Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-30 (of 42 Records) |
Query Trace: Zucker JR[original query] |
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Effect of childcare influenza vaccine requirement on vaccination rates, New York City, 2012-2020
Metroka AE , Papadouka V , Ternier A , Cheng I , Zucker JR . Public Health Rep 2024 333549241260166 OBJECTIVES: In 2014, New York City initiated a childcare influenza vaccine requirement to increase influenza vaccination rates among children aged 6-59 months attending city-regulated childcare, including prekindergarten. We evaluated the requirement's effect on vaccination rates in childcare-aged children in New York City. METHODS: We examined influenza vaccination rates in children aged 6-59 months and by age groups of 1, 2, 3, and 4 years for 8 influenza seasons (2012-2013 through 2019-2020), representing 2 seasons before the requirement, 2 seasons during the requirement, 2 seasons after its suspension, and 2 seasons after its reinstatement. We also assessed rates in a comparison group of children aged 5-8 years. We performed a difference-in-differences analysis to compare rate differences in age groups when the requirement was and was not in effect. We considered P < .05 as significant based on the Wald χ(2) test. RESULTS: Influenza vaccination rates among children aged 6-59 months increased 3.7 percentage points (from 47.7% to 51.4%) by the requirement's second year and declined 6.7 percentage points to 44.7% after suspension. After reinstatement, rates increased 10.7 percentage points to 55.4%. Rate changes were most pronounced among 4-year-olds, increasing 12.7 percentage points (from 45.3% to 58.0%) by the requirement's second year, declining 14.1 percentage points to 43.9% after suspension, and increasing 22.2 percentage points to 66.1% after reinstatement. In the comparison group, rates increased 4.9 percentage points (from 36.5% to 41.4%) after reinstatement. Rates increased significantly among 4-year-olds before versus at the initial requirement and decreased significantly after suspension. After reinstatement, rates increased significantly among all groups except 1-year-olds. CONCLUSION: The New York City influenza vaccine requirement improved influenza vaccination rates among preschool-aged children, adding to the evidence base showing that vaccine requirements raise vaccination rates. |
JYNNEOS™ effectiveness as post-exposure prophylaxis against Mpox: Challenges using real-world outbreak data
Rosen JB , Arciuolo RJ , Pathela P , Boyer CB , Baumgartner J , Latash J , Malec L , Lee EH , Reddy V , King R , Edward Real J , Lipsitch M , Zucker JR . Vaccine 2024 BACKGROUND: JYNNEOS(TM) vaccine has been used as post-exposure prophylaxis (PEP) during a mpox outbreak in New York City (NYC). Data on effectiveness are limited. METHODS: Effectiveness of a single dose of JYNNEOS(TM) vaccine administered subcutaneously ≤ 14 days as PEP for preventing mpox disease was assessed among individuals exposed to case-patients from May 22, 2022-August 24, 2022. Individuals were evaluated for mpox through 21 days post-exposure. An observational study was conducted emulating a sequence of nested "target" randomized trials starting each day after exposure. Results were adjusted for exposure risk and race/ethnicity. Analyses were conducted separately based on last (PEP(L)) and first (PEP(F)) exposure date. We evaluated the potential to overestimate PEP effectiveness when using conventional analytic methods due to exposed individuals developing illness before they can obtain PEP (immortal time bias) compared to the target trial. RESULTS: Median time from last exposure to symptom onset (incubation period) among cases that did not receive PEP(L) was 7 days (range 1-16). Time to PEP(L) receipt was 7 days (range 0-14). Among 549 individuals, adjusted PEP(L) and PEP(F) effectiveness was 19 % (95 % Confidence Interval [CI], -54 % to 57 %) and -7% (95 % CI, -144 % to 53 %) using the target trial emulation, respectively, and 78 % (95 % CI, 50 % to 91 %) and 73 % (95 % CI, 31 % to 91 %) using conventional analysis. CONCLUSIONS: Determining PEP effectiveness using real-world data during an outbreak is challenging. Time to PEP in NYC coupled with the observed incubation period resulted in overestimated PEP effectiveness using a conventional method. The target trial emulation, while yielding wide confidence intervals due to small sample size, avoided immortal time bias. While results from these evaluations cannot be used as reliable estimates of PEP effectiveness, we present important methodologic considerations for future evaluations. |
Modeling undetected poliovirus circulation following the 2022 outbreak in the United States
Kalkowska DA , Badizadegan K , Routh JA , Burns CC , Rosenberg ES , Brenner IR , Zucker JR , Langdon-Embry M , Thompson KM . Expert Rev Vaccines 2024 23 (1) 186-195 BACKGROUND: New York State (NYS) reported a polio case (June 2022) and outbreak of imported type 2 circulating vaccine-derived poliovirus (cVDPV2) (last positive wastewater detection in February 2023), for which uncertainty remains about potential ongoing undetected transmission. RESEARCH DESIGN AND METHODS: Extending a prior deterministic model, we apply an established stochastic modeling approach to characterize the confidence about no circulation (CNC) of cVDPV2 as a function of time since the last detected signal of transmission (i.e. poliovirus positive acute flaccid myelitis case or wastewater sample). RESULTS: With the surveillance coverage for the NYS population majority and its focus on outbreak counties, modeling suggests a high CNC (95%) within 3-10 months of the last positive surveillance signal, depending on surveillance sensitivity and population mixing patterns. Uncertainty about surveillance sensitivity implies longer durations required to achieve higher CNC. CONCLUSIONS: In populations that maintain high immunization coverage with inactivated poliovirus vaccine (IPV), rare polio cases may occur in un(der)-vaccinated individuals. Modeling demonstrates the unlikeliness of such outbreaks reestablishing endemic transmission or resulting in large absolute numbers of paralytic cases. Achieving and maintaining high immunization coverage with IPV remains the most effective measure to prevent outbreaks and shorten the duration of imported poliovirus transmission. |
Modeling poliovirus transmission and responses in New York State
