Medical Director Notes

Spring, Measles and Mumps

2019 is on track to have the highest number of measles cases since the disease was declared eliminated from the U.S. in the year 2000. Why are we seeing these outbreaks and what can we do to protect our community?

This has been a busy spring for vaccine-preventable diseases! Temple University is experiencing a mumps outbreak among students and reported almost 150 cases as of mid-April. While, across the nation, the Centers for Disease Control and Prevention (CDC) reports more than 600 cases of measles so far this year. While we have not yet had any measles cases in Philadelphia, some of the largest outbreaks are right next door. The MMR vaccine prevents both measles and mumps, and most schools require it for entry. Despite that, 2019 is on track to have the highest number of measles cases since the disease was declared eliminated from the U.S. in the year 2000. Why are we seeing these outbreaks and what can we do to protect our community? 

Mumps

Between January 2016 and July 2017, there were 150 mumps outbreaks (9,200 cases) across the country. Half of these outbreaks took place on college campuses despite the majority of students being vaccinated. Why? The effectiveness of two doses of MMR vaccine is 88% for mumps, meaning that out of 100 people, 12 may still get sick if exposed. Additionally, it appears that protection against mumps may decrease over time. How easy is it to be exposed to mumps? Mumps spreads through contact with saliva or respiratory droplets from an infected person. In a community like a college campus, where young students live in dormitories and socialize frequently, there are many opportunities for the mumps virus to spread. And, unfortunately, people with mumps can start spreading the virus before they know for sure that they are sick. The virus can be spread up to two days before developing the most common symptom, a swollen, painful jaw. The ability to spread the mumps virus before one knows that they are sick along with close personal contact inherit to dorm style living and college life, and a decreased protection from the MMR vaccine creates the ideal conditions for an outbreak. 

Measles

Unlike mumps, measles outbreaks are primarily occurring among unvaccinated individuals. The majority of our current measles cases are in New York City and state where returning travelers brought measles to some Orthodox Jewish communities where vaccination rates are low.  Large outbreaks have also occurred in Oregon where there are high rates of vaccine refusal among parents. The measles virus is so highly contagious, it is easy for it to spread quickly through a community if there are any unprotected people. How well does MMR vaccine work for measles? The effectiveness of 2 doses of MMR is 97% against measles AND immunity is lifelong. If we can maintain 95% or higher MMR vaccination rates we can prevent the spread of measles. 

Vaccine Hesitancy

While there is no explicit content barring vaccination in major religious texts and no evidence of any association between vaccines and autism, some parents still seek exemption on these grounds.

If MMR vaccine has been a part of the routine immunization schedule for decades, why do some communities have low MMR vaccination rates? In every state, MMR is one of the vaccines required for school attendance. And, nationally, MMR rates are greater than 90%. Yet, despite requirements, almost every state allows exemptions based upon personal or religious beliefs. And there are a wide range of reasons some parents refuse vaccination or choose to pursue an exemption. For example, some religious communities refuse vaccines based upon interpretation of religious teachings. And some parents refuse MMR vaccine because of vaccine safety concerns related to autism. While there is no explicit content barring vaccination in major religious texts and no evidence of any association between vaccines and autism, some parents still seek exemption on these grounds. 

Preventing Outbreaks

Simply, the best prevention tool that we have for both is the MMR vaccine.

What can we do to prevent or stop mumps and measles outbreaks? Simply, the best prevention tool that we have for both is the MMR vaccine. Be sure that your patients, whether children or adults, are up to date as per current recommendations. Early identification of cases of mumps and measles is also important. When we suspect cases, we can use appropriate isolation practices to prevent further spread. We can also identify contacts to make sure they are protected. 

For mumps specifically, it is time to implement requirements that all university and college students are up to date on their MMR vaccine and provide documentation of vaccine receipt. It is also important to consider a third MMR booster dose for people who are at risk of being exposed to mumps cases when there is an outbreak. At Temple, this has meant setting up vaccination clinics to provide MMR vaccine to students. 

