Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated

Sugerman, David; Barskey, Albert E.; Delea, Maryann G.; Ortega-Sánchez, Ismael R.; Bi, Daoling; Ralston, Kimberly; Rota, Paul A.; Waters-Montijo, Karen; LeBaron, Charles W.

doi:10.1542/peds.2009-1653

Cited by 246 publications

(131 citation statements)

References 18 publications

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“…Much can be learned from measles outbreaks, especially in describing pockets of under-immunized people that may require targeted preventive efforts, 27 and in documenting response strategies that were successful in limiting measles spread. Data from elimination settings indicate that the characteristics of unvaccinated populations are diverse; they may be faith-based groups, 12 ethnic subpopulations, 14 , 28 and certain age-cohorts 29 or members of a socioeconomic strata 30 that experienced lower immunization coverage historically. As such, preventive and response measures should be tailored to each population to be effective.…”

Section: Outbreak Response Activitiesmentioning

confidence: 99%

“…Costs incurred by the public health sector during the response, or even a full economic evaluation, are also of interest. 30-32 Finally, data from social media and search engines have been used to measure public measles vaccine confidence and the effectiveness of communication strategies during measles outbreaks, 23-26 and might also be helpful for the early detection of outbreaks and to monitor disease spread, as has been done for other pathogens. 21 , 22 Findings from these analyses should be disseminated to relevant stakeholders, e.g., frontline clinicians involved in the response, state or national public health authorities responsible for identifying and closing immunity gaps, and policy makers.…”

Section: Outbreak Response Activitiesmentioning

confidence: 99%

“…11 , 12 , 14 , 30 , 48-50 Limited evidence suggests that using quarantine for non-immune close contacts of cases may considerably reduce the number of secondary cases from these contacts. During an outbreak in Geneva, an 18-day quarantine recommendation resulted in 6 secondary cases from 50 quarantined cases, compared to 81 secondary cases from 173 non-quarantined cases (relative risk: 0.26; 95% CI: 0.06–0.65).…”

Section: Containment Strategies — Guidance Evidence Challenges and mentioning

confidence: 99%

“…30 , 53 During a measles outbreak in California in 2008, for example, families incurred an estimated cost of $775 per quarantined child. 30 …”

Section: Containment Strategies — Guidance Evidence Challenges and mentioning

confidence: 99%

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Public health responses during measles outbreaks in elimination settings: Strategies and challenges

Gastañaduy

Banerjee

DeBolt

et al. 2018

Human Vaccines & Immunotherapeutics

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In late September 2016, the Americas became the first region in the world to have eliminated endemic transmission of measles virus. Several other countries have also verified measles elimination, and countries in all six World Health Organization regions have adopted measles elimination goals. The public health strategies used to respond to measles outbreaks in elimination settings are thus becoming relevant to more countries. This review highlights the strategies used to limit measles spread in elimination settings: (1) assembly of an outbreak control committee; (2) isolation of measles cases while infectious; (3) exclusion and quarantining of individuals without evidence of immunity; (4) vaccination of susceptible individuals; (5) use of immunoglobulin to prevent measles in exposed susceptible high-risk persons; (6) and maintaining laboratory proficiency for confirmation of measles. Deciding on the extent of containment efforts should be based on the expected benefit of reactive interventions, balanced against the logistical challenges in implementing them.

