<i>Notes from the Field:</i> Response to Measles Among Persons Evacuated from Afghanistan — Joint Base McGuire-Dix-Lakehurst, New Jersey, August–October 2021

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

On August 29, 2021, the U.S. government initiated Operation Allies Welcome (OAW) to resettle eligible persons from Afghanistan. Evacuees were housed at military bases in the United States while completing immigration resettlement processing. On September 4, 2021, the Fort McCoy, Wisconsin, OAW site reported the first confirmed case of measles in an Afghan evacuee; during the subsequent 10 days, five additional cases were identified across multiple sites ( 1 ). On September 6, OAW response leadership learned that 16 evacuees at Joint Base McGuire-Dix-Lakehurst (JBMDL) had been exposed to a patient with confirmed measles during a September 3 United States-bound flight. Because of low routine measles vaccination coverage rates in Afghanistan ( 2 ), risk for measles transmission was high among evacuees at JBMDL, a population that would expand to >10,000 persons living in large tents and multifamily rooms, if any exposed evacuees developed measles. During September 7–9, the JBMDL OAW public health team, with support from local and state health departments and guidance from CDC, provided measles, mumps, and rubella (MMR) vaccine or immunoglobulin to exposed persons. Because of delayed reporting of the exposures and challenges locating evacuees, whose lodgings assignments were not always well documented or might have changed, postexposure prophylaxis was not administered within the recommended time frame.* Exposed persons were asked to quarantine and complied; however, because of space constraints, they were not moved into quarantine until 1 week after the exposure. None of the evacuees exposed to the patient on September 3 experienced measles signs or symptoms † during quarantine. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. § Although MMR vaccination was already part of the immigration medical exam ( 3 ), the planned rate of 250 exams per day would have been inadequate to mitigate a potential measles outbreak, in light of the large number of evacuees housed at JBMDL. The public health team, in coordination with OAW leadership, recommended an immediate mass MMR vaccination campaign for all evacuees. The campaign was part of a coordinated effort to vaccinate evacuees at U.S. OAW sites and overseas transit locations after measles cases had been identified. Immigration medical exams were paused, and personnel were reassigned for campaign activities. The campaign ran during September 8–12; a total of 8,849 of 9,503 evacuees (93%) were screened for eligibility and a reliable record of vaccination. Vaccines were administered to eligible persons without documentation of previous vaccination, according to CDC recommendations. ¶ Age-specific vaccination rates were calculated by merging vaccination and registration data. By September 12, among the 9,065 eligible evacuees residing at JBMDL, 7,962 (88%) had been vaccinated (Table). After the vaccination campaign, immigration medical exams resumed and were expected to identify any remaining unvaccinated persons. By October 31, among a total of 12,670 eligible evacuees, 12,437 (98%) had received the MMR vaccine.** TABLE Selected characteristics and measles, mumps, and rubella vaccination rates among Afghan evacuees — Joint Base McGuire-Dix-Lakehurst, New Jersey, September 12 and October 31, 2021 Characteristic Total and vaccinated JBMDL evacuee population on specified date* September 12 October 31 Total population Vaccinated† no. (%) Total population Vaccinated§ no. (%) Total eligible¶ 9,065 7,962 (88) 12,670 12,437 (98) Age group upon arrival 6 mos–4 yrs 1,396 1,192 (85) 1,925 1,907 (99) 5–19 yrs 3,085 2,712 (88) 4,213 4,175 (99) 20–49 yrs 4,191 3,708 (88) 5,952 5,813 (92) ≥50 yrs 389 348 (89) 560 534 (95) Unknown 4 2 (50) 20 8 (40) Sex Female 3,729 3,275 (88) 5,152 5,051 (98) Male 5,330 4,683 (88) 7,430 7,315 (98) Unknown 6 4 (67) 88 71 (81) Abbreviations: JBMDL = Joint Base McGuire-Dix-Lakehurst; MMR = measles, mumps, and rubella. * Cumulative population. Departures from the base have not been subtracted. † Includes persons who were vaccinated while at JBMDL and 40 persons who provided reliable proof of MMR vaccination. § Includes persons who were vaccinated while at JBMDL and 57 persons who provided reliable proof of MMR vaccination. ¶ Persons eligible for MMR vaccination include nonpregnant persons aged ≥6 mos. The public health team reinforced measles surveillance by briefing OAW medical providers on the measles case definition and reporting procedures. In September, four suspected measles cases were identified at JBMDL; all received negative test results †† from the New Jersey Department of Health. On October 3, a male infant aged 4 months was evaluated at the OAW medical facility with fever, diaper rash, and diarrhea; a fine maculopapular rash was observed on the chest but not the face. The infant was transferred to a local pediatric hospital and received a positive measles test result on October 6. The infant was not a known contact and was not age-eligible for MMR vaccination during the mass vaccination campaign; all other members of his family had been vaccinated on September 10. The infant arrived on September 9 with rash onset on October 3, indicating at least one undetected primary case at JBMDL. Contact tracing identified 56 unvaccinated persons who lived in the same residential tent or were registered at the OAW medical facility on the same days as the infant with measles. Among these persons, 54 (96%) were not vaccine-eligible because of age (18; 32%), pregnancy (35; 63%), or medical contraindication to vaccination (one; 2%) at the time of the campaign. The public health team located and moved 45 (83%) of these persons into quarantine (11 persons could not be located). Among the 45 persons who were located, MMR vaccine was administered to the six eligible persons; immunoglobulin was offered to the 39 who remained ineligible, 36 (92%) of whom received it. §§ No one developed measles symptoms during quarantine; as of February 1, 2022, no additional cases had been reported. Early mass vaccination and other response efforts successfully halted the spread of measles; however, inaccurate documentation of evacuee lodging locations led to delays in locating or the inability to locate some exposed persons, and insufficient space resulted in delaying quarantine of exposed persons. Also, reliance on off-site laboratory testing delayed confirmation of suspected cases and prevented serologic testing of pregnant women, which would have eliminated the need to administer immunoglobulin to immune women. Future missions might consider vaccination of persons before arrival, reinforcing disease surveillance, and expanding capabilities for isolation, quarantine, and local testing.

