Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019 

National Update on Measles Cases and Outbreaks — United States, January 1–October 1, 2019

MMWR Early Release / October 4, 2019 / Vol. 68

A total of 1,249 measles cases have been reported in the United States in 2019, with most cases associated with large and closely related outbreaks in New York City (NYC) and the rest of New York State (NYS). Consistent with previous outbreaks that have occurred since measles was declared eliminated in the United States in 2000, most of the other US outbreaks reported in 2019 were of limited size and duration because of high population immunity and rapid implementation of outbreak control measures by local and state public health authorities. In contrast, the two sustained outbreaks in NYC and NYS were larger and lasted longer because of a combination of three important risk factors for measles transmission: 

1. pockets of low vaccination coverage and variable vaccine acceptance; 
2. relatively high population density and closed social nature of the affected community; and
   
3. repeated importations of measles cases among unvaccinated persons traveling internationally and returning to or visiting the affected communities.

These two almost year-long outbreaks placed the US at risk for losing measles elimination status. Robust responses in NYC and NYS with multiple partners involved vaccination efforts, including: administration of ~60,000 MMR vaccine doses in the affected communities; tailored communication campaigns; partnerships with religious leaders, local physicians, health centers, and advocacy groups; and use of local public health statutory authorities. These efforts ended transmission before the 12 month elimination deadline, with the most recent cases reported with rash onset on July 15, 2019 in NYC, and August 19, 2019 in the rest of NYS. Both jurisdictions have since passed two incubation periods for measles with no additional reported cases associated with these outbreaks as of October 1, 2019; however, continued vigilance is important to ensure that elimination is sustained.

Increased global measles activity and the existence of undervaccinated communities place the US at continual risk for measles cases and outbreaks. Control measures for measles outbreaks have been in place for decades in the US to limit transmission and prevent reestablishment of endemic transmission. Core elements include a highly sensitive surveillance system with multiple feedback loops between providers, laboratories, local and state public health authorities, and CDC. These measures are coupled with rapid activation of local and state public health departments in response to every measles case to determine the source of infection, identify susceptible contacts, and implement control measures. Measures include including post-exposure prophylaxis, exclusion and quarantine, and community-wide vaccination. High national MMR vaccination coverage remains the foundation for preventing more widespread measles transmission. The limited size and duration of 24 of the 26 outbreaks reported between during September 2018 and September 2019 indicate that high baseline vaccination coverage and standard measles control measures effectively controlled most outbreaks in the US.

Resources for Emergency Health Professionals for All Disasters

CDC offers a variety of resources and educational materials for clinicians, communicators, laboratorians, emergency planners and responders, and disaster relief volunteers to help prepare and respond to a public health emergency. Free educational materials, such as flyers, posters, stickers, and public service announcements in various languages that are suitable for printing and sharing are also included.

Health and Safety Concerns for All Disasters 

See below for information about a variety of health and safety concerns for all disasters:

• Animal and insect-related hazards 
• Food and water safety
• Carbon monoxide (CO) poisoning 
• Injury and illness 
• Sudden loss of power 
• Clean-up safety 
• Mental health and resilience and stress-coping

National Trends in Hepatitis C Infection by Opioid Use Disorder Status Among Pregnant Women at Delivery Hospitalization — United States, 2000–2015

MMWR / October 4, 2019 / 68(39);833–838 

Hepatitis C virus (HCV) is transmitted primarily through parenteral exposures to infectious blood or body fluids that contain blood (e.g., via injection drug use, needle stick injuries). In the last 10 years, increases in HCV infection in the general US population and among pregnant women are attributed to a surge in injection drug use associated with the opioid crisis. Opioid use disorders among pregnant women have increased, and approximately 68% of pregnant women with HCV infection have opioid use disorder. National trends in HCV infection among pregnant women by opioid use disorder status have not been reported to date. CDC analyzed hospital discharge data from the 2000–2015 Healthcare Cost and Utilization Project (HCUP) to determine whether HCV infection trends differ by opioid use disorder status at delivery. During this period, the national rate of HCV infection among women giving birth increased >400%, from 0.8 to 4.1 per 1,000 deliveries. Among women with opioid use disorder, rates of HCV infection increased 148%, from 87.4 to 216.9 per 1,000 deliveries. Among those without opioid use disorder, rates increased 271%, although the rates in this group were much lower, increasing from 0.7 to 2.6 per 1,000 deliveries. These findings align with prior ecological data linking hepatitis C increases with the opioid crisis. Treatment of opioid use disorder should include screening and referral for related conditions such as HCV infection.

