2019 June 13 Measles Presentation



hello everybody how are you doing today so well thank you for coming to this conversation about these are very important issues with a very fast capacity of dissemination but before doing that I want to say thank you known to all of you for coming here this morning to a Productivity College and attend our presentation or conversation about about is a very important in tastin disseminating these years but also I want to appreciate and I want to say thank you to the Columbia County Department of Health in the presence of mr. Tom toughness so in also the presence of mr. Meaghan gunky so from the Bureau of Epidemiology or the state that they Health Department of the state of Florida so in for sure my colleagues Thor islambol and I part of so for him to – for them – to help us with this this very complex preparation of our presentation but there's the spatial thanks not only to for my administrators but also to mr. Mike McKee who have been doing a lot of efforts for us to make it possible well let's begin well when we are talking about measles look at this beautiful view of Florida gateway college so what we have to go a little bit to the history of measles remember the measles he said exists that having described since a long time ago if the first description was in the 19th century in 1757 was described by dr. Francis home a Aceves is caused by will we keep on see there as produced by an infectious agent so but in nineteen thousand 1912 become in Maine generally notifiable disease blue how important and how fast the dissemination was but in 1962 to 1963 the first vaccine became available so actually I'm sure that some people I'm including the list we receive the first the first vaccines that were produced in a 1962 batch of it well initially this vaccine had a name was called Edmisten Enders that was formerly all Morton but I want you to observe something very important from this slide in the year 2000 this disease in the United States was declared as totally eliminated what is going on with our our health well we are talking about and talked about and talking about viruses environment virus transmitted diseases but what is a virus well I already mentioned that is an infective agent confirmed by Walt confirm fight either RNA or ribonucleic acid or deoxyribonucleic acid in this course do I know that here in the audience we have students and I need to refresh where the DNA is placed in work is that are in a or ribonucleic acid DNA is a molecule that is inside of the nucleus can has the blueprint of the genetic information of the cell but there are some infectious agents like is the case of the viruses that can contain either or can be made of either RNA or DNA and that is so that is why so deep we go for the for the human body to control them because they need to each being inserted into the cells for them to reproduce well in summary they need a host they need a cell for to be reproduced let's go to missiles well missiles are I'm insisting I have the students here in the audience so I have to mention how measles virus is classified is called single-stranded what is the meaning of single stranded instead of happening to his strengths of the DNA has only one negative sense means that we'll be using the information from the DNA of the host for him to be reproduced and below protected protected by a couple of layers of proteins that help the virus not only to be protected against possible agents of a defense but also for him to be invading other cells and belongs to the family car a mix of eveyday okay but why am talking about this very complicated amount of names and denominations for one simple reason please observe this light in this light what am pretending to show you is that we have two families of the family initially that I initially described so okay but I want you to observe something on your own you're right right side so you can assert that there is a word human respiratory syncytial virus respiratory okay and on the left you can observe that has a the same word is close to it so in what I'm trying parainfluenza influenza sounds familiar to all of you I'm sure okay but what I'm trying to tell you is that the most complicated thing from this virus is that as dr. long-bore and dr. Parker will be describing this virus has the capacity of producing signs and symptoms similar to the tubes of families well I'm going to show you a lot of graphics that will be very impressive work they were impressive for me and I'm sure that will be impressive for you and I will be passing those graphics in a very fast way so for just for you to observe how fast the dissemination of the disease had been in a very fast or very short period of time 2014 was the last outbreak in oh sorry how in 2019 I'm talking about April the fourth we had reported around 450 cases but let me jump to another one that was on April 26 officer how we surpassed the outbreak from 2014 well right here we have more than 700 cases reported a these are reported but what happens to the ones who are going reported well I'm insisting on this guy on this on this slide year 2000 totally eliminated year 2000 for 37 cases what is going on since 220 2014 and on 644 cases in let me tell you now more than once out that 1000 cases if I go if I project this to the map of the United States after the initial maps and observe the areas that were compromised look how fast where I'm running absurd absurd is one of the last report reports of the decimation the states compromised with the disease not only the west coast but Central right here we have Central States and now we have the East Coast north and south compromised over here look how dramatic is the change of the amount of the presence of the cases all over the United States well the last that I have was from June the 6th more than 1,000 cases well how is possible for a person to get the measles the first important thing you need to know is that missiles will be transmitted by every single one of the human secretions so beginning