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During January 1-October 1, 2019, a total of 1,249 measles cases and 22 measles outbreaks were reported in the United States. This represents the most U.S. cases reported in a single year since 1992 (1), and the second highest number of reported outbreaks annually since measles was declared eliminated* in the United States in 2000 (2). Measles is an acute febrile rash illness with an attack rate of approximately 90% in susceptible household contacts (3). Domestic outbreaks can occur when travelers contract measles outside the United States and subsequently transmit infection to unvaccinated persons they expose in the United States. Among the 1,249 measles cases reported in 2019, 1,163 (93%) were associated with the 22 outbreaks, 1,107 (89%) were in patients who were unvaccinated or had an unknown vaccination status, and 119 (10%) measles patients were hospitalized. Closely related outbreaks in New York City (NYC) and New York State (NYS; excluding NYC), with ongoing transmission for nearly 1 year in large and close-knit Orthodox Jewish communities, accounted for 934 (75%) cases during 2019 and threatened the elimination status of measles in the United States. Robust responses in NYC and NYS were effective in controlling transmission before the 1-year mark; however, continued vigilance for additional cases within these communities is essential to determine whether elimination has been sustained. Collaboration between public health authorities and undervaccinated communities is important for preventing outbreaks and limiting transmission. The combination of maintenance of high national vaccination coverage with measles, mumps, and rubella vaccine (MMR) and rapid implementation of measles control measures remains the cornerstone for preventing widespread measles transmission (4).

During January 1-October 1, 2019, a total of 1,249 measles cases and 22 measles outbreaks were reported in the United States. This represents the most U.S. cases reported in a single year since 1992 (1), and the second highest number of reported outbreaks annually since measles was declared eliminated* in the United States in 2000 (2). Measles is an acute febrile rash illness with an attack rate of approximately 90% in susceptible household contacts (3). Domestic outbreaks can occur when travelers contract measles outside the United States and subsequently transmit infection to unvaccinated persons they expose in the United States. Among the 1,249 measles cases reported in 2019, 1,163 (93%) were associated with the 22 outbreaks, 1,107 (89%) were in patients who were unvaccinated or had an unknown vaccination status, and 119 (10%) measles patients were hospitalized. Closely related outbreaks in New York City (NYC) and New York State (NYS; excluding NYC), with ongoing transmission for nearly 1 year in large and close-knit Orthodox Jewish communities, accounted for 934 (75%) cases during 2019 and threatened the elimination status of measles in the United States. Robust responses in NYC and NYS were effective in controlling transmission before the 1-year mark; however, continued vigilance for additional cases within these communities is essential to determine whether elimination has been sustained. Collaboration between public health authorities and undervaccinated communities is important for preventing outbreaks and limiting transmission. The combination of maintenance of high national vaccination coverage with measles, mumps, and rubella vaccine (MMR) and rapid implementation of measles control measures remains the cornerstone for preventing widespread measles transmission (4).

BACKGROUND Acute flaccid myelitis (AFM), a serious paralytic illness, was first recognized as a distinct condition in 2014, when cases were reported concurrent with a large U.S. outbreak of severe respiratory illness caused by enterovirus D-68 (EV-D68). Since 2014, nationwide outbreaks of AFM have occurred every 2 years in the United States; the cause for the recent change in the epidemiology of AFM in the United States, including the occurrence of outbreaks and a biennial periodicity since 2014, is under investigation. This report updates clinical, laboratory, and outcome data for cases reported to CDC during 2018. METHODS Clinical data and specimens from persons in the United States who met the clinical criterion for AFM (acute onset of flaccid limb weakness) with onset in 2018 were submitted to CDC for classification of the illnesses as confirmed, probable, or non-AFM cases. Enterovirus/rhinovirus (EV/RV) testing was performed on available specimens from persons meeting the clinical criterion. Descriptive analyses, laboratory results, and indicators of early recognition and reporting are summarized. RESULTS From January through December 2018, among 374 reported cases of AFM, 233 (62%) (from 41 states) were classified as confirmed, 26 (7%) as probable, and 115 (31%) as non-AFM cases. Median ages of patients with confirmed, probable, and non-AFM cases were 5.3, 2.9, and 8.8 years, respectively. Laboratory testing identified multiple EV/RV types, primarily in respiratory and stool specimens, in 44% of confirmed cases. Among confirmed cases, the interval from onset of limb weakness until specimen collection ranged from 2 to 7 days, depending on specimen type. Interval from onset of limb weakness until reporting to CDC during 2018 ranged from 18 to 36 days, with confirmed and probable cases reported earlier than non-AFM cases. CONCLUSION Identification of risk factors leading to outbreaks of AFM remains a public health priority. Prompt recognition of signs and symptoms, early specimen collection, and complete and rapid reporting will expedite public health investigations and research studies to elucidate the recent epidemiology of AFM and subsequently inform treatment and prevention recommendations.

