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_onthly reported WPV3 cases decreased from a peak of 1 cases in December 2007 to 32 cases in March 2008; netheless, 199 cases of WPV3 had been reported in 2008, marily in Bihar, compared with 13 during the same iod in 2007. Nigeria. Reported WPV1 cases declined 86% in Nige

from 843 in 2006 to 116 in 2007, and reported WPV3 es declined 39%, from 277 in 2006 to 169 in 2007. e number of WPV1-affected districts declined 62%, from 3 in 2006 to 78 in 2007. The number of WPV3-afted districts declined 14%, from 125 in 2006 to 108 in 37; however, WPV3 outbreaks and isolated cases occurred districts in certain previously polio-free southern states. of April 30, 2008, a total of 113 WPV1 cases and 13 "V3 cases with onset in 2008 had been reported, comed with 15 WPV1 cases and 46 WPV3 cases reported the same period in 2007. Pakistan and Afghanistan. WPV circulates between cistan and Afghanistan. WPV1 cases decreased in Paki1, from 20 in 2006 to 19 in 2007, whereas WPV3 cases creased 35%, from 20 in 2006 to 13 in 2007. Twelve cricts were affected with WPV1 in both 2006 and 2007, ereas the number of WPV3-affected districts declined %, from 14 in 2006 to nine in 2007. Transmission has nained confined to two known virus reservoirs along the

kistan-Afghanistan border, with the southern reservoir ending well into nonborder districts in southern Pakia provinces (4). By April 30, 2008, four WPV1 cases h onset in 2008 had been reported in Pakistan, comed with two WPV1 and five WPV3 cases during the ne period in 2007. Although access during SIAs in Afghanistan did not prove until late in 2007 in the areas with security probis, the number of WPV1 cases decreased 79%, from 29 es in 2006 to six in 2007; however, the number of WPV3 es increased from two cases in 2006 to 11 in 2007 (4). V1 and WPV3 transmission continued in the South

Region, and two cases of WPV1 were reported in the tern Region in areas bordering Pakistan. The number WPV1-affected districts decreased 65%, from 17 in 2006 six in 2007, whereas the number of WPV3-affected dists increased from two in 2006 to nine in 2007 (4). As April 30, 2008, four WPV1 cases and one WPV3 case h onset in 2008 had been reported in Afghanistan, comed with no WPV cases during the same period in 2007. Other countries. Thirteen countries, once polio-free, orted WPV cases in 2006 following WPV importation's;

six of these countries reported polio cases in 2007 (Angola, Chad, Democratic Republic of the Congo (DRC), Nepal, Niger, and Somalia). *** In Angola and DRC, transmission in 2007 (with eight and 41 cases, respectively) followed importation of WPV1 originating in India; as of April 30, 2008, Angola and DRC each had reported one WPV1 case in 2008, compared with no cases and 12 cases, respectively, during the same period in 2007. In addition, two WPV3 cases were identified in Angola in 2008, both with onset in March, also genetically indicating origin in India. In Chad, circulation of WPV1 (18 cases) and WPV3 (three cases) in 2007 continued after introduction from Nigeria in past years and 2007. In Niger, with a total of 10 WPV1 cases and one WPV3 case, certain importations from neighboring Nigeria resulted in clusters of cases from internal transmission. As of April 30, 2008, two WPV3 cases had been reported in 2008 from Chad and five WPV1 cases from Niger.+++ Nepal, bordering India, had five sporadic WPV3 importations in 2007; as of April 30, 2008, three WPV3 cases had been reported in Nepal in 2008. Somalia reported eight WPV1 cases in 2007 but has had >1 year without detection of cases after an outbreak during July 2005-March 2007.

