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National, state, and selected local area vaccination coverage among children aged 19-35 months - United States, 2013.
Author(s): Laurie Elam-Evans, David Yankey, James Singleton, Maureen Kolasa
Publication date: 2014-08-29
Keywords: Age Distribution, Bacterial Capsules, Chickenpox Vaccine, administration & dosage, Child, Preschool, Disease Outbreaks, prevention & control, Ethnic Groups, statistics & numerical data, Female, Haemophilus Vaccines, Hepatitis A Vaccines, Hepatitis B Vaccines, Humans, Infant, Infection Control, Male, Pertussis Vaccine, Population Surveillance, Poverty, Rubella Vaccine, Socioeconomic Factors, United States, epidemiology, Vaccination, utilization
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Abstract
In the United States, among children born during 1994-2013, vaccination will prevent an estimated 322 million illnesses, 21 million hospitalizations, and 732,000 deaths during their lifetimes. Since 1994, the National Immunization Survey (NIS) has monitored vaccination coverage among children aged 19-35 months in the United States. This report describes national, regional, state, and selected local area vaccination coverage estimates for children born January 2010-May 2012, based on results from the 2013 NIS. In 2013, vaccination coverage achieved the 90% national Healthy People 2020 target for ≥ 1 dose of measles, mumps, and rubella vaccine (MMR) (91.9%); ≥ 3 doses of hepatitis B vaccine (HepB) (90.8%); ≥ 3 doses of poliovirus vaccine (92.7%); and ≥ 1 dose of varicella vaccine (91.2%). Coverage was below the Healthy People 2020 targets for ≥ 4 doses of diphtheria, tetanus, and pertussis vaccine (DTaP) (83.1%; target 90%); ≥ 4 doses of pneumococcal conjugate vaccine (PCV) (82.0%; target 90%); the full series of Haemophilus influenzae type b vaccine (Hib) (82.0%; target 90%); ≥ 2 doses of hepatitis A vaccine (HepA) (54.7%; target 85%); rotavirus vaccine (72.6%; target 80%); and the HepB birth dose (74.2%; target 85%). Coverage remained stable relative to 2012 for all of the vaccinations with Healthy People 2020 objectives except for increases in the HepB birth dose (by 2.6 percentage points) and rotavirus vaccination (by 4.0 percentage points). The percentage of children who received no vaccinations remained below 1.0% (0.7%). Children living below the federal poverty level had lower vaccination coverage compared with children living at or above the poverty level for many vaccines, with the largest disparities for ≥ 4 doses of DTaP (by 8.2 percentage points), full series of Hib (by 9.5 percentage points), ≥ 4 doses of PCV (by 11.6 percentage points), and rotavirus (by 12.6 percentage points). MMR coverage was below 90% for 17 states. Reaching and maintaining high coverage across states and socioeconomic groups is needed to prevent resurgence of vaccine-preventable diseases.
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National, State, and Local Area Vaccination Coverage Among Children Aged 19–35 Months — United States, 2012
Carla L Black, David Yankey, Maureen Kolasa (2013)
The National Immunization Survey (NIS) is a random-digit–dialed telephone survey used to monitor vaccination coverage among U.S. children aged 19–35 months. This report describes national, state, and selected local area vaccination coverage estimates for children born during January 2009–May 2011, based on results from the 2012 NIS. Healthy People 2020 * objectives set childhood vaccination targets of 90% for ≥1 doses of measles, mumps, and rubella vaccine (MMR); ≥3 doses of hepatitis B vaccine (HepB); ≥3 doses of poliovirus vaccine; ≥1 doses of varicella vaccine; ≥4 doses of diphtheria, tetanus, and pertussis vaccine (DTaP); ≥4 doses of pneumococcal conjugate vaccine (PCV); and the full series of Haemophilus influenzae type b vaccine (Hib). Vaccination coverage remained near or above the national Healthy People 2020 target for ≥1 doses of MMR (90.8%), ≥3 doses of poliovirus vaccine (92.8%), ≥3 doses of HepB (89.7%), and ≥1 doses of varicella vaccine (90.2%). Coverage increased from 68.6% in 2011 to 71.6% in 2012 for the birth dose of HepB.† Coverage was below the Healthy People 2020 target and either decreased or remained stable relative to 2011 for ≥4 doses of DTaP (82.5%), the full series of Hib (80.9%), and ≥4 doses of PCV (81.9%). Coverage also remained stable relative to 2011 and below the Healthy People 2020 targets of 85% and 80%, respectively, for ≥2 doses of hepatitis A vaccine (HepA) (53.0%), and rotavirus vaccine (68.6%). The percentage of children who had not received any vaccinations remained 15 weeks, and the final dose should be given by age 8 months (5). These age restrictions might preclude infants from starting or completing the series. Health-care providers should make every effort to start and complete administration of the rotavirus vaccine series on time. What is already known on this topic? Healthy People 2020 set childhood vaccination targets of 90% for ≥1 doses of measles, mumps, rubella vaccine (MMR); ≥3 doses of hepatitis B vaccine (HepB); ≥3 doses of poliovirus vaccine; ≥1 doses of varicella vaccine; ≥4 doses of diphtheria, tetanus, and pertussis vaccine; ≥4 doses of pneumococcal conjugate vaccine; and the full series of Haemophilus influenzae type b