A summary of presentations from the weekly Summit partner webinars
January 19, 2023 – The latest Summit Summary
- Central Ohio Measles Outbreak Update – Elizabeth Tiller (CDC)
- RESP-NET Update – Catherine Bozio (CDC)
Central Ohio Measles Outbreak Update – Elizabeth Tiller (CDC)
Elizabeth Tiller, PA-C, MPH, CIC, EISO at Columbus Public Health, CDC, gave an update on the Ohio measles outbreak. Joined by David Sugerman, MD, MPH, measles, rubella, CMV team lead, Viral Vaccine Preventable Disease Branch, CDC.
Ms. Tiller began by giving an overview of clinical measles
- Acute, febrile rash viral illness
- Transmitted by direct contact with infectious droplets/airborne spread
- Most contagious vaccine-preventable diseases (Ro=12–16)
- Clinical presentation
- Incubation period 10–14 days (range 7–21 days)
- The secondary attack rate in susceptible household contacts is about 90%
- Incubation period 10–4 days
- 2–4 day prodrome
- Cough, coryza (rhinitis), and conjunctivitis
- Kolpik spots (white lesions on inner cheek 2 days before rash)
- Fever up to 105° F
- Rash begins 14 days after exposure
- Maculopapular (raised and flat areas of the rash throughout the body; can coalesce to form larger areas of redness)
- Head to toe progression (cavalcade fashion)
- Infectious period 4 days prior to 4 days after rash onset (9-day total period)
- Incubation period 10–14 days (range 7–21 days)
- Clinical Complications
- Hospitalization/supportive care: 1 in 4 cases
- Death 1–3/1K cases
- Comorbid conditions
- Diarrhea: 8% cases
- Otitis media (ear infection): 7–9% cases
- Pneumonia: 1–6% cases
- Encephalitis: 1 in about 1000 cases
- Subacute sclerosing panencephalitis: 1 in about 100,000 cases (develops 6–8 years post-measles infection and ultimately fatal)
Reported Measles Cases, U.S., 1962–2022
- Years prior to measles vaccine, there were 500K cases reported annually
- Almost everyone born prior to 1957 was infected with measles
- Licensure of measles vaccine in 1963
- Measles plummeted through the 1960s and 1970s
- Second measles dose was recommended in 1989
- Slight resurgence of measles from 1989–1991
- Vaccines for Children (VFC) program began in 1993
- Elimination of measles in the U.S. was declared in 2000 (absence of endemic measles and transmission)
Measles Reported in the U.S., 2001–2022
- Since its elimination, measles has been relatively rare in the U.S.
- Around 100 cases/year
- Cases typically imported by international travelers where measles is endemic or outbreak status
- Can lead to local outbreaks
- Increase in measles cases in 2014 (California and Ohio)
- Large increase between 2018 and 2019 due to outbreaks in New York and New Jersey
- Saw nearly no measles in 2022; however, the majority of cases are from the current central Ohio measles outbreak
Measles Outbreaks with ≥50 cases, U.S., 2001–2021
- Since elimination, measles outbreaks have been linked to under-vaccinated in close-knit communities such as Jewish, Amish, Ukrainian, and Somali communities
- In 2018 and 2019, outbreaks located in New York were divided into two groups based on jurisdiction but considered epidemiologically linked
- Outbreak in 2014 in Ohio comprised of 383 cases
- Outbreak in 2014 and 2015 originated in California and were related to exposure at Disneyland
- Other outbreaks
- Washington 2019, with 79 cases
- Minnesota in 2017, with 75 cases
- New York City in 2013, with 59 cases
Large or Disruptive Outbreaks (Last 12 Months)
- Largest outbreaks have been in several countries in Africa and west Asia
- Due in part to disruptions in routine immunization during pandemic
Central Ohio Outbreak Background
- Last measles outbreak in Ohio was 2014 among Amish in northeast
- Measles last reported in Ohio in 2019,
- First measles cases (PCR positive) without recent international travel confirmed on November 7 and 8
- 85 total confirmed cases this year
- Outbreak slowing but ongoing
- Age < 1 year: 24 cases (not yet age eligible for routine childhood MMR vaccine at 12 months)
- Age 1-2 years: 37 cases
- Age: 3-17 years: 24 cases
- No cases 18 years or older.
- MMR vaccination status
- 78 unvaccinated (54 age-eligible, 24 under-age)
- 6 partially vaccinated
- 1 unknown vaccination status
- 40% hospitalized
- Higher percentage than 25% hospitalization rate from prior U.S. outbreaks
- 40% hospitalized
Public Health Response
- CDC Epi-Aid performed from November 27–December 10
- Working on multiple fronts to increase awareness of measles, access to MMR vaccine, and encourage vaccination of unvaccinated persons
Q: Do we know if the traveler(s), who bring measles back to the U.S. from endemic countries, are themselves typically unvaccinated?
