Measles outbreaks in Washington State



Andrew received a dose of measles, mumps, rubella, and varicella (MMRV) vaccine at 12 months of age.



This past week we saw the first case of measles in a Pierce County resident since 2006.

Our newest case is a 13-month-old child that was seen in an emergency department (ED) in Tacoma on June 10th for an unrelated condition. Unfortunately, there was a King County resident in the ED who had contracted measles from an unvaccinated person who had returned to the U.S. on May 26th. While he was contagious, the 13-month-old Pierce County resident was seen in the Mary Bridge/Tacoma General ED on June 22^nd and June 24^th and at the St Joseph ED June 24^th – 25^th.

My colleagues and I at the Tacoma-Pierce County Health Department have been anxiously watching previous outbreaks of measles in Washington State and preparing for an outbreak in our jurisdiction.

On March 29^th of this year, a Whatcom County resident with measles travelled to King and Pierce counties. That person's infection was linked to a large outbreak in Fraser Valley, British Columbia. Fortunately, no secondary cases of measles from those exposures were reported in either Pierce or King county.

 

The incubation period for measles is usually 1 to 3 weeks. A person with measles becomes contagious 4 days before developing a rash, that is, before that person has any signs or symptoms of measles.

For people who have not been vaccinated or those whose immunization status is unknown, measles vaccine can be given up to 72 hours after exposure to prevent measles or reduce the severity of the disease. For people who cannot receive measles vaccine or for people at high risk of complications from measles, immune globulin can be used up to 6 days after exposure to reduce the severity of disease.

In the United States, measles vaccine is usually not given to children less than one year of age. This is because maternal antibodies, which partially protect babies from measles, can interfere with the immune response to measles vaccine. Measles vaccine can be given as early as 6 months of age if a baby has been exposed to measles or in preparation for travel to a country in which measles is endemic. A dose given before 12 months of age does not count as that child's first dose, so that child should receive a dose at 12 to 15 months of age and 4 to 6 years of age.

The health department sent an alert to health care providers in Pierce County asking them to be on the lookout for cases of measles. Health care providers are required by state law to immediately notify the health department of suspected cases of measles. My colleagues and I at the health department are on call 24/7 to respond to those notifications.

Fortunately, most school children in Pierce County have received 2 doses of measles, mumps, and rubella (MMR) vaccine. The vaccine provides life-long protection against measles to more than 99% of people who receive two doses.

My previous posts on measles and related topics:

·       Measles

·       Diseases eliminated from the U.S. by vaccines

·       Attack ratios

·       Travel immunizations update

Center for Disease Control and Prevention (CDC) information on measles and measles vaccine:

·       Measles (Rubeola)

·       Measles Vaccination

·       MMR ACIP Vaccine Recommendations

·       Pink Book

Reference:

Centers for Disease Control and Prevention. (2013). Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 62(4), 1-34. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm.

 

 

 

Travel immunizations update

 

 

This summer I will spend a month teaching nurses in Tanzania. In preparation for my trip, I'm reviewing travel medicine recommendations and would like to address some developments since my previous post on travel immunizations.

 

Measles

In previous years, the Centers for Disease Control and Prevention (CDC) reported that most of the cases of measles in the United States are associated with importations from countries where measles immunization coverage is low. In the first 5 months this year, there have been more cases of measles in this country than in any year since 2000 when measles was eliminated from the U.S.

 

 

 

 

Once again, most of those cases are associated with importations, nearly half of which were travelers returning from the Philippines, and most of the cases are unvaccinated people. There has also been a large outbreak of measles in Fraser Valley, B.C. that centered on a community with low measles immunization coverage and was associated with importation from the Netherlands. Here in Washington State there were several cases associated with the Fraser Valley outbreak in Whatcom County. One individual traveled to King and Pierce Counties. Fortunately, there were no known cases from those exposures.

 

The CDC reiterated its measles vaccine recommendation for travelers.

 

Polio

On May 5^th 2014 the Director General of the World Health Organization (WHO) declared ongoing international transmission of wild polio virus (WPV) a public health emergency and issued temporary requirements for polio immunization for travel between countries that are currently exporting WPV.

 

WHO requested the following countries ensure that long-term visitors (more than 4 weeks) show documentation of a polio vaccine booster between 4 weeks and 12 months prior to departure (countries currently exporting WPV):

 

·       Cameroon

·       Pakistan

·       Syria

 

WHO requested the following countries encourage long-term visitors (more than 4 weeks) to receive a polio vaccine booster between 4 weeks and 12 months prior to departure (countries with active WPV transmission but not currently exporting WPV):

 

·       Afghanistan

·       Equatorial Guinea

·       Ethiopia

·       Iraq

·       Israel

·       Nigeria

·       Somalia

 

These are measures are temporary and may change.

