National Immunization Conference, Dallas, TX Laboratory Methods to Support Measles Control Programs: Enhancing Virologic Surveillance for Measles Viruses April 1, 2009 Paul Rota Measles, Mumps, Rubella and Herpesviruses Laboratory Branch, CDC

Outline of the Presentation Lessons learned after 20 years of studies of the molecular epidemiology of measles virus Summary of measles cases and genotypes in the USA, 2008 Methods to improve virologic surveillance Goal of this presentation is to emphasize the importance of virologic surveillance for measles (and other VPDS)

Lessons Learned from Molecular Epidemiology of Measles: 1 Molecular techniques must be used in conjunction with standard epidemiologic techniques Can be used to monitor transmission of measles virus during and after outbreaks Confirm or suggest epidemiologic links Differentiate between ongoing transmission of endemic virus from new, imported source of virus Provides valuable tool for measurement of measles elimination

Lessons Learned from Molecular Epidemiology of Measles: 2 Must be able to compare sequence information in addition to genotypes There are multiple, distinct genetic lineages within each genotype Sequences from viruses is a single chain of transmission are nearly identical

Lessons Learned from Molecular Epidemiology of Measles: 3 If there are outbreaks anywhere, there is the potential for outbreaks everywhere Rapid global travel of measles lineages Kenya/Somalia B3: 2005 Switzerland/Japan D5: 2007-2009

Potential measles transmission patterns! 6

Lessons Learned from Molecular Epidemiology of Measles: 4 Transmission can occur anywhere Airports, amusement parks, passport control, sporting events, hospitals, physicians offices

Measles Cases 2007: 3rd generation cases, Texas (spread from sporting event in Pennsylvania) INS Agent Detroit IgM neg, IgG+ serum 1 day post rash. PCR+

Lessons Learned from Molecular Epidemiology of Measles: 5 All measles vaccines are in genotype A Vaccine has been effective globally despite different endemic genotypes When necessary, vaccine reactions can be confirmed by genetic characterization of the virus

Viral Surveillance for Measles in the USA, 2008 140 cases (provisional), 6 outbreaks Genotypes from 6/6 outbreaks, 7 sporadic cases

Viral Surveillance for Measles in the USA, 2008 Date State Source Activity Genotype 2/08 CA Switzerland Outbreak (12) D5 NY Israel Outbreak (4) D4 AZ Outbreak (14) 3/08 MI Unknown 2 cases 4/08 WI Germany 1 case Israel/Belgium Outbreak (21) China H1 WA Japan? Outbreak (19) 5/08 GA Pakistan IL Italy? Outbreak (29) 6/08 Italy 12/08 FL UK MA India

Measles Cases with genotypes USA, 2008 California import Italy June 2008 Measles Cases with genotypes USA, 2008 Illinois import unknown May 2008 New York import Israel May 2008 New York import Israel May 2008 D4 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel February 2008 montreal.can 89 d4 Georgia import Pakistan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Wisconsin import Germany May 2008 D5 Wisconsin import Germany May 2008 Arizona import Switzerland Mar 2008 Arizona import Switzerland Mar 2008 Arizona import Switzerland Mar 2008 Arizona import Switzerland Mar 2008 California import Switzerland Mar 2008 California import Switzerland Mar 2008 California import Switzerland Mar 2008 bangkok.tha 93 d5 palau.bla 93 d5 vic.aus 99 d9 chicago.usa 89 d3 manches.unk 94 d8 vic.aus 85 d7 illin.usa 99 d7 nj.usa 94 d6 mvp.uk 74 d1 johann.soa 88 d2 uganda-01-d10 Wisconsin vaccine May 2008 Vaccine A Wisconsin vaccine May 2008 Arizona vaccine May 2008 Wisconsin vaccine April 2008 ed-wt a yaounde.cae 83 b1 ny.usa 94 b3 ibadan.nie 97 b3 libreville.gab 84 b2 jm.usa 77 c2 wtf.deu 90 c2 tokyo.jpn 84k c1 braxator.deu 71 e madrid.spa 94 f H1 Wisconsin import China April 2008 Wisconsin import China April 2008 hunan.chn 93 h1 beijing.chn 94 h2 berkeley.usa 83 g1 amster.net 97 g2 gresik.ino 02 g3 5 changes