Thompson KM , Kalkowska DA , Routh JA , Brenner IR , Rosenberg ES , Zucker JR , Langdon-Embry M , Sugerman DE , Burns CC , Badizadegan K . J Infect Dis 2023 BACKGROUND: In July 2022, New York State (NYS) reported a case of paralytic polio in an unvaccinated young adult, and subsequent wastewater surveillance confirmed sustained local transmission of type 2 vaccine-derived poliovirus (VDPV2) in NYS with genetic linkage to the paralyzed patient. METHODS: We adapted an established poliovirus transmission and oral poliovirus vaccine (OPV) evolution model to characterize dynamics of poliovirus transmission in NYS, including consideration of the immunization activities performed as part of the declared state of emergency. RESULTS: Despite sustained transmission of imported VDPV2 in NYS involving potentially thousands of individuals (depending on seasonality, population structure and mixing assumptions) in 2022, the expected number of additional paralytic cases in years 2023 and beyond is small (less than 0.5). However, continued transmission and/or reintroduction of poliovirus into NYS and other populations remains a possible risk in communities that do not achieve and maintain high immunization coverage. CONCLUSION: In countries such as the US that use only inactivated poliovirus vaccine, even with high average immunization coverage, imported polioviruses may circulate and pose a small but non-zero risk of causing paralysis in non-immune individuals. |
Reduced Odds of SARS-CoV-2 Reinfection after Vaccination among New York City Adults, June-August 2021 (preprint)
Levin-Rector A , Firestein L , McGibbon E , Sell J , Lim S , Lee EH , Weiss D , Geevarughese A , Zucker JR , Greene SK . medRxiv 2021 11 Background Belief in immunity from prior infection and concern that vaccines might not protect against new variants are contributors to vaccine hesitancy. We assessed effectiveness of full and partial COVID-19 vaccination against reinfection when Delta was the predominant variant in New York City. Methods We conducted a case-control study in which case-patients with reinfection during June 15-August 31, 2021 and control subjects with no reinfection were matched (1:3) on age, sex, timing of initial positive test in 2020, and neighborhood poverty level. Conditional logistic regression was used to calculate matched odds ratios (mOR) and 95% confidence intervals (CI). Results Of 349,598 adult residents who tested positive for SARS-CoV-2 infection in 2020, did not test positive again >90 days after initial positive test through June 15, 2021, and did not die before June 15, 2021, 1,067 were reinfected during June 15-August 31, 2021. Of 1,048 with complete matching criteria data, 499 (47.6%) were known to be symptomatic for COVID-19-like-illness, and 75 (7.2%) were hospitalized. Unvaccinated individuals, compared with fully vaccinated individuals, had elevated odds of reinfection (mOR, 2.23; 95% CI, 1.90, 2.61), of symptomatic reinfection (mOR, 2.17; 95% CI, 1.72, 2.74), and of reinfection with hospitalization (mOR, 2.59; 95% CI, 1.43, 4.69). Partially versus fully vaccinated individuals had 1.58 (95% CI: 1.22, 2.06) times the odds of reinfection. All three vaccines authorized or approved for use in the U.S. were similarly effective. Conclusion Among adults with previous SARS-CoV-2 infection, vaccination reduced odds of reinfections when the Delta variant predominated. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Increases in COVID-19 vaccination among NYC municipal employees after implementation of vaccination requirements
Rubenstein BL , Amiel PJ , Ternier A , Helmy H , Lim S , Chokshi DA , Zucker JR . Health Aff (Millwood) 2023 42 (3) 357-365 In July 2021 New York City (NYC) instituted a requirement for all municipal employees to be vaccinated against COVID-19 or undergo weekly testing. The city eliminated the testing option November 1 of that year. We used general linear regression to compare changes in weekly primary vaccination series completion among NYC municipal employees ages 18-64 living in the city and a comparison group of all other NYC residents in this age group during May-December 2021. The rate of change in vaccination prevalence among NYC municipal employees was greater than that of the comparison group only after the testing option was eliminated (employee slope = 12.0; comparison slope = 5.3). Among racial and ethnic groups, the rate of change in vaccination prevalence among municipal employees was higher than the comparison group for Black and White people. The requirements were associated with narrowing the gap in vaccination prevalence between municipal employees and the comparison group overall and between Black municipal employees and employees from other racial and ethnic groups. Workplace requirements are a promising strategy for increasing vaccination among adults and reducing racial and ethnic disparities in vaccination uptake. |
Pfizer-BioNTech COVID-19 vaccine effectiveness against SARS-CoV-2 infection among long-term care facility staff with and without prior infection in New York City, January-June 2021.
Peebles K , Arciuolo RJ , Romano AS , Sell J , Greene SK , Lim S , Mulready-Ward C , Ternier A , Badenhop B , Blaney K , Real JE , Spencer M , McPherson TD , Ahuja SD , Sullivan Meissner J , Zucker JR , Rosen JB . J Infect Dis 2023 227 (4) 533-542 ![]() ![]() BACKGROUND: Evidence is accumulating of coronavirus disease 2019 (COVID-19) vaccine effectiveness among persons with prior severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: We evaluated the effect against incident SARS-CoV-2 infection of (1) prior infection without vaccination, (2) vaccination (2 doses of Pfizer-BioNTech COVID-19 vaccine) without prior infection, and (3) vaccination after prior infection, all compared with unvaccinated persons without prior infection. We included long-term care facility staff in New York City aged <65 years with weekly SARS-CoV-2 testing from 21 January to 5 June 2021. Test results were obtained from state-mandated laboratory reporting. Vaccination status was obtained from the Citywide Immunization Registry. Cox proportional hazards models adjusted for confounding with inverse probability of treatment weights. RESULTS: Compared with unvaccinated persons without prior infection, incident SARS-CoV-2 infection risk was lower in all groups: 54.6% (95% confidence interval, 38.0%-66.8%) lower among unvaccinated, previously infected persons; 80.0% (67.6%-87.7%) lower among fully vaccinated persons without prior infection; and 82.4% (70.8%-89.3%) lower among persons fully vaccinated after prior infection. CONCLUSIONS: Two doses of Pfizer-BioNTech COVID-19 vaccine reduced SARS-CoV-2 infection risk by ≥80% and, for those with prior infection, increased protection from prior infection alone. These findings support recommendations that all eligible persons, regardless of prior infection, be vaccinated against COVID-19. |
Wastewater Testing and Detection of Poliovirus Type 2 Genetically Linked to Virus Isolated from a Paralytic Polio Case - New York, March 9-October 11, 2022.
