Measles in New York City 2008 and the

Measles in New York City, 2008 and the use of an Immunization Information System in Outbreak Control Activities C Zimmerman*, M Asfaw*, K Cummings*, V Papadouka, M* Mickle-Hope*, A Metroka*, J Zucker*¶ *Bureau of Immunization (BOI) New York City Department of Health and Mental Hygiene (NYC DOHMH) ¶Immunization Services Division, Program Operations Branch, Centers for Disease Control and Prevention

Overview • Epidemiology of Measles in NYC • How we used our immunization information system (IIS) in outbreak response and control activities • How the IIS provided important information to understand why the outbreak may have occurred

# of Measles Cases NYC Measles, 1988 -2008 Year

Measles in 2008 • 29 cases (28 confirmed, 1 probable) • Most cases since 1992 • Complex outbreak with multiple importations • Several generations of local transmission • Large numbers of contacts ~2, 000 contact were identified and contacted about exposure

Complex Outbreak Sporadic Cases Cluster #1 Cluster #2 Cluster #3 Hatched pattern represents direct importations

Age Distribution 34% 28% 24% 14%

Pediatric Cases • 66% of cases were children (range 5 -42 months) – 37% (7/19) <12 months of age – 42% (8/19) 12 -15 months of age • 6 were 14 -15 months) – 4 (21%) >15 months of age • 4 cases >15 months of age and unvaccinated • Reasons for non-vaccination – 1 personal belief (42 month old) – 2 missed opportunities (16 months & 20 months old) – 1 unknown reason (24 months old) • 2 Hospitalizations for pneumonia • 1 possible nosocomial transmission from adult to child in a providers office

Adult Cases • 10/29 cases adults • Age range 20 -41 years • All imported cases were adults (Israel, Belgium, Italy) • Immunization status – 5 reported no previous measles vaccination – 4 reported unknown measles vaccination status – 1 had two well documented measles vaccinations >20 years earlier but was Ig. M positive

Molecular Epidemiology • 38% (11/29) of cases had culture/PCR testing for measles • 54% (6/11) were PCRculture positive all were D 4 genotype – D 4 know to be circulating in Belgium, UK, and Israel at that time

Geography • 90% of all the 2008 cases occurred in Borough of Brooklyn (Kings County) – 2000 census population for Brooklyn 3. 5 million – Birth cohort ~40, 000 • Of pediatric cases 79%(15/19) occurred in Borough Park neighborhood of Brooklyn – Population 2000 census of 185, 046 (51, 399/square mile*) – Birth cohort ~ 5, 300 *www. demographia. com/db-nyc-warddensch. htm

Outbreak Response • Issued alerts to medical community through local Health Alert Network (HAN) • Press release to media (TV, radio, print) • Outreach to community and religious leaders • Fliers distributed in Borough Park • Used school immunization compliance information to review public and private school Immunization coverage • Used IIS to target interventions

Use of the IIS in Outbreak Response Activities

NYC IIS- The Citywide Immunization Registry (CIR) • Initiated in 1997 • Populated with vital records data – ~ 125, 000 births per year • Over 1, 900 providers • ~70% of population <19 years of age are VFC eligible • 96% of VFC doses distributed are now accounted by the CIR

Using the IIS for Response I • IIS used to generate list of all (114) practices in 7 zip codes within Brooklyn, centered around Borough Park, and assessed their MMR coverage on children 24 -48 months of age – Providers with “large” numbers of unvaccinated were contacted by phone (10 practices) • Outbreak was discussed, strongly encouraged to recall children not UTD

Using the IIS for Response II • A list of all practices (72) reporting immunizations in Borough Park were generated from the IIS – A provider at each practice was contacted directly by phone by BOI physician • Items discussed included, infection control, postexposure prophylaxis, disease reporting, recommendation for first MMR to be given at 12 months of age

Use of IIS for Response III • IIS used to generate a list of all children in Borough Park, 12 -48 months of age with an immunization but no measles vaccine – 7, 312 letters generated and mailed • Letter informed parents of outbreak, and of child’s status of being not up-to-date, encouraged to follow-up with child’s provider, and encouraged MMR at 12 months of age

Use of IIS for Response IV • Use IIS to compile lists of children not UTD for measles ages 12 -48 months for practices in Borough Park regardless of whether child live in Borough Park or not – 69 Facilities were faxed a list of not UTD children for their practice for recall for vaccination

Why Borough Park? • More travel between neighborhood and Israel? • Traditional measures of coverage in Borough Park consistent with the rest of NYC – No higher proportion of refusal or exemption in Borough Park – Anecdotal reports of preference for delaying MMR although not refusing MMR • Notable given disease in 12 -15 month age group

Cumulative % of cohort with MMR at give age Timing of 1 st MMR Age in Months when 1 st MMR dose give to children born in 2005

%of MMR doses at 13 months of all MMR <4 years Timing of MMR Doses by Month Pre-Outbreak (1/07 -1/08) NYC 60. 2% Rest of Brooklyn 57. 4% Borough Park 38. 7% Post-Outbreak (6/08 -12/08) NYC 60. 9% Rest of Brooklyn 57. 5% Borough Park 45. 4% In each month what proportion of all MMR doses given to children <4 years of age were given at 12 -13 months of age

Limitations of the IIS • Incomplete reporting of immunizations • Duplicate records, unmerged records • Unable to identify who moves out of the area – Children reported to no longer be affiliated with a given practice when recall lists distributed • Missing immunization data due to children moving in and past records not being entered • Keeping address data current – ~1, 000 letters returned

Conclusions • The risk of measles remains high in NYC and throughout the U. S. due to imported disease • A quality IIS can provide important tools for outbreak response and for understanding areas of increased risk transmission • Children 12 -15 months who are not yet immunized are at considerable risk during an outbreak • In addition to getting vaccinated, getting vaccinated on-time matters, particularly in outbreak situations

Recommendations • NYC recommends that the 1 st dose of MMR be given at 12 months of age • ACIP should review its recommendations with respect to the first dose of MMR being given at 1215 months of age, in light of the events in NYC in 2008

Acknowledgements • BOI Surveillance Unit – – – – – • • – Karen Fernandez – Paul Mc. Namee – Cassandra Deas Program Support Unit – – – Paul Schaeffer Rezaul Kabir Angel Aponte Michael Hansen Provider Quality Assurance Unit Vaccine Management Unit – Angel La Paz – Jack Rodriguez NYC CIR – – • Francis Megafu Mohammed Mannan Gamal Sihly Vanessa Collado Luis Baez George Robinson Yvelouse Tannis Grace Reyes Renee Stewart Antonine Jean • • • Betty Sanchez Gracia Caines Paulette Kentish Nancy Villaneuva Reva Thomas Sharon Spence Mirleine Joseph Irene Burks Jane Tubridy Natalie Black Emily Le Osayuki Oshodin NYC Public Health Laboratory CDC Measles, Mumps Rubella Laboratory