vaccine. The National Immunization Survey estimates coverage among U.S. children aged 19–35 months for these and other vaccines. What is added by this report? In 2012, childhood vaccination coverage remains near or above national target levels for ≥1 doses of MMR (90.8%), ≥3 doses of HepB (89.7%), ≥3 doses of poliovirus vaccine (92.8%), and ≥1 doses of varicella vaccine (90.2%); however, coverage varied by state and tended to be lower among children in families with incomes below the federal poverty level. What are the implications for public health practice? Sustaining current coverage levels and increasing coverage for those vaccines below national target levels is needed to maintain the low levels of vaccine-preventable diseases and prevent a resurgence of these diseases in the United States. Ensuring systems such as client reminder/recall and vaccination programs are in place in settings such as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics and child-care facilities can help support high vaccination coverage. Although few differences in coverage by racial/ethnic group were observed after adjustment for poverty status, differences in coverage by poverty level remained for many vaccines. The Vaccines For Children program¶¶¶ has been successful in removing differences in coverage between children living above and below the poverty level that once existed for vaccines such as MMR, polio, and HepB (6); however, coverage among children living below the poverty level still lags behind coverage of children living at or above the poverty level for newer vaccines (HepA and rotavirus) and vaccines that require 4 doses to complete the series. Vaccination coverage continues to vary across states. Clusters of unvaccinated children leave communities vulnerable to outbreaks of disease. The continued occurrence of measles outbreaks among unvaccinated persons in the United States (7) underscores the importance of maintaining uniformly high coverage to prevent transmission of imported disease. Recent budget cuts to state and local health departments (8) as well as differences by state in factors such as population characteristics, immunization program activities, vaccination requirements for child-care centers, and vaccine financing policies might contribute to variations in vaccination coverage. The findings in this report are subject to at least four limitations. First, the proportion of the NIS sampled by cellular telephone in 2012 was about half compared with only 11% in 2011 and zero in earlier years. Living in a household with only cellular telephone service is associated with poverty and other demographic factors that might be related to vaccination status (3). Second, underestimates of vaccination coverage might have resulted from the exclusive use of provider-reported vaccination histories because completeness of these records is unknown. Third, bias resulting from nonresponse and exclusion of households without telephone service might persist after weighting adjustments, although estimated bias from these sources for the 2011 NIS was low for selected vaccines examined, ranging from 0.3 (for MMR) to 1.5 (for ≥4 DTaP) percentage points (9). The potential for nonresponse bias was increased in 2012 because of the lower response rate for the cellular telephone sample. However, a comparison of vaccination coverage estimates from the NIS from July 2011 through June 2012 with those from the National Health Interview Survey during the same period yielded similar results, both overall and for children living in cellular-only households, despite largely different response rates between the two surveys (Assessment Branch, Immunization Services Division, National Center for Immunization and Respiratory Diseases, and Survey Planning and Special Surveys Branch, Division of Health Interview Statistics, National Center for Health Statistics, CDC; unpublished data; 2013). Finally, although national coverage estimates are precise, estimates for state and local areas should be interpreted with caution because of smaller sample sizes and wider confidence intervals. High vaccination coverage among preschool-aged children has resulted in historically low levels of most vaccine-preventable diseases in the United States (1). The results of the 2012 NIS indicate that vaccination coverage among young children remained relatively stable and the proportion of children who do not receive any vaccinations has remained low. Slight decreases in coverage for some vaccines relative to 2011 cannot be immediately explained but could be attributable to a change in NIS methods. The 2012 results should be considered a baseline against which future trends in coverage can be evaluated. Careful monitoring of coverage levels overall and in subpopulations (e.g., racial/ethnic and geographic) is important to ensure that all children remain adequately protected. Parents and health-care providers should work to sustain high coverage and improve coverage for the more recently recommended vaccines and those that require booster doses after age 12 months. In addition to health system–based interventions previously described, national, state and local immunization programs should continue to partner with providers to implement the Guide to Community Preventive Services–recommended interventions aimed at increasing community demand for vaccination, such as client reminder/recall and client or family incentives. Enhanced access to health services also is recommended, through reduced out-of-pocket costs, home visits, and vaccination programs in child-care centers, schools, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) settings**** (4). Health insurance reforms of the Affordable Care Act require health plans to cover recommended immunizations without cost to the enrollee when administered by an in-network provider (10).††††