Ryerson AB , Lang D , Alazawi MA , Neyra M , Hill DT , St George K , Fuschino M , Lutterloh E , Backenson B , Rulli S , Ruppert PS , Lawler J , McGraw N , Knecht A , Gelman I , Zucker JR , Omoregie E , Kidd S , Sugerman DE , Jorba J , Gerloff N , Ng TFF , Lopez A , Masters NB , Leung J , Burns CC , Routh J , Bialek SR , Oberste MS , Rosenberg ES . MMWR Morb Mortal Wkly Rep 2022 71 (44) 1418-1424 ![]() In July 2022, a case of paralytic poliomyelitis resulting from infection with vaccine-derived poliovirus (VDPV) type 2 (VDPV2)(§) was confirmed in an unvaccinated adult resident of Rockland County, New York (1). As of August 10, 2022, poliovirus type 2 (PV2)(¶) genetically linked to this VDPV2 had been detected in wastewater** in Rockland County and neighboring Orange County (1). This report describes the results of additional poliovirus testing of wastewater samples collected during March 9-October 11, 2022, and tested as of October 20, 2022, from 48 sewersheds (the community area served by a wastewater collection system) serving parts of Rockland County and 12 surrounding counties. Among 1,076 wastewater samples collected, 89 (8.3%) from 10 sewersheds tested positive for PV2. As part of a broad epidemiologic investigation, wastewater testing can provide information about where poliovirus might be circulating in a community in which a paralytic case has been identified; however, the most important public health actions for preventing paralytic poliomyelitis in the United States remain ongoing case detection through national acute flaccid myelitis (AFM) surveillance(††) and improving vaccination coverage in undervaccinated communities. Although most persons in the United States are sufficiently immunized, unvaccinated or undervaccinated persons living or working in Kings, Orange, Queens, Rockland, or Sullivan counties, New York should complete the polio vaccination series as soon as possible. |
Reduced Odds of SARS-CoV-2 Reinfection after Vaccination among New York City Adults, July-November 2021.
Levin-Rector A , Firestein L , McGibbon E , Sell J , Lim S , Lee EH , Weiss D , Geevarughese A , Zucker JR , Greene SK . Clin Infect Dis 2022 76 (3) e469-e476 ![]() BACKGROUND: Belief that vaccination is not needed for individuals with prior infection contributes to COVID-19 vaccine hesitancy. Among individuals infected with SARS-CoV-2 before vaccines became available, we assessed whether vaccinated individuals had reduced odds of reinfection. METHODS: We conducted a case-control study among adult New York City residents who tested positive for SARS-CoV-2 infection in 2020, did not test positive again >90 days after initial positive test through July 1, 2021, and did not die before July 1, 2021. Case-patients with reinfection during July-November 2021 and control subjects with no reinfection were matched (1:3) on age, sex, timing of initial positive test in 2020, and neighborhood poverty level. Matched odds ratios (mOR) and 95% confidence intervals (CI) were calculated using conditional logistic regression. RESULTS: Of 349,827 eligible adults, 2,583 were reinfected during July-November 2021. Of 2,401 with complete matching criteria data, 1,102 (45.9%) were known to be symptomatic for COVID-19-like-illness, and 96 (4.0%) were hospitalized. Unvaccinated individuals, compared with individuals fully vaccinated within the prior 90 days, had elevated odds of reinfection (mOR, 3.21; 95% CI, 2.70, 3.82), of symptomatic reinfection (mOR, 2.97; 95% CI, 2.31, 3.83), and of reinfection with hospitalization (mOR, 2.09; 95% CI, 0.91, 4.79). All three vaccines authorized or approved for use in the U.S. were similarly effective. CONCLUSION: Vaccination reduced odds of reinfections when the Delta variant predominated. Further studies should assess risk of severe outcomes among reinfected persons as new variants emerge, infection- and vaccine-induced immunity wanes, and booster doses are administered. |
Maintenance of measles elimination status in the United States for 20 years despite increasing challenges
Mathis AD , Clemmons NS , Redd SB , Pham H , Leung J , Wharton AK , Anderson R , McNall RJ , Rausch-Phung E , Rosen JB , Blog D , Zucker JR , Bankamp B , Rota PA , Patel M , Gastañaduy PA . Clin Infect Dis 2021 75 (3) 416-424 BACKGROUND: Measles elimination (interruption of endemic measles virus transmission) in the United States was declared in 2000; however, the number of cases and outbreaks have increased in recent years. We characterized the epidemiology of measles outbreaks and measles transmission patterns post-elimination to identify potential gaps in the U.S. measles control program. METHODS: We analyzed national measles notification data from January 1, 2001-December 31, 2019. We defined measles infection clusters as single cases (isolated cases not linked to additional cases), 2-case clusters, or outbreaks with 3 or more linked cases. We calculated the effective reproduction number (R) to assess changes in transmissibility and reviewed molecular epidemiology data. RESULTS: During 2001-2019, 3,873 measles cases, including 747 international importations, were reported in the United States; 29% of importations were associated with outbreaks. Among 871 clusters, 69% were single cases and 72% had no spread. Larger and longer clusters were reported since 2013, including seven outbreaks with >50 cases lasting >2 months, 5 of which occurred in known underimmunized, close-knit communities. No measles lineage circulated in a single transmission chain for >12 months. Higher estimates of R were noted in recent years, although R remained below the epidemic threshold of 1. CONCLUSIONS: Current epidemiology continues to support the interruption of endemic measles virus transmission in the United States. However, larger and longer outbreaks in recent post-elimination years and emerging trends of increased transmission in underimmunized communities emphasize the need for targeted approaches to close existing immunity gaps and maintain measles elimination. |
Trends in hepatitis B surveillance among pregnant women in New York City, 1998-2015
