Surveillance of Vaccine-Preventable Diseases

Surveillance of Vaccine-Preventable Diseases


♪>>>HELLO. I’M ANNE SCHUCHAT,
DIRECTOR OF THE NATIONAL CENTER FOR IMMUNIZATION AND RESPIRATORY
DISEASES. I’M DELIGHTED TO WELCOME YOU TO
THE 2011 EDITION OF “SURVEILLANCE OF
VACCINE-PREVENTABLE DISEASES.” DISEASE SURVEILLANCE IS A
CRITICAL ELEMENT OF PUBLIC HEALTH.SURVEILLANCE PROVIDES US
WITH INFORMATION ABOUT WHERE AND WHEN VACCINE-PREVENTABLE
DISEASES ARE OCCURRING. THESE DATA ALSO HELP US TO
EVALUATE THE IMPACT OF OUR VACCINATION PROGRAMS AND SUGGEST
AREAS IN WHICH THESE PROGRAMS MIGHT BE IMPROVED. THIS PROGRAM
WILL PROVIDE YOU WITH CURRENT GUIDELINES FOR THE SURVEILLANCE
OF VACCINE-PREVENTABLE DISEASES. THE INFORMATION WE DISCUSS IN
THIS PROGRAM SHOULD BE ESPECIALLY HELPFUL FOR THOSE OF
YOU IN LOCAL AND STATE HEALTH DEPARTMENTS AND HEALTH CARE
PROVIDERS WHO IDENTIFY AND REPORT CASES OF
VACCINE-PREVENTABLE DISEASE. YOUR PARTICIPATION IS CRITICAL. WITHOUT YOU, THERE WOULD BE NO
NATIONAL SURVEILLANCE. IN ROUTINE DISEASE-CONTROL
PROGRAMS, ROUTINE DISEASE SURVEILLANCE SYSTEMS ARE USUALLY
ADEQUATE TO MEET NATIONAL PROGRAM NEEDS, DESPITE THEIR
LIMITATIONS. IN CONTRAST, IN DISEASE
ELIMINATION OR ERADICATION PROGRAMS, ROUTINE SURVEILLANCE
ACTIVITIES ARE OFTEN INADEQUATE ONCE THE GOAL IS NEAR. THIS IS THE SITUATION NOW IN THE
UNITED STATES WITH DISEASES LIKE MEASLES AND RUBELLA. EVERY CASE COUNTS AND MUST BE
THOROUGHLY INVESTIGATED AND REPORTED. WITHOUT ADEQUATE SURVEILLANCE, WE WILL BE UNABLE TO ACHIEVE AND SUSTAIN ELIMINATION OF
VACCINE-PREVENTABLE DISEASES. WE HOPE YOU WILL FIND THE
INFORMATION IN THIS COURSE USEFUL. YOUR WORK IN THE RAPID
IDENTIFICATION,INVESTIGATION, AND REPORTING OF
VACCINE-PREVENTABLE DISEASES FORMS THE FOUNDATION OF OUR
NATIONAL PREVENTION AND CONTROL PROGRAMS. BECAUSE OF YOU, OUR NATIONAL
DISEASE SURVEILLANCE SYSTEM WORKS. THANK YOU.>>AS A RESULT OF EFFECTIVE
IMMUNIZATION PROGRAMS, DISEASES THAT ONCE WERE MAJOR CAUSES OF
DEATH AND MORBIDITY AMONG CHILDREN IN THIS COUNTRY NOW
OCCUR SO INFREQUENTLY THAT MANY OF US HAVE NEVER SEEN A CASE. OUR CHALLENGE NOW IS TO IDENTIFY
THE FACTORS THAT ALLOW THE REMAINING CASES TO OCCUR. WE ALSO WANT TO EXTEND OUR
SUCCESSES WITH THE ELIMINATION OF MEASLES, RUBELLA, AND POLIO
TO OTHER DISEASES, LIKE PERTUSSIS, HEPATITIS “A,” AND
VARICELLA. WE DO CASE INVESTIGATIONS TO
HELP US FIGURE OUT IF WE NEED TO TAKE PUBLIC HEALTH ACTION. IF ACTION IS NEEDED, EXACTLY
WHAT DO WE NEED TO DO? AT THE LOCAL LEVEL, WE NEED
SURVEILLANCE INFORMATION RAPIDLY SO WE CAN START DISEASE-CONTROL
ACTIVITIES. AN EXAMPLE IS PROVIDING
ANTIBIOTIC PROPHYLAXIS FOR CONTACTS OF A PERSON WITH
PERTUSSIS OR VACCINATING SUSCEPTIBLE PERSONS WHEN
OUTBREAKS OCCUR. BEFORE CASES OF ANY DISEASE CAN
BE COUNTED, WE MUST DEFINE WHAT IT IS WE’RE COUNTING. THIS CRITICAL COMPONENT OF ALL
SURVEILLANCE SYSTEMS REQUIRES STANDARDIZED CASE DEFINITIONS. CASE DEFINITIONS HAVE BEEN
ESTABLISHED FOR VACCINE-PREVENTABLE DISEASES,
AND WE’LL MENTION MANY OF THEM IN THE COURSE OF THIS PROGRAM. CASE DEFINITIONS CAN BE FOUND IN
THE MANUAL FOR THE SURVEILLANCE OF VACCINE-PREVENTABLE DISEASES. WE’LL INCLUDE A LINK TO THE
SURVEILLANCE MANUAL ON THE PROGRAM WEB PAGE. CDC ALSO MAINTAINS A WEB PAGE
THAT CONTAINS THE CASE DEFINITIONS FOR ALL INFECTIOUS
CONDITIONS UNDER NATIONAL PUBLIC HEALTH SURVEILLANCE, INCLUDING
VACCINE-PREVENTABLE DISEASES. THIS IS A VERY USEFUL WEB PAGE,
AND WE’LL ALSO PUT A LINK TO IT ON THE RESOURCES WEB PAGE FOR
THIS PROGRAM. FOR EACH VACCINE-PREVENTABLE
DISEASE, THERE ARE SPECIFIC CRITICAL DATA THAT MUST BE
COLLECTED IN ORDER TO PLAN AND IMPLEMENT APPROPRIATE
PUBLIC-HEALTH ACTION. FOR EACH CASE, WE NEED
DEMOGRAPHIC INFORMATION AND RELEVANT CLINICAL DATA,
VACCINATION HISTORY, AND LABORATORY TEST RESULTS. THIS IS THE INFORMATION NEEDED
TO CLASSIFY CASES, AND IT’S CRITICAL FOR THE EVALUATION OF
CASES OF VACCINE-PREVENTABLE DISEASES. IN ADDITION TO GATHERING
INFORMATION ABOUT THE CASE, YOU NEED TO TRY TO IDENTIFY THE
PEOPLE THAT THE PERSON MAY HAVE TRANSMITTED THE INFECTION TO. AND YOU NEED TO IDENTIFY THE
PERSON THE PATIENT GOT THE INFECTION FROM. YOU NEED TO FIND OUT WHETHER THE
CASE IS LINKED TO AN OUTBREAK OR IS AN ISOLATED, SPORADIC CASE. JUST BECAUSE NO OTHER CASES HAVE
BEEN REPORTED, YOU CANNOT ASSUME THAT NO OTHER CASES HAVE
OCCURRED. AT THE STATE LEVEL, SURVEILLANCE
DATA ON VACCINE-PREVENTABLE DISEASES IS NEEDED TO EVALUATE
THE EFFECTIVENESS OF DISEASE-CONTROL PROGRAMS. WHEN THERE IS A CASE OF A
VACCINE-PREVENTABLE DISEASE IN SOMEONE FOR WHOM THERE IS A
VACCINATION RECOMMENDATION, IT SHOULD SERVE AS A WARNING TO
PUBLIC-HEALTH OFFICIALS. THERE MAY BE OTHER SUSCEPTIBLE
INDIVIDUALS WHO SHOULD HAVE BEEN VACCINATED BUT WERE NOT OR THERE
MAY HAVE BEEN WANING IMMUNITY IN A VACCINATED INDIVIDUAL. YOU NEED TO FIND OUT, WAS THE
PERSON VACCINATED? AND IF NOT, WHY NOT? WERE THERE MISSED OPPORTUNITIES
TO VACCINATE? IS THERE A MORE WIDESPREAD
PROBLEM? IN ADDITION TO THE EVALUATION OF
DISEASE-CONTROL PROGRAMS, STATES HAVE OTHER NEEDS FOR
SURVEILLANCE DATA. SURVEILLANCE DATA ARE ALSO
NEEDED TO FORMULATE AND EVALUATE IMMUNIZATION POLICY. AT THE NATIONAL LEVEL, WE USE
SURVEILLANCE DATA TO FORMULATE NATIONAL IMMUNIZATION POLICY AND
TO EVALUATE THE EFFECTIVENESS OF IMMUNIZATION PROGRAMS. WE ALSO RELY ON SURVEILLANCE
DATA TO EVALUATE THE EFFECTIVENESS OF THE VACCINES
THEMSELVES AND TO DOCUMENT THE IMPACT OF NATIONAL IMMUNIZATION
EFFORTS. THIS IS ESPECIALLY IMPORTANT
WITH RELATIVELY NEW VACCINES, SUCH AS THE MENINGOCOCCAL
CONJUGATE VACCINE AND THE TETANUS, DIPHTHERIA, AND
PERTUSSIS VACCINE, OR TDAP, FOR ADOLESCENTS AND ADULTS. NEW VACCINE SCHEDULES ALSO
REQUIRE CAREFUL SURVEILLANCE AND EVALUATION. AN EXAMPLE OF THIS IS THE 2007
RECOMMENDATION FOR THE SECOND DOSE OF VARICELLA VACCINE. ANDREW?>>WHAT WE NEED FROM A
SURVEILLANCE SYSTEM DEPENDS ON WHERE WE ARE IN OUR
DISEASE-CONTROL PROGRAM. WHAT WE NEED EARLY IN THE
PROGRAM OR WHEN THERE ARE LARGE NUMBERS OF CASES IS QUITE
DIFFERENT THAN WHAT WE NEED WHEN THE PROGRAM IS VERY FAR ALONG
WITH FEW CASES. OF COURSE, WE NEED TO ENSURE
ADEQUATE SURVEILLANCE FOR VACCINE ADVERSE EVENTS FOR ANY
VACCINE CURRENTLY IN USE, REGARDLESS OF THE STAGE OF
DISEASE CONTROL. BEFORE A VACCINE IS AVAILABLE
FOR ROUTINE USE, THE INFORMATION WE NEED IS PRETTY SIMPLE. WE NEED TO HAVE A BASELINE OF
REPORTED DISEASE. COMPLETE REPORTING IS NOT
ESSENTIAL, BUT WE DO NEED YEAR-TO-YEAR CONSISTENCY. WE NEED NATIONAL DATA TO
REPRESENT THE EPIDEMIOLOGY OF THE DISEASE PRIOR TO THE
AVAILABILITY OF A VACCINE. BUT DURING THIS PHASE, AGGREGATE
REPORTING OF CASE COUNTS IS USUALLY SUFFICIENT. WHEN A NEW VACCINE IS
RECOMMENDED FOR ROUTINE USE AND DISEASE REMAINS COMMON, OUR GOAL
SHIFTS TO MONITORING THE IMPACT OF THE NATIONAL VACCINATION
EFFORTS. AT THIS POINT, AGGREGATE
REPORTING OF CASE COUNTS IS STILL SUFFICIENT. WHEN WE HAVE GOOD DISEASE
CONTROL, AS WE HAVE NOW WITH HAEMOPHILUS INFLUENZAE TYPE B,
WE NEED ENHANCED SURVEILLANCE SO WE CAN DOCUMENT VACCINE IMPACT,
EVALUATE EFFECTIVENESS, AND MONITOR PROGRESS TOWARD DISEASE
ELIMINATION. WE CAN USE THIS INFORMATION TO
FIGURE OUT WHY THE CASES THAT REMAIN CONTINUE TO OCCUR. WITH GOOD DISEASE CONTROL, WE
NEED DETAILED INFORMATION FROM INDIVIDUAL CASE INVESTIGATIONS,
INCLUDING VACCINATION STATUS AND LABORATORY CONFIRMATION. WE ALSO NEED HIGHLY SPECIFIC
CASE DEFINITIONS, BECAUSE WE REALLY WANT TO MAKE SURE THAT
THE CASES WE ARE COUNTING ARE REAL CASES OF THE DISEASE. THIS IS THE PHASE WHEN EVERY
CASE COUNTS. WHEN DISEASE INCIDENCE IS VERY
LOW AND WE ARE STRIVING FOR ELIMINATION, THE COMPLETENESS OF
REPORTING AND THE QUALITY OF INDIVIDUAL CASE INVESTIGATIONS
ARE VERY IMPORTANT. AT THIS POINT, THE ORGANISM MAY
NO LONGER EVEN BE CIRCULATING, AND WE CAN USE MOLECULAR-TYPING
METHODS TO HELP DOCUMENT THAT. IN SUMMARY, SURVEILLANCE
ACTIVITIES MUST BE DESIGNED TO FIT THE PUBLIC-HEALTH NEED. WE NEED BASELINE DATA FOR
DISEASES FOR WHICH A NEW VACCINE IS AVAILABLE, BUT WE NEED
DETAILED INDIVIDUAL CASE INVESTIGATIONS WHEN WE HAVE
ACHIEVED HIGHER LEVELS OF DISEASE CONTROL THROUGH
VACCINATION PROGRAMS. WE RELY ON SURVEILLANCE TO
MONITOR THE EFFECTIVENESS OF OUR IMMUNIZATION PROGRAMS BUT HOW CAN WE MONITOR THE
EFFECTIVENESS OR QUALITY OF OUR SURVEILLANCE? SURVEILLANCE IS A CHALLENGE WHEN
THE DISEASE FOR WHICH WE ARE DOING SURVEILLANCE IS RARE. HOW DO WE KNOW WHETHER NO CASES
WERE REPORTED BECAUSE THERE REALLY WERE NO CASES OR BECAUSE
NO ONE WAS LOOKING? WE RELY ON SURVEILLANCE
INDICATORS TO MONITOR THE QUALITY OF NATIONAL
SURVEILLANCE. CERTAIN CRITICAL ELEMENTS NEED
TO BE COLLECTED DURING INVESTIGATION OF CASES OF
VACCINE-PREVENTABLE DISEASES. THESE INCLUDE DEMOGRAPHIC
INFORMATION, RELEVANT CLINICAL AND LABORATORY DATA, AND
VACCINATION STATUS. MONITORING WHETHER OR NOT THESE
DATA ARE REPORTED LETS US TRACK THE QUALITY OF CASE
INVESTIGATION, AND WE DO THIS ROUTINELY. BUT THAT DOES NOT TELL US
WHETHER OR NOT ZERO CASES REPORTED REALLY MEANS ZERO
DISEASE OR INFECTION. WE MUST ENSURE THAT WE CAN
IDENTIFY AND RESPOND TO EVERY CASE WHEN DISEASE RATES ARE VERY
LOW. FOR INSTANCE, BETWEEN JANUARY 1,
2011 AND NOVEMBER 30, 2011, CDC WAS NOTIFIED OF 72 INTERNATIONAL
MEASLES IMPORTATIONS AND 17 MEASLES OUTBREAKS IN THE U.S. ONE OF THESE 17 OUTBREAKS
INVOLVED 20 ASSOCIATED SPREAD CASES THIS ILLUSTRATES THAT WE MUST
MAINTAIN OUR VIGILANCE AND SURVEILLANCE FOR
VACCINE-PREVENTABLE DISEASES. SANDY?>>NATIONAL SURVEILLANCE FOR
VACCINE-PREVENTABLE DISEASES TRADITIONALLY RELIES ON PASSIVE
REPORTING, WHICH IS OFTEN INCOMPLETE. IN SPITE OF THIS LIMITATION,
DATA FROM PASSIVE REPORTING ARE USEFUL FOR ROUTINE NATIONAL
SURVEILLANCE BECAUSE THEY ARE USED PRIMARILY FOR MONITORING
TRENDS IN DISEASE OCCURRENCE RATHER THAN IN RESPONSE TO
INDIVIDUAL CASES. HOWEVER, FOR DISEASES WITH VERY
FEW REMAINING CASES, AS WITH MOST OF THE VACCINE-PREVENTABLE
DISEASES, SURVEILLANCE DATA MUST BE VERY COMPLETE. EVERY CASE COUNTS. WE NEED TO KNOW WHETHER ZERO
REPORTED CASES MEAN THAT THERE IS REALLY NO DISEASE. SURVEILLANCE INDICATORS HAVE
BEEN DEVELOPED TO ASSESS THE QUALITY OF NATIONAL
SURVEILLANCE. SPECIFICALLY, THEY CAN ASSESS
THE COMPLETENESS OF REPORTING — THAT IS, THE ABILITY OF OUR
SURVEILLANCE SYSTEM TO IDENTIFY ALL CASES, IF AND WHEN THEY ARE
PRESENT. REMEMBER THAT SURVEILLANCE MUST
ALSO BE SPECIFIC ENOUGH TO EXCLUDE NON-CASES BY ADEQUATE
CASE INVESTIGATION AND LABORATORY TESTING. SURVEILLANCE INDICATORS CAN ALSO
BE USED TO ASSESS INVESTIGATIVE EFFORT AND THE COMPLETENESS OF
EPIDEMIOLOGICALLY IMPORTANT SURVEILLANCE DATA. METHODS TO MONITOR SURVEILLANCE
QUALITY WERE FIRST DEVELOPED IN 1988 BY THE PAN AMERICAN HEALTH
ORGANIZATION AS PART OF THE POLIO-ERADICATION EFFORT IN THE
WESTERN HEMISPHERE. IN THE POLIO-ERADICATION EFFORT,
SURVEILLANCE WAS PERFORMED NOT JUST FOR PARALYTIC POLIOMYELITIS
BUT FOR A SYNDROME INCLUDING BOTH PARALYTIC POLIO AND OTHER
CLINICALLY COMPATIBLE CONDITIONS. IN THE ABSENCE OF POLIO, THESE
OTHER CONDITIONS CAUSING ACUTE FLACCID PARALYSIS, OR AFP,
REMAIN CONSTANT THROUGH TIME. SO IF THE REPORTED AFP RATE
REMAINED CONSTANT WITHOUT CONFIRMED OR COMPATIBLE POLIO,
THERE WAS CONFIDENCE THAT THE ABSENCE OF REPORTED CASES OF
POLIO, IN FACT, MEANT THE ABSENCE OF POLIO THE SYSTEM WAS SENSITIVE ENOUGH
TO FIND AFP AND POLIO, IF IT WERE PRESENT. THIS SURVEILLANCE INDICATOR USED
AN EXTERNAL STANDARD — AFP — TO MEASURE SURVEILLANCE QUALITY. SURVEILLANCE INDICATORS FOR
MEASLES, MUMPS, AND RUBELLA ARE SIMILAR TO EACH OTHER. THE INDICATORS INCLUDE
COMPLETENESS OF DATA, TIMELINESS OF REPORTING, PROPORTION OF
CASES THAT ARE LABORATORY CONFIRMED, AND PROPORTION OF
CASES THAT HAVE AN IMPORTED SOURCE. IF OUR SURVEILLANCE SYSTEM CAN
IDENTIFY EVEN IMPORTED CASES OF MEASLES AND RUBELLA, FOR
EXAMPLE, WE HAVE CONFIDENCE THAT THE SYSTEM COULD ALSO IDENTIFY
INDIGENOUS CASES, IF THEY WERE PRESENT. FOR RUBELLA, WE ALSO MEASURE THE
PROPORTION OF CASES AMONG WOMEN OF CHILD-BEARING AGE WITH KNOWN
PREGNANCY STATUS. FOR MEASLES, WE MEASURE THE
PROPORTION OF CASES FOR WHICH A CLINICAL SPECIMEN IS SUBMITTED
FOR VIRUS ISOLATION. WE HAVE ALSO DEVELOPED
INDICATORS FOR HAEMOPHILUS INFLUENZAE AND PERTUSSIS
SURVEILLANCE. FOR HAEMOPHILUS INFLUENZAE, WE
MEASURE THE TIMELINESS AND COMPLETENESS OF CASE INFORMATION
FOR CHILDREN YOUNGER THAN 5 YEARS OF AGE, INCLUDING VACCINE
HISTORY AND SEROTYPE. WE CAN ALSO TRACK THE INCIDENCE
OF NON-TYPE-B DISEASE AMONG CHILDREN YOUNGER THAN 5 YEARS OF
AGE. THE MOST RECENT NATIONAL
SURVEILLANCE INDICATOR REPORTS FOR MEASLES, MUMPS, RUBELLA,
PERTUSSIS, AND HAEMOPHILUS INFLUENZAE ARE AVAILABLE ON THE
RESOURCES WEB PAGE FOR THIS PROGRAM. FOR PERTUSSIS, WE MEASURE
TIMELINESS AND COMPLETENESS OF EPIDEMIOLOGIC DATA, ESPECIALLY
VACCINATION HISTORY FOR CHILDREN YOUNGER THAN 7 YEARS OF AGE. WE ALSO LOOK AT THE PROPORTION
OF CLINICALLY COMPATIBLE CASES THAT HAVE LABORATORY TESTING. THESE ARE A FEW APPROACHES TO
MONITORING THE QUALITY OF SURVEILLANCE. WE DO SURVEILLANCE TO MONITOR
THE QUALITY OF OUR IMMUNIZATION PROGRAM. WE USE SURVEILLANCE INDICATORS
TO MONITOR THE QUALITY OF OUR SURVEILLANCE. WITH THE INCIDENCE OF MANY OF
THE VACCINE-PREVENTABLE DISEASES AT ALL-TIME RECORD LOWS, WE
CANNOT BE SURE THAT ZERO MEANS ZERO UNLESS WE CAN DOCUMENT THAT
SOMEONE IS LOOKING.>>HUMAN PAPILLOMAVIRUS, OR HPV,
IS THE MOST COMMON SEXUALLY TRANSMITTED INFECTION IN THE
UNITED STATES, WITH AN ESTIMATED 6.2 MILLION NEW INFECTIONS EVERY
YEAR. MORE THAN 100 HPV TYPES HAVE
BEEN IDENTIFIED, AND MORE THAN 40 OF THESE TYPES CAN INFECT THE
GENITAL AREA. HPV TYPES ARE CLASSIFIED BY
THEIR ASSOCIATION WITH CANCER INTO EITHER LOW-RISK, OR
NON-ONCOGENIC TYPES, AND HIGH-RISK, OR ONCOGENIC TYPES. THE ONCOGENIC TYPES ARE
RESPONSIBLE FOR MANY ANOGENITAL AND OROPHARYNGEAL CANCERS. MOST HPV INFECTIONS ARE
ASYMPTOMATIC AND DO NOT RESULT IN ANY CLINICAL CONSEQUENCE. HOWEVER, SOME PERSISTENT
ONCOGENIC HPV INFECTIONS CAN CAUSE CERTAIN ASSOCIATED
CANCERS. IT IS IMPOSSIBLE TO DISTINGUISH
WHICH INFECTIONS BECOME PERSISTENT AND MAY GO ON TO
PRODUCE CANCER YEARS LATER. THE PREVENTION OF HPV INFECTION
THROUGH VACCINATION IS IMPORTANT IN ORDER TO PREVENT THE CANCER
OUTCOMES WHICH MAY DEVELOP. HIGH-RISK HPV TYPES ARE DETECTED
