1. Vaccine-Preventable Diseases: Situations Requiring Immediate Action
Carrie A. Thomas, PhD
Epidemiologist (VPD/IBD)
Division of Infectious Disease Epidemiology
West Virginia Bureau for Public Health
(304)

2. Objectives
Overview 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 investigation

3. Measles – Why is it an Emergency?
Endemic measles declared eliminated in the US in 2000
Almost 30% of cases experience complications
Inflammation of the middle ear (7%)
Pneumonia (6%)
Encephalitis (0.1%)
Hospitalization (19%)
Death (0.3%)
Susceptible populations at higher risk for disease and complications

4. Measles – Populations for Special Consideration
Children < 1 year of age
Susceptible immunocompromised patients
Healthcare workers (HCWs)
Increased risk of exposure and transmission through patient care
Pregnant women
High risk for pregnancy complications
People travelling to places where measles are endemic

5. Measles – What to Do
Immediately isolate suspect cases with airborne transmission precautions
4 days after rash onset in otherwise healthy individuals
duration of illness in immunocompromised patients
Confirm/rule out suspect cases rapidly through lab results
Work with DIDE to submit sample to CDC
High false positive rate of results in commercial labs

6. Measles – What to Do (cont.)
Confirm immune status of exposed individuals
Need written confirmation (verbal indication is not acceptable)
Acceptable evidence of immunity
Evidence of physician-diagnosed natural measles infection
Documentation of two doses of measles containing vaccine, or
A positive IgG antibody test for measles

7. 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
† vaccination contraindicated in these populations

8. 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

9. Rubella – Why is it an Emergency?
Endemic rubella declared eliminated in the US in 1994
Complications are rare, occurring more frequently in adults than children
However, arthralgia or arthritis may occur in up to 70% of adult women
Encephalitis or hemorrhagic manifestations are rare
Urgency comes from desire to prevent Congenital Rubella Syndrome

10. Rubella – Populations for Special Consideration
Susceptible immunocompromised patients
Children < 1 year of age
Healthcare workers (HCWs)
Pregnant women
High risk for pregnancy complications
Congenital Rubella Syndrome – affects up to 85% of infants infected during 1st trimester

11. Rubella – Congenital Rubella Syndrome (CRS)
Can affect all organ systems; manifestations include
Deafness - most common
Cataracts & other eye defects
Heart defects including holes in the walls or blood vessels; malformations of heart valves or blood vessels
Microcephaly and/or mental retardation
Bone alterations
Liver and spleen damage
Diabetes mellitus, progressive encephalopathy and autism have also been observed in children with CRS

12. Rubella – What to Do
Immediately isolate suspect cases with contact precautions for 7 days after rash onset
Confirm/rule out suspect cases rapidly through lab results
Work with DIDE to submit sample to CDC for confirmation
False positive IgM results seen in persons with parvovirus B19 infections, infectious mononucleosis, or a positive rheumatoid factor

13. Rubella – What to Do (cont.)
Confirm immune status of exposed individuals
Documentation of at least 1 dose of rubella-containing vaccine
Positive IgG antibody test
Born before 1957
Note: clinical diagnosis is unreliable and should not be considered when assessing immune status
Confirm pregnancy status of exposed women

14. 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 exposed
Assess immune status

15. 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 include
Inflammation of the heart muscle (myocarditis)
Paralysis
Inflammation of the middle ear
Respiratory insufficiency

16. Diphtheria – Populations for Special Consideration
Susceptible 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

17. Diphtheria – What to Do
Isolate suspect cases with droplet precautions for 48 hours after beginning antibiotics
Confirm diagnosis through lab results
Work 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)

18. 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 diphtheria
Cutaneous diphtheria is not a reportable condition
Transmitted through contact with skin lesions

19. Meningococcal Meningitis – Why is it an Emergency?
Infection can progress rapidly and result in death
10-14% case-fatality rate
Approx 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 days

20. 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, including
terminal complement component deficiencies
anatomic or functional asplenia

21. Meningococcal Meningitis – What to Do
Trace 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 contacts
Persons directly exposed to patient’s oral secretions by kissing, mouth-to-mouth resuscitation, or endotracheal intubation/tube management
Add from red book

22. 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 PEP
You probably don’t need to provide PEP to the receptionist who checked the patient in

23. Invasive Haemophilus Influenzae b (Hib) – Why is it an Emergency?
Before vaccine, 15-30% of survivors experienced serious complications
Hearing impairment
Severe permanent neurologic consequences
Mental retardation
Seizure disorder
Cognitive & developmental delay
Paralysis
Rapid identification important for early vaccination and chemoprophylaxis of susceptible contacts

24. Hib – Populations for Special Consideration
Children under 5 years of age
Immunocompromised children
Older children and adults who were not vaccinated in childhood and have the following conditions
Functional or anatomical asplenia
Immunodeficiency from IgG2 subclass deficiency
Immunosuppression from cancer chemotherapy
HIV
Hematopoietic stem cell transplant

25. Hib – What to Do
Isolate 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 possible
With at least 1 contact < 4 years old who is unimmunized or incompletely immunized
With a child younger than 12 months who has not received the primary series
With an immunocompromised child (regardless of immunization status

26. 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 case
Contacts in households where
Members months old are fully vaccinated
Members <12 months old have received primary series of Hib immunizations
Nursery school/childcare center contacts of 1 index case
Pregnant women

27. Mumps – Why is it an Emergency?
20-40% infections asymptomatic
Major cause of sensorineural deafness in children
Complications more common in adults
Meningoencephalitis
Orchitis , oophoritis, mastitis
Permanent consequences are rare
Susceptible HCW are who you need to be concerned about
Define parotitis

28. Mumps – What to Do
Isolate cases with droplet precautions for 5 days after onset of parotitis
Evaluate immune state of exposed contacts
Written documentation of vaccination
Positive mumps IgG
Lab confirmation of disease
Birth before 1957 (except in healthcare setting)

29. 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 days after exposure, regardless of vaccination status

30. Pertussis during Pregnancy
Pertussis 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

31. Pertussis during Pregnancy (cont.)
Pregnant women should receive a single dose of Tdap during an outbreak
Preferably 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

32. Varicella during Pregnancy
Primary infection with VZV in pregnant women is rare
Varicella in pregnancy is associated with
VZV infection of the fetus
Low birth weight
Skin scarring
Malformed limbs
Mental retardation
Vision problems

33. 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

34. Summary Isolate case patient Inform appropriate agencies – DIDE, CDC
Confirm diagnosis with appropriate lab testing
Trace contacts and assess immunity
Provide appropriate PEP

35. References
Manual 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