As of April 26, 2019, CDC had reported 704 cases of measles in the United States since the beginning of 2019, representing the largest number of cases reported in the country in a single year since 1994, when 963 cases occurred, and since measles was declared eliminated* in 2000 (1,2). Measles is a highly contagious, acute viral illness characterized by fever and a maculopapular rash; complications include pneumonia, encephalitis, and death. Among the 704 cases, 503 (71%) were in unvaccinated persons and 689 (98%) occurred in U.S. residents. Overall, 66 (9%) patients were hospitalized. Thirteen outbreaks have been reported in 2019, accounting for 663 cases, 94% of all reported cases. Six of the 13 outbreaks were associated with underimmunized close-knit communities and accounted for 88% of all cases. High 2-dose measles vaccination coverage in the United States has been critical to limiting transmission (3). However, increased global measles activity poses a risk to U.S. elimination, particularly when unvaccinated travelers acquire measles abroad and return to communities with low vaccination rates (4). Health care providers should ensure persons are up to date with measles, mumps, rubella (MMR) vaccine, including before international travel, and rapidly report all suspected cases of measles to public health authorities.

BACKGROUND: Although measles was declared eliminated from the United States in 2000, measles cases and outbreaks continue to occur, resulting from importations of the disease from countries where it remains endemic. METHODS: We describe the epidemiology of international importations of measles virus into the United States during the post-elimination era. RESULTS: From 2001 to 2016, 553 imported measles cases were reported to the Centers for Disease Control and Prevention. A median of 28 importations occurred each year (range: 18–80). The median age of imported case-patients was 18 years (range: three months–75 years); 87% were unvaccinated or had an unknown vaccination status. U.S. residents (as opposed to foreign visitors) accounted for 62% of imported measles cases. Overall, 62% of all imported case-patients reported travel to countries in the Western Pacific and European Regions of the World Health Organization during their exposure periods. The number of measles importations from specific countries was related to the incidence of measles in and the volume of travel to and from the source country. CONCLUSIONS: Our findings emphasize the importance of measles vaccination of U.S. residents aged ≥6 months before international travel according to Advisory Committee on Immunization Practices recommendations and supporting global measles elimination efforts.

BACKGROUND: Acute flaccid myelitis (AFM) is a neurologic condition characterized by flaccid limb weakness. After a large number of reports of AFM in 2014, the Centers for Disease Control and Prevention began standardized surveillance in the United States to characterize the disease burden and explore potential etiologies and epidemiologic associations. METHODS: Persons meeting the clinical case criteria of acute flaccid limb weakness from January 1, 2015, through December 31, 2017, were classified as confirmed (spinal cord gray matter lesions on MRI) or probable (white blood cell count >5 cells per mm3 in cerebrospinal fluid [CSF]). We describe clinical, radiologic, laboratory, and epidemiologic findings of pediatric patients (age ≤21 years) confirmed with AFM. RESULTS: Of 305 children reported from 43 states, 193 were confirmed and 25 were probable. Of confirmed patients, 61% were male, with a median age of 6 years (range: 3 months to 21 years; interquartile range: 3 to 10 years). An antecedent respiratory or febrile illness was reported in 79% with a median of 5 days (interquartile range: 2 to 7 days) before limb weakness. Among 153 sterile-site specimens (CSF and serum) submitted to the Centers for Disease Control and Prevention, coxsackievirus A16 was detected in CSF and serum of one case patient and enterovirus D68 was detected in serum of another. Of 167 nonsterile site (respiratory and stool) specimens, 28% tested positive for enterovirus or rhinovirus. CONCLUSIONS: AFM surveillance data suggest a viral etiology, including enteroviruses. Further study is ongoing to better characterize the etiology, pathogenesis, and risk factors of this rare condition.