IN ALMOST ALL CERVICAL CANCERS, AND 70% OF CERVICAL CANCERS
WORLDWIDE ARE DUE TO JUST TWO HPV TYPES — 16 AND 18. WHILE PERSISTENT INFECTION WITH
HIGH-RISK TYPES IS CONSIDERED NECESSARY FOR THE DEVELOPMENT OF
CERVICAL CANCER, IT IS NOT THE ONLY FACTOR, BECAUSE THE VAST
MAJORITY OF WOMEN WITH HIGH-RISK HPV INFECTION DO NOT DEVELOP
CANCER. IN ADDITION TO ITS ASSOCIATION
WITH CERVICAL CANCER, HIGH-RISK HPV INFECTION IS ALSO ASSOCIATED
WITH CANCER OF THE VULVA, VAGINA, PENIS, ANUS, AND
OROPHARYNX — THAT IS, CANCERS IN THE BACK OF THE THROAT,
INCLUDING BASE OF TONGUE AND EACH OF THESE IS LESS COMMON
THAN CERVICAL CANCER, AND UNLIKE CERVICAL CANCER, NOT ALL CASES
OF THESE LESS-COMMON ANOGENITAL AND OROPHARYNGEAL CANCERS ARE
RELATED TO HPV INFECTION. LOW-RISK, OR NON-ONCOGENIC
TYPES, SUCH AS HPV TYPES 6 OR 11, CAN CAUSE ANOGENITAL WARTS
AND A DISEASE OF THE RESPIRATORY TRACT CALLED RECURRENT
RESPIRATORY PAPILLOMATOSIS, OR RRP. AS OF DECEMBER 2011, THERE ARE
TWO APPROVED HPV VACCINES IN THE UNITED STATES. ONE IS A QUADRIVALENT VACCINE,
WHOSE BRAND NAME IS GARDASIL AND IS PRODUCED BY MERCK. THE SECOND IS A BIVALENT
VACCINE, BRAND NAME CERVARIX, PRODUCED BY GlaxoSmithKline. NEITHER VACCINE IS A LIVE
VACCINE. BOTH VACCINES CONTAIN CAPSID
PROTEINS OF THE TARGETED HPV TYPES AND ARE NOT INFECTIOUS. THE BIVALENT VACCINE CONTAINS
THE CAPSID PROTEINS OF TWO ONCOGENIC HPV TYPES — 16 AND
18. THE QUADRIVALENT VACCINE
CONTAINS THE CAPSID PROTEINS OF THE TWO ONCOGENIC HPV TYPES —
16 AND 18 — AND TWO NON-ONCOGENIC HPV TYPES — 6 AND
11. BOTH VACCINES ARE HIGHLY
EFFECTIVE AGAINST CERVICAL PRE-CANCERS DUE TO HPV 16 OR 18
IF ADMINISTERED PRIOR TO INFECTION WITH THE VIRUS. THE QUADRIVALENT VACCINE ALSO
HAS HIGH EFFICACY AGAINST GENITAL WARTS CAUSED BY HPV 6
AND 11. NEITHER VACCINE HAS A
THERAPEUTIC EFFECT ON HPV-RELATED DISEASE OR ON RISK
OF PROGRESSION TO DISEASE IN PERSONS WHO HAVE HPV INFECTION
AT THE TIME OF VACCINATION. THE QUADRIVALENT VACCINE WAS
LICENSED BY THE FOOD AND DRUG ADMINISTRATION, OR FDA, IN 2006
FOR USE IN FEMALES AND IN 2009 FOR USE IN MALES. THE BIVALENT VACCINE WAS
LICENSED BY THE FDA IN 2009 FOR USE IN FEMALES. THE ADVISORY COMMITTEE ON
IMMUNIZATION PRACTICES, OR ACIP, RECOMMENDS ROUTINE VACCINATION
OF 11- OR 12-YEAR-OLD GIRLS WITH THREE DOSES OF EITHER THE
BIVALENT OR THE QUADRIVALENT VACCINE. VACCINATION CAN BE STARTED
BEGINNING AT 9 YEARS OF AGE. CATCH-UP IMMUNIZATION OF FEMALES
13 THROUGH 26 YEARS OF AGE WHO HAVE NOT BEEN PREVIOUSLY
VACCINATED OR WHO HAVE NOT COMPLETED THE FULL SERIES IS
ALSO RECOMMENDED. THE SAME HPV VACCINE SHOULD BE
USED FOR THE COMPLETE VACCINATION SERIES WHENEVER
FEASIBLE. ACIP ALSO RECOMMENDS ROUTINE HPV
VACCINATION OF MALES AT 11 OR 12 YEARS OF AGE, WITH CATCH-UP
VACCINATION OF MALES THROUGH AGE 21 YEARS. AS WITH FEMALES, THE VACCINATION
SERIES MAY BE STARTED AT 9 YEARS OF AGE CATCH-UP VACCINATION THROUGH 26
YEARS OF AGE IS RECOMMENDED FOR MEN WHO HAVE SEX WITH MEN AND
FOR THOSE WHO ARE IMMUNOCOMPROMISED. NEITHER VACCINE IS CURRENTLY
LICENSED OR RECOMMENDED FOR PERSONS OLDER THAN 26 YEARS. IN CONSIDERING SURVEILLANCE FOR
HPV, IT IS IMPORTANT TO NOTE THAT MOST SEXUALLY ACTIVE
INDIVIDUALS WILL ACQUIRE HPV INFECTION AT SOME POINT IN THEIR
LIVES. MOST OF THESE INFECTIONS WILL
NOT RESULT IN CLINICAL DISEASE. IT IS FOR THIS REASON THAT
ROUTINE SURVEILLANCE FOR HPV INFECTION IS NOT NECESSARY. HPV INFECTION AND MANY OTHER
HPV-ASSOCIATED CLINICAL CONDITIONS ARE NOT NATIONALLY
NOTIFIABLE, EXCEPT FOR CANCERS. HOWEVER, A VARIETY OF MONITORING
ACTIVITIES ARE ONGOING TO HELP DETERMINE THE IMPACT OF HPV
VACCINES IN THE U.S. ON THESE OUTCOMES. IMPORTANTLY, THE BURDEN FROM
CERVICAL AND OTHER HPV-RELATED CANCERS WILL BE MONITORED BY
CANCER REGISTRIES THAT COVER 100% OF THE U.S. POPULATION. THESE REGISTRIES ARE PART OF THE
CDC’s NATIONAL PROGRAM OF CANCER REGISTRIES, OR NPCR, AND THE
NATIONAL CANCER INSTITUTE’S SURVEILLANCE, EPIDEMIOLOGY AND
END RESULTS, OR SEER, PROGRAM. THE REGISTRIES ARE DESIGNED TO
MONITOR CANCER TRENDS OVER TIME, DETERMINE CANCER PATTERNS IN
VARIOUS POPULATIONS, AND GUIDE PLANNING AND EVALUATION OF
CANCER-CONTROL PROGRAMS, INCLUDING VACCINE, SCREENING,
AND TREATMENT. DATA FROM THE REGISTRIES ARE
COMBINED TO ESTIMATE NATIONAL CANCER INCIDENCE AND MORTALITY
ANNUALLY. SURVEILLANCE DATA ON CANCER END
POINTS WILL BE EXTREMELY USEFUL IN MONITORING THE IMPACT OF HPV
VACCINE ON THE U.S. POPULATION. BUT 20 OR 30 YEARS OF CANCER
SURVEILLANCE MAY BE REQUIRED BEFORE ANY IMPACT CAN BE
ACCURATELY MEASURED. MORE QUICKLY ATTAINABLE
END-POINT MEASURES OF VACCINE IMPACT INCLUDE OUTCOMES SUCH AS
HPV PREVALENCE, ANOGENITAL WARTS, AND CERVICAL-CANCER
PRECURSORS. MONITORING THE PREVALENCE OF
GENOTYPE-SPECIFIC HPV INFECTION IN A GENERAL POPULATION MAY
PROVIDE THE EARLIEST EVIDENCE OF VACCINE IMPACT. TYPE-SPECIFIC HPV INFECTION HAS
BEEN MONITORED NATIONALLY SINCE 2002 AS PART OF A RESEARCH
PROTOCOL CONDUCTED THROUGH THE NATIONAL HEALTH AND NUTRITION
EXAMINATION SURVEY, OR NHANES. NHANES IS REPRESENTATIVE OF THE
NON-INSTITUTIONALIZED CIVILIAN U.S. POPULATION. NHANES DATA WILL PROVIDE
INFORMATION ON TRENDS IN HPV INFECTION OVER TIME TO DETERMINE
VACCINE IMPACT AT THE NATIONAL HPV GENOTYPE PREVALENCE IS ALSO
BEING DETERMINED IN YOUNG WOMEN UNDERGOING ROUTINE PAP SCREENING
IN A MANAGED CARE ORGANIZATION. CHANGES IN HPV GENOTYPES WILL BE
FOLLOWED AS A MEASURE OF VACCINE IMPACT. DECREASES IN GENITAL-WART
INCIDENCE COULD BE ONE OF THE EARLIEST IMPACTS OF THE
QUADRIVALENT HPV VACCINE. GENITAL-WART SURVEILLANCE IS
BEING CONDUCTED IN A SENTINEL NETWORK OF 41 SEXUALLY
TRANSMITTED DISEASE CLINICS LOCATED IN 12 STATES. DATA ARE BEING COLLECTED ON
NUMBERS OF PATIENTS WITH GENITAL WARTS BY SEX, AGE, SEXUAL
ORIENTATION, AND WART TREATMENT. GENITAL-WARTS MONITORING WILL
ALSO BE CONDUCTED USING ADMINISTRATIVE AND CLAIMS DATA
IN REGIONAL AND NATIONAL DATABASES. IN THE U.S., WOMEN ARE ROUTINELY
SCREENED WITH THE PAP TEST FOR HIGH-GRADE HPV-ASSOCIATED
CERVICAL LESIONS THAT CAN PROGRESS TO CERVICAL CANCER IF
LEFT UNTREATED. PAP SCREENING IS PART OF ROUTINE
PREVENTIVE HEALTHCARE IN THE U.S. WHEN HIGH-GRADE ABNORMALITIES
ARE FOUND ON PAP TESTING, THE WOMAN IS REFERRED FOR CERVICAL
BIOPSY TO DETERMINE IF THE ABNORMALITIES ARE DUE TO
CERVICAL CANCER OR CERVICAL-CANCER PRECURSORS. TWO POPULATION-BASED PROJECTS
HAVE BEEN PILOTED TO MONITOR HPV-VACCINE IMPACT ON
BIOPSY-CONFIRMED, HIGH-GRADE CERVICAL LESIONS ONE SYSTEM USES EXISTING
INFRASTRUCTURE IN SELECT POPULATION-BASED CANCER
REGISTRIES TO MONITOR HIGH-GRADE CERVICAL LESIONS IN ADULT
FEMALES. THESE AREAS ARE LOCATED IN
KENTUCKY, LOUISIANA, MICHIGAN, AND LOS ANGELES COUNTY. ONE PARTICIPATING REGISTRY —
THE MICHIGAN CENTRAL CANCER SURVEILLANCE PROGRAM — WILL
ALSO BE EVALUATING THE FEASIBILITY OF LINKING CASE DATA
WITH IMMUNIZATION REGISTRY RECORDS. THE SECOND PROJECT ALSO MONITORS
HIGH-GRADE LESIONS IN A POPULATION OF FEMALES 18 AND
OLDER RESIDING IN DEFINED CATCHMENT AREAS IN FIVE STATES. DATA COLLECTED ON ALL CASES
INCLUDE AGE, RACE, ETHNICITY, AND INSURANCE STATUS. AN IMPORTANT PART OF THIS
PROJECT IS GENOTYPING OF THE PRE-CANCEROUS LESIONS TO MONITOR
TRENDS IN SPECIFIC HPV TYPES. IN ADDITION, MORE DETAILED
INFORMATION, INCLUDING HPV VACCINE HISTORY, WILL BE
DETERMINED THROUGH A VARIETY OF METHODS, INCLUDING LINKAGE WITH
THE STATE IMMUNIZATION INFORMATION SYSTEMS. CERVICAL-CANCER SCREENING IN THE
GENERAL POPULATION WILL BE ESTIMATED TO BE ABLE TO ACCOUNT
FOR CHANGES IN SCREENING PRACTICES. OTHER THAN THE CANCER-RELATED
DATA ALREADY BEING COLLECTED THROUGH CANCER REGISTRIES, THERE
IS NO RECOMMENDATION FOR COLLECTION OF ROUTINE
HPV-ASSOCIATED SURVEILLANCE DATA AT THE NATIONAL LEVEL. HOWEVER, SEVERAL STATES HAVE
INITIATED CASE REPORTING AND OTHER SURVEILLANCE ACTIVITIES TO
MEASURE THE HPV-RELATED-DISEASE BURDEN IN THEIR AREAS. THE SURVEILLANCE APPROACHES
BEING UNDERTAKEN BY CDC AND STATES WILL HELP DETERMINE NEEDS
FOR ADDITIONAL SURVEILLANCE END POINTS AND MEASURES OF
HPV-RELATED DISEASE.>>THE HEALTHY PEOPLE 2010
OBJECTIVES FOR THE UNITED STATES ESTABLISHED A TARGET OF
ELIMINATION OF INDIGENOUS CASES OF MEASLES. WE HAVE MET THAT OBJECTIVE. IN MARCH 2000, A GROUP OF
EXPERTS MET IN ATLANTA TO REVIEW THE CURRENT MEASLES SITUATION IN
THE UNITED STATES. THEY CONCLUDED THAT MEASLES WAS
NO LONGER A YEAR-ROUND ENDEMIC DISEASE IN THE U.S. THEY ALSO WARNED THAT WE SHOULD
NOT BECOME COMPLACENT, BECAUSE MEASLES CONTINUES TO BE IMPORTED
INTO THE U.S. FROM OTHER PARTS OF THE WORLD. ENDEMIC TRANSMISSION COULD BE
RE-ESTABLISHED AT ANY TIME. WE HAVE EXPERIENCED MEASLES
TRANSMISSION THAT WAS SUSTAINED FOR WEEKS OR EVEN MONTHS
FOLLOWING AN IMPORTED CASE, SO WE MUST KEEP BOTH IMMUNIZATION
LEVELS AND SURVEILLANCE QUALITY HIGH. IN 2011, THE U.S., IN
CONJUNCTION WITH THE PAN AMERICAN HEALTH ORGANIZATION, OR
PAHO, BEGAN THE PROCESS OF VERIFYING AND DOCUMENTING THE
CONTINUED ELIMINATION OF MEASLES IN THE U.S. THIS IS PART OF THE PAHO
OBJECTIVE TO VERIFY AND DOCUMENT ELIMINATION OF MEASLES, RUBELLA,
AND CONGENITAL RUBELLA SYNDROME, OR CRS, IN ALL OF THE AMERICAS. THIS EFFORT HIGHLIGHTS THE NEED
FOR HIGH IMMUNIZATION LEVELS AND SURVEILLANCE QUALITY. TYPICAL MEASLES DISEASE INCLUDES
A PRODROME OF FEVER AND MALAISE, COUGH, CORYZA, AND/OR
CONJUNCTIVITIS, FOLLOWED BY A MACULOPAPULAR RASH. BEFORE A VACCINE WAS AVAILABLE,
MEASLES WAS USUALLY A MODERATELY SEVERE CHILDHOOD ILLNESS, BUT
SEVERE COMPLICATIONS OCCURRED, AND 1 TO 3 CASES PER 1,000
RESULTED IN DEATH. MEASLES IS HIGHLY CONTAGIOUS,
AND A SINGLE IMPORTATION CAN LEAD TO AN OUTBREAK IF NOT
QUICKLY IDENTIFIED AND CONTAINED. MEASLES OUTBREAKS CAN OCCUR EVEN
IN THE PRESENCE OF HIGH VACCINATION COVERAGE WHEN
POCKETS OF SUSCEPTIBLE PERSONS ARE PRESENT OR WHERE
TRANSMISSION IS FACILITATED BY CLOSE LIVING CONDITIONS. THIS GRAPH SHOWS THE NUMBER OF
MEASLES CASES REPORTED IN THE UNITED STATES BY YEAR FROM 1950
THROUGH SEPTEMBER 2011. BEFORE THE INTRODUCTION OF A
MEASLES VACCINE, THERE WERE MORE THAN 500,000 CASES OF MEASLES
REPORTED EVERY YEAR, ALTHOUGH 3 TO 4 MILLION CASES ACTUALLY
OCCURRED. THESE CASES RESULTED IN 48,000
HOSPITALIZATIONS AND 450 TO 500 DEATHS EVERY YEAR ON AVERAGE. THIS DISEASE BURDEN SPURRED
DEVELOPMENT OF A VACCINE TO PREVENT MEASLES. IN THE FIRST FIVE YEARS
FOLLOWING LICENSURE OF THE VACCINE — 1963 THROUGH 1967 —
THE INCIDENCE OF MEASLES FELL MORE THAN 90%. THIS GRAPH SHOWS THE NUMBER OF
REPORTED CASES OF MEASLES BY YEAR SINCE 1980. IN 1989 THROUGH 1991, THERE WAS
A MAJOR RESURGENCE OF MEASLES IN THE UNITED STATES. THESE EPIDEMICS HIGHLIGHTED THE
RISKS OF MEASLES AMONG UNVACCINATED PRESCHOOL-AGED
CHILDREN. THE EPIDEMICS LED TO MAJOR
EFFORTS TO IMPROVE IMMUNIZATION COVERAGE AMONG YOUNG CHILDREN,
AMONG WHOM COVERAGE LEVELS WERE QUITE LOW, ESPECIALLY IN
LOW-INCOME, URBAN POPULATIONS. THE OUTBREAKS ALSO ACCELERATED
EFFORTS TO IMPLEMENT A ROUTINE SECOND MEASLES DOSE FOR
SCHOOL-AGED CHILDREN, WHICH WAS RECOMMENDED IN 1989. SINCE 1992, IMMUNIZATION
COVERAGE AMONG PRESCHOOL-AGE CHILDREN HAS INCREASED
SUBSTANTIALLY AND HAS BEEN HIGHER THAN 90% EACH YEAR SINCE
1996. IN ADDITION, THE IMMUNIZATION
COVERAGE FOR TWO DOSES OF MEASLES VACCINE AMONG 13-
THROUGH 17-YEAR-OLDS IS APPROXIMATELY 90%. AS A RESULT, MEASLES VIRUS NO
LONGER CONTINUALLY CIRCULATES IN THIS COUNTRY. THE CASES THAT NOW OCCUR ARE DUE
TO IMPORTATION AND SUBSEQUENT LIMITED SPREAD OF THE MEASLES
VIRUS. 2011 HAS SEEN THE MOST
IMPORTATIONS AND RECORDED CASES SINCE 1996. THROUGH SEPTEMBER 2011, THERE
HAVE BEEN 213 REPORTED MEASLES CASES IN THE U.S., INCLUDING 72
DIRECT IMPORTATIONS FROM BETWEEN 19 AND 22 SOURCE COUNTRIES. 72% OF THE IMPORTATIONS WERE
U.S. RESIDENTS TRAVELING ABROAD. ANOTHER 32 CASES WERE CLASSIFIED
AS IMPORTED-VIRUS CASES, MEANING THEY HAD A VIRUS GENOTYPE
IDENTIFIED BUT NO SOURCE OF EXPOSURE. THIS MEANS OUR SURVEILLANCE
SYSTEM IS MISSING A NUMBER OF IMPORTED MEASLES CASES, SO EVERY
EFFORT SHOULD BE MADE TO MAINTAIN AWARENESS FOR MEASLES
CASES AND EDUCATE CLINICIANS ON THE IMPORTANCE OF REPORTING ALL
SUSPECTED MEASLES CASES. WESTERN EUROPE HAS EXPERIENCED A
LARGE OUTBREAK IN 2011 AND HAS BEEN A MAJOR SOURCE OF
IMPORTATIONS TO THE U.S. THERE HAVE BEEN MORE THAN 14,000
CASES IN FRANCE ALONE AND AT LEAST SEVEN REPORTED DEATHS IN
THE REGION. IN THE UNITED STATES, WITH MMR
VACCINATION COVERAGE AT SUSTAINED HIGH LEVELS, MANY OF
THE PEOPLE WHO REMAIN SUSCEPTIBLE ARE UNVACCINATED
BECAUSE OF RELIGIOUS OR PHILOSOPHICAL EXEMPTION. THEY ARE LIKELY TO HAVE CLOSE
CONTACT WITH OTHER PERSONS WHO SHARE THESE BELIEFS. THIS SETS UP A SITUATION WHERE
FURTHER SPREAD IS VERY LIKELY. FOR EXAMPLE, IN EARLY 2005, AN
UNVACCINATED 16-YEAR-OLD RETURNED TO THE U.S. FROM A
MISSION TRIP IN ROMANIA WITH MEASLES. THE SINGLE IMPORTATION LED TO AN
OUTBREAK OF 34 CASES, MOSTLY IN HER UNVACCINATED CLOSE CONTACTS. IN 2008, AN INTENTIONALLY
UNVACCINATED 7-YEAR-OLD BOY RETURNED TO SAN DIEGO AFTER
BEING INFECTED WITH MEASLES IN SWITZERLAND. 11 MORE CASES RESULTED, ONE OF
WHICH WAS IN A 10-MONTH-OLD INFANT TOO YOUNG TO HAVE BEEN
VACCINATED, WHO WAS HOSPITALIZED FOR THREE DAYS. COST OF THE OUTBREAK WAS
ESTIMATED AT $177,000, INCLUDING PUBLIC-SECTOR EXPENDITURES,
MEDICAL CHARGES, AND COSTS INCURRED BY FAMILIES IN
QUARANTINE. THE GOOD NEWS IS THAT PROMPT
RECOGNITION OF THE DISEASE, WITH THE GOOD NEWS IS THAT PROMPT
RECOGNITION OF THE DISEASE, WITH APPROPRIATE CONTROL MEASURES,
CAN LIMIT THE SPREAD OF MEASLES. SO, LET’S MOVE ON TO SOME
GUIDELINES THAT WILL HELP YOU RECOGNIZE AND CONTAIN MEASLES,
SHOULD YOU SUSPECT IT. THE MEASLES CASE DEFINITION
INCLUDES A GENERALIZED RASH FOR THREE DAYS OR MORE, A
TEMPERATURE OF 101 DEGREES FAHRENHEIT OR HIGHER, WHICH IS
38.3 DEGREES CELSIUS, AND EITHER A COUGH OR CORYZA, OR
CONJUNCTIVITIS. SOME PERSONS WITH MEASLES VIRUS
INFECTION, ESPECIALLY THOSE WHO HAVE RECEIVED A
MEASLES-CONTAINING VACCINE IN THE PAST, MAY HAVE A MILDER
DISEASE WITH FEWER SYMPTOMS. THESE CASES MAY NOT MEET THE
CLINICAL CASE DEFINITION AND SHOULD BE LAB-TESTED IN THE
CONTEXT OF AN OUTBREAK OR IF THERE IS EPIDEMIOLOGICAL LINKAGE
TO A CONFIRMED CASE. LABORATORY STUDIES ARE CRITICAL
IN THE EVALUATION OF A PERSON WITH A FEBRILE-RASH ILLNESS. WE ASKED DR. WILLIAM BELLINI,
CHIEF OF THE CDC MEASLES LABORATORY, TO DISCUSS THIS
