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BACKGROUND: In 2014, the Centers for Disease Control and Prevention (CDC) reported the highest number of measles cases since the disease was declared eliminated in the United States in 2000. Most cases in recent years have resulted from international travel to regions where measles is endemic.
METHODS: In May 2014, Public Health – Seattle & King County (PHSKC) was notified of measles in a recent traveler to the Federated States of Micronesia (FSM); three epidemiologically-linked measles case-patients were reported three weeks later. PHSKC undertook efforts to identify, immunize, and isolate susceptible case-contacts and sought consultation from CDC and FSM Department of Health and Social Affairs experts to develop a culturally appropriate outreach plan. In partnership with FSM leaders, PHSKC conducted two community-based MMR clinics. Washington State Immunization Information System (WIIS) records were used to retrospectively estimate pre-existing vaccine coverage among clinic attendees.
RESULTS: Sixteen outbreak-associated measles case-patients were identified between May and September 2014; 12 among members of the FSM community, and 4 linked to exposures to FSM cases in healthcare settings. The median age was 4 years (range, 5 months - 48 years); two (13%) were hospitalized. Eleven cases (69%) were unvaccinated, nine of whom were eligible. Approximately 283 MMR vaccines were administered at the community-based vaccination clinics. Standard measles contact tracing procedures were complicated by fluid household structure in the FSM community, and cultural naming practices that made family identification difficult. Additionally, cases’ and contacts’ wariness of sharing information with persons outside of their community, lack of familiarity with U.S. health systems, and low use of internet and cell phones introduced challenges in case identification and communication of key measles prevention messages. However, through rapid response from state and local public health jurisdictions, health care facilities, and the cooperation and support of FSM community leaders, the outbreak was halted within four generations.
CONCLUSIONS: This was the largest measles outbreak in Washington State in six years. Because of the unique cultural contexts of the affected population, standard public health protocol was insufficient to rapidly control measles transmission. Subject matter experts and community leaders assisted in the development of an effective, culturally sensitive outbreak control plan.