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Progress in Immunization Information Systems — United States, 2012
Cristina V Cardemil, Terence Ng, Laura Pabst (2013)
Immunization information systems (IIS) are confidential, computerized, population-based systems that collect and consolidate vaccination data from vaccination providers that can be used in designing and sustaining effective immunization strategies (1,2). To monitor progress toward achieving IIS program goals, CDC annually surveys immunization program grantees using the IIS Annual Report (IISAR). Results from the 2012 IISAR, completed by 54 of 56 grantees, indicate that 86% (19.5 million) of U.S. children aged <6 years, and 25% (57.8 million) of U.S. adults participated in IIS. Eight of 12 minimum functional standards for IIS published by the National Vaccine Advisory Committee (NVAC) (3,4) have been met by ≥90% of grantees. During 2011–2012, progress was also made in meeting three additional functional standards, including the presence of core data element fields, timeliness of vaccine records, and Health Level 7 (HL7) messaging, and will be monitored in new functional standards for IIS published in 2013 (5). Several new and ongoing initiatives, including interoperability between IIS and electronic health records (i.e., ensuring systems can work together and exchange information), the use of IIS to support vaccine ordering and inventory management, the use of two-dimensional barcodes to record vaccination information (1), and collaboration with pharmacies, federal agencies, and other adult vaccination providers, will support further progress in meeting functional standards and enhance reporting of adult vaccinations to IIS. Of the 56 immunization program grantees (50 states, five cities,* and the District of Columbia [DC]), 2012 IISAR data† were available for 54 grantees. DC did not report and New Hampshire was not eligible because it did not have an IIS in 2012. The self-administered survey asked about participation in IIS, data quality indicators, and IIS functionality (e.g., interoperability with electronic health records). Child and Adult Participation in IIS Child participation was defined as having two or more vaccinations for children aged <6 years documented in an IIS. Adult participation was defined as having one or more vaccinations administered to adults aged ≥19 years documented in an IIS. Participation was calculated by dividing the number of children or adults in an IIS who met their age group and vaccination criteria by the 2012 U.S. Census estimate of the same age group in the grantee’s geographic area (6). National estimates were calculated by summing the number of children or adults reported to be participating and dividing by the U.S. Census estimate for the total population for that age group. Nationally, 19.5 million U.S. children aged <6 years (86.2%) participated in an IIS in 2012. This child participation measure is used to track a Healthy People 2020 objective (IID-18) to increase to 95% the proportion of children aged <6 years whose immunization records are in fully operational, population-based IIS (7). Child participation in IIS has increased steadily, from 63% in 2006 to 86% in 2012 (1). Of the 54 grantees with available data in 2012, 26 (48%) reported that ≥95% of children aged <6 years in their geographic area participated in their IIS (Figure 1). Nationally, 57.8 million U.S. adults aged ≥19 years (24.5%) participated in an IIS in 2012 (Figure 2). Two IIS did not collect immunization information for adults. The Connecticut IIS includes only children aged <6 years, and the Rhode Island IIS includes only persons aged <19 years. Adult participation in IIS among the remaining 52 grantees responding in 2012 ranged from 0.5% (Houston) to 85.4% (Minnesota). Functional Standards for IIS Functional standards for IIS were developed in 2001 and revised in 2007. The standards have been approved by NVAC (3,4) for assessing IIS progress in meeting minimum functionalities. Substantial progress has been made in meeting these functional standards since inception, and in 2012, eight of 12 functional standards had been met by ≥90% of grantees (Figure 3). Increases were observed during 2011–2012 in the percentage of grantees meeting three of the four remaining functional standards. The percentage of grantees meeting functional standard (FS) 1 (i.e., reporting the presence of fields in their IIS for 18 required NVAC core data elements) increased from 57% in 2011 to 65% in 2012. Completeness of core data elements has been reported on previously (1). The percentage of grantees meeting FS 4 (i.e., percentage of grantees who reported receiving and processing ≥70% of vaccine and other immunization encounter information within 30 