with what with saliva a in dr. long with dr. pol we'll be talking about the population at risk in why college students yes why host people who work in hospital guess again well how is the possibility of being contaminated by this at this year's well the person who is already contaminated can become contagious from the fourth day before the rash which is a sign is a sign of mechanisms of defense until four days after the presence of it and I'm talking about the period of time that can range in between one to two weeks well and how long is the whole process of the disease well can last for several weeks it depends on the mechanisms of Defense of the person the symptoms will have will have a period prodrome that camp are in between two to four to five days and then the initial symptoms as doctor party will be describing a little bit later so we'll begin from the day seven to the day 14th after someone is exposed to the threat to the virus well and now I have the pleasure of inviting dr. Parr to continue the presentation dr. Parr who is a medical doctor and have been with us for a long time as well I think the more than 20 years isn't it no no I'm just excited thank you doctor pardon good morning everyone thank you for coming I am going to continue with a presentation about missiles really is one important viral infection highly contagious viral infection that the normally is attack our respiratory system this is why it's an infections the symptoms and this sign beginning between seven days to 14 days after the contact with these buyers this virus should by many hours after the contact and enter and stay in our mucosa in our oral in oral cavity and in our forage the first symptom is high fever between 100 to 104 degrees and it's infection normally we can confuse we can compare a this inflation to another are similar this is why in the first time we don't understand what happen with this field another symptoms in the same time are cough coryza and Conda virus you have said all three beginning in Zee coryza cough and conjunctivitis this is now the memo tinea that the people are using to identify yes this disease and it's important for every nursing every people dugout for example in Emerson room me that I worked many years is important to recognize the symptoms that that clarifies the situation yes it's inflammation in the conduct even one important membrane in our eyes produce red color and sometimes produce wire secretion warrior this check after two three days this after they appear the symptoms continue with the copic spot in our cavity oral cavity and continue with the rest the rush beginning under the reliant or the forehead continue with the face after that in the trunk art of upper limbs and continuing with the abdominal wall and the local villains in this is light we can observe perfect the copied spots in the oral cavity here the copied spot very close to the inferior second and third molar the rush in these patients in whole face oh this is light look the rush is very clear in the face and continuing with the trunk yes in the back lower limbs or in this patient we cannot separate eras in the back or in the thorax it abdominal anterior region now complication the missile is a one important viral infection that produce complication well the first of course attack the respiratory system this is why the best complication of the more frequently complication 30% that is a half statistic is pneumonia another complication can be ear infection diarrhea all one ratio big problem in the patients encephalitis in this case this patient can lead to convulsions or mental disability during pregnancy is some woman acquire this disease the problem is for the baby that can be the primitive build all the deliveries early or the baby there with no way this launcher complication the name to acute sclerosing for encephalitis some time oh cool because the virus produced that this protein the protein M is luck and the virus stay long time in the body yes I produce problem in our central dress central nervous system in this is light in this x-rays we can observe here the pneumonia here we can observe the ear infection which Christian or everyone know with the name depart now here in this is life we can see perfect one MRIs this is a one's coronal planes and we can observe that the virus effect here the brain this is a Pleiades is inflammation the our plane good morning as you can see previously we have a group of boys and girls that are looking smiling that's what we want in our community have everybody happy and prevent the complications that we will have with this viral disease measles what group it is at risk during an outbreak of measles then we're gonna recognize babies or infants women that are pregnant also we have at-risk population with poor nutrition or certain type of treatments that make them weak then those are at-risk college students why because we are in the same room for a period of time that can easily just spread viral diseases and other type of disease as well people working in medical facilities dealing with patients that are sick that's a risk a group of population as well as international travelers then it is important to keep in mind that all of these are part of the risk group just to be familiar with some of these how do we do the diagnosis of this disease just basically everybody will notice the symptoms and you're able to tell that you feel sick you feel fever or any of the symptoms described before also clearly taking the blood sample we're gonna see immunoglobulin or antibodies which are the first response from the body in order to protect our body from invaders we're gonna have immunoglobulins em it is the first one to appear and be increase when they rush it is just onset also we're gonna have the viral isolation we can show up the virus and that will be done basically with certain techniques probably dr. Megan gamble can call talk about the way they describe the taking of the sample which is guided by the World Health Organization those