ISSUE.>>THE LABORATORY EVALUATION OF
A PERSON IN WHOM MEASLES IS>>THE LABORATORY EVALUATION OF
A PERSON IN WHOM MEASLES IS SUSPECTED INVOLVES COLLECTION OF
SPECIMENS FOR VIRAL ISOLATION OR SERUM SPECIMENS FOR ANTIBODY
TESTING OR BOTH. THE BEST WAY TO CONFIRM A CASE
OF MEASLES IS ISOLATION OF MEASLES VIRUS FROM THE PERSON. VIRAL ISOLATES AND DETERMINATION
OF VIRUS GENOTYPE ARE ESSENTIAL FOR TRACKING THE MOLECULAR
EPIDEMIOLOGY OF MEASLES NOW THAT WE NO LONGER HAVE ONGOING
INDIGENOUS TRANSMISSION IN THE UNITED STATES VIRUS IDENTIFICATION, EITHER BY
CULTURE OR BY REVERSE TRANSCRIPTASE POLYMERASE CHAIN
REACTION, OR RT-PCR, SHOULD BE ATTEMPTED FOR ALL SPORADIC CASES
AND FROM AT LEAST SOME CASES IN EACH OUTBREAK. APPROPRIATE SPECIMENS FOR VIRAL
ISOLATION, SUCH AS THROAT SWABS OR ORAL FLUIDS, SHOULD BE
COLLECTED ALONG WITH BLOOD SPECIMENS, NOT AFTER SEROLOGIC
TEST RESULTS ARE RECEIVED. SEROLOGIC TESTING FOR MEASLES
ANTIBODY HAS BEEN THE CORNERSTONE OF MEASLES DIAGNOSIS
FOR MANY YEARS. GENERALLY, A SUSCEPTIBLE PERSON
INFECTED WITH MEASLES VIRUS WILL FIRST DEVELOP AN IgM ANTIBODY
RESPONSE. THE IgM RESPONSE, SHOWN HERE BY
THE PURPLE LINE, IS USUALLY DETECTABLE IN THE FIRST 48 TO 72
HOURS AFTER ONSET OF RASH AND PEAKS ABOUT TWO WEEKS LATER. IgG ANTIBODY, SHOWN BY THE
YELLOW LINE, IS USUALLY NOT DETECTABLE UNTIL LATER IN THE
ILLNESS. IgG PEAKS LATER THAN IgM AND
REMAINS DETECTABLE FOR MANY YEARS, PROBABLY FOR THE REST OF
THE PERSON’S LIFE. FOR SEROLOGIC CONFIRMATION OF
MEASLES, IgM TESTING IS THE METHOD OF CHOICE. IgG TESTING REQUIRES THE
DEMONSTRATION OF A SIGNIFICANT RISE IN MEASLES ANTIBODY OR
SEROCONVERSION BETWEEN THE ACUTE AND CONVALESCENT SPECIMENS, SO
TWO SPECIMENS ARE NECESSARY. BECAUSE TESTS FOR IgG REQUIRE
TWO SERUM SPECIMENS AND BECAUSE A CONFIRMED DIAGNOSIS CANNOT BE
MADE UNTIL THE SECOND SPECIMEN IS OBTAINED, IgM TESTS AND VIRAL
ISOLATION ARE PREFERRED. THE FIRST SERUM SPECIMEN SHOULD
BE OBTAINED AS SOON AS POSSIBLE AFTER RASH ONSET AND, AT THE
LATEST, WITHIN SEVEN DAYS AFTER RASH ONSET. THE SECOND SPECIMEN SHOULD BE
DRAWN 10 TO 30 DAYS AFTER THE FIRST ONE. IF THE FIRST BLOOD SPECIMEN IS
DRAWN TOO EARLY IN THE COURSE OF THE DISEASE, IT MAY BE FALSELY
NEGATIVE AND SHOULD BE REPEATED AFTER 72 HOURS OF RASH ONSET. 80% OF INFECTED PERSONS WILL BE
IgM-POSITIVE THREE DAYS AFTER RASH ONSET, AND 99% WILL BE
IgM-POSITIVE AT FOUR DAYS. A NEGATIVE IgM, EVEN WHEN
PROPERLY DRAWN, DOES NOT RULE OUT MEASLES IN A PREVIOUSLY
VACCINATED PERSON, AND ACUTE AND CONVALESCENT IgG TESTING OR
VIROLOGIC TESTING WILL BE NECESSARY. THE SEROLOGIC TEST MOST COMMONLY
PERFORMED FOR MEASLES ANTIBODY IS AN ENZYME-LINKED IMMUNOASSAY,
WHICH IS ALSO KNOWN AS AN ELISA OR EIA. THERE ARE A NUMBER OF COMMERCIAL
IgM TESTS AVAILABLE, AND THE TESTING LABORATORIES ARE
WELL-ADVISED TO RUN A PANEL OF KNOWN IgM-POSITIVE AND -NEGATIVE
SERUM SPECIMENS IF USING THOSE TEST KITS FOR THE FIRST TIME. IN GENERAL, MOST PERFORM WELL IN
DIAGNOSTIC LABORATORIES, BUT LARGE VARIATIONS IN SENSITIVITY
AND SPECIFICITY HAVE BEEN ASSOCIATED WITH SOME KITS. CDC HAS DEVELOPED A HIGHLY
SENSITIVE AND SPECIFIC IgM-CAPTURE ASSAY FOR MEASLES
AND ACCEPTS SPECIMENS FOR CONFIRMATION OF IgM TESTING. CDC NO LONGER PROVIDES THE
COMPONENTS OF THIS ASSAY TO PUBLIC-HEALTH LABORATORIES. CONTACT INFORMATION FOR THE
MEASLES LABORATORY WILL BE PROVIDED ON THE RESOURCES WEB
PAGE FOR THIS PROGRAM.>>ONCE A SUSPECTED CASE IS
IDENTIFIED, CONTINGENCY PLANNING FOR PUBLIC-HEALTH ACTION SHOULD
BEGIN. IDEALLY, RESULTS FROM MEASLES
IgM ANTIBODY TESTING AND MOLECULAR ASSAYS WOULD BE
AVAILABLE QUICKLY. BUT IF THEY ARE NOT, IT MAY BE
NECESSARY TO INITIATE PUBLIC-HEALTH RESPONSE IN THE
ABSENCE OF LABORATORY CONFIRMATION. CONTROL ACTIVITIES SHOULD NOT BE
DELAYED PENDING THE RETURN OR CONFIRMATION OF LABORATORY
RESULTS. A MEASLES INVESTIGATION
WORKSHEET LIKE THIS ONE IS INCLUDED IN THE SURVEILLANCE
MANUAL. WE WILL ALSO PUT A LINK TO THE
MEASLES AND OTHER WORKSHEETS ON THE WEB PAGE FOR THIS PROGRAM. THERE IS SPECIFIC INFORMATION
THAT IS ESSENTIAL TO COLLECT DURING A MEASLES CASE
INVESTIGATION. IN ADDITION TO COLLECTING
DEMOGRAPHIC AND CLINICAL DATA, LABORATORY CONFIRMATION IS
ABSOLUTELY ESSENTIAL FOR ALL OUTBREAKS AND FOR ALL ISOLATED
OR SPORADIC CASES. AS WE MENTIONED, IN THE
UNITED STATES, ENDEMIC MEASLES HAS BEEN ELIMINATED, SO MEASLES
IS NOW A RARE DISEASE COMPARED WITH THE PAST. MOST CASES OF MEASLES-LIKE
ILLNESS WILL NOT BE MEASLES. EVEN IN OUTBREAKS, LABORATORY
CONFIRMATION SHOULD BE OBTAINED ON AS MANY CASES AS POSSIBLE. IN THE CONTEXT OF AN OUTBREAK, A
PERSON MEETING THE MEASLES CLINICAL CASE DEFINITION SHOULD
BE CONSIDERED TO HAVE MEASLES FOR CONTAINMENT PURPOSES,
REGARDLESS OF IgM RESULTS. ONCE COMMUNITY AWARENESS IS
INCREASED DURING AN OUTBREAK, MANY CASES OF FEBRILE-RASH
ILLNESS MAY BE REPORTED AS SUSPECTED MEASLES. THE MAGNITUDE OF THE OUTBREAK
WILL BE EXAGGERATED IF THESE CASES ARE CLASSIFIED AS
CONFIRMED IN THE ABSENCE OF LABORATORY CONFIRMATION. THIS IS PARTICULARLY IMPORTANT
AS THE OUTBREAK IS ENDING. AT THAT POINT, LABORATORY
CONFIRMATION SHOULD BE SOUGHT ON ALL SUSPECTED CASES. DURING A CASE INVESTIGATION, IT
IS IMPORTANT TO OBTAIN AN ACCURATE AND COMPLETE
IMMUNIZATION HISTORY ON ALL CONFIRMED CASES. MEASLES CASE INVESTIGATIONS
SHOULD INCLUDE COMPLETE IMMUNIZATION HISTORIES THAT
DOCUMENT ALL DOSES OF MEASLES-CONTAINING VACCINE,
INCLUDING DATES OF VACCINATION. EFFORTS SHOULD BE MADE TO
IDENTIFY THE SOURCE OF INFECTION FOR EVERY CONFIRMED CASE OF
MEASLES. CASE PATIENTS OR THEIR
CAREGIVERS SHOULD BE ASKED ABOUT CONTACT WITH OTHER KNOWN CASES. WHEN NO HISTORY OF CONTACT WITH
A KNOWN CASE CAN BE ELICITED, OPPORTUNITIES FOR EXPOSURE TO
UNKNOWN CASES SHOULD BE SOUGHT. SUCH EXPOSURES MAY OCCUR IN
SCHOOLS OR CHILDCARE FACILITIES, FOLLOWING CONTACT WITH
INTERNATIONAL VISITORS, WHILE VISITING TOURIST LOCATIONS OR
SETTINGS SUCH AS CONVENTIONS, DURING AIR TRAVEL, INCLUDING AT
AIRPORTS, OR, UNFORTUNATELY, IN HEALTHCARE SETTINGS. UNLESS THERE IS A HISTORY OF
EXPOSURE TO A KNOWN PERSON WITH MEASLES, PATIENTS OR THEIR
CAREGIVERS SHOULD BE CLOSELY QUESTIONED ABOUT ALL EXPOSURE
SETTINGS. AL?>>THANKS, JANE. AFTER DETERMINING THE SOURCE OF
INFECTION, YOU SHOULD ASSESS THE POTENTIAL FOR TRANSMISSION AND
IDENTIFY CONTACTS. TRANSMISSION IS PARTICULARLY
LIKELY IN HOUSEHOLDS, SCHOOLS, AND OTHER INSTITUTIONS, SUCH AS
COLLEGES, PRISONS, AND HEALTHCARE SETTINGS. CONTACTS OF THE CASE PATIENT
DURING THE INFECTIOUS PERIOD SHOULD BE IDENTIFIED AND
EVALUATED FOR THEIR EVIDENCE OF IMMUNITY TO MEASLES — THAT IS,
THEIR VACCINATION AND/OR DISEASE STATUS. FOR MEASLES, THE INFECTIOUS
PERIOD IS FROM FOUR DAYS BEFORE TO FOUR DAYS AFTER RASH ONSET. CONTACTS WITHOUT EVIDENCE OF
MEASLES IMMUNITY ARE AT RISK FOR INFECTION AND SHOULD BE
VACCINATED AS SOON AS POSSIBLE AFTER EXPOSURE, IDEALLY WITHIN
72 HOURS. CONTACTS WHO CHOOSE NOT TO BE
VACCINATED SHOULD BE ASKED TO QUARANTINE THEMSELVES AT HOME
FOR 21 DAYS AFTER THEIR LAST EXPOSURE AND TO MONITOR THEIR
SYMPTOMS DAILY. IMMUNE GLOBULIN CAN BE
ADMINISTERED WITHIN SIX DAYS OF EXPOSURE. IMMUNE GLOBULIN IS INDICATED FOR
HOUSEHOLD OR OTHER CLOSE CONTACTS OF PATIENTS WITH
MEASLES WHO LACK EVIDENCE OF MEASLES IMMUNITY, PARTICULARLY
CONTACTS YOUNGER THAN 1 YEAR OF AGE, PREGNANT WOMEN, AND
IMMUNOCOMPROMISED PERSONS FOR WHOM THE RISK OF COMPLICATIONS
IS HIGHEST. NOW THAT MEASLES IS NO LONGER AN
ENDEMIC DISEASE IN THIS COUNTRY, IMPORTATION OF MEASLES CASES
FROM OUTSIDE THE UNITED STATES AND SUBSEQUENT TRANSMISSION IS
THE ONLY WAY CASES CAN OCCUR. AMONG THOSE CASES CLASSIFIED AS
U.S.-ACQUIRED — THAT IS, PERSONS INFECTED WITHIN THE
UNITED STATES — MOST CAN BE LINKED TO KNOWN IMPORTATIONS. THE CASES THAT WE ARE NOT ABLE
TO LINK ARE PROBABLY DUE TO UNRECOGNIZED IMPORTATIONS. THIS SITUATION WILL ALMOST
CERTAINLY CONTINUE IN THE FUTURE, UNTIL BETTER MEASLES
CONTROL IS ACHIEVED WORLDWIDE. UNTIL MEASLES IS ERADICATED FROM
THE PLANET, OUR BEST DEFENSE IS A WELL-VACCINATED POPULATION,
CAREFUL SURVEILLANCE, AND RAPID PUBLIC-HEALTH RESPONSE TO
OUTBREAKS.>>ROTAVIRUS IS THE MOST COMMON
CAUSE OF SEVERE GASTROENTERITIS IN INFANTS AND YOUNG CHILDREN
WORLDWIDE. NEARLY EVERY UNVACCINATED CHILD
IN THE U.S. IS INFECTED WITH ROTAVIRUS BY AGE 5 YEARS, AND
THE MAJORITY WILL HAVE SYMPTOMATIC GASTROENTERITIS. THE CLINICAL SPECTRUM OF
ROTAVIRUS ILLNESS RANGES FROM MILD, WATERY DIARRHEA OF LIMITED
DURATION TO SEVERE DIARRHEA WITH VOMITING AND FEVER. THIS CAN RESULT IN DEHYDRATION
WITH SHOCK, ELECTROLYTE IMBALANCE, HOSPITALIZATION, AND
DEATH, ALTHOUGH DEATHS ARE RARE IN THE UNITED STATES. FOLLOWING AN INCUBATION PERIOD
OF ONE TO THREE DAYS, THE ILLNESS OFTEN BEGINS ABRUPTLY. VOMITING OFTEN PRECEDES THE
ONSET OF DIARRHEA. SEVERE, DEHYDRATING ROTAVIRUS
INFECTION OCCURS PRIMARILY AMONG CHILDREN 3 TO 35 MONTHS OF AGE. GASTROINTESTINAL SYMPTOMS
GENERALLY RESOLVE IN THREE TO SEVEN DAYS. ROTAVIRUSES ARE SHED IN HIGH
CONCENTRATIONS IN THE STOOL OF INFECTED CHILDREN AND ARE
TRANSMITTED PRIMARILY BY THE FECAL-ORAL ROUTE, BOTH THROUGH
CLOSE PERSON-TO-PERSON CONTACT AND THROUGH FOMITES. ROTAVIRUS IS HIGHLY
COMMUNICABLE, WITH AN INFECTIOUS DOSE OF LESS THAN 100 VIRUS
PARTICLES. IN THE U.S., BEFORE USE OF
ROTAVIRUS VACCINES, ROTAVIRUS CAUSED MARKED WINTER SEASONAL
PEAKS OF GASTROENTERITIS. PEAK ACTIVITY USUALLY BEGAN IN
THE SOUTHWEST DURING NOVEMBER OR DECEMBER AND SPREAD TO THE
NORTHEAST BY APRIL OR MAY. SINCE THE WIDESPREAD USE OF
ROTAVIRUS VACCINES, THIS SEASONALITY HAS SHIFTED, AND
THIS TREND IN ROTAVIRUS PEAK ACTIVITY IS NO LONGER
CONSISTENTLY OBSERVED. TWO ROTAVIRUS VACCINES ARE
CURRENTLY LICENSED IN THE UNITED STATES. RV5, WHOSE BRAND NAME IS
RotaTeq, IS PRODUCED BY MERCK. IT IS A LIVE, ORAL, HUMAN-BOVINE
REASSORTANT ROTAVIRUS VACCINE THAT WAS LICENSED IN THE U.S. IN
2006. THE ADVISORY COMMITTEE ON THE
IMMUNIZATION PRACTICES RECOMMENDS ROUTINE VACCINATION
OF INFANTS WITH THREE DOSES OF THIS VACCINE ADMINISTERED AT 2,
4, AND 6 MONTHS OF AGE. RV1, BRAND NAME ROTARIX, IS
PRODUCED BY GlaxoSmithKline. IT WAS LICENSED IN THE U.S. IN
2008. THIS LIVE ORAL VACCINE CONTAINS
AN ATTENUATED MONOVALENT HUMAN ROTAVIRUS STRAIN. RV1 IS RECOMMENDED TO BE
ADMINISTERED IN TWO DOSES TO INFANTS AT AGES 2 AND 4 MONTHS. WITH THE INTRODUCTION OF
ROTAVIRUS VACCINES INTO THE U.S. CHILDHOOD IMMUNIZATION PROGRAM,
SURVEILLANCE DATA ARE NEEDED TO MONITOR THE IMPACT OF
VACCINATION IN REDUCING THE MORBIDITY AND MORTALITY FROM
ROTAVIRUS DISEASE. SURVEILLANCE DATA WILL ALSO BE
NECESSARY TO EVALUATE VACCINE EFFECTIVENESS IN FIELD USE OVER
TIME AND DETERMINE THE CAUSES OF POSSIBLE VACCINE FAILURE,
MONITOR POSSIBLY EMERGING ROTAVIRUS STRAINS, IDENTIFY
POPULATION GROUPS THAT MIGHT NOT BE ADEQUATELY COVERED BY
VACCINATION, AND CONTINUE TO MONITOR THE SAFETY OF ROTAVIRUS
VACCINES. SINCE NEARLY EVERY UNVACCINATED
CHILD DEVELOPS ROTAVIRUS GASTROENTERITIS BY 5 YEARS OF
AGE AND CONFIRMING A DIAGNOSIS OF ROTAVIRUS REQUIRES LABORATORY
TESTING OF FECAL SPECIMENS, IDENTIFICATION OF EVERY CASE OF
ROTAVIRUS IS NOT PRACTICAL OR NECESSARY AT THIS STAGE OF THE
ROTAVIRUS VACCINATION PROGRAM. INSTEAD, SURVEILLANCE EFFORTS AT
THE NATIONAL LEVEL SHOULD FOCUS ON MONITORING TRENDS OF SEVERE
ROTAVIRUS DISEASE, SUCH AS ROTAVIRUS HOSPITALIZATIONS OR
EMERGENCY DEPARTMENT VISITS, AND THROUGH MORE INTENSIVE EFFORTS
AT SOME SENTINEL SITES. IN ADDITION TO SURVEILLANCE FOR
SEVERE DISEASE, VIRAL-STRAIN SURVEILLANCE IS ALSO ESSENTIAL. IN THE UNITED STATES, ROTAVIRUS
SURVEILLANCE IS CONDUCTED IN SEVERAL WAYS. THE NEW VACCINE SURVEILLANCE
NETWORK, KNOWN AS NVSN, CONDUCTS ACTIVE, PROSPECTIVE,
POPULATION-BASED SURVEILLANCE FOR ROTAVIRUS-ASSOCIATED
HOSPITALIZATIONS AND EMERGENCY-ROOM VISITS AMONG
CHILDREN. NVSN COMMENCED ROTAVIRUS
SURVEILLANCE DURING THE 2006 ROTAVIRUS SEASON WITH THREE
ORIGINAL SITES. IN 2011, THE NETWORK INCLUDES
SEVEN SURVEILLANCE SITES AT MEDICAL CENTERS LOCATED IN
TENNESSEE, NEW YORK, OHIO, TEXAS, KANSAS, WASHINGTON, AND
CALIFORNIA. ACUTE GASTROENTERITIS CASES ARE
IDENTIFIED AND ADDITIONAL EPIDEMIOLOGICAL AND CLINICAL
INFORMATION IS COLLECTED FROM PARENTAL INTERVIEWS AND MEDICAL
CHART REVIEWS. STOOL SPECIMENS ARE TESTED FOR
ROTAVIRUS ANTIGEN AT EACH SURVEILLANCE SITE, AND CDC
LABORATORIES TYPE ALL POSITIVE SPECIMENS. ANALYSES ARE CONDUCTED TO
ESTIMATE DISEASE BURDEN AND TO ASSESS ROTAVIRUS VACCINE
EFFECTIVENESS IN FIELD USE. LABORATORY-BASED SENTINEL
SURVEILLANCE SYSTEMS THAT MONITOR TEMPORAL AND GEOGRAPHIC
PATTERNS OF ROTAVIRUS INCLUDE THE NATIONAL RESPIRATORY AND
ENTERIC VIRUS SURVEILLANCE SYSTEM AND THE NATIONAL
ROTAVIRUS STRAIN SURVEILLANCE SYSTEM. DATA FROM NATIONAL HEALTHCARE
UTILIZATION DATA SETS ARE ALSO ROUTINELY ANALYZED TO DETECT
NATIONAL TRENDS IN ROTAVIRUS HEALTHCARE ENCOUNTERS. SOME IMPORTANT FINDINGS FROM
THESE SURVEILLANCE ACTIVITIES INCLUDE THE NEARLY REAL-TIME
OBSERVATION IN 2008 THAT THE U.S. ROTAVIRUS SEASON HAD
SHORTENED AND THAT ROTAVIRUS CASES HAD DROPPED DRAMATICALLY. IN 2009, SURVEILLANCE SYSTEMS
EMPIRICALLY INDICATED THAT ROTAVIRUS REDUCTIONS AMONG
OLDER, LARGELY UNVACCINATED CHILDREN IN 2008 LIKELY RESULTED
FROM INDIRECT PROTECTION CONFERRED BY YOUNGER, VACCINATED
CHILDREN WITHIN THE HOUSEHOLD AND COMMUNITY. POST-LICENSURE RV5 VACCINE
EFFECTIVENESS STUDIES HAVE BEEN CONDUCTED SHOWING REMARKABLY
CONSISTENT FINDINGS OF 86% TO 95% PROTECTION AGAINST ROTAVIRUS
HOSPITALIZATIONS AND EMERGENCY-DEPARTMENT VISITS. COMPARABLE ESTIMATES OF VACCINE
EFFECTIVENESS WERE OBSERVED IN THE FIRST AND SECOND YEARS OF
LIFE AND BY ROTAVIRUS STRAIN. RV1 VACCINE WAS LICENSED TWO
YEARS LATER THAN RV5 IN THE U.S., AND SIMILAR POST-LICENSURE
VACCINE EFFECTIVENESS EVALUATIONS OF RV1 VACCINE ARE
UNDER WAY. AT THIS STAGE IN THE ROTAVIRUS
VACCINATION PROGRAM, CASE INVESTIGATIONS ARE USUALLY NOT
WARRANTED. HOWEVER, ROTAVIRUS OUTBREAKS
AMONG ELDERLY ADULTS IN RESIDENTIAL COMMUNITIES CONTINUE
TO BE IMPORTANT TO INVESTIGATE. IN ADDITION, OUTBREAKS OF
ROTAVIRUS AMONG CHILDCARE OR SCHOOL SETTINGS COULD INDICATE
WHERE GAPS IN VACCINE COVERAGE OCCUR AND ANY POSSIBLE
INDICATION OF WANING IMMUNITY IN OLDER CHILDREN. BECAUSE DIARRHEAL OUTBREAKS CAN
BE CAUSED BY MANY PATHOGENS, A LABORATORY INVESTIGATION FOR THE