days of vaccine administration) increased from 63% in 2011 to 76% in 2012. The percentage of grantees meeting FS 7 (i.e., meeting basic HL 7 functionality§) increased from 58% in 2011 to 77% in 2012. The percentage of grantees meeting more advanced HL7 functionality¶ increased from 35% in 2011 to 37% in 2012. In 2012, 37% (19) of grantees were sending and receiving any HL7 v.2.5.1 messages, an increase from 17.3% (9) of grantees in 2011. The percentage of grantees meeting FS 2 (i.e., reporting the establishment of a birth record within an average time of ≤6 weeks) decreased from 85% in 2011 to 84% in 2012. This slight decline occurred because three grantees who previously met the functional standard in 2011 reported a decrease in timeliness in 2012 resulting from their acceptance of larger amounts of data, which slowed processing times; however, two grantees achieved the functional standard in 2012 who had not previously. Editorial Note Child participation in IIS increased steadily from 2006 to 2012, reaching 86%; adult participation, however, only reached 25% in 2012. Eight of 12 IIS functional standards were met by ≥90% of grantees in 2012. Increases in grantees meeting minimum functional standards for IIS data quality and interoperability, including the presence of core data element fields, timeliness for vaccination records, and HL7 messaging functionality, also have been demonstrated from 2011 to 2012, although challenges remain for IIS to reach their full potential in these areas, and for improving the timeliness of birth records in IIS. Historically, the primary focus of IIS and immunization programs has been pediatric populations. This focus was warranted because of the increasing complexity of the routine pediatric immunization schedule, mobility of children among different providers resulting in vaccination record scattering (8) that makes tracking and catch-up immunization challenging, and the role of the IIS in supporting the Vaccines for Children program through ordering and inventory management, report generation, and vaccine accountability. Nevertheless, interest is growing in ensuring that adult populations are included and vaccinations tracked in IIS. Adults are vaccinated by multiple and diverse providers, beyond traditional health-care providers (e.g., pharmacies, retail clinics, and subspecialists), and consolidated adult vaccination records maintained by IIS could play an instrumental role in providing clinical point-of-care support and population-level immunization coverage, particularly in special circumstances such as tracking doses administered during an influenza pandemic. Currently, 53 of 56 immunization program grantees have IIS with lifespan systems, yet adult participation in IIS remains low. Challenges to increase adult participation in IIS include 1) identifying and enrolling the diverse providers that serve adults, 2) a lack of adult immunization reporting mandates in many grantees’ jurisdictions, and 3) competing priorities for state and local immunization programs. To support increased adult provider participation in IIS, CDC is supporting several new initiatives, including partnering with the Veterans Administration, the Indian Health Service, and federal occupational health clinics; providing supplemental funding to IIS Sentinel Sites to support adult provider enrollment and completeness of adult data in IIS as part of pandemic preparedness; and collaborating with the American Immunization Registry Association to better understand barriers and opportunities for pharmacy reporting to IIS. CDC also has initiated the Clinical Decision Support for Immunization (CDSi) project for the adult vaccine schedule, which will provide a single, authoritative, software-independent foundation for development and maintenance of evaluation and forecast systems (9).** By capturing Advisory Committee on Immunization Practices (ACIP) recommendations for adult vaccination in an unambiguous manner, it will improve the uniform representation of vaccination decision guidelines, and the ability to automate vaccine evaluation and forecasting (9). CDSi for the childhood schedule was completed in October 2012 and has already proven successful in clarifying ACIP recommendations and designing new and existing computer systems. What is already known on this topic? In 2011, 84% of U.S. children aged <6 years (19.2 million) participated in immunization information systems (IIS). What is added by this report? In 2012, 86% of U.S. children aged <6 years participated in IIS. Adult participation (25%) in IIS lags behind. Eight of 12 minimum functional standards for IIS published by the National Vaccine Advisory Committee have been met by ≥90% grantees, but gaps still exist in meeting Health Level 7 (HL7) interoperability and some data quality standards. What are the implications for public health practice? To realize the full benefits of IIS, progress is needed to reach lifespan participation in IIS, advanced bidirectional HL7 messaging between IIS and electronic health records, and improved data quality in IIS. Initiatives designed to increase adult participation in IIS, and promote HL7 messaging and electronic health records use among providers, are expected to support progress in these areas. In addition to capturing the complete population