Comparison of 20th Century Annual Morbidity and Current Morbidity

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					Vaccine-
Preventable
Diseases
Update



Rita Espinoza, MPH
Epidemiologist
Emerging and Acute Infectious Disease Branch
Infectious Disease Control Unit
January 9, 2009
                Overview
• Incidents
  – Mumps
  – Measles
• Texas Data
  – Pertussis
  – Varicella
  Comparison of 20th Century Annual
   Morbidity and Current Morbidity,
 Vaccine-Preventable Diseases, Texas
              Highest Case            Percent
Disease       Count during    2007   Decrease
              20th Century
Measles       88,000 (1958)    7      99.9%
Rubella        8,408 (1970)    0      100%
CRS               12 (1974)    0      100%
Mumps         32,939 (1950)    21     99.9%
Pertussis     21,588 (1947)   1051    95.1%
Diphtheria     1,544 (1946)    0      100%
Tetanus           55 (1954)    0      100%
Polio          2,778 (1950)    0      100%
(paralytic)
Epidemiology of Mumps and
Multistate Mumps Outbreak
    United States 2006
                Mumps Epidemiology
•   Reservoir          Human

•   Transmission       Respiratory drop nuclei

                       Subclinical infections
                       may transmit

•   Temporal pattern   Peak in late winter and spring

•   Communicability    Three days before to four
                       days after onset of active
                       disease
                    Mumps – United States, 1968- 2005*
                    160
                    160
                    140
                    140
Cases (thousands)
Cases (thousands)




                    120
                    120
                    100
                    100
                    80
                    80
                    60
                    60
                    40
                    40
                    20
                    20
                     0
                     0
                     1968 1972 1976 1980 1984 1988 1992 1996 2000 2004
                      1968 1972 1976 1980 1984 1988 1992 1996


                      *2005 provisional data
                      *2005 provisional data
Mumps – United States, 1980- 2005*

        14000
        14000
        12000
        12000                        2-dose schedule
        10000
        10000
Cases




        8000
Cases




        8000
        6000
        6000
        4000
        4000
        2000
        2000
           0
           0
           1980
            1980      1984
                      1984        1988
                                  1988   1992
                                         1992   1996
                                                1996   2000
                                                       2000   2004
                                                              2004


         *2005 provisional data
         *2005 provisional data
             U.S. Mumps Cases
•   2005 – 265 cases
•   2004 – 258 cases
•   2002 – 270 cases
•   1996 – 751 cases
•   1993 – 1,692 cases

    2010 Health Objective is to eliminate indigenous
    mumps by 2010
Mumps Outbreak NY State, 2005
 MMWR Feb 24, 2006
                 Mumps Outbreak United States 2006*

                                                           Total reported cases 4,602




                                                       4
                                            193                650                         1

                                            349        1,921                         85*
                                                               501
                                    3
                                                 782       134


                                1

                                                                  2




                                        *In PA, 14 of the 85 cases are considered outbreak-associated.

*Provisional Number of Cases by State as of June 20, 2006
Incidence of Mumps/100,000, 8 Outbreak-
 Associated States, NNDSS (Provisional)
        January 1 – June 20 2006
 •   Iowa                                                  65.3
 •   Kansas                                                28.0
 •   South Dakota                                          24.1
 •   Nebraska                                              17.1
 •   Wisconsin*                                            4.9
 •   Missouri                                              3.1
 •   Illinois*                                             1.1
 •   Pennsylvania                                          0.7


     *States with delayed reporting through NNDSS, rates likely to increase
Incidence of Mumps by Age Group in the Eight Outbreak States,
   NNDSS (Provisional), 1 January – 20 June 2006 (n=3860)

