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Original Investigation |

Elimination of Endemic Measles, Rubella, and Congenital Rubella Syndrome From the Western Hemisphere:  The US Experience

Mark J. Papania, MD, MPH1; Gregory S. Wallace, MD, MPH2; Paul A. Rota, PhD1; Joseph P. Icenogle, PhD1; Amy Parker Fiebelkorn, MSN, MPH2; Gregory L. Armstrong, MD2; Susan E. Reef, MD3; Susan B. Redd2; Emily S. Abernathy, MS1; Albert E. Barskey, MPH2,4; Lijuan Hao, MD1; Huong Q. McLean, PhD2,5; Jennifer S. Rota, MPH1; William J. Bellini, PhD1; Jane F. Seward, MBBS6
[+] Author Affiliations
1Measles, Mumps, Rubella, and Herpesvirus Laboratory Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
2Epidemiology Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
3Global Immunization Division, Coordinating Office for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
4HIV Incidence and Case Surveillance Branch, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
5Marshfield Clinic Research Foundation, Marshfield, Wisconsin
6Office of the Director, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
JAMA Pediatr. 2014;168(2):148-155. doi:10.1001/jamapediatrics.2013.4342.
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Importance  To verify the elimination of endemic measles, rubella, and congenital rubella syndrome (CRS) from the Western hemisphere, the Pan American Health Organization requested each member country to compile a national elimination report. The United States documented the elimination of endemic measles in 2000 and of endemic rubella and CRS in 2004. In December 2011, the Centers for Disease Control and Prevention convened an external expert panel to review the evidence and determine whether elimination of endemic measles, rubella, and CRS had been sustained.

Objective  To review the evidence for sustained elimination of endemic measles, rubella, and CRS from the United States through 2011.

Design, Setting, and Participants  Review of data for measles from 2001 to 2011 and for rubella and CRS from 2004 to 2011 covering the US resident population and international visitors, including disease epidemiology, importation status of cases, molecular epidemiology, adequacy of surveillance, and population immunity as estimated by national vaccination coverage and serologic surveys.

Main Outcomes and Measures  Annual numbers of measles, rubella, and CRS cases, by importation status, outbreak size, and distribution; proportions of US population seropositive for measles and rubella; and measles-mumps-rubella vaccination coverage levels.

Results  Since 2001, US reported measles incidence has remained below 1 case per 1 000 000 population. Since 2004, rubella incidence has been below 1 case per 10 000 000 population, and CRS incidence has been below 1 case per 5 000 000 births. Eighty-eight percent of measles cases and 54% of rubella cases were internationally imported or epidemiologically or virologically linked to importation. The few cases not linked to importation were insufficient to represent endemic transmission. Molecular epidemiology indicated no endemic genotypes. The US surveillance system is adequate to detect endemic measles or rubella. Seroprevalence and vaccination coverage data indicate high levels of population immunity to measles and rubella.

Conclusions and Relevance  The external expert panel concluded that the elimination of endemic measles, rubella, and CRS from the United States was sustained through 2011. However, international importation continues, and health care providers should suspect measles or rubella in patients with febrile rash illness, especially when associated with international travel or international visitors, and should report suspected cases to the local health department.

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Figure 1.
Reported Incidences of Measles and Rubella in the United States, 1993-2011
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Figure 2.
Reported Cases of Measles (2001-2011) and Rubella (2004-2011) in the United States, by Import Status

An imported case is a case that results from exposure outside the United States; an import-linked case is a case that is epidemiologically linked to an imported case; an imported-virus case is a case without an epidemiologic link to an imported case, for which viral genetic evidence indicates an imported genotype; and an unknown source case is a case without an epidemiologic or virologic link to importation. The data are from the National Center for Immunization and Respiratory Diseases and the National Notifiable Diseases Surveillance System.

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