To evaluate HCV infection prevalence at hospital delivery among women with and without opioid use disorder, data from HCUP’s National Inpatient Sample (NIS, 2000–2015) were analyzed. The fourth quarter of 2015 and more recent data were excluded because of the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) during that period. The NIS is the largest publicly available all-payer inpatient health care database in the United States, yielding national estimates representing approximately 35 million hospitalizations. Discharges for in-hospital deliveries were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes pertaining to obstetric delivery.

In the US, the 2015 rate of HCV infection at delivery hospitalization (4.1 per 1,000) was approximately five times higher than it was in 2000 (0.8 per 1,000). Rates were substantially higher among women with opioid use disorder, suggesting a link between the opioid crisis and increases in HCV infection. Results from this analysis are consistent with previously reported findings. For example, these estimates using hospital discharge data are similar to those from an analysis of birth certificate data, which found that maternal HCV infection almost doubled during 2009–2014 from 1.8 to 3.4 per 1,000 live births. Increased likelihood of HCV infection, opioid use disorder diagnosis, or both among women with publicly billed deliveries is similar to previous findings that women with HCV infection were more likely to be Medicaid-insured. In this analysis, Native American women were significantly more likely to have an HCV infection or opioid use disorder diagnosis at delivery than were non-Hispanic black women. High rates of overdose deaths and HCV infection in American Indian and Alaska Native persons were previously noted in the general adult population (7,8). Lower HCV infection rates at delivery among women in the West reflect distribution of HCV infection in the general population.

Current U.S. Preventive Service Task Force and CDC guidelines recommend hepatitis C testing for persons at high risk (e.g., persons who inject drugs); however, epidemiologic changes in HCV infection in the US have prompted a review of the evidence informing HCV testing by the U.S. Preventive Services Task Force and CDC. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend hepatitis C screening for all pregnant women (9). Hepatitis C treatment for adults with direct-acting antiviral agents consists of an oral regimen of ≤12 weeks, resulting in a virologic cure in >90% of infected persons. Although treatment of HCV infection with direct-acting antiviral agents during pregnancy is not approved, testing remains important to identify infections, engage infected women in postpartum treatment, and identify infants who might have been exposed. Left untreated, HCV infection might lead to cirrhosis and pose continued risk to others through parenteral exposures (e.g., injection drug use or transmission via subsequent pregnancies).

Read the entire MMWR.

Influenza and Tdap Vaccination Coverage Among Pregnant Women

MMWR / September 28, 2018 / 67(38);1055–1059

Background: Vaccinating pregnant women with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines can reduce the risk for influenza and pertussis for themselves and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered any time during pregnancy. The ACIP also recommends that women receive Tdap during each pregnancy, preferably from 27 through 36 weeks’ gestation. To assess influenza and Tdap vaccination coverage among women pregnant during the 2017–18 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28–April 10, 2018. 

Methods: An Internet panel survey was conducted to assess end-of-season influenza vaccination coverage and Tdap coverage estimates among women pregnant during the 2017–18 influenza season, as previously described. The survey was conducted during March 28–April 10, 2018, among women aged 18–49 years who reported being pregnant at any time since August 1, 2017, through the date of the survey. Among 14,858 women who entered the survey site, 2,342 reported they were eligible, and of these, 2,236 completed the survey (cooperation rate = 95.5%). Data were weighted to reflect the age, race/ethnicity, and geographic distribution of the total US population of pregnant women. Analysis of influenza vaccination coverage was limited to 1,771 women who reported being pregnant any time during the peak influenza vaccination period (October 2017–January 2018).

Results: Findings from this survey indicate that many pregnant women are unvaccinated, and they and their babies continue to be vulnerable to influenza and pertussis infection, and potentially serious complications including that include hospitalization and death. Providers are encouraged to strongly recommend vaccines that their patients need and either administer needed vaccines or refer patients to a vaccination provider. Vaccination coverage, regardless of vaccine type, was highest among pregnant women with a provider offer of vaccination, which has been reported previously. For providers unable to offer vaccination, referring patients to a vaccination provider was also shown to help improve vaccination coverage, especially for Tdap.

Conclusion: Despite ACIP recommendations, maternal vaccination with influenza and Tdap vaccines is suboptimal, and missed opportunities to vaccinate are common. Findings in this report reinforced the importance of a provider’s recommendation and offer of vaccination, or referral, to pregnant patients in receipt of recommended vaccination. Vaccination coverage of pregnant women can be increased by implementation of evidence-based practices, as indicated by the Standards for Adult Immunization Practices, such as screening patients for recommended vaccinations at every opportunity, reminders to notify providers that their patients need vaccinations, and patient education about ACIP vaccination recommendations and safety and benefits of maternal vaccination (5,9,10).