vaccination programs are not like it all of the sudden we decided to do vaccines it is since long time ago that we have established rules and regulations for vaccines which are going to protect the community and prevent infections and not only that we're gonna protect the fact that we're gonna have hospitalizations and other type of problems including deaths of people we haven't seen really a clear outbreak and that's why probably there is the thinking of saying no I don't want a vaccine then the samples should be taking with pubes without additives and we need one millimeter of blood to recognize the virus on the left-hand side of the screen you can see the isolation of the virus and on the right-hand side of the screen you can see um a big giant cell in cases of pneumonia which is one of the complications that sounds weird but we don't want to face those type of complications now in the lab we're gonna see the lab count the white blood cell count increase because white blood cells are gonna protect you from getting an infection we're gonna see increase in leukocytes and also increase in lymphocytes that could be seen basically in cases of encephalitis which is one of the most serious complications of measles now let's see what happens with the vaccine the vaccine it is chemically treated the virus inward it is not capable of transmitting the infection it is a weak harmless virus that it is injected to promote the production of project of protection it's not going to cause the disease is basically going to influence the presence of protection then build up defenses it is the main job after vaccine I also want to answer certain questions and I guarantee it won't overload the immune system a vaccine and increase the risk of other infections it will not increase the risk of other infections at times we feared those type of things and neither is gonna cause any auto immune disease then up to date there is no proof of causing auto immune disease by vaccines how do we prevent the missiles spread with the vaccine it is alive activated or weakened virus that they're fickle see it will be 93 percent with the first doses and 97 percent with the second dose let me tell you those numbers can be a little bit different depending on the sources that you look at but pretty much it is more than 90 percent the protection against the disease which is an important thing because without the vaccine I'm gonna show you soon how it will be the case also it is important in women that are not pregnant and more important it is if you are in contact with the vaccine with the virus you have been in contact with somebody sick you can get a vaccine in the 72 hour period you can get the protection from the vaccine that's an important thing that is not happening in all type of vaccines that's a particular case of the measles vaccine yes okay your question is that if the vaccine it is it is similar to the pneumonia vaccine the vaccine it is just weak virus that will not cause an infection now pneumonia that you listen before it is a complication after disease let's let's understand this if if somebody is sick with measles is gonna have all the symptoms of five fever mmm runny nose coryza conjunctivitis the rash that was shown and one of the complications it means instead of being only measles it became pneumonia which is an infection in the long those are other type of vaccines and you can get other type of vaccines normally without interfere with one another then if you need if people needs the vaccine at pneumonia it's okay but this is for measles and pneumonia can be a complication of measles then you can have different type of vaccines without any problem there is no problem related in fact there are several vaccines that are offered for kids and a different group of population depending on the conditions correct and you said that you have another part of your question okay you're ahead of time I'm just going into that topic immediately and I know there are so many fears and questions about these type of disease and we're here to clarify all those type of things because that's what it is important that's what we are here for now the immunity that we have with the vaccine it will last for your life period in fact I can tell you that my immune system it is really strong because I work more than 20 years a little bit old and in health care environment I work in a public hospital for many years then it was involved in seeing patients constantly which that builds up my immune system strong enough to fight a lot of infections otherwise you will be sick and die working in a hospital then if you are really that's why health care feels healthier workers are exposed and then it is important for them to have the vaccine yes it is not a requirement depending on the facilities probably it and I read it is not a law by a state but it is recommended just to prevent you from getting a really bad infection probably you can get the position without having a vaccines however we were talking about before while we were doing the presentation we talked about we are immigrants and whenever you came and you come to the States you have to have proof of having all the vaccines apply because as you have seen the risk factor of international travelers to bring infections and all the paperwork for an immigration one of the first requirements it is to have all your vaccinations up-to-date even though it is not a law you are required to then it is good to know and it is important to educate our health care students just because it is your protection then let's talk about the vaccine mmm our vaccine which is mumps measles and rubella vaccine it will be given to children the first dose are they fit between 12 to 15 months of age then the second dose will be given between four to six years or we can give the second dose four weeks after the first one now individual cases are going to be solved individually pretty much this is the way the vaccine can be administered or given now here you come with your question then took