Containing a measles outbreak in Minnesota,2017: methods and challenges

Abstract

Aims:

We report on a measles outbreak largely occurring in Minnesota’s under-vaccinated Somali community in the spring of 2017. The outbreak was already into its third generation when the first two cases were confirmed, and rapid public health actions were needed. The aim of our response was to quickly end transmission and contain the outbreak.

Methods:

The state public health department performed laboratory testing on suspect cases and activated an Incident Command staffed by subject matter experts that was operational within 2 h of case confirmation. Epidemiologic interviews identified exposures in settings where risk of transmission was high, that is, healthcare, childcare, and school settings. Vaccination status of exposed persons was assessed, and postexposure prophylaxis (PEP) was offered, if applicable. Exposed persons who did not receive PEP were excluded from childcare centers or schools for 21 days. An accelerated statewide measles, mumps, and rubella (MMR) recommendation was made for Somali Minnesota children and children in affected outbreak counties. Partnerships with the Somali Minnesota community were deepened, building off outreach work done with the community since 2008.

Results:

Public health identified 75 measles cases from 30 March to 25 August 2017: 43% were female, 81% Somali Minnesotan, 91% unvaccinated, and 28% hospitalized. The median age of cases was 2 years (range: 3 months–57 years). Most transmission (78%) occurred in childcare centers and households. A secondary attack rate of 91% was calculated for unvaccinated household contacts. Over 51,000 doses of MMR were administered during the outbreak above expected baseline. At least 8490 individuals were exposed to measles; 155 individuals received PEP; and over 500 persons were excluded from childcare and school. State and key public health partners spent an estimated $2.3 million on response.

Conclusion:

This outbreak demonstrates the necessity of immediate, targeted disease control actions and strong public health, healthcare, and community partnerships to end a measles outbreak.

Keywords

vaccination measles outbreak response secondary attack rate exclusion mumps and rubella vaccine

Get full access to this article

View all access options for this article.

References

Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps. MMWR Recomm Rep 2013;62(4):1–34.

Moss

Griffin

DE.

Measles. Lancet 2012;379:153–164. Available online at: www.thelancet.com

Wendorf

Winter

Zipprich

et al Subacute sclerosing panencephalitis: the devastating measles complication that might be more common than previously estimated. Clin Infect Dis 2017;65(2):226–32.

Centers for Disease Control and Prevention. Measles. In: Hamborsky

Kroger

Wolfe

(eds). Epidemiology and prevention of vaccine-preventable diseases. 13th edn. Washington, DC: Public Health Foundation; 2015. pp. 209–30.

Dabbagh

Laws

Steulet

et al Progress toward regional measles elimination-worldwide, 2000–2017. MMWR Morb Mortal Wkly Rep 2018;67(47):1323–9.

Moss

Griffin

DE.

Global measles elimination. Nat Rev Microbiol 2006;4(12):900–8.

Patel

Lee

Redd

et al Increase in measles cases – United States, January 1–April 26, 2019. MMWR Morb Mortal Wkly Rep 2019;68(17):402–4.

Zimmerman

Mark

Singh

et al Progress toward measles elimination – European Region, 2009–2018. MMWR Morb Mortal Wkly Rep 2017;68(17):396–401. Available online at: https://www.who.int/immunization/monitoring_surveillance/data/en/

European Centre for Disease Prevention and Control. Who is at risk for measles in the EU/EEA? Identifying susceptible groups to close immunity gaps towards measles elimination. Stockholm: ECDC; 2019.

10.

Ehresmann

Crouch

Henry

et al An outbreak of measles among unvaccinated young adults and measles seroprevalence study: implications for measles outbreak control in adult populations. J Infect Dis 2004;189(Suppl 1):S104–17.

11.

Gastañaduy

Banerjee

DeBolt

et al Public health responses during measles outbreaks in elimination settings: strategies and challenges. Hum Vaccin Immunother 2018;14:2222–38. Available online at: http://www.tandfonline.com/action/journalInformation?journalCode=khvi20

12.

Gallup. Wellcome Global Monitor – First Wave Findings. London; 2019. Available online at: https://wellcome.ac.uk/reports/wellcome-global-monitor/2018

13.

Gahr

DeVries

Wallace

et al An outbreak of measles in an undervaccinated community. Pediatrics 2014;134(1): e220–8.

14.

Bahta

Ashkir

Addressing MMR vaccine resistance in Minnesota’s Somali Community. Minn Med 2015;98:33–6.

15.

Leeds

Muscoplat

MH.

Timeliness of receipt of early childhood vaccinations among children of immigrants – Minnesota, 2016. MMWR Morb Mortal Wkly Rep 2017;66(42):1125–9.

16.

Minnesota Department of Health. Minnesota Immunization Information Connection, unpublished data, 2018.

17.

Hall

Banerjee

Kenyon

et al Measles outbreak – Minnesota April–May 2017. MMWR Morb Mortal Wkly Rep 2017;66(27):713–7.

18.

Centers for Disease Control and Prevention. Measles/Rubeola 2013 Case Definition, CSTE Position Statement 12-ID-07, 2012. Available online at: https://wwwn.cdc.gov/nndss/conditions/measles/case-definition/2013/ (last accessed 20 February 2019).

19.

Minnesota Department of Health. Minnesota Immunization Information Connection (MIIC), 2014. Available online at: http://www.health.state.mn.us/miic (last accessed 20 February 2019).

20.

Rota

Brown

Mankertz

et al Global distribution of measles genotypes and measles molecular epidemiology. J Infect Dis 2011;204:S514–23.

21.

Minnesota Department of Health. Childhood Immunization Coverage in Minnesota, 2015. pp.2014–5. Available online at: https://www.health.state.mn.us/people/immunize/stats/child/coverdata.html (last accessed 20 February 2019).

22.

Chen

Anderson

Kutty

et al Health care-associated measles outbreak in the United States after an importation: challenges and economic impact. J Infect Dis 2011;203:1517–25.

23.

Sugerman

Barskey

Delea

et al Measles outbreak in a highly vaccinated population, San Diego, 2008: role of the intentionally undervaccinated. Pediatrics 2010;125(4):747–55.

24.

Marx

Chase

Jasperse

et al Public health economic burden associated with two single measles case investigations – Colorado, 2016–2017. MMWR Morb Mortal Wkly Rep 2017;66(46):1272–5.

25.

Rosen

Arciuolo

Khawja

et al Public Health Consequences of a 2013 measles outbreak in New York City. JAMA Pediatr 2018;172(9):811–7.

26.

Shefer

Atkinson

Friedman

et al Immunization of health-care personnel, recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60(7):1–45.

27.

Dayan

Ortega-Sanchez

LeBaron

et al The cost of containing one case of measles: the economic impact on the public health infrastructure – Iowa, 2004. Pediatrics 2005;116(1):e1–4.

28.

Minnesota Department of Health. Public Health Response Account: Update and Expenditures. Saint Paul, MN; 2018. Available online at: http://www.leg.state.mn.us/lrl/lrl.asp (last accessed 20 February 2019).

29.

Plans-Rubio

Evaluation of the establishment of herd immunity in the population by means of serological surveys and vaccination coverage. Hum Vaccin Immunother 2012;8(2):184–8.

30.

May

Silverman

RD.

‘Clustering of exemptions’ as a collective action threat to herd immunity. Vaccine 2003;21(11–12):1048–51.

31.

UNICEF. Measles Explained: What’s Behind the Recent Outbreaks? 2019. Available online at: https://www.unicef.org/stories/measles-explained-whats-behind-recent-outbreaks (last accessed 10 July 2019).