Jane R. Zucker

Outbreak of Measles Among Persons With Prior Evidence of Immunity, New York City, 2011

BACKGROUNDnMeasles was eliminated in the United States through high vaccination coverage and a public health system able to rapidly respond to measles. Measles may occur among vaccinated individuals, but secondary transmission from such individuals has not been documented.nnnMETHODSnSuspected patients and contacts exposed during a measles outbreak in New York City in 2011 were investigated. Medical histories and immunization records were obtained. Cases were confirmed by detection of measles-specific immunoglobulin M and/or RNA. Tests for measles immunoglobulin G (IgG), IgG avidity, measurement of measles neutralizing antibody titers, and genotyping were performed to characterize the cases.nnnRESULTSnThe index patient had 2 doses of measles-containing vaccine; of 88 contacts, 4 secondary patients were confirmed who had either 2 doses of measles-containing vaccine or a past positive measles IgG antibody. All patients had laboratory confirmation of measles infection, clinical symptoms consistent with measles, and high-avidity IgG antibody characteristic of a secondary immune response. Neutralizing antibody titers of secondary patients reached >80 000 mIU/mL 3-4 days after rash onset and that of the index was <500 mIU/mL 9 days after rash onset. No additional cases of measles occurred among 231 contacts of secondary patients.nnnCONCLUSIONSnThis is the first report of measles transmission from a twice-vaccinated individual with documented secondary vaccine failure. The clinical presentation and laboratory data of the index patient were typical of measles in a naive individual. Secondary patients had robust anamnestic antibody responses. No tertiary cases occurred despite numerous contacts. This outbreak underscores the need for thorough epidemiologic and laboratory investigation of suspected cases of measles regardless of vaccination status.

An Ounce of Prevention is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001

Protocols for mass antibiotic prophylaxis against anthrax were under development in New York City beginning in early 1999. This groundwork allowed the city’s Department of Health to rapidly respond in 2001 to six situations in which cases were identified or anthrax spores were found. The key aspects of planning and lessons learned from each of these mass prophylaxis operations are reviewed. Antibiotic distribution was facilitated by limiting medical histories to issues relevant to prescribing prophylactic antibiotic therapy, formatting medical records to facilitate rapid decision making, and separating each component activity into discrete work stations. Successful implementation of mass prophylaxis operations was characterized by clarity of mission and eligibility criteria, well-defined lines of authority and responsibilities, effective communication, collaboration among city agencies (including law enforcement), and coordination of staffing and supplies. This model can be adapted for future planning needs including possible attacks with other bioterrorism agents, such as smallpox.

Epidemiologic Investigation and Targeted Vaccination Initiative in Response to an Outbreak of Meningococcal Disease among Illicit Drug Users in Brooklyn, New York

BACKGROUNDnAn outbreak of serogroup C meningococcal disease that involved illicit drug users and their contacts occurred in Brooklyn, New York, during 2005 and 2006.nnnMETHODSnThe objectives of this study were to identify the population at risk for meningococcal disease, describe efforts to interrupt disease transmission, and assess the impact of a vaccine initiative. Descriptive and molecular epidemiological analysis was used to define the extent of the outbreak and the common risk factors among outbreak-related cases. A vaccine initiative that used community-based service providers was targeted to illicit drug users and their close contacts. The vaccine initiative was assessed through cessation of outbreak-related cases and the reduction in carriage rate.nnnRESULTSnThe investigation identified 23 outbreak-related cases of serogroup C meningococcal disease; 17 isolates were indistinguishable and 4 isolates were closely related according to pulsed-field gel electrophoresis. Two additional culture-negative cases had epidemiological links to laboratory-confirmed cases. The median age of patients with outbreak-related cases was 41 years, and 19 (83%) of 23 patients reported an association with illicit drug use. There were 7 outbreak-related deaths. Vaccination was administered to 2763 persons at 29 community locations, including methadone treatment centers, syringe-exchange programs, and soup kitchens. Three additional cases of meningococcal disease due to strains with the same pulsed-field gel electrophoresis pattern were identified after the vaccination initiative.nnnCONCLUSIONSnCommunity-based outbreaks of meningococcal disease are difficult to control, and the decision to vaccinate is not straightforward. Current national guidelines for implementing a vaccination campaign are not strict criteria and cannot be expected to accommodate the myriad of factors that occur in community-based invasive meningococcal disease outbreaks, such as the inability to enumerate the population at risk.

