Rubella Outbreak—Westchester County, New York, 1997-1998 FREE

MMWR. 1999;48:560-563

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Since licensure of rubella vaccines in 1969, the incidence of rubella and congenital rubella syndrome (CRS) in the United States has decreased substantially. Rubella infection during the first trimester of pregnancy can result in miscarriage, stillbirth, or infants with a pattern of birth defects (i.e., CRS).¹ One of the national health objectives for 2000 is to eliminate indigenous rubella and CRS (objective 20.1).² During 1997-1998, 524 cases of rubella were reported in the United States (CDC, unpublished data, 1999). This report describes a rubella outbreak in Westchester County, New York, demonstrates the importance of accurately defining and vaccinating at-risk populations to prevent transmission, and underscores how collaboration with community-based organizations can facilitate the development and implementation of control measures.

During the outbreak, a clinical case of rubella was defined as an illness with an acute onset of generalized maculopapular rash, a temperature of >99 F (>37.2 C), and arthralgia/arthritis, lymphadenopathy, or conjunctivitis. Laboratory confirmation of rubella required a positive serologic test for rubella IgM antibody, a substantial increase in acute- and convalescent-phase titers in serum rubella IgG antibody levels by any standard serologic assay, or isolation of rubella virus.³ A confirmed case of rubella required either laboratory confirmation or meeting the clinical case definition and epidemiologic linkage to a laboratory-confirmed case.

From December 1997 through May 1998, 95 confirmed rubella cases were identified in Westchester County (attack rate: 10.7 per 100,000 population); 79 (83%) were laboratory-confirmed and 16 (17%) were linked epidemiologically to a laboratory-confirmed case. During this period, 333 cases were reported in the United States. The outbreak peaked during mid-January and mid-February. The index case-patient in Westchester County was a 23-year-old man from Mexico who first noticed a rash on December 6, 1997. He was exposed previously to a Hispanic co-worker with rubella in Port Chester, New York, who resided in Connecticut, where there was an ongoing rubella outbreak. Port Chester reported 53 (50%) cases; cases were identified in 14 towns, cities, or villages. The outbreak spread through the county along train lines and through work sites.

The median age of case-patients was 23 years (range: 4 months-59 years); 76% were males aged 16-54 years. Of the 22 female patients, 19 were of childbearing age (15-44 years). Of five (26%) pregnant women, three were infected during the first trimester and elected to terminate their pregnancies. The other pregnant women delivered infants with no CRS. Eighty-eight (93%) patients were foreign born; the median time in the United States was 4 years (range: 12 days-26 years). Among foreign-born patients, 34 (39%) were born in Mexico and 31 (35%) in Guatemala. The remaining 23 (27%) patients were born in Colombia, Dominican Republic, El Salvador, Ecuador, Nicaragua, or Portugal. None of the patients born outside the United States had received rubella vaccine. Of the seven U.S.-born patients, four were aged ≥29 years with no history of rubella vaccination, and three were aged <1 year and had parents who were born in Latin American countries.

Local health authorities initiated control measures including case and contact investigations, vaccination of contacts and susceptible persons in the community, and increased awareness to screen pregnant women for susceptibility to rubella and asymptomatic infection. Active surveillance for rash illness was conducted at 28 sites in the county, including emergency departments, health departments, and private providers. Health alerts in Spanish and English were sent to all schools and physicians and distributed in Hispanic communities. Although rubella vaccine was available at no cost at the county health department, special clinics, and work sites, only 248 doses were administered during December 6, 1997-February 9, 1998.

To facilitate rubella-control efforts, health department staff identified community leaders and formed partnerships between Hispanic community-based organizations and Hispanic outreach workers from the Westchester County Health Department. These community-based organizations collaborated with the health department to provide targeted educational materials and one-on-one counseling about the importance of rubella vaccination and bilingual personnel for vaccination sites.

The number of sites offering measles, mumps, and rubella (MMR) vaccine was increased by the health department at work sites (e.g., restaurants, landscaping companies, and cleaning services), special vaccination clinics (e.g., churches, day labor pick-up sites, and a mobile van), and at district public health clinics. The number of vaccinations administered increased, and by the end of May 1998, 4539 doses of MMR vaccine had been administered. The last case of rubella associated with the outbreak was identified on May 2, 1998.