CAUSATIVE AGENT THAT INCLUDES VIRAL, BACTERIAL, AND PARASITIC
AGENTS SHOULD BE CONSIDERED FOR GASTROENTERITIS CASES SEEKING
MEDICAL ATTENTION. AS THE U.S. ROTAVIRUS
VACCINATION PROGRAM EVOLVES AND ROTAVIRUS CEASES TO BE A
UNIVERSAL INFECTION OF CHILDHOOD, OUR ROTAVIRUS
SURVEILLANCE WILL ALSO NEED TO EVOLVE.>>MUMPS VIRUS CAN CAUSE ILLNESS
WITH AN ACUTE ONSET OF UNILATERAL OR BILATERAL TENDER,
SELF-LIMITED SWELLING OF THE PAROTID OR OTHER SALIVARY GLAND,
LASTING TWO OR MORE DAYS. THE COMBINATION MEASLES, MUMPS,
AND RUBELLA VACCINE HAS CONTRIBUTED TO THE SAME HIGH
COVERAGE RATE FOR MUMPS AS WE HAVE ACHIEVED FOR MEASLES AND
RUBELLA. SINCE THE START OF THE MUMPS
VACCINATION PROGRAM IN 1967, THE NUMBER OF REPORTED MUMPS CASES
IN THE U.S. DECREASED MORE THAN 99% BY 1999, WHEN FEWER THAN 500
CASES WERE REPORTED FOR THE FIRST TIME. DURING 2000 TO 2005, 200 TO 400
MUMPS CASES WERE REPORTED ANNUALLY. MOST CASES OF MUMPS REPORTED IN
THE U.S. ARE SPORADIC CASES OR RESULT IN VERY LIMITED SPREAD,
EVEN IN CLOSE-CONTACT SETTINGS THAT MAY FACILITATE
TRANSMISSION. HOWEVER, LARGER OUTBREAKS DO
OCCASIONALLY OCCUR. SINCE 2005, MUMPS OUTBREAKS IN
HIGHLY VACCINATED COMMUNITIES HAVE OCCURRED IN THE U.S. AND
ELSEWHERE. IN 2006, THE U.S. EXPERIENCED THE LARGEST MUMPS
OUTBREAK IN 20 YEARS, WITH MORE THAN 6,500 CASES REPORTED FROM
45 STATES AND WASHINGTON D.C. AND WITH OUTBREAKS REPORTED ON
MANY COLLEGE CAMPUSES. EIGHT MIDWEST STATES ACCOUNTED
FOR 85% OF THE REPORTED CASES. THE MOST-AFFECTED AGE GROUP WAS
YOUNG ADULTS 18 THROUGH 24 YEARS OF AGE, AND THE MAJORITY HAD
RECEIVED TWO DOSES OF THE MMR VACCINE. REPORTED MUMPS CASES DECLINED TO
FEWER THAN 500 CASES IN 2008. HOWEVER, DURING 2009 AND 2010,
REPORTED MUMPS CASES INCREASED AGAIN. MORE THAN 3,500 OUTBREAK-RELATED
CASES OF MUMPS WERE REPORTED IN ORTHODOX JEWISH COMMUNITIES IN
NEW YORK CITY, TWO UPSTATE NEW YORK COUNTIES, AND ONE
NEW JERSEY COUNTY. STUDENTS IN MIDDLE AND HIGH
SCHOOL HAD THE HIGHEST MUMPS INCIDENCE, AND THE VAST MAJORITY
HAD RECEIVED TWO DOSES OF MMR VACCINE. ALSO IN 2010, THE ISLAND OF GUAM
EXPERIENCED A COMMUNITY OUTBREAK RESULTING IN OVER 500 REPORTED
CASES. WE LEARNED A LOT FROM THESE AND
OTHER OUTBREAKS AND MADE CHANGES TO THE CASE DEFINITION,
LABORATORY CRITERIA, AND CASE CLASSIFICATIONS, WHICH WENT INTO
EFFECT BEGINNING IN JANUARY 2012. THE LANGUAGE OF THE PREVIOUS
DEFINITION OFTEN RESULTED IN INCONSISTENT INTERPRETATIONS,
ESPECIALLY FOR THE PROBABLE CASES. THE NEW LANGUAGE MORE CLEARLY
OUTLINES THE CHARACTERISTICS OF A PROBABLE CASE AND ALLOWS STATE
HEALTH DEPARTMENTS TO DEFINE THE GROUP OR COMMUNITY THAT SHOULD
BE CONSIDERED EPIDEMIOLOGICALLY LINKED. FINALLY, THE UPDATED LANGUAGE
RECOGNIZES THE IMPROVEMENTS THAT HAVE BEEN MADE IN MUMPS
LABORATORY DIAGNOSTICS SINCE 2008. THE UPDATED CASE DEFINITION
SPECIFIES THAT, IN ADDITION TO CERTAIN CLINICAL SYMPTOMS, A
CASE MUST HAVE POSITIVE LABORATORY RESULTS FROM EITHER
REVERSE TRANSCRIPTASE POLYMERASE CHAIN REACTION, OR RT-PCR, OR
CULTURES IN ORDER TO BE CLASSIFIED AS CONFIRMED. THE CDC LABORATORY HAS MADE THE
PROTOCOL FOR MUMPS RT-PCR, AS WELL AS CONTROL RNA AND PRACTICE
PANELS AVAILABLE TO PUBLIC-HEALTH LABORATORIES. AS A RESULT, RT-PCR TESTING IS
BECOMING INCREASINGLY AVAILABLE IN STATE AND LOCAL PUBLIC-HEALTH
LABORATORIES. WE WILL DISCUSS MUMPS LABORATORY
TESTING IN MORE DETAIL IN A MOMENT. JANE?>>THANKS, AL. IN THE OUTBREAKS IN THE
NORTHEAST UNITED STATES IN 2009 AND 2010 AND IN GUAM IN 2010, A
THIRD VACCINE DOSE INTERVENTION WAS EVALUATED UNDER IRB-APPROVED
PROTOCOLS. LESSONS LEARNED FROM THESE
INTERVENTIONS MAY HELP GUIDE POLICIES FOR RESPONSES TO FUTURE
OUTBREAKS IN VACCINATED COMMUNITIES. HIGH VACCINE COVERAGE IS STILL
THE BEST WAY TO PREVENT AND CONTROL MUMPS. ACIP RECOMMENDATIONS FOR THE
PREVENTION AND CONTROL OF MUMPS INCLUDE TWO DOSES OF MMR VACCINE
FOR SCHOOL-AGED CHILDREN KINDERGARTEN THROUGH HIGH SCHOOL
AND FOR ADULTS AT HIGH RISK, SUCH AS THOSE WHO WORK IN
HEALTHCARE FACILITIES, INTERNATIONAL TRAVELERS, AND
STUDENTS AT POST-HIGH-SCHOOL EDUCATIONAL INSTITUTIONS. ROUTINE VACCINATION
RECOMMENDATIONS FOR HEALTH CARE PERSONNEL INCLUDE THOSE BORN
DURING OR AFTER 1957 WITHOUT EVIDENCE OF IMMUNITY SHOULD HAVE
WRITTEN DOCUMENTATION OF HAVING RECEIVED TWO DOSES OF LIVE MUMPS
VIRUS VACCINE. HEALTHCARE PERSONNEL BORNBEFORE
1957 WITHOUT OTHER EVIDENCE OF IMMUNITY, SHOULD CONSIDER TWO
DOSES OF MMR VACCINE AT THE APPROPRIATE INTERVAL. IN OUTBREAK SETTINGS, IF AGE
GROUPS RECOMMENDED FOR ONE VACCINE DOSE ARE AFFECTED BY THE
OUTBREAK, A SECOND DOSE OF MMR VACCINE SHOULD BE CONSIDERED. THESE GROUPS ARE CHILDREN 1
THROUGH 4 YEARS OF AGE AND ADULTS NOT CLASSIFIED AS HIGH
RISK. DURING AN OUTBREAK, TWO DOSES AT
THE APPROPRIATE INTERVAL SHOULD BE RECOMMENDED FOR HEALTH CARE
PERSONNEL BORN BEFORE 1957 WITHOUT OTHER EVIDENCE OF
IMMUNITY. AS WE NOTED EARLIER, LABORATORY
TESTING FOR MUMPS VIRUS INFECTION HAS IMPROVED IN THE
LAST FEW YEARS. WE ASKED DR. WILLIAM BELLINI,
CHIEF OF THE CDC MUMPS LABORATORY, TO DISCUSS THIS
ISSUE.>>AS WITH MEASLES, LABORATORY
STUDIES ARE VERY USEFUL IN THE EVALUATION OF A PERSON WITH
SUSPECTED MUMPS. HOWEVER, SOME STUDIES,
PARTICULARLY THE RESULTS OF ANTIBODY TESTING, CAN BE
DIFFICULT TO INTERPRET. ACUTE-MUMPS-VIRUS INFECTION CAN
BE LABORATORY-CONFIRMED BY ISOLATION OF MUMPS VIRUS OR
DETECTION OF MUMPS VIRUS BY POLYMERASE CHAIN REACTION, OR
PCR. LABORATORY CONFIRMATION CAN ALSO
INCLUDE A SIGNIFICANT RISE IN SERUM MUMPS IgG ANTIBODY OR
SEROCONVERSION FROM IgG-NEGATIVE TO IgG-POSITIVE IN ACUTE AND
CONVALESCENT SPECIMENS, RESPECTIVELY. THE LATTER SCENARIO IS RARELY
ENCOUNTERED, SINCE ALMOST EVERYONE HAS EITHER BEEN
VACCINATED OR HAS BEEN PREVIOUSLY INFECTED WITH MUMPS
VIRUS. MOREOVER, EVEN IN THE CASE OF
PRIMARY MUMPS INFECTION, IT IS NOT UNUSUAL FOR IgG TO APPEAR
VERY EARLY AFTER ONSET OF PAROTITIS. FINALLY, LABORATORY CONFIRMATION
MAY ALSO BE OBTAINED BY THE DETECTION OF SERUM MUMPS IgM
ANTIBODY. THIS TEST IS QUITE VARIABLE AND
IS MOST USEFUL WHEN THE PERSON HAS NOT BEEN VACCINATED AND HAS
NOT BEEN PREVIOUSLY INFECTED WITH MUMPS VIRUS. AS WITH MEASLES, MUMPS IgM MAY
BE TRANSIENT OR ABSENT IN INDIVIDUALS WHO PREVIOUSLY
RECEIVED MUMPS VACCINE. IN HIGHLY VACCINATED
POPULATIONS, COMMERCIAL MUMPS IgM ASSAYS PERFORM VERY POORLY,
DETECTING ONLY BETWEEN 10% AND 30% OF MUMPS CASES. CAPTURE IgM ASSAYS PERFORM
BETTER THAN INDIRECT ASSAYS. SERA SHOULD BE COLLECTED AS SOON
AS POSSIBLE AFTER SYMPTOM ONSET FOR IgM TESTING OR AS ACUTE
SPECIMEN FOR IgG. CONVALESCENT SERA SHOULD BE
DRAWN TWO WEEKS LATER. THE BEST SPECIMEN FOR
MUMPS-VIRUS ISOLATION IS A SWAB FROM THE PAROTID, OR STENSEN’S
DUCT. THE PAROTID DUCT DRAINS IN THE
SPACE NEAR THE UPPER REAR MOLARS. FLUID FROM THE BUCCAL AREA MAY
YIELD THE BEST VIRAL SAMPLE, PARTICULARLY WHEN THE
PAROTID-GLAND AREA JUST BELOW THE EAR IS MASSAGED FOR 30
SECONDS PRIOR TO THE COLLECTION OF SECRETIONS. BUCCAL SWABS SHOULD IDEALLY BE
OBTAINED WITHIN THREE DAYS OF PAROTITIS AND NOT BE ATTEMPTED
AFTER MORE THAN SEVEN DAYS. URINE SAMPLES ARE NOW
DISCOURAGED DUE TO LOW VIRAL YIELD. COLLECTION OF VIRAL SAMPLES FROM
PERSONS SUSPECTED OF HAVING MUMPS IS STRONGLY RECOMMENDED. THE MOLECULAR CHARACTERISTICS OF
MUMPS VIRUSES PROVIDES IMPORTANT INFORMATION THAT WILL HELP
INFORM ON IMPORTATIONS OF MUMPS AND ENDEMIC MUMPS TRANSMISSION
IN THE U.S. FOR SPORADIC CASES, ONE SHOULD
CONSIDER ALSO TESTING FOR OTHER ETIOLOGIES FOR THE ILLNESSES,
SUCH AS INFLUENZA VIRUS, EPSTEIN-BARR VIRUS, ADENOVIRUS,
PARAINFLUENZA VIRUSES TYPES 1, 2, AND 3, OR BACTERIA, INCLUDING
STAPH AUREUS AND ALPHA HEMOLYTIC STREPTOCOCCUS.>>THE INDICATORS WE TRACK TO
MONITOR THE QUALITY OF MUMPS SURVEILLANCE SHOW THAT THERE IS
A DEFINITE NEED FOR IMPROVEMENT ON THE COMPLETENESS OF
COLLECTION OF SOME KEY VARIABLES DURING CASE INVESTIGATIONS,
INCLUDING VACCINATION STATUS. IN ADDITION TO DEMOGRAPHIC AND
CLINICAL DATA, IT IS IMPORTANT TO OBTAIN ACCURATE AND COMPLETE
IMMUNIZATION HISTORY SO WE CAN UNDERSTAND CHANGES IN MUMPS
EPIDEMIOLOGY. RECENT OUTBREAKS HAVE INCLUDED
MANY CASES WHO HAD ALREADY RECEIVED ONE OR TWO DOSES OF A
MUMPS-CONTAINING VACCINE. THE SOURCE OF INFECTION SHOULD
BE IDENTIFIED FOR EACH CONFIRMED CASE OF MUMPS. IF THERE IS NO HISTORY OF
CONTACT WITH A KNOWN CASE, OPPORTUNITIES FOR EXPOSURE TO
UNKNOWN CASES SHOULD BE IDENTIFIED SO THAT INVESTIGATIVE
EFFORTS CAN BE DIRECTED TO LOCATIONS OF POSSIBLE EXPOSURE. FINALLY, POTENTIAL FOR FURTHER
TRANSMISSION SHOULD BE ASSESSED, AND CONTACTS OF THE CASE PATIENT
DURING THE INFECTIOUS PERIOD SHOULD BE IDENTIFIED. FOR CONTACT INVESTIGATIONS FOR
MUMPS, PERSONS ARE CONSIDERED INFECTIOUS FROM ONE TO TWO DAYS
BEFORE, THROUGH FIVE DAYS AFTER THE ONSET OF PAROTITIS. MUMPS VACCINE SHOULD BE GIVEN TO
ALL EXPOSED PERSONS WHO ARE UNABLE TO PROVIDE EVIDENCE OF
IMMUNITY. EVIDENCE OF IMMUNITY IS DEFINED
AS APPROPRIATE VACCINATION STATUS, PHYSICIAN-CONFIRMED
DISEASE HISTORY, SEROLOGICAL EVIDENCE, OR BIRTH BEFORE 1957. NOTE THAT PHYSICIAN-CONFIRMED
MUMPS DISEASE HISTORY IS NO LONGER CONSIDERED ACCEPTABLE
EVIDENCE OF IMMUNITY FOR HEALTHCARE PERSONNEL. ALTHOUGH VACCINE HAS NOT BEEN
PROVEN TO PREVENT THE OCCURRENCE OF DISEASE WHEN ADMINISTERED
AFTER EXPOSURE, IT WILL PROVIDE PROTECTION FOR FUTURE EXPOSURES. DURING AN OUTBREAK IN A SCHOOL,
CHILDCARE CENTER, OR COLLEGE, UNVACCINATED CHILDREN OR
STUDENTS SHOULD BE EXCLUDED UNTIL 25 DAYS AFTER THE LAST
CASE OR UNTIL THEY RECEIVE THE FIRST DOSE OF MMR VACCINE. THE OCCURRENCE OF MUMPS
OUTBREAKS IN THE UNITED STATES, PARTICULARLY AMONG HIGHLY
VACCINATED POPULATIONS, IS CHALLENGING. HOWEVER, CAREFUL INVESTIGATION
OF RECENT OUTBREAKS HAS PROVIDED USEFUL INFORMATION ABOUT THE
EPIDEMIOLOGY OF THIS DISEASE. WE HOPE THAT CONTINUED
INVESTIGATIONS OF MUMPS CASES AND OUTBREAKS WILL PROVIDE
INSIGHTS TO HELP US ACHIEVE EVEN BETTER CONTROL.>>VARICELLA, OR CHICKEN POX, IS
A HIGHLY INFECTIOUS VIRAL DISEASE. BEFORE VARICELLA VACCINE WAS
LICENSED IN THE UNITED STATES, IN 1995, ABOUT 4 MILLION CASES
OF VARICELLA OCCURRED EACH YEAR, WITH MORE THAN 10,000
VARICELLA-RELATED HOSPITALIZATIONS AND ABOUT 100
TO 150 DEATHS. THE GOOD NEWS IS THAT
VACCINATION COVERAGE AMONG CHILDREN HAS RISEN STEADILY, AND
FEWER CASES OF CHICKEN POX ARE OCCURRING AND BEING REPORTED. IN 2010, ONE-DOSE VARICELLA
VACCINATION COVERAGE FOR U.S. CHILDREN 19 TO 35 MONTHS OF AGE,
AS ESTIMATED BY THE NATIONAL IMMUNIZATION SURVEY, WAS 90%,
AND TWO-DOSE COVERAGE AMONG ADOLESCENTS WAS 58%. WE NEED TO CONTINUE EFFORTS TO
PROVIDE CATCH-UP OF THE SECOND DOSE OF VARICELLA VACCINE FOR
OLDER CHILDREN AND ADOLESCENTS. WITH EXPANDED VARICELLA
VACCINATION, FURTHER DECLINES IN VARICELLA INCIDENCE ARE
EXPECTED. AS THE NUMBER OF CASES DECREASE,
THE NEED FOR MORE COMPLETE SURVEILLANCE INCREASES, AND
STATE-WIDE CASE-BASED SURVEILLANCE FOR VARICELLA
BECOMES FEASIBLE. WE ARE AT A CRITICAL STAGE FOR
VARICELLA SURVEILLANCE. IN THE PAST, MOST OF THE
DETAILED INFORMATION ABOUT THE CHANGE IN VARICELLA
EPIDEMIOLOGY, INCLUDING REDUCED DISEASE INCIDENCE BY AGE GROUP,
CAME FROM TWO ACTIVE SURVEILLANCE SITES IN
ANTELOPE VALLEY, CALIFORNIA, AND WEST PHILADELPHIA, PENNSYLVANIA. THESE SITES WERE ESTABLISHED IN
1995 TO MONITOR THE IMPACT OF VACCINATION PROGRAM BECAUSE
NATIONAL SURVEILLANCE FOR VARICELLA DID NOT EXIST AT THE
TIME OF VACCINE LICENSURE. HOWEVER, DUE TO THE EXTREMELY
LOW NUMBERS OF VARICELLA CASES NOW OCCURRING, THIS SURVEILLANCE
PROJECT HAS ENDED, AND BEGINNING IN 2012, WE WILL BE RELYING
ENTIRELY ON SURVEILLANCE THROUGH THE NATIONAL NOTIFIABLE DISEASES
SURVEILLANCE SYSTEM, OR NNDSS, TO MONITOR THE IMPACT OF OUR
VACCINE POLICIES, INCLUDING CHANGES IN VARICELLA
EPIDEMIOLOGY IN THE U.S. REDUCTION IN VARICELLA INCIDENCE
HAS BEEN OBSERVED IN ALL AGE GROUPS. THE OVERALL REDUCTION IN
VARICELLA SINCE IMPLEMENTATION OF THE ONE-DOSE PROGRAM IS NOT
UNIQUE TO THE ACTIVE SURVEILLANCE SITES. AMONG THE STATES THAT HAVE
CONSISTENTLY REPORTED CASES THROUGH NNDSS, THERE WAS A
SIGNIFICANT REDUCTION IN CASES COMPARED TO THE PRE-VACCINE ERA. NATIONALLY, VARICELLA
HOSPITALIZATIONS AND DEATHS HAVE ALSO DECLINED SUBSTANTIALLY,
ESPECIALLY AMONG CHILDREN, FOR WHOM THERE HAVE BEEN DECLINES OF
90% OR GREATER. EXTENSIVE POST-LICENSURE
EXPERIENCE FROM OUTBREAK INVESTIGATIONS AND STUDIES HAS
SHOWN THAT ONE DOSE OF VARICELLA VACCINE IS, ON AVERAGE, ABOUT
85% EFFECTIVE IN PREVENTING VARICELLA AND CLOSE TO 100%
EFFECTIVE IN PREVENTING SEVERE VARICELLA. THIS LEVEL OF EFFECTIVENESS HAD
CONSIDERABLE IMPACT ON VARICELLA MORBIDITY AND MORTALITY, BUT IT
WAS NOT HIGH ENOUGH TO INTERRUPT ENDEMIC DISEASE TRANSMISSION. OUTBREAKS, THOUGH MUCH SMALLER
THAN IN THE PRE-VACCINE ERA, CONTINUED TO OCCUR IN SCHOOLS
WITH HIGH ONE-DOSE VARICELLA VACCINE COVERAGE AMONG THEIR
STUDENTS. THESE OUTBREAKS WERE A MAJOR
IMPETUS BEHIND THE TWO-DOSE POLICY RECOMMENDATION. TO IMPROVE OUR CONTROL OF
VARICELLA IN THE UNITED STATES, IN JUNE 2006, THE ADVISORY
COMMITTEE ON IMMUNIZATION PRACTICES, OR ACIP, RECOMMENDED
A ROUTINE TWO-DOSE SCHEDULE FOR CHILDREN. THE FIRST DOSE SHOULD BE GIVEN
AT 12 TO 15 MONTHS OF AGE AND THE SECOND DOSE AT 4 TO 6 YEARS
OF AGE. A SECOND DOSE IS ALSO
RECOMMENDED FOR ALL PERSONS WHO HAVE PREVIOUSLY RECEIVED ONLY
ONE DOSE. IN ADDITION, ACIP RECOMMENDED
THE USE OF SCHOOL ENTRY REQUIREMENTS FOR MIDDLE, HIGH
SCHOOL, AND COLLEGE TO HELP INCREASE VARICELLA IMMUNITY. FINALLY, A SECOND DOSE WAS
RECOMMENDED FOR OUTBREAK CONTROL. SINCE IMPLEMENTATION OF THE
ROUTINE TWO-DOSE VARICELLA VACCINATION PROGRAM IN 2006,
VARICELLA INCIDENCE IN THE TWO ACTIVE SURVEILLANCE SITES
DECLINED 79% BY 2010. CHILDREN AND ADOLESCENTS AGED 5
TO 14 YEARS CONTINUE TO EXPERIENCE THE GREATEST
REDUCTION IN DISEASE. AMONG THE STATES WITH ADEQUATE
AND CONSISTENT REPORTING THROUGH NNDSS, DECLINES IN INCIDENCE OF
UP TO 72% HAVE BEEN NOTED SINCE IMPLEMENTATION OF THE TWO-DOSE
VACCINATION PROGRAM. A REDUCTION OF THE NUMBER AND
SIZE OF VARICELLA OUTBREAKS HAS ALSO BEEN NOTED IN OUR ACTIVE
SURVEILLANCE SITES AND VARIOUS STATES. JANE?>>THANK YOU, ADRIANA. IN 2002, THE COUNCIL OF STATE
AND TERRITORIAL EPIDEMIOLOGISTS, OR CSTE, RECOMMENDED THAT
VARICELLA BE INCLUDED IN THE NNDSS. STATES WERE ENCOURAGED TO
CONDUCT ONGOING VARICELLA SURVEILLANCE TO MONITOR VACCINE
IMPACT ON MORBIDITY. CSTE SPECIFICALLY RECOMMENDED