After several years without polio, Burma (Myanmar) had an outbreak of 11 WPV1 cases in 2007, with the last reported case occurring in May. Sudan, which had no reported polio cases in 2006, reported a single confirmed case of WPV1 circulating in Chad. However, as of April 30, 2008, a case with onset in February 2008 occurred on the Sudan-Ethiopia border; the exact location is under investigation. Genomic sequencing analysis indicates years of undetected WPV1 chains of transmission within Sudan, western Ethiopia, or both; the closest genetic relationship is with WPV1 isolated from a patient in Sudan in 2004. Reported by: Polio Eradication Dept, World Health Organization, Geneva, Switzerland. Div of Viral Diseases and Global Immunization Div, National Center for Immunization and Respiratory Diseases, CDC. Editorial Note: In 2007, substantial progress was made toward limiting the geographic extent and number of cases of WPV1 transmission in India as a result of intensive SIAs with increased use of mOPV1 in affected areas. However, WPV3 transmission increased in Uttar Pradesh and Bihar because of the intended focus on elimination of WPVI, limited mOPV3 supply in India, restricted tOPV use in

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ngola, Bangladesh, Chad, Democratic Republic of the Congo, Ethiopia, idonesia, Kenya, Namibia, Nepal, Niger, Somalia, Sudan, and Yemen.

SIAs in 2007, and underlying insufficient routine vaccination coverage (3). Combined use of mOPV1, mOPV3, and TOPV is expected to lead to interruption of WPV1 transmission and a substantial decrease in WPV3 transmission in India by the end of 2008.

WPV1 cases and affected districts also decreased substantially in Nigeria during 2007, compared with 2006. However, this decrease has not been sustained; more WPV1 cases have occurred in 2008 than during the same period in 2007. The proportion of children entirely missed during SIAs and routine vaccinations remains high (>10%) in certain states in Nigeria. Major efforts to strengthen routine vaccination services and the quality of SIA implementation are continuing (2).

The number of confirmed WPV1 cases decreased nearly 80% in Afghanistan but has not substantially decreased in Pakistan; security and access problems in border areas of Afghanistan and Pakistan are continuing, but improved access (compared with early 2007) in Afghanistan and continuing coordinated cross-border vaccination efforts might produce better results in 2008. Operational problems in vaccinating children in secure areas of Pakistan also are being addressed (4).

The WHO stakeholders meeting in February 2007 established three milestones for the end of 2007 (6). The first milestone was to reduce the number of affected districts in the four polio-endemic countries by >50% compared with 2006. A 59% reduction in WPV1-affected districts has occurred, but WPV3-affected districts have increased 37% (for a net 24% reduction in WPV-affected districts).

The second milestone, reducing the proportion of zerodose children in polio-affected areas to less than that in polio-free areas, has been met in India and major portions of affected areas in Afghanistan and Pakistan. However, this milestone has not been achieved in the high-risk areas of Nigeria and Afghanistan.

The third milestone involves interrupting transmission in all 13 countries with polio cases resulting from imported WPV in 2006. WPV transmission continued in Chad and DRC through 2007 and into 2008. New cases and transmission were reported in Angola and Niger during 2007, and Nepal experienced repeated WPV3 importations in 2007. However, Sudan or western Ethiopia, or both, have had longstanding WPV1 circulation since importation of WPV of Nigerian origin into Sudan in 2004 (9) without detection during 2006–2007, which indicates that surveillance quality should be monitored within each country by subnational area and strengthened where needed.

Ongoing WPV transmission in Angola, Chad, DRC, dr. Sudan and/or Ethiopia requires continuing efforts to ort" come the operational impediments limiting the vaccin tion of children.

The technical feasibility of polio eradication has been der onstrated repeatedly by the ability to interrupt WPV trai. mission in some of the most difficult to access and inscours areas in the world, including areas that have limited heai. infrastructure, such as Somalia. In 2007, the feasibility : polio eradication was highlighted by the substantial progres toward WPV1 interruption in India. The concerted effort i interrupt WPV1 transmission worldwide continues in 2017 with a focus on administering mOPV1 in SIAs, combina with periodic use of mOPV3 and tOPV. Sustained commi ment by governments and international partners wil ongoing program evaluation and adaptation to changing cir cumstances is crucial for progress to continue. References 1. CDC. Progress toward interruption of wild poliovirus transmissor

worldwide, January 2006–May 2007. MMWR 2007;56:682-5. 2. CDC. Progress toward poliomyelitis eradication-Nigeria, 2005

MMWR 2007;56:278–81. 3. CDC. Progress toward poliomyelitis eradication—India, January 2016

September 2007. MMWR 2007;56:1187-91. 4. CDC. Progress toward poliomyelitis eradication-Pakistan and Afghan

stan, 2007. MMWR 2008;57:315-9. 5. CDC. Apparent global interruption of wild poliovirus type 2 transte

sion. MMWR 2001;50:222-4. 6. World Health Organization. The case of completing polio eradicata