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Section: Outbreak Response Activitiesmentioning

confidence: 99%

Section: Outbreak Response Activitiesmentioning

confidence: 99%

Section: Containment Strategies — Guidance Evidence Challenges and mentioning

confidence: 99%

“…30 , 53 During a measles outbreak in California in 2008, for example, families incurred an estimated cost of $775 per quarantined child. 30 …”

Section: Containment Strategies — Guidance Evidence Challenges and mentioning

confidence: 99%

See 2 more Smart Citations

Public health responses during measles outbreaks in elimination settings: Strategies and challenges

Gastañaduy

Banerjee

DeBolt

et al. 2018

Human Vaccines & Immunotherapeutics

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“…Other studies have characterized unvaccinated children belonging to families intentionally refusing vaccines with similar demographic characteristics. 9,[26][27][28][29][30] There are several reasons for parents claiming non-medical exemptions to routine childhood immunizations for school entry. A case-control study of unvaccinated children claiming nonmedical exemption reported significantly lower perceived vaccine safety (61% vs. 15%) and efficacy (54% vs. 17%), lower perceived disease susceptibility (58% vs. 15%) and severity (51% vs. 18%), and low trust in the government (40% vs. 23%) compared with vaccinated children.…”

Section: Perception Of Vaccine Exemptors and Hesitant Parentsmentioning

confidence: 99%

Epidemiology of vaccine hesitancy in the United States

2013

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Forecasted Size of Measles Outbreaks Associated With Vaccination Exemptions for Schoolchildren

et al. 2019

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IMPORTANCE Vaccine exemptions, which allow unvaccinated children to attend school, have increased by a factor of 28 since 2003 in Texas. Geographic clustering of unvaccinated children facilitates the spread of measles introductions, but the potential size of outbreaks is unclear. OBJECTIVE To forecast the range of measles outbreak sizes in each metropolitan area of Texas at 2018 and future reduced school vaccination rates. DESIGN, SETTING, AND PARTICIPANTS An agent-based decision analytical model using a synthetic population of Texas, derived from the 2010 US Census, was used to simulate measles transmission in the Texas population. Real schools were represented in the simulations, and the 2018 vaccination rate of each real school was applied to a simulated hypothetical equivalent. Single cases of measles were introduced, daily activities and interactions were modeled for each population member, and the number of infections over the course of 9 months was counted for 1000 simulated runs in each Texas metropolitan area. INTERVENTIONS To determine the outcomes of further decreases in vaccination coverage, additional simulations were performed with vaccination rates reduced by 1% to 10% in schools with populations that are currently undervaccinated. MAIN OUTCOMES AND MEASURES Expected distributions of outbreak sizes in each metropolitan area of Texas at 2018 and reduced vaccination rates. RESULTS At 2018 vaccination rates, the median number of cases in large metropolitan areas was typically small, ranging from 1 to 3 cases, which is consistent with outbreaks in Texas 2006 to 2017. However, the upper limit of the distribution of plausible outbreaks (the 95th percentile, associated with 1 in 20 measles introductions) exceeded 400 cases in both the Austin and Dallas metropolitan areas, similar to the largest US outbreaks since measles was eliminated in 2000. Decreases in vaccination rates in schools with undervaccinated populations in 2018 were associated with exponential increases in the potential size of outbreaks: a 5% decrease in vaccination rate was associated with a 40% to 4000% increase in potential outbreak size, depending on the metropolitan area. A mean (SD) of 64% (11%) of cases occurred in students for whom a vaccine had been refused, but a mean (SD) of 36% (11%) occurred in others (ie, bystanders). CONCLUSIONS AND RELEVANCE This study suggests that vaccination rates in some Texas schools are currently low enough to allow large measles outbreaks. Further decreases are associated with dramatic increases in the probability of large outbreaks. Limiting vaccine exemptions could be associated with a decrease in the risk of large measles outbreaks.

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Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated

Abstract: Despite high community vaccination coverage, measles outbreaks can occur among clusters of intentionally undervaccinated children, at major cost to public health agencies, medical systems, and families. Rising rates of intentional undervaccination can undermine measles elimination.

Cited by 246 publications

References 18 publications

Public health responses during measles outbreaks in elimination settings: Strategies and challenges

Public health responses during measles outbreaks in elimination settings: Strategies and challenges

Epidemiology of vaccine hesitancy in the United States

Forecasted Size of Measles Outbreaks Associated With Vaccination Exemptions for Schoolchildren

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