THAT STATES ESTABLISH INDIVIDUAL CASE-BASED REPORTING SYSTEMS FOR
VARICELLA SURVEILLANCE BY 2005. HOWEVER, OTHER FORMS OF
SURVEILLANCE, SUCH AS CASE-BASED REPORTING IN SENTINEL SITES,
WERE CONSIDERED TO BE REASONABLE INTERIM STEPS TOWARD STATEWIDE
CASE REPORTING. AS OF JANUARY 2011, 38 STATES
HAVE IMPLEMENTED EITHER STATEWIDE OR SENTINEL-SITE CASE
REPORTING. CASE-BASED VARICELLA
SURVEILLANCE WILL ALLOW US TO MONITOR THE IMPACT OF THE
VARICELLA VACCINATION PROGRAM ON VARICELLA DISEASE. SYSTEMATIC NATIONAL CASE-BASED
VARICELLA SURVEILLANCE WILL ALSO ALLOW US TO CONTINUE EVALUATING
THE EFFECTIVENESS OF OUR VACCINATION PROGRAM AND
POLICIES. AS MENTIONED EARLIER, THIS IS
OUR SOLE SOURCE OF VARICELLA SURVEILLANCE DATA BEGINNING IN
2012. WE ARE NOW MORE THAN FIVE YEARS
PAST THE DATE THAT CSTE SET FOR ALL STATES TO ESTABLISH
INDIVIDUAL CASE SURVEILLANCE. STATES SHOULD NOW BE CONDUCTING
STATEWIDE CASE-BASED SURVEILLANCE. FOR CASE-BASED SURVEILLANCE,
STANDARD DEMOGRAPHIC, CLINICAL, AND EPIDEMIOLOGICAL DATA SHOULD
BE COLLECTED ON EACH CASE. AGE OF THE PERSON, VACCINATION
HISTORY, INCLUDING NUMBER OF DOSES, AND THE SEVERITY OF
DISEASE BASED ON LESION COUNT ARE KEY VARIABLES FOR MONITORING
IMPACT OF THE VACCINATION PROGRAM ON VARICELLA INCIDENCE,
INCLUDING CHANGES IN VARICELLA EPIDEMIOLOGY AND SEVERE
OUTCOMES. A VARICELLA CASE, ACCORDING TO
THE DEFINITION ESTABLISHED IN 1999, IS AN ILLNESS WITH ACUTE
ONSET OF A DIFFUSE, GENERALIZED MACULOPAPULOVESICULAR RASH
WITHOUT OTHER APPARENT CAUSE. BREAKTHROUGH DISEASE IS
VARICELLA THAT OCCURS IN A VACCINATED PERSON MORE THAN 42
DAYS AFTER VACCINATION. BREAKTHROUGH DISEASE OCCURS IN
ABOUT 15% OF PERSONS VACCINATED WITH ONE DOSE WHO ARE EXPOSED TO
VARICELLA AND IN LESS THAN 5% OF PERSONS VACCINATED WITH TWO
DOSES. IN ABOUT 70% TO 80% OF
BREAKTHROUGH CASES, DISEASE IS MILD, WITH FEWER THAN 50 LESIONS
AND HAS A SHORTER DURATION. THE RASH MAY ALSO BE ATYPICAL IN
APPEARANCE — MACULOPAPULAR WITH FEW OR NO VESICLES. BECAUSE OF THE INCREASING
LIKELIHOOD OF ATYPICAL RASH, LABORATORY TESTING, WHENEVER
POSSIBLE, OR EPIDEMIOLOGICAL LINKAGE TO A TYPICAL CASE OR
LABORATORY-CONFIRMED CASE SHOULD BE SOUGHT TO CONFIRM OR RULE OUT
VARICELLA. HERE IS DR. STEPHANIE BIALEK,
HERPESVIRUS TEAM LEAD IN THE CDC DIVISION OF VIRAL DISEASES, TO
TELL US MORE ABOUT LABORATORY TESTING FOR VARICELLA.>>LABORATORY EVALUATION OF
SUSPECTED VARICELLA CASES IS AN IMPORTANT ADJUNCT TO VARICELLA
SURVEILLANCE, PARTICULARLY IN PERSONS WHOSE ILLNESS IS NOT
TYPICAL. LABORATORY METHODS FOR
CONFIRMATION OF VARICELLA INCLUDE VIROLOGIC TECHNIQUES,
SUCH AS POLYMERASE CHAIN REACTION, OR PCR, DIRECT
FLUORESCENT ANTIBODY, OR DFA, AND VIRAL CULTURE. SEROLOGIC METHODS INCLUDE
VARICELLA IgM ANTIBODY POSITIVITY, SEROCONVERSION FOR
IgG, OR A SIGNIFICANT RISE BETWEEN ACUTE AND CONVALESCENT
IgG ANTIBODY. VIROLOGIC METHODS ARE PREFERRED
FOR DIAGNOSIS, AND AMONG THESE, PCR IS THE BEST CHOICE FOR
CONFIRMATION, BECAUSE IT IS THE MOST SENSITIVE AND SPECIFIC. DFA, THE OTHER RAPID DETECTION
METHOD, CAN BE USED IF PCR IS UNAVAILABLE. THE PREFERRED SPECIMEN FOR PCR
IS MATERIAL FROM SKIN LESIONS AND SCABS. MANY STATE PUBLIC-HEALTH
LABORATORIES NOW HAVE THE CAPACITY TO DO PCR TESTING TO
CONFIRM VARICELLA. COMMERCIALLY AVAILABLE TESTS FOR
IgM ANTIBODY ARE NOT RELIABLE AND SHOULD NOT BE USED. IN VACCINATED PERSONS, SEROLOGIC
METHODS ARE NOT USEFUL. IgM MAY NOT BE PRESENT, AND A
FOURFOLD RISE IN IgG MAY NOT OCCUR. THE NATIONAL VZV LABORATORY AT
CDC HAS DEVELOPED A RELIABLE IgM CAPTURE ASSAY AND CAN ASSIST
WITH LABORATORY EVALUATION OF UNUSUAL CASES, IF NEEDED. CONTACT INFORMATION FOR THE
NATIONAL VZV LABORATORY IS AVAILABLE ON THE RESOURCES WEB
PAGE FOR THIS PROGRAM.>>SURVEILLANCE TARGETED AT
TRACKING DEATHS CONTINUES TO BE IMPORTANT FOR DETERMINING THE
IMPACT OF THE VACCINATION PROGRAM. VARICELLA DEATHS BECAME
NATIONALLY NOTIFIABLE ON JANUARY 1, 1999. STATES SHOULD INVESTIGATE AND
REPORT EVERY VARICELLA DEATH. EACH DEATH REPRESENTS A
POTENTIAL FAILURE OF OUR VARICELLA VACCINATION PROGRAM. AN OUTBREAK OF VARICELLA IS
DEFINED AS FIVE OR MORE EPIDEMIOLOGICALLY LINKED CASES
IN ONE LOCATION, SUCH AS A SCHOOL OR CHILDCARE CENTER. VARICELLA OUTBREAK CONTROL
STARTS WITH THE EXCLUSION OF PERSONS WITH VARICELLA, AS WELL
AS UNVACCINATED CHILDREN FROM THE OUTBREAK SETTING. PERSONS RECEIVING THEIR FIRST
DOSE AS PART OF OUTBREAK CONTROL MAY BE READMITTED TO SCHOOL
IMMEDIATELY. ALONG WITH THE SECOND-DOSE
RECOMMENDATION, ACIP NOW RECOMMENDS THAT PERSONS WHO HAVE
RECEIVED ONE DOSE OF VARICELLA VACCINE RECEIVE A SECOND DOSE
DURING A VARICELLA OUTBREAK FOR OUTBREAK CONTROL. CDC GUIDELINES FOR THE
INVESTIGATION AND MANAGEMENT OF VARICELLA OUTBREAKS ARE
AVAILABLE ON THE CDC WEBSITE. AS VARICELLA OUTBREAKS HAVE
BECOME LESS COMMON, IT IS INCREASINGLY IMPORTANT TO MAKE
EVERY EFFORT TO LABORATORY-CONFIRM AT LEAST ONE
CASE IN EACH OUTBREAK AND INVESTIGATE THE OUTBREAK TO
UNDERSTAND WHY THEY ARE OCCURRING. SEVERAL STATES HAVE ALREADY
DEVELOPED THEIR OWN OUTBREAK GUIDELINES. AS OF JANUARY 2011, 33 STATES
ARE CONDUCTING OUTBREAK SURVEILLANCE. A WORKSHEET FOR OUTBREAK
SURVEILLANCE AND REPORTING HAS BEEN DEVELOPED AND IS AVAILABLE
ON THE RESOURCE WEB PAGE FOR THIS PROGRAM. REPORTING OF CASES, DEATHS, AND
OUTBREAKS OF VARICELLA WILL PROVIDE EVIDENCE FOR
PROGRAMMATIC CHANGES THAT MAY BE NEEDED AND WILL IMPROVE
VARICELLA CONTROL. WE CANNOT CHANGE POLICY OR
IMPROVE OUR PROGRAM FOR VACCINE DELIVERY WITHOUT THIS
INFORMATION. JANE?>>THANK YOU, ADRIANA. FINALLY, WE WOULD LIKE TO
COMMENT ON SURVEILLANCE FOR HERPES ZOSTER, ALSO KNOWN AS
SHINGLES. FOLLOWING PRIMARY INFECTION,
VARICELLA ZOSTER VIRUS REMAINS IN A LATENT STATE IN HUMAN NERVE
TISSUE. THE VIRUS REACTIVATES IN
APPROXIMATELY 15% TO 30% OF INFECTED PERSONS DURING THEIR
LIFETIME, RESULTING IN HERPES ZOSTER. ZOSTER USUALLY PRESENTS AS A
VESICULAR RASH WITH PAIN AND ITCHING IN A DERMATOMAL
DISTRIBUTION. HERPES ZOSTER INCIDENCE
INCREASES WITH INCREASING AGE, ESPECIALLY AFTER AGE 50, AND IS
INCREASED AMONG IMMUNOCOMPROMISED PERSONS. A ZOSTER VACCINE IS NOW LICENSED
IN THE UNITED STATES FOR PERSONS 50 YEARS OF AGE AND OLDER AND
RECOMMENDED BY ACIP FOR ADULTS 60 YEARS OF AGE AND OLDER. HERPES ZOSTER IS NOT NATIONALLY
NOTIFIABLE, AND THERE ARE CURRENTLY NO PLANS TO RECOMMEND
THAT IT BE MADE NATIONALLY NOTIFIABLE. AT THIS STAGE OF THE HERPES
ZOSTER VACCINATION PROGRAM, DATA REGARDING THE BASELINE INCIDENCE
OF HERPES ZOSTER IS IMPORTANT FOR SURVEILLANCE. FOR EXAMPLE, STATES COULD USE
DATA FROM HEALTHCARE MAINTENANCE ORGANIZATIONS OR THE BEHAVIORAL
RISK FACTOR SURVEILLANCE SYSTEM TO ASSESS THE INCIDENCE OF
ZOSTER. CDC IS USING SOME OF THESE
METHODS, SUCH AS NATIONAL DATABASES AND HMO DATA, TO
CONDUCT HERPES ZOSTER SURVEILLANCE NATIONALLY. AS THE ZOSTER VACCINATION
PROGRAM DEVELOPS, IT WILL BE IMPORTANT FOR US TO FIND WAYS TO
MEASURE ITS IMPACT.>>IN 2009, ABOUT 3,400 CASES OF
ACUTE HEPATITIS B WERE REPORTED IN THE UNITED STATES. THIS IS AN INCIDENCE OF 1.1
CASES PER 100,000 POPULATION AND IS THE LOWEST INCIDENCE OF
HEPATITIS B EVER REPORTED IN THE U.S. THE RATE OF HEPATITIS B HAS
DECLINED 87% SINCE 1990, DUE IN LARGE PART TO THE IMPLEMENTATION
OF UNIVERSAL CHILDHOOD IMMUNIZATION. THE GREATEST DECLINE IN RATES
OCCURRED AMONG CHILDREN BORN SINCE THE RECOMMENDATION OF
UNIVERSAL CHILDHOOD IMMUNIZATION WAS IMPLEMENTED IN 1991. BUT THE IMPACT OF VACCINATION
HAS ALSO BEEN SEEN IN DECLINING RATES IN OLDER ADOLESCENTS AND
YOUNG ADULTS. THE HIGHEST RATE OF ACUTE
HEPATITIS B ARE NOW AMONG PERSONS 30 THROUGH 39 YEARS OF
AGE. TRANSMISSION OF HEPATITIS B
VIRUS, OR HBV, OCCURS AS A RESULT OF PERCUTANEOUS OR
PERMUCOSAL EXPOSURE TO BLOOD OF A PERSON ACUTELY OR CHRONICALLY
INFECTED WITH HBV. MODES OF TRANSMISSION VARY BY
AGE. AMONG INFANTS, PERINATAL
TRANSMISSION OF HBV FROM MOTHER TO CHILD CAN OCCUR AS A RESULT
OF BLOOD EXPOSURE DURING BIRTH. CHILDREN CAN ACQUIRE INFECTIONS
VIA TRANSMISSION FROM INFECTED FAMILY AND HOUSEHOLD MEMBERS. AMONG ADOLESCENTS AND ADULTS,
COMMON RISK FACTORS FOR ACQUIRING INFECTION WITH
HEPATITIS B VIRUS INCLUDE SEX WITH MULTIPLE PARTNERS AND
INJECTION DRUG USE. OTHER RISK FACTORS INCLUDE
OCCUPATIONAL EXPOSURE TO HUMAN BLOOD OR MEDICAL INTERVENTIONS,
SUCH AS SURGERY, BLOOD TRANSFUSION, OR ORGAN
TRANSPLANTS. THE INCUBATION PERIOD FOR ACUTE
HEPATITIS B AVERAGES 120 DAYS, WITH A RANGE OF 45 TO 160 DAYS. INFANTS, CHILDREN YOUNGER THAN
10 YEARS OF AGE, AND IMMUNOSUPPRESSED ADULTS WITH
NEWLY ACQUIRED HBV INFECTION ARE USUALLY ASYMPTOMATIC. 30% TO 50% OF OLDER CHILDREN AND
ADULTS ARE SYMPTOMATIC. WHEN PRESENT, CLINICAL SYMPTOMS
AND SIGNS INCLUDE NAUSEA, VOMITING, ABDOMINAL PAIN, AND
JAUNDICE. THE FATALITY RATE AMONG PERSONS
WITH ACUTE HEPATITIS B IS ABOUT 0.5% TO 1%. ALTHOUGH THE CONSEQUENCES OF
ACUTE HEPATITIS B CAN BE SEVERE, MOST OF THE SERIOUS SEQUELAE
ASSOCIATED WITH THIS DISEASE OCCURS IN PERSON IN WHOM CHRONIC
INFECTIONS DEVELOP. PERSONS WITH CHRONIC HBV
INFECTION ARE OFTEN INITIALLY ASYMPTOMATIC. HOWEVER, CHRONIC LIVER DISEASE
DEVELOPS IN 15% TO 25% OF PERSONS WITH CHRONIC HBV
INFECTION. 15% TO 25% WILL DIE PREMATURELY
FROM CIRRHOSIS OR LIVER CANCER. IN INFANTS, YOUNG CHILDREN, AND
IMMUNOSUPPRESSED PERSONS, MOST NEWLY ACQUIRED HBV INFECTIONS
RESULT IN CHRONIC INFECTION. 90% OF INFANTS WITH PERINATAL
INFECTION DEVELOP CHRONIC INFECTION. IN CONTRAST, IN PERSONS WITH
NORMAL IMMUNE SYSTEMS WHO BECOME INFECTED AS ADULTS, ALMOST
ALL — 94% TO 98% — RECOVER COMPLETELY FROM NEWLY ACQUIRED
HBV INFECTION. THE HIGH RISK OF CHRONIC
INFECTION WITH PERINATAL HBV INFECTION IS WHY PREVENTION OF
MATERNAL-TO-INFANT TRANSMISSION IS SUCH A HIGH PRIORITY IN THE
HEPATITIS B ELIMINATION PROGRAM. UNTIL RECENTLY, NATIONAL
SURVEILLANCE FOR HEPATITIS B INCLUDED ONLY ACUTE SYMPTOMATIC
DISEASE AND PERINATAL HEPATITIS B CHRONIC HEPATITIS B VIRAL
INFECTION WAS ADDED TO THE LIST OF NATIONALLY NOTIFIABLE
DISEASES IN 2003. SUSPECTED CASES OF ACUTE
HEPATITIS B, CHRONIC HBV INFECTION, AND PERINATAL HBV
INFECTION, IDENTIFIED BY HEALTH DEPARTMENTS, SHOULD BE
INVESTIGATED TO CONFIRM THAT THE CASE MEETS THE CASE DEFINITION,
DETERMINE THE CHARACTERISTIC OF THE CASE, AND ENSURE THAT
RECOMMENDED INTERVENTIONS OCCUR, INCLUDING THE VACCINATION OF
SUSCEPTIBLE CONTACTS. THE CASE DEFINITION FOR ACUTE
HEPATITIS B INCLUDES HAVING CLINICAL COMPATIBLE SYMPTOMS,
JAUNDICE, OR AN ELEVATION IN LIVER ENZYMES AND LABORATORY
CONFIRMATION. THE PREFERRED TEST FOR
LABORATORY CONFIRMATION OF A CASE OF ACUTE HBV INFECTION IS A
POSITIVE TEST FOR IgM ANTIBODY TO THE HEPATITIS B CORE ANTIGEN. IgM ANTIBODY TO CORE ANTIGEN IS
A GOOD MARKER FOR ACUTE HEPATITIS B BECAUSE IT IS
GENERALLY DETECTABLE FOR ONLY THE FIRST SIX MONTHS AFTER
INFECTION. IF THIS TEST IS NOT AVAILABLE, A
POSITIVE TEST FOR HEPATITIS B SURFACE ANTIGEN, OR HBSAG, WITH
A NEGATIVE TEST FOR ACUTE HEPATITIS “A” VIRAL INFECTION,
IF DONE, IS SUFFICIENT TO CONFIRM A DIAGNOSIS OF ACUTE
HEPATITIS B IN A SYMPTOMATIC PERSON. ANTIBODY TO HEPATITIS B SURFACE
ANTIGEN INDICATES IMMUNITY TO HEPATITIS B VIRUS. IN INVESTIGATING A CONFIRMED
CASE OF ACUTE HEPATITIS B, IN ADDITION TO COLLECTING THE
APPROPRIATE DEMOGRAPHIC AND CLINICAL DATA TO DESCRIBE THE
CASE, THERE ARE TWO ADDITIONAL PRIORITIES. FIRST, YOU SHOULD IDENTIFY
WHETHER THERE ARE CONTACTS TO THE PATIENT AT RISK OF BECOMING
INFECTED. SECOND, YOU SHOULD DETERMINE, IF
POSSIBLE, THE SOURCE OF INFECTION FOR THE INDEX CASE. CRITICAL DATA TO BE COLLECTED
FOR AN ACUTE HEPATITIS CASE INVESTIGATION SHOULD INCLUDE
DEMOGRAPHIC AND CLINICAL DATA, LABORATORY DATA INCLUDING
SEROLOGIC TESTING AND LIVER ENZYME LEVELS, RISK-FACTOR
INFORMATION, AND VACCINATION STATUS. PREGNANCY STATUS OF ANY
HBV-INFECTED WOMAN SHOULD BE DETERMINED TO MAKE SURE THAT
ACTION IS TAKEN TO PREVENT PERINATAL TRANSMISSION TO HER
INFANT. IF AN HBV-INFECTED WOMAN OF
CHILD-BEARING AGE IS IDENTIFIED, INFORMATION ON THE PATIENT
SHOULD BE SHARED WITH THE LOCAL PERINATAL HEPATITIS B
COORDINATOR. THIS WILL HELP TO ENSURE THAT
INFANTS BORN TO THESE WOMEN RECEIVE APPROPRIATE
POST-EXPOSURE PROPHYLAXIS. CONTACTS OF A PERSON WITH ACUTE
HEPATITIS B WHO ARE AT RISK OF INFECTION SHOULD BE IDENTIFIED
AND GIVEN POST-EXPOSURE PROPHYLAXIS AS APPROPRIATE. FOR ACUTE HEPATITIS B, THE
GENERAL RECOMMENDATION FOR POST-EXPOSURE PROPHYLAXIS IS TO
GIVE HEPATITIS B IMMUNE GLOBULIN, OR HBIG, AND TO BEGIN
THE HEPATITIS B VACCINE SERIES WITHIN 14 DAYS OF LAST EXPOSURE. CONTACTS WHO REQUIRE
POST-EXPOSURE PROPHYLAXIS INCLUDE SEXUAL CONTACTS OF THE
PATIENT AND ANY INFANT YOUNGER THAN 12 MONTHS OF AGE FOR WHOM
THE PATIENT IS A PRIMARY CAREGIVER. IN ADDITION, OTHER PERSONS WITH
IDENTIFIABLE PERCUTANEOUS OR PERMUCOSAL EXPOSURE TO THE BLOOD
OF THE PATIENT SHOULD BE GIVEN PROPHYLAXIS. PROVIDING HBIG POST-EXPOSURE
PROPHYLAXIS TO NON-SEXUAL HOUSEHOLD CONTACTS OF THE
PATIENT OR OTHERS WITH NO CLEAR EXPOSURE TO BLOOD OF THE PERSON
IS NOT RECOMMENDED. HOWEVER, PROVIDING HEPATITIS B
VACCINE TO NON-SEXUAL HOUSEHOLD CONTACTS, ESPECIALLY CHILDREN
AND ADOLESCENTS, IS HIGHLY RECOMMENDED. IN ADDITION TO CONTACT
INFORMATION FOR POST-EXPOSURE PROPHYLAXIS, IT IS ALSO
IMPORTANT TO IDENTIFY THE SOURCE OF THE INFECTION FOR ACUTE
CASES. THERE MAY BE OTHER PERSONS WHO
CONTINUE TO BE AT RISK OF INFECTION FROM THE SAME SOURCE. TO IDENTIFY THE SOURCE OF ACUTE
HEPATITIS B INFECTION, IT IS IMPORTANT TO ASK ABOUT EXPOSURE
DURING THE PREVIOUS SIX WEEKS TO SIX MONTHS, INCLUDING CONTACT
WITH ANOTHER PERSON WITH ACUTE OR CHRONIC HBV INFECTION,
OCCUPATIONAL EXPOSURE TO HUMAN BLOOD, INJECTION DRUG USE,
MEDICAL INTERVENTIONS SUCH AS DIALYSIS, BLOOD TRANSFUSION,
ORGAN TRANSPLANTS, OR RECEIPT OF BLOOD PRODUCTS. IT IS ALSO IMPORTANT TO
DETERMINE THE SEXUAL HISTORY OF THE PATIENT, INCLUDING WHETHER
THE INDIVIDUAL HAS MULTIPLE SEX PARTNERS OR IS A MAN WHO HAS HAD
SEX WITH MEN. PERINATAL HEPATITIS B VIRAL
INFECTION IS DEFINED AS THE PRESENCE OF HEPATITIS B SURFACE
ANTIGEN IN AN INFANT 1 TO 24 MONTHS OF AGE, BORN IN THE U.S. OR U.S. TERRITORY TO A
HEPATITIS-B-SURFACE-ANTIGEN- POSITIVE WOMAN. SINCE PERINATAL HBV INFECTIONS
ARE ALMOST ALWAYS ASYMPTOMATIC, THERE ARE NO CLINICAL CRITERIA
FOR THESE CASES. THE IDENTIFICATION OF INFECTED