Arciuolo RJ , Lazaroff JE , Rosen JB , Lim S , Zucker JR . Public Health Rep 2020 135 (5) 676-684 OBJECTIVE: Infants born to women with hepatitis B virus (HBV) infection are at high risk for chronic HBV infection and premature death. We examined epidemiologic trends among women with HBV infection who gave birth in New York City (NYC) to inform public health prevention activities. METHODS: We obtained data on HBV-infected women residing and giving birth in NYC during 1998-2015 from the NYC Perinatal HBV Prevention Program. We obtained citywide birth data from the NYC Office of Vital Statistics. We calculated the incidence of births to HBV-infected women per 100 000 live births and stratified by maternal race, birthplace, and age. We calculated annual percentage change (APC) in incidence of births to HBV-infected women by using joinpoint regression. RESULTS: Of 29 896 HBV-infected women included in the study, 28 195 (94.3%) were non-US-born, of whom 16 600 (58.9%) were born in China. Overall incidence of births to HBV-infected women per 100 000 live births increased from 1156 in 1998 to 1573 in 2006 (APC = 3.1%; P < .001) but declined to 1329 in 2015 (APC = -1.4%; P = .02). Incidence among US-born women declined from 1998 to 2015 (330 to 84; APC = -7.3%; P < .001) and among non-US-born women increased from 1998 to 2007 (1877 to 2864; APC = 3.6%; P < .001) but not thereafter. Incidence among women born in China increased from 1998 to 2006 (13 275 to 16 480; APC = 1.8%; P = .02) but decreased to 12 631 through 2015 (APC = -3.3%; P < .001). CONCLUSIONS: The incidence of births to HBV-infected women in NYC declined significantly among US-born women but not among non-US-born women, highlighting the need for successful vaccination programs worldwide. |
Notes from the Field: Rebound in Routine Childhood Vaccine Administration Following Decline During the COVID-19 Pandemic - New York City, March 1-June 27, 2020.
Langdon-Embry M , Papadouka V , Cheng I , Almashhadani M , Ternier A , Zucker JR . MMWR Morb Mortal Wkly Rep 2020 69 (30) 999-1001 Concerns have been raised about falling childhood vaccine administration and vaccination coverage rates (1,2) during the coronavirus disease 2019 (COVID-19) pandemic. In New York City (NYC), decreasing vaccination coverage has been of particular concern in light of recent outbreaks of vaccine-preventable diseases, including a large measles outbreak during 2018–2019 (3). The effect of the COVID-19 pandemic on routine childhood vaccination was monitored by the NYC Department of Health and Mental Hygiene (DOHMH) using the Citywide Immunization Registry (CIR),* a population-based immunization information system with high data quality and provider participation (4,5). CIR includes 2.7 million patient records for NYC persons aged 0–18 years and receives reports from approximately 1,600 immunization facilities. The weekly number of routine childhood vaccine doses administered to persons aged <24 months and 2–18 years in 2020 was compared with the number administered during the same period in 2019; influenza vaccine and vaccines administered in pharmacies and hospital nurseries were excluded from this report.† Likewise, the weekly number of unique facilities that reported administering at least one childhood vaccine in 2020 to 2019 was also compared. |
Use of capture-recapture analysis to assess reporting completeness of births to hepatitis B-positive women in New York City, 2013-2014
Devinney K , Lazaroff J , Rosen JB , Zimmerman CM , Zucker JR . Public Health Rep 2020 135 (3) 322-328 OBJECTIVES: The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) depends on reporting by health care facilities and laboratories for disease surveillance. Our objective was to evaluate the completeness of DOHMH surveillance to identify births to hepatitis B virus (HBV)-positive women to prevent perinatal transmission. METHODS: We identified infants born to HBV-positive women by matching mothers of all infants born in NYC during May 1, 2013-May 1, 2014, identified from the Citywide Immunization Registry (CIR) to persons with HBV-positive laboratory reports in the Electronic Laboratory Reporting (ELR) system. We then matched infants born to mothers identified in the CIR/ELR match to infants born to HBV-positive women from the DOHMH perinatal HBV surveillance database. We performed capture-recapture analysis to evaluate completeness of DOHMH case identification. We compared the proportion of infants born to HBV-positive mothers reported to DOHMH with the proportion of infants identified only through the CIR/ELR match for receipt of postexposure prophylaxis (PEP) and completion of the HBV vaccination series and post-vaccination serology testing. RESULTS: Of 1662 infants identified from the CIR/ELR match and 1554 infants in the DOHMH database, 1493 infants matched. Of 169 infants only in the CIR/ELR data set, 55 were born to HBV-positive women residing in NYC. Sixty-one infants were only in the DOHMH database. An estimated 2 infants were not identified by either method. The CIR/ELR match increased infant identification by 3.5%, from 1554 to 1609 infants. The proportion of infants who received PEP was significantly higher among infants whose mothers were reported to DOHMH (vs not reported to DOHMH). PRACTICAL IMPLICATIONS: Use of the CIR/ELR match may further improve DOHMH identification of infants born to HBV-positive women and receipt of infant PEP. |
Surveillance data confirm multiyear predictions of rotavirus dynamics in New York City
Olson DR , Lopman BA , Konty KJ , Mathes RW , Papadouka V , Ternier A , Zucker JR , Simonsen L , Grenfell BT , Pitzer VE . Sci Adv 2020 6 (9) eaax0586 Prediction skill is a key test of models for epidemic dynamics. However, future validation of models against out-of-sample data is rare, partly because of a lack of timely surveillance data. We address this gap by analyzing the response of rotavirus dynamics to infant vaccination. Syndromic surveillance of emergency department visits for diarrhea in New York City reveals a marked decline in diarrheal incidence among infants and young children, in line with data on rotavirus-coded hospitalizations and laboratory-confirmed cases, and a shift from annual to biennial epidemics increasingly affecting older children and adults. A published mechanistic model qualitatively predicted these patterns more than 2 years in advance. Future efforts to increase vaccination coverage may disrupt these patterns and lead to further declines in the incidence of rotavirus-attributable gastroenteritis. |
Consequences of undervaccination - measles outbreak, New York City, 2018-2019