RM Martin, PhD, AJ Huang, MD, HN Adel, MD, CM Larsen, MPA, CE Daleo, MS, MM Landrigan, MPA, H Martinez, Westchester County Dept of Health, New York. BJ Wallace, MD, J Maffei, PF Smith, MD, State Epidemiologist, New York State Dept of Health. Child Vaccine Preventable Diseases Br, Epidemiology and Surveillance Div; and Community Outreach and Planning Br, National Immunization Program, CDC.

The rubella outbreak in Westchester County occurred among young Hispanic adults who were born in countries either without national rubella vaccination programs or where such programs were implemented recently. The demographic characteristics of case-patients were similar to those reported in other recent rubella outbreaks in the United States.⁴ Most cases occurred among unvaccinated persons aged ≥20 years and among persons who were foreign born, primarily Hispanics (63% of reported cases in 1997) (CDC, unpublished data, 1998). Previous community outbreaks were localized in close-knit, circumscribed, Hispanic neighborhoods (CDC, unpublished data, 1997). The Westchester County outbreak differed in that it did not remain localized, but spread to 14 towns, cities, and villages and occurred among eight different Hispanic nationalities. The wide distribution of cases and the multiple Hispanic nationalities made it difficult to identify and access the at-risk population for targeted control measures. Factors that may have contributed to the low receipt of rubella vaccine included difficulty identifying who the leaders were in the Hispanic communities, limited demographic information about the Hispanic communities, and the Hispanic communities' distrust of persons affiliated with the government because of immigration concerns.

In outbreaks of rubella in foreign-born populations, both prevention and control measures require a culturally sensitive approach. Collaboration between health departments and community-based organizations may be useful in effectively informing and mobilizing the at-risk population.

In recent years, rubella vaccination programs have been introduced throughout the Americas to decrease the morbidity and mortality from rubella infections during pregnancy. However, because these programs were only recently implemented, persons who have entered the United States as adults probably are not vaccinated and may be susceptible to rubella. Further decreases in rubella incidence in the United States will require increased vaccine coverage in susceptible populations.

During rubella outbreaks, vaccination is the most effective preventive measure. In the United States, two doses of MMR vaccine are recommended at age 12-15 months and 4-6 years.⁵ For adults who have not received rubella vaccine, a single dose of a rubella-containing vaccine is considered evidence of immunity.⁶ Reduction in rubella morbidity in Latin America is expected to lower the number of cases imported from this area and indigenous outbreaks in the United States.

References: 6 available

MMWR. 1999;48:830

Following publication of the results of a CDC assessment of the readiness for the year 2000 (Y2K) of state health agencies,¹ CDC conducted a follow-up survey during June-August 1999 in which 47 states and the District of Columbia—covering 98.7% of the U.S. population—responded. Overall, responding states are 99% complete with Y2K assessment and 90% complete with Y2K readiness. Additional information from the states and trends from the initial to the follow-up survey identify no significant Y2K readiness vulnerabilities in critical public health functions. Complete results of this survey are available on the World-Wide Web at http://www.cdc.gov/y2k/y2kssurvey.htm and from the Information Resources Management Office, CDC, Mailstop D45, 1600 Clifton Rd., N.E., Atlanta, GA 30333. CDC continues to work with states on Y2K readiness, including identifying and communicating Y2K issues that may occur during the transition to 2000.

In addition, CDC has completed end-to-end testing of six "high impact" federal systems covering disease monitoring, vaccine ordering, and financial transactions involving external partners. The tests were fully successful; results are available at http://www.cdc.gov/y2k/y2khighimpact.htm.

MMWR. 1999;48:914-917

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A needs assessment conducted in rural southwestern Virginia in 1996 indicated higher rates of birth defects in that region than in the entire state.¹ In response to these findings, in January 1997 the regional perinatal council conducted a community folic acid information campaign designed to raise awareness about the 1992 Public Health Service recommendation that all women who are capable of becoming pregnant consume 400 µg (0.4 mg) of the B vitamin folic acid every day to decrease their risk for having a pregnancy affected with spina bifida or other neural tube defects (NTDs).² This report describes the information campaign and the findings from precampaign and postcampaign surveys, which showed a significant increase in reported awareness and knowledge of the benefits of folic acid and reported knowledge about the sources of folic acid.

