Amy Parker Fiebelkorn

Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older - United States, 2014.

In October 2015, the Advisory Committee on Immunization Practices (ACIP)* approved the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2016. This schedule provides a summary of ACIP recommendations for the use of vaccines routinely recommended for adults aged 19 years or older in two figures, footnotes for each vaccine, and a table that describes primary contraindications and precautions for commonly used vaccines for adults. Although the figures in the adult immunization schedule illustrate recommended vaccinations that begin at age 19 years, the footnotes contain information on vaccines that are recommended for adults that may begin at age younger than age 19 years. The footnotes also contain vaccine dosing, intervals between doses, and other important information and should be read with the figures.

Measles in the United States during the Postelimination Era

BACKGROUND Measles affected entire birth cohorts in the prevaccine era but was declared eliminated in the United States in 2000 because of a successful measles vaccination program. METHODS We reviewed US surveillance data on confirmed measles cases reported to the Centers for Disease Control and Prevention and data on national measles-mumps-rubella (MMR) vaccination coverage during postelimination years 2001-2008. RESULTS During 2001-2008, a total of 557 confirmed cases of measles (annual median no. of cases, 56) and 38 outbreaks (annual median no. of outbreaks, 4) were reported in the United States; 232 (42%) of the cases were imported from 44 countries, including European countries. Among case-patients who were US residents, the highest incidences of measles were among infants 6-11 months of age and children 12-15 months of age (3.5 and 2.6 cases/1 million person-years, respectively). From 2001 through 2008, national 1-dose MMR vaccine coverage among children 19-35 months of age ranged from 91% to 93%. From 2001 through 2008, a total of 285 US-resident case-patients (65%) were considered to have preventable measles (ie, the patients were eligible for vaccination but unvaccinated). During 2004-2008, a total of 68% of vaccine-eligible US-resident case-patients claimed exemptions for personal beliefs. CONCLUSIONS The United States maintained measles elimination from 2001 through 2008 because of sustained high vaccination coverage. Challenges to maintaining elimination include large outbreaks of measles in highly traveled developed countries, frequent international travel, and clusters of US residents who remain unvaccinated because of personal belief exemptions.

Elimination of Endemic Measles, Rubella, and Congenital Rubella Syndrome From the Western Hemisphere The US Experience

IMPORTANCE To verify the elimination of endemic measles, rubella, and congenital rubella syndrome (CRS) from the Western hemisphere, the Pan American Health Organization requested each member country to compile a national elimination report. The United States documented the elimination of endemic measles in 2000 and of endemic rubella and CRS in 2004. In December 2011, the Centers for Disease Control and Prevention convened an external expert panel to review the evidence and determine whether elimination of endemic measles, rubella, and CRS had been sustained. OBJECTIVE To review the evidence for sustained elimination of endemic measles, rubella, and CRS from the United States through 2011. DESIGN, SETTING, AND PARTICIPANTS Review of data for measles from 2001 to 2011 and for rubella and CRS from 2004 to 2011 covering the US resident population and international visitors, including disease epidemiology, importation status of cases, molecular epidemiology, adequacy of surveillance, and population immunity as estimated by national vaccination coverage and serologic surveys. MAIN OUTCOMES AND MEASURES Annual numbers of measles, rubella, and CRS cases, by importation status, outbreak size, and distribution; proportions of US population seropositive for measles and rubella; and measles-mumps-rubella vaccination coverage levels. RESULTS Since 2001, US reported measles incidence has remained below 1 case per 1,000,000 population. Since 2004, rubella incidence has been below 1 case per 10,000,000 population, and CRS incidence has been below 1 case per 5,000,000 births. Eighty-eight percent of measles cases and 54% of rubella cases were internationally imported or epidemiologically or virologically linked to importation. The few cases not linked to importation were insufficient to represent endemic transmission. Molecular epidemiology indicated no endemic genotypes. The US surveillance system is adequate to detect endemic measles or rubella. Seroprevalence and vaccination coverage data indicate high levels of population immunity to measles and rubella. CONCLUSIONS AND RELEVANCE The external expert panel concluded that the elimination of endemic measles, rubella, and CRS from the United States was sustained through 2011. However, international importation continues, and health care providers should suspect measles or rubella in patients with febrile rash illness, especially when associated with international travel or international visitors, and should report suspected cases to the local health department.

Epidemiology of a mumps outbreak in a highly vaccinated island population and use of a third dose of measles-mumps-rubella vaccine for outbreak control--Guam 2009 to 2010.