Measles Cases with genotypes USA, 2008 California import Italy June 2008 Measles Cases with genotypes USA, 2008 Illinois import unknown May 2008 New York import Israel May 2008 New York import Israel May 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel February 2008 montreal.can 89 d4 Georgia import Pakistan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Major lineages circulating in Europe in 2007-2008 Washington import Japan May 2008 Washington import Japan May 2008 Washington import Japan May 2008 Wisconsin import Germany May 2008 Wisconsin import Germany May 2008 Arizona import Switzerland Mar 2008 Arizona import Switzerland Mar 2008 Arizona import Switzerland Mar 2008 Arizona import Switzerland Mar 2008 California import Switzerland Mar 2008 California import Switzerland Mar 2008 California import Switzerland Mar 2008 bangkok.tha 93 d5 palau.bla 93 d5 vic.aus 99 d9 chicago.usa 89 d3 manches.unk 94 d8 vic.aus 85 d7 illin.usa 99 d7 nj.usa 94 d6 mvp.uk 74 d1 johann.soa 88 d2 uganda-01-d10 Wisconsin vaccine May 2008 Vaccine A Wisconsin vaccine May 2008 Arizona vaccine May 2008 Wisconsin vaccine April 2008 ed-wt a yaounde.cae 83 b1 ny.usa 94 b3 ibadan.nie 97 b3 libreville.gab 84 b2 jm.usa 77 c2 wtf.deu 90 c2 tokyo.jpn 84k c1 braxator.deu 71 e madrid.spa 94 f H1 Wisconsin import China April 2008 Wisconsin import China April 2008 hunan.chn 93 h1 beijing.chn 94 h2 berkeley.usa 83 g1 amster.net 97 g2 gresik.ino 02 g3 5 changes

Multiple sources of genotype D4 California import Italy June 2008 Illinois import unknown May 2008 New York import Israel May 2008 New York import Israel May 2008 D4 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel April 2008 New York import Israel February 2008 montreal.can 89 d4 Georgia import Pakistan May 2008 Identical sequences suggest a single chain of transmission or multiple importations from the same source Different sequences (or genotypes) suggest multiple chains of transmission

Expanding and Improving Virologic Surveillance-1 Need to collect samples for viral detection (throat swab, NPA, urine) from as many suspected cases as possible Goal is to obtain genetic information from every chain of transmission and sporadic case Detection of viral RNA by real time RT-PCR or isolation of virus in cell culture has an expanding role in diagnosis A few samples have been virus isolation+, but PCR - Sequence analysis is still the only way to distinguish between a vaccine reaction and natural infection Consider a study to compare oral fluid and throat swabs/NPA for sensitivity of viral detection because some labs have reported that viral RNA is detectable in oral for a longer period after rash onset

Expanding and Improving Virologic Surveillance-2 Expand state lab capacity for virus isolation The WHO recommends a single cell line, Vero/hSLAM, for isolation of measles and rubella Efficiency of Vero/hSLAM is equivalent to that of B95a, but is much safer because Vero/hSLAM do not secrete Epstein Barr Virus CDC can provide protocols and cell line (under MTA)

Expanding and Improving Virologic Surveillance-3 Need timely and efficient reporting of sequence information on a global scale CDC has validated all historic sequence information from GenBank New database should provide for rapid exchange of sequence information CDC sequence database WHO reporting Health Protection Agency, London

Increase in Measles Sequences Reported

Thank You Measles, Mumps, Rubella and Herpesviruses Laboratory Branch, DVD/CDC Global Immunization Division/CDC Epidemiology Branch, DVD/CDC WHO/HQ, RRL and NLs State and Local Public Health Labs