5/2/2019

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Measles: Right Here, Right Now

Noelle Bessette, MPH

Surveillance Specialist

Vaccine Preventable Disease Program

New Jersey Department of Health

71

Measles Case Update

Measles Around the World• Measles Incidence Rate per Million (12 month period), WHO

• United States measles cases, 2019

• Largest # of cases reported in the US since measles was declared eliminated in 2000

• Current United States measles outbreaks

• Rockland County, NY • Michigan

• New York City • New Jersey

• Washington • California (Butte, LA, Sacramento)

• Georgia • Maryland

2018 Ocean County Measles Outbreak

• Case Count: 33

• 30 Ocean County residents

• 3 Passaic County residents (one household with direct epi-link to Ocean County)

• Onset date range: 10/17-11/30

• Age Distribution

• Age range: 6 months-59 years (mean=11.5 years)

• Distribution

• Under 1: 1

• 1-5: 9

• 5-18: 19

• 19-29: 3

• 30+: 1

• 52% female

• Vaccination rates

• 0 MMR: 79%

• 1 MMR: 3%

• 2 MMR: 15%

• Unknown vaccine status: 3%

2019 New Jersey Measles Cases

• Total confirmed cases: 14*

• 1 Bergen County resident w/ contact with a community outside NJ experiencing an ongoing

outbreak

• 1 Essex County resident w/ international travel from a country experiencing an ongoing outbreak

• 12 outbreak-associated cases

• 2019 Ocean County measles outbreak update

*As of 4/24

Measles Contact Investigations

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NJ Residents are being exposed to measles:

• On airplanes

• In other states

• Medical facilities

• Private events

• Hotels

• In other NJ jurisdictions

• Notified by phone, email, fax, CDC Epi-X Notification

Measles Flight Notifications

• NJDOH alerted of NJ residents exposed to measles on airplanes via CDC Epi-X message

• CDC has a protocol to identify passengers who may have been exposed to measles on a flight based on the disease, how it spreads, and where a passenger was seated in relation to the index patient

Red=index patient

Teal=contact zone

• For measles, passengers in the same row as the patient and two rows in front of and

behind patient are the only passengers considered “at risk”

• Exceptions:

• All travel companions of the index patient on the same flight

• All children younger than 2 anywhere on the plane

Contact Investigation: Exposed Individuals

• Make initial contact with exposed individual to inform him/her of exposure

• Educate contacts on signs & symptoms/ what to do if they become symptomatic

• Call ahead before seeking medical attention to alert them of exposure and symptoms so arrangements can be made to

prevent exposures at the facility

• Inquire if anyone accompanied individual to the facility where exposure occurred/ if there was a babe-in-arms on the flight

• Assess and obtain documented evidence of immunity for all exposed individuals

• Consider post-exposure prophylaxis (PEP) if applicable

• Vaccine (within 72 hours from 1st exposure) or Immune globulin (IG -within 6 days from 1st exposure)

• Quarantine contacts without presumptive evidence of immunity

• Starting day 5 from 1st exposure through 21 days after last exposure

• Consult with NJDOH before recommending quarantine

• Provide “Exposed to Measles?” document

• Follow up at the end of the incubation period

• Return CDC form to NJDOH (not CDC) if flight notification

Measles Investigation

Considerations and Challenges

Challenges With Exposure Notifications

• Patients may or may not have been notified by the exposure facility

• Incomplete or incorrect locating information (e.g. no phone number)

• Some options include searching town tax records, Google search, NJIIS search, sending email,

sending a certified letter, conducting a home visit

• Concerns about period of time between exposure and notification

• Difficulties in obtaining documentation of immunity

• NJ school, college, military, OB records if woman who has been pregnant previously, other

states’ immunization registries, titer

• Request for documentation from LHD re: exposure for workplace

• Individuals without proof of immunity unwilling to abide by quarantine recommendations

IgM + Electronically Entered into CDRSS

• First call should be to ordering MD

• Inquire about symptoms

• Inquire why test was ordered

• If asymptomatic and test was ordered just to check immunity, case can be closed as “Not a Case” an MD should be educated on not ordering IgM unless suspecting disease (IgG should be specified)

• If symptomatic, investigate as suspect case

• Use Measles One Pager as an outline

• Request appropriate testing, etc.