For measles, we are encouraging providers to remain vigilant and consider measles when seeing patients with fever and a rash, especially if they have traveled domestically or internationally. Talk to your patients and their families about any vaccine-related concerns, especially if they have a history of vaccine refusal. Know about resources to help address specific questions, such as concerns about vaccine safety. And consider partnering with community leaders to communicate the importance of vaccination. 

Healthcare providers should also use our immunization registry, Philavax, to check your patients’ immunization histories and keep patients, especially students, up to date on their MMR. The Vaccines for Children (VFC) program can help you provide vaccines for publicly, under – or uninsured kids up to the age of 19. 

Working together we can keep measles and mumps from spreading any further this spring and keep everyone healthy to enjoy this wonderful weather. 

Medical Director Notes

Staying Resilient: Controlling Hepatitis A Outbreak

City personnel evacuated Kensington’s last homeless encampment during January’s polar vortex. Forty-five people left the Emerald City encampment and were referred for a combination of housing, medical or social services as a part of Mayor Kenney’s Philadelphia Resilience Project.

Launched in October 2018, the Philadelphia Resilience Project aims to bolster affected Philadelphia neighborhoods by uniting partners to address homelessness, drug addiction, violence, metal health challenges, and neighborhood clean-up. While these are all crucial needs, it is also important to remember that persons and communities affected by the opioid crisis are at higher risk for certain infectious diseases. Indeed, Philadelphia has seen increases in Hepatitis A, B and C, HIV and syphilis within neighborhoods most affected by the crisis. Hepatitis A has been particularly concerning.

Now is the time to immunize everyone who should get a Hepatitis A vaccine and the Immunization Program is here to support your efforts

Many states are experiencing outbreaks of Hepatitis A, especially among homeless persons. Hepatitis A spreads when stool from infected persons contaminates food, water or other surfaces. It is much easier for the virus to spread when it is difficult to wash hands or have regular access to a bathroom. Hepatitis A can also be spread through sexual activity or sharing needles. That is one of the reasons why there have been a rising number of outbreaks in communities affected by homelessness and injection drug use. Since March 2017, several states have declared Hepatitis A outbreaks for a total of more than 4,000 cases, the majority of whom have been hospitalized and over fifty have died. Pennsylvania joined the list of affected states in November 2018. Fortunately, there are things we can do to prevent the outbreak from escalating here…vaccinate!

Hepatitis A vaccines were first introduced in the U.S. in 1996. Since then they have been routinely recommended for all infants 12-23 months old and for anyone at increased risk for Hepatitis A exposure. Why vaccinate 12 month olds? When Hepatitis A was more common, it was often spread by young children who would be more likely to have asymptomatic infection and could spread virus without knowing it. This strategy helps reduce the amount of hepatitis A in the community – but it won’t stop all transmission. Only about 70% of infants get the vaccines. And there are many adolescent and adults who didn’t have a chance to get vaccinated as kids. Now is the time to immunize everyone who should get a Hepatitis A vaccine and the Immunization Program is here to support your efforts

• If you see children and adolescents in your practice, check whether your patients have received Hepatitis A vaccine and catch them up if they haven’t. If you see adults, offer Hepatitis A vaccine to everyone but make sure you give it to your patients with a history of drug use or homelessness. Use our immunization registry, Philavax, to check your patients’ immunization histories.
• The Vaccines for Children (VFC) and Vaccines for Adults at Risk (VFAAR) programs can help you provide vaccines for publicly, under- or uninsured kids and uninsured adults.
• If any of your patients have signs of acute hepatitis (fever, jaundice, nausea, light colored stools), test for Hepatitis A and report any positive results. We can help make sure that the virus won’t spread to others.
• Check the Health Information Portal for more information about Hepatitis A and other infections affecting persons who are homeless or use drugs.

In October and November, our team provided 222 Hepatitis A and over 200 influenza vaccines to people living in and around encampments in Kensington through street outreach. We have also collaborated with Prevention Point, Philadelphia’s needle exchange program, to provide vaccines to their clients. While we have been able to target a high risk community, let’s do what we can to increase Hepatitis A vaccination rates across the city.

