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In 2018, an unvaccinated child returned home from Israel to New York City with measles. Other cases followed. The NYC Department of Health and Mental Hygiene (NYC DOHMH) investigated suspected cases as well as MMR vaccine uptake and intervened to control the outbreak. Between September 2018 and July 2019, 649 cases of outbreak-related measles were confirmed.
Median age of patients was 3 years (age range, 1 month–70 years). Among those with known vaccination history, 85.8% were unvaccinated. Complications included diarrhea, otitis media, and pneumonia. Among 49 (7.6%) hospitalized, 40.8% received intensive care. The majority (93.4%) were from the Orthodox Jewish community, primarily in the Williamsburg area of Brooklyn. About 40% acquired infection through community-wide transmission. Contact tracing identified >20,000 named contacts, including about 1000 infants. Contacts were managed with postexposure MMR, immune globulin, or home quarantine. Schools and childcare programs required proof of vaccination or measles immunity, and an emergency order expanded requirement of vaccination or proof of immunity for all persons living, working, or going to school in the most affected areas. Outbreak responses involved 559 NYC DOHMH staff; the estimated direct cost was $8.4 million. Interventions included a campaign to combat vaccine myths in affected communities.
Zucker JR et al. Consequences of undervaccination— measles outbreak, New York City, 2018–2019. N Engl J Med 2020 Mar 12; 382:1009. (https://doi.org/10.1056/NEJMoa1912514)
Comment
Although measles was declared eliminated from the U.S. in 2000, imported cases continue to ignite outbreaks where pockets of undervaccinated children persist. The outbreak in New York City, which is especially vulnerable because of the regular influx of travelers from other countries, was the largest in the U.S. in almost 30 years. A targeted campaign by antivaccination groups resulted in large unvaccinated populations, especially in children 1 to 4 years old. The existence of the Citywide Immunization Registry, established in 1996, provided high-quality data critical to an effective response, which also included mandatory vaccination and exclusion from school.