Public health labs aren’t just on the frontlines of vaccine-preventable outbreaks. They’re often the only line.

Public health labs aren’t just on the frontlines of vaccine-preventable outbreaks. They’re often the only line. | www.APHLblog.org

by Kim Krisberg

In the U.S., rates of vaccine-preventable diseases are so low that many commercial labs don’t even have the ability to test for them anymore. The shift reflects the hard work of decades-long immunization efforts. But it also means that when there is a vaccine-preventable outbreak, just about all of our rapid diagnostic capacity resides in one place: the public health lab.

The latest example of this is in Minnesota, where a measles outbreak hit 78 confirmed cases as of June 16. The state is typically home to less than a handful of measles cases each year — most years, the case count is between zero and two. At the Minnesota Department of Health’s Public Health Laboratory, which is the only lab in the state that can do real-time reverse-transcription polymerase chain reaction (rRT-PCR) testing for measles, staff have received more than 800 specimens for measles testing since April, with a goal of fully processing each one the same day it’s received. To stop an outbreak, both speed and accuracy are critical.

Fortunately, Minnesota lab workers are trained and ready to provide both. But sustaining that kind of surge capacity over the long run and in the face of new and emerging disease threats is always challenging — even in the best funding environments.

“We’ve spent a lot of time increasing our capacity over the last 10 years and we’re seeing that capacity being put to work,” said Sara Vetter, PhD, manager for infectious diseases at the Minnesota Public Health Laboratory. Vetter noted that Minnesota last experienced a measles outbreak in 2011 — “and that one seemed huge and it was just 26 cases of measles.”

This year’s measles outbreak is almost entirely concentrated in a Somali community in Minnesota’s Hennepin County, home to more than 1 million residents. The outbreak officially began on April 10, the same day the lab confirmed the first positive case. Nearly all the cases are among unvaccinated children younger than 4 years old. No deaths have occurred, though about a quarter of infections have led to hospitalization.

Inside the public health lab’s Virology/Immunology Unit, technicians track the measles outbreak using a rRT-PCR test, which allows them to detect the highly contagious virus much quicker than private labs that can perform serological testing for measles antibodies. That quickness is key, said Anna Strain, PhD, supervisor of the Virology/Immunology Unit, because it means the health agency’s epidemiology team can then quickly locate people who may have been infected and get ahead of the outbreak before it spreads.

The rRT-PCR test may be quicker than serological testing — it detects measles RNA, as opposed to measles antibodies, and is less confounding than serology — but it’s not completely definitive, Strain said. After conducting rRT-PCR testing on each of the more than 800 specimens that come into the lab, any positive specimens undergo genotyping to determine if the patient is infected with a wild-type measles strain or if the rRT-PCR is simply picking up on the live attenuated virus that’s contained in the measles-mumps-rubella vaccine. Genotyping can also determine if the case is related to the larger outbreak. (On a side note: In addition to its regular testing responsibilities, the Minnesota Public Health Lab is partnering with the Centers for Disease Control and Prevention and Canadian public health officials to develop a PCR test that’s specific to the vaccine strain of measles. Such an test would be particularly helpful in an outbreak, Strain said, because technicians could then forgo the extra step of genotyping.)

“It’s actually meant quite a lot of maneuvering,” Strain said, referring to the logistics of responding to the surge in measles testing. “In some ways, we were lucky that it happened in April when flu season was dying down — otherwise a number of testing staff trained for measles testing would have also been doing flu testing. If the (measles outbreak) had happened any sooner, it would have been really hard to keep up.”

From start to finish, the measles test takes about five hours, Strain said. Lab staff can process 10 measles specimens at a time and up to 30 specimens in day — though that’s a stretch, she noted. In comparison, the lab can process up to 150 flu samples in day and often does.

“As hard as it’s been in the lab, it’s been even harder for our epidemiologists — they’ve had more than 7,000 contacts to trace and to follow up on,” said Joanne Bartkus, PhD, director of the Minnesota Public Health Laboratory. “It’s been daunting for all of us.”

Vetter said that most of the lab’s current surge and response capacity is thanks to federal public health preparedness funding as well as funding from CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program, both of which currently sit on the budgetary chopping block. On preparedness, President Trump’s fiscal year 2018 budget proposal calls for cutting CDC’s emergency preparedness budget by $136 million — that’s on top of years of preparedness cuts public health agencies have already absorbed. (In total, Trump’s budget calls for cutting CDC’s budget by $1.2 billion, or a whopping 17 percent.) The ELC, on the other hand, is wholly entwined with the Affordable Care Act’s Prevention and Public Health Fund, which allocates $40 million in annual ELC funds to state and local health departments in every state. Under current ACA repeal-and-replace bills in Congress, the Prevention and Public Health Fund would disappear.