Related collections

Most cited references 1

Record: found
Abstract: found
Article: found

Is Open Access

Public Health Actions to Control Measles Among Afghan Evacuees During Operation Allies Welcome — United States, September–November 2021

Nina B. Masters, Adria Mathis, Jessica Leung … (2022)

On August 29, 2021, the United States government oversaw the emergent establishment of Operation Allies Welcome (OAW), led by the U.S. Department of Homeland Security (DHS) and implemented by the U.S. Department of Defense (DoD) and U.S. Department of State (DoS), to safely resettle U.S. citizens and Afghan nationals from Afghanistan to the United States. Evacuees were temporarily housed at several overseas locations in Europe and Asia* before being transported via military and charter flights through two U.S. international airports, and onward to eight U.S. military bases, † with hotel A used for isolation and quarantine of persons with or exposed to certain infectious diseases. § On August 30, CDC issued an Epi-X notice encouraging public health officials to maintain vigilance for measles among Afghan evacuees because of an ongoing measles outbreak in Afghanistan (25,988 clinical cases reported nationwide during January–November 2021) ( 1 ) and low routine measles vaccination coverage (66% and 43% for the first and second doses, respectively, in 2020) ( 2 ). On September 4, CDC was notified of a suspected measles case in an Afghan evacuee at Fort McCoy, Wisconsin. In partnership with state and local health departments, CDC provided technical guidance to DHS, DoD, and DoS to increase measles surveillance, conduct case investigations and contact tracing, and implement a mass measles vaccination campaign at overseas and domestic military bases and hotel A. Among 72,299 evacuees, 47 (0.065%) confirmed measles cases were reported from August 29 (the beginning of OAW) through November 26. ¶ Vaccination efforts across domestic and overseas locations that achieved an estimated 96% coverage with measles, mumps, and rubella (MMR) vaccine in this evacuee population were critical in limiting measles importations into the United States and preventing subsequent spread at military bases and into U.S. communities. Investigation and Results Measles was first diagnosed in an evacuee aged 17 years who began experiencing prodromal symptoms on September 1 in Germany while awaiting transport to the United States (disclosed on later interview). The patient traveled on military flights from Ramstein Air Base, Germany to Washington Dulles International Airport (IAD) on September 3, and from IAD to Fort McCoy, Wisconsin on September 4. A few hours after completing the intake process, the patient sought care at the on-site acute care clinic with a fever of 107.6°F (42°C) and a maculopapular rash (Box). The patient was transferred to a local emergency department where specimens were collected for measles testing, which was performed by the Wisconsin State Laboratory of Hygiene. Upon return to Fort McCoy on September 5, the patient was isolated at an on-site facility. Measles was confirmed by real-time reverse transcription–polymerase chain reaction (RT-PCR) on September 5; molecular characterization yielded genotype B3, consistent with genotypes recently identified in countries neighboring Afghanistan.** BOX Time line of events associated with measles cases detected among Afghan evacuees during Operation Allies Welcome — United States and Afghanistan, August 17–October 15, 2021 August 17 Flights with Afghan evacuees began arriving in the United States at IAD. August 28 Flights with Afghan evacuees began arriving at PHL. August 24–September 24 MMR and varicella vaccination efforts began, transitioning to rapid scale-up of vaccination on September 6 after the first measles case was identified and accelerated mass vaccination campaigns after the September 14 directive. Mass vaccination campaigns continued until September 24 across U.S. military bases and hotel A. August 30 Epi-X notice issued to encourage U.S. health departments and clinicians to maintain vigilance for measles and polio among Afghan evacuees. September 2 Rash onset in earliest measles case (patient aged 9 months) at hotel A, Virginia (laboratory confirmed September 9). September 4 Rash onset in first identified measles case (patient aged 17 years) at Fort McCoy, Wisconsin (laboratory confirmed September 5). September 10 International flights carrying OAW evacuees to the United States temporarily halted. September 14 CDC directive issued to pause international evacuation flights from overseas locations to the United States and initiate mass MMR and varicella vaccination campaigns and quarantine for 21 days