INFANTS IS DEPENDENT UPON SEROLOGIC TESTING OF INFANTS
BORN TO WOMAN WHO ARE HBSAG-POSITIVE. STATE-BASED PERINATAL
HEPATITIS-B-PREVENTION PROGRAMS EXIST TO FOLLOW UP PREGNANT
WOMEN KNOWN TO BE HbSAg POSITIVE THIS ACTIVITY HELPS TO ENSURE
THAT THEIR INFANTS RECEIVE POST-EXPOSURE PROPHYLAXIS. AS PART OF THEIR FOLLOW-UP,
EXPOSED INFANTS SHOULD BE TESTED FOR HbSAg THREE MONTHS AFTER
RECEIVING THE THIRD DOSE OF VACCINE. WHEN A PERINATAL CASE IS
IDENTIFIED, THE CASE SHOULD BE REVIEWED AND VERIFIED WITH THE
LOCAL PERINATAL HEPATITIS B COORDINATOR. IF THE INFANT HAS BEEN INFECTED,
IT SHOULD BE REPORTED AS A CASE OF PERINATAL HBV INFECTION
THROUGH THE NATIONAL NOTIFIABLE DISEASE SURVEILLANCE SYSTEM. ALTHOUGH THE IMPLEMENTATION OF
PROGRAMS FOR THE PREVENTION OF PERINATAL HBV HAS CONSIDERABLE
SUCCESS IN PREVENTING PERINATAL AND CHILDHOOD TRANSMISSION OF
HBV, CHALLENGES REMAIN. FOR EXAMPLE, ALTHOUGH MORE THAN
90% OF PREGNANT WOMEN NATIONALLY ARE SCREENED BEFORE DELIVERY,
CDC ESTIMATES THAT ONLY ABOUT HALF OF THE EXPECTED BIRTHS TO
INFECTED WOMEN ARE IDENTIFIED TO STATE PERINATAL
HEPATITIS-B-PREVENTION PROGRAMS FOR CASE MANAGEMENT. CASE MANAGEMENT OF INFANTS BORN
TO HBV-INFECTED WOMEN IS NEEDED TO MAXIMIZE ON-TIME DELIVERY OF
POST-EXPOSURE PROPHYLAXIS. IN ADDITION, ERRORS IN
MANAGEMENT OF INFANTS BORN TO HbSAg-POSITIVE WOMEN AND INFANTS
BORN TO WOMEN WITH UNKNOWN HBSAG STATUS HAVE KEPT MANY OF THESE
INFANTS FROM RECEIVING APPROPRIATE POST-EXPOSURE
PROPHYLAXIS TO PREVENT HBV INFECTION. SURVEILLANCE FOR HBV INFECTION
IS AN IMPORTANT PUBLIC-HEALTH TOOL. IDENTIFICATION AND REPORTING OF
PERSONS WITH HBV INFECTION ASSISTS PUBLIC-HEALTH
PROFESSIONALS IN REACHING CONTACTS OF CASES — PERSONS WHO
ARE AT RISK OF INFECTION — SO THAT VACCINATION AND
POST-EXPOSURE PROPHYLAXIS CAN BE PROVIDED, IF APPROPRIATE. SURVEILLANCE ALSO HELPS US
UNDERSTAND THE RISK OF INFECTION IN ORDER TO PROVIDE THE
APPROPRIATE PROGRAMMATIC RESOURCES TO REDUCE THE RISK OF
HBV INFECTION IN THE U.S.>>IN FEBRUARY 2010, THE FOOD
AND DRUG ADMINISTRATION LICENSED THE 13-VALENT PNEUMOCOCCAL
CONJUGATE VACCINE, OR PCV13. PCV13 WAS MADE A PART OF THE
RECOMMENDED CHILDHOOD IMMUNIZATION SCHEDULE SOON
THEREAFTER, REPLACING THE 7-VALENT PNEUMOCOCCAL CONJUGATE
VACCINE, OR PCV7, WHICH WAS ORIGINALLY INTRODUCED IN 2000. NATIONAL IMMUNIZATION SURVEY
DATA FOR 2010 INDICATE THAT NATIONAL COVERAGE WITH FOUR
DOSES OF PNEUMOCOCCAL CONJUGATE VACCINE IS ABOUT 83%, WITH
COVERAGE IN STATES AND METROPOLITAN AREAS RANGING FROM
68% TO 93%. AS WITH OTHER
VACCINE-PREVENTABLE DISEASES, WE NEED TO ESTABLISH SURVEILLANCE
TO MONITOR THE IMPACT OF OUR VACCINATION PROGRAM. BEFORE WE TALK ABOUT WHAT SUCH A
PROGRAM MIGHT LOOK LIKE, LET’S REVIEW A LITTLE BACKGROUND ON
PNEUMOCOCCAL DISEASE. STREPTOCOCCUS PNEUMONIAE IS A
GRAM-POSITIVE BACTERIA WITH MORE THAN 90 KNOWN SEROTYPES. AS WITH OTHER ENCAPSULATED
ORGANISMS, THE POLYSACCHARIDE CAPSULE IS AN IMPORTANT
VIRULENCE FACTOR, AND THE CAPSULAR TYPE-SPECIFIC ANTIBODY
IS PROTECTIVE. ALTHOUGH ALL SEROTYPES MAY CAUSE
SERIOUS DISEASE, A RELATIVELY LIMITED NUMBER OF SEROTYPES
CAUSE THE MAJORITY OF INVASIVE INFECTIONS. OVERALL, SIX TO 11 SEROTYPES ARE
ESTIMATED TO ACCOUNT FOR MORE THAN 70% OF INVASIVE DISEASE
WORLDWIDE, BUT THE RANKING OF SEROTYPE PREVALENCE DIFFERS BY
AGE GROUP AND BY GEOGRAPHIC AREA. AT THE TIME OF PCV7 INTRODUCTION
IN 2000, THE SEVEN VACCINE SEROTYPES ACCOUNTED FOR 80% OF
ISOLATES FROM BLOOD OR CEREBROSPINAL FLUID AMONG
CHILDREN YOUNGER THAN 5 YEARS OF AGE. IN 2011, 11 YEARS AFTER VACCINE
LICENSURE, THE SEVEN VACCINE SEROTYPES INCLUDED IN PCV7
ACCOUNT FOR ABOUT 2% OF CASES IN CHILDREN YOUNGER THAN 5 YEARS OF
AGE. PNEUMOCOCCUS MAY BE ISOLATED
FROM THE UPPER RESPIRATORY TRACT OF ABOUT 10% OF PEOPLE AT ANY
GIVEN TIME. CARRIAGE RATES AMONG CHILDREN
ARE USUALLY HIGHER. ALL PERSONS PROBABLY CARRY
PNEUMOCOCCUS AT SOME TIME DURING THE COURSE OF A YEAR. TRANSMISSION CAN OCCUR AS LONG
AS THE ORGANISM IS PRESENT IN RESPIRATORY SECRETIONS. WE DON’T UNDERSTAND WHY SOME
PEOPLE GO ON TO DEVELOP INVASIVE DISEASE. HOST FACTORS, SUCH AS UNDERLYING
ILLNESS, ARE PROBABLY IMPORTANT. HAVING A VIRAL INFECTION AT THE
SAME TIME PNEUMOCOCCUS IS PRESENT IN THE UPPER AIRWAY
MIGHT ALSO MAKE SOMEONE MORE LIKELY TO DEVELOP INVASIVE
DISEASE. BUT PERSONS WITHOUT ANY
UNDERLYING ILLNESS MAY ALSO DEVELOP INVASIVE PNEUMOCOCCAL
DISEASE. ALTHOUGH PNEUMOCOCCAL INFECTIONS
OCCUR IN HEALTHY PERSONS, THERE ARE FACTORS THAT SIGNIFICANTLY
INCREASE THE RISK FOR INVASIVE CHILDREN WITH FUNCTIONAL OR
ANATOMIC ASPLENIA, SICKLE CELL DISEASE, AND OTHER
HEMOGLOBINOPATHIES, AS WELL AS CHILDREN WITH HIV INFECTION ARE
AT EXTREMELY HIGH RISK OF INVASIVE DISEASE. SOME STUDIES ESTIMATE RATES MORE
THAN 50 TIMES HIGHER THAN THE RATES AMONG CHILDREN OF THE SAME
AGE WITHOUT THESE CONDITIONS. OUT-OF-HOME CHILDCARE HAS BEEN
SHOWN TO INCREASE THE RISK OF INVASIVE PNEUMOCOCCAL DISEASE
AND ACUTE OTITIS MEDIA. THE RISK FOR CHILDREN IN THESE
SETTINGS IS INCREASED TWO- TO THREE-FOLD AMONG CHILDREN
YOUNGER THAN 5 YEARS OF AGE. FINALLY, CHILDREN OF CERTAIN
RACIAL AND ETHNIC GROUPS HAVE INCREASED RATES OF INVASIVE
PNEUMOCOCCAL DISEASE. THESE INCLUDE ALASKA NATIVES,
CERTAIN AMERICAN INDIAN GROUPS, AND AFRICAN-AMERICANS. THE REASONS FOR THIS INCREASED
RISK IS NOT CLEAR. MUCH OF OUR KNOWLEDGE OF THE
INCIDENCE AND RISK FACTORS FOR INVASIVE PNEUMOCOCCAL DISEASE
COMES FROM SPECIAL STUDIES AND SURVEILLANCE SYSTEMS. ONE SUCH SURVEILLANCE SYSTEM IS
CDC’s ACTIVE BACTERIAL CORE SURVEILLANCE, OR ABCs. WE ASKED DR. GAYLE LANGLEY, THE
MEDICAL DIRECTOR OF ABCs, TO DESCRIBE THIS SYSTEM FOR US.>>CDC’s ACTIVE BACTERIAL CORE
SURVEILLANCE, OR ABCs, IS AN>>CDC’s ACTIVE BACTERIAL CORE
SURVEILLANCE, OR ABCs, IS AN ACTIVE LABORATORY AND
POPULATION-BASED SURVEILLANCE SYSTEM FOR INVASIVE DISEASE DUE
TO SIX BACTERIAL PATHOGENS. THE PATHOGENS INCLUDE GROUPS “A”
AND “B” STREPTOCOCCUS, HAEMOPHILUS INFLUENZAE,
NEISSERIA MENINGITIDIS, STREPTOCOCCUS PNEUMONIAE, AND
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS, OR MRSA. THE PRINCIPAL OBJECTIVES OF ABCs
ARE TO ACCURATELY MEASURE THE INCIDENCE OF THESE SIX BACTERIAL
PATHOGENS, TO DETERMINE THEIR EPIDEMIOLOGIC CHARACTERISTICS,
TO TRACK TRENDS OVER TIME, AND TO PROVIDE AN INFRASTRUCTURE FOR
FURTHER PUBLIC-HEALTH RESEARCH. ABCs IS A CORE COMPONENT OF THE
EMERGING INFECTIONS PROGRAM NETWORK, OR EIP, AND IS
CONDUCTED AT 10 EIP SITES ACROSS THE UNITED STATES. THESE SITES REPRESENT A
POPULATION OF MORE THAN 42 MILLION PERSONS. ABCs IS MANAGED BY STAFF IN THE
NATIONAL CENTER FOR IMMUNIZATION AND RESPIRATORY DISEASES. FOR EACH CASE OF INVASIVE
DISEASE IN THE SURVEILLANCE POPULATION, A CASE REPORT FORM
WITH BASIC DEMOGRAPHIC AND CLINICAL INFORMATION IS
COMPLETED. THE BACTERIAL ISOLATE IS SENT TO
CDC AND OTHER REFERENCE LABORATORIES FOR ADDITIONAL
EVALUATION. ABCs ALSO PROVIDES AN
INFRASTRUCTURE FOR SPECIAL STUDIES, INCLUDING ONES AIMED AT
IDENTIFYING RISK FACTORS FOR DISEASE, EVALUATING
POST-LICENSURE VACCINE EFFECTIVENESS, AND MONITORING
THE IMPACT OF PREVENTION POLICIES. FOR STREPTOCOCCUS PNEUMONIAE,
THE MAIN OBJECTIVES OF SURVEILLANCE ARE TO MEASURE THE
BURDEN OF INVASIVE PNEUMOCOCCAL DISEASE AMONG PERSONS OF ALL
AGES, TO TRACK EMERGING ANTIBIOTIC RESISTANCE, AND TO
STUDY THE IMPACT OF PNEUMOCOCCAL VACCINES. DATA FROM ABCs HAS BEEN
PARTICULARLY USEFUL IN DOCUMENTING THE IMPACT OF
PNEUMOCOCCAL CONJUGATE VACCINE AMONG CHILDREN AND THE INDIRECT
BENEFIT OF THIS VACCINE FOR OLDER PERSONS. DATA FOR ALL SIX DISEASES
INCLUDED IN ABCs, AS WELL AS ESTIMATES OF DISEASE BURDEN
EXTRAPOLATED TO THE U.S. POPULATION ARE AVAILABLE ON THE
ACTIVE BACTERIAL CORE SURVEILLANCE WEBSITE.>>DATA FROM ABCs HAVE BEEN
VALUABLE FOR DOCUMENTING THE BURDEN OF INVASIVE PNEUMOCOCCAL
DISEASE, OR IPD, AMONG CHILDREN AND FOR IDENTIFYING GROUPS OF
CHILDREN AT INCREASED RISK OF DISEASE. THE ABCs DATA HAVE ALSO BEEN
VALUABLE IN DOCUMENTING THE IMPACT OF PNEUMOCOCCAL
VACCINATION OF CHILDREN. IN FACT, SINCE IMPLEMENTATION OF
PNEUMOCOCCAL CONJUGATE VACCINES, ABCs HAS DOCUMENTED THAT RATES
OF INVASIVE PNEUMOCOCCAL DISEASE HAVE FALLEN SIGNIFICANTLY. THIS GRAPH SHOWS THE RATES OF
INVASIVE PNEUMOCOCCAL DISEASE AMONG CHILDREN LESS THAN 5 YEARS
OF AGE, BEGINNING IN 1998 AND CONTINUING THROUGH 2010. THE VERTICAL AXIS SHOWS
INCIDENCE, EXPRESSED AS CASES PER 100,000 POPULATION. THE BLUE LINE INDICATES RATES OF
INVASIVE DISEASE DUE TO THE SEVEN PNEUMOCOCCAL SEROTYPES
CONTAINED IN PCV7. THE GRAY LINE DEPICTS RATES OF
DISEASE DUE TO SEROTYPES CONTAINED IN PCV13, BUT NOT IN
PCV7. AND THE PURPLE LINE DEPICTS
RATES OF DISEASE DUE TO NON-VACCINE SEROTYPES. PRIOR TO INTRODUCTION OF THE
PNEUMOCOCCAL CONJUGATE VACCINE IN 2000, RATES OF INVASIVE
PNEUMOCOCCAL DISEASE DUE TO THE SEVEN VACCINE SEROTYPES WERE
AROUND 90 CASES PER 100,000 POPULATION. AFTER THE INTRODUCTION OF PCV7
IN 2000, RATES OF DISEASE DUE TO THESE SEVEN SEROTYPES DROPPED
DRAMATICALLY TO LESS THAN ONE CASE PER 100,000 BY 2007. HOWEVER, DURING THE LAST SEVERAL
YEARS, RATES OF DISEASE DUE TO SEROTYPES NOT COVERED BY PCV7
HAVE INCREASED. IN ORDER TO PROVIDE INCREASED
COVERAGE FOR THESE SEROTYPES, PCV-13 WAS INTRODUCED IN 2010. WITH THE INTRODUCTION OF PCV-13,
IT IS ANTICIPATED THAT CASES OF INVASIVE DISEASE DUE TO THE SIX
ADDITIONAL SEROTYPES COVERED BY THE VACCINE WILL DECREASE. ABCs ONLY OPERATES IN 10
SELECTED LOCATIONS. WE CANNOT RELY ON IT TO DOCUMENT
THE IMPACT OF EACH STATE’S PROGRAM FOR VACCINATION OF
CHILDREN WITH PNEUMOCOCCAL CONJUGATE VACCINE. TO MONITOR THIS, EACH STATE MUST
EVALUATE INVASIVE PNEUMOCOCCAL DISEASE THROUGH TIME AND WITHIN
POPULATIONS. NATIONAL DATA, BASED ON EACH
STATE’S SURVEILLANCE, SHOULD BE USED TO LOOK AT RATES BETWEEN
GROUPS TO SEE IF STATE PROGRAMS ARE REACHING INDIVIDUALS AND
GROUPS RECOMMENDED FOR VACCINATION. FORTUNATELY, WE HAVE A GOOD
MODEL FOR HOW TO DO THIS FROM SURVEILLANCE FOR HAEMOPHILUS
INFLUENZAE INVASIVE DISEASE. INVASIVE DISEASE DUE TO EITHER
OF THESE ORGANISMS IS A LABORATORY-BASED DIAGNOSIS, AND
MANY PERSONS WITH THESE INFECTIONS ARE HOSPITALIZED. NATIONAL REPORTING FOR INVASIVE
PNEUMOCOCCAL DISEASE CAN BE NEARLY COMPLETE WITH
LABORATORY-BASED REPORTS. DURING 1994 THROUGH 2006,
VARIOUS CHANGES WERE MADE TO THE CASE DEFINITION FOR INVASIVE
PNEUMOCOCCAL DISEASE, ESPECIALLY AS IT RELATES TO
ANTIBIOTIC-RESISTANT INFECTIONS. HOWEVER, AS OF 2009, ALL CASES
OF INVASIVE PNEUMOCOCCAL DISEASE ARE TO BE REPORTED USING A
SINGLE CASE DEFINITION — THAT IS, ISOLATION OF ANY
PNEUMOCOCCUS FROM A NORMALLY STERILE SITE. ADDITIONAL INFORMATION, SUCH AS
INFORMATION ON ANTIBIOTIC SUSCEPTIBILITY TESTING, CAN BE
PROVIDED AS SUPPLEMENTAL INFORMATION. CHAD?>>THANKS, GINA. ONCE WE IDENTIFY A CASE OF
INVASIVE PNEUMOCOCCAL DISEASE, OR IPD, IN A CHILD YOUNGER THAN
5 YEARS OLD, WHAT INFORMATION SHOULD BE COLLECTED? WE NEED THE CORE DATA THAT
SHOULD BE COLLECTED FOR EVERY CASE OF VACCINE-PREVENTABLE
DISEASE, INCLUDING DEMOGRAPHIC INFORMATION AND CLINICAL DATA,
AS WELL AS RISK FACTORS FOR INVASIVE DISEASE. FOR PNEUMOCOCCAL DISEASE, RISK
FACTORS INCLUDE UNDERLYING MEDICAL CONDITIONS, SUCH AS
ASPLENIA OR HIV INFECTION AND OUT-OF-HOME CHILDCARE. AND, OF COURSE, WE ARE
INTERESTED IN VACCINATION HISTORY. SOME CASES OF IPD WILL OCCUR
AMONG UNVACCINATED OR INCOMPLETELY VACCINATED
CHILDREN, BUT THERE WILL BE CASES REPORTED AMONG FULLY
VACCINATED CHILDREN, AS WELL. THESE FULLY VACCINATED CHILDREN
COULD REPRESENT VACCINE FAILURES, DEFINED AS DISEASE
CAUSED BY A SEROTYPE INCLUDED IN THE VACCINE. A MORE LIKELY POSSIBILITY IS
THAT THEY WILL REPRESENT DISEASE CAUSED BY A SEROTYPENOT
INCLUDED IN THE VACCINE. TO FACILITATE THE DISTINCTION
BETWEEN VACCINE FAILURES AND INFECTION CAUSED BY NON-VACCINE
SEROTYPES, CDC HAS DEVELOPED A PROTOCOL FOR IDENTIFYING
PNEUMOCOCCAL SEROTYPES USING POLYMERASE CHAIN REACTION, OR
PCR. THIS PROTOCOL IS AVAILABLE ON
THE CDC WEBSITE. WE WILL INCLUDE A LINK TO THE
PCR-BASED SEROTYPING PROTOCOL ON THE RESOURCES WEB PAGE FOR THIS
PROGRAM. PCR IS USED BY MOST STATE
PUBLIC-HEALTH LABORATORIES TO DETECT A VARIETY OF INFECTIOUS
DISEASES. THIS TECHNOLOGY SHOULD ALLOW
MOST, IF NOT ALL, STATE HEALTH DEPARTMENTS TO ENHANCE
SURVEILLANCE FOR INVASIVE A KEY FOCUS OF STATE-BASED
SURVEILLANCE SHOULD BE TO A KEY FOCUS OF STATE-BASED
SURVEILLANCE SHOULD BE TO COMPARE STATE RATES TO RATES
ELSEWHERE TO SEE IF THEY ARE WITHIN THE EXPECTED RANGE AND TO
COMPARE AMONG POPULATIONS WITHIN THE STATE. IMPORTANTLY, RATES OF DISEASE
SHOULD BE CONSIDERED IN THE CONTEXT OF PCV13 COVERAGE RATES. IF RATES OF INVASIVE DISEASE ARE
ELEVATED, THE NEXT STEP WOULD BE TO DETERMINE THE CAUSE. LIKE ANY EPIDEMIOLOGIC
INVESTIGATION, CASES SHOULD BE CHARACTERIZED IN TERMS OF
PERSON, PLACE, AND TIME. THESE FUNDAMENTAL PIECES OF DATA
CAN SHED LIGHT ON WHETHER AN OUTBREAK MIGHT BE OCCURRING IN A
PARTICULAR GEOGRAPHIC LOCATION OR IN A SPECIFIC POPULATION. CLINICAL MICROBIOLOGY
LABORATORIES SHOULD BE CONTACTED AND ASKED TO SAVE ALL
PNEUMOCOCCAL ISOLATES OR TO SHIP THEM TO THE STATE PUBLIC-HEALTH
LABORATORY FOR STORAGE. THE PCR-BASED PROTOCOL FOR
PNEUMOCOCCAL SEROTYPING CAN BE USED TO DETERMINE WHETHER A
SPECIFIC SEROTYPE IS COMMON TO SOME OR ALL OF THE CASES. THIS INFORMATION CAN HELP
DETERMINE WHETHER AN OUTBREAK IS OCCURRING. CDC IS AVAILABLE TO PROVIDE
EPIDEMIOLOGIC AND LABORATORY SUPPORT IN OUTBREAK SITUATIONS. STATE HEALTH DEPARTMENTS SHOULD
CONTACT THE RESPIRATORY DISEASES BRANCH OF THE NATIONAL CENTER
FOR IMMUNIZATION AND RESPIRATORY DISEASES TO DISCUSS THEIR
SPECIFIC SITUATION. CONTACT INFORMATION FOR THE
RESPIRATORY DISEASES BRANCH IS INCLUDED ON THE PROGRAM
RESOURCES WEB PAGE. IF YOU IDENTIFY A CHILD WITH
INVASIVE PNEUMOCOCCAL DISEASE, YOU MAY CONSIDER ASKING THE
LABORATORY TO SAVE THE ISOLATE. THESE STORED ISOLATES WOULD THEN
BE AVAILABLE, IF NEEDED, IN CASES OF OUTBREAKS, UNEXPLAINED
INCREASE IN RATES, OR DISPARITY IN RATES BETWEEN THE SUBSETS OF
STATES’ POPULATIONS. REMEMBER, WE WILL BE RELYING ON
YOUR HELP IN CONDUCTING NATIONAL SURVEILLANCE TO UNDERSTAND THE
IMPACT OF THE 13-VALENT PNEUMOCOCCAL CONJUGATE VACCINE.>>AMONG YOUNG CHILDREN,
INVASIVE DISEASE DUE TO HAEMOPHILUS INFLUENZAE TYPE B,
OR HIB, HAS VIRTUALLY DISAPPEARED IN THE
UNITED STATES. WITH WIDESPREAD USE OF CONJUGATE