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Investigation Tips

• How to handle calls from non-healthcare providers re: “cases” and exposures

• Inquire about all symptoms/ symptom progression to help determine likelihood of measles

• Inquire about travel/ known exposure/ risk factors/ vaccination status

• Ask for picture of the rash (no face, no genitals)

• Work on timeline early

Timeline

• Timeline should be compiled over course of investigation before the lab result comes back for highly suspect cases of measles

• Often this is the step that holds up public health response and public notification

• Compile list of all places suspect case visited during infectious period (4 days before rash onset through 4 days after rash onset- total of 9 days)

• Patient should begin compiling timeline upon first LHD contact

• Will need minute-by-minute breakdown of the 9 days

• Important details to request: time arrived, time left, name of location, address, transportation

method to/from

Specimen Collection

• NP swab, urine, and blood should be collected on all suspect measles cases

• Viral specimens (NP swab and urine) can only be tested at CDC/CDC Reference Laboratory

• NJDOH approval is needed to send viral specimens to CDC for testing

• If specimen is approved for testing, many options for sending specimens

• FedEx, if available

• State courier

• Scheduled courier pickup sites

• Private courier

• LHDs to help medical facilities coordinate specimen transport

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New Resources Available

https://nj.gov/health/cd/documents/topics/measles/measles_travel_flyer.pdf https://nj.gov/health/cd/documents/topics/measles/measles_ob_guide.pdf

Resources Available

• NJDOH website: https://www.state.nj.us/health/cd/topics/measles.shtml

• “Exposed to Measles?” document: https://www.state.nj.us/health/cd/documents/topics/measles/measles_exposure_guidance_public.pdf

• CDC website: https://www.cdc.gov/measles/index.html

• CDC measles cases & outbreaks page: https://www.cdc.gov/measles/cases-outbreaks.html

Thank You!

Noelle Bessette

Noelle.Bessette@doh.nj.gov

(609) 826-5964

LOCAL LENS

Neisseria meningitis serogroup B Rutgers University – New Brunswick

2019

Eric Adler, MPH Regional Epidemiologist NJDOH

Sherie Wolpert, MPH Epidemiologist Middlesex County Office of Health Services

Outline

• Meningococcal disease

• Overview

• Serogroup B

• Outbreaks

• University-based outbreaks of meningococcal

disease caused by serogroup B

• Middlesex County Office of Health Services

• Situation update

• Recommendations

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Meningococcal Disease

• Presentations

• Meningitis

• Bacteremia

• 10-15% case-fatality ration

• 11-19% permanent sequelae

Neisseria meningitis

• Bacteria

• 12 serogroups

• A, B, C, W, X, and Y primarily cause disease worldwide

• B, C, W, an Y cause most disease in United States

Meningococcal Transmission

• Humans are the only reservoir

• Asymptomatic nasopharyngeal carriage

• >5-10% of population are asymptomatic carriers

• Adolescents and adults have highest rates of carriage

• Carriage is an immunizing process that results in a systemic, serougroup-specific protective

antibody response

• Spread through close contact

• Respiratory or oral secretions

• Patients or asymptomatic carriers

Risk Factors for Meningococcal Disease

• Medical conditions

• Functional or anatomic asplenia

• Persistent complement component deficiency

• Treatment with Soliris (eculizumab)

• Recent viral respiratory infection

• Smoking

• Among college students

• Living in dormitories (freshmen in dormitories have 3-23X increase in risk)1

• Social mixing (Greek life membership, attend bars)1

Serogroup B Meningococcal Disease

• Meningococcal conjugate vaccine (MenACWY) does not protect against serogroup B

• Most common cause of meningococcal disease in persons aged 16 to 21 years

• Recent cause of university based clusters/outbreaks

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Meningococcal Disease Outbreaks

• <5% of meningococcal disease cases in the U.S.