Zucker JR , Rosen JB , Iwamoto M , Arciuolo RJ , Langdon-Embry M , Vora NM , Rakeman JL , Isaac BM , Jean A , Asfaw M , Hawkins SC , Merrill TG , Kennelly MO , Maldin Morgenthau B , Daskalakis DC , Barbot O . N Engl J Med 2020 382 (11) 1009-1017 BACKGROUND: Measles was declared eliminated in the United States in 2000, but the risk of outbreaks owing to international importations remains. An outbreak of measles in New York City began when one unvaccinated child returned home from Israel with measles; onset of rash occurred on September 30, 2018, 9 days after the child returned home. METHODS: We investigated suspected cases of measles by conducting interviews, reviewing medical and immunization records, identifying exposed persons, and performing diagnostic testing. Measles-mumps-rubella (MMR) vaccine (given as either MMR or measles-mumps-rubella-varicella vaccine and collectively referred to as MMR vaccine) uptake was monitored with the use of the Citywide Immunization Registry. The total direct cost to the New York City Department of Health and Mental Hygiene was calculated. RESULTS: A total of 649 cases of measles were confirmed, with onsets of rash occurring between September 30, 2018, and July 15, 2019. A majority of the patients (93.4%) were part of the Orthodox Jewish community, and 473 of the patients (72.9%) resided in the Williamsburg area of Brooklyn, New York. The median age was 3 years; 81.2% of the patients were 18 years of age or younger, and 85.8% of the patients with a known vaccination history were unvaccinated. Serious complications included pneumonia (in 37 patients [5.7%]) and hospitalization (in 49 patients [7.6%]); among the patients who were hospitalized, 20 (40.8%) were admitted to an intensive care unit. As a result of efforts to promote vaccination, the percentage of children in Williamsburg who received at least one dose of MMR vaccine increased from 79.5% to 91.1% among children 12 to 59 months of age. As of September 9, 2019, a total of 559 staff members at the Department of Health and Mental Hygiene (7% of the agency) had been involved in the measles response. The cost of the Department of Health and Mental Hygiene response was $8.4 million. CONCLUSIONS: Importation of measles and vaccination delays among young children led to an outbreak of measles in New York City. The outbreak response was resource intensive and caused serious illness, particularly among unvaccinated children. |
Mumps: an Update on Outbreaks, Vaccine Efficacy, and Genomic Diversity.
Lam E , Rosen JB , Zucker JR . Clin Microbiol Rev 2020 33 (2) ![]() SUMMARYMumps is an acute viral infection characterized by inflammation of the parotid and other salivary glands. Persons with mumps are infectious from 2 days before through 5 days after parotitis onset, and transmission is through respiratory droplets. Despite the success of mumps vaccination programs in the United States and parts of Europe, a recent increase in outbreaks of mumps virus infections among fully vaccinated populations has been reported. Although the effectiveness of the mumps virus component of the measles-mumps-rubella (MMR) vaccine is suboptimal, a range of contributing factors has led to these outbreaks occurring in high-vaccination-coverage settings, including the intensity of exposure, the possibility of vaccine strain mismatch, delayed implementation of control measures due to the timeliness of reporting, a lack of use of appropriate laboratory tests (such as reverse transcription-PCR), and time since last vaccination. The resurgence of mumps virus infections among previously vaccinated individuals over the past decade has prompted discussions about new strategies to mitigate the risk of future outbreaks. The decision to implement a third dose of the MMR vaccine in response to an outbreak should be considered in discussions with local public health agencies. Traditional public health measures, including the isolation of infectious persons, timely contact tracing, and effective communication and awareness education for the public and medical community, should remain key interventions for outbreak control. Maintaining high mumps vaccination coverage remains key to U.S. and global efforts to reduce disease incidence and rates of complications. |
National update on measles cases and outbreaks - United States, January 1-October 1, 2019
Patel M , Lee AD , Clemmons NS , Redd SB , Poser S , Blog D , Zucker JR , Leung J , Link-Gelles R , Pham H , Arciuolo RJ , Rausch-Phung E , Bankamp B , Rota PA , Weinbaum CM , Gastanaduy PA . MMWR Morb Mortal Wkly Rep 2019 68 (40) 893-896 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). |
Notes from the field: Interventions to reduce measles virus exposures in outpatient health care facilities - New York City, 2018
Alroy KA , Vora NM , Arciuolo RJ , Asfaw M , Isaac BM , Iwamoto M , Jean A , Benkel DH , Blaney K , Crouch B , Geevarughese A , Graham KA , Lash M , Daskalakis D , Zucker JR , Rosen JB . MMWR Morb Mortal Wkly Rep 2019 68 (36) 791-792 Strengthening health care facility infection control is crucial to preventing infectious disease transmission. Guidelines to prevent or minimize airborne pathogen spread in outpatient health care facilities exist (1); however, few reports describe practical implementation when engineering controls, such as recommended airborne infection isolation rooms (negative pressure rooms), are unavailable* (2). On September 30, 2018, a person with measles, a highly contagious respiratory illness characterized by fever and rash, that is spread by airborne transmission, was detected in New York City (NYC),† and as of December 10, 42 laboratory or epidemiologically linked cases had been confirmed. By September 3, 2019, with 654 confirmed cases, this measles outbreak had become the largest in the United States since 1992, well before endemic domestic measles transmission was declared eliminated in 2000§,¶ (3,4). Interventions used in 15 outpatient health care facilities to attempt to prevent health care facility exposure from patients with suspected measles were evaluated. |
Improving HPV vaccine delivery at school-based health centers