HAEMOPHILUS INFLUENZAE TYPE B VACCINES SINCE THE EARLY 1990s,
THIS DISEASE HAS CHANGED FROM THE MOST COMMON CAUSE OF
BACTERIAL MENINGITIS IN INFANTS TO A MEDICAL RARITY. THE BACTERIUM HAEMOPHILUS
INFLUENZAE CAN EITHER BE ENCAPSULATED OR UNENCAPSULATED. THE CAPSULE IS COMPOSED OF
POLYSACCHARIDE, OF WHICH THERE ARE SIX ANTIGENICALLY DISTINCT
TYPES. THE CAPSULAR TYPES ARE
DESIGNATED BY THE LETTERS “A” THROUGH “F.” NON-TYPE-B ENCAPSULATED STRAINS
CAN CAUSE DISEASE SIMILAR TO TYPE B INFECTIONS. UNENCAPSULATED STRAINS ARE
REFERRED TO AS NON-TYPABLE. NON-TYPABLE STRAINS ARE A COMMON
CAUSE OF EAR INFECTIONS IN CHILDREN AND BRONCHITIS IN
ADULTS, BUT MAY ALSO CAUSE INVASIVE DISEASE, SUCH AS
BACTEREMIA AND PNEUMONIA. BEFORE INTRODUCTION OF EFFECTIVE
VACCINES, THE TYPE B ENCAPSULATED STRAIN ACCOUNTED
FOR MORE THAN 95% OF INVASIVE HAEMOPHILUS INFLUENZAE DISEASE
AMONG CHILDREN. IN THE PRE-VACCINE ERA, THERE
WERE AN ESTIMATED 20,000 CASES OF INVASIVE HIB DISEASE ANNUALLY
AMONG CHILDREN YOUNGER THAN 5 YEARS OF AGE IN THE
UNITED STATES. HIB WAS THE LEADING CAUSE OF
BACTERIAL MENINGITIS IN THE UNITED STATES AMONG CHILDREN IN
THAT SAME AGE GROUP. APPROXIMATELY 2/3 OF CASES WERE
AMONG CHILDREN YOUNGER THAN 18 MONTHS OF AGE. CONJUGATE VACCINES AGAINST THE
HIB BACTERIUM WERE FIRST LICENSED FOR USE IN INFANTS IN
THE UNITED STATES IN 1990. INVASIVE HAEMOPHILUS INFLUENZAE
INFECTIONS IN CHILDREN YOUNGER THAN 5 YEARS OF AGE BECAME
NATIONALLY NOTIFIABLE IN 1991. SINCE THEN, VACCINE COVERAGE
INCREASED RAPIDLY, AND HIB DISEASE DECREASED RAPIDLY. THIS GRAPH SHOWS THE INCIDENCE
OF INVASIVE TYPE B DISEASE AMONG CHILDREN YOUNGER THAN 5 YEARS OF
AGE SINCE 1989, SHOWN BY THE YELLOW LINE. THE RATE FELL RAPIDLY AFTER
INTRODUCTION OF THE CONJUGATE VACCINE. BY 1994, THE INCIDENCE OF HIB
AMONG CHILDREN YOUNGER THAN 5 YEARS OF AGE HAD DECREASED BY
95% COMPARED WITH THE PRE-VACCINATION ERA. BY 2005, THE INCIDENCE HAD
DECLINED BY 99% OR MORE, AND THE RATE HAS REMAINED VERY LOW SINCE
THEN. NOTICE THAT THE RATES OF
NON-TYPE-B AND NON-TYPABLE DISEASE, SHOWN BY THE RED AND
GREEN LINES, HAVE REMAINED BASICALLY UNCHANGED. CHEMOPROPHYLAXIS IS ONLY
RECOMMENDED FOR HIB CASES, BECAUSE DISEASE AMONG CLOSE
CONTACTS HAS NOT BEEN IDENTIFIED WITH OTHER HAEMOPHILUS
INFLUENZAE STRAINS. THEREFORE, TO MAKE PUBLIC-HEALTH
DECISIONS ABOUT WHETHER CHEMOPROPHYLAXIS IS NEEDED, WE
MUST SEROTYPE ISOLATES FROM ALL HAEMOPHILUS INFLUENZAE CASES. ON AVERAGE, 40 CASES OF HIB ARE
REPORTED EACH YEAR IN CHILDREN YOUNGER THAN 5 YEARS OF AGE IN
THE UNITED STATES. HOWEVER, ON AVERAGE, 121
HAEMOPHILUS INFLUENZAE CASES IN CHILDREN YOUNGER THAN 5 YEARS OF
AGE HAVE AN UNKNOWN SEROTYPE EACH YEAR. SEROTYPE DATA MAY BE UNKNOWN IF
ISOLATE SEROTYPING IS NOT CONDUCTED OR IS MISCLASSIFIED
DURING DATA TRANSMISSION FROM STATES TO CDC. SOME OF THESE CASES WITH UNKNOWN
SEROTYPE MAY BE HIB CASES. WE ESTIMATE THAT EACH YEAR, SIX
TO 12 CASES OF HAEMOPHILUS INFLUENZAE WITH AN UNKNOWN
SEROTYPE ARE ACTUALLY HIB. FOR THIS REASON, IT IS IMPORTANT
TO SEROTYPE ISOLATES OF ALL CASES SO THAT HIB CASES ARE
IDENTIFIED AND APPROPRIATE CHEMOPROPHYLAXIS MEASURES CAN BE
TAKEN. GINA?>>INVASIVE HAEMOPHILUS
INFLUENZAE DISEASE INCLUDES A NUMBER OF CLINICAL SYNDROMES,
INCLUDING MENINGITIS, EPIGLOTTITIS, PERIORBITAL AND
BUCCAL CELLULITIS, SEPTIC ARTHRITIS, SEPSIS, AND
PNEUMONIA. OF COURSE, THESE SYNDROMES CAN
BE CAUSED BY OTHER BACTERIAL AND VIRAL AGENTS, AS WELL, SO CASE
CONFIRMATION REQUIRES ISOLATION OF HAEMOPHILUS INFLUENZAE FROM A
NORMALLY STERILE BODY SITE. BUT ISOLATION OF THE ORGANISM IS
NOT THE END OF THE LABORATORY INVESTIGATION. THE NEXT STEP IS SEROTYPING. SEROTYPING IS AN EXTREMELY
IMPORTANT LABORATORY PROCEDURE THAT SHOULD BE PERFORMED ON
EVERY ISOLATE OF HAEMOPHILUS INFLUENZAE FROM A NORMALLY
STERILE SITE. SEROTYPING IS THE ONLY WAY TO
DETERMINE IF AN ISOLATE IS TYPE B. THIS IS IMPORTANT BECAUSE ONLY
TYPE B IS PREVENTABLE BY VACCINATION. SEROTYPING PROVIDES CRITICAL
INFORMATION TO THOSE IN PUBLIC HEALTH WHO NEED TO DECIDE
WHETHER OR NOT THE CONTACTS OF THE PATIENT REQUIRE
CHEMOPROPHYLAXIS. THE SEROTYPE CAN ALSO HELP A
PHYSICIAN DETERMINE WHETHER THE IMMUNOLOGICAL STATUS OF THE
PATIENT SHOULD BE EVALUATED — THAT IS, HIB DISEASE IN A PERSON
WHO HAD ALREADY BEEN VACCINATED MAY INDICATE THAT THE PERSON MAY
NOT HAVE RESPONDED NORMALLY TO THE VACCINE. LABORATORY SUPPORT FOR
HAEMOPHILUS INFLUENZAE SEROTYPING SHOULD BE READILY
AVAILABLE THROUGH YOUR STATE LABORATORY. FOR ADVICE ON SEROTYPING
CAPABILITY WITHIN YOUR STATE, CONTACT YOUR STATE HEALTH
DEPARTMENT. OTHER THAN GETTING THE ISOLATE
FOR SEROTYPING, WHAT ELSE NEEDS TO BE DONE FOR CASE
INVESTIGATION? AFTER YOU HEAR ABOUT A POSSIBLE
CASE, YOU NEED TO REVIEW LABORATORY, HOSPITAL, AND OTHER
CLINICAL RECORDS TO OBTAIN THE CRITICAL INFORMATION NEEDED ON
EVERY CASE. THIS INCLUDES DEMOGRAPHIC
INFORMATION AND RELEVANT CLINICAL DATA. CLINICAL DATA NEEDED INCLUDES
THE CLINICAL SYNDROME, DATES OF HOSPITALIZATION, DATE OF FIRST
POSITIVE CULTURE, AND OUTCOME OF THE ILLNESS. RESULTS OF LABORATORY TESTING
ARE CRITICAL. THE SEROTYPE OF THE ISOLATE,
BODY-FLUID SOURCE OF THE ISOLATE, AND ANTIBIOTIC
SUSCEPTIBILITY ARE ALL IMPORTANT. VACCINATION STATUS SHOULD BE
OBTAINED FOR EVERY CASE. SINCE THERE ARE SEVERAL TYPES OF
HIB VACCINES, THIS MEANS THE DATE, MANUFACTURER, AND LOT
NUMBER OF EACH HIB VACCINE DOSE. THIS INFORMATION TELLS US
WHETHER THE CASE OCCURRED AS A RESULT OF VACCINE FAILURE OR
FAILURE TO VACCINATE. FINALLY, WE NEED INFORMATION ON
RISK FACTORS FOR HIB DISEASE. ONE OF THE MOST IMPORTANT OF
THESE IS WHETHER OR NOT THE CHILD ATTENDED CHILDCARE. IF THE CHILD ATTENDED CHILDCARE,
CONTROL MEASURES MAY BE NEEDED FOR OTHER CENTER ATTENDEES. INVASIVE HAEMOPHILUS INFLUENZAE
DISEASE IS RARE IN THE UNITED STATES. IT IS CRITICAL THAT EVERY STATE
INVESTIGATE, LAB-CONFIRM, SEROTYPE, AND REPORT EVERY CASE
OF INVASIVE DISEASE. HOW CAN SURVEILLANCE FOR HIB
DISEASE BE IMPROVED? HIB IS A LABORATORY-BASED
DIAGNOSIS, AND ALMOST ALL CASES ARE HOSPITALIZED FOR THE FIRST
FEW DAYS OF THE ILLNESS. AS A RESULT, REPORTING CAN BE
NEARLY COMPLETE IF ALL CLINICAL MICROBIOLOGY LABORATORIES AND
ALL HOSPITALS REPORT THE CASES THAT THEY SEE. ELIZABETH?>>THANK YOU, GINA. WITH SO FEW CASES OF HIB DISEASE
NOW OCCURRING, HOW CAN WE BE SURE THAT OUR SURVEILLANCE IS
GOOD ENOUGH TO DETECT THE FEW CASES THAT MAY BE STILL OUT
THERE? REMEMBER, ONLY TYPE B DISEASE IS
PREVENTABLE BY VACCINATION. THAT MEANS THAT DISEASE THAT
LOOKS LIKE HIB BUT IS CAUSED BY NON-TYPE-B OR NON-TYPABLE
STRAINS IS STILL OCCURRING. ALTHOUGH RATES VARY IN DIFFERENT
POPULATIONS, DATA FROM THE ACTIVE BACTERIAL CORE
SURVEILLANCE SYSTEM, OR ABCs, SUGGEST THAT EACH YEAR, AMONG
CHILDREN YOUNGER THAN 5 YEARS OF AGE, NON-B CASES CONTINUE TO
OCCUR AT A RATE OF LESS THAN ONE CASE PER 100,000 CHILDREN. NON-TYPABLE CASES OCCUR AT A
RATE OF 1.5 TO 2 CASES PER 100,000 CHILDREN. IF CASES OF INVASIVE HAEMOPHILUS
INFLUENZAE DISEASE ARE BEING SEROTYPED AND REPORTED AMONG
CHILDREN AND YOU ARE NOT FINDING TYPE B CASES, BUT YOU ARE
FINDING NON-TYPE-B OR NON-TYPABLE CASES, THAT IS GOOD
EVIDENCE THAT SURVEILLANCE IS PROBABLY GOOD ENOUGH TO DETECT
TYPE B CASES. TYPE B DISEASE IS PROBABLY NOT
PRESENT IN YOUR COMMUNITY. THIS IS AN EXAMPLE OF A
SURVEILLANCE INDICATOR. A DISCUSSION OF SURVEILLANCE
INDICATORS IS INCLUDED IN A SEPARATE MODULE OF THIS PROGRAM.>>HIGH VACCINATION COVERAGE HAS
LED TO ALL-TIME RECORD LOW LEVELS OF MANY
VACCINE-PREVENTABLE DISEASES, BUT NOT PERTUSSIS. PERTUSSIS REMAINS ENDEMIC IN THE
UNITED STATES. SPORADIC CASES AND
COMMUNITY-WIDE OUTBREAKS CONTINUE TO OCCUR IN SPITE OF
RECORD-HIGH VACCINE COVERAGE AMONG CHILDREN. PERTUSSIS, OR WHOOPING COUGH, IS
CAUSED BY THE BACTERIUM BORDETELLA PERTUSSIS. CLASSIC PERTUSSIS ILLNESS IS
CHARACTERIZED BY SEVERE PAROXYSMAL COUGHING, SOMETIMES
FOLLOWED BY AN INSPIRATORY “WHOOP.” ILLNESS CAN BE MILDER AND THE
TYPICAL “WHOOP” ABSENT, ESPECIALLY IN THOSE WHO HAVE
BEEN VACCINATED. PERTUSSIS OCCURS IN A CYCLICAL
PATTERN, WITH THE NUMBER OF CASES PEAKING EVERY THREE TO
FIVE YEARS AS IMMUNITY WANES AND THE BACTERIA BEGIN CIRCULATING
AGAIN. PEAK YEARS OCCUR WHEN ENOUGH
SUSCEPTIBLE PEOPLE ARE PRESENT IN THE POPULATION TO ALLOW FOR
SUSTAINED TRANSMISSION OF PERTUSSIS. BEFORE A VACCINE WAS AVAILABLE,
PERTUSSIS WAS A UNIVERSAL INFECTION OF CHILDHOOD, WITH
THOUSANDS OF DEATHS EACH YEAR. AFTER THE INTRODUCTION OF
PERTUSSIS VACCINE IN THE LATE 1940s, THE NUMBER OF REPORTED
CASES BEGAN TO DROP. THE LOWEST ANNUAL TOTAL WAS IN
1976, WHEN ABOUT 1,000 CASES WERE REPORTED. SINCE 1980, THE NUMBER OF
REPORTED CASES OF PERTUSSIS HAS BEEN GRADUALLY RISING WITH
PERIODIC PEAKS. REPORTED CASES OF PERTUSSIS
PEAKED IN 2004 AND 2005, WITH MORE THAN 25,000 CASES REPORTED
EACH YEAR, AND AGAIN IN 2010, WITH MORE THAN 27,000 CASES. MOST DEATHS OCCUR AMONG INFANTS
YOUNGER THAN 2 MONTHS OF AGE, WHO ARE TOO YOUNG TO BE
VACCINATED. 27 PERTUSSIS-RELATED DEATHS WERE
REPORTED DURING 2010. ALTHOUGH WE USUALLY THINK OF
PERTUSSIS AS A DISEASE OF YOUNG CHILDREN, THERE IS INCREASING
RECOGNITION OF PERTUSSIS IN OLDER CHILDREN, ADOLESCENTS, AND
ADULTS. ALTHOUGH INFANTS TYPICALLY HAVE
THE MOST SEVERE CASES OF PERTUSSIS, OLDER CHILDREN AND
ADOLESCENTS CAN ALSO HAVE SEVERE ILLNESS. HERE IS A SHORT VIDEO OF AN
ADOLESCENT WITH PERTUSSIS.>>[ COUGHING, WHEEZING ]>>[ SPEAKING FRENCH ]>>[ COUGHING AND WHEEZING
CONTINUES ]>>[ SPEAKING FRENCH ]>>[ BREATHING DEEPLY ]
>>ADOLESCENTS AND ADULTS ACCOUNTED FOR AN INCREASING
PROPORTION OF REPORTED PERTUSSIS CASES DURING THE EARLY 2000s. THE PROPORTION OF CASES REPORTED
OCCURRING IN PERSONS 10 YEARS OF AGE AND OLDER INCREASED FROM 20%
IN 1990 TO 66% IN 2006. MORE RECENTLY, INCREASED RATES
OF DISEASE HAVE BEEN OBSERVED AMONG SCHOOL-AGE CHILDREN. OUTBREAKS HAVE BEEN REPORTED IN
ELEMENTARY, MIDDLE, AND HIGH THIS IS A REMINDER THAT FULLY
VACCINATED PERSONS OF ANY AGE CAN BECOME INFECTED WITH
PERTUSSIS, ESPECIALLY IF PERTUSSIS IS INCREASINGLY
CIRCULATING IN THE COMMUNITY. NO VACCINE IS 100% EFFECTIVE,
AND PROTECTION AFFORDED BY THE VACCINE WANES OVER TIME. HOWEVER, WHEN A VACCINATED
PERSON GETS PERTUSSIS, THE INFECTION IS USUALLY LESS
SEVERE. GINA?>>THERE ARE CURRENTLY SIX
DIPHTHERIA, TETANUS, AND ACELLULAR PERTUSSIS VACCINES
LICENSED FOR USE IN INFANTS AND CHILDREN THROUGH 6 YEARS OF AGE. WE WILL REFER TO THE PEDIATRIC
VACCINES AS D-T-A-P. SOME OF THESE VACCINES ARE
AVAILABLE IN COMBINATION WITH OTHER VACCINES. THERE ARE ALSO TWO ACELLULAR
PERTUSSIS VACCINES APPROVED FOR USE IN ADOLESCENTS AND ADULTS. THESE VACCINES ARE ALSO COMBINED
WITH DIPHTHERIA AND TETANUS TOXOIDS. WE WILL REFER TO THESE VACCINES
AS TDAP. THE PEDIATRIC VACCINES ARE
DIFFERENT FROM THE ADOLESCENT AND ADULT VACCINES. THERE ARE ALSO DIFFERENCES AMONG
VACCINES APPROVED FOR THE SAME AGE GROUPS. COMPARED TO TDAP, THE PEDIATRIC
VACCINES CONTAIN DIFFERENT COMPONENTS OF THE PERTUSSIS
ORGANISM, DIFFERENT AMOUNTS OF THESE COMPONENTS, AND THE
COMPONENTS ARE MADE BY DIFFERENT PROCESSES. DIPHTHERIA AND TETANUS TOXOIDS
IN THE PEDIATRIC VACCINES ALSO DIFFER IN AMOUNTS. ADOLESCENT AND ADULT VERSIONS OF
THE VACCINES HAVE REDUCED QUANTITIES OF PERTUSSIS,
DIPHTHERIA, AND TETANUS COMPONENTS COMPARED WITH THE
PEDIATRIC FORMULATIONS. THE ADVISORY COMMITTEE ON
IMMUNIZATION PRACTICES, OR ACIP, ROUTINELY RECOMMENDS A FIVE-DOSE
DTAP VACCINE SERIES FOR ALL CHILDREN, BEGINNING AT 2 MONTHS
OF AGE THROUGH 6 YEARS OF AGE. A SINGLE DOSE OF TDAP VACCINE IS
RECOMMENDED FOR ALL ADOLESCENTS AT 11 OR 12 YEARS OF AGE. TDAP IS ALSO RECOMMENDED FOR
OLDER ADOLESCENTS, 13 THROUGH 18 YEARS OF AGE, WHO HAVE NOT YET
RECEIVED A DOSE OF TDAP. ADULTS 19 THROUGH 64 YEARS OF
AGE ARE ALSO RECOMMENDED TO RECEIVE A SINGLE DOSE OF TDAP TO
REPLACE THE NEXT DOSE OF ADULT TETANUS-DIPHTHERIA VACCINE. ADULTS WHO ARE OR ANTICIPATE
BEING IN CLOSE CONTACT WITH AN INFANT YOUNGER THAN 12 MONTHS OF
AGE SHOULD BE VACCINATED. THIS INCLUDES ADULTS 65 YEARS
AND OLDER. ALSO, PREGNANT WOMEN SHOULD BE
VACCINATED DURING THE THIRD OR LATE SECOND TRIMESTER OF
PREGNANCY — AFTER 20 WEEKS GESTATION — IF THEY HAVE NOT
PREVIOUSLY BEEN VACCINATED WITH TDAP. COLLECTION OF VACCINE HISTORY
FOR ALL CASES IS ESPECIALLY IMPORTANT. AS YOU TALK WITH VACCINE
PROVIDERS, ENCOURAGE THEM TO REMIND ADULTS TO KEEP THEIR
VACCINATION RECORDS. RECORDING MANUFACTURER, TYPE OF
VACCINE, AND LOT NUMBER WILL MAKE IT EASIER TO IDENTIFY THE
TYPE OF VACCINE. THIS WILL BE USEFUL, BOTH FOR
SURVEILLANCE AND FOR PHYSICIANS PROVIDING VACCINES FOR THEIR
ADULT PATIENTS. AT THIS TIME, WE ARE NOT CERTAIN
HOW LONG PROTECTION WILL LAST FROM THE BOOSTER DOSE IN
ADOLESCENTS OR ADULTS. WE WILL NEED GOOD SURVEILLANCE
DATA TO HELP US ADDRESS THIS ISSUE. TAMI?>>THANKS, GINA. NOW LET’S TALK ABOUT THE
INVESTIGATION OF A SUSPECTED PERTUSSIS CASE. PERTUSSIS SHOULD BE SUSPECTED IN
A PERSON WHO DEVELOPS A COUGH ILLNESS THAT LASTS MORE THAN
SEVEN DAYS AND HAS FITS, OR PAROXYSMS, OF COUGHING. COUGH IS THE HALLMARK OF
PERTUSSIS, BUT VERY YOUNG INFANTS WITH PERTUSSIS MAY
PRESENT WITH APNEA, OR LONG PAUSES IN BREATHING. WHEN PERTUSSIS IS CLINICALLY
SUSPECTED, APPROPRIATE SPECIMENS SHOULD BE OBTAINED FOR
LABORATORY TESTING. FOR NATIONAL REPORTING, THERE
ARE TWO DIFFERENT METHODS BY WHICH CASES CAN BE
LABORATORY-CONFIRMED. THESE METHODS ARE ISOLATION OF
BORDETELLA PERTUSSIS FROM A CLINICAL SPECIMEN OR A POSITIVE
POLYMERASE CHAIN REACTION, OR PCR, ASSAY. LET ME REPEAT THAT. FOR LABORATORY CONFIRMATION OF
PERTUSSIS, WE NEED EITHER A POSITIVE BORDETELLA PERTUSSIS
CULTURE OR A POSITIVE PCR TEST. COMMERCIAL SEROLOGICAL TESTS FOR
PERTUSSIS INFECTION ARE NOT STANDARDIZED. RESULTS OF SEROLOGIC TESTING ARE
NOT USED FOR CASE CONFIRMATION FOR NATIONAL REPORTING, EXCEPT
IN MASSACHUSETTS, WHERE A STANDARDIZED SEROLOGICAL ASSAY
HAS BEEN IN USE FOR MANY YEARS. CULTURE OF A NASOPHARYNGEAL
ASPIRATE IS CONSIDERED THE GOLD STANDARD FOR DIAGNOSIS. WHILE CULTURE IS HIGHLY
SPECIFIC, SENSITIVITY DECREASES WHEN PATIENTS HAVE RECEIVED
ANTIBIOTICS, HAVE BEEN VACCINATED, OR WHEN THERE ARE
DELAYS IN SPECIMEN COLLECTION. CULTURE RESULTS MAY NOT BE
AVAILABLE FOR SEVEN TO 14 DAYS. OPTIMAL TIMING FOR DIAGNOSING
PERTUSSIS USING CULTURE IS LESS THAN TWO WEEKS AFTER COUGH
ONSET. HOWEVER, EVEN IN THE BEST