During 1997, a year-long community information campaign targeted an estimated 22,500 women of childbearing age in a four-county area of southwestern Virginia. The campaign included television and radio public service announcements (PSAs), a news conference, newspaper advertisements, and billboards. The television and radio PSAs used actors from the local theater and local broadcasting students. Printed materials included brochures, posters, information cards, food labels, flyers, banners, and display boards. Focus groups and readability tests were conducted to help develop print materials. A local grocery store chain helped promote the use of folate-dense foods, folic acid vitamin supplements, fortified cereals, and multivitamin supplements by having volunteers specially label specific foods and hand out educational materials. Volunteers also distributed green ribbons in the communities to promote folic acid awareness. Local school board members and teachers developed a folic acid teaching packet for use in health education and biology classes for students in grades 5-12 and college-level nursing programs.

The campaign activities and results were evaluated using precampaign and postcampaign random sample telephone surveys to assess folic acid awareness and knowledge. The precampaign survey, conducted during January 1997, included 412 women aged 18-45 years chosen by a systematic random sample of listed telephone numbers. The postcampaign telephone surveys were conducted during January 1998 (n = 419) and February 1999 (n = 278), using identical survey methods and an additional question about the source of folic acid information.

Based on responses to the question "Have you heard about the benefits of folic acid?", reported awareness increased significantly, from 31% in 1997 (precampaign) to 54% in 1998 (postcampaign), and to 75% in 1999 (sustainability survey) (p<0.05, chi-square test). Among women who reported hearing about the benefits of folic acid, the proportion who correctly answered that one benefit of folic acid was to help prevent certain birth defects increased from 77% in 1997 to 81% in 1998 and to 88% in 1999. Among women who reported in the postcampaign survey that they had heard about folic acid, knowledge about ways to increase consumption increased from 55% in 1997 to 73% in 1999, but correct knowledge about the best time to take folic acid (before or during pregnancy) did not increase. Women who had heard of folic acid cited television and health-care providers as the two leading sources of information.

K Broome, MPH, Region I Perinatal Coordinating Council of Abingdon, Virginia. Div of Birth Defects, Child Development, and Disability and Health, National Center for Environmental Health, CDC.

National surveys indicate that awareness of folic acid among reproductive-aged women increased from 52% in 1995 to 68% in 1998, although increases in use of folic acid-containing vitamins were modest, from 28% to 32%.³ Increasing the number of women who consume 400 µg of folic acid per day depends on the success of national and local health communication campaigns. The campaign described in this report demonstrated that with limited resources, community volunteers and campaign staff were able to use qualitative formative research methods to develop health communication materials, enlist the assistance of private- and public-sector community partners, and survey women about folic acid knowledge and awareness in this community.

The findings of the surveys in southwestern Virginia are subject to at least four limitations. First, the changes in awareness and knowledge might have resulted from other national media efforts rather than the local campaign. Second, because the survey did not collect information about characteristics such as age, parity, or pregnancy intention, different awareness and knowledge levels among these subsets of reproductive-aged women cannot be assessed. For example, awareness and knowledge could have increased more among women who were planning a pregnancy than among women not planning a pregnancy. Third, the women in the counties surveyed may not be representative of reproductive-aged women in this age group in this region of Virginia or in the United States. Finally, an increase in knowledge is an intermediate outcome and may not be related directly to an increase in intake of folic acid or a decrease in the occurrence of NTDs. For example, women knowledgeable about the benefits of folic acid may have other barriers to changing their behavior to increase consumption. To overcome these barriers, women need both knowledge and resources to make and sustain behavior change, particularly for an active modification such as daily vitamin consumption.⁴

Another method to facilitate increased folic acid intake without relying solely on active behavior change is through food fortification. Since January 1998, "enriched" cereal grain products must be fortified with folic acid at a level of 140 µg per 100 g of cereal grain product.⁵ Fortification will increase folic acid consumption among reproductive-aged women, but many women will still consume less than 400 µg of synthetic folic acid daily.⁶ In 1998, the Institute of Medicine recommended that women capable of becoming pregnant take 400 µg of synthetic folic acid daily from fortified foods and/or supplements in addition to consuming food folate from a varied diet.⁷ Women are advised to consume foods fortified with folic acid (e.g., breakfast cereals, enriched breads, and pastas) in addition to a balanced diet including folate-dense foods, such as leafy green vegetables, orange juice, and beans. Use of supplements containing folic acid, even though it requires a behavior change, remains a convenient way to assure consumption of 400 µg daily.