And while ELC and preparedness monies don’t categorically support the Minnesota lab’s vaccine-preventable disease work, Vetter said the funds have been essential in ensuring the lab can quickly scale up its response, regardless of whether the emergency is vaccine-preventable or not. In other words, the Minnesota lab has spent years building an all-hazards response system that readies it to face any health threat that lands at its doorstep. Being able to sustain that nimbleness, however, would be at risk if funding declined.

“Without that funding, we’d probably have to choose what we respond to because we’d run out of people and out of machines — we just couldn’t keep up,” Vetter said. “If our funding gets cut, we can’t maintain our machines, we can’t replace machines, we can’t train more people … what we do is very complex.”

At the same time the Minnesota Virology/Immunology Unit has been responding to the measles outbreak, it’s also been responding to a mumps outbreak on the University of Minnesota-Twin Cities campus, providing surge testing for a mumps outbreak in Washington state that recently hit nearly 900 cases, and taking in and testing about 20 specimens a week for Zika virus. All of that is in addition to its more regular duties, like rabies and West Nile monitoring.

In the wake of the measles outbreak, Minnesota Health Commissioner Edward Ehlinger, MD, MSPH, called on state policymakers to create and support a public health response contingency fund. Such a bill was introduced into the Minnesota House of Representatives for consideration in May.

“Our commissioner always says that data are the coins of public health,” Bartkus said. “And it’s the public health lab that creates that data.”

As of late May, Strain said the Minnesota measles outbreak — which exceeded total U.S. cases for all of 2016 — seemed to be entering a “tapering phase.” As she said that, however, she paused — and quickly added “we all just knocked on wood.”

 

For more on the Minnesota measles outbreak, visit www.health.state.mn.us/divs/idepc/diseases/measles.

 

 

 

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Year in Review: Measles Linked to Disneyland

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Throughout the month of December, Public Health Matters is conducting a series of year-in-review posts of some of the most impactful disease outbreaks of 2015. These posts will help explain how CDC is working to prevent, identify, and respond to these outbreaks. Measles infiographic

Measles in Disneyland

After an uncharacteristically high number of measles cases in late 2014, the highly publicized California measles outbreak hit the media early this year.  Linked to Disneyland Resort Theme Parks in California the outbreak quickly became a multi-state public health incident that resulted in a total of 147 cases. Cases related to this outbreak were identified in seven states in the U.S., as well as Mexico and Canada.

Attention to this outbreak was further fueled by the interest surrounding vaccinations. Among the reported measles cases, the majority of patients were unvaccinated or had an unknown or undocumented vaccination status.

Why a Measles Outbreak in the U.S. is a Big Deal

In 2000, the United States declared that measles was eliminated from this country. The elimination of measles in the U.S. was due to a highly effective measles vaccine, a strong vaccination program that achieves high vaccine coverage in children, and a strong public health system for detecting and responding to measles cases and outbreaks.

Before a measles vaccine became available in 1963, 3 to 4 million people in the United States were infected with measles each year, resulting in an estimated 48,000 hospitalizations and 400 to 500 deaths.  Most people in the U.S. today are protected against measles through vaccination, so measles cases are uncommon compared to the number of cases before a vaccine was available. However, the risk of measles re-establishing itself as a prominent disease in the U.S. is possible—especially if vaccine coverage levels drop.

Today, measles is still endemic in many parts of the world, and measles outbreaks in the U.S. occur when measles is brought into the United States by unvaccinated travelers (Americans or foreign visitors) who get measles while they are in other countries. These travelers can spread measles to other people who are not protected against the disease, which sometimes leads to outbreaks. While the source of the Disneyland-associated measles outbreak was not identified, it is likely that a traveler (or more than one traveler) who was infected with measles overseas visited one or both of the Disney parks in December during their infectious period and infected other visitors to the park.

Measles: a Serious Sickness

Measles is extremely contagious. It is so contagious that if one person has it, 90% of the people close to the person who are not immune will be infected. You can catch measles just by being in the same room as a person with measles. Even if the infected person has left the room, the virus can live for up to two hours in an airspace where the infected person coughed or sneezed. The measles virus lives in the nose and throat mucus of an infected person, and can spread to others through coughing and sneezing.

Common symptoms of measles include, high fever, cough, runny nose, red, watery eyes, and a rash 3-5 days after symptoms begin. In some cases complications from measles can result in pneumonia, encephalitis (swelling of the brain), and death.

People at high risk for severe illness and complications from measles include, infants and children under 5 years of age, adults over the age of 20, pregnant women, and people with compromised immune systems.

What can be done to protect the public from measles outbreaks?