Oliver K , McCorkell C , Pister I , Majid N , Benkel DH , Zucker JR . Hum Vaccin Immunother 2019 15 1870-1877 OBJECTIVE: To identify characteristics associated with human papilloma virus (HPV) vaccination rates, describe barriers and facilitators to vaccine uptake and the potential role for clinician-to-clinician Assessment, Feedback, Incentives, and eXchange (AFIX) visits in school-based health centers (SBHCs). METHODS: We conducted clinician-to-clinician AFIX visits at 24 New York City (NYC) high-school and middle-school SBHCs with up-to-date adolescent vaccination rates below 40%. Using NYC's immunization information system, we assessed HPV initiation and series completion rates at the time of AFIX visit and follow-up three to five months later. We analyzed responses to a questionnaire and summarized interviews to identify barriers and facilitators to HPV immunization practices and quality improvement (QI) implementation. RESULTS: Baseline initiation and completion rates were 76% and 43% for high schools, and 81% and 45% for middle schools. SBHCs that allowed adolescent self-consent or did not require separate vaccine consent had higher baseline rates, but was not statistically significant. Barriers to series completion included challenges with scheduling and appointment compliance. At follow-up, high school SBHCs increased HPV vaccine initiation by 2.9 percentage points (p < 0.01) and series completion by 2.7 percentage points (p < 0.05). There was no statistically significant increase at middle school SBHCs. Most SBHCs (88%) chose reminder/recall systems as a QI strategy. Fewer than half (42%) implemented their QI strategy. CONCLUSIONS: We identified barriers to HPV vaccine series completion at our sample of SBHCs. Clinician-to-clinician AFIX visits may help improve vaccination rates and encourage providers to address barriers, including streamlining consent processes for HPV vaccination. |
Public health consequences of a 2013 measles outbreak in New York City
Rosen JB , Arciuolo RJ , Khawja AM , Fu J , Giancotti FR , Zucker JR . JAMA Pediatr 2018 172 (9) 811-817 Importance: Internationally imported cases of measles into the United States can lead to outbreaks requiring extensive and rapid control measures. Importation of measles from an unvaccinated adolescent in 2013 led to what has been the largest outbreak of measles in New York City, New York, since 1992. Objective: To describe the epidemiology and public health burden in terms of resources and cost of the 2013 measles outbreak in New York City. Design, Setting, and Participants: This epidemiologic assessment and cost analysis conducted between August 15, 2013, and August 5, 2014, examined all outbreak-associated cases of measles among persons residing in New York City in 2013. Exposures: Measles virus. Main Outcomes and Measures: Numbers of measles cases and contacts. Total personnel time and total direct cost to the New York City Department of Health and Mental Hygiene (DOHMH), calculated as the sum of inputs (supplies and materials, equipment, and logistics) and personnel time (salary and fringe benefits). Results: Between March 13, 2013, and June 9, 2013, 58 persons in New York City with a median age of 3 years (range, 0-32 years) were identified as having measles. Among these individuals, 45 (78%) were at least 12 months old and were unvaccinated owing to parental refusal or intentional delay. Only 28 individuals (48%) visited a medical health care professional who suspected measles and reported the case to the DOHMH at the initial clinical suspicion. Many case patients were not immediately placed into airborne isolation, resulting in exposures in 11 health care facilities. In total, 3351 exposed contacts were identified. Total direct costs to the New York City DOHMH were $394448, and a total of 10054 hours were consumed responding to and controlling the outbreak. Conclusions and Relevance: Vaccine refusals and delays appeared to have propagated a large outbreak following importation of measles into the United States. Prompt recognition of measles along with rapid implementation of airborne isolation of individuals suspected of measles infection in health care facilities and timely reporting to public health agencies may avoid large numbers of exposures. The response and containment of measles outbreaks are resource intensive. |
Effectiveness of measles vaccination and immune globulin post-exposure prophylaxis in an outbreak setting - New York City, 2013
Arciuolo RJ , Jablonski RR , Zucker JR , Rosen JB . Clin Infect Dis 2017 65 (11) 1843-1847 Background: Measles, mumps, and rubella vaccine (MMR) or immune globulin (IG) are routinely used for measles post-exposure prophylaxis (PEP). However, current literature on the effectiveness of measles PEP is limited and variable. Here, we examined the effectiveness of MMR and IG PEP among children exposed to measles during an outbreak in New York City (NYC) in 2013. Methods: Contacts were identified by the NYC Department of Health and Mental Hygiene between 13 March 2013 and 30 June 2013. Immunity to measles and receipt of PEP was determined for contacts. PEP effectiveness [(1 - relative risk of developing measles) x 100] was calculated for MMR, IG, and any PEP (MMR or IG) for nonimmune contacts aged <19 years. Results: A total of 3409 contacts were identified, of which 208 (6.1%), 274 (8.0%), and 318 (9.3%) met the inclusion criteria for analysis of MMR, IG, and any PEP effectiveness, respectively. Of the contacts included, 44 received MMR PEP and 77 received IG PEP. Effectiveness of MMR PEP was 83.4% (95% confidence interval [CI], 34.4%, 95.8%). No contact who received IG PEP developed measles; effectiveness of IG PEP was 100% (approximated 95% CI, 56.2%, 99.8%). Effectiveness of receiving any PEP (MMR or IG) was 92.9% (95% CI, 56.2%, 99.8%). Conclusions: Contacts who received PEP were less likely to develop disease. Our findings support current recommendations for administration of PEP following exposure to measles. These results highlight the importance of a rapid public health outbreak response to limit measles transmission following case identification. |
Identifying gaps in respiratory syncytial virus disease epidemiology in the United States prior to the introduction of vaccines
Kim L , Rha B , Abramson JS , Anderson LJ , Byington CL , Chen GL , DeVincenzo J , Edwards KM , Englund JA , Falsey AR , Griffin MR , Karron RA , Martin KG , Meissner HC , Munoz FM , Pavia AT , Piedra PA , Schaffner W , Simoes EAF , Singleton R , Talbot HK , Walsh EE , Zucker JR , Gerber SI . Clin Infect Dis 2017 65 (6) 1020-1025 Respiratory syncytial virus (RSV) causes lower respiratory tract illness frequently. No effective antivirals or vaccines for RSV are approved for use in the United States; however, there are at least 50 vaccines and monoclonal antibody products in development, with those targeting older adults and pregnant women (to protect young infants) in phase 2 and 3 clinical trials. Unanswered questions regarding RSV epidemiology need to be identified and addressed prior to RSV vaccine introduction to guide the measurement of impact and future recommendations. The Centers for Disease Control and Prevention (CDC) convened a technical consultation to gather input from external subject matter experts on their individual perspectives regarding evidence gaps in current RSV epidemiology in the United States, potential studies and surveillance platforms needed to fill these gaps, and prioritizing efforts. Participants articulated their individual views, and CDC staff synthesized individuals' input into this report. |
