Grant County Health DistrictGrant County Health DistrictMeasles OutbreakMeasles OutbreakApril – July 2008April – July 2008Dr. Alex Brzezny, HODr. Alex Brzezny, HO

Peggy Grigg, GCHD AdministratorPeggy Grigg, GCHD AdministratorJackie Dawson, Region 7 EpiJackie Dawson, Region 7 Epi

History of MeaslesHistory of Measles References to References to measlesmeasles can be found as far back can be found as far back

as the 7th century A.D. as the 7th century A.D. Described by Rhazes (Persian philosopher and Described by Rhazes (Persian philosopher and

physician) in the 10th century A.D. as "more physician) in the 10th century A.D. as "more dreaded than dreaded than smallpoxsmallpox""

Before the 1963 measles vaccine:Before the 1963 measles vaccine:– Approximately 3 to 4 million casesApproximately 3 to 4 million cases– Average of 450 deaths a year in the U.S.Average of 450 deaths a year in the U.S.– Epidemic cycles occurring every 2 to 3 yearsEpidemic cycles occurring every 2 to 3 years– >1/2 the population had measles by 6 yo >1/2 the population had measles by 6 yo – 90% had measles by 15 yo90% had measles by 15 yo

Measles Control Goals by WHO Region, 2006

20002000

20102010

20102010 20122012

Africa and SE Asia have mortality reduction goals

Americas, Europe, E. Mediterranean, W. Pacific have elimination goals

CDC – Measles UpdateCDC – Measles Update Measles outbreaks are ongoing in: Measles outbreaks are ongoing in:

– Switzerland Switzerland – Israel Israel – Europe Europe

Measles is endemic in many countries including:Measles is endemic in many countries including:– Japan Japan – India India

Serologic and virologic specimens (serum, NP Serologic and virologic specimens (serum, NP wash/swab & urine)wash/swab & urine) should be obtainedshould be obtained for measles for measles virus detection and genotypingvirus detection and genotyping

Laboratory testing should be conducted in the most Laboratory testing should be conducted in the most expeditious manner possibleexpeditious manner possible

CDC Measles Summary CDC Measles Summary

January 1 - April 25, 2008January 1 - April 25, 2008 64 64 confirmed measles cases in 9 statesconfirmed measles cases in 9 states Highest # for the same time period since Highest # for the same time period since

2001 2001 Outbreaks (3 or more cases linked in time Outbreaks (3 or more cases linked in time

or place) are ongoing in AZ, NY, MI & WIor place) are ongoing in AZ, NY, MI & WI 10 recent patients acquired measles 10 recent patients acquired measles

abroad abroad Remaining cases linked to imported casesRemaining cases linked to imported cases

Measles Measles Measles is classified as morbillivirus of the family Measles is classified as morbillivirus of the family

ParamyxoviridaeParamyxoviridae Virus enters the respiratory tract via droplet nuclei and Virus enters the respiratory tract via droplet nuclei and

multiplies in epithelial cellsmultiplies in epithelial cells Incubation period ranges from 7 to 18 daysIncubation period ranges from 7 to 18 days Prodrome typically includes fever, cough, coryza, Prodrome typically includes fever, cough, coryza,

conjunctivitis and Koplik spots on the buccal mucosaconjunctivitis and Koplik spots on the buccal mucosa Red blotchy rash appears around the 3rd day of illness, Red blotchy rash appears around the 3rd day of illness,

beginning on the face and becoming generalizedbeginning on the face and becoming generalized Maybe complicated by middle ear infection or diarrhea Maybe complicated by middle ear infection or diarrhea Severe complications include pneumonia & Severe complications include pneumonia &

encephalitis encephalitis leading to death in approximately 2 /1,000 leading to death in approximately 2 /1,000 casescases

Most common among children, but also seen in Most common among children, but also seen in nonimmune adultsnonimmune adults

CDC- Case DefinitionCDC- Case Definition

The diagnosis of measles should be considered The diagnosis of measles should be considered in any person with in any person with a:a:– generalized maculopapular rash lasting ≥ 3 days generalized maculopapular rash lasting ≥ 3 days – a temperature ≥ 101ºF (38.3ºC)a temperature ≥ 101ºF (38.3ºC)– and cough, coryza, or conjunctivitis and cough, coryza, or conjunctivitis