                                        30
  I n c id e n c e p e r 1 0 0 ,0 0 0


                                        25

                                        20

                                        15

                                        10

                                        5

                                        0
                                             <1   1-4   5-17   18-24   25-39   40-59   60+
                                                         Age Group (years)
Multistate Mumps Outbreak 2006
• College students especially in Iowa
• Cases in health care workers
• Few outbreaks reported in schools or child care
  centers
• Transmission remained fairly focal
   – Little or no spread to vaccine refuser populations and very few
     cases in infants
• Vaccination status cases
   – 7% unvaccinated
   – 14% 1 dose
   – 50% 2 doses
   – 30% unknown vaccination status (majority adults)
Clinical Summary of Reported Mumps Cases, NNDSS
   (Provisional), January 1-June 20, 2006 (n=3860)
           Clinical Feature (n)1                                Number (%)
           Parotitis (2741)                                     2215 (80.8%)
           Meningitis (2542)                                    10 (0.4%)
           Encephalitis (2530)                                  5 (0.2%)
           Orchitis (1333)2                                     59 (4.4%)
           Deafness (2536)                                      6 (0.2%)
           Hospitalization (2745)                               43 (1.6)
           Death (2745)                                         0


     1   Number with “Yes” or “No” in data field included. Cases with “Unknown” or missing data excluded.
     2   Data collected among males only.
                                         Hospitalizations

       •     Two data sources for hospitalization (1 January – 20 June 2006)
              –    NNDSS = 43 hospitalizations
              –    Biweekly Report = 66 hospitalizations
       •     Data source for reason for hospitalization: Biweekly Report only
       •     11 of 66 hospitalizations likely NOT to be mumps-related
              –    Hospitalized for another reason (e.g., colitis, pneumonia) and found to have mumps
       •     Reason for hospitalization (n=55)1




                   Meningitis             10           Pancreatitis                               1
                   Encephalitis           3            Pregnancy                                  2
                   Orchitis               4            Fever/dehydration/pain/HA/swelling         12
                   Oophoritis             1            Other/Unknown                              27
                   Mastitis               1


1   Not mutually exclusive (ie., may have >1 reason)
    Epidemiological and Laboratory Investigations
                  Preliminary Data

•    Attack rates in 2 highly affected college campuses [Iowa]
      – 2.0% (97% college students 2 vaccine doses)
      – 3.8% (77% college students 2 vaccine doses)


•    Vaccine failure rate (college room mate contact study Iowa)
      – 2 dose recipients ~ 8%
                Mumps Vaccine
• Composition        Live virus (Jeryl Lynn strain)

• Efficacy                   95% (Range, 90% - 97%)

• Duration of
  Immunity           Lifelong

• Schedule           2 Doses (as MMR)

• Should be administered with measles and rubella (MMR)
Mumps Vaccine (MMR) Indications

• All infants >12 months of age

• Susceptible adolescents and adults
  without documented evidence of
  immunity
        Mumps Immunity
• Born before 1957
• Documentation of physician-diagnosed
  mumps
• Serologic evidence of mumps immunity
• Documentation of adequate vaccination
                     Updated ACIP
                    Recommendations
•   Changes in evidence of immunity through vaccination
     – 1 dose children 1-4 years and low risk adults
     – 2 doses school aged children, students in post high school educational
       facilities, international travelers and workers in health care facilities
•   Health facility workers without other evidence of immunity
     – 2 doses routinely
     – Birth before 1957 – consider one dose in non outbreak setting and strongly
       consider 2 doses during outbreak
•   Outbreak control recommendations
     – 2nd dose for children 1-4 years and low risk adults if affected by outbreak
  Reported Cases of Mumps in Texas
             1946-2007
                               Mumps Vaccine Licensed in 1950
35000


30000


25000


20000


15000


10000


 5000

    0
        1940




                        1950




                                       1960




                                               1970




                                                        1980




                                                                1990




                                                                       2000
        * Provisional as of 05/03/05
     Mumps in Texas, 2000-2007
70

60

50

40

30

20

10

0
     2000   2001   2002   2003   2004   2005   2006   2007
  Percentage of Mumps Cases by
        Age Group, 2007
100
90
80
70
60
50
40
30
20
10
 0
      5-9   10-14   15-19   20+
         Percentage of Mumps
        cases by Race/Ethnicity
100
 90
 80
 70
 60
 50
 40
 30
 20
 10
  0
      Asian   Black   Hispanic   White   Other   Unknown

                          2006   2007
       Measles Epidemiology
• Reservoir:           Humans
• Transmission:        Respiratory
• Communicability:     4 days before rash
                       onset to 4 days after
                       rash appearance
• Temporal Pattern:    Late winter-spring
• Incubation Period:   14 days
                       (range 7-18 days)
     Reported Cases of Measles in
          Texas 1920-2007
                                     Measles Vaccine Licensed in 1963
100000