David Sugerman (CDC): The vast majority of travelers are either age ineligible, haven’t received a first dose, or are unvaccinated and traveling abroad and returning from locations that have circulating measles. We recommend dropping the age to six months for MMR vaccination for international travel of children <12 months compared to the 12–15 months where a typical first dose is recommended.
Q: Are you recommending also lowering the first dose to six months in the affected communities in Ohio?
David Sugerman (CDC): That has been done in prior outbreaks, including the one in New York City and in parts of Minnesota during those outbreaks. But in this situation, we did an accelerated second dose, but there was not a recommendation for dropping the age of the first dose to 6 months.
Q: Are you getting any sense of the settings in which transmission is occurring for these kids?
Elizabeth Tiller: This is ongoing, so I can’t give too many details, unfortunately. We did identify some settings outside of the home and public sites where people gather and things like that. The overall community awareness is especially important.
Q: It looks like you are seeing this mostly in children under six months. Do you attribute some of that to the efforts that Ohio took to improve MMR vaccination in 2014?
Elizabeth Tiller: There’s still some overall hesitancy and not remembering that outbreak from 2014 that was ocated in a different part of the state from where the current outbreak is ongoing. So, I can’t say for sure if they’ve seen an uptick since then, but my sense is that it hasn’t really been on people’s minds.
Q: The 2014 outbreak was more clustered in a religious community. Is this more in the general population?
Elizabeth Tiller: Most of the cases have been pretty geographically located within the Columbus metro area, but I can’t get into much else right now since the investigation is ongoing.
Q: If a child gets an MMR dose prior to their first birthday, for example, in an outbreak, should the dose be counted as valid for the 12–15-month dose, or will they need another dose at 12–15 months as long as the minimum intervals are met? Can you explain why if you give an MMR dose before 12 months that it needs to be repeated?
David Sugerman (CDC): The child will need another dose at 12–15 months and a third dose between age 4 and 6, because the vaccine will have lower efficacy when it’s administered less than one year of age between 6 and 12 months. There’s increasing efficacy towards a year of age, but still not the same efficacy at 12 to 15 months, and that’s in part due to competition with maternal antibodies. That’s probably shifting as antibodies that women have now are not from natural infection, but from immunization, but that’s still our general recommendation, that it needs to be repeated.
Q: Are you seeing in Ohio more hesitancy since the COVID-19 vaccination program? Is it bleeding into routine pediatric hesitancy?
Elizabeth Tiller: This is not something we have had the time to look at but definitely something we are curious about. Its possible that maybe hesitancy has been enhanced by COVID-19 and the politicization around vaccines, but we haven’t looked at that as of yet.
David Sugerman (CDC): I’m sure many saw the NIS child that was released this past week and didn’t show much of a decline in childhood vaccines post-pandemic. The investigation is ongoing, but there are hopes of doing more of a community assessment to understand beliefs toward vaccination within the greater Columbus area.
Q: Are some of these 1–2-year-olds not vaccinated due to missed routine appointments due to people concerned about going to medical offices and concerned about getting COVID-19 or is it more due to hesitancy?
Elizabeth Tiller: I would say it’s a combination of the two. We looked into the reasons but this was during the time when COVID-19, RSV, and flu were rampant among pediatric populations in October and November, so overall, there was a lot of illness in the community that complicated matters.
RESP-NET Update – Catherine Bozio (CDC)
Laboratory-confirmed flu-associated hospitalizations have been historically tracked in FluSurv-NET. Pediatric surveillance began in the 2003–2004 season, and adult began in the 2005–2006 season. RESP-NET surveillance began tracking RSV-associated hospitalizations in adults flu hospitalization surveillance in the 2016–2017 season and in children in the 2018–2019 season. With the emergence of COVID-19-associated hospitalizations in people of all ages starting in March 2020. All three networks use the same infrastructure and together comprise the multi-pathogen platform called the Respiratory Virus Hospitalization Surveillance Network or RES-NET, as of 2022.
- Comprised of three platforms that conduct population-based surveillance for laboratory-confirmed hospitalizations associated with flu, RSV, and COVID-19 among children and adults
- Conducted in select counties in 13 states, representing 8-10% of the U.S. population
- Surveillance is conducted from October 1–April 30 for influenza and RSV and year-round for COVID-19
- Testing for flu and COVID-19 is clinician-driven or based on faculty practices and therefore is not systematic
- Methods for collecting flu data are similar to those testing for COVID-19 and RSV
- Surveillance staff within each site use multiple sources of data for hospitalization rates
- The numerator is calculated as the number of residents at the defined surveillance catchment area who are hospitalized with a positive flu test within 14 days prior to or during hospitalization
- Population denominators stratified by age, sex, and race/ethnicity are defined using bridge race population estimates from the National Center for Health Statistics.