CIRCUMSTANCES, THE ORGANISM TAKES TIME TO ISOLATE. BUT YOU SHOULD TRY, ESPECIALLY
IN THE SETTING OF AN OUTBREAK. PCR IS THE MOST READILY
AVAILABLE METHOD FOR DIAGNOSING PERTUSSIS AND IS OPTIMALLY
SENSITIVE LESS THAN THREE WEEKS AFTER COUGH ONSET. WHILE PCR IS A SENSITIVE AND
TIMELY DIAGNOSTIC TOOL, SIGNS AND SYMPTOMS OF THE PATIENT
SHOULD BE CONSISTENT WITH PERTUSSIS TO CONFIRM DIAGNOSIS. A NASOPHARYNGEAL ASPIRATE IS THE
PREFERRED METHOD OF OBTAINING A SPECIMEN FOR PERTUSSIS CULTURE
AND PCR. HOWEVER, NYLON SWABS MAY BE
USED, AS WELL. MANY EPIDEMIOLOGISTS AND
HEALTHCARE PROVIDERS HAVE NEVER PERFORMED A NASOPHARYNGEAL
ASPIRATE OR SWAB. THE QUALITY OF THE SPECIMEN IS
CRITICAL TO OBTAINING AN ACCURATE RESULT. SINCE GOOD TECHNIQUE IN
OBTAINING A NASOPHARYNGEAL SPECIMEN IS SUCH AN IMPORTANT
PART OF PERTUSSIS SURVEILLANCE, WE WOULD LIKE TO SHOW YOU A
SHORT VIDEO THAT DEMONSTRATES THE PROPER COLLECTION TECHNIQUE.>>IDEALLY, YOU SHOULD COLLECT
TWO N.P. SWABS — ONE TO BE USED FOR CULTURE AND ONE TO BE USED
FOR PCR. ONE SWAB FOR CULTURE AND PCR IS
ALSO ACCEPTABLE. THE N.P. SWAB TIPS MAY BE
COMPOSED OF POLYESTER, SUCH AS DACRON OR RAYON OR THEY MAY BE
NYLON-FLOCKED. THE SWAB SHAFT SHOULD BE
ALUMINUM OR FLEXIBLE PLASTIC. COTTON-TIPPED OR CALCIUM
ALGINATE SWABS ARE NOT ACCEPTABLE, AS RESIDUES PRESENT
IN THESE MATERIALS MAY INHIBIT PCR ASSAYS. WHEN COLLECTING N.P. SWABS,
YOU’LL ALSO NEED A TUBE CONTAINING SEMI-SOLID REGAN-LOWE
TRANSPORT AGAR. ONCE YOU HAVE THE NECESSARY
SUPPLIES ON HAND, YOU CAN COLLECT THE SPECIMEN FOLLOWING
THESE STEPS. FIRST, PUT ON YOUR MASK AND EYE
PROTECTION. FOLLOWING HAND-WASHING, PUT ON
YOUR GLOVES. ASK THE PATIENT IF HE OR SHE HAS
A DEVIATED SEPTUM OR NASAL OBSTRUCTION, AND THEN ASK THEM
TO BLOW THEIR NOSE TO REMOVE ANY EXCESS MUCUS FROM THE NASAL
CAVITY. GENTLY INSERT THE SWAB STRAIGHT
BACK INTO A NOSTRIL, AIMING POSTERIORLY, ALONG THE FLOOR OF
THE NASAL CAVITY, UNTIL REACHING THE POSTERIOR WALL OF THE
NASOPHARYNX, BEING CAREFUL NOT TO INSERT IT UPWARDS. THE DISTANCE FROM THE NOSE TO
THE EAR GIVES AN ESTIMATE OF THE DISTANCE THE SWAB SHOULD BE
INSERTED. DO NOT FORCE THE SWAB. IF AN OBSTRUCTION IS
ENCOUNTERED, TRY THE OTHER NOSTRIL. LEAVE SWAB IN PLACE FOR UP TO 10
SECONDS AND THEN REMOVE SLOWLY. AFTER COLLECTION, PLACE ONE N.P. SWAB IN A REGAN-LOWE TRANSPORT
TUBE FOR CULTURE AND THE OTHER N.P. SWAB IN AN EMPTY TUBE FOR
PCR. IT IS IMPORTANT TO USE
REGAN-LOWE TRANSPORT AGAR, WHICH CONTAINS THE ANTIBIOTIC
CEPHALEXIN, TO PREVENT OVERGROWTH OF NORMAL
NASOPHARYNGEAL FLORA. DEPENDING ON THE BRAND OF SWAB
USED FOR COLLECTION, THE SHAFT MAY NEED TO BE BENT SLIGHTLY,
CUT, OR BROKEN OFF AT SCORE MARK TO FIT THE SWAB INTO THE
TRANSPORT TUBE. IF ONLY ONE SWAB CAN BE
OBTAINED, PLACE IT IN THE REGAN-LOWE TRANSPORT TUBE, WHICH
CAN BE USED FOR BOTH CULTURE AND PCR. STORE TUBES AT 4 DEGREES CELSIUS
AND TRANSPORT TO THE LAB WITHIN 24 HOURS OF COLLECTION IN A
COOLER WITH ICE PACKS TO MAINTAIN 4 DEGREES CELSIUS. PLATING FOR CULTURE WILL NEED TO
BE COMPLETED WITHIN 24 HOURS OF SPECIMEN COLLECTION, SO TIMELY
TRANSPORTATION TO THE LABORATORY IS ESSENTIAL.>>LABORATORY RESULTS,
PARTICULARLY CULTURES, ARE AN IMPORTANT PART OF THE
INVESTIGATION OF A SUSPECTED CASE OF PERTUSSIS, BUT THERE IS
OTHER INFORMATION YOU WILL NEED TO COLLECT, AS WELL. AS ALWAYS, WE NEED DEMOGRAPHIC
INFORMATION LIKE AGE AND GENDER. WE ALSO NEED CLINICAL DATA, SUCH
AS THE DURATION OF COUGH AND THE PRESENCE OF PAROXYSMS, WHOOP,
AND POST-TUSSIVE VOMITING. THIS INFORMATION IS IMPORTANT,
BECAUSE LABORATORY TESTING CANNOT ALWAYS BE OBTAINED OR MAY
NOT BE CONCLUSIVE. WE USE THE CLINICAL DATA TO
DETERMINE IF THE PERSON MET THE CLINICAL CASE DEFINITION FOR
PERTUSSIS. WE NEED TO KNOW HOW SEVERE THE
ILLNESS IS, WHICH IS WHY WE ASK ABOUT COMPLICATIONS LIKE
PNEUMONIA AND WHETHER OR NOT THE PATIENT SURVIVED. AND, OF COURSE, KNOWING THE
VACCINATION HISTORY IS CRITICAL. A COMPLETE VACCINATION HISTORY
INCLUDES THE DATE, VACCINE TYPE, MANUFACTURER, AND LOT NUMBER FOR
EACH DOSE OF VACCINE. THIS IS IMPORTANT FOR ALL CASES
NOW THAT VACCINES ARE RECOMMENDED FOR ALL AGES. A PERTUSSIS SURVEILLANCE
WORKSHEET IS INCLUDED IN THE SURVEILLANCE MANUAL. THE WORKSHEET WILL HELP YOU
ORGANIZE YOUR CASE INVESTIGATION SO YOU WILL NOT MISS ANY
CRITICAL INFORMATION. WE WILL INCLUDE A LINK TO THE
MANUAL ON THE RESOURCES WEB PAGE FOR THIS PROGRAM. HOW CAN YOU FIND OUT IF YOUR
PERTUSSIS SURVEILLANCE SYSTEM IS WORKING? ONE EASY METHOD IS BY USING A
SURVEILLANCE INDICATOR. FOR PERTUSSIS, THAT MEANS
FINDING OUT IF ANYONE IS EVEN CONSIDERING THE DIAGNOSIS. IF LABORATORY TESTING IS NOT
BEING DONE, NO CASES WILL BE REPORTED BECAUSE NO ONE IS
LOOKING. IF YOU DETERMINE THAT NO ONE IS
LOOKING, THERE IS A LOT THAT CAN BE DONE TO IMPROVE PERTUSSIS
SURVEILLANCE AT THE COMMUNITY LEVEL. MOST IMPORTANTLY, CLINICIANS
NEED TO KNOW THAT PERTUSSIS IS AN IMPORTANT CAUSE OF COUGH
ILLNESS IN ALL PERSONS, REGARDLESS OF AGE OR VACCINE
STATUS. MANY PEOPLE UNDERGO EXTENSIVE
AND UNNECESSARY EVALUATIONS FOR PROLONGED COUGH WITHOUT THE
DIAGNOSIS OF PERTUSSIS EVEN BEING CONSIDERED. INCREASING AWARENESS OF
PROVIDERS ABOUT THIS INFECTION AND THE APPROPRIATE DIAGNOSTIC
TESTS IS VERY IMPORTANT. WITH ADDITIONAL VACCINES
AVAILABLE AND CHANGES IN THE RECOMMENDED VACCINATION
SCHEDULES, SURVEILLANCE WILL BE ESSENTIAL TO EVALUATE THE IMPACT
ON PERTUSSIS INCIDENCE IN THE UNITED STATES.>>ALTHOUGH THE INCIDENCE OF
MENINGOCOCCAL DISEASE IS AT A HISTORIC LOW, HEALTH DEPARTMENTS
CONTINUE TO PLAY AN IMPORTANT ROLE IN INVESTIGATING CASES TO
PREVENT SECONDARY CASES AND TO MONITOR DISEASE TRENDS. TWO QUADRIVALENT MENINGOCOCCAL
POLYSACCHARIDE-PROTEIN CONJUGATE VACCINES, WHICH WE WILL REFER TO
AS MCV4, ARE LICENSED BY THE FOOD AND DRUG ADMINISTRATION. BOTH VACCINES PROVIDE PROTECTION
FOR SEROGROUPS “A,” “C,” “Y,” AND W-135. BOTH MCV4 VACCINES ARE APPROVED
FOR USE IN PERSONS 2 THROUGH 55 YEARS OF AGE. MENACTRA BRAND MCV4 IS ALSO
APPROVED BY THE FOOD AND DRUG ADMINISTRATION AS A TWO-DOSE
SERIES IN CHILDREN AGED 9 THROUGH 23 MONTHS. ACIP RECOMMENDS ROUTINE
VACCINATION AT 11 OR 12 YEARS, WITH A BOOSTER DOSE AT 16 YEARS. ROUTINE VACCINATION IS ALSO
RECOMMENDED FOR COLLEGE FRESHMEN LIVING IN A DORMITORY AND FOR
OTHER POPULATIONS AT INCREASED RISK. EXAMPLES OF GROUPS AT INCREASED
RISK INCLUDE PERSONS WITH ANATOMIC OR FUNCTIONAL ASPLENIA,
MILITARY RECRUITS, AND CERTAIN INTERNATIONAL TRAVELERS. MENINGOCOCCAL VACCINES THAT ARE
A FOUR-DOSE SERIES, STARTING AT 2 MONTHS OF AGE, MAY BE LICENSED
IN 2012. NATIONAL SURVEILLANCE IS
IMPORTANT TO IDENTIFY OUTBREAKS OF MENINGOCOCCAL DISEASE, TO
FOLLOW DISEASE TRENDS, AND TO MONITOR THE IMPACT OF THE
VACCINATION PROGRAM. BEFORE WE DISCUSS THE COMPONENTS
OF SURVEILLANCE, LET’S GO THROUGH SOME BACKGROUND
INFORMATION ABOUT NEISSERIA MENINGITIDIS. NEISSERIA MENINGITIDIS IS
TRANSMITTED THROUGH DIRECT CONTACT WITH RESPIRATORY
SECRETIONS FROM A PERSON WITH INVASIVE DISEASE OR, MUCH MORE
COMMONLY, FROM AN ASYMPTOMATIC CARRIER. MENINGOCOCCAL DISEASE OCCURS IN
THREE COMMON CLINICAL FORMS — MENINGITIS IN ABOUT 50% OF
CASES, BLOOD INFECTION IN ABOUT 30% OF CASES, AND PNEUMONIA IN
ABOUT 10% OF CASES. OTHER FORMS ACCOUNT FOR THE
REMAINING 10% OF CASES. 5% TO 20% OF PATIENTS DEVELOP
PURPURA FULMINANS, ALSO CALLED MENINGOCOCCEMIA, A SEVERE AND
OVERWHELMING BLOOD INFECTION. APPROXIMATELY 800 TO 1,200 CASES
OF MENINGOCOCCAL DISEASE ARE REPORTED EACH YEAR IN THE
UNITED STATES, WITH A CASE-FATALITY RATIO OF 10% TO
14%. IN ADDITION, SERIOUS SEQUELAE,
INCLUDING DEAFNESS, NEUROLOGIC DEFICIT, OR LIMB LOSS, OCCUR IN
11% TO 19% OF SURVIVORS. SEROGROUPS “B,” “C,” AND “Y” ARE
THE MAJOR CAUSES OF MENINGOCOCCAL DISEASE IN THE
U.S., EACH CURRENTLY BEING RESPONSIBLE FOR ABOUT 1/3 OF
CASES. THE PROPORTION OF CASES CAUSED
BY EACH SEROGROUP CHANGES WITH TIME AND VARIES BY AGE GROUP. FOR EXAMPLE, SEROGROUP “B”
ACCOUNTS FOR MORE THAN 50% OF CASES AMONG INFANTS YOUNGER THAN
1 YEAR OF AGE. THERE IS NO SEROGROUP “B”
VACCINE AVAILABLE IN THE U.S. AT THIS TIME. AMONG PERSONS 11 TO 19 YEARS OF
AGE, 75% OF CASES ARE CAUSED BY SEROGROUPS “C,” “Y,” OR W-135,
WHICH ARE INCLUDED IN U.S.-LICENSED VACCINES. THE MAJORITY OF THESE CASES ARE
SPORADIC SINGLE CASES. ALTHOUGH OUTBREAKS CAUSE
TREMENDOUS PUBLIC CONCERN AND DISRUPTION, THEY ACCOUNT FOR
VERY FEW OF CASES. IN THE UNITED STATES,
MENINGOCOCCAL DISEASE IS SEASONAL, WITH CASES PEAKING IN
DECEMBER AND JANUARY. RATES OF MENINGOCOCCAL DISEASE
ARE CURRENTLY THE LOWEST SINCE THE EARLY 1990s, AND THESE RATES
HAVE REMAINED LOW FOR SEVERAL YEARS. THIS GRAPH, FROM THE ACTIVE
BACTERIAL CORE SURVEILLANCE SYSTEM, OR ABCs, SHOWS RATES OF
ALL REPORTED MENINGOCOCCAL DISEASE, NOT JUST VACCINE
SEROGROUPS, BY SINGLE YEAR OF AGE DURING 2000 THROUGH 2009. THE OVERALL RATE IN THE
UNITED STATES IS ABOUT 0.3 CASES PER 100,000 POPULATION. RATES ARE HIGHEST IN INFANCY, ON
THE LEFT OF THE GRAPHIC. A SECOND, LOWER PEAK OCCURS IN
ADOLESCENCE, AROUND 18 YEARS OF AGE. IT IS THIS SECOND PEAK AMONG
ADOLESCENTS THAT OUR CURRENT MENINGOCOCCAL VACCINATION
STRATEGY IS INTENDED TO REDUCE. FUTURE VACCINES LICENSED FOR
INFANTS OR THAT INCLUDE SEROGROUP “B” MAY GIVE US A TOOL
TO ALSO REDUCE THE RISK OF MENINGOCOCCAL DISEASE AMONG
INFANTS. IN THE U.S., DISEASE CAUSED BY
NEISSERIA MENINGITIDIS IS NATIONALLY NOTIFIABLE. STATES REPORT CASES TO THE CDC
AS PART OF THE NATIONAL NOTIFIABLE DISEASES SURVEILLANCE
SYSTEM, OR NNDSS. THE NNDSS INCLUDES CASE REPORTS
FROM HEALTHCARE PROVIDERS AND LABORATORIES IN ALL 50 STATES. IN ADDITION, ACTIVE SURVEILLANCE
FOR MENINGOCOCCAL DISEASE IS CONDUCTED BY THE ABCs. ABCs IS A UNIQUE SURVEILLANCE
SYSTEM THAT PROVIDES INFORMATION FOR OTHER BACTERIAL PATHOGENS,
AS WELL. WE ASKED DR. GAYLE LANGLEY, THE
MEDICAL DIRECTOR OF ABCs, TO DESCRIBE THE SYSTEM FOR US.>>CDC’s ACTIVE BACTERIAL CORE
SURVEILLANCE, OR ABCs, IS AN ACTIVE LABORATORY AND
POPULATION-BASED SURVEILLANCE SYSTEM FOR INVASIVE DISEASE DUE
TO SIX BACTERIAL PATHOGENS. THE PATHOGENS INCLUDE GROUPS “A”
AND “B” STREPTOCOCCUS, HAEMOPHILUS INFLUENZAE,
NEISSERIA MENINGITIDIS, STREPTOCOCCUS PNEUMONIAE, AND
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS, OR MRSA. THE PRINCIPAL OBJECTIVES OF ABCs
ARE TO ACCURATELY MEASURE THE INCIDENCE OF THESE SIX BACTERIAL
PATHOGENS, TO DETERMINE THEIR EPIDEMIOLOGIC CHARACTERISTICS,
TO TRACK TRENDS OVER TIME, AND TO PROVIDE AN INFRASTRUCTURE FOR
FURTHER PUBLIC-HEALTH RESEARCH. ABCs IS A CORE COMPONENT OF THER
EMERGING INFECTIONS PROGRAMRCH. ABCs IS A CORE COMPONENT OF THE
EMERGING INFECTIONS PROGRAM NETWORK, OR EIP, AND IS
CONDUCTED AT 10 EIP SITES ACROSS THE UNITED STATES. THESE SITES REPRESENT A
POPULATION OF MORE THAN 42 MILLION PERSONS. ABCs IS MANAGED BY STAFF IN THE
NATIONAL CENTER FOR IMMUNIZATION AND RESPIRATORY DISEASES. FOR EACH CASE OF INVASIVE
DISEASE IN THE SURVEILLANCE POPULATION, A CASE REPORT FORM
WITH BASIC DEMOGRAPHIC AND CLINICAL INFORMATION IS
COMPLETED. THE BACTERIAL ISOLATE IS SENT TO
CDC AND OTHER REFERENCE LABORATORIES FOR ADDITIONAL
EVALUATION. ABCs ALSO PROVIDES AN
INFRASTRUCTURE FOR SPECIAL STUDIES, INCLUDING ONES AIMED AT
IDENTIFYING RISK FACTORS FOR DISEASE, EVALUATING
POST-LICENSURE VACCINE EFFECTIVENESS, AND MONITORING
THE IMPACT OF PREVENTION POLICIES. THE PRINCIPAL OBJECTIVES FOR
NEISSERIA MENINGITIDIS ARE TO PROVIDE BASELINE DATA RELATED TO
THE MENINGOCOCCAL VACCINE, TO EVALUATE VACCINE IMPACT ON
DISEASE BURDEN, HERD IMMUNITY, AND MOLECULAR EPIDEMIOLOGY, AND
TO DETERMINE APPROPRIATE VERIFICATION AND VALIDATION
CRITERIA FOR CURRENT AND POTENTIAL SEROGROUPING METHODS. DATA FOR ALL SIX DISEASES
INCLUDED IN ABCs, AS WELL AS ESTIMATES OF DISEASE BURDEN
EXTRAPOLATED TO THE U.S. POPULATION ARE AVAILABLE ON THE
ACTIVE BACTERIAL CORE SURVEILLANCE WEBSITE.>>BECAUSE INVASIVE
MENINGOCOCCAL DISEASE IS QUITE RARE IN THE UNITED STATES AND
BECAUSE ALL CASES NEED APPROPRIATE CONTACT
INVESTIGATIONS AND OUTBREAKS NEED TO BE IDENTIFIED, WE CANNOT
RELY ON ABCs SURVEILLANCE ALONE. IT IS CRITICAL THAT EVERY STATE
INVESTIGATE, CONFIRM, SEROGROUP, AND REPORT EVERY CASE OF
MENINGOCOCCAL DISEASE. MENINGOCOCCAL CASES ARE
CONFIRMED BASED ON ISOLATION OF THE ORGANISM FROM A NORMALLY
STERILE SITE, SUCH AS BLOOD OR CEREBROSPINAL FLUID OR FROM SKIN
SCRAPINGS FROM PURPURIC LESIONS. WITH NATIONAL REPORTING,
LABORATORY CONFIRMATION, AND HOSPITAL STAFF REPORTING CASES,
REPORTING SHOULD BE NEARLY COMPLETE. A DIAGNOSIS BASED ON CULTURE IS
QUITE SPECIFIC, WITH INFREQUENT FALSE-POSITIVES. BUT NOT ALL CASES ARE
CULTURE-CONFIRMED, ESPECIALLY IN PATIENTS WHO ALREADY HAVE
RECEIVED ANTIBIOTICS. A PROBABLE CASE IS DEFINED AS A
CLINICALLY COMPATIBLE ILLNESS AND EVIDENCE OF NEISSERIA
MENINGITIDIS DNA, USING A VALIDATED POLYMERASE CHAIN
REACTION, OR PCR, OBTAINED FROM A NORMALLY STERILE SITE, OR
EVIDENCE OF NEISSERIA MENINGITIDIS ANTIGEN BY
IMMUNOHISTOCHEMISTRY ON FORMALIN-FIXED TISSUE, OR LATEX
AGGLUTINATION OF CEREBROSPINAL FLUID. PCR AND LATEX AGGLUTINATION
TESTING IS AVAILABLE AT SOME STATE HEALTH DEPARTMENTS, AS
WELL AS CDC. IMMUNOHISTOCHEMISTRY TESTING IS
AVAILABLE ONLY AT CDC. INFORMATION THAT SHOULD BE
COLLECTED FOR A CASE OF NEISSERIA MENINGITIDIS IS
SIMILAR TO OTHER DISEASES WE HAVE DISCUSSED DURING THIS
PROGRAM. REPORT CORE DATA, INCLUDING
DEMOGRAPHIC, CLINICAL, AND RISK-FACTOR INFORMATION. SEROGROUP AND VACCINATION
HISTORY ARE ALSO IMPORTANT DATA TO REPORT. TESTING SHOULD BE PERFORMED TO
DETERMINE THE SEROGROUP OF THE ISOLATE, BECAUSE VACCINATION CAN
BE USED TO CONTROL OUTBREAKS CAUSED BY SEROGROUPS IN THE
VACCINE. SEROGROUP TESTING OF NEISSERIA
MENINGITIDIS ISOLATES IS PERFORMED BY HOSPITAL AND STATE
PUBLIC-HEALTH LABORATORIES. CASES OF SEROGROUP “A,” “C,”
“Y,” OR W-135 IN PERSONS ELIGIBLE FOR VACCINATION MAY
REPRESENT EITHER A VACCINE FAILURE OR A FAILURE TO
VACCINATE. CASES THAT ARE SEROGROUP “B” ARE
NOT VACCINE-PREVENTABLE. THE ADOLESCENT MENINGOCOCCAL
VACCINATION PROGRAM IS NOW WELL UNDER WAY. NEW VACCINES TO PREVENT INFANT
DISEASE AND SEROGROUP “B” DISEASE ARE ON THE HORIZON. SURVEILLANCE WILL PLAY AN
IMPORTANT ROLE AS WE MONITOR MENINGOCOCCAL DISEASE TRENDS AND
EVALUATE THE BEST STRATEGIES FOR USE OF NEW VACCINES.

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