Carrie A. Thomas, PhDEpidemiologist (VPD/IBD)

Division of Infectious Disease EpidemiologyWest Virginia Bureau for Public Health

www.dide.wv.gov(304) 558-5358

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ObjectivesOverview of vaccine-preventable diseases

that require rapid response & why it is important

Consequences of non-response or untimely response

Populations for special consideration

Highlight key steps in the investigation2

Measles – Why is it an Emergency?Endemic measles declared eliminated in the US

in 2000

Almost 30% of cases experience complicationsInflammation of the middle ear (7%)Pneumonia (6%) Encephalitis (0.1%)Hospitalization (19%)Death (0.3%)

Susceptible populations at higher risk for disease and complications

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Measles – Populations for Special ConsiderationChildren < 1 year of ageSusceptible immunocompromised patients

Healthcare workers (HCWs)Increased risk of exposure and transmission

through patient care

Pregnant womenHigh risk for pregnancy complications

People travelling to places where measles are endemic

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Measles – What to DoImmediately isolate suspect cases with

airborne transmission precautions 4 days after rash onset in otherwise healthy

individualsduration of illness in immunocompromised

patients

Confirm/rule out suspect cases rapidly through lab resultsWork with DIDE to submit sample to CDC

High false positive rate of results in commercial labs

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Measles – What to Do (cont.)Confirm immune status of exposed

individualsNeed written confirmation (verbal indication is

not acceptable)

Acceptable evidence of immunityEvidence of physician-diagnosed natural

measles infectionDocumentation of two doses of measles

containing vaccine, or A positive IgG antibody test for measles

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Measles – What to Do (cont.)Post-exposure prophylaxis (PEP) for

susceptible contacts, including HCWs

Vaccination within 72 hours of exposure*

Immune globulin, given within 6 days of exposure for Susceptible household or other close contacts Contacts < 1 year of age Pregnant women† Immunocompromised patients†

*preferred method of PEP

7† vaccination contraindicated in these populations

Measles – What to Do (cont.)Susceptible persons do not receive PEP

should be excluded for 21 days after rash onset in last case of measles

Furlough susceptible HCWs from 5th-21st day after exposure, regardless of PEP

Furlough ill HCWs for 4 days after development of rash

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Rubella – Why is it an Emergency?Endemic rubella declared eliminated in the US

in 1994

Complications are rare, occurring more frequently in adults than childrenHowever, arthralgia or arthritis may occur in up

to 70% of adult womenEncephalitis or hemorrhagic manifestations are

rare

Urgency comes from desire to prevent Congenital Rubella Syndrome

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Rubella – Populations for Special ConsiderationSusceptible immunocompromised patients

Children < 1 year of age

Healthcare workers (HCWs)

Pregnant womenHigh risk for pregnancy complicationsCongenital Rubella Syndrome – affects up to

85% of infants infected during 1st trimester

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Rubella – Congenital Rubella Syndrome (CRS)Can affect all organ systems; manifestations include

Deafness - most commonCataracts & other eye defectsHeart defects including holes in the walls or blood

vessels; malformations of heart valves or blood vesselsMicrocephaly and/or mental retardationBone alterationsLiver and spleen damage

Diabetes mellitus, progressive encephalopathy and autism have also been observed in children with CRS

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Rubella – What to DoImmediately isolate suspect cases with

contact precautions for 7 days after rash onset

Confirm/rule out suspect cases rapidly through lab resultsWork with DIDE to submit sample to CDC for

confirmationFalse positive IgM results seen in persons with

parvovirus B19 infections, infectious mononucleosis, or a positive rheumatoid factor

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Rubella – What to Do (cont.)Confirm immune status of exposed individuals

Documentation of at least 1 dose of rubella-containing vaccine

Positive IgG antibody testBorn before 1957

Note: clinical diagnosis is unreliable and should not be considered when assessing immune status

Confirm pregnancy status of exposed women

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Rubella – What to Do (cont.)PEP for susceptible contacts, including HCWs

Vaccination ASAP after exposure to prevent spread of disease, especially in settings where pregnant women may be exposed Vaccination is contraindicated 4 weeks prior to and

during pregnancy and in immunocompromised individuals

If pregnant woman is exposedAssess immune status

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Diphtheria– Why is it an Emergency?Endemic in many parts of the developing world

Approximately 50% of US adults are susceptible

Formation of pseudomembrane over tonsils, pharynx or larynx can cause airway obstruction

Complications includeInflammation of the heart muscle (myocarditis)ParalysisInflammation of the middle ear Respiratory insufficiency

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Diphtheria – Populations for Special ConsiderationSusceptible HCWs

HCWs who are not up-to-date on Td boosters may become infected and spread disease to susceptible populations

People travelling to places where diphtheria is endemic

Immunocompromised patients and those with existing history of respiratory and/or heart conditions

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Diphtheria – What to DoIsolate suspect cases with droplet precautions

for 48 hours after beginning antibiotics

Confirm diagnosis through lab resultsWork with DIDE to submit sample to CDC

Do not wait for lab confirmation to treat those meeting clinical case definition with antibiotics & diphtheria antitoxin (only available from CDC since 1997)

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Diphtheria – What to Do (cont.)Assess vaccination history in case/contacts.

