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CDC Update on Measles Outbreaks in United States Transcript

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					CDC Update on Measles Outbreaks in United States
Moderator: Dr. Anne Schuchat May 1, 2008 1:00 p.m. ET OPERATOR: Welcome. And thank you all for standing by. At this time, I would like to remind parties that your lines are on a listen-only mode until the question-and-answer session, at which time you may press star one to ask a question. Today's call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the meeting over to Curtis Allen. Thank you, sir. You may begin. CURTIS ALLEN: I thank you for your patience. Today, we will be giving you an update on measles outbreaks throughout the United States. The main speaker will be Dr. Anne Schuchat. That is Dr. Anne Schuchat. She is director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. Also joining her will be Dr. Jane Seward. That is Jane Seward. Jane is deputy director of the Division of Viral Diseases in the National Center for Immunization and Respiratory Diseases. Dr. Schuchat will make a few opening remarks, and then we will open the floor to questions. There will be an early release MMWR posted on the CDC Web site this afternoon. I believe many in the media have already received a fact sheet concerning this briefing. So now I'll turn it over to Dr. Schuchat. DR. ANNE SCHUCHAT, DIRECTOR, NATIONAL CENTER FOR IMMUNIZATION AND RESPIRATORY DISEASES: Thank you, Curtis. I want to speak with you today about a concerning situation. We have had more cases of measles this year than in any year since 2001. People have heard about outbreaks in individual communities, but in the country as a whole, between January 1st and April 25th, there have been 64 cases of measles reported to CDC. These are occurring in nine different states. And there are a couple important themes that I want to stress about these cases. Many people have forgotten about measles. It causes about 20 million infections around the world every year. But fortunately in the U.S., we declared the condition eliminated in 2000 after we interrupted ongoing transmission within the country. But measles is still in many parts of the world and can come in easily through visitors or through Americans traveling abroad who bring it back. What we have this year is 64 cases to date reported to us, and 20 percent of those have been hospitalized. None of them have died, fortunately.

The three issues that I want to stress are about importations and travel, about the healthcare settings, and about unimmunized persons, because each of those is relevant to this year's situation. Most of the importations that we are seeing are coming from the World Health Organization's European region, in particular from outbreaks that are ongoing in Switzerland and Israel. In Switzerland, there have already been more than 2,000 cases in their outbreak, and in Israel, more than 1,000. So many of our importations are associated with Europe, as well as Israel. Many people don't think of traveling to Europe as a place where you can come down with an infectious disease, but, of course, measles is still endemic in most of the European region. It's very important for travelers heading off to Europe to make sure that they're up to date on their immunizations and that measles is an ongoing risk. Measles is extremely infectious and it really is able to find that one unimmunized person in a population. And so next I want to talk about the healthcare role or healthcare setting as a role for transmission of measles. Many of the cases that we're seeing this year have been in children who are too young to have been immunized with measles vaccine, children who are under 12 months of age. At least one of those children acquired measles in the doctor's office, in the waiting room. And other cases have been acquired in the hospital setting, emergency rooms or in healthcare workers, actually. It's very important for people who are working in healthcare settings to make sure that they are immune from measles, either by being fully immunized or having their immunity checked with a titer or by a documented birth before 1954. So it's extremely infectious in the healthcare setting. Because measles can be severe, most people do seek medical care. And it's in those medical settings where they can transmit the infection. The third issue I want to mention is about the unimmunized population. In the United States, we're very fortunate to enjoy very high levels of immunization. When we look at our toddler population around the country, more than 92 percent of toddlers are immunized with the MMR vaccine. When we look at kindergarten entry, about 96 percent of kindergartners have gotten their measles immunizations. They're supposed to get a second dose by kindergarten. But that doesn't mean that there aren't pockets of unimmunized children and adults around the country. And we know that measles can make its way to those communities. In the outbreaks so far this year, two-thirds of children who are old enough to be immunized but are not turned out to not be immunized because of personal belief or religious exemption. So we want to make sure that parents who are making decisions about immunizing their children are aware of the measles risk that's ongoing around the country and make sure that they have a chance to talk with their provider about opportunities for protection. We have seen resurgences of measles in the past. Between 1989 and 1991, the United States suffered 55,000 cases of measles and 123 deaths. The measles vaccine is extremely effective, 99 percent effective, and we strongly recommend unimmunized persons to be immunized. I'd like to be able to answer questions that you may have. And so the final points I want to make are that measles is extremely infectious and can be severe, that cases of measles are increasing in the United States,

