Measles, mumps, and rubella vaccine (MMR) or immune globulin (IG) are routinely used for measles post-exposure prophylaxis (PEP). However, current literature on the effectiveness of measles PEP is limited and variable. Here, we examined the effectiveness of MMR and IG PEP among children exposed to measles during an outbreak in New York City (NYC) in 2013.Contacts were identified by the NYC Department of Health and Mental Hygiene between 13 March 2013 and 30 June 2013. Immunity to measles and receipt of PEP was determined for contacts. PEP effectiveness [(1 - relative risk of developing measles) × 100] was calculated for MMR, IG, and any PEP (MMR or IG) for nonimmune contacts aged <19 years.A total of 3409 contacts were identified, of which 208 (6.1%), 274 (8.0%), and 318 (9.3%) met the inclusion criteria for analysis of MMR, IG, and any PEP effectiveness, respectively. Of the contacts included, 44 received MMR PEP and 77 received IG PEP. Effectiveness of MMR PEP was 83.4% (95% confidence interval [CI], 34.4%, 95.8%). No contact who received IG PEP developed measles; effectiveness of IG PEP was 100% (approximated 95% CI, 56.2%, 99.8%). Effectiveness of receiving any PEP (MMR or IG) was 92.9% (95% CI, 56.2%, 99.8%).Contacts who received PEP were less likely to develop disease. Our findings support current recommendations for administration of PEP following exposure to measles. These results highlight the importance of a rapid public health outbreak response to limit measles transmission following case identification.
Internationally imported cases of measles into the United States can lead to outbreaks requiring extensive and rapid control measures. Importation of measles from an unvaccinated adolescent in 2013 led to what has been the largest outbreak of measles in New York City, New York, since 1992.
Objective
To describe the epidemiology and public health burden in terms of resources and cost of the 2013 measles outbreak in New York City.
Design, Setting, and Participants
This epidemiologic assessment and cost analysis conducted between August 15, 2013, and August 5, 2014, examined all outbreak-associated cases of measles among persons residing in New York City in 2013.
Exposures
Measles virus.
Main Outcomes and Measures
Numbers of measles cases and contacts. Total personnel time and total direct cost to the New York City Department of Health and Mental Hygiene (DOHMH), calculated as the sum of inputs (supplies and materials, equipment, and logistics) and personnel time (salary and fringe benefits).
Results
Between March 13, 2013, and June 9, 2013, 58 persons in New York City with a median age of 3 years (range, 0-32 years) were identified as having measles. Among these individuals, 45 (78%) were at least 12 months old and were unvaccinated owing to parental refusal or intentional delay. Only 28 individuals (48%) visited a medical health care professional who suspected measles and reported the case to the DOHMH at the initial clinical suspicion. Many case patients were not immediately placed into airborne isolation, resulting in exposures in 11 health care facilities. In total, 3351 exposed contacts were identified. Total direct costs to the New York City DOHMH were $394 448, and a total of 10 054 hours were consumed responding to and controlling the outbreak.
Conclusions and Relevance
Vaccine refusals and delays appeared to have propagated a large outbreak following importation of measles into the United States. Prompt recognition of measles along with rapid implementation of airborne isolation of individuals suspected of measles infection in health care facilities and timely reporting to public health agencies may avoid large numbers of exposures. The response and containment of measles outbreaks are resource intensive.
During January 1-October 1, 2019, a total of 1,249 measles cases and 22 measles outbreaks were reported in the United States. This represents the most U.S. cases reported in a single year since 1992 (1), and the second highest number of reported outbreaks annually since measles was declared eliminated* in the United States in 2000 (2). Measles is an acute febrile rash illness with an attack rate of approximately 90% in susceptible household contacts (3). Domestic outbreaks can occur when travelers contract measles outside the United States and subsequently transmit infection to unvaccinated persons they expose in the United States. Among the 1,249 measles cases reported in 2019, 1,163 (93%) were associated with the 22 outbreaks, 1,107 (89%) were in patients who were unvaccinated or had an unknown vaccination status, and 119 (10%) measles patients were hospitalized. Closely related outbreaks in New York City (NYC) and New York State (NYS; excluding NYC), with ongoing transmission for nearly 1 year in large and close-knit Orthodox Jewish communities, accounted for 934 (75%) cases during 2019 and threatened the elimination status of measles in the United States. Robust responses in NYC and NYS were effective in controlling transmission before the 1-year mark; however, continued vigilance for additional cases within these communities is essential to determine whether elimination has been sustained. Collaboration between public health authorities and undervaccinated communities is important for preventing outbreaks and limiting transmission. The combination of maintenance of high national vaccination coverage with measles, mumps, and rubella vaccine (MMR) and rapid implementation of measles control measures remains the cornerstone for preventing widespread measles transmission (4).