Despite the limitations of survey methods used in the study in southwestern Virginia, the relatively low cost and ease of implementation made such a survey feasible in this community evaluation. Other more objective evaluation methodologies for folic acid interventions include measurements of blood folate levels and monitoring the rates of NTD-affected pregnancies. Preintervention and postintervention blood folate levels can be used to assess the effectiveness of interventions at the community level but require substantial resources to obtain and measure the blood samples. On the national level, blood folate measurements collected in the National Health and Nutrition Examination Survey can be used to evaluate the impact of interventions. Accurate NTD monitoring requires the inclusion of affected pregnancies that were prenatally detected to assess the impact of consuming folic acid independent from that of the increasing use of prenatal diagnosis. The large population size necessary to detect a change in NTD rates limits the use of NTD rate monitoring to evaluate local campaigns, although NTD data from several states or communities can be combined to assess the impact of interventions in larger populations.

NTDs occur very early in pregnancy. Because more than 50% of pregnancies in the United States are mistimed or unplanned,⁸ it is especially important to increase women's knowledge about the importance of consuming folic acid before pregnancy. In 1999, CDC, the National March of Dimes Birth Defects Foundation, and the National Council on Folic Acid began a national education campaign with materials targeted to women who are thinking about pregnancy ("Before You Know It") and to women who are able to get pregnant even though they are not planning on it in the near future ("Ready, Not"). The campaign includes a series of PSAs and other outreach activities to women of reproductive age and to health-care providers.

More experience is needed in implementing and evaluating folic acid campaigns to determine which interventions are most effective. States and communities are encouraged to share their experiences and lessons learned with other states and communities that are planning interventions. The folic acid education campaign in Virginia is one of several examples included in a resource guide for folic acid campaigns.⁹ The resource guide and other educational materials on folic acid are available by contacting CDC by e-mail, flo@cdc.gov, or by telephone, (888) 232-6789.

References: 9 available

MMWR. 1999;48:825-828

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In 1988, the World Health Assembly adopted a resolution to eradicate poliomyelitis globally by 2000. During the same year, the Regional Committee, Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) resolved to eradicate polio from the region by 2000. Substantial progress in reaching this goal has been made globally and in countries of EMR.^1- 3 This report describes the current status of polio eradication in Afghanistan, a country in EMR with ongoing civil conflict where eradication efforts began in late 1994.

Routine vaccination services have been maintained through approximately 20 years of civil conflict in Afghanistan. In 1996, estimated national coverage with three doses of oral poliovirus vaccine (OPV) among infants aged <1 year was 30%. Coverage surveys conducted during the 1998 Expanded Program on Immunization (EPI) review suggested that vaccination coverage levels varied widely by region. Coverage levels <30% were reported in several regions; in northern areas, coverage levels were even lower because of access problems resulting from the ongoing conflict. Supplemental campaigns to accelerate overall EPI coverage using diphtheria and tetanus toxoids and pertussis vaccine (DTP) and measles vaccine (MV) for children and tetanus toxoid (TT) for women of childbearing age have been conducted annually since 1997. The 1999 EPI acceleration campaigns provided catch-up vaccination to children aged <2 years (n = 82,000) and women of reproductive age (n = 206,000) in 14 urban areas.

Supplementary vaccination for polio eradication began with three multiantigen immunization campaigns (MICs) conducted during 1994-1996. MICs provided DTP, MV, and OPV for children aged <5 years and TT for women of childbearing age. Reported MICs coverage levels were >80% in most targeted areas; however, MICs targeted approximately 70% of the total population. Beginning with MICs and continuing with National Immunization Days (NIDs),* the United Nations Children's Fund (UNICEF) and WHO attempted to arrange periods of cease-fire between warring parties in conflict areas to allow vaccination of children.

The first NIDs were conducted nationwide during April-May 1997, and repeated during April-May 1998 and May-June 1999. In 1997, an estimated 80% of Afghan children aged <5 years (approximately 3.5 million) received two doses of OPV during NIDs.

In 1998, NIDs were not conducted in northern Afghanistan because of armed conflict; as a result, approximately one third of the target group was excluded from vaccination. Nevertheless, 1998 NID coverage for the accessible areas was >85%. The first round of 1999 NIDs was delayed in three northern provinces because of the conflict; surveys following both rounds indicated that 83%-87% of targeted children had been vaccinated. Afghanistan will conduct two additional NID rounds in late October and November 1999. In 1998 and 1999, supplemental OPV vaccination campaigns were conducted in border districts with Pakistan and Iran simultaneously with the NIDs in these countries. Surveillance for Acute Flaccid Paralysis (AFP)

No national disease surveillance system is in place in Afghanistan. In 1997, AFP surveillance was established at major health facilities in regional capitals. Local staff were trained in AFP surveillance procedures to conduct regular active surveillance visits to surveillance sites to identify and investigate AFP cases. Local offices of WHO and UNICEF facilitate the collection and shipment of stool specimens to the WHO Afghanistan support office in Islamabad, Pakistan through scheduled United Nations flights; specimens are forwarded for processing to the Regional Polio Network Laboratory at the National Institute of Health in Islamabad.