90000

80000

70000

60000

50000

40000

30000

20000

10000

     0
         1920




                1930




                       1940




                              1950




                                        1960




                                                1970




                                                         1980




                                                                  1990




                                                                         2000
             2005 Measles
• Family reunion in Cabo San Lucas,
  Mexico
• 48 individuals attended
  – Houston, Dallas, Austin, and Los Angeles
• Travel dates: 11/22-11/27/05
• Stayed in villas
• 3 add’l members reported to have rash
  illness
                         Case C
•   38 year old female
•   Vaccinated
•   Symptoms:
                               o
     – fever onset: 12/5 (104.5 F)
     – rash onset: 12/10 (X days)
     – cough
     – coryza
     – conjunctivitis
     – light sensitivity
•   ER visits – 1X
•   Office visits – 2X
•   Hospitalized with double pneumonia – 12/12
•   IgM positive for measles –12/12
  DSHS/CDC Measles Laboratory
           Results
Case    IgG        IgM        PCR       Culture    Genotype



 A      Pos        Pos        Pos       Present      B3
       12/21/05   12/21/05   12/6/05     12/6/05

 B      Pos        Neg        N/A         N/A         -
       12/21/05   12/21/05

 C      Pos        Pos        Pos       Negative     B3
       12/21/05   12/21/05   12/22/05
     Additional Lab Results

Case    Rubella IgG   Mumps IgG



 A         Neg          Neg

 B         Pos           N/A

 C         Pos           N/A
        US Genotyping Results 2005
State   First & Last rash date   Genotype Comments             No. Cases
                                                               identified
TX      12/04/05 ; 12/10/05      B3      Travel to Cabo San    3
                                         Lucas
WA      11/16/05                 D4      Import: Romania       1
NJ      11/09/05                 B3      Import: Kenya         1
WA      8/20/05                  D4      Inter’l conf: Paris   1
MI      8/16/05                  D4      Import: Yemen         1
IN      5/16 ; 6/23/05           D4      Import: Romania       33
IL      5/26/05                  D4      Spread from IN        1
WI      4/16/05                  D4      Import: Germany       2
NY      2/26/05                  D8      Import: India         1
AZ      1/17/05                  D6      Import: Armenia       1
NY      1/10/05                  D8      Import: India         1
NY      1/2/05                   D9      Import: Indonesia     1
 Geographic distribution of measles virus genotypes for regions that
 have not yet eliminated measles transmission,* 1995–2005




* The countries in the western hemisphere and Australia have eliminated measles and are not shown.
† In western Europe, genotype D7 was the most commonly reported genotype. Australia, Spain, the United Kingdom, and the countries of the western
hemisphere have reported multiple genotypes attributed to importation.
   International Youth Sporting
              Event
• Held annually in Williamsport, Pennsylvania
• August 17–26, 2007
• 8 US and 8 international teams
• 200 boys aged 10 – 13 years
• Residential compound
• Estimated attendance 265,000
  Index Case
Suspected measles case reported




             16

         Aug 2007
  Index Case
Japanese male, aged 12 years
International youth sporting event




              16

          Aug 2007
Index Case


    Isolation




       16

    Aug 2007
Index Case


    Isolation



           Measles IgM detected




       16 17

    Aug 2007
                    Index Case
Exposed to ill sibling

                         Isolation



                                Measles IgM detected




                            16 17

 Jul 2007                Aug 2007
           Index Case
           Tokyo → Detroit




                   Isolation




           13         16

Jul 2007          Aug 2007
           Index Case
           Tokyo → Detroit
                Detroit → Baltimore




                     Isolation




           13           16

Jul 2007            Aug 2007
           Index Case
           Tokyo → Detroit
                Detroit → Baltimore
                  Baltimore → Williamsport



                    Isolation




           13          16

Jul 2007           Aug 2007
            Contact Tracing
• Persons exposed during August 13–20
  – Residential compound attendees
  – Airline passengers
  – Airport workers
• Criteria for measles immunity
  – Birth before 1957
  – History of measles disease
  – 2 doses of measles-containing vaccine
  – Detection of measles IgG antibodies
Laboratory Diagnostic Methods
• Serology
  – IgM antibodies
  – IgG antibodies