State and local health departments lead investigations of measles cases and outbreaks when they occur. CDC helps and supports health departments in these investigations and continually gathers data reported by states on confirmed measles cases to provide evaluation and monitoring from a national perspective.

High sustained measles vaccine coverage and rapid public health response are critical for preventing and controlling measles cases and outbreaks. It is possible to get rid of measles in the U.S. completely, but the first step is to eliminate measles from each country and region of the world. Once this happens, there will be no place from which measles can spread.

Until measles is eliminated worldwide, it remains a risk to any unvaccinated person exposed to the virus. Do your part to protect yourself, your family, and those around you from measles and make sure you and everyone in your family who is eligible gets vaccinated. The best protection against measles is measles-mumps-rubella (MMR) vaccine. MMR vaccine provides long-lasting protection against all strains of measles.

To learn more about measles, the MMR vaccine, and CDC’s efforts to reduce the number of measles case worldwide visit CDC’s Measles webpage.

 

Inflationary universe data bites dust, herbs are absent, plus a measles vaccine tale

  Nearly fourteen billion years ago expansion started. Wait! Last March’s claim that the BICEP2 telescope in Antarctica had uncovered proof that the universe had indeed expanded explosively 10-35 seconds after the Big Bang has bitten the dust–the dust that … Continue reading »

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Vaccination rate and measles outbreak simulation

Vax rate and infection simulation

You've probably heard about herd immunity by now. Vaccinations help the individual and the community, especially those who are unable to receive vaccinations for various reasons. The Guardian simulated what happens at various vaccination rates.

Luckily, the measles vaccine — administered in the form of the MMR for measles, mumps and rubella — is very effective. If delivered fully (two doses), it will protect 99% of people against the disease. But, like all vaccines, it’s not perfect: 1% of cases are likely to result in vaccine failure, meaning recipients won’t develop an immune response to the given disease, leaving them vulnerable. Even with perfect vaccination, one of every 100 people would be susceptible to measles, but that’s much better than the alternative.

If you're still unsure, please consult this flowchart to decide.

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Remembering The Pre-Vaccine Era: The Diseases of Childhood

Many of us of a certain age have vivid memories of the “diseases of childhood.” We remember missing weeks of school, sky-high fevers, spots and pox, cheeks so puffed from mumps that eating was impossible, for days. Our mothers, for … Continue reading »

The post Remembering The Pre-Vaccine Era: The Diseases of Childhood appeared first on PLOS Blogs Network.

SynBio B***********: Genetic recoding. Also, measles goes to Disneyland

  An early triumph for the infant synthetic biology? Do you suppose Science‘s Breakthrough (Arrrrgh!) of the Year for 2015 has already arrived? In January, no less? Via two papers in Nature? Which venue, I suppose, might take it out … Continue reading »

The post SynBio B***********: Genetic recoding. Also, measles goes to Disneyland appeared first on PLOS Blogs Network.

Why Measles Isn’t Just An Anti-Vaxxer Problem

I have a little metaphor I use with my kid. When he asks why we get shots at the doctor, I remind him of all the super powers he has. One day he got super powers against whooping cough and … Continue reading »

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Vaccine Memories: From Polio to Autism

Salk_Thank_You“April 15 – Polio Vaccine Perfected!!!!”

So wrote my mother in 1955, on the “Baby’s Health Record” page of my baby book. I unearthed it a few days ago while looking for some old writing clips.

Just a …

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What We’re Reading

Is it just me or is there an abundance of important infectious disease articles floating around this week?  Here are just a few that we have found particularly interesting.

  • How one unvaccinated child sparked Minnesota measles outbreak — This is a scary look back at a 2011 measles outbreak in Minnesota where 21 people (19 kids and two adults) became ill. A new report determined that one unvaccinated two-year-old contracted measles while traveling with her family in Kenya and brought the disease back home. It only takes one.
  • Rotavirus Vaccine Still Reaping Dividends With Fewer Hospitalizations, ER Visits, And Healthcare Costs — A new study shows that since the introduction of the rotavirus vaccine in the 1990s, nearly $1 billion in health care costs have been saved. Fewer sick people means fewer hospital stays, fewer trips to the emergency room and fewer doctor visits. Talk about return on investment!
  • US Virgin Islands Confirms 1st Chikungunya Case — Chikungunya is a painful mosquito-borne virus that has been plaguing people in the Caribbean for some time. CDC is anticipating its arrival in the mainland US this summer. We are watching it creep closer and closer with imported cases arriving in Florida, cases in Puerto Rico and now a case in the US Virgin Islands. Public health labs are prepared.
  • 11 amazing images from high-powered microscopes –  Despite the seriousness of these diseases, they sure do pose beautifully for photos!  The image of the immune system cell swallowing anthrax looks like something from a Dr. Seuss book.