WASHINGTON’S MEASLES

OUTBREAKS AND RESPONSE

Secretary John Wiesman, DrPH, MPH
 Objectives

Objectives

 Share the narrative: pre-outbreak situation and identify issues

ripe for an outbreak

 In-depth look at measles outbreak and identify the roles of

the governmental public system

 Discuss issues of interest to you all

Washington State Department of Health | 2

 The Tale of Two Measles Outbreaks

 Outbreak #1  Outbreak #2
• January – April, 2019
• 72 Cases in WA
• Clark (71) and King
County (1)
• In addition: Oregon (2)
and Georgia (2) had
measles cases
associated with WA
outbreak
• May 2019 – present
• 13 Cases as of July 18
• King (10), Pierce (2) ,
and Snohomish (1)
counties
• In addition: California
(1), Oklahoma (1),
Illinois (1) associated
with SeaTac outbreak

Washington State Department of Health | 3

PRE-OUTBREAK: PREPAREDNESS
 The story starts in 2001:
A new era for governmental public health

Washington State Department of Health | 5

Emergency
Preparedness and
Outbreak Response
• Constant nurturing,
maintenance, and relationship
building
• Tabletop exercises
• Drills
• Full-scale Exercises
• Real Life Events
Incident Management Team Activations

 2014  2018
• Central WA wildfires • Healthcare Acquired
• Ebola Infections
• Oso landslide • Hep C Exposure
 2016  2019
• October storms • Measles x 2
• Seattle Pain Clinic surge
• Zika
 2017
• Hanford PUREX
• Influenza surge
• Mumps
• September fires

Washington State Department of Health | 7

Incident Management Team Membership

2015 60 IMT members, all DOH staff (0%)

2016 54 IMT members, 6 non-DOH staff (11%)
2017 59 IMT members, 7 non-DOH staff (12%)
2018 52 IMT members, 10 non-DOH staff (19%)
2019 124 IMT members, 13 non-DOH staff (10%)

Washington State Department of Health | 8

PRE-OUTBREAK: VACCINATION
WA Vaccination Law
7 Required Vaccinations for Child
Care and 5 for School Entry
State Law Allows:
• Personal/Philosophical Belief
Exemption* (1 of 17 states)
• Religious Exemption
• Medical Exemption
School immunization exemptions for
students in grades K-12, 1998 - 2018
Any kind of
exemption: 4.9%

Personal/philosophical
exemptions: 3.7%

Healthcare provider
signature required on Medical exemptions
Certificate of Exemption 0.9% (decrease from the
Separate Certificate of 1.2% reported last year.)
Exemption required
Religious
exemptions*: 0.4%

*Includes religious and religious

membership types
 Immunization Status
Kindergartners, 1998 - 2018

: 85.7%

: 8.0%
: 4.7%
: 1.6%
 Complete Required Immunizations

Kindergartners, 2010 - 2018

HP2020 goal*: 95%

Hepatitis B
Pertussis MMR
Polio
Varicella

All vaccines

*HP2020: Healthy People 2020, ten-year national goal for kindergarten immunization completeness.
 School Immunization Exemptions

Kindergartners (by school district), School Year 2017 - 2018

Out of Compliance with Immunization Documentation

Kindergartners (by school district), School Year 2017 - 2018

Immunization rates

Washington State School Immunization Slide Set, 2017-2018 School Year. Washington State
Department of Health, 2018. Updated March 2018.

Public Health measles response 16

 Washington State Population Served
San Juan Whatcom
(Northeast Tri County)
17,150 225,300
Okanogan Pend
Ferry
Skagit 42,730 Oreille
7,830
129,200 Stevens 13,740
Island
45,570
84,820
Clallam Snohomish
76,010 818,700
(Chelan-Douglas)
Jefferson
Kitsap Chelan Douglas
31,900 Lincoln Spokane
270,100 Seattle & King 78,420 42,820 10,960 515,250
Grays County
Harbor Mason 2,226,300
74,160 64,980 Grant
Kittitas
98,740 Adams Whitman
Tacoma-Pierce* 46,570
Thurston 20,150 50,130
888,300
285,800
Pacific Lewis Garfield
(Benton-Franklin)
21,640 79,480 Yakima 2,220
Franklin
255,950 94,680 Columbia Asotin
Wahkiakum Cowlitz Benton Walla Walla 4,160
Skamania 22,520
4,190 108,950 201,800 62,200
12,060
Klickitat
Clark*
*Agency leader is 22,430 Washington State Total Population (estimate)
488,500
both director and April 2019: 7,546,410
health officer (2) Source: Office of Financial Management

Departments that have combined public

Public Health Department (8)
health with human services (16)

Single County District (8) Multi County District (3)

OUTBREAK #1: CLARK COUNTY
 Beginning of the Outbreak

Dec 31, 2018

First known case visits
Memorial Urgent Care

Jan 4, 2019
Lab confirms measles in a child
1–10 years old with unknown
immunization history

Jan 15, 2019

2 additional confirmed cases and 11 suspect cases identified.
Public Health activates Incident Command System to respond to
the outbreak.