mostly related to importations from Europe and Israel, and that our communities with many unimmunized persons are at risk for ongoing transmission of the virus. So I'd be happy to answer questions. OPERATOR: Thank you. At this time, if you'd like to ask a question, press star, followed by one, on your touchtone phone. You'll be prompted to record your name. Please state your name and unmute your phone, and we'll announce you prior to asking your question. Again, press star, followed by one, on your touchtone phone. The first question is from Ron Lynn (ph), Los Angeles Times. Your line is open. RON LYNN (ph), LOS ANGELES TIMES: I just wanted to ask you two questions. Are there signs that these pockets of unimmunized people are growing? And do you feel that health officials are struggling to convince the public that the MMR vaccine is safe? SCHUCHAT: Thank you for that question. You know, we don't have data for every community, but we do know from our national surveys that there is clustering of unimmunized or underimmunized persons. Ten or 15 years ago, those clusters were in pockets of needs where people were poor or had limited access to healthcare, but with a strong immunization program and the vaccines for children program, which overcomes the cost barrier to immunization, now I think we're seeing a different trend, with communities or pockets of unimmunized or underimmunized children that are more closely linked to exempt from immunization, either religious or personal beliefs. I am concerned that those communities may be growing. And I think it's very important for parents to have good information to make decisions, to discuss with their doctor the risks and benefits of vaccines, and the ongoing risk of vaccine-preventable diseases. So I think I can take the next question. OPERATOR: The next is from Will Dunham from Reuters. Your line is open. WILL DUNHAM, REUTERS: Yes, hi. Just a couple questions, please. You mentioned the nine states. Washington state, since the 26th, also has reported a case, so it's actually 10 states – correct? And could you go through all the countries from which the importation took place? SCHUCHAT: Right, thank you. That's right. The MMWR that we're releasing today goes through the cases reported to CDC by April 25th. We are aware of a number of additional cases. In Washington State, there are eight confirmed cases now that have occurred – that have been reported to us since the April 25th cutoff. And it's a sad story, a family that has a number of affected children, including a few that have been hospitalized. The actual countries where importations have been documented include – I will go through these, and then maybe let Jane supplement, if I can't remember them all – but they include: Switzerland, Israel, Belgium, Italy, probable Japan, and probable China, and India, as well.

Japan and India have been on sort of the list of importations for a number of years, but they're not – so it's the European countries that are a bit newer for us, in terms of dominating the importations that we're seeing. OK, I think we also – for those, we also have a map that shows the locations of the outbreaks and individual cases that we're aware of, as well as the sources. And that will be in the MMWR that I think most of you will be getting. Did you have another question or was that it? DUNHAM: The total number of confirmed cases you have now is what, including the Washington state cases? SCHUCHAT: You know, I think we're still going with the total being 64, as we tally up the next week's cases. DUNHAM: As of a week ago, you're now aware that Washington state has cases numbering eight? SCHUCHAT: Yes, that's right. DUNHAM: OK. OK. Thank you. OPERATOR: The next is from Rob Stein. Your line is up, the Washington Post. ROB STEIN, WASHINGTON POST: Yes, hi. Thanks very much. Two questions – can you just list the, I guess, 10 states? And, also, I guess, how worried are you about the fact that fewer parents are getting their kids immunized and how much of a role that's playing in this? SCHUCHAT: Right. The states that – the 64 cases include 15 from Arizona, 12 from California, three from Hawaii, one from Illinois, four from Michigan, 22 in New York City, and then one in New York state outside of New York City, one from Pennsylvania, one from Virginia, and four from Wisconsin. And those numbers, again, will be in the MMWR. You know, I think it's important for states who aren't on that list to have their alerts up, because we know there are unimmunized people out there and that measles is extremely infectious and that we have visitors to the country, and many of us travel frequently outside the country. And so I don't think not being on the list should be reassuring to people. I think this is a really important issue for parents and for providers. I am concerned. This is different than what we've been seeing the past few years. And we know that some of our European colleagues were having major challenges controlling the outbreaks in their countries. And so I expect there to be importations very frequently for our population traveling overseas frequently. And I think we really need to make sure that our protection is as strong as possible and that people understand there are benefits and risks associated with the measles vaccine. Next question? OPERATOR: The next is from Mike Stobbe. Please state your affiliation. MIKE STOBBE, ASSOCIATED PRESS: Hi, it's Mike from the A.P. Thanks for taking the question.