of children and adults within each IIS jurisdiction, IIS must maintain and enhance system functionality to ensure that data quality is high, protect the confidentiality of data, and serve multiple stakeholders. Although IIS have made great strides in implementing functional standards, progress can still be made in areas such as timeliness of record submission, completeness of core data elements, and HL7 functionality. Several ongoing and new initiatives are expected to support these functional standards, including the use of IIS to support vaccine ordering and inventory management, the use of two-dimensional barcodes to record vaccination information, and interoperability between IIS and electronic health records (1). Implementation of stage 2 meaningful use criteria for the Medicare and Medicaid electronic health record incentive program (10), emphasizing use of HL7 version 2.5.1 and promotion of successful, ongoing submission from providers to IIS, is expected to increase child and adult participation in IIS and improve data quality in IIS, including completeness and timeliness of records. Stage 2 implementation was scheduled to launch in October 2013 for hospitals and January 2014 for providers. The findings in this report are subject to at least two limitations. First, although CDC provides guidance to grantees to validate IISAR responses, data are self-reported and self-validated, which might result in overestimation or underestimation of participation rates. Second, because two of the 56 grantees did not report data during the period studied, the percentage of grantees meeting each of the functional standards might be higher or lower than calculated. New functional standards for IIS for 2013–2017 have been developed by CDC through a consensus process involving input from IIS managers and technical experts nationwide (5). Those standards are intended to lay a framework for the development of IIS through 2017, and supersede the minimum functional standards for registries adopted by NVAC in 2001. These new functional standards encompass areas within the old functional standards where progress is still being achieved, including timeliness of records submission, completion of core data elements, and HL7 interoperability standards. They also include new areas, such as supporting the Vaccines for Children program and state vaccine purchase programs through vaccine inventory functions and capture of program eligibility at the dose-level, and enhanced data quality through patient- and vaccine-level de-duplication. Grantees meeting and exceeding these new functional standards will lead the way in realizing and demonstrating the full potential of IIS.
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Measles — United States, January 1–May 23, 2014
Paul Gastañaduy, Susan Redd, Amy Fiebelkorn … (2014)
Measles is a highly contagious, acute viral illness that can lead to serious complications and death. Although measles elimination (i.e., interruption of year-round endemic transmission) was declared in the United States in 2000 (1), importations of measles cases from endemic areas of the world continue to occur, leading to secondary measles cases and outbreaks in the United States, primarily among unvaccinated persons (2). To update national measles data in the United States, CDC evaluated cases reported by states from January 1 through May 23, 2014. A total of 288 confirmed measles cases have been reported to CDC, surpassing the highest reported yearly total of measles cases since elimination (220 cases reported in 2011) (3). Fifteen outbreaks accounted for 79% of cases reported, including the largest outbreak reported in the United States since elimination (138 cases and ongoing). The large number of cases this year emphasizes the need for health-care providers to have a heightened awareness of the potential for measles in their communities and the importance of vaccination to prevent measles. Confirmed measles cases in the United States are reported by state and local health departments to CDC using a standard case definition.* A measles case is considered confirmed if it is laboratory-confirmed or meets the clinical case definition (an illness characterized by a generalized rash lasting ≥3 days, a temperature of ≥101°F [≥38.3°C], and cough, coryza, and/or conjunctivitis) and is linked epidemiologically to a confirmed case. Measles cases are laboratory confirmed if there is detection in serum of measles-specific immunoglobulin M, isolation of measles virus, or detection of measles virus nucleic acid from a clinical specimen. Cases are considered imported if at least some of the exposure period (7–21 days before rash onset) occurred outside the United States and rash occurred within 21 days of entry into the United States, with no known exposure to measles in the United States during that time. An outbreak of measles is defined as a chain of transmission of three or more confirmed cases. Patients with reported measles cases this year have ranged in age from 2 weeks to 65 years; 18 (6%) were aged <12 months, 48 (17%) were aged 1–4 years, 71 (25%) were aged 5–19 years, and 151 (52%) were aged ≥20 years. Forty-three (15%) were hospitalized, and complications have included pneumonia (five patients), hepatitis (one), pancytopenia (one), and