following receipt of MMR vaccine; total of six measles cases confirmed by this date. September 17 Executive Order issued adding measles to the list of federally quarantinable communicable diseases. September 20 CDC issued Health Alert Network Update: Guidance for Clinicians Caring for Individuals Recently Evacuated from Afghanistan;* total of 16 measles cases confirmed by this date. October 5 Flights resumed to United States (PHL). October 15 Rash onset in last measles case at Marine Corps Base Quantico, Virginia; total of 47 measles cases identified. Abbreviations: Epi-X = Epidemic Information Exchange; IAD = Dulles International Airport; MMR = measles, mumps, and rubella; OAW = Operation Allies Welcome; PHL = Philadelphia International Airport. * https://emergency.cdc.gov/han/2021/han00452.asp A confirmed measles case was defined as an acute febrile rash illness and either detection of measles virus RNA using real-time RT-PCR or measles-specific immunoglobulin M antibody by enzyme immunoassays, or direct epidemiologic linkage to a laboratory-confirmed case ( 3 ). By September 14, five additional measles cases had been confirmed: four in patients at hotel A and one in a patient at Fort Pickett, Virginia. To identify additional cases, active case finding and tracing of exposed contacts were conducted by DoD and DHS public health surveillance and medical staff members and contractors at domestic military bases, international airports, and hotel A. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. †† A total of 47 confirmed measles cases were reported among Afghan evacuees at six domestic sites in four jurisdictions (22 cases in Virginia, 22 in Wisconsin, two in New Mexico, and one in New Jersey). Rash onset dates ranged from September 2 to October 15. §§ The median age of patients was 1 year (range = 0–26 years); 16 (34%) patients were aged <12 months, 17 (36%) were aged 1–4 years, 11 (23%) were aged 5–19 years, and three (6%) were aged 20–29 years; 55% were male. All 47 patients were unvaccinated or had unknown vaccination status upon arrival in the United States. Overall, 46 (98%) cases were laboratory-confirmed. Genotyping performed on 43 real-time RT-PCR–positive specimens identified genotype B3 in all. The crude attack rate was 0.065%. Domestic sites also reported 57 varicella cases, 14 mumps cases, and one rubella case. ¶¶ Public Health Response After DoD began larger-scale emergency evacuations, administration of routine predeparture vaccinations in Afghanistan was not operationally feasible because of the urgency and scope of the evacuations, and efforts shifted to providing MMR vaccine to evacuees soon after arrival in the United States. Following the detection of measles cases, rapid scale-up of DoD-led vaccination efforts began across domestic military bases housing evacuees on September 6, and evacuation flights from overseas locations to the United States were temporarily halted on September 10. CDC issued a directive on September 14 recommending urgent implementation of measures to limit measles spread; this directive included a pause on evacuation flights from overseas locations and the acceleration of mass MMR and varicella vaccination for all eligible evacuees aged ≥6 months and ≥12 months, respectively, who did not have contraindications ( 4 , 5 ), at both OAW overseas and domestic locations. Because of the lack of documentation of previous vaccination or disease history of evacuees, more targeted vaccination of susceptible persons was not possible. In addition, all evacuees were presumed to have been exposed to measles and thus were recommended to remain in quarantine (i.e., on bases and in overseas locations) for 21 days following receipt of MMR vaccine ( 3 ). Efforts were also made to provide immunoglobulin to persons ineligible for MMR vaccine (infants aged <6 months and seronegative pregnant women) at domestic sites. By September 24, an estimated 91% of eligible evacuees at the domestic military bases had been vaccinated with MMR vaccine, increasing to 96% by November 25. No measles cases were reported in military personnel, volunteers and staff members supporting the OAW response, or in the community (areas surrounding the military bases or hotel A); no measles-related deaths occurred. OAW international flights resumed on October 5, with no measles cases identified among evacuees arriving after the pause. An additional tool for measles control became available on September 17 with the addition of measles to the list of federally quarantinable diseases via Executive Order 14047.