1. 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

2. 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)

3. 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

4. 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

5. 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:

6. Potential measles transmission patterns!6

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

9. 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+

10. 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

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

12. 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

13. 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

14. 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
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

15. 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

16. 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

17. 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)

18. 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

19. Increase in Measles Sequences Reported

21. 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