Immunocompromised patients may not exhibit Immunocompromised patients may not exhibit rash or may exhibit an atypical rashrash or may exhibit an atypical rash

Newborns receiving maternal antibody and Newborns receiving maternal antibody and people who have received IsG can have an people who have received IsG can have an atypical presentation (rash progresses in atypical presentation (rash progresses in opposite fashion) opposite fashion)

DOH Measles Case ClassificationDOH Measles Case Classification SuspectedSuspected: Any febrile illness accompanied by a : Any febrile illness accompanied by a

rashrash ProbableProbable: A case that meets the clinical case : A case that meets the clinical case

definition, has noncontributory or no serologic definition, has noncontributory or no serologic or virologic testing, and is not epi linked to a or virologic testing, and is not epi linked to a confirmed caseconfirmed case

ConfirmedConfirmed: A case that is lab confirmed or that : A case that is lab confirmed or that meets the clinical case definition and is epi meets the clinical case definition and is epi linked to a confirmed caselinked to a confirmed case

Preventing Transmission in HC SettingsPreventing Transmission in HC Settings   Suspected patients should be removed from waiting Suspected patients should be removed from waiting

areas as soon as they are identified and:areas as soon as they are identified and:– Placed in a private room with the door closedPlaced in a private room with the door closed– Asked to wear a surgical maskAsked to wear a surgical mask

In hospital settings, suspect patients should be placed In hospital settings, suspect patients should be placed immediately in a negative-pressure isolation roomimmediately in a negative-pressure isolation room

Do not send patient to other parts of the hospital for Do not send patient to other parts of the hospital for examination or testingexamination or testing

All HC personnel should have documented evidence of All HC personnel should have documented evidence of measles immunity on file at their work location measles immunity on file at their work location

Draw blood samples for serologic evidence of immunity Draw blood samples for serologic evidence of immunity when documentation is not availablewhen documentation is not available

Vaccinate personnel without evidence of immunityVaccinate personnel without evidence of immunity http://www.cdc.gov/ncidod/dhqp/gl_isolation.htmlhttp://www.cdc.gov/ncidod/dhqp/gl_isolation.html

CDC RecommendationsCDC Recommendations

Case investigation and vaccination of household or other close Case investigation and vaccination of household or other close contacts without evidence of immunity should not be delayed contacts without evidence of immunity should not be delayed pending the return of lab resultspending the return of lab results– Isolate known and suspected case-patientsIsolate known and suspected case-patients– Administer vaccine Administer vaccine – Immune globulin within 6 days of exposure, particularly contacts ≤ 6 Immune globulin within 6 days of exposure, particularly contacts ≤ 6

months of age, pregnant women, and immunocompromised peoplemonths of age, pregnant women, and immunocompromised people For contacts who were not immune at the time of exposure: For contacts who were not immune at the time of exposure:

– Exclude from day care, school, or work Exclude from day care, school, or work – Home quarantine from 7 to 21 days following exposure Home quarantine from 7 to 21 days following exposure

Persons who are known contacts of measles patients and who Persons who are known contacts of measles patients and who develop fever and/or rash should be considered suspected measles develop fever and/or rash should be considered suspected measles case-patients and be appropriately evaluated by a HC provider case-patients and be appropriately evaluated by a HC provider

If HC providers are aware of the need to assess a suspected case, If HC providers are aware of the need to assess a suspected case, they should schedule the patient at the end of the day after other they should schedule the patient at the end of the day after other patients have left the office and inform clinics or emergency rooms patients have left the office and inform clinics or emergency rooms if they are referring a suspected measles patient for evaluation so if they are referring a suspected measles patient for evaluation so that airborne infection control precautions can be implemented that airborne infection control precautions can be implemented prior to their arrival prior to their arrival 

CDC- MMR During OutbreaksCDC- MMR During Outbreaks During a measles outbreak, additional vaccine During a measles outbreak, additional vaccine

recommendations should be considered: recommendations should be considered: – Children ≥12 months should receive their 1st dose of Children ≥12 months should receive their 1st dose of

MMR vaccine as soon after their 1st birthday as MMR vaccine as soon after their 1st birthday as possible & their 2nd dose 4 weeks later possible & their 2nd dose 4 weeks later