*** This policy change enabled the use of federal regulatory authority to control measles transmission by allowing the issuance of federal public health orders, if necessary. CDC developed operating procedures and policies to determine situations for which issuing a federal order for isolation of patients and quarantine of exposed contacts might be necessary for the protection of public health. As a result of the high measles vaccination coverage achieved through this response and the adherence with voluntary isolation and quarantine recommendations, no federal public health orders were issued. Discussion Measles is an extremely contagious viral illness, with one infectious patient capable of infecting an average of 12–18 persons in a fully susceptible population ( 6 ). Measles-containing vaccines are highly effective, with 2 doses conferring approximately 97% protection ( 4 ). Measles elimination ††† has been maintained in the United States since 2000; however, measles cases reached a 25-year high in 2019, with 1,274 cases reported across 32 U.S. jurisdictions; 85% of these cases occurred among pockets of undervaccinated persons, where the virus spread following international importations ( 7 ). Reduced global travel, physical distancing, and other COVID-19 pandemic-related mitigation measures likely contributed to only 15 measles cases being reported in the United States from 2020 to 2021 before the start of OAW ( 8 ). However, the lessons of the 2019 U.S. outbreaks highlight the need for vigilance as well as the importance of prompt interventions to control measles ( 8 ). In addition, global standards for humanitarian crises §§§ recommend conducting a mass measles vaccination campaign when estimated measles coverage is ≤90% or is not known. The low measles vaccination coverage among evacuees, coupled with the high potential for multiple importations, increased risk for transmission in congregate settings, and possible spread into U.S. communities during the OAW response, demanded immediate public health action requiring a whole-of-government approach. All identified cases occurred among evacuees who arrived during August 17–September 10 before international flights from overseas locations were temporarily halted to permit mass vaccination of all evacuees. The absence of additional cases in evacuees who arrived after flights resumed is evidence of the success of this strategy in preventing new introductions of measles into the United States. This response also highlights the effectiveness of the mass vaccination campaign in minimizing further transmission on military bases (attack rates for measles outbreaks among refugee populations in congregate settings have ranged from 0.9% to 25.5%) ( 9 , 10 ), as well as preventing transmission into communities with health care systems already strained by the COVID-19 pandemic. Efforts continued to 1) ensure high vaccination coverage among the remainder of incoming evacuees, 2) identify and isolate ill persons among evacuees on military bases, and 3) perform contact tracing to identify and quarantine exposed persons. The findings in this report are subject to at least two limitations. First, cases might have been missed because of clinical misdiagnoses, limited available staff members to conduct timely and regular wellness checks, and failure of ill persons to seek care at acute care clinics. Second, contact tracing and ascertainment of exposures were difficult because of evacuees mixing at overseas locations, on international and domestic flights, at receiving airports, and at military bases, creating challenges for adequate monitoring among exposed persons. Rapid implementation of a high-coverage mass measles vaccination campaign by DoD with a 21-day quarantine after receipt of MMR vaccine reduced measles importations and prevented substantial potential spread of measles on military bases and into U.S. communities, and the morbidity and mortality associated with such outbreaks. The robust MMR and varicella vaccination campaign also likely limited the number of varicella, mumps, and rubella cases identified across military bases. Summary What is already known about this topic? Low measles immunization coverage and an ongoing measles outbreak in Afghanistan led to U.S. measles importations among Afghan evacuees who were resettled as part of Operation Allies Welcome. What is added by this report? Forty-seven measles cases were reported among 72,299 Afghan evacuees (attack rate = 0.065%) in U.S. military bases and a contracted hotel. A coordinated response and a high-coverage mass vaccination campaign led to rapid containment. What are the implications for public health practice? Mass vaccination of an undervaccinated evacuee population can limit measles importations, control measles spread, and prevent transmission into U.S. communities.