thrombocytopenia (one). No cases of encephalitis and no deaths have been reported. Measles cases have been reported from 18 states and New York City. Most cases were reported from Ohio (138), California (60), and New York City (26). Fifteen outbreaks have accounted for 227 (79%) of the 288 cases. The median outbreak size has been five cases (range: 3–138 cases). There is an ongoing outbreak involving 138 cases, occurring primarily among unvaccinated Amish communities in Ohio. Of the 288 cases, 280 (97%) were associated with importations from at least 18 countries. The source of measles acquisition could not be identified for eight (3%) cases. Forty-five direct importations (40 U.S. residents returning from abroad and five foreign visitors) have been reported. Almost half (22 [49%]) of these importations were travelers returning from the Philippines, where a large outbreak has been occurring since October 2013. Imported cases were also associated with travel from other countries in the World Health Organization (WHO) Western Pacific Region (seven cases), as well as countries in the WHO South-East Asia (eight), European (four), Americas (three), and Eastern Mediterranean (one) regions. Measles genotype information was obtained from 103 (36%) of the 288 measles cases. Four measles virus genotypes were identified: B3 (67 cases), D9 (23), D8 (12), and H1 (one) (Table). Most of the 288 measles cases reported this year have been in persons who were unvaccinated (200 [69%]) or who had an unknown vaccination status (58 [20%]); 30 (10%) were in persons who were vaccinated. Among the 195 U.S. residents who had measles and were unvaccinated, 165 (85%) declined vaccination because of religious, philosophical, or personal objections, 11 (6%) were missed opportunities for vaccination, and10 (5%) were too young to receive vaccination (Figure). Discussion Measles elimination has been maintained in the United States since elimination was declared almost 15 years ago. However, approximately 20 million cases of measles occur each year globally, and importations into the United States continue to pose a risk for measles cases and outbreaks among unvaccinated persons. The 288 measles cases reported during January 1–May 23, 2014, including an ongoing outbreak involving 138 persons in Ohio, represent the highest number of measles cases reported for that period since 1994. The increase in measles this year serves as a reminder for health-care providers to be cognizant of the possibility of measles cases occurring in their communities. Health-care providers should maintain a high suspicion for measles among febrile patients with rash. Patients with clinical symptoms compatible with measles (febrile rash plus cough, coryza, and/or conjunctivitis), should be asked about recent travel abroad and contact with returning travelers, and their vaccination status should be verified. Measles cases have been initially misdiagnosed as Kawasaki disease, dengue, and scarlet fever, among other diseases, underscoring the importance of considering measles in the differential diagnosis of clinically compatible cases. It is important to obtain viral specimens for confirmation and genotyping on any patient when measles is suspected, in addition to serology. Genetic characterization of measles virus can suggest the likely source of an imported virus. Because patients with measles often seek medical care, early recognition of suspected measles cases and implementation of appropriate infection control measures are vital to reduce transmission in health-care settings. Where possible, because of the high transmissibility of measles, patients with suspected measles should be promptly screened before entering waiting rooms and appropriately isolated (i.e., in an airborne isolation room or, if not available, in a separate room with the door closed), or have their office appointments scheduled at the end of the day to prevent exposure of other patients (4). To assist state and local public health departments with rapid investigation and control efforts to limit the spread of disease, suspected measles cases should be reported to local health departments immediately. State health departments should notify CDC about cases of measles within 24 hours of detection (5). To date in 2014, a total of 40 importations have been reported among unvaccinated returning U.S. travelers. Among these, 22 acquired measles in the Philippines, where 32,030 measles cases (26,014 suspected cases and 6,016 confirmed cases) and 41 measles deaths have been reported from January 1 through April 20†. The large number of importations from the Philippines highlights how importations are related to increases in measles incidence in countries that are common destinations for U.S. travelers. Because measles remains endemic in countries in five out of the six WHO regions of the world, including India, from where six importations have occurred this year, the source of imported cases could be any country where measles continues to circulate. This underscores the importance of ensuring age-appropriate vaccination for all persons before international travel to any region of the world. Health-care providers should remind persons who plan to travel internationally, including travel to large international events and gatherings (e.g., the 2014 FIFA World Cup in Brazil), of the increased risk for measles, § and encourage timely vaccination of all persons aged ≥6 months without evidence of measles immunity.