documented in: � Physician offices � Emergency rooms � Hospital wards � Schools � Airplanes � Theme parks � Highest Ro of all communicable diseases ◆ 13

◆ 2/16/15 Implications of those exposed Postexposure Prophylaxis (PEP) � MMR vaccine can be given to exposed, susceptible contacts within 72 hours of exposure � Immunoglobulin (IG) can be given to exposed, susceptible contacts < 6 days of exposure � MMR is preferred for persons >12 months � IG is preferred for infants (IM), pregnant women (IV) � Quarantine is not indicated for persons who receive PEP in the recommended time frame…HOWEVER….for “high risk” individuals this is not true/need to be quarantined � A high-risk contact is defined as an exposed person who is at high-risk of measles infection or complications (pregnant or immunocompromised ) or who works in a sensitive setting (healthcare personnel of any age ) or works in or attends a setting with known unvaccinated persons (e.g., school/childcare) or who had significant exposure to the case (household contact). ◆ 14

◆ 2/16/15 Quarantine � Persons considered susceptible after assessment who did not receive PEP should be quarantined from day 5 through day 21 after exposure � Quarantine can be accomplished by: � Verbal instructions communicated to the exposed person, or � A legal order of quarantine issued by the health officer � Active symptom monitoring, particularly for people who may be noncompliant, can be considered � Quarantined people should be contacted at the end of the quarantine period to determine their status In the last few years in US and in California ◆ 15

◆ 2/16/15 Measles in the United States, 2013 � Of 159 cases (Jan-Aug 2013) � 157 (99%) import-associated � 42 (26%) directly from 18 countries � 21 (50%) from WHO European Region � Imported cases resulted in outbreaks � Some of these were quite large outbreaks � New York: 58 cases • Index case; unvaccinated 17 year old returned from London, UK to New York City, 6 generations of measles, none had been vaccinated, contact investigation=3500!! � North Carolina: 23 cases • Index case: unvaccinated, travel to India � Texas: 21 cases • Index case: adult with unknown measles vaccination history, travel to Indonesia ◆ CDC, MMWR, Sept 2013 Measles in the United States, 2013 Total of 189 cases reported � At that time, 2 nd largest number in US since measles eliminated in 2000 � Most occurred in unvaccinated persons ◆ 16

◆ 2/16/15 And then in 2014 ….. � 610 cases, 20 outbreaks [by comparison 189 cases in 2013] California 2014 January 1-April 18, 2014 � 58 cases � 54 (93%) import associated � 13 directly imported � Of the 13 imported � Philippines (8), India (2), Singapore (1), Vietnam (1), West Europe (1) Genotyping data -39 patients: 32 (80%) B3, 7 (20%) D8 -B3 is genotype currently circulating in Philippines - Notes from Field, MMWR, April 2014 ◆ 17

◆ 2/16/15 Late 2014-early 2015 Ca ses in California linked to travel to Disneyland Dec 2014-Jan 2015 Additional cases in other states—Utah, Texas, Colorado, Washington � � Currently in 3 rd -4th wave/4th generation transmission. Will now see several cases without Disneyland exposure Measles Outbreak Epi Curve • 39 cases primary Disney • 1 case who reports visiting Disney outside of initial time period ◆ 18

◆ 2/16/15 Vaccination Status Among Measles Cases with Vaccine Documentation (n=53) Genotyping data and 2015 Outbreak Measles genotype information was available from 9 measles cases; all were genotype B3 and all sequences linked to this outbreak are identical. The sequences are also identical to the genotype B3 virus that caused a large outbreak in the Philippines in 2014. During the last 6 months, identical genotype B3 viruses were also detected in at least 14 countries and at least 6 U.S. states, not including those linked to the current outbreak. ◆ 19