Through partnership, we can contribute to resilient communities.

Notes from the Medical Director

HPV vaccine for adults?

On October 5, 2018, the Food and Drug Administration expanded the age range for HPV vaccines to include 27-45 years old men and women. The change has gotten a lot of coverage in the media and perhaps you have been getting questions about the expanded age range from patients, family or friends. Why was this change made and what does this change mean for you?

FDA approval does not mean that recommendations have changed.
While the FDA has approved the expanded age range, the Advisory Commission on Immunization Practices (ACIP), who makes our recommendations about when and to whom to give approved vaccines, has not yet changed their recommendations about who should get HPV vaccines. So, for now, HPV vaccines recommendations still focus on 9-26 year old males and females.

The committee has been reviewing information about not only how well HPV vaccines work, but also how much of an impact it is likely to have on preventing HPV infections, in this older age group. Adding a new recommendation takes resources to make sure there is enough vaccine supply, raise awareness and get providers ready to stock and recommend a vaccine. The ACIP considers all of this before making changes to the program.

Why wouldn’t HPV vaccines be recommended for adults, especially since HPV is a sexually-transmitted infection?
Current recommendations for HPV vaccines target 11-12 years old adolescents for routine vaccination with catch up through age 26. Our current recommendation target younger age groups for several reasons:

1. The goal of vaccination is to get everyone protected BEFORE exposure: HPV vaccines work by providing immunity before exposure to the HPV types covered by the vaccine. Since HPV is a sexually transmitted infection, that means before onset of sexual activity. The best way to make sure this happens is to get kids vaccinated just as they are entering adolescence, well before likely exposure. HPV is very common- almost all of us are exposed at some point during adolescence and adulthood.
2. HPV vaccine can be given as a part of the adolescent vaccine platform: This approach also works well because young adolescents are coming in to get other vaccines, Tdap and MCV4, when they are 11 or 12 years old. This an excellent time to make sure adolescents have everything they need to keep them healthy as they enter middle and high school.
3. We have data that shows how well the vaccines work in this age group: The immune response in younger adolescents is so good, only 2 doses of the HPV vaccine are needed if you start the series before age 15 years, compared to 3 doses for older teens.

Recommendations have not included adults because as we get older, we are more likely to be exposed to HPV. Since the vaccine protects us BEFORE exposure- it won’t help if we have already been infected by the types covered by the vaccine. So, for now, recommendations focus on early protection to get as much impact as possible.

If adults are more likely to already be exposed to HPV, why did the FDA approve the expanded age range?
Even though adults are more likely to be already exposed to HPV, adults are not likely to have been exposed to ALL the HPV types covered by the vaccine. That means that there may still be some benefit to vaccination. Let’s say you have a patient who has been exposed to types 6 and 16. Your patient would still be protected against the 7 other types covered by the vaccine.
To make its decision, the FDA considered benefit by reviewing studies that show how well the vaccine works in women and men ages 27-45 years old. These studies looked at two things: the immune response (antibody levels) and vaccine effectiveness (ability to prevent HPV disease) in this age group. These studies showed that there is a good immune response but effectiveness is not quite as high since adults may have already been exposed to HPV before vaccination. No studies showed any safety issues.

Does this mean that I should or shouldn’t vaccinate adults >27 years old?
Remember that recommendations from the ACIP still have not changed. Keep emphasizing routine vaccination for 11-12 year olds. This is the best and most cost-effective way to ensure good protection before exposure to any HPV and reduce the overall prevalence of HPV in the community. For this reason, it is difficult to know whether HPV vaccines will be recommended universally for adults aged 27-45 years old. But, there still may be room for individual decision making. While adolescents and young adults are at highest risk of first exposure to HPV once they become sexually active, that does not mean the exposure risk goes away. HPV vaccination for 27-45 year old adults could still provide protection against some HPV types, especially for adults who remain at risk of exposure (i.e. have a new partner). While our HPV vaccination rates have been improving, we are still below Healthy People 2020 goals so there are unvaccinated adults out there.