0 comments Cited 5 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (nlm-ta): MMWR Morb Mortal Wkly Rep

Journal ID (iso-abbrev): MMWR Morb Mortal Wkly Rep

Journal ID (publisher-id): WR

Title: Morbidity and Mortality Weekly Report

Publisher: Centers for Disease Control and Prevention

ISSN (Print): 0149-2195

ISSN (Electronic): 1545-861X

Publication date (Electronic): 29 April 2022

Publication date Collection: 29 April 2022

Volume: 71

Issue: 17

Pages: 609-610

Affiliations

Navy Medicine Readiness and Training Command Twentynine Palms, Twentynine Palms, California; Center for Global Health, CDC; International SOS, Houston, Texas; 60th Aeromedical Evacuation Squadron, Travis Air Force Base, California; Epidemic Intelligence Service, CDC; Navy Medicine Readiness and Training Command Camp Pendleton, Oceanside, California; Air Force Medical Readiness Agency, Falls Church, Virginia.

Author notes

Corresponding author: Nikki Pritchard, nikki.l.pritchard.mil@ 123456mail.mil .

Article

Publisher ID: mm7117a3

DOI: 10.15585/mmwr.mm7117a3

PMC ID: 9098233

PubMed ID: 35482554

SO-VID: c0654fc0-dbc0-44aa-bf63-02d014600e5e

License:

All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

History

Comments

Comment on this article

scite_

Smart Citations

Citing PublicationsSupportingMentioningContrasting

View Citations

See how this article has been cited at scite.ai

scite shows how a scientific paper has been cited by providing the context of the citation, a classification describing whether it supports, mentions, or contrasts the cited claim, and a label indicating in which section the citation was made.