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Carrie A. Thomas, PhDEpidemiologist (VPD/IBD)
Division of Infectious Disease EpidemiologyWest Virginia Bureau for Public Health
www.dide.wv.gov(304) 558-5358
1
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
3
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
4
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
5
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
6
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
8
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
9
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
10
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
11
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
12
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
13
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
14
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
15
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
16
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)
17
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
18
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
20
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
21
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
22
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
23
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
24
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
25
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
26
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
27
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)
28
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
29
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
30
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
31
Varicella during Pregnancy
VZV infection of the fetus Low birth weightSkin scarring
Malformed limbsMental retardationVision problems
32
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
33
SummaryIsolate case patient
Inform appropriate agencies – DIDE, CDC
Confirm diagnosis with appropriate lab testing
Trace contacts and assess immunity
Provide appropriate PEP
34
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