Dr. Schuchat, if you could amplify just a little bit more on the comment you made just a second ago, your concern this is different from what we've been seeing the last few years. It's different because, what, because of inadequate vaccination? And I have a part two question, also. SCHUCHAT: OK. Sure. I think the principle difference this year is the extent of outbreaks in Europe, in places where people are not – places where there's frequent travel back and forth and where travelers don't necessarily take the same kind of travel precautions they do when they're traveling to other locations. And I think it's different because the outbreaks have been so challenging to manage, in Switzerland in particular. The second factor is the – you know, we are in a very different era right now where many doctors, nurses and parents are not familiar with measles, where people can seek medical care for something and transmission can occur because we don't take all the precautions that we would have. Twenty or 30 years ago, people were much more familiar with measles as parents, as well as doctors. And so we isolated people when they came into the healthcare setting, and we really limited transmission opportunities. We're really lucky that we aren't so familiar with measles anymore. But I think we're at a turning point where we need to make sure we don't go back to those days. So those are the factors that I think are driving things. Of course, there are unimmunized children. And there are pockets where many children are unimmunized. And those are particularly of concern, because they can foster ongoing transmission, you know, from one person to another, generation of people to another group of people. And those circumstances can make it harder to nip this in the bud. Every year in the United States, the public health system is called into action repeatedly to investigate suspected measles cases, to confirm them and to control around them, to make sure that we don't see it spread. I think we have some circumstances today that will make this continue to be challenging for us. STOBBE: Thank you. And my part two, is there a cycle to the disease? Is it always worse in the spring or the winter, anything like that? SCHUCHAT: Yes, I think because this is a global condition – the American situation is really import-related. And so because we see people from all over the world, we don't really have a seasonality here in the United States. OPERATOR: The next question is from Denise Grady. And please state your affiliation. DENISE GRADY, NEW YORK TIMES: Thank you, from the New York Times. Two questions, please. Is it possible to say how many of these cases were in people who actually caught the disease overseas and brought it back? And then, how many of the cases where in people who caught it from the travelers, any kind of even approximate breakdown? And then the second question is, overseas, are they having these big outbreaks because they're having the same kind of resistance to vaccination that we are starting to see here? Thank you.

SCHUCHAT: Right, OK. So let me do the second question first, while I seek the numbers for the first question. The situation in Switzerland did begin with a community that, for philosophical purposes, was not being immunized. And so that may be analogous to some of the communities here in the United States. In Israel, I don't think that is – that is not what's going on. They actually have pretty high coverage in young children, and they have pretty high coverage at school entry. But this has just been a very challenging outbreak for them. So I think we can see resurgences in difficult-to-control outbreaks for many different reasons. I think the – I believe the number is 10 of the cases are importation-associated. And of the 64 – I'm sorry, 10 of them are actually imported, five of those in U.S. visitors and the other 5 in Americans who were traveling abroad and basically brought the virus back with them. Of the 64 total, we think that 54 are importation-associated. They basically either were that importation case, or they're linked in the chain of transmission to that case, or the virus characteristics that we've looked at are associated with a well-documented outbreak that's overseas. So the vast majority of the 64 cases have a clear link with outbreaks in other areas. Only 10 of the 64 were actually in travelers, either Americans or visitors. Next question? OPERATOR: The next is from Miriam Falco. Please state your affiliation. MIRIAM FALCO, CNN MEDICAL NEWS: Hi, I'm from CNN Medical News. Can you tell me if any of these pockets or any of these states with the higher incidence are connected to pockets of people who purposely did not get immunized? Do you have any breakdown on that? And, also, you mentioned that 96 percent of kindergartners are vaccinated. Then why are we – why is it such a risk, if only four percent of the children in that age group haven't gotten the vaccine? SCHUCHAT: Right. The thing about measles is that it's extremely contagious and that, if you put the measles virus in a room with unimmunized people, they would essentially all come down with measles. It's extremely, extremely contagious. It also persists in the environment for a couple of hours after the person has been there. And so we've even seen – in the older days, we saw times where, in the doctor's office, if the environment wasn't carefully cleaned up, somebody could get measles without ever having been in the office at the same time as the person – the first child. I'm trying to remember the first question. It was about … FALCO: The relation between … SCHUCHAT: Oh, that's the one – I'm sorry – about the areas without immunization. Yes, we do know that some of these outbreaks have been occurring in places where there is really aggregation of people who are unimmunized.