¶ One dose of measles-mumps-rubella (MMR) vaccine is recommended for infants aged 6–11 months before travel, and 2 doses for persons aged ≥12 months, with a minimum interval between doses of 28 days (6). In the three largest outbreaks of 2014, which account for over a half of all cases this year, transmission occurred after introduction of measles into communities with pockets of persons who were unvaccinated because of philosophical or religious beliefs. Although high population immunity throughout the United States (through maintaining ≥90% MMR vaccine coverage among children aged 19–35 months and adolescents) prevents spread from most importations (7,8), coverage varies at the local level, and unvaccinated children tend to cluster geographically, increasing the risk for outbreaks (9). Thus, maintaining high measles vaccination coverage is critical to prevent large measles outbreaks in the United States, and to protect and limit spread to infants too young to be vaccinated and to persons who cannot be vaccinated because of medical contraindications. In the United States, routine MMR vaccination is recommended for all children, with the first dose given at age 12–15 months, and a second dose at age 4–6 years. Catch-up vaccination is recommended for children and adolescents who have not received 2 appropriately spaced doses. Unless they have other evidence of immunity, adults should receive at least 1 dose of MMR vaccine, and 2 appropriately spaced doses of MMR vaccine are recommended for health-care personnel, college students, and international travelers (6). The findings in this report are subject to at least two limitations. First, underreporting might have occurred. Second, for a few cases complete data could not be ascertained (e.g., the source of infection). However, national surveillance is considered adequate to detect measles circulation in the United States in the postelimination era (10). These numbers are considered preliminary and are subject to change should additional details become available. What is already known on this topic? Measles elimination (i.e., interruption of year-round endemic transmission) has been maintained in the United States since 2000. Despite progress in global measles control, measles remains common in many countries of the world, and measles is imported regularly into the United States. What is added by this report? Both the highest number of measles cases and the largest outbreak since elimination have been reported to CDC this year. As of May 23, 2014, a total of 288 cases were reported, of which 258 (90%) were in persons who were unvaccinated or had unknown vaccination status. Forty (89%) of the 45 importations were associated with U.S. travelers returning from abroad. What are the implications for public health practice? Importations of measles into communities with unvaccinated persons can lead to measles cases and outbreaks in the United States. Maintenance of high vaccination coverage, ensuring timely vaccination before travel, and early detection and isolation of cases, are key factors to limit importations and the spread of disease. Despite maintenance of measles elimination in the United States, importations from endemic countries continue to occur and have caused an unusually high number of measles cases in 2014. The most frequent sources of importations were unvaccinated U.S. travelers returning from abroad, with subsequent transmission among clusters of unvaccinated persons. Encouraging timely delivery of measles vaccination for persons traveling internationally and sustaining high vaccination coverage in the United States in accordance with the Advisory Committee on Immunization Practices (ACIP) routine immunization schedule are essential to limit measles importations and the spread of disease. To help expedite public health containment strategies, health-care providers should maintain a high awareness of measles, implement appropriate infection control measures when measles is suspected, and promptly report suspected cases to their local health departments.
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PubMed ID:: 25166924
ScienceOpen disciplines: Chemistry
Keywords: Age Distribution,Bacterial Capsules,Chickenpox Vaccine,administration & dosage,Child, Preschool,Disease Outbreaks,prevention & control,Ethnic Groups,statistics & numerical data,Female,Haemophilus Vaccines,Hepatitis A Vaccines,Hepatitis B Vaccines,Humans,Infant,Infection Control,Male,Pertussis Vaccine,Population Surveillance,Poverty,Rubella Vaccine,Socioeconomic Factors,United States,epidemiology,Vaccination,utilization
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ScienceOpen disciplines: Chemistry
Keywords: Age Distribution, Bacterial Capsules, Chickenpox Vaccine, administration & dosage, Child, Preschool, Disease Outbreaks, prevention & control, Ethnic Groups, statistics & numerical data, Female, Haemophilus Vaccines, Hepatitis A Vaccines, Hepatitis B Vaccines, Humans, Infant, Infection Control, Male, Pertussis Vaccine, Population Surveillance, Poverty, Rubella Vaccine, Socioeconomic Factors, United States, epidemiology, Vaccination, utilization