Effectiveness of 1 Dose of 2009 Influenza A (H1N1) Vaccine at Preventing Hospitalization With Pandemic H1N1 Influenza in Children Aged 7 Months–9 Years

The availability of a well-established immunization registry to provide vaccination information, a school-located vaccination campaign followed by continued 2009 influenza A (H1N1) (pH1N1) activity, and a requirement to report hospitalized influenza cases provided an opportunity to estimate vaccine effectiveness (VE) of an initial dose of pH1N1 monovalent vaccine in children aged 7 months-9 years. Seventy-eight case children and 729 date-of-birth- and zipcode-matched controls were studied. The VE of a single vaccine dose in preventing pH1N1 hospitalization ≥ 14 days after vaccination was 82% (95% confidence interval [CI], 0%-100%; P = .04) in children aged 3-9 years but was zero (-3%; 95% CI, <0%-75%) in children aged 7-35 months. These findings are consistent with those from prelicensure immunogenicity studies and have implications for interpretation of immunogenicity studies and setting priorities for vaccination of young children in future pandemics. Immunization registries can provide a simple, rapid assessment of VE to evaluate and inform vaccination policy.

Mumps vaccine effectiveness and risk factors for disease in households during an outbreak in New York City

BACKGROUND AND OBJECTIVESnMumps outbreaks have been reported among vaccinated populations, and declining mumps vaccine effectiveness (VE) has been suggested as one possible cause. During a large mumps outbreak in New York City, we assessed: (1) VE of measles-mumps-rubella vaccine (MMR) against mumps and (2) risk factors for acquiring mumps in households.nnnMETHODSnCases of mumps were investigated using standard methods. Additional information on disease and vaccination status of household contacts was collected. Case households completed follow-up phone interviews 78-198 days after initial investigation to ascertain additional cases. Mumps cases meeting the study case definition were included in the analysis. Risk factors for mumps were assessed, and VE was calculated using secondary household attack rates.nnnRESULTSnThree hundred and eleven households with 2176 residents were included in the analysis. The median age of residents was 13 years (range <1-85), and 462 (21.2%) residents met the study mumps case definition. Among 7-17 year olds, 89.7% received one or more doses of MMR vaccine, with 76.7% receiving two doses. Young adults aged 10-14 years (OR=2.4, CI=1.3-4.7) and 15-19 years (OR=2.5, CI=1.3-5.0) were at highest risk of mumps. The overall 2-dose VE for secondary contacts aged five and older was 86.3% (CI 63.3-94.9).nnnCONCLUSIONSnThe two-dose effectiveness of MMR vaccine against mumps was 86.3%, consistent with other published mumps VE estimates. Many factors likely contributed to this outbreak. Suboptimal MMR coverage in the affected population combined with VE may not have conferred adequate immunity to prevent transmission and may have contributed to this outbreak. Achieving high MMR coverage remains the best available strategy for prevention of mumps outbreaks.

Mumps Outbreak Among a Highly Vaccinated University Community—New York City, January–April 2014