 

The CDC maintains its recommendation the travelers to polio-affected countries are fully vaccinated against polio and that adults receive a one-time polio vaccine booster.

 

Yellow fever

As I discussed in my previous post, International Health Regulations (IHR) require yellow fever vaccanation for travel between certain countries. The requirement includes booster doses of yellow fever vaccine every 10 years.

 

Last year the WHO Strategic Advisory Group of Experts (SAGE) on immunizations examined the effectiveness and duration of immunity of yellow fever vaccine and concluded that, for healthy people, immunity to yellow fever from a single dose of vaccine is probably life-long and that booster doses are not required. Further research is needed to determine in the efficacy and safety of yellow fever vaccine in certain populations including people who are immunocompromised and pregnant woman.

 

The current recommendations for booster doses of yellow fever vaccine every 10 years will remain in effect until June 2016 – long before I'm due for another dose.

 

Traveler's health

There are specific recommendations for each of the vaccines that I've discussed. For example, documentation of receipt of a yellow fever vaccine may only be required for persons traveling from an endemic country and may not be required for a person traveling directly from the United States. International Health Regulations require that yellow fever vaccine be administered at an authorized yellow vaccine clinic.

 

There are also specific contraindications and precautions for each of these vaccines.

 

In addition to required and recommended vaccines, there are other recommendations for travelers for health risks specific to endemic counties or areas within those countries.

 

Please consult a travel medicine specialist at least 4 to 6 weeks prior to departure.

 

Vaccine information

·       Measles

·       Polio

·       Yellow fever

 

Recommended reading

·       The Cutter Incident: How America's First Polio Vaccine Led to the Growing Vaccine Crisis

·       The American Plague: The Untold Story of Yellow Fever, the Epidemic that Shaped Our History

·       Could Yellow Fever Return to the United States?

 

I'll miss you while I'm away, little man.

 

References

 

Centers for Disease Control and Prevention. (2000). Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 49(5), 1-22. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4905a1.htm.

 

Centers for Disease Control and Prevention. (2009). Updated recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding routine poliovirus vaccination. Morbidity and Mortality Weekly Report, 58(30), 829-830. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5830a3.htm.

 

Centers for Disease Control and Prevention. (2013). Clinical update: yellow fever vaccine booster. http://wwwnc.cdc.gov/travel/news-announcements/yellow-fever-vaccine-booster.

 

Centers for Disease Control and Prevention. (2014). Guidance to U.S. clinicians regarding new WHO polio vaccination requirements for travel by residents of and long-term visitors to countries with active polio transmission. http://emergency.cdc.gov/han/han00362.asp.

 

Gastañaduy, P. A., Redd, S. B., Fiebelkorn, A. P., Rota, J. S., Rota, P. A., Bellini, W. J. et al. (2014). Measles – United States, January 1 – May 23, 2014. Morbidity and Mortality Weekly Report, 63(22), 496-499. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm.

 

Gotuzzo, E., Yactayo, S., & Córdova, E. (2013). Efficacy and duration of immunity after yellow fever vaccination: systematic review on the need for a booster every 10 years. American Journal of Tropical Medicine and Hygiene, 89(3), 434-444. http://www.ajtmh.org/content/89/3/434.long.

 

McLean, H. Q., Fiekelkorn, A. P., Temte, J. L., & Wallace, G. S. (2013). Prevention of measles, rubella, congenital rubella syndrome, and umps, 2013. Summary recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report, 62(4), 1-34. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm.

 

Staples, J. E., Gershman, M., & Fischer, M. (2010). Yellow fever vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 59(7), 1-27. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5907a1.htm.

 

World Health Organization. (2013). Meeting of the Strategic Advisory Group of Experts in immunizations, April 2013 – conclusions and recommendations. Weekly Epidemiological Review, 88(20), 201-216. http://www.who.int/wer/2013/wer8820.pdf.

 

World Health Organization. (2013). Vaccines and vaccination against yellow fever. Weekly Epidemiological Review, 88(27), 269-283. http://www.who.int/wer/2013/wer8827.pdf.

 

World Health Organization. (2014). WHO guidance for implementation of the IHR temporary recommendations under the IHR (2005) to reduce the international spread of polio. http://www.polioeradication.org/Portals/0/Document/Emergency/PolioPHEICguidance.pdf.

 

World Health Organization. (2014). Yellow fever vaccination booster. http://www.who.int/ith/updates/20140605/en.