Coordinate with neighboring counties Coordinate with neighboring counties

– Provide 1 dose of MMR vaccine to unvaccinated HC Provide 1 dose of MMR vaccine to unvaccinated HC personnel born <1957 who don’t have serologic personnel born <1957 who don’t have serologic evidence of immunity or medical documentation of evidence of immunity or medical documentation of measles diseasemeasles disease

– 1 dose of MMR vaccine should be considered for 1 dose of MMR vaccine should be considered for infants ≥ 6 months of ageinfants ≥ 6 months of age

King

Chelan

Douglas Spokane

Yakima

Klickitat

Cowlitz

Clark

Skamania

GraysHarborMason

Thurston

Jefferson

Clallam

San Juan Whatcom

Skagit

Snohomish

Pierce

LewisPacific

Wahkiakum

Kitsap

Okanogan

Kittitas Grant

Ferry

Stevens

PendOreille

Lincoln

Adams Whitman

Benton

Franklin

WallaWalla

Colum

bia

Garfield

Island

Asotin

<2.0% 2.0-2.9% 3.0-3.9% 4.0-4.9% 5.0%

WA State Counties’ School Exemption Rates 2004

Source: WA State Department of Health

Grant Co. Measles Outbreak

012345

4/11

/08

4/18

/08

4/25

/08

5/2/

08

5/9/

08

5/16

/08

5/23

/08

5/30

/08

Date of Rash Onset

Num

ber o

f Per

sons

Grant County Measles OutbreakGrant County Measles Outbreak Case Investigation Case Investigation

First 2 cases attended Generation Conf in First 2 cases attended Generation Conf in Kirkland, WA-March 27-29, 2008 Kirkland, WA-March 27-29, 2008

Conference hosts Jr High – University Conference hosts Jr High – University studentsstudents

3,000 students3,000 students 12 states, Japan, Mexico, Canada12 states, Japan, Mexico, Canada No other country, state or county No other country, state or county

reported measles in attendeesreported measles in attendees CDC reports measles endemic in JapanCDC reports measles endemic in Japan

Grant County Measles OutbreakGrant County Measles OutbreakCase InvestigationCase Investigation

Index case was home schooledIndex case was home schooled During infectious period case-patient also: During infectious period case-patient also:

– Attended Church Youth GroupAttended Church Youth Group– Taught Bible Study Taught Bible Study – Attended piano lessonsAttended piano lessons

All 7 siblings developed measlesAll 7 siblings developed measles 3/7 developed pneumonia3/7 developed pneumonia Neither parent became illNeither parent became ill 22ndnd case that attended the Generation Conference: case that attended the Generation Conference:

– Developed rash one day after 1Developed rash one day after 1stst case case– Attended a Christian School in Moses LakeAttended a Christian School in Moses Lake– Attended same church Youth Group as index caseAttended same church Youth Group as index case

Subsequent 15 cases could be linked to these 2 families Subsequent 15 cases could be linked to these 2 families through school or religious activities through school or religious activities

Grant County Measles OutbreakGrant County Measles Outbreak Aerosol TransmissionAerosol Transmission

One case attended piano lessons with 2 siblings One case attended piano lessons with 2 siblings during infectious periodduring infectious period

All 3 left residence after piano lessonAll 3 left residence after piano lesson Unvaccinated 12 yo child entered home within Unvaccinated 12 yo child entered home within

1 hour1 hour 12 yo also attended the same school as Case#212 yo also attended the same school as Case#2 12 yo developed measles within 2 weeks12 yo developed measles within 2 weeks 22ndnd unvaccinated child entered the same home unvaccinated child entered the same home

>2 hrs after 3 siblings departed>2 hrs after 3 siblings departed Child never developed measlesChild never developed measles Unvacc nephew of 12 yo developed measles Unvacc nephew of 12 yo developed measles

Grant County Measles OutbreakGrant County Measles Outbreak1818thth case case

Traveled to Oregon with one parent, one Traveled to Oregon with one parent, one unvacc sibling and one partially vacc siblingunvacc sibling and one partially vacc sibling

Diagnosis made in Oregon ED due to history of Diagnosis made in Oregon ED due to history of family’s recent travel from Moses Lakefamily’s recent travel from Moses Lake

Oregon HO and nurse traveled to family’s Oregon HO and nurse traveled to family’s temporary residencetemporary residence