Read the entire MMWR.

The current issue of CDC Science Clips: Volume 11, Issue 38, September 24, 2019 contains other articles which may be of particular interest to clinicians and public health professionals.

Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States

MMWR Early Release / October 8, 2019 / Vol. 68

Introduction: Vaccinating pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can reduce influenza and pertussis risk for themselves and their infants.

Methods: Surveillance data were analyzed to ascertain influenza-associated hospitalization among pregnant women and infant hospitalization and death associated with influenza and pertussis. An Internet panel survey was conducted during March 27–April 8, 2019, among women aged 18–49 years who reported being pregnant any time since August 1, 2018. Influenza vaccination before or during pregnancy was assessed among respondents with known influenza vaccination status who were pregnant any time during October 2018–January 2019 (2,097). Tdap receipt during pregnancy was assessed among respondents with known Tdap status who reported a live birth by their survey date

Results: From 2010 to 2018, pregnant women accounted for 24%–34% of influenza-associated hospitalizations per season among females aged 15–44 years. From 2010 to 2017, a total of 3,928 pertussis-related hospitalizations were reported among infants aged <2 months (annual range = 262–743). Maternal influenza and Tdap vaccination coverage rates reported as of April 2019 were 53.7% and 54.9%, respectively. Among women whose healthcare providers offered vaccination or provided referrals, 65.7% received influenza vaccine and 70.5% received Tdap. The most commonly reported reasons for nonvaccination were believing the vaccine is not effective (influenza; 17.6%) and not knowing that vaccination is needed during each pregnancy (Tdap; 37.9%), followed by safety concerns for the infant (influenza =15.9%; Tdap = 17.1%).

Conclusions and Implications for Public Health Practice: Many pregnant women do not receive the vaccines recommended to protect themselves and their infants, even when vaccination is offered. CDC and provider organizations’ resources are available to help providers convey strong, specific recommendations for influenza and Tdap vaccination that are responsive to pregnant women’s concerns.

Read the MMWR.

2019–2020 Influenza Season

Bookmark CDC's Information for Health Professionals page for updates about and recommendations for the 2019–2020 flu season. This page also offers public health and healthcare professionals key information about vaccination, infection control, prevention, treatment, and diagnosis of seasonal influenza. 

What viruses will the 2019–2020 flu vaccines protect against? 

There are many different flu viruses and they are constantly changing. The composition of U.S. flu vaccines is reviewed annually and updated as needed to match circulating flu viruses. Flu vaccines protect against the three or four viruses (depending on the vaccine) that research suggests will be most common. For 2019-2020, trivalent (three-component) vaccines are recommended to contain:

• A/Brisbane/02/2018 (H1N1)pdm09-like virus (updated)
• A/Kansas/14/2017 (H3N2)-like virus (updated)
• B/Colorado/06/2017-like (Victoria lineage) virus
  

2018–2019 Influenza Season Week 39 ending October 3, 2019

All data are preliminary and may change as more reports are received.

Nationwide during week 39, 1.3% of patient visits reported through the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) were due to influenza-like illness (ILI). This percentage is below the national baseline of 2.2%. (ILI is defined as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.) For weeks 21-39, the percent of patient visits for ILI was below the national baseline for all weeks and ranged from 0.7% - 1.4%. In addition, no region exceeded their region-specific baseline during this time.

Additional data on medically attended visits for ILI for current and past seasons and by geography (national, HHS region, or select states) are available on FluView Interactive.

An overview of CDC's influenza surveillance system, including methodology and detailed descriptions of each data component, is available. Read the full situational update. View the current United States flu activity map. 

Seasonal Influenza Resource Center 

Visit CDC's Seasonal Influenza Resource Center to sign-up for CDC’s weekly influenza newsletter. Receive the latest on flu research and guidance, flu season updates, and CDC’s seasonal flu vaccination campaign. In addition, you can subscribe to CDC's weekly email for technical flu season updates on this webpage. Technical flu season emails will provide weekly updates during flu season on influenza-related key points, surveillance and vaccination data, health alerts, publication notices, and other timely scientific immunization information. This page also contains communication resources including images, infographics, print materials, factsheets in multiple languages, videos, podcasts, and other communication materials about seasonal flu.

Be sure to print and share with your colleagues a copy of CDC’s Intramuscular Influenza (Flu) Vaccination Infographic, You Call the Shots to serve as a reminder in your practice about safe intramuscular injection practices in adults.

