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Measles Epidemiology United States, 2006

Measles Epidemiology United States, 2006. Jane Seward, MBBS, MPH Acting Deputy Director, Division Viral Diseases Centers for Disease Control and Prevention. FDA BPAC Meeting Bethesda, August 16 th , 2007. Measles. Highly contagious viral illness

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Measles Epidemiology United States, 2006

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  1. Measles EpidemiologyUnited States, 2006 Jane Seward, MBBS, MPH Acting Deputy Director, Division Viral Diseases Centers for Disease Control and Prevention FDA BPAC Meeting Bethesda, August 16th, 2007

  2. Measles • Highly contagious viral illness • Near universal childhood infection in the pre-vaccine era • Morbidity and mortality 1950s, United States • 450 deaths annually • 48,000 hospitalizations • 4,000 cases encephalitis

  3. Measles Prevention • Live, attenuated measles vaccine licensed 1963 • Almost all administered as MMR vaccine • Efficacy • One dose ≥ 12 months: 95% • Two doses at least 4 weeks apart ≥ 12 months: 99% • Schedule: 2 doses • Children 4-6 years (school students) • College students • Health care workers • International travelers

  4. Maximize population immunity to measles • Deliver the first dose on time • Increase second dose coverage in school children • Vaccinate high risk adults • Assure adequate surveillance • Respondrapidly to outbreaks • Work to improve global control Strategies to Control and Eliminate Measles, US

  5. Reported Measles Cases by Year, United States, 1950-2006 Second dose strategy and school laws Vaccine licensed School immunization laws started in all states Improved first dose preschool coverage

  6. Reported Measles IncidenceUnited States, 1992-2006* Measles elimination declared 1 case/million *provisional 2006 data

  7. Measles Cases by Age GroupUnited States, 1976-2006

  8. Measles Cases by Age GroupUnited States, 1976-2006

  9. Age Specific Incidence of Measles, 1996-2006

  10. Largest Measles OutbreaksUnited States, 1999-2006

  11. Age Distribution of Measles CasesUS, 2001-2006 * Provisional

  12. Vaccination Status Measles CasesUS, 2001-2006 * From NNDSS

  13. Internationally Imported Measles Cases, 1985 – 2006

  14. Measles Genotypes and Measles Cases USA: 1980-2005 30,000 25,000 20,000 Interruption in transmission 15,000 Measles Cases 10,000 5,000 0 80 81 82 83 84 85 86 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 87 G1 D3 A, C2, B2, B3, D2, D4, D3, D5, D6, D7, D8, G2, H1, H2 Viral Genotypes (2 strains in 1983) (30 isolations) (>100 isolations)

  15. Imported Measles Cases1996-2005* Total Cases Imported - 348 Japan - 50 cases China - 36 cases Germany - 26 cases India - 23 cases Philippines - 19 cases Italy - 17 cases Pakistan - 15 cases Greece, United Kingdom – 11 cases each 54 other countries – 140 cases *2005 provisional data through Oct 29

  16. Measles in the U.S.—2006* • 55 cases reported by 16 states • States reporting largest number of cases: MA (18), NY (10), CA (6) & FL (4) • 52 cases (95%) were imported-associated cases: • 31 imports • 20 epi-linked to imported cases • 1 virus only case • 3 cases were unknown source cases *CDC data, unpublished

  17. Source Countries for 2006 Imported Measles Cases (N=31) India 6 Ukraine 6 China 5 U.K. 3 Pakistan 2 Australia 2 Italy 1 Hong Kong 1 Thailand 1 Kenya 1 Ethiopia 1 Uganda 1 Yemen 1

  18. 2006 Measles Outbreaks • 4 outbreaks: • MA (18 cases) resulting from single import from India -- Office Building(s) • FL (3 cases) among cruise ship employees, source Ukraine • NYS (3 cases) among Immigrants living in a Yemen community • CA (1 case) WA (1 case) MO (1 case) - 3 mothers exposed in China during adoptions

  19. Cases in US in 2006 with genotype associated with case(s) or outbreaks 1 case : H1 [Hong Kong] 1 case: D6 [Ukraine] 1 case: B3 [inter’l travel, UK] Oregon Indiana New York City 1 case: D8 [inter’l travel Australia] Boston 17 cases: D8 [India] 2 cases: B3 [travel: Disneyworld] 1 case: D8 [India] 3 cases: B3 [Yemen] 1 case: D4 [Pakistan] 1 case: D6 [Ukraine] 1 case: H1 [China] 1 case: B3 [UK]

  20. Cases in US in 2005 with genotype associated with case(s) or outbreaks 1 case: D4 [inter’l meeting, France] 2 cases: D4 [inter’l travel, Germany] 34 case outbreak: D4 [Romania] & 1 case: D4 [Romania] Washington 1 case: D4 [Yemen] Wisconsin 2 Indiana Illinois 1case:D8 [India] Michigan New York 2 3 1 case: D9 Indonesia] & 1 case: D8 [India] New York City 1 33 1 New Jersey 1 3 1 case: B3 [Kenya] Arizona Texas 1 case: D6 [Armenia] 3 cases: B3 [inter’l travel, Mexico]

  21. Extremely low incidence • Majority of cases are internationally imported or import associated • Surveillance system is adequate • Population immunity is very high • No endemic strain of measles virus Evidence for Elimination of Endemic Measles in the U.S.

  22. Adequate Surveillance to Detect Endemic Measles • Consistent detection of imported measles cases • Detection of isolated cases and small outbreaks • High level of investigative effort for measles • Molecular typing consistent with elimination of indigenous genotype of measles virus

  23. First dose coverage > 90% since 1996 for 19-35 month-old children • First dose coverage > 97% for school-age children • Second dose required for 82% of school children as of 2001 • Seroprevalence 1999-2004 shows 96% immunity (EIA) ages 6-49 years High Population Immunity

  24. Prevalence of Measles AntibodiesU.S Population, 1988-1994 93% ≥ 6 years Born < 1957 99% Born >= 1957 87% Born 1967-76 81% Hutchins SS et al, JID 2004

  25. Duration of Vaccine Induced Immunity? • US has used measles vaccine since 1963 • Some vaccine recipients received measles vaccine 40 years ago • Younger cohorts are not being exposed to wild measles virus • Important to monitor population immunity including whether immunity remains above the protective level

  26. Persistence of Measles Antibodies After 2 Doses of Measles Vaccine in a Postelimination Environment LeBaron CW, Beeler J, Sullivan BJ et al. Arch Pediatr Adolesc Med. 2007;161:294-301

  27. Projected Measles Antibody Levels following MMR2 Vaccination at Kindergarten Age A, Titers in the kindergarten group B, Percentage potentially susceptible in the kindergarten group.

  28. Persistence of Vaccine-Induced Measles Antibody • Small long term follow up study of persons from vaccine trial in 1971 • Participants 26-33 years after last measles vaccine dose • No known exposures to measles • All 56 participants had PRN antibody ≥ 1:8 • 9% had PRN titer ≤ 120 (not considered protective) • Cellular immunity? Dine MS, Hutchins SS et al JID 2004

  29. Conclusions • Measles no longer endemically transmitted in U.S. • Almost 100% cases are import associated • Importations continue to challenge population immunity • Extremely limited spread from importations due to high population immunity • No indication of immunity waning to “susceptibility” from epidemiological data • Continue long term monitoring of vaccine-induced immunity

  30. Thank You

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