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Measles Outbreak in Clark County: Challenges to Immunization

This article discusses the measles outbreak in Clark County, Washington in 2018-19 and the challenges faced in implementing immunization legislative action. It covers the case investigation, healthcare provider advisories, case and contact investigation, immunization recommendations, exposure sites, school exclusions, response efforts, and challenges of misinformation on social media.

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Measles Outbreak in Clark County: Challenges to Immunization

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  1. Measles and Rubella Initiative Washington D.C., September 11, 2019

  2. Outbreak, Clark County 2018-19 Challenges to Immunization Legislative Actionin Washington

  3. Beginning of the Outbreak Dec 31, 2018 First known case visits Memorial Urgent Care Jan 4, 2019 Lab confirms measles in a child 1–10 years old with unknown immunization history Jan 15, 2019 2 additional confirmed cases and 11 suspect cases identified. Public Health activates Incident Command System to respond to the outbreak. January 2019 February 2019 March 2019

  4. Case Investigation Measles is a notifiable condition. State law requires physicians and other healthcare providers to notify Public Health of any suspected measles cases. Clinicians collect specimens and coordinate with Public Health to arrange testing at public health labs. Public Health staff interview the case/parents of the case to gather information about illness onset and where the case had been the previous 21 days.

  5. Healthcare Provider Advisories Multiple Healthcare Provider Advisories were issued from January through March of 2019: Jan 17 Measles Regional Alert Feb 3 Measles Regional Alert Jan 15 Measles Regional Alert Feb 13 Measles Regional Alert Jan 25 Measles Regional Alert Mar 5 Measles Regional Alert Jan 4 Measles Alert January 2019 February 2019 March 2019

  6. Provider Advisory Content • Clinical presentation • Infection control recommendations • Exposure locations • Suspect measles worksheet • Determination whether case is highly suspect based on clinical presentation, immunization status, exposure and travel history • Lab recommendations: specimen collection/storage, lab testing • Specimen collection guidelines • Instructions for arranging specimen shipping to public health lab • Recommendations regarding exclusion, post exposure prophylaxis • Sources for more information

  7. Case and Contact Investigation Case at a large public setting while contagious: Notify public through news releases, website and social media Case at school while contagious: Identify susceptible students and staff Exclude from school and other public settings for 21 days Actively monitor for 21 days (daily calls) Case at a health care facility while contagious: Obtain list and contact information of exposed patients and contact them Identify those who are susceptible and actively monitor for 21 days (home quarantine, daily calls) Recommendations on PEP Identify whether anyone else was present/exposed and contact them and actively monitor if indicated

  8. Immunization Recommendations Post Exposure: • MMR to eligible unvaccinated if within 72 hours of exposure • Do not give MMR post 72 hours to unimmunized individuals • IG within 6 days for: Unvaccinated pregnant women Infants Severely immunocompromised and ineligible for vaccine Routine Vaccination: Do not extend to infants 6-11 months

  9. Case Contacts Investigated

  10. Summary: 71 Cases

  11. Exposure Sites 54 exposure sites, some with multiple exposure times: 12 health care facilities 15 schools: 3 public school districts 2 private schools 1 child care facility 26 other locations: Including churches, grocery stores, Moda Center and Portland International Airport

  12. Public Exposures By Type 96 Exposures: 30 General Public 29 Healthcare Facility 31 School 2 Daycare 4 Workplace

  13. 71 Cases in Time Measles cases, by transmission setting and date of rash onset: Clark County, WA 12/30/2018 – 3/13/2019

  14. School Exclusions Public Health excluded susceptible students and staff at 13 public schools in three school districts, and two private schools: Evergreen Public Schools 293 students excluded Cornerstone Christian Academy 20 students excluded Battle Ground Public Schools 398 students excluded Slavic Christian Academy No students excluded Vancouver Public Schools 138 students excluded