All three poliovirus serotypes were isolated within a few months after the establishment of AFP surveillance. Poliovirus has been detected in many parts of the country. All three serotypes were detected in 1997; however, type 2 virus has not been isolated during 1998 and 1999. Since May 1999, an outbreak of polio is occurring in Kunduz province in northern Afghanistan.⁴

The sensitivity of AFP surveillance is measured by the rate of nonpolio AFP per 100,000 population aged <15 years (target: 1 per 100,000 population), and the quality is assessed by the percentage of cases from which two stool specimens are taken within 14 days of paralysis onset ("adequate" stool specimen; target: 80%). Both performance indicators continue to improve. From 1998 to 1999, the nonpolio AFP rate increased from 0.6 to 1.2, and the proportion of AFP cases with two adequate stool specimens increased from 52% to 61% in 1999.

Afghanistan Country Office, World Health Organization, Islamabad, Pakistan. Eastern Mediterranean Regional Office, World Health Organization, Alexandria, Egypt. Vaccines and Other Biologicals Dept, World Health Organization, Geneva, Switzerland. Respiratory and Enterovirus Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Vaccine Preventable Disease Eradication Div, National Immunization Program, CDC.

Polio remains the leading cause of permanent disability in Afghanistan, a country with civil strife for approximately 20 years.⁵ Poliovirus transmission must be interrupted in Afghanistan both to prevent morbidity, mortality, and permanent disability and to reach the 2000 global polio eradication target.

Limited cease-fire agreements were effective between fighting parties during MICs and NIDs, allowing health-care workers to vaccinate children in areas with ongoing conflict. Since 1997, NIDs have achieved relatively high coverage rates among the target population; however, interruption of virus transmission in Afghanistan may take longer than in countries with well-functioning routine vaccination programs.

AFP surveillance systems require a well-coordinated and sustained effort to identify suspected cases; collect, store, and ship stool specimens; and collect, tabulate, and analyze data. Despite the prevailing conflict, AFP surveillance has improved rapidly in Afghanistan and is becoming the model for establishing AFP surveillance in other countries under difficult circumstances.⁶ Measles and neonatal tetanus case reporting have been added to the AFP surveillance system as a first step toward establishing an integrated communicable disease reporting system. Contributing to the success in establishing surveillance is the cooperation among national health services, WHO, UNICEF, and nongovernmental organizations and with resources provided by the international donors. Although the quality of AFP surveillance in Afghanistan is better than in other countries where polio is endemic, it must improve to better establish the degree of virus transmission and to target areas for supplemental vaccination activities.

Polio eradication activities, particularly NIDs, can play a key role in initiating and revitalizing health services in countries where conflict has damaged the infrastructure; the investment in vaccination may serve as an example to restore other basic health services in the country. As demonstrated in other countries, critical elements of the polio eradication strategies implemented in Afghanistan—political commitment, international partnerships, capacity for surveillance, and integration of preventive services—now serve as a platform for strengthening vaccination and other preventive health services. Social mobilization and additional resources available for polio eradication (i.e., cold chain equipment, training, and additional staff) may lead to increased awareness and use of routine vaccination services.

Continued public health efforts are essential to eradicate polio in Afghanistan. End-stage acceleration of polio eradication in Afghanistan will require extra rounds of NIDs and house-to-house vaccination activities to administer OPV, which will require substantial additional external funding.† In the final phase of polio eradication, increased efforts are necessary. Unless polio eradication succeeds even under the most challenging circumstances, polio will remain endemic in some countries, resulting in exportation of poliovirus into neighboring and distant polio-free areas, and delaying regional and global polio eradication.

*Mass campaigns over a short period (days to weeks) in which two doses of OPV are administered to all children in the target group (usually aged 0-4 years) regardless of previous vaccination history, with an interval of 4-6 weeks between doses.

† Polio eradication in Afghanistan is supported by the national government. External support is provided by global polio eradication partners, including Rotary International, UNICEF, WHO, and the governments of the United States, Great Britain, Denmark, Norway, Netherlands, Sweden, Luxemburg, Germany, and the European Community.