- For each case, trained surveillance staff conduct extensive medical chart abstractions using a standardized case report form to collect data on underlying conditions, clinical course, and outcomes
RESP-NET Interactive Dashboard
- Flu, COVID-19, and RSV-associated hospitalization rates have been posted weekly during the respective season for each respiratory virus on separate pages of CDC’s website
- Rates presented on the RESP-NET interactive dashboard can be used to follow trends and comparisons of the viruses and hospitalization rates in different demographic groups and across seasons
- The dashboard is updated weekly
RESP-NET Interactive Dashboard
- Hospitalizations can be viewed as weekly or cumulative rates
- Data can be filtered by the pathogen, age, group, or season
- Data can be displayed in a graph or as a table
- To view the table, right-click on a graph and then select “show as a table”
- Hovering a mouse over a data point will display detailed information, including estimated hospitalization rates for a given epidemiologic week
Lab-Confirmed COVID-19 Influenza, and RSV-associated Weekly Hospitalization Rates; RESP-NET, October 1, 2022–January 7, 2023
- Starting in early October 2022, the COVID-19-associated hospitalization rate was higher than for RSV and flu, with a slight increase in fall and early winter
- RSV-associated hospitalization rate peaked in early November, which was primarily driven by children age 0–4 years old
- Early December observed a peak in the rate of influenza-associated hospitalizations
- Hospitalization rates for each of the three pathogens, along with the combined rate, appear to be declining recently but are subject to potential reporting delays
- Delays increase around holidays during periods of increased hospitalization
- Data is received every week, so previous rates are updated accordingly
Lab-Confirmed COVID-19, Influenza, and RSV-Associated Weekly Hospitalization Rates among Children age <5 years; RESP-NET, October 1, 2022–January 7, 2023
- Among children age 0–4 years, RSV-associated hospitalizations have been high, with the peak rate of 65/100K population observed in mid-November
- Hospitalizations for each pathogen have been declining
- As the season progressed, the rates of RSV-associated hospitalizations remain higher relative to flu and COVID-19
Lab-Confirmed COVID-19, Influenza, and RSV-Associated Weekly Hospitalization Rates among Children aged 5–17 years; RESP-NET, October 1, 2022–January 7, 2023
- Respiratory virus-associated hospitalization rates have been lower in older children than in younger children
- So far this season, rates of COVID-19-associated hospitalization have been relatively stable around 1/100K population among children 5-17 years
- RSV-associated hospitalization rates peaked at 2.5/100K population in early November, followed by a peak of flu-associated hospitalization rates at 3.8/100K population in late November
Lab-Confirmed COVID-19, Influenza, and RSV-Associated Weekly Hospitalization Rates among Adults age ≥65 years; RESP-NET, October 1, 2022–January 7, 2023
- So far in the season, rates of COVID-19-associated hospitalizations have been slowly increasing over the season
- Flu-associated hospitalization rates were low initially, but had increased into November and then peaked at 27/100K population in early December
- RSV-associated hospitalization rates have been low and stable, not exceeding 6/100K population
- This trend has also been seen in adults age 18–49 years and 50–64 years, though much lower rates
Lab-Confirmed COVID-19, Influenza, and RSV-Associated Weekly Hospitalization Rates; RESP-NET, 2021–2022 and 2022–2023 Seasons
- Influenza- and RSV-associated hospitalization rates were low throughout the 2021–2022 season
- Activity did not exceed 6/100K population
- COVID-10-associated hospitalization rates were higher, including a peak weekly rate of 37/100K population in early January 2022, with the Omicron wave
- This season there has been co-circulation with these three viruses
Key Public Health Messages
- While multiple respiratory viruses are circulating, continue testing to identify the cause of respiratory illness. This is critical, especially for people who are at higher risk of severe outcomes from respiratory disease.
- Testing can help determine the treatment to reduce illness severity from flu or COVID and infection control measures to reduce further spread
- An annual flu vaccine is the best way to prevent flu infection and can prevent serious outcomes in people who get vaccinated but get sick. Everyone six months and older are recommended to get the flu vaccine as long as activity continues
- COVID-19 vaccines remain effective and can protect against hospitalization and death. People are best protected when they stay up to date with recommended vaccines
- Immunize.org, with pain mitigation expert, Anna Taddio, PhD, will host a free, 1-hour webinar, Improving the Vaccination Experience: Reducing Pain and Anxiety for Children and Adults, on February 28 at 1:00 p.m. (ET). All are welcome to register!
- The dates for the NAIIS in person meeting will be May 9–11, so mark your calendar. Registration information to come.
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