2007. Available at http://www.polioeradication.org/content/publicat

thecase_final.pdf. 7. World Health Organization. WHO vaccine-preventable diseases mor

toring system: 2007 global summary. Geneva, Switzerland: We'. Health Organization;2007. Available at http://whqlibdoc.who.inth

2007/who_ivb_2007_eng.pdf. 8. World Health Organization. Advisory committee on polio erack.

tion-standing recommendations for responding to circulating pond.

ruses in polio-free areas. Wkly Epidemiol Rec 2005;80:330-1. 9. CDC. Resurgence of wild poliovirus type 1 transmission and cos

quences of importation—21 countries, 2002–2005. MMWR 2016 55:145-50.

Measles United States,

January 1-April 25, 2008 On May 1, this report was posted as an MMWR Early Release. " the MMWR website (http://www.cdc.gov/mmwr).

Measles, a highly contagious acute viral disease, can të sult in serious complications and death. As a result of a successful U.S. vaccination program, measles eliminative : (i.e., interruption of endemic measles transmission) 3. declared in the United States in 2000 (1). The number of reported measles cases has declined from 763,094 in 1948

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fewer than 150 cases reported per year since 1997 (1). -ring 2000–2007,* a total of 29–116 measles cases ean: 62, median: 56) were reported annually. However,

ring January 1-April 25, 2008, a total of 64 confirmed --asles cases were preliminarily reported to CDC, the most 1" vorted by this date for any year since 2001. Of the | -- cases, 54 were associated with importation of measles Sum other countries into the United States, and 63 of the

patients were unvaccinated or had unknown or undocuD [:ented vaccination status. This report describes the 64 cases

provides guidance for preventing measles transmission

controlling outbreaks through vaccination, infection 1. trol, and rapid public health response. Because these I es resulted from importations and occurred almost

:lusively in unvaccinated persons, the findings underre the ongoing risk for measles among unvaccinated peris and the importance of maintaining high levels of cination. Measles cases in the United States are reported by state uth departments preliminarily to CDC, and confirmed es are reported officially via the National Notifiable Dise Surveillance System, using standard case definitions I case classifications. Cases are considered importation ociated if they are 1) acquired outside the United States ., international importation) or 2) acquired inside the ited States and either epidemiologically linked via a chain transmission to an importation or accompanied by viroic evidence of importation (i.e., a chain of transmission m which a measles virus is identified that is not endemic the United States). Other cases in the United States are ssified as having an unknown source. During January 1-April 25, 2008, a total of 64 prelimiy confirmed measles cases were reported from the folving areas: New York City (22 cases), Arizona (15), lifornia (12), Michigan and Wisconsin (four each), waii (three), and Illinois, New York state, Pennsylvania, i Virginia (one each) (Figure). Patients ranged in age m 5 months to 71 years; 14 patients were aged 2 months, 18 were aged 1-4 years, 11 were aged $19 years, 18 were aged 20-49 years, and three were aged ) years, including one U.S. resident born before 1957.S

Fourteen (22%) patients were hospitalized; no deaths were reported. Transmission occurred in both health-care and community settings. One of the 44 patients for whom transmission setting was known was an unvaccinated healthcare worker who was infected in a hospital. Seventeen (39%) were infected while visiting a health-care facility, including a child aged 12 months who was exposed in a physician's office when receiving a routine dose of measles, mumps, and rubella (MMR) vaccine.

Fifty-four (84%) of the 64 measles cases were importation associated: 10 (16%) of the 64 were importations (five in visitors to the United States and five in U.S. residents traveling abroad) from Switzerland (three), Israel (three), Belgium (two), and India and Italy (one each); 29 (45%) cases were epidemiologically linked to importations; and 15 (23%) cases had virologic evidence of importation. The remaining 10 (16%) cases were from unknown sources; however, all occurred in communities with importationassociated cases. Specimens from 14 patients were genotyped at CDC, and four different genotypes were identified: three from Arizona (genotype D5), three from California (D5), five from New York City (one in a case epidemiologically linked to an imported case from Belgium and four in cases in communities where importations from Israel had occurred; all D4), two from Wisconsin (H1), and one from Michigan (D5).