  15. Response: Staffing and Cost Days in response: 58 Total responders: 237 Daily average: 40 to 50 Clark County Public Health: 89 Washington Department of Health: 57 Centers for Disease Control and Prevention: 3 Medical Reserve Corps: 50 Mutual aide, local volunteers, Emergency Management Assistance Compact, Interpreters, others: 38 Cost: $864,678.73

  16. Challenges to Immunization

  17. Misinformation on Social Media Sites False Claims: Measles False Claims: MMR Getting measles is best way to develop immunity Measles prevents cancer Measles is benign (no deaths or complications) The vaccine contains toxins and fetal parts Measles vaccine sheds and infects others Genetic susceptibility to adverse effects Measles vaccine causes autism Misinformation regarding risk of seizures and encephalitis “Big Pharma” conspiracy Data Misinformation Claims that Public Health is misrepresenting exclusion data Misunderstanding between WAIIS (registry) and school report data (reported proportion of unimmunized higher than exemptions)

  18. Immunization and Exemption Rates Immunization¹ Rates: Exemption² Rates: 7.5% Overall 78% of 6-18 year olds have two doses of MMR 81% of 1-5 year olds have one dose of MMR 5.9% personal 0.9% medical 0.6% religious 1Washington State Immunization Information System 2 Washington State Department of Health School Immunization report

  19. 2017-18 Exemption rates Percent of kindergarteners withany vaccine exemption (By attendance area, 2017-18 school year) Washington State School Immunization Slide Set, 2017-2018 School Year. Washington State Department of Health, 2018. Updated March 2018.

  20. 2017-18 Immunization Rates Percent of kindergarteners complete for all immunizations (By attendance area, 2017-18 school year) Washington State School Immunization Slide Set, 2017-2018 School Year. Washington State Department of Health, 2018. Updated March 2018.

  21. 2017-18 Immunization Rates Percent of kindergarteners complete for the MMR vaccine (By attendance area, 2017-18 school year) Washington State School Immunization Slide Set, 2017-2018 School Year. Washington State Department of Health, 2018. Updated March 2018.

  22. Image credit: https://commons.wikimedia.org/wiki/User:Cacophony Legislative Action in Washington

  23. Immunization Increases

  24. Immunization Increases

  25. Proposed Legislation Senate Bill 5841 House Bill 1638 Eliminated personal/philosophical exemptions from school immunization requirements for all school-required vaccines Multiple amendments added that would create a list of vaccines, “grandfather” personal exemptions already in place, continue to allow the personal exemption for daycare and preschool Did not make it out of committee Eliminated personal/philosophical exemptions for MMR Passed the House with several anti-vaccination amendments added

  26. Misinformation Affecting House Bill 1638 Misinformation led to legislative amendments, specifically inappropriate medical exclusions: Immune problem in first degree relative Adverse reaction in first degree relative

  27. Examples of Misinformation in Amended Bill “The reasons for which a health care practitioner may certify that a vaccine is not advisable for a child include, but are not limited to, if the child has a biological parent, brother, or sister, with a documented history of immune system problems or a documented adverse reaction to a particular vaccine required by rule of the state board of health “A written certification signed by any parent or legal guardian of the child, or any adult in loco parentis to the child, that the child has a biological parent, brother, or sister, with either of the following, documented by a health care practitioner: A history of immune system problems sufficient to make a particular vaccine contraindicated for the child under guidelines issued by the United States centers for disease control and prevention; or An adverse reaction to a particular vaccine required by rule of the state board of health sufficient to make the particular vaccine contraindicated for the child under guidelines issued by the United States centers for disease control and prevention; or

  28. Final House Bill 1638 At the 11th hour, amendments stricken Final “clean” bill passed the legislature Involved of state and local public health jurisdictions and partners Removed philosophical or personal exemption for MMR Governor signed into law

  29. Good News, Bad News Good News… Outbreak declared over on April 28 House Bill 1638 …and Bad News: Another outbreak, either in Clark County or elsewhere, is inevitable

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