In August 2018, CDC noted an increased number of reports of patients having symptoms clinically compatible with acute flaccid myelitis (AFM), a rare condition characterized by rapid onset of flaccid weakness in one or more limbs and spinal cord gray matter lesions, compared with August 2017. Since 2014, CDC has conducted surveillance for AFM using a standardized case definition (1,2). An Epi-X* notice was issued on August 23, 2018, to increase clinician awareness and provide guidance for case reporting.

Background Since 2012, there has been a steady increase in the number of reported mumps cases and outbreaks in the United States, primarily affecting young, two-dose vaccinated adults. We analyzed epidemiologic characteristics of mumps cases reported nationally from 2016 to 2018. Methods We included confirmed and probable mumps cases transmitted from January 2016 to April 2018 by 52 health department jurisdictions (50 states, DC and NYC) that report cases to the National Notifiable Diseases Surveillance System (NNDSS). We calculated overall and age-specific incidence rates (IR) by dividing the annual number of mumps cases by the corresponding US Census Bureau’s Bridged Race population estimates. Cases were reported as outbreak-related or non-related in NNDSS by the submitting jurisdiction. Results Between January 1, 2016–April 21, 2018, 13,348 mumps cases (n = 6,369 in 2016, n = 6,056 in 2017 and n = 923 in 2018) were reported to NNDSS. IRs were 20, 19, and 2.9/million population in 2016, 2017, and January–April 2018, respectively. Young adults (18–22 years) had the highest IR: 88, 76, and 7.3/million population in 2016, 2017, and 2018, respectively. During January–April timeframe, 348 more cases were reported in 2016 (IR = 3.8/million) and almost four times as many cases were reported in 2017 (n = 3,376, IR = 10.5/million) compared with 2018 (P < 0.0001). The number of jurisdictions that reported cases in the first 4 months of each year was 39, 44, and 47 in 2016, 2017, and 2018, respectively. During the same timeframe, the number of outbreak-related cases reported was lower in 2018 (n = 523) vs. 2017 (n = 2,350) and 2016 (n = 1,271) (P < 0.0001), and the number of jurisdictions reporting outbreak-related cases was lower in 2018 (n = 16) vs. 2017 (n = 32, P = 0.002) and 2016 (n = 22, P = 0.23). Conclusion Preliminary data suggest that the overall and outbreak-related mumps cases may be decreasing in 2018 after 2 years of increased reports. However, the number of jurisdictions reporting mumps cases has not decreased. Thorough investigations of sporadic cases may lead to improved identification of epidemiologic linkages and earlier identification of outbreaks. Disclosures All authors: No reported disclosures.

Background Although human immunodeficiency virus (HIV) infection is an established risk factor for several bacterial infections, the association between HIV infection and meningococcal disease remains unclear. Methods Expanded chart reviews were completed on persons with meningococcal disease and HIV infection reported from 2000 through 2008 from 9 US sites participating in an active population-based surveillance system for meningococcal disease. The incidence of meningococcal disease among patients meeting Centers for Disease Control and Prevention acquired immune deficiency syndrome (AIDS) surveillance criteria was estimated using data from the National HIV Surveillance System for the participating sites. Results Thirty-three cases of meningococcal disease in individuals with HIV infection were reported from participating sites, representing 2.0% of all reported meningococcal disease cases. Most (75.8%) persons with HIV infection were adult males aged 25 to 64 years old. Among all meningococcal disease cases aged 25 to 64 years old, case fatality ratios were similar among HIV-infected and HIV-uninfected persons (13.3% vs 10.6%; P = .6). The cumulative, mean incidence of meningococcal disease among patients aged 25 to 64 years old with HIV infection ever classified as AIDS was 3.5 cases per 100000 person years (95% confidence interval [CI], 2.1–5.6), compared with 0.3 cases per 100000 person years (95% CI, 0.3–0.3) for persons of the same age group not reported to have AIDS (relative risk = 12.9; 95% CI, 7.9–20.9). Conclusions Individuals with HIV infection meeting the AIDS surveillance case definition have a higher incidence of meningococcal disease compared with the general adult population.