Rubella surveillance and diagnostic testing among a low-prevalence population, New York City, 2012-2013
Isaac BM , Zucker JR , Giancotti FR , Abernathy E , Icenogle J , Rakeman JL , Rosen JB . Clin Vaccine Immunol 2017 24 (9) The New York City Department of Health and Mental Hygiene (DOHMH) receives clinical and laboratory reports for rubella. Because rubella immunoglobulin M (IgM) assays may produce false positive results and rubella infections may be asymptomatic, interpretation of positive IgM results can be challenging. Rubella reports received by DOHMH in 2012-2013 were reviewed. Rubella IgM testing purpose was determined through case investigation. Results of IgM testing by indirect enzyme-linked immunosorbent assay (ELISA) and capture enzyme immunoassay (EIA) were compared to determine positive predictive value (PPV) and specificity. DOHMH received 199 rubella reports; 2 were true cases. Of all reports, 77.9% were tested for rubella IgM erroneously, 19.6% were tested for diagnostic purposes, 2.0% had unknown test purpose, and 0.5% were not tested. PPV of indirect ELISA was 6% overall, 14% for diagnostic tests, and 0% for tests ordered erroneously. PPV of capture EIA was 29% overall, 50% for diagnostic tests, and 0% for tests ordered erroneously. Overall, specificity was 52% for indirect ELISA and 85% for capture EIA. Limiting rubella IgM testing to patients for whom rubella diagnosis is suspected and using a more specific IgM assay have the potential to reduce false positive rubella IgM results. |
Hepatitis A cases among food handlers: A local health department response - New York City, 2013
Ridpath A , Reddy V , Layton M , Misener M , Scaccia A , Starr D , Stavinsky F , Varma JK , Waechter H , Zucker JR , Balter S . J Public Health Manag Pract 2017 23 (6) 571-576 During 2013, the New York City Department of Health and Mental Hygiene (DOHMH) received reports of 6 hepatitis A cases among food handlers. We describe our decision-making process for public notification, type of postexposure prophylaxis (PEP) offered, and lessons learned. For 3 cases, public notification was issued and DOHMH offered only hepatitis A vaccine as PEP. Subsequent outbreaks resulted from 1 case for which no public notification was issued or PEP offered, and 1 for which public notification was issued and PEP was offered too late. DOHMH continues to use environmental assessments to guide public notification decisions and offer only hepatitis A vaccine as PEP after public notification but recognizes the need to evaluate each situation individually. The PEP strategy employed by DOHMH should be considered because hepatitis A vaccine is immunogenic in all age groups, can be obtained by local jurisdictions more quickly, and is logistically easier to administer in mass clinics than immunoglobulin. |
Notes from the Field: use of social media as a communication tool during a mumps outbreak - New York City, 2015
Isaac BM , Zucker JR , MacGregor J , Asfaw M , Rakeman JL , Fu J , Deocharan B , Liu D , Rosen JB . MMWR Morb Mortal Wkly Rep 2017 66 (2) 60-61 On August 16, 2015, a case of parotitis in a resident of the Rockaways neighborhood of Queens, New York City (NYC), was reported to the NYC Department of Health and Mental Hygiene (DOHMH) as a suspected mumps case. Subsequent investigations by DOHMH discovered an outbreak of mumps in the Rockaways, with 52 confirmed and probable mumps cases. DOHMH conducted a Facebook advertisement campaign providing information about mumps and the outbreak, which was targeted to Facebook users in the Rockaways neighborhood. The advertisement was shown to 86,111 persons during an approximately 2-week period and provided a timely and inexpensive means of effectively communicating with a large, targeted population. |
Mumps outbreak among a highly vaccinated university community - New York City, NY, January - April 2014
Patel LN , Arciuolo R , Fu J , Giancotti FR , Zucker JR , Rakeman J , Rosen JB . Clin Infect Dis 2016 64 (4) 408-412 BACKGROUND: On January 14, 2014, a vaccinated student presented with parotitis. Mumps IgM testing was negative and reverse-transcription polymerase chain reaction (RT-PCR) testing was not performed, resulting in a missed diagnosis and the start of an outbreak at a New York City (NYC) university. METHODS: Mumps case investigations included patient interviews, medical records review, and laboratory testing including mumps serology and RT-PCR. Cases were considered linked to the outbreak if they attended or had epidemiologic linkage to the university. Epidemiologic, clinical, and laboratory data for outbreak cases residing in NYC were analyzed. RESULTS: Fifty-six NYC residents with mumps were identified with onsets between January 12 and April 30, 2014. Fifty-three cases (95%) were university students, 1 (2%) was a staff member, and 2 (4%) had epidemiologic links to the university. The median age was 20 years (range 18-37 years). All cases had parotitis. Three cases were hospitalized, including one of two cases with orchitis. Fifty-four (96%) cases had received ≥1 mumps-containing vaccine, 1 (2%) was unvaccinated due to religious exemption, and 1 (2%) had unknown vaccination status. Two (5%) of the 44 cases tested by serology were mumps IgM positive, and 27 (68%) of the 40 tested by RT-PCR were positive. CONCLUSIONS: Mumps outbreaks can occur in highly-vaccinated populations. Mumps should be considered in patients with parotitis regardless of vaccination status. RT-PCR is the preferred testing method; providers should not rely on IgM testing alone. High vaccination coverage and control measures likely limited the extent of the outbreak. |
Effects of Health Level 7 messaging on data quality in New York City’s immunization information system, 2014