BackgroundnOn 14 January 2014, a vaccinated student presented with parotitis. Mumps immunoglobulin M (IgM) testing was negative and reverse-transcription polymerase chain reaction (RT-PCR) testing was not performed, resulting in a missed diagnosis and the start of an outbreak at a New York City (NYC) university.nnnMethodsnMumps case investigations included patient interviews, medical records review, and laboratory testing including mumps serology and RT-PCR. Case patients were considered linked to the outbreak if they attended or had epidemiologic linkage to the university. Epidemiologic, clinical, and laboratory data for outbreak cases residing in NYC were analyzed.nnnResultsnFifty-six NYC residents with mumps were identified with onset between 12 January and 30 April 2014. Fifty-three cases (95%) were university students, 1 (2%) was a staff member, and 2 (4%) had epidemiologic links to the university. The median age was 20 years (range 18-37 years). All cases had parotitis. Three cases were hospitalized, including 1 of 2 cases with orchitis. Fifty-four (96%) cases had received ≥1 mumps-containing vaccine, 1 (2%) was unvaccinated due to religious exemption, and 1 (2%) had unknown vaccination status. Two of the 44 (5%) cases tested by serology were mumps IgM positive, and 27 of the 40 (68%) tested by RT-PCR were positive.nnnConclusionsnMumps outbreaks can occur in highly vaccinated populations. Mumps should be considered in patients with parotitis regardless of vaccination status. RT-PCR is the preferred testing method; providers should not rely on IgM testing alone. High vaccination coverage and control measures likely limited the extent of the outbreak.

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.

Pandemic Influenza Planning in New York City

Planning for an outbreak of pandemic influenza is a complex undertaking because of the potential impact on not only health care and public health, but also because of the need for greater societal preparedness. Coping with a pandemic in a large city presents additional challenges. Close living conditions and reliance on crowded mass transportation systems may facilitate the spread of influenza virus. The potential tidal wave of ill persons seeking care may overwhelm already overcrowded fragile health care delivery systems in many cities. Finally, communication plans need to be more robust to reach the diverse ethnic populations of cities and must take into account vulnerable populations. n nIn New York City (NYC) much of our influenza preparedness activities build on the foundation of emergency preparedness accomplishments established in the last several years. These activities include: syndromic surveillance, enhanced relationships with the health care community, large scale immunization clinics, communication strategies, development of incident management systems, surge capacity for Health Department staff, and a new biosafety level three facility. However, because of the special challenges presented by a pandemic, new activities have been initiated as well. This article will describe some of our planning goals and challenges. n nSeveral assumptions have influenced our planning. First, we need to prepare for any pandemic strain, not just for the current H5N1 strain. Given that New York City is a global destination, if any novel strain becomes easily transmissible from human to human, we will not be able to keep influenza from entering the City prevent transmission once it arrives but will attempt to slow transmission. Our goal in reacting to a pandemic is to limit mortality and to maintain essential services. Once a pandemic strain vaccine becomes available, we will oversee distribution of the vaccine. Strategies need to be appropriate for the WHO phase of the pandemic, recognizing that certain activities that might be emphasized during Phase 5 (limited human-to-human transmission), may not be practical in Phase 6 (full pandemic). n nDuring Phase 6, we will recommend that ill persons stay home. Cancellation of public gatherings and school closure decisions would be made when there is better understanding of the epidemiologic and clinical features of the illness caused by the pandemic strain. Some of the pandemic scenarios that have received much public attention actually play only a small role in our plans. For example, quarantine facilities for large groups or the cordoning off of neighborhoods is not anticipated. Once there is widespread community transmission, these measures will have no public health rationale.

Cost-Effectiveness of Meningococcal Vaccination Among Men Who Have Sex With Men in New York City.

Background:To control an outbreak of invasive meningococcal disease (IMD) among men who have sex with men (MSM) in New York City, the New York City Department of Health and Mental Hygiene recommended vaccination of all HIV-infected MSM and at-risk HIV-uninfected MSM in October 2012. Methods:A decision-analytic model estimated the cost-effectiveness of meningococcal vaccination compared with no vaccination. Model inputs, including IMD incidence of 20.5 per 100,000 HIV-positive MSM (42% fatal) and 7.6 per 100,000 HIV-negative MSM (20% fatal), were from Department of Health and Mental Hygiene reported data and published sources. Outcomes included costs (2012 US dollars), IMD cases averted, IMD deaths averted, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs;

Adolescent Vaccine Co-administration and Coverage in New York City: 2007–2013

/QALY). Scenarios with and without herd immunity were considered, and sensitivity analyses were performed on key inputs. Results:Compared with no vaccination, the targeted vaccination campaign averted an estimated 2.7 IMD cases, 1.0 IMD deaths, with an ICER of