Background Mumps is an acute viral illness that classically presents with parotitis. Infected persons who are asymptomatic or have non-specific respiratory symptoms can still transmit disease. Recently, mumps cases and outbreaks (OB) among young adults (18-22 years) in the US have been increasing. In 2016, university and close-knit community OB accounted for the highest incidence rates (IR) since 2006 (Figure 1). Methods The Centers for Disease Control and Prevention (CDC) assessed reports of confirmed and probable mumps cases transmitted through passive surveillance by 52 state/local health departments (jurisdictions). Nine jurisdictions submitted enhanced OB data including symptoms and complications directly to CDC. We calculated overall and age-specific IR (per 1,000,000 persons, 95% CI) by dividing the annual number of mumps cases by U.S. Census Bureau’s population estimates. SAS (v9.4) was used for analysis. Results From January–December 31, 2016, 5,724 mumps cases from 48 jurisdictions were reported (overall IR: 18). Of 79% with vaccination status, 88% had ≥1 dose and 60% had ≥2 doses of measles mumps rubella (MMR) vaccine. Median age was 20 years (range

Background. A recent increase in Bordetella pertussis without the pertactin protein, an acellular vaccine immunogen, has been reported in the United States. Determining whether pertactin-deficient (PRN – ) B. pertussis is evading vaccine-induced immunity or altering the severity of illness is needed. Methods. We retrospectively assessed for associations between pertactin production and both clinical presentation and vaccine history. Cases with isolates collected between May 2011 and February 2013 from 8 states were included. We calculated unadjusted and adjusted odds ratios (ORs) using multivariable logistic regression analysis. Results. Among 753 isolates, 640 (85%) were PRN – . The age distribution differed between cases caused by PRN – B. pertussis and cases caused by B. pertussis producing pertactin (PRN + )( P =. 01). The proportion reporting individual pertussis symptoms was similar between the 2 groups, except a higher proportion of PRN + case-patients reported apnea (P= .005). Twenty-two case-patients were hospitalized; 6% in the PRN + group compared to 3% in the PRN – group (P= .11). Case-patients having received at least 1 pertussis vaccine dose had a higher odds of having PRN – B. pertussis compared with unvaccinated case-patients (adjusted OR = 2.2; 95% confidence interval [CI], 1.3– 4.0). When restricted to case-patients at least 1 year of age and those age-appropriately vaccinated, the adjusted OR increased to 2.7 (95% CI, 1.2–6.1). Conclusions. The significant association between vaccination and isolate pertactin production suggests that the likelihood of having reported disease caused by PRN – compared with PRN + strains is greater in vaccinated persons. Additional studies are needed to assess whether vaccine effectiveness is diminished against PRN – strains.

Background Measles is a highly contagious vaccine-preventable disease that can lead to serious complications. Although measles was declared eliminated from the United States in 2000, measles cases and outbreaks continue to occur each year as a result of importations of the disease from countries in which it remains endemic. We describe the epidemiology of importations of measles virus into the US during the post-elimination era. Methods Measles is nationally notifiable in the USA and local and state health departments report confirmed measles cases to the Centers for Disease Control and Prevention (CDC). A case is considered internationally imported if at least some of the exposure period (7-21 days before rash onset) occurred outside of the USA, rash onset occurred within 21 days of entering the USA, and there was no known exposure to measles in the US during that time. We describe the demographic characteristics, source regions, and vaccination status of measles importations during 2001–2015. Results From 2001 to 2015, 2,012 measles cases were reported to CDC; 535 (27%) were imported. A median of 28 importations occurred each year (range: 18–80). The median age of imported cases was 18 years (range