Fifty-six of the 64 measles cases reported in 2008 have occurred in five outbreaks (defined as three or more cases linked in time or place). In New York City, an outbreak of 22 cases has been reported, including four importations and 18 other cases (10 importation associated). In Arizona, 15 cases have been reported; the index patient was an unvaccinated adult visitor from Switzerland. In San Diego, California, 11 cases have been reported, and an additional case spread to Hawaii; the index patient in the San Diego outbreak was an unvaccinated child who had traveled to Switzerland. In Michigan, four cases have been reported; the index patient was an unvaccinated youth aged 13 years with an unknown source of infection. In Wisconsin, four cases have been reported; the index patient was a person aged 37 years with unknown vaccination status who likely was exposed to a Chinese visitor with measlescompatible illness.

Sixty-three of the 64 patients were unvaccinated or had unknown or undocumented' vaccination status, and one patient had documentation of receiving 2 doses of MMR vaccine. None of the five patients who were visitors to the

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sed on MMWR surveillance summaries (2000–2006) and CDC unpublished ovisional data as of December 31, 2007. zasles clinical case definition: an illness characterized by a generalized

culopapular rash, a temperature of >101°F (238.3°C) and cough, coryza, or - junctivitis. A case is considered confirmed if it is laboratory confirmed (using ologic or virologic methods) or if it meets the clinical case definition and is demiologically linked to a confirmed case.

e other two cases in persons aged >50 years occurred in a U.S. resident aged Ć years and a visitor from Switzerland aged 71 years.

Two adults in the Arizona outbreak reported receipt of 1 and 2 vaccine doses, respectively, but lacked documentation.

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FIGURE. Number of reported measles cases* (N = 64) — United States, January 1-April 25, 2008

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United States had been vaccinated. Among the 59 patients who were U.S. residents, 13 were aged <12 months and too young to be vaccinated routinely, seven were children aged 12–15 months and had not yet received vaccination, 21 were children aged 16 months-19 years, including 14 (67%) who claimed exemptions because of religious or personal beliefs (Table). Among the 18 patients aged 220 years, 14 had unknown or undocumented vaccination status, two had claimed exemptions and acquired measles in Europe, one had evidence of immunity because of birth before 1957, and one had documentation of receiving 2 doses of MMR vaccine.

Of the five U.S. residents with measles who were vaccine eligible and had traveled abroad, all were unvaccinated. One was a child aged 15 months who was not vaccinated before travel, and two were adults who were unvaccinated because of personal belief exemptions. For two adults, the reason for not being vaccinated was unknown. Reported by: SB Redd, PK Kutty, MD, AA Parker, MSN, MPH, CW LeBaron, MD, AE Barskey, MPH, JF Seward, MBBS, JS Rota, PA Rota, PhD, L Lowe, PhD, WJ Bellini, PhD, Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Editorial Note: Although ongoing measles transmission was declared eliminated in the United States in 2000 (1) and in the World Health Organization (WHO) Region of

the Americas in 2002 (2), approximately 20 million case of measles occur each year worldwide. The 2008 upsur in measles cases serves as a reminder that measles is se imported into the United States and can result in outbreak unless population immunity remains high through vaci nation. Among the 64 confirmed measles cases, prior va cination could be documented for only one person.

Before introduction of measles vaccination in 1963 approximately 3 to 4 million persons had measles annual in the United States; approximately 400–500 died, 48,00 were hospitalized, and 1,000 developed chronic disabilir from measles encephalitis (1). Even after elimination endemic transmission in 2000, imported measles has cortinued to create a substantial U.S. public health burde of the 501 measles cases reported during 2000–2007, or in four patients was hospitalized, and one in 250 died (i

Thus far in 2008, five U.S. residents and five visitors has been documented as acquiring measles abroad. Of these 10 persons, nine acquired measles in the WHO European Region. These importations likely are related to an increase in 2008 in measles activity in Europe. In Switzerland approximately 2,250 measles cases have been reported since November 2006. The Swiss measles outbreak started Lucerne, where the measles vaccination coverage level in children is 78%, and spread across the country, predomi

ABLE. Number and percentage of reported measles cases among U.S. residents (N = 59), by age group and vaccination status nited States, January 1-April 25, 2008

Vaccination status
Unvaccinated
Born Nonmedical Reason

Missed Vaccinated
Too young before 1957 exemption* unknown opportunity with 2 doses Unknown