Measles was declared eliminated in the United States in 2000, but the risk of outbreaks owing to international importations remains. An outbreak of measles in New York City began when one unvaccinated child returned home from Israel with measles; onset of rash occurred on September 30, 2018, 9 days after the child returned home.
We assume that the high rates of PNTMD in Japan are consistent with data suggesting that Asians are particularly susceptible to PNTMD (1,7,8).Other factors contributing to the increase might be the simplified diagnosis according to the 2007 American Thoracic Society/Infectious Diseases Society of America statements, increased awareness by medical staff, population aging, and increased frequency of medical checkups with computed tomography of the chest.Another finding was the characteristic gradient clustering of the ratios of M. avium and M. intracellulare (online Technical Appendix Figure 2).This finding supports the widely accepted belief that environmental factors strongly affect the epidemiology of PNTMD; therefore, the role of factors such as soil, humidity, temperature, and saturated vapor pressure should be seriously considered (9).We also found dramatic increases in incidence of pulmonary M. abscessus disease and pulmonary MAC disease, whereas incidence of pulmonary M. kansasii disease was stable.Although we did not distinguish M. massiliense from M. abscessus, the incidence rate for pulmonary M. abscessus disease increased from 0.1 cases in 2001 to 0.5 cases per 100,000 person-years in 2014.This epidemiologic tendency should be monitored ( 10).This study has several limitations.First, differing characteristics between the responding and nonresponding hospitals could cause bias.Second, we did not collect data outside of hospitals.Third, incomplete reporting could undermine the accuracy of our estimates (online Technical Appendix Tables 3,4).Therefore, the epidemiologic data should be verified by using other approaches (online Technical Appendix Table 1).The dramatic increase in incidence rates for PNTMD warrants its recognition as a major public health concern.Because the prevalence rates of this currently incurable lifelong chronic disease are estimated to be high, the effect on the community could be enormous.Further investigations are needed.
New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States during spring 2020 (1).During March-May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH).To obtain more complete data, DOHMH used supplementary information sources and relied on direct data importation and matching of patient identifiers for data on hospitalization status, the occurrence of death, race/ethnicity, and presence of underlying medical conditions.The highest rates of cases, hospitalizations, and deaths were concentrated in communities of color, high-poverty areas, and among persons aged ≥75 years or with underlying conditions.The crude fatality rate was 9.2% overall and 32.1% among hospitalized patients.Using these data to prevent additional infections among NYC residents during subsequent waves of the pandemic, particularly among those at highest risk for hospitalization and death, is critical.Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization and death is an urgent priority.Similar to NYC, other jurisdictions might find the use of supplementary information sources valuable in their efforts to prevent COVID-19 infections.This report describes cases of laboratory-confirmed COVID-19 among NYC residents diagnosed during February 29-June 1, 2020, that were reported to DOHMH.DOHMH began COVID-19 surveillance in January 2020 when testing capacity for SARS-CoV-2 (the virus that causes COVID-19) using real-time reverse transcription-polymerase chain reaction (RT-PCR) was limited by strict testing criteria because of limited test availability only through CDC.The NYC and New York State public health laboratories began testing hospitalized patients at the end of February and early March.DOHMH encouraged patients with mild symptoms to remain at home rather than seek health care because of shortages of personal protective equipment and laboratory tests at hospitals and clinics.Commercial laboratories began testing for SARS-CoV-2 in mid-to late March.During February 29-March 15, patients with laboratory-confirmed COVID-19 were interviewed by DOHMH, and close contacts were identified for monitoring.The rapid rise in laboratory-confirmed cases (cases) quickly made interviewing all patients, as well as contact tracing, unsustainable.Subsequent case investigations