In the San Diego outbreak, there was a school where a high proportion of children were not vaccinated. And that's the kind of circumstances where it's easy for the virus to spread. In Arizona, it's been a bit more of the healthcare-associated spread, where people weren't really thinking about making sure they were protected against measles, and there were opportunities for many to be exposed. The Washington state situation was associated with a conference or event of a church group that is actually, I believe, many of the members don't vaccinate their children. So I think the idea that we have very – we have 96 percent of kindergartners protected is great. But when we have clustering of unimmunized, we have a chance for the virus to spread. I think the good news is that parents whose children are fully immunized are very, very unlikely to get measles. Of the 64 cases, only one of these cases has occurred in someone who was documented to have been fully immunized with two doses of measles vaccine. So the vaccine is very effective. Unfortunately, there are a lot of people who can't be vaccinated, because children under 12 months aren't recommended to get the vaccine, and they're really vulnerable to the communities that they live in. And people who have certain medical conditions, who are on chemotherapy or have immunosuppression, also can't get the measles vaccine. So I think that we do – while we enjoy very high rates of immunization coverage, there are pockets where the percent unimmunized is much, much higher. Next question? OPERATOR: The next is from Dan Sorenson. And please state your affiliation. DAN SORENSON, ARIZONA DAILY STAR: The Arizona Daily Star in Tucson. I was wondering if there was any parallel to the mutations, the different strains that you see in influenza with measles that might be lowering the efficacy of the vaccine that's used? SCHUCHAT: No, there are different strains of measles that circulate around the world. And that's one of the ways that our lab is able to tell us, where did this virus come from? You know, this virus looks like the strain that's circulating in Switzerland. But the measles vaccine is extremely effective, 99 percent effective, and we have no evidence from the circumstance today that there's any problem with the vaccine. SORENSON: Thank you. OPERATOR: The next is from Kate Traynor. Please state your affiliation. KATE TRAYNOR, AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY: Hi, I'm with the American Journal of Health-System Pharmacy. I was wondering if you could tell us a little bit more about the measles outbreaks that you said are occurring in hospitals and other healthcare organizations. And are these – is the virus being transmitted by healthcare workers, by doctors, nurses, housekeeping? Or is it being brought in to waiting rooms and whatnot?

SCHUCHAT: The situation – you know, measles virus is a respiratory virus that's spread by coughing or sneezing, but can also persist in the environment. When you cough or sneeze, it can be in the environment for about two hours afterwards. The circumstances in the healthcare settings have been more that someone with measles is in the healthcare setting and others are there either seeking care or being healthcare workers and acquire measles. It does not appear that healthcare workers have been transmitting the infection, at this point to my knowledge. But I think it's very important for healthcare workers to be immunized, not just for measles, but for influenza and for whooping cough, because healthcare workers can be the vehicles of transmission in some infectious diseases. Next question? OPERATOR: The next is from Meg Kissinger. Please state your affiliation. MEG KISSINGER, MILWAUKEE JOURNAL SENTINEL: I'm with the Milwaukee Journal Sentinel. And I'm wondering, you mentioned that there have been no deaths, but previously there have been. How does a person die from measles? SCHUCHAT: You know, we're very fortunate that there haven't been any deaths so far. As I said, in the 1989 to 1991 resurgence, we did have more than 100 deaths. I think it was 123 deaths. And before vaccine, measles used to kill 400 to 500 children a year in the United States. But since we've had this very effective and very safe vaccine, we really don't see that kind of problem anymore. People can die from measles from a number of ways. Complications of measles include pneumonia and encephalitis. And those are two very dangerous complications that can be fatal. So those would be ways that measles moves from a rash illness to a more severe internal illness onto a potentially life-threatening or fatal condition. Next question? OPERATOR: The next is from Richard Knox. Please state your affiliation. RICHARD KNOX, NATIONAL PUBLIC RADIO: From National Public Radio. You partially answered my question earlier when you talked about the situation in Switzerland. But I wonder, since Israel does have good coverage, what explains their difficulty? SCHUCHAT: Yes, I'm going to let Dr. Jane Seward answer that because she's more familiar with the story in Israel. JANE SEWARD, DEPUTY DIRECTOR, DIVISION OF VIRAL DISEASES: That's an excellent question. And I think it raises the issue that we may be facing in the United States, because Israel is experiencing an outbreak of more than 1,000 cases within the context of vaccine coverage in their children overall in the country of 93 percent. And so they have a pocket of their population who are opposing vaccination, quite a large pocket, and those people are being affected by vaccination. So you can get pockets and large outbreaks in a situation of high coverage in a country.