Total ge group No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)

No. (%) <12 mos 13 (22.0)

13 (22.0) 12–15 mos

0
6 (10.2)

1 (1.7)

7 (11.9) : o mos-4 yrs 4 (6.8) 2 (3.4) 5 (8.5) 1

0

11 (18.7) 10 (16.9) 0

0
0
0

10 (16.9) 2 (3.4) 1 (1.7) 0

1 (1.7) 12 (20.3)**17

(27.1) 1 (1.7) 0

0
0

1
(1.7)

2 (3.4) otal

13 (22.0) 1 (1.7) 16 (27.1) 9 (15.3) 5 (8.5) 1 (1.7) 14 (23.7) 59 (100.0) Persons who claimed exemption from vaccination because of religious or personal beliefs. One infant aged 7 months received a dose of measles, mumps, and rubella (MMR) vaccine (because of an accelerated vaccine schedule) the day before exposure. One child aged 12 months received a routine MMR vaccine dose on the day of exposure in a physician's office. One child aged 2 years, who was unvaccinated on the day of exposure, received a dose of MMR vaccine 6 days later; the delay was attributed to a parental request for single-antigen measles vaccine because of vaccine safety concerns. Includes two self-reports of receipt of 1 or more doses of measles vaccine. Two adults received postexposure MMR vaccine (one on the day of exposure and one on the day after exposure).

5-19 yrs 20-49 yrs

250 yrs

16

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antly affecting children aged 5–15 years who were unvacnated because of parental opposition to vaccination. ** In rael (which is included in the WHO European Region), measles outbreak with approximately 1,000 cases is ngoing (Ministry of Health, Israel, unpublished data, 008), and measles transmission is occurring in other uropean countries, predominantly among populations - pposed to vaccination. This situation prompted travel elvisories to be issued in the United States and Europe.

ealth-care providers should advise patients who travel :-. road of the importance of measles vaccination and should

onsider the diagnosis of measles in persons with clinically
mpatible illness who have traveled abroad recently or have
ad contact with travelers.
The limited size of recent measles outbreaks in the United
ates has resulted from highly effective measles and MMR
iccines, preexisting high vaccination coverage levels in

eschool and school-aged children, and a rapid and effecve public health response. All children should receive doses of MMR vaccine, with the first dose recommended age 12–15 months and the second dose at age 4–6 years. nless they have other documented evidence of measles imunity,SS all adults should receive at least 1 dose. Two ses are recommended for international travelers aged

212 months, health-care personnel, and students at secondary and postsecondary educational facilities. Infants aged 6-11 months should receive 1 dose before travel abroad (3). During a measles outbreak, the vaccination response should be guided by the epidemiology of the outbreak and the outbreak setting and might include offering 1 dose of measles or MMR vaccine to infants aged 6-11 months, offering the second dose to preschool-aged children provided that 28 days have elapsed since the first dose, and recommending 1 dose to health-care workers born before 1957 unless they show other evidence of immunity.

Patients with measles frequently seek medical care, and emergency departments are common sites of measles transmission (4). To prevent transmission of measles in healthcare settings, patients should be asked to wear a surgical mask (if tolerated) for source containment, airborne infection-control precautions (5) should be followed stringently, and patients should be placed in a negative airpressure room as soon as possible. If a negative air-pressure room is not available, the patient should be placed in a room with the door closed. Measles cases should be investigated, patients isolated promptly, and specimens obtained for laboratory confirmation and viral genoptying. Case contacts without documented evidence of measles immunity should be vaccinated, offered immune globulin, or asked to quarantine themselves at home from the fifth day after their first exposure to the twenty-first day after their last exposure. Contacts with measles-compatible symptoms should be managed in a manner that will prevent further spread (3,5).

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World Health Organization. Measles and rubella surveillance bulletin. Geneva,

Switzerland: World Health Organization; 2008. Available at http://www.euro. en who.int/vaccine/publications/20080401_1.

U.S. travel advisories available at http://wwwn.cdc.gov/travel/content
measles.aspx. European travel advisories available at http://ecdc.europa.eu/
health_topics/measles/080423_travel_advice.html.
Laboratory evidence of immunity, documentation of physician-diagnosed
measles, or birth before 1957.

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