Metroka AE , Papadouka V , Ternier A , Zucker JR . Public Health Rep 2016 131 (4) 583-587 Objective. We compared the quality of data reported to New York City’s immunization information system, the Citywide Immunization Registry (CIR), through its real-time Health Level 7 (HL7) Web service from electronic health records (EHRs), with data submitted through other methods. Methods. We stratified immunizations administered and reported to the CIR in 2014 for patients aged 0–18 years by reporting method: (1) sending HL7 messages from EHRs through the Web service, (2) manual data entry, and (3) upload of a non-standard flat file from EHRs. We assessed completeness of reporting by measuring the percentage of immunizations reported with lot number, manufacturer, and Vaccines for Children (VFC) program eligibility. We assessed timeliness of reporting by determining the number of days from date of administration to date entered into the CIR. Results. HL7 reporting accounted for the largest percentage (46.3%) of the 3.8 million immunizations reported in 2014. Of immunizations reported using HL7, 97.9% included the lot number and 92.6% included the manufacturer, compared with 50.4% and 48.0% for manual entry, and 65.9% and 48.8% for non-standard flat file, respectively. VFC eligibility was 96.9% complete when reported by manual data entry, 95.3% complete for HL7 reporting, and 87.2% complete for non-standard flat file reporting. Of the three reporting methods, HL7 was the most timely: 77.6% of immunizations were reported by HL7 in <1 day, compared with 53.6% of immunizations reported through manual data entry and 18.1% of immunizations reported through non-standard flat file. Conclusion. HL7 reporting from EHRs resulted in more complete and timely data in the CIR compared with other reporting methods. Providing resources to facilitate HL7 reporting from EHRs to immunization information systems to increase data quality should be a priority for public health. © 2016, Association of Schools of Public Health. All rights reserved. |
Elevated pertussis reporting in response to 2011-2012 outbreak, New York City, New York, USA
Arciuolo RJ , Rosen JB , Zucker JR . Emerg Infect Dis 2016 22 (6) 1117-9 Pertussis is a highly communicable, acute bacterial respiratory infection caused by Bordetella pertussis. In the United States, the incidence of pertussis declined dramatically after pertussis-containing vaccine was introduced in the 1940s (1,2). However, a resurgence of disease results in widespread outbreaks of pertussis nationally (3). | Beginning in August 2011, an outbreak of pertussis occurred in New York City (NYC), New York, USA. Reported pertussis incidence by month peaked in December 2011 (1.03 cases/100,000 persons) and remained above the baseline average monthly incidence of 0.11 cases/100,000 persons until February 2013. We hypothesized that provider awareness and altered practices after the start of the outbreak contributed to the sustained elevation in reported pertussis incidence. | To test this hypothesis, we surveyed NYC providers to assess their awareness of the outbreak, their consideration of pertussis in symptomatic patients, and the type and frequency of diagnostic testing ordered. The survey (available on request) was designed in FeedbackServer 5 (University of Massachusetts, Worcester, MA, USA; https://w3.umassmed.edu/fs/FeedbackServer/help/feedbackserver.htm) and consisted of 20 questions that required ≈5 minutes to complete by using a Web link. We distributed the survey in January 2013 to providers through 3 health department email lists: the NYC Health Alert Network, the Citywide Immunization Registry, and the Primary Care Information Project. The lists included ≈30,000 email addresses that were not mutually exclusive and that included nonmedical providers. |
Cost-effectiveness of meningococcal vaccination among men who have sex with men in New York City
Simon MS , Weiss D , Geevarughese A , Kratz MM , Cutler B , Gulick RM , Zucker JR , Varma JK , Schackman BR . J Acquir Immune Defic Syndr 2015 71 (2) 146-54 BACKGROUND: To control an outbreak of invasive meningococcal disease (IMD) among men who have sex with men (MSM) in New York City (NYC), the NYC Department of Health and Mental Hygiene (DOHMH) recommended vaccination of all HIV-infected MSM and at-risk HIV-uninfected MSM in October 2012. METHODS: A decision analytic model estimated the cost-effectiveness of meningococcal vaccination compared to no vaccination. Model inputs, including IMD incidence of 20.5 per 100,000 HIV-positive MSM (42% fatal) and 7.6 per 100,000 HIV-negative MSM (20% fatal), were from DOHMH reported data and published sources. Outcomes included costs (2012 US dollars), IMD cases averted, IMD deaths averted, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER; $/QALY). Scenarios with and without herd immunity were considered and sensitivity analyses were performed on key inputs. RESULTS: Compared to no vaccination, the targeted vaccination campaign averted an estimated 2.7 IMD cases, 1.0 IMD deaths, with an ICER of $66,000/QALY when herd immunity was assumed. Without herd immunity, vaccination prevented 1.1 IMD cases, 0.4 IMD deaths, with an ICER of $177,000/QALY. In one-way sensitivity analyses, variables that exerted the greatest influence on results in order of effect were the magnitude of herd immunity, IMD case fatality ratio and IMD incidence. In probabilistic sensitivity analyses, at a cost-effectiveness threshold of $100,000/QALY, vaccination was preferred in 97% of simulations with herd immunity and 20% of simulations without herd immunity. CONCLUSIONS: Vaccination during an IMD outbreak among MSM with and without HIV infection was projected to avert IMD cases and deaths and could be cost-effective depending on IMD incidence, case fatality, and herd immunity. |
Community-based outbreak of Neisseria meningitidis serogroup C infection in men who have sex with men, New York City, New York, USA, 2010-2013
Kratz MM , Weiss D , Ridpath A , Zucker JR , Geevarughese A , Rakeman J , Varma JK . Emerg Infect Dis 2015 21 (8) 1379-86 In September 2012, the New York City Department of Health and Mental Hygiene identified an outbreak of Neisseria meningitidis serogroup C invasive meningococcal disease among men who have sex with men (MSM). Twenty-two case-patients and 7 deaths were identified during August 2010-February 2013. During this period, 7 cases in non-MSM were diagnosed. The slow-moving outbreak was linked to the use of websites and mobile phone applications that connect men with male sexual partners, which complicated the epidemiologic investigation and prevention efforts. We describe the outbreak and steps taken to interrupt transmission, including an innovative and wide-ranging outreach campaign that involved direct, internet-based, and media-based communications; free vaccination events; and engagement of community and government partners. We conclude by discussing the challenges of managing an outbreak affecting a discrete community of MSM and the benefits of using social networking technology to reach this at-risk population. |
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