• Case-patients share common affiliation or area of residence but not

direct close contact

• Transmission within population via asymptomatic carriage

• Most outbreak cases in U.S. occur in persons <25 years of age1

• CDC recently updated outbreak definitions and guidelines available at

https://www.cdc.gov/vaccines/vpd/mening/index.html

• 10 university-based outbreaks occurred in 7 states during 2013-2018

• January 2013 – May 2018

• Total of 39 cases and 2 deaths

Case Characteristics

• Median patient age – 19 years

• 62% male

• 36 (92%) were undergraduate at 4-year university; 3 in close contact of undergrads

• 2-9 cases per outbreak (median 3 cases)

• Attack rate 10-34 cases/100,000 (median 35/100,000 (compared to baseline .11 cases/100,000 in 2017)

Response

• Chemoprophylaxis provided to all close contacts

• MenB vaccines were used in response to all 10 outbreaks

• 2 outbreaks (NJ and CA) before vaccine licensed

• 8 outbreaks following vaccine licensure

• 6 implemented after 2 cases

– 4 had no further cases; 2 had 1 additional case (one 6 days post vaccine)

1 after 3 cases

- 2 additional cases

1 after 4 cases

- 3 additional cases

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Current College Outbreaks

• Columbia University’s School of International and Public Affairs

• 2 cases

• San Diego State University

• 3 cases

• Five College Consortium

• Amherst College

• Hampshire College

• Mount Holyoke College

• Smith College

• UMass Amherst

Rutgers University – New BrunswickCase Description

• Case 1

• Undergraduate – 3rd year

• 1 dose Trumenba 2017

• Off-campus housing

• Member of Greek life

• Case 2

• Undergraduate – 2nd year

• No MenB vaccine

• On-campus housing

• Involvement with Greek life

• Following each case, close contacts were identified and recommended to receive antimicrobial prophylaxis

Neisseria meningitis serogroup B:Local Investigation

Two cases in February

• 1st case: onset Feb 3rd, HD notified Feb 5th

• Home address Union County, school address

Middlesex County

• Hospitalized Union County

• 2nd case: onset Feb 19, HD notified Feb 23rd

• Home address Monmouth County, school address

Middlesex County

• Hospitalized Monmouth County

Where do we start?

First Steps

• Receive call

• Make notifications

• Gather information (as much as you can)

• Begin investigation

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First RU CASE, Early Feb

• Who is primary investigator?

• Must get patient history for past 10 days.

• Identify close contacts back to 1/27

• PROBLEMS:

• Patients unable to speak due to illness.

Investigation

• Patient had many close contacts at RU. (Greek life )

• Patient traveled, by car, with 3 other friends to another

State for Superbowl party. That State was cooperative in

follow up for those exposed people.

• Patient well enough to be discharged after 3 days in

hospital.

• Result: serogroup B

Second RU Case, late Feb.

• Who is primary investigator?

• Must get patient history for past 10 days. (this patient was

unresponsive for first 2 days)

• How do you get information when patient can’t talk to you?

Investigation

• Mother and brother given prophylaxis

• Frequents Greek life events

• Attended parties, doesn’t remember which ones

• Discharged from hospital on 3/4/19

• Serogroup B

Prophylaxis and Vaccine

• After contacts were identified by HD and RU, all contacts were offered

prophylaxis.

• RU students were strongly recommended to receive Meningitis B

vaccine.

• No obvious link between cases.

THANK YOU

Board of Chosen Freeholders

Ronald G. Rios, Director

Charles E. Tomaro, Deputy Director

Kenneth Armwood, Charles Kenny, Leslie Koppel,

Shanti Narra, Blanquita B. Valenti

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Questions? Questions and Suggestions

sherif.ibrahim@doh.nj.gov