The coverage we have is a similar level to Israel. And so one of the points that we make in the MMWR is that we are concerned, as Dr. Schuchat said, about the population of people who are choosing not to be vaccinated and whether we may be on the verge of facing larger-scale outbreaks in the United States. SCHUCHAT: OK, next question, if there is any. OPERATOR: The next is from John Reichard. Your line is open, and please state your affiliation. JOHN REICHARD, CONGRESSIONAL QUARTERLY: Yes, thank you, with Congressional Quarterly. My question is how many deaths have occurred in Europe and Israel? SCHUCHAT: I don't think – do we have those data? I don't think we have those data. There has recently been a surveillance summary from Europe that we could probably get. SEWARD: About 1,000. SCHUCHAT: Right, there's over 1,000 hospitalizations in Europe. And so the death numbers I don't believe we have. I think another important point that's somewhat related is that the numbers we're all talking about here are reported cases. And so these are episodes we know about, where there's a confirmation that it's measles or by laboratory or it's been linked with a confirmed case through epidemiologic exposures. And so I think that we may not know the full burden of measles here in the United States or certainly not in Europe. We have a very good surveillance system here in the U.S. Because we are at such low levels, our public health system is very busy looking at suspect cases and sorting out whether they truly are measles are not. But I think the numbers from Europe are likely to be underestimates. OPERATOR: The next is from Arthur Allen. Please state your affiliation. ARTHUR ALLEN, WASHINGTON INDEPENDENT: Washington Independent. I had a couple of questions. In assessing how these outbreaks are occurring, I realize that the number is higher than previous years. I was wondering if you could talk about numbers in, say, 2007, 2006, so we have a basis for comparison. And, also, I was wondering if the pattern of these outbreaks is any different. I mean, in the previous years, is this a larger number of places where there are outbreaks than has occurred in previous years? Or is the spread, the secondary spread greater than in previous years? And I have a second question. SCHUCHAT: Sure. Let me read off the numbers of cases for the entire year for the past five years. As I said, so far, just through April 25th, there have been 64 confirmed measles cases reported to us. In 2006, for the entire year it was 55 cases; in 2005, there were 66 cases; in 2004, 37 cases; and in 2003, 56 cases; 2002, 44 cases; and then 2001, which is the one that we're sort of in the same ballpark as so far this year, there ended up being 116 cases.