The mission of CDC's Travelers' Health Branch is to reduce illness and injury in U.S. residents traveling internationally or living abroad. Applying the best science, the Travelers' Health Branch provide alerts, recommendations, education, and technical support to travelers and the healthcare providers who serve them. 

Now Available: CDC “Yellow Book” 2020, Health Information for International Travel 

Interested in the latest travel health recommendations? CDC’s “Yellow Book” 2020 (Health Information for International Travel) is now available to answer your patients’, employees’, or your own travel health questions. 

What is the “Yellow Book”? 

CDC wants all travelers to stay healthy while enjoying the sights, activities, and cultures of countries around the world. As travelers plan the details of their itinerary, clinicians can use the “Yellow Book” to help inform their health protection strategy. 

• Travel industry 
• Corporations and chief medical officers
• Missionary and volunteer organizations
• Americans who live abroad, and travelers taking short trips. 

Ebola

Ebola is a rare and deadly disease spread by direct contact with blood or body fluids of a person infected with Ebola virus. It is also spread by contact with a contaminated object or infected animal.

For most travelers, there is a very low risk for Ebola. Travelers who have close contact with nonhuman primates (such as monkeys, chimpanzees, and gorillas) or bats in tropical Africa are at risk. People who care for people sick with Ebola are also at risk. There have been confirmed cases in African countries such as Republic of the Congo, Ivory Coast, Democratic Republic of the Congo, Gabon, South Sudan, Uganda, Guinea, Liberia, Sierra Leone, and Nigeria.  

Although there is no approved or widely available vaccine for Ebola, travelers should take these steps to prevent infection:

• Don’t handle items that may have come in contact with a sick person’s blood or body fluids.
• Avoid contact with monkeys, chimpanzees, gorillas, and bats.
• Don’t eat or handle raw or undercooked meat or any bushmeat (wild animals hunted for food).
• Wash your hands often. If soap and water aren’t available, clean your hands with hand sanitizer (containing at least 60% alcohol).
• Don’t touch your eyes, nose, or mouth. If you must, make sure your hands are clean first.

Healthcare workers who may be exposed to people infected with Ebola virus should follow these steps:

• Avoid contact with infected patients without the use of recommended protective equipment.
• Always wear protective equipment, including masks, gloves, gowns, and goggles.
• Practice proper infection control and sterilization measures. For more information, see “Infection Control for Viral Hemorrhagic Fevers in the African Health Care Setting.”Isolate patients with Ebola from unprotected persons.

If symptoms consistent with Ebola develop:

• Talk to a doctor immediately. Tell the doctor about your recent travel and your symptoms before you go to his or her office or emergency room.
• For more information about medical care abroad, see Get Care Abroad.
• If you are sick, try to stay away from others. Stay home or in your hotel room unless you need medical care.

Traveler Information

• CDC Ebola Website
• Ebola Questions & Answers
• US Department of State Smart Traveler Enrollment Program (STEP)

Clinician Information

• Viral Hemorrhagic Fevers in CDC Health Information for International Travel, the “Yellow Book”
• International Infection Control for Healthcare Workers
• Guidance for Managing Patients in US Healthcare Settings

MedWatch: The FDA Safety Information and Adverse Event Reporting Program

(FDA) 

MedWatch is your FDA gateway for clinically important safety information and reporting serious problems with human medical products. 

FoodSafety.gov: Reports of FDA and USDA Food Recalls, Alerts, Reporting, and Resources

(HHS/USDA/FDA/CDC/NIH)

Foodsafety.gov lists notices of recalls and alerts from both FDA and USDA. Visitors to the site can report a problem, make inquiries, and sign up to receive email updates about the content on this page. You can also embed the Food Safety Alerts and Tips widget on your website, blog, or other platform. 

Stay up-to-date on the infectious disease outbreaks that CDC is currently reporting. CDC's Current Outbreak List provides a complete list of U.S. and international outbreaks, travel notices affecting international travelers, food recalls, and further sources for content about specific outbreaks.

The Emergency Risk Communication Branch in the Division of Emergency Operations, Center for Preparedness and Response is responsible for the management of all COCA products.

For information about this update or other clinical issues, or to send your feedback, please contact us at coca@cdc.gov

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Clinician Outreach and Communication Activity—resources for healthcare providers

COCA RSS Feed—subscribe to be notified of conference calls, updates, and CDC guidance for health providers

Crisis & Emergency Risk Communication Training—training program that draws from lessons learned during public health emergencies, and incorporates best practices from the fields of risk and crisis communication

Health Alert Network—CDC's primary method of sharing cleared information about urgent public health incidents with public information officers; federal, state, territorial, and local public health practitioners; clinicians; and public health laboratories

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