Parent ordered to remain in ORParent ordered to remain in OR Grant Co HO Directive placed at ML residenceGrant Co HO Directive placed at ML residence ML contact tracing yielded 2 babysitters, family, ML contact tracing yielded 2 babysitters, family,

and Bible Study attendanceand Bible Study attendance Same Bible Study that the 1st case attended, Same Bible Study that the 1st case attended,

although not at the same time although not at the same time

Grant County Measles OutbreakGrant County Measles Outbreak1919thth case case

23 yr old 23 yr old Educated in Grant CountyEducated in Grant County 2 X MMR2 X MMR Enrolled in military post HS graduationEnrolled in military post HS graduation Dx: ITPDx: ITP SplenectomySplenectomy Military discharge 2003Military discharge 2003 IgG negativeIgG negative 2 siblings worked at Wal-Mart in ML2 siblings worked at Wal-Mart in ML Case-patient visited store during infectious Case-patient visited store during infectious

periodperiod

Grant County Measles OutbreakGrant County Measles Outbreak Commercial Cooperation-19Commercial Cooperation-19thth case case

Case-patient entered Wal-Mart during infectious periodCase-patient entered Wal-Mart during infectious period A good working relationship was developed with local A good working relationship was developed with local

Wal-Mart managersWal-Mart managers Corporate Wal-Mart did not know or use appropriate Corporate Wal-Mart did not know or use appropriate

communication channels. They also contacted communication channels. They also contacted legislator(s) about the local HO applying stricter legislator(s) about the local HO applying stricter guidelines than they found on the internet (requirement guidelines than they found on the internet (requirement of second MMR to return to work)of second MMR to return to work)

Public media release Public media release List of all employees working during that period and 2 List of all employees working during that period and 2

hours subsequenthours subsequent Approx 200 employees who could not prove immunity Approx 200 employees who could not prove immunity

were vaccinated or titeredwere vaccinated or titered Commercial lab increased throughput and released Commercial lab increased throughput and released

results directly to GCHDresults directly to GCHD This resulted in expedited return rate to workThis resulted in expedited return rate to work Store did not have to be closedStore did not have to be closed

Grant County Measles OutbreakGrant County Measles OutbreakMoses Lake, WashingtonMoses Lake, Washington

19 case-patients resided in Moses Lake19 case-patients resided in Moses Lake 12/19 infected by siblings12/19 infected by siblings Age range = 9 months to 23 yearsAge range = 9 months to 23 years Female = 52.6% ; Male = 47.4%Female = 52.6% ; Male = 47.4% Highest temp = 103.4FHighest temp = 103.4F 18/19 cases unvaccinated18/19 cases unvaccinated Genotype = D5 Genotype = D5

Switzerland, Germany, Japan, AZSwitzerland, Germany, Japan, AZ

26 other patients ruled out26 other patients ruled out

Grant County Measles OutbreakGrant County Measles OutbreakHO Directives & Quarantine OrdersHO Directives & Quarantine Orders

Directive required to obtain Generation Conference Directive required to obtain Generation Conference participant list of approx 60 students/chaperonesparticipant list of approx 60 students/chaperones

HO Directive required to obtain list of Bible Study HO Directive required to obtain list of Bible Study participantsparticipants

Quarantine order required for 21 days if:Quarantine order required for 21 days if:– Direct exposure + no MMR or immunity Direct exposure + no MMR or immunity

documentationdocumentation– Direct exposure + receive 1Direct exposure + receive 1stst MMR plus work in high MMR plus work in high

risk categoryrisk categoryHigh risk defined as HC worker, school teacher, High risk defined as HC worker, school teacher,

EMT, retail, etc EMT, retail, etc Rash Watch=255 persons (English, Spanish, & Russian)Rash Watch=255 persons (English, Spanish, & Russian)

– Form developedForm developed– Required daily call by GCHD staffRequired daily call by GCHD staff

Grant County Measles OutbreakGrant County Measles Outbreak17.3% increase in full immunity from May 1317.3% increase in full immunity from May 13thth to June 20 to June 20thth

Total Number of Persons = 1075Total Number of Persons = 1075IgG positive = 223IgG positive = 223

May 13, 2008

Full Immunity 1X MMR Unvaccinated

June 20, 2008

Full Immunity 1X MMR Unvaccinated

Grant County Measles OutbreakGrant County Measles OutbreakPrimary Case ContactsPrimary Case Contacts