• Real-time reverse transcription
  polymerase chain reaction (RT-PCR)
• Conventional RT-PCR
• Viral culture
              Genotyping
• Determine likely source
• Confirm epidemiologic association
• Detection of multiple genotypes in
  previous US outbreaks suggests
  importation
             Notifications
• Media
• Health Alert Network
• Epi-X
• WHO Revised International Health
  Regulations
     Contact Tracing Results
• Follow-up of >1,300 potentially exposed
  persons
  – 186 persons vaccinated
  – 3 received immunoglobulin

• 6 additional measles cases identified
          Japan        U.S.   Case 2
                              Male, 12
                  2           No documented vaccination
                  PA
                              Exposed Aug 12: Japan
      1
          PA
                              Aug 15: Travel to US
                              Aug 23: Rash




August 2007    12
                                   Exposure Date
          Japan        U.S.      Case 3
                                 Male, 25
                  2              No documented vaccination
                  PA
                        3        Exposed Aug 13: Detroit
      1                     MI
                                 Airport officer
          PA
                                 Aug 27: Rash




August 2007    12      13
                                     Exposure Date
          Japan        U.S.        Case 4
                                   Female, 53
                  2                No documented vaccination
                  PA
                        3          Exposed Aug 13:
      1                     MI
                                       Detroit → Baltimore
          PA            4          Passenger
                            MI
                                   Aug 28: Rash




August 2007    12      13     14
                                       Exposure Date
        1   Index Case
        4   Case 4
            Occupied
            Seat within
            1 row of
4           Index Case

    1
          Japan        U.S.           Case 5
                                      Male, 40
                  2                   No documented vaccination
                  PA
                        3             Exposed Aug 14: PA
      1                     MI
                                      Corporate representative
          PA            4
                            MI        Aug 28: Rash
                                      Aug 29: T 105.7°F, seizure,
                                      pneumonia, hospitalized
                              5
                                 TX



August 2007    12      13     14
                                           Exposure Date
          Japan        U.S.           Cases 6 and 7
                                      Males, 18 and 19
                  2                   2 prior doses MMR
                  PA
                        3             Exposed Aug 28: Case 5
      1                     MI
                                      Sep 11: Rash
          PA            4
                            MI                       6
                                                         TX
                              5
                                 TX                  7
                                                         TX


August 2007    12      13     14                 28
                                          Exposure Date
                                    Index Case

                                    2nd Generation Case
               2
               PA                   3rd Generation Case
                    3
      1                  MI

          PA        4
                         MI               6
                                               TX
                          5
                              TX          7
                                               TX


August 2007    12   13    14              28
                                   Exposure Date
                        Rash Onset Dates
            3
No. cases




            2



            1



            0
                13 15 17 19 21 23 25 27 29 31   2   4   6   8   10 12 14

                            Aug                         Sep
                                       Date
     Laboratory Confirmation
                               Laboratory Results
Case State Sex   Age Vaccine     IgM    Other
 1    PA   M     12     ?         +     Culture
 2    PA   M     12     ?         +     Culture
 3    MI   M     25     ?         +     RT-PCR
 4    MI   F     53     ?         +     RT-PCR
 5    TX   M     40     ?         +     RT-PCR
 6    TX   M     18     Y         +     RT-PCR
 7    TX   M     19     Y         +     RT-PCR
     Genotyping Results

Case   Sex   Age   Genotype
 1      M    12    D5
 2      M    12    D5
 3      M    25    undetermined
 4      F    53    D5
 5      M    40    D5
 6      M    18    D5
 7      M    19    D5
              Varicella
            Epidemiology
• Reservoir           Humans
• Transmission        Respiratory or contact with
                      lesions
• Communicability     1-2 days before and 4-5
                      days after rash onset
• Temporal Pattern    Winter, early spring
• Incubation Period   14-16 days
                      (range 2-3 weeks)
Reported Cases of Varicella in Texas
            1972-2007
                      Varicella Vaccine Licensed in 1995
30000


25000


20000


15000


10000


 5000


    0
        1970




               1980




                        1990




                                         2000
        Reported Cases of Varicella
               2000-2007
14000


12000


10000


 8000


 6000


 4000


 2000


    0
        2000   2001   2002   2003   2004   2005   2006   2007
       Varicella Cases by Age Group
             Texas, 2002-2007
8000
7000
6000
5000
4000
3000
2000
1000
   0
       <1          1-4      5-9    10-14     15-19       20-29
            2002     2003   2004   2005    2006   2007
         Varicella Cases and Vaccination
          Coverage† reported in Texas

