Factors Associated With Measles Transmission in the United States During the Postelimination Era | Infectious Diseases | JAMA Pediatrics | JAMA Network
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    Original Investigation
    November 18, 2019

    Factors Associated With Measles Transmission in the United States During the Postelimination Era

    Author Affiliations
    • 1Division of Viral Diseases, National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 2Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
    • 3Rollins School of Public Health, Emory University, Atlanta, Georgia
    • 4Epidemiological Modelling Unit, Monash University, Melbourne, Victoria, Australia
    • 5Health Modelling and Analytics Team, IBM Research Australia, Melbourne, Victoria, Australia
    • 6Department of Ecology and Evolutionary Biology, Princeton University, Princeton, New Jersey
    • 7Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
    JAMA Pediatr. 2020;174(1):56-62. doi:10.1001/jamapediatrics.2019.4357
    Key Points

    Question  What are the factors causing the transmission of measles in long-standing measles control programs?

    Findings  This cross-sectional study found that lack of vaccination and birth on or after 1957, as well assortative transmission by age (particularly among school-aged children), are the primary factors associated with measles transmission in the United States. Although current measles vaccines are known to be highly effective in decreasing susceptibility to measles, these analyses shed light on the degree by which vaccination also limits measles transmission.

    Meaning  The findings underscore the importance of maintaining homogenous, high, 2-dose measles vaccine coverage, especially among school-aged children, to sustain elimination of measles in the United States.


    Importance  Measles cases and outbreaks continue to occur in the United States after the introduction of measles from endemic settings.

    Objective  To discern the factors associated with measles transmission in the United States after measles had been eliminated.

    Design, Setting, and Participants  This cross-sectional study was conducted from January 1, 2001, to December 31, 2017, in the United States among US residents and international visitors with confirmed measles. A maximum likelihood algorithm that uses the observed dates of rash onset and the known distribution of the serial interval (time between symptom onset in related consecutive cases) was applied to outbreak notification data to estimate the effective reproduction number (R), or the mean number of new infections generated per case. Transmissibility was assessed by comparing R based on the characteristics of primary and secondary cases of measles.

    Exposures  Measles virus.

    Main Outcomes and Measures  Effective reproduction number (R), or the mean number of successful transmission events per case of measles (ie, the mean number of persons to whom each patient with measles spreads measles).

    Results  A total of 2218 individuals with confirmed measles cases (1025 female, 1176 male, and 17 sex not reported; median age, 15 years [range, 0-89 years]) reported from 2001 to 2017 were evaluated. Among patients who received no doses of measles vaccine, R was 0.76 (95% CI, 0.71-0.81); among patients who received 1 dose of measles vaccine, R was 0.17 (95% CI, 0.11-0.26); among patients who received 2 doses or more of measles vaccine, R was 0.27 (95% CI, 0.17-0.39); and among patients with unknown vaccination status, R was 0.52 (95% CI, 0.44-0.60). Among patients born before 1957, R was 0.35 (95% CI, 0.20-0.58), and among those born on or after 1957, R was 0.64 (95% CI, 0.61-0.68). R was higher when primary and secondary cases of measles were patients aged 5 to 17 years (0.36 [95% CI, 0.31-0.42]) compared with assortative transmission in other age groups (<1 year, 0.14 [95% CI, 0.10-0.20]; 1-4 years, 0.25 [95% CI, 0.20-0.30]; 18-29 years, 0.19 [95% CI, 0.15-0.24]; 30-49 years, 0.15 [95% CI, 0.11-0.20]; ≥50 years, 0.04 [95% CI, 0.01-0.10]).

    Conclusions and Relevance  The findings of this study support having high targets for 2-dose measles vaccine coverage, particularly among school-aged children in the United States.