Total Number of Persons = 1075Total Number of Persons = 1075

Case Contacts

Case #1 Case #2 Case #3 Case #4 Case #5 Case #6

Grant County Measles Outbreak Grant County Measles Outbreak School TypeSchool Type

Total Number of Persons = 325Total Number of Persons = 325

School Type

Private Christian Academy One Private Christian Academy Two Home

Grant County Measles OutbreakGrant County Measles OutbreakContact Investigation ActivitiesContact Investigation Activities

Total Number of Persons = 250Total Number of Persons = 250

Activities

Generation Conf Gig Harbor Skating Rink SATs Kite Day

Seattle Yakima Local Library Spokane Youth Group

Grant County Measles OutbreakGrant County Measles Outbreak Child ProfileChild Profile

Adult vs peds immunization historyAdult vs peds immunization history– Most adult imms records were difficult to locateMost adult imms records were difficult to locate– Most imms records for young WA State children were Most imms records for young WA State children were

availableavailable Missing imms records were obtained from HC Missing imms records were obtained from HC

providers or schoolsproviders or schools Titers were provided at low cost by Samaritan Titers were provided at low cost by Samaritan

Healthcare Healthcare All titer and imms results were entered into CP All titer and imms results were entered into CP

by GCHD staffby GCHD staff Rapid access to records resulted in a fast return Rapid access to records resulted in a fast return

to work or schoolto work or school

Grant County Measles Outbreak Grant County Measles Outbreak Healthcare FacilitiesHealthcare Facilities

Response: posted signs on all doors indicating Response: posted signs on all doors indicating those with rash and fever can not enter without those with rash and fever can not enter without maskmask

If the patient contacted PH first we screened If the patient contacted PH first we screened the cases the cases

Those who required immediate HC were told to Those who required immediate HC were told to call provider firstcall provider first

Facilities provided lists of employees and Facilities provided lists of employees and patients who were present 0.5 hr before and 2 patients who were present 0.5 hr before and 2 hrs after case-patient hrs after case-patient

Hundreds of people were screened for each Hundreds of people were screened for each case-patientcase-patient

Grant County Measles OutbreakGrant County Measles OutbreakHC and Media ReleasesHC and Media Releases

Periodic Emails/fax to HC providers, EMSPeriodic Emails/fax to HC providers, EMS Media releases to keep public informedMedia releases to keep public informed All media releases posted at All media releases posted at

www.granthealth.orgwww.granthealth.org July 22July 22ndnd- “Grant County measles - “Grant County measles

outbreak may be over”outbreak may be over”

Grant Co. Measles OutbreakGrant Co. Measles OutbreakLessons LearnedLessons Learned

Provide timely written notification of any HO requested or ordered Provide timely written notification of any HO requested or ordered restriction; delivering them in person is effectiverestriction; delivering them in person is effective

Hold daily update meetings with staff – both officesHold daily update meetings with staff – both offices Work closely with commercial labs to assure “collection” of all Work closely with commercial labs to assure “collection” of all

suspect patients and to obtain rapid resultssuspect patients and to obtain rapid results Moses Lake bus station was not able to support transport of Moses Lake bus station was not able to support transport of

specimens, had to take them to Ellensburg (extra driving)specimens, had to take them to Ellensburg (extra driving) Negotiate a specific time to provide updates to DOHNegotiate a specific time to provide updates to DOH ICS-like structure was utilized; increased specificity of assignments ICS-like structure was utilized; increased specificity of assignments

with actual ICS would have been helpful with actual ICS would have been helpful Using one office for measles EOC and the other one for other Using one office for measles EOC and the other one for other

routine PH including most immunizations was helpful, especially routine PH including most immunizations was helpful, especially during concurrent Varicella outbreak measuresduring concurrent Varicella outbreak measures

One clinic made an isolated location available for collecting lab One clinic made an isolated location available for collecting lab samples, for their own and other patients samples, for their own and other patients

Specific extension was set up for a "measles hotline”; prioritizing Specific extension was set up for a "measles hotline”; prioritizing those and other voicemails was helpfulthose and other voicemails was helpful

ExpenseExpense

HOHO AttorneyAttorney GCHD staffGCHD staff Regional EpiRegional Epi Vaccine, IsGVaccine, IsG