January 2019 February 2019 March 2019

Case Investigation

 Measles is a notifiable condition.

State law requires physicians and other
healthcare providers to notify Public
Health of any suspected measles cases.

 Clinicians collect specimens and

coordinate with Public Health to
arrange testing at public health labs.

 Public Health staff interview the

case/parents of the case to gather
information about illness onset and
where the case had been the previous
21 days.
 Case Evaluation

Clinical Case Definition

 Generalized rash lasting ≥ 3 days
 Temperature ≥ 101.0°F (≥ 38.3°C)
 Cough or coryza or conjunctivitis

Suspect Case
 Meets the clinical case definition, but no labs and no epi link

Confirmed Case
An acute febrile rash illness with:
 Isolation of measles virus from a clinical specimen or
 Positive PCR or
 IgG seroconversion or a significant rise in measles IgG or
 A positive serologic test for measles IgM or
 Epi link to a confirmed case
 Healthcare Provider Advisories &
Governor Emergency Proclamation

Multiple Healthcare Provider Advisories were issued

from January through March of 2019:

Jan 17
Measles Feb 3
Regional Measles
Alert Regional
Alert

Jan 15 Jan 25
Measles Measles Feb 13
Regional Regional Measles
Alert Alert & Regional Mar 5
Governor Alert Measles
Emergency Regional
Jan 4 Proclamation Alert
Measles
Alert

January 2019 February 2019 March 2019

Provider Advisory Content

 Clinical presentation
 Infection control recommendations
 Exposure locations
 Suspect measles worksheet
 Determination whether case is highly suspect
based on clinical presentation, immunization
status, exposure and travel history
 Lab recommendations: specimen
collection/storage, lab testing
 Specimen collection guidelines
 Instructions for arranging specimen shipping
to public health lab

 Recommendations regarding exclusion, post

exposure prophylaxis
 Sources for more information
 Immunization Recommendations

Post Exposure:
 MMR to eligible unvaccinated if within 72 hours of exposure
 Do not give MMR post 72 hours to unimmunized individuals
 IG within 6 days for:
― Unvaccinated pregnant women
― Infants
― Severely immunocompromised and ineligible for vaccine

Routine Vaccination:
 Do not extend to infants 6-11 months
Governor Proclaimed Public Health Emergency

 January 25, 2019

 Mutual aid assistance through the Emergency Management

Assistance Compact (EMAC)

 Public health responders

• North Dakota
• Idaho
• Oregon

Washington State Department of Health | 25

 Case and Contact Investigation

Case at a large public setting while contagious:

 Notify public through news releases, website and social media

Case at school while contagious:

 Identify susceptible students and staff

 Exclude from school and other public settings for 21 days
 Actively monitor for 21 days (daily calls)

Case at a health care facility while contagious:

 Obtain list and contact information of exposed patients and contact them
 Identify those who are susceptible and actively monitor for 21 days (home
quarantine, daily calls)
 Recommendations on PEP
 Identify whether anyone else was present/exposed and contact them
 Case Contacts Investigated

Initial Interviews >4,137

Monitoring Letters Sent >3,300

Daily Monitoring >839

Tested 586 Samples | Jan – May 14: 533 Tests

Washington State Department of Health | 28

 Exposure Sites

54 exposure sites, some with multiple exposure times:

12 health care facilities

15 schools:
3 public school
districts
2 private schools

1 child care facility

26 other locations:
Including churches,
grocery stores, Moda
Center and Portland
International Airport
 School Exclusions

Public Health excluded susceptible

students and staff at 13 public
schools in three school districts, Vancouver Public Schools
and two private schools:
138 students excluded

