1. RUBELLA SURVEILLANCE IN NEW YORK CITY March 23, 2005 A Scaccia 1, S Shah 1, M Misener 1, F Mostashari 2, JR Zucker 1,3 1: Bureau of Immunization, NYC DOHMH; 2: Division of Epidemiology, NYC DOHMH; 3: CDC/NIP/ISD

2. Presentation Outline Overview of NYC demographics Overview of rubella surveillance in NYC Summary of CRS case investigation Retrospective search for CRS cases Would we detect an outbreak? What are the next steps? CDC Data

3. Introduction to New York City Population of 8.1 million ~ 120,000 births annually Demographics – White: 35% – Hispanic: 27% – Black: 24% – Asian: 10% – Other: 4% CDC Data

4. The NYC Melting Pot One-third of New Yorkers are foreign born –1/2 from Latin America and 1/3 from Asia 2.1 million Hispanics – Puerto Rico: 36.5% – Dominican Republic: 18.8% – South America: 10.9% – Mexico: 8.6% – Central America: 4.6% 787,000 Asians –China: 45.9% –India: 27.7% –Korea: 11.0% CDC Data

5. Hispanic Population by Neighborhood

6. Overview of Rubella Surveillance in NYC Passive surveillance Active surveillance Total of 3 staff at main office and 16 staff at 2 field offices All dedicated to vaccine-preventable disease surveillance CDC Data

7. Passive Surveillance: Methods Mail/Phone/ Fax from: – ECLRS- Electronic Lab Reporting System – QUEST and other commercial laboratories – Private Physicians – School Health/other (each elementary school has an nurse) – Public Health Laboratories – Hospitals and Clinics

8. Reporting Sources for Suspected Rubella Cases: 2004 Average reporting delays (Receive date-Diagnosis date)= 4.2 days

9. ICN ER Monthly Visit to all hospitals Lab Monthly Call Active Surveillance

10. Surveillance continued Public Health Laboratories – Always tests for rubella and measles IgM and IgG for fever/rash cases Varicella surveillance in schools – We know it works – 862 cases reported in the 2004 – ~ 700 elementary schools with nurses Public Health Law requires rubella testing during pregnancy

11. Total Number of Reported Rubella Cases ConfirmedProbableSuspectedMisdxTotal 1999714571124 2000900126135 20016206068 20020016364 20031004748 20041003233 Total24346399472

12. Summary of CRS Surveillance: NYC ConfirmedProbableSuspectedMisdiag- nosis Total 199900022 20002121 0002 200100000 200200000 20031212 0001 200400000 Total30025 1: DR and Venezuela import-linked 2: CRS index case

13. Confirmed Rubella Cases by Travel and Ethnicity Year# casesImportedNo travelHispanic 199972121 52 200094242 55 200161313 50 20020000 200311414 01 20041010 Total248168 1: Russia and Pakistan 2: France, Brazil, England, DR 3: Trinidad 4: DR (CRS mom)

14. Clinical Features of Investigated Rubella Cases, 2004 N=33

15. Reports of Pregnant Women who were IgM + Year# of IgM + SymptomsPrior immunity No prior immunity 2002270225151 2003100 0 2004170161212 Total54048 (89%)6 1: all 5 classified as misdiagnosis based on convalescent serology 2: IgM – and IgG – over 4 weeks at CDC

16. Congenital Rubella Syndrome Case: 2003 DOB: 12/24/2003 Normal vaginal delivery at 39 weeks Birth weight was 6 lbs, 8 oz White, Hispanic female Newborn hearing screening - passed Seen at 15 days of age with a complaint from mom of white spot on the eyes CDC Data

17. Laboratory Studies Rubella IgM + and IgG + –2/2/04: IgM + (4.41 at Quest) –3/11/04: IgM + (2.6) ; IgG 6.19 (CDC) –5/5/04: IgM – (0.53); IgG 7.91 (CDC) –11/29/04: IgM – (PHL); IgG 6.73 (CDC) Multiple throat and urine specimens taken for viral isolation –Negative by culture and RT-PCR Chromosomal studies were normal CMV, toxo, HSV, syphilis: all negative CDC Data

18. Summary of 2003 CRS Case Meets the confirmed case definition: –Laboratory evidence of infection –Bilateral cataracts –Developmental delay Incomplete hearing evaluation No cardiac abnormalities by echo Normal MRI CDC Data

19. Summary of the Index Case’s Mother 22 years old, G2P2 Born in the Dominican Republic First child born 5/8/01 in NYC Mom documented to be rubella susceptible Did not receive MMR vaccine upon discharge postpartum despite a hospital order CDC Data

20. Case Investigation No reported rash illness, other illness or travel during pregnancy No reported visitors or exposure to ill person from the Dominican Republic (DR) Reported working in a restaurant 1 st trimester Son immunized, not in day care Husband is a cab driver, goes back and forth to the DR Neighborhood with large immigrant population History confirmed by family Only confirmed rubella case in NYC in 2003 CDC Data

21. Case Investigation Conclusion Mother’s illness was acquired in the US Hypothesis is that this case is import- linked to an unrecognized case CRS case was a secondary case related to the mother’s infection CDC Data

22. Retrospective Search for CRS Cases Hospital discharge dataset 1999-2002 Infants < 1 year Searched for the following ICD 9 codes: – 771.0: Congenital Rubella – 743.3: Cataracts – 389.1: Deafness – 745.5/747: Congenital Heart Disease – 742.1: Microcephaly – 759.89: Dermal Erythropoiesis

23. Summary of Hospital Discharge Data Year# of Records# with CRS code Syndrome Consistent (not CRS) 1999241 9 (9) 2000241212 5 (9) 20012605 (5) 2002281313 2 (2) Total102321 (21) 1: Import from Haiti 2: Confirmed CRS case from NJ 3: IgM -

24. Other Sources Calls made to major hospitals that would care for CRS babies have yielded no additional cases Calls made to agencies that would provide care to CRS patients have yielded no additional cases Quest data: ~ 7,200 IgMs done annually – ~ 1% positive – ~ 40% from NYC – ~ 29 per year

25. Would We Detect an Outbreak? Confident we would identify an outbreak among school age children Confident we would identify a large cluster or 12 months of transmission Could miss isolated cases among adults in the immigrant community – Health seeking behavior – Fever/rash poorly detected in syndromic surveillance – Index mother not recognized – Almost missed a measles case in 2003

26. Conclusion Evidence of sporadic cases with limited transmission of rubella in NYC No evidence of endemic transmission (continued transmission of > 12 months)

27. Next Steps Continue to maintain quality of surveillance and thorough investigation of all report cases Expand testing for alternative diagnoses, such as parvovirus Consideration of the need for sentinel surveillance sites Query implement national review of discarded cases?