                                                            100
     25000
                                                            80
     20000
     15000                                                  60

     10000                                                  40
      5000                                                  20
         0                                                  0
             92
             93
             94


             96
             95




             98
             97


             99
             00
             01


             03
             02


             04
             05
             06
             07
        19
          19
          19
          19
          19
          19
          19
          19
          20
          20
          20
          20
          20
          20
          20
          20
                     Number of cases   Coverage


†Among children 19-35 months of age, National Immunization Survey (NIS)
By 2005, K-5 and 7-11 grades covered by school entry laws
2007 Percent of Varicella Cases by
             Gender
60

50

40

30

20

10

0
      Male      Female    Unknown
        Percentage of Varicella
        cases by Race/Ethnicity
100
 90
 80
 70
 60
 50
 40
 30
 20
 10
  0
      Asian   Black   Hispanic   White   Other   Unknown

                          2006   2007
       Pertussis Epidemiology
• Reservoir          Human
                     (Adolescents/Adults)
• Transmission       Respiratory droplets
• Communicability    Maximum in catarrhal
                     stage, may transmit in
                     paroxysmal stage,
                     secondary attack
                     rate up to 80%
• Temporal pattern   No distinct season, may
                     increase in summer-fall
    Reported Cases of Pertussis in
          Texas 1920-2007

25000
                             Pertussis Toxoid Licensed in 1949


20000


15000


10000


 5000


    0
        1920




               1930




                      1940




                              1950




                                     1960




                                             1970




                                                    1980




                                                            1990




                                                                   2000
              Pertussis Trends
                2000-2007
2500


2000


1500


1000


500


   0
       2000   2001   2002   2003   2004   2005   2006   2007
 Deaths due to Pertussis in Texas
10
9
8
7
6
5
4
3
2
1
0
         2000      2001       2002   2003   2004   2005   2006   2007   2008*


     Provisional as of 11/12/08
        Percentage of Pertussis
        cases by Race/Ethnicity
100
 90
 80
 70
 60
 50
 40
 30
 20
 10
  0
      Asian   Black   Hispanic   White   Other   Unknown

                          2006   2007
Percentage of Texas Pertussis
 Cases by Age Group, 2007
40
35
30
25
20
15
10
 5
0
     <1 year    1-4      5-9       10-14      15-19    20+
               years    years      years      years   years

                       2005     2006   2007
2005 Incidence of Pertussis
          How can ED help?
• Vaccination policies
  – Employees
  – Patients
• Collecting specimens
  – Prior to antibiotic treatment
  – Viral and serologic
  – Send to state lab for confirmation
• Reporting suspects to LHD
Specimen Collection & Shipping
Guidelines (Measles, Mumps, Rubella)
• Serology
  – Collect a minimum of 6-8 mL of blood in a red-top
    tube or tiger top tube
  – Within 8 hrs of collection may be transported at
    room temperature in the original blood collection
    tube
  – Within 48 hours of collection, sera must be
    separated from the blood and shipped on cold
    packs, between 20 and 80C
  – > 48 hours of collection, then the samples must be
    frozen at –200C or lower and shipped on dry ice
  – Do not freeze whole blood
Specimen Collection & Shipping
      Guidelines (cont’d)
• Virology
  – Specimen should be collected within four (4)
    days of rash onset
  – Urine: Collect 50-100 mL of urine (first
    morning voided urine is ideal)
  – Transport cold on ice packs within 48 hours
    of collection
  – > 48 hours, freeze and ship on dry ice
                              Resources
• DSHS
   – TXVPD Guidelines
  http://www.dshs.state.tx.us/idcu/health/vaccine_preventable_diseases/resources/vpd_guide.pdf


   – Laboratory Website
  http://www.dshs.state.tx.us/lab/default.shtm


• Centers for Disease Control and Prevention
   – Vaccine Information:
   www.cdc.gov/vaccines

   – ACIP Recommendations & Guidelines:
   www.cdc.gov/vaccines/recs/default.htm