Background: Despite high 2-dose measles-mumps-rubella (MMR) vaccine coverage, a large mumps outbreak occurred on the US Territory of Guam during 2009 to 2010, primarily in school-aged children. Methods: We implemented active surveillance in April 2010 during the outbreak peak and characterized the outbreak epidemiology. We administered third doses of MMR vaccine to eligible students aged 9–14 years in 7 schools with the highest attack rates (ARs) between May 18, 2010, and May 21, 2010. Baseline surveys, follow-up surveys and case-reports were used to determine mumps ARs. Adverse events postvaccination were monitored. Results: Between December 1, 2009, and December 31, 2010, 505 mumps cases were reported. Self-reported Pohnpeians and Chuukese had the highest relative risks (54.7 and 19.7, respectively) and highest crowding indices (mean: 3.1 and 3.0 persons/bedroom, respectively). Among 287 (57%) school-aged case-patients, 270 (93%) had ≥2 MMR doses. A third MMR dose was administered to 1068 (33%) eligible students. Three-dose vaccinated students had an AR of 0.9/1000 compared with 2.4/1000 among students vaccinated with ⩽2 doses >1 incubation period postintervention, but the difference was not significant (P = 0.67). No serious adverse events were reported. Conclusions: This mumps outbreak occurred in a highly vaccinated population. The highest ARs occurred in ethnic minority populations with the highest household crowding indices. After the third dose MMR intervention in highly affected schools, 3-dose recipients had an AR 60% lower than students with ⩽2 doses, but the difference was not statistically significant and the intervention occurred after the outbreak peaked. This outbreak may have persisted due to crowding at home and high student contact rates.

Systematic review of behavior change research on point-of-use water treatment interventions in countries categorized as low- to medium-development on the human development index

Point-of-use water treatment (i.e., water purification at the point of consumption) has proven effective in preventing diarrhea in developing countries. However, widespread adoption has not occurred, suggesting that implementation strategies have not motivated sustained behavior change. We conducted a systematic literature review of published behavioral research on factors influencing adoption of point-of-use water treatment in countries categorized as low- to medium-development on the United Nations Development Programme Human Development Index. We used 22 key words to search peer-reviewed literature from 1950 to 2010 from OVID Medline, CINAHL, and PsycINFO. Twenty-six (1.7%) of 1551 papers met our four inclusion criteria: 1) implemented a point-of-use water treatment intervention, 2) applied a behavioral intervention, 3) evaluated behavior change as the outcome, and 4) occurred in a low- or medium-development country. We reviewed these 26 publications for detailed descriptions of the water treatment intervention, theoretical rationales for the behavioral intervention, and descriptions of the evaluation. In 5 (19%) papers, details of the behavioral intervention were fully specified. Seven (27%) papers reported using a behavioral theory in the design of the intervention and evaluation of its impact. Ten (38%) studies used a comparison or control group; 5 provided detailed descriptions. Seven (27%) papers reported high sustained use of point-of-use water treatment with rates >50% at the last recorded follow-up. Despite documented health benefits of point-of-use water treatment interventions in reducing diarrheal diseases, we found limited peer-reviewed behavioral research on the topic. In addition, we found the existing literature often lacked detailed descriptions of the intervention for replication, seldom described the theoretical and empirical rationale for the implementation and evaluation of the intervention, and often had limitations in the evaluation methodology. The scarcity of papers on behavior change with respect to point-of-use water treatment technologies suggests that this field is underdeveloped.

A global perspective of vaccination of healthcare personnel against measles: Systematic review

Measles transmission has been well documented in healthcare facilities. Healthcare personnel who are unvaccinated and who lack other evidence of measles immunity put themselves and their patients at risk for measles. We conducted a systematic literature review of measles vaccination policies and their implementation in healthcare personnel, measles seroprevalence among healthcare personnel, measles transmission and disease burden in healthcare settings, and impact/costs incurred by healthcare facilities for healthcare-associated measles transmission. Five database searches yielded 135 relevant articles; 47 additional articles were found through cross-referencing. The risk of acquiring measles is estimated to be 2 to 19 times higher for susceptible healthcare personnel than for the general population. Fifty-three articles published worldwide during 1989-2013 reported measles transmission from patients to healthcare personnel; many of the healthcare personnel were unvaccinated or had unknown vaccination status. Eighteen articles published worldwide during 1982-2013 described examples of transmission from healthcare personnel to patients or to other healthcare personnel. Half of European countries have no measles vaccine policies for healthcare personnel. There is no global policy recommendation for the vaccination of healthcare personnel against measles. Even in countries such as the United States or Finland that have national policies, the recommendations are not uniformly implemented in healthcare facilities. Measles serosusceptibility in healthcare personnel varied widely across studies (median 6.5%, range 0-46%) but was consistently higher among younger healthcare personnel. Deficiencies in documentation of two doses of measles vaccination or other evidence of immunity among healthcare personnel presents challenges in responding to measles exposures in healthcare settings. Evaluating and containing exposures and outbreaks in healthcare settings can be disruptive and costly. Establishing policies for measles vaccination for healthcare personnel is an important strategy towards achieving measles elimination and should be a high priority for global policy setting groups, governments, and hospitals.