Battle Ground Public Schools Cornerstone Christian Academy

398 students excluded 20 students excluded

Evergreen Public Schools Slavic Christian Academy

293 students excluded No students excluded
Public Exposures By Type

96 Exposures:
30 General Public

29 Healthcare Facility

31 School

2 Daycare

4 Workplace
 Summary: 71 Cases

Age Range Vaccination Status

60

52 One MMR 3

50
Unverified 7

40
Unvaccinated 61

30
0 20 40 60 80

20 Confirmation Type
14

10
Epi-linked 30
4
1
0
1-10 11-18 19-29 30-39
Years Years Years Years Lab Confirmed 41

0 10 20 30 40 50
 71 Cases in Time

Measles cases, by transmission setting and date of rash onset:

Clark County, WA 12/30/2018 – 3/13/2019
Immunization increases

Public Health measles response 34

Immunization increases

Public Health measles response 35

Response: Staffing and Cost

Days in response: 58
Total responders: 237
 Daily average: 40 to 50
 Clark County Public Health: 89
 Washington Department of Health: 57
 Centers for Disease Control and
Prevention: 3
 Medical Reserve Corps: 50
 Mutual aide, local volunteers,
Emergency Management Assistance
Compact, Interpreters, others: 38

Cost: $864,678.73
 Activation Jan-Mar 2019 May 2019 2019
Totals Response* Response Cumulative Total

Total Staff Involvement 222 79 301

Hours Worked 14,305 1,428 15,288

Total DOH Effort $1,011,100 $101,800 $1,112,900

Non-Budgeted Expenditures $152,800 $18,000 $170,800

Average Daily Cost $18,100 $11,300

Total Costs $1,011,100 $70,100 $1,081,200

*Costs verified as of 5/20/19. Could change as actuals are still being reconciled.
 What Else Was Going On

Legislation
House Bill 1638/Senate Bill 5841
 Removes personal and philosophical exemption for MMR
 Religious and medical exemption still allowed
 Effective July 28, 2019

U.S. Senate
 March 5: HELP Full Committee Hearing—Vaccines Save Lives:
What Is Driving Preventable Disease Outbreaks?

Lots of Media

Washington State Department of Health | 38

 In the News

Washington State Department of Health | 39

OUTBREAK #2: SEATAC AIRPORT
 Sea-Tac Outbreak

April 25, 2019

Unknown person with
measles at Sea-Tac
International airport

May 9-14, 2019 June 23, 2019

Measles rash begins in Unexpected case
7 exposed at airport found –
genetically
identical virus

April 2019 May 2019 June 2019

 0
1
2
3
4
4/25/2019
4/27/2019

Common
4/29/2019

SeaTac Airport
exposure date at
5/1/2019
5/3/2019
5/5/2019
5/7/2019
5/9/2019
5/11/2019

Airport, WA Resident
5/13/2019
21-day incubation period

5/15/2019
5/17/2019
5/19/2019
5/21/2019
5/23/2019
5/25/2019
5/27/2019
5/29/2019
5/31/2019

Airport, Out-of-State Resident

6/2/2019
6/4/2019
6/6/2019
6/8/2019

Date of Rash Onset

6/10/2019
6/12/2019
6/14/2019
21-day incubation period

6/16/2019
6/18/2019
6/20/2019
Non-Airport Public Setting

6/22/2019
6/24/2019
6/26/2019
Washington State Department of Health | 42

6/28/2019
6/30/2019
Household

7/2/2019
7/4/2019
Measles Cases by Exposure Setting (n=16)

7/6/2019
7/8/2019
Unknown

7/10/2019
7/12/2019
7/14/2019
Confirmed Cases (current outbreak) as of 7/15/19

Jurisdiction Number
Washington State 13
King (10)
Pierce (2)
Snohomish (1)

Out-of-State 3
Oklahoma (1)
California (1)
Illinois (1)
TOTAL 16

Washington State Department of Health | 43

 Age of confirmed cases
The majority of confirmed cases are in persons 19 years and
older (11 of 16 cases).

Age Number
<1 year 2
1 to 10 years 0
11 to 18 years 3
19 to 29 years 1
30 to 39 years 3
40 to 49 years 5
50 to 59 years 2

Washington State Department of Health | 44

Immunization Status of confirmed cases

MMR Number

0 doses 7
1 dose 3
2 or more doses 2
Other evidence of immunity 0
Unknown 4
TOTAL 16

Washington State Department of Health | 45

Tested 586 Samples | May 14 – 24: 64 Tests

Washington State Department of Health | 46

Discussion & Questions
 John Wiesman, DrPH, MPH

Washington State Secretary of Health

jmwiesman@doh.wa.gov

@WADeptHealth
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