Administer appropriate dose(s) of DTaP/DTP/DT/Td/Tdap

Submit samples for culture for and administer prophylactic antibiotics to close contacts

These recommendations apply to respiratory diphtheriaCutaneous diphtheria is not a reportable condition

Transmitted through contact with skin lesions

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Meningococcal Meningitis – Why is it an Emergency?Infection can progress rapidly and result in

death10-14% case-fatality rateApprox 40% meningococcal disease cases present

as bacteremia,

Of those surviving invasive disease, 10-20% experience sequelae, including limb loss from gangrene, extensive skin scarring or cerebral infarction

70% of secondary cases occur within 7 days19

Meningococcal Meningitis – Populations for Special Consideration

College freshman living in dorms

Military recruits

People travelling to countries where meningococcal disease is hyperendemic or epidemic

Persons with conditions leading to decrease immune system functions, includingterminal complement component deficienciesanatomic or functional asplenia

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Meningococcal Meningitis – What to DoTrace patient contacts within 7 days of

symptom onset in index patient

Close contacts defined as Household members (including dormitory room

and barrack roommates)Childcare center contactsPersons directly exposed to patient’s oral

secretions by kissing, mouth-to-mouth resuscitation, or endotracheal intubation/tube management

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Meningococcal Meningitis – What to Do (cont.)Offer PEP as soon as possible (preferably

within 24 hours)If given more that 14 days after symptom onset

in index patient, PEP is probably of limited or no benefit

Offer PEP to exposed HCWs, but think before you offer PEPYou probably don’t need to provide PEP to the

receptionist who checked the patient in

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Invasive Haemophilus Influenzae b (Hib) – Why is it an Emergency?Before vaccine, 15-30% of survivors

experienced serious complicationsHearing impairmentSevere permanent neurologic consequences

Mental retardation Seizure disorder Cognitive & developmental delay Paralysis

Rapid identification important for early vaccination and chemoprophylaxis of susceptible contacts

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Hib – Populations for Special ConsiderationChildren under 5 years of age

Immunocompromised children

Older children and adults who were not vaccinated in childhood and have the following conditionsFunctional or anatomical aspleniaImmunodeficiency from IgG2 subclass deficiencyImmunosuppression from cancer chemotherapyHIVHematopoietic stem cell transplant

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Hib – What to DoIsolate suspected cases with droplet precautions

until 24 hours after starting antibiotics

Confirm diagnosis and have isolate serotyped (OLS)

Offer PEP for all household contacts as soon as possibleWith at least 1 contact < 4 years old who is

unimmunized or incompletely immunizedWith a child younger than 12 months who has not

received the primary seriesWith an immunocompromised child (regardless of

immunization status

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Hib – What to Do (cont.)PEP should also be provided for

Nursery school/childcare center contacts when > 2 cases occur within 60 days

PEP is NOT recommended for Contacts in households with no children < 4

years old except index caseContacts in households where

Members 12-48 months old are fully vaccinated Members <12 months old have received primary

series of Hib immunizationsNursery school/childcare center contacts of 1

index casePregnant women

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Mumps – Why is it an Emergency?20-40% infections asymptomatic

Major cause of sensorineural deafness in children

Complications more common in adultsMeningoencephalitisOrchitis , oophoritis, mastitis

Permanent consequences are rare

Susceptible HCW are who you need to be concerned about

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Mumps – What to DoIsolate cases with droplet precautions for 5

days after onset of parotitis

Evaluate immune state of exposed contactsWritten documentation of vaccinationPositive mumps IgGLab confirmation of diseaseBirth before 1957 (except in healthcare

setting)

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Mumps – What to Do (cont.)Susceptible children should receive 2 doses MMR

Susceptible children should be excluded from school until the 26th day after onset of parotitis in the last case

HCWs without evidence of immunity should be furloughed from the 9th-25th day after exposure

All HCW should be alert for symptoms of mumps 12-25 days after exposure, regardless of vaccination status

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Pertussis during PregnancyPertussis can cause severe illness and death

in infants

Any woman who might become pregnant is encouraged to receive a single dose of Tdap

Women who have not received Tdap should receive a single dose in the immediate postpartum period

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Pertussis during Pregnancy (cont.)Pregnant women should receive a single dose

of Tdap during an outbreakPreferably in the 2nd or 3rd trimester to avoid

coincidental association of vaccination and spontaneous termination of a pregnancy, which is more common in the 1st trimester

Vaccination during pregnancy can provide some protection for newborns

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Varicella during Pregnancy

VZV infection of the fetus Low birth weightSkin scarring

Malformed limbsMental retardationVision problems

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Primary infection with VZV in pregnant women is rare

Varicella in pregnancy is associated with

Varicella during Pregnancy (cont.)Vaccination contraindicated during pregnancy

Women should be vaccinated before they attempt to become pregnant

If not immune pre-pregnancy, should be vaccinated immediately post-partum

Immune globulin can prevent or reduce severity of disease if given within 96 hours of exposure

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SummaryIsolate case patient

Inform appropriate agencies – DIDE, CDC

Confirm diagnosis with appropriate lab testing

Trace contacts and assess immunity

Provide appropriate PEP

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ReferencesManual for the Surveillance of Vaccine-

Preventable Diseases, 4th edition, CDC, 2008

Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book), 12th edition, CDC, 2011

Red Book: 2009 Report of the Committee on Infectious Diseases, 28th edition, American Academy of Pediatrics, 2009

www.mayoclinic.com35