More to come…

Notes from the Medical Director

How bad can the flu get?

Flu season is challenging. First, we need a new flu vaccine every year because the flu virus is always changing.  Before each flu season, a new flu vaccine is developed to match the flu strain that scientists expect will be dominant during the upcoming season. Then, vaccine producers start manufacturing the vaccine and distribute it all over the world. Finally, local public health professionals like us here in Philadelphia work hard to remind everybody to get a flu vaccine as early as September to make sure everyone is protected before flu arrives.

From vaccine development to vaccine delivery, it is a large amount of work. But it is important work because flu is serious, every year. During the height of a bad flu season, up to 8% of all emergency room visits in the USA – 1 out of every 12 – is somebody who’s sick with the flu and hundreds of thousands of people are hospitalized with illness caused by the flu. Last year’s flu season killed an estimated 80,000 people in the USA.

Despite flu’s severity every year, too few people get the flu vaccine – immunization rates hover around 40% in the USA. Why? Often, I think we underestimate how bad flu can be. We call lots of things ‘the flu,’ including milder infections like the common cold. That can lead us to think that the flu does not really make you very sick. But influenza can invade your lungs and make you feel horrible. In severe cases, your lungs can get so inflamed that they stop working.

The worst example of how bad the flu can get was the 1918 flu pandemic. It was so bad that “cities ran out of wood for coffins” as the virus killed 3 to 5 percent of the world’s population – an estimated 50 to 100 million people. The 1918 pandemic was caused by a new strain of influenza. We have had pandemics since that time and will probably have more the future. And we will continue to have flu epidemics every season. While we now have more tools to prevent and treat influenza, we need to keep being prepared and keep working to reduce the toll that the seasonal flu takes on our population.

To help, we’ve got a Flu Toolkit that health care providers can use to boost flu vaccination rates at their clinics this fall and winter – and, of course, resources for Philadelphia residents to Get Your Annual Flu Shot.

Notes from the Medical Director

The historical impact of vaccines

It can be so easy to lose sight of the incredible impact that vaccines have had on our society. Mike Bostock, a data visualization specialist, reminds us of the history of the measles vaccine with the data visualization below.

Measles used to be incredibly common, but when the vaccine was introduced to the US in 1963, cases plummeted. Bostock’s visualization shows this clearly: moving from left to right, the darker colors begin to fade, just as the number of cases in each state decline immediately following the introduction of the vaccine.

If there are so few measles cases in the U.S., do we still need to maintain high immunization rates? Yes. The dramatic impact of measles vaccine introduction is testament to both the individual and community effects with immunizations.  Vaccinated children were no longer getting infected themselves, and they could no longer spread measles to others.  But to see the community effects of measles vaccines, we do need high vaccination rates.  Measles is one of the most contagious vaccine-preventable disease out there so almost everyone needs to be protected to stop transmission.  When we keep our measles vaccination rates above at least 92%, we eliminate measles outbreaks.

Measles still affects about 20 million people per year worldwide.  No other vaccine-preventable illness causes as many deaths.  Most cases occur in developing areas of Africa and Asia but there are also tens of thousands of cases in several European countries due to decreasing immunization rates. In fact, the Centers for Disease Control and Prevention has issued travel advisories for places from which many of us may receive visitors or visit ourselves.  So the likelihood of being exposed to measles is very real.  If communities do not maintain high immunization rates, outbreaks can happen here as well.

Here at the Philadelphia Department of Public Health, we’ve done similar work to highlight the history of vaccines and their important public health impact. The history of vaccine-preventable diseases in Philadelphia shows how these diseases used to kill nearly 3,000 Philadelphians per year. As more vaccines were licensed and distributed, this death toll fell steadily until the modern era, when vaccine-preventable diseases only kill 11 Philadelphians per year.  Let’s work together to make sure these trends don’t change.

Measles in the USA