Mumps Antibody Response in Young Adults after a Third Dose of Measles-Mumps-Rubella Vaccine

Baseline mumps antibody titers were high-seropositive for 93.4% of subjects, low-seropositive for 5.8%, and seronegative for <1%. One month after a third measles-mumps-rubella vaccine dose, mumps titers had a modest but significant increase. One year later, titers returned to near baseline.

Mumps postexposure prophylaxis with a third dose of measles-mumps-rubella vaccine, Orange County, New York, USA.

Although the measles-mumps-rubella (MMR) vaccine is not recommended for mumps postexposure prophylaxis (PEP), data on its effectiveness are limited. During the 2009–2010 mumps outbreak in the northeastern United States, we assessed effectiveness of PEP with a third dose of MMR vaccine among contacts in Orthodox Jewish households who were given a third dose within 5 days of mumps onset in the household’s index patient. We compared mumps attack rates between persons who received a third MMR dose during the first incubation period after onset in the index patient and 2-dose vaccinated persons who had not. Twenty-eight (11.7%) of 239 eligible household members received a third MMR dose as PEP. Mumps attack rates were 0% among third-dose recipients versus 5.2% among 2-dose recipients without PEP (p = 0.57). Although a third MMR dose administered as PEP did not have a significant effect, it may offer some benefits in specific outbreak contexts.

Environmental factors potentially associated with mumps transmission in yeshivas during a mumps outbreak among highly vaccinated students: Brooklyn, New York, 2009-2010.

During 2009–2010, a large US mumps outbreak occurred affecting two-dose vaccinated 9th–12th grade Orthodox Jewish boys attending all-male yeshivas (private, traditional Jewish schools). Our objective was to understand mumps transmission dynamics in this well-vaccinated population. We surveyed 9th-12th grade male yeshivas in Brooklyn, NY with reported mumps case-students between 9/1/2009 and 3/30/2010. We assessed vaccination coverage, yeshiva environmental factors (duration of school day, density, mixing, duration of contact), and whether environmental factors were associated with increased mumps attack rates. Ten yeshivas comprising 1769 9th–12th grade students and 264 self-reported mumps cases were included. The average yeshiva attack rate was 14.5% (median: 13.5%, range: 1–31%), despite two-dose measles-mumps-rubella vaccine coverage between 90–100%. School duration was 9–15.5 h/day; students averaged 7 h face-to-face/day with 1–4 study partners. Average daily mean density was 6.6 students per 100 square feet. The number of hours spent face-to-face with a study partner and the number of partners per day showed significant positive associations (p < 0.05) with classroom mumps attack rates in univariate analysis, but these associations did not persist in multivariate analysis. This outbreak was characterized by environmental factors unique to the yeshiva setting (e.g., densely populated environment, prolonged face-to-face contact, mixing among infected students). However, these features were present in all included yeshivas, limiting our ability to discriminate differences. Nonetheless, mumps transmission requires close contact, and these environmental factors may have overwhelmed vaccine-mediated protection increasing the likelihood of vaccine failure among yeshiva students.

A Comparison of Postelimination Measles Epidemiology in the United States, 2009-2014 Versus 2001-2008.

Background Measles, a vaccine-preventable disease that can cause severe complications, was declared eliminated from the United States in 2000. The last published summary of US measles epidemiology was during 2001-2008. We summarized US measles epidemiology during 2009-2014. Methods We compared demographic, vaccination, and virologic data on confirmed measles cases reported to the Centers for Disease Control and Prevention during January 1, 2009-December 31, 2014 and January 1, 2001-December 31, 2008. Results During 2009-2014, 1264 confirmed measles cases were reported in the United States, including 275 importations from 58 countries and 66 outbreaks. The annual median number of cases and outbreaks during this period was 130 (range, 55-667 cases) and 10 (range, 4-23 outbreaks), respectively, compared with an annual median of 56 cases (P = .08) and 4 outbreaks during 2001-2008 (P = .04). Among US-resident case-patients during 2009-2014, children aged 12-15 months had the highest measles incidence (65 cases; 8.3 cases/million person-years), and infants aged 6-11 months had the second highest incidence (86 cases; 7.3 cases/million person-years). During 2009-2014, 865 (74%) of 1173 US-resident case-patients were unvaccinated and 188 (16%) had unknown vaccination status; of 917 vaccine-eligible US-resident case-patients, 600 (65%) were reported as having philosophical or religious objections to vaccination. Conclusions Although the United States has maintained measles elimination since 2000, measles outbreaks continue to occur globally, resulting in imported cases and potential spread. The annual median number of cases and outbreaks more than doubled during 2009-2014 compared with the earlier postelimination years. To maintain elimination, it will be necessary to maintain high 2-dose vaccination coverage, continue case-based surveillance, and monitor the patterns and rates of vaccine exemption.