We do expect to have many more cases this year than we had in 2001, based on what's going today. We have multiple, near simultaneous outbreaks with different importation sources. And we have gone on to the third, fourth or possibly fifth generation of transmission in some of these circumstances. We have had outbreaks in the past few years that involve many people, over 30 people in an outbreak in Indiana a few years ago. But this year does appear to have more simultaneous, ongoing outbreaks from different places. And we also see the outbreaks occurring in communities where many children are unimmunized. So I think that there is reason for concern that we haven't seen the end of this and a really important message for parents and for providers and for travelers that measles can be serious, that there's a very effective and safe vaccine, and that measles may not be on the tip of the tongue of your doctor, and you may want to remind your doctor that, oh, I was just overseas or my child hasn't been immunized and I'm wondering. So I think we really – we are seeing something different right now. ALLEN: OK, one follow-up question. I think many of us are probably looking for the story that this is caused by these sort of expanding pockets of unimmunized children. But I'm wondering, because of the severity of these outbreaks in Israel and Switzerland, is it more likely that this is a case of sort of more heavy bombardment from overseas that's finding those pockets? Or is it that the pockets are larger? I mean, I know that's kind of a hard thing to quantify. But I don't know. SCHUCHAT: Yes, I think there are multiple factors. I think Europe and Israel are having big outbreaks that are ongoing. And we have many people, adults and children, who are not fully protected against measles and are able to acquire it and spread it. So I think the two factors are both important in the circumstances we're seeing today. I think there's time for two more questions. OPERATOR: Thank you. Again, if you'd like to ask a question, press star, followed by one. The next is from Rob Lin. Please state your affiliation. ROB LIN, LOS ANGELES TIMES: From the L.A. Times. Could you go into more detail about the Washington state case? You mentioned sort of a tragic example that happened with a family up there, related to that outbreak affiliated with that convention of churchgoers? SCHUCHAT: Yes, I'll say a little bit, but I really encourage you to contact the Washington health department that's actually going to be much more familiar with circumstances than I am. As I understand it, there was a church-related conference that brought a couple thousand people together, both from around the United States and from some other countries, and that one family in Washington who attended this conference in Washington has now suffered – multiple children, I believe it's eight total affected children – with measles in a family, a couple of whom have been hospitalized. So I really urge you to talk to the health department, because I may not have the data perfect.

OPERATOR: And our final question is from Denise Grady. Please state your affiliation. GRADY: Thank you, New York Times. It's a follow-up. Thank you. I would like to ask you why the children or the patients who are in the hospital here are in the hospital? I mean, are we assuming that they still are – you mentioned that 14 have been hospitalized. And so we're wondering how they're doing. And then just a second part. Do you advice for parents of children now who are too young to be immunized, if they are exposed or about avoiding exposure? Thank you. SCHUCHAT: Yes. I believe most of the hospitalizations that we're aware of, the cause for hospitalization was pneumonia. That was the type of complication of measles that was recognized. But I think we probably are still getting information about the full clinical details. So far, everyone who has been followed out has recovered. There, of course, have been some recent cases reported. And I do believe there are still people in the hospital. So I don't think everybody has left the hospital and is fine. But, you know, I think those are wakeup calls that this can be serious, and no one wants to see their child hospitalized. The other question was advice for parents who are too young to be immunized. You know, I think that's a very heartfelt question and would like to do it justice. Unfortunately, babies too young to be immunized really depend on other people being immunized, the older siblings and family members and the community. If people are going to be traveling to Switzerland or Israel or to a country that's having an outbreak, we actually do relax the age for immunization. So if you're traveling into an area where an epidemic is ongoing, we recommend vaccination down to the age of six months. But for people who aren't traveling overseas, I think the issue of the protection of the community is really the key. Oh, actually, let me let Dr. Seward expand a little bit, because the circumstances are somewhat different if your child has actually been exposed to someone with measles. And then there's a lot we can do. So let me let you answer that. SEWARD: As Dr. Schuchat has said, these measles outbreaks have been a lot of work for health departments around the country. And a lot of the work they do is that they follow up every case and every contact who comes into contact with a case. And so those contacts include children less than 12 months. If they identify the contacts very quickly, they can be offered vaccination if they're over six months. In an outbreak setting, you can actually vaccinate in the United States down to six months, if it's a close contact. That is currently being done in Arizona. Out to six days, you can offer a baby immune globulin. So the important thing, message here is to identify cases quickly and then quickly identify contacts. And that is the job of state and local health departments. They do this job extremely well.

But then, finally, as Dr. Schuchat said very well, babies are protected by people being vaccinated around them. And that's how we decrease their chance of transmission, by maintaining our high immunity in the country. Thank you. ALLEN: Thank you for joining us today. Just to remind you, the MMWR will be posted online within the next couple of hours. There will also be online a transcript of this briefing. You may reach that transcript at www.cdc.gov slash od slash oc slash media. And that should be up in about an hour, hour and a half. Thank you very much. END