vaccinations custody see that they are designed to prevent yes they do that's why we use vaccines they do they they do not cause I'm sorry I said yes they do not cast the vaccine that they are going to set to be protected they cause mild symptoms and in less than 5% because they cause those mild symptoms and almost never they they cause the pool disease now I received this information from one of my students and I thought it was extremely interesting for you to see it let's look at this you can observe on your own and you can have your own answers because what we want it is everybody to know and take their own decisions and be able to just tell others how important is this you can see on the left side of the screen lower percentage of vaccination on the right side of the screen higher percentage of vaccination and let's look at this look how amazing this will be how the virus it is a spread over the lower percentage and look the protection from the vaccine is shown by itself then over 95% you barely see something over here then that's important to be aware it really protects you against an infection the treatment we're gonna give a treatment based on symptoms then we're gonna give fluids and humidifiers vitamin A supplements it is recommended by the World Health Organization just to protect your eyes somebody asked about conjunctivitis and that's one of the main reasons because the virus will affect the conjunctiva and it is extremely unpleasant to have something in your eyes that the work Health Organization recommends the supplement of vitamin A as well as other medications as needed you can see acetaminophen and antibiotics based on the individual means can vaccines be given together different vaccines yes as require or as needed we can have different vaccines giving together like the MMR mmm art that I mentioned for measles mumps and rubella and varicella and you can read all over just they can be given together as needed or as indicated now we get you we got to the point of the most important part of this presentation which is the possibility of the risk of autism I think it all of you have heard about this gossip about autism and vaccines yes you said you have a question okay I'm sorry vaccination has been proven to be safe the World Health Organization the CDC and other institutions are there and they work every day hard to protect the population worldwide from preventable disease there is not a link to developmental disorders of vaccines also it was confirmed by a federal law and you can see all the institutions that are named there to tell you the American Medical Association is one of them then all of those are related to the confirmation by a federal court now unfortunately we don't know the or it after false report linking vaccinations with autism and the problem it is that now a lot of people it is without vaccines and that it is a really serious risk of getting infections because when you are not I have seen mothers that said I don't want my baby to be vaccinated the problem it is you can have your baby at risk but you are placing at risk a higher risk all the others that are going to the same care facilities to the same to daycare or to the same school that's a serious problem for the others and as you can see unfortunately there is people related to that yes were contracted these diseases wildly there were no vaccine seconds so what they were noticing was that their work when a certain percentage of people have wild measles or whatever then a certain percentage would be protected so I guess my question is how do we ever achieve with vaccines because in most areas in the United States we have close to 100 percent and people that are being vaccinated but when you can't guarantee you know efficacy when you can't guarantee these things from vaccine you're getting you know we started with one dose and Alan MMR with two doses and three doses and then sometimes you go back in and your child doesn't have any titers and so you think say well maybe you need another nose how do we ever achieve hurt immunity when we're trying to you know people are trying to convince me as a parent you know you need to vaccinate your kids because of herd immunity well I don't understand how that works because most of us as adults are walking around without a gazillion booster shots so how do we achieve herd immunity even if we have a 100% if the whole entire country vaccinate how do we achieve for immunity if vaccine Wayne and some of them you know for some people they won't even take the first time so I guess I just wanted explanation how do we achieve that really how do we have the question it is how do we have and they're achievable of 100 percent copper to against the virus it is that your question okay we are not gonna have 100 percent we're gonna have a higher percentage of protection against the infection we cannot and there is no guarantee in medicine there is nothing that we can guarantee we are gonna try to protect as much as possible and the World Health Organization has these guidelines to do the vaccines in order to protect as much as possible now once you have whether the vaccine it is doing basically it is a weak virus that it is chemically treated it is not with infective power is not gonna cause the disease but get to know the virus and the body itself builds up ante by antibodies which are the defense against the virus that's what the goal of the vaccine it is the protection that's how is build up that 97 percent with the 7 with the second dose and basically having as much as population being vaccinated we are we were able to see the description of dr. Guzman in word in 2000 devack's the measles was the declare absent in the u.s. territory 2000 you can see variations in numbers but basically the more vaccine the population it is vaccinated the higher rates of vaccination decreases dramatically and now we have seen an outbreak that's why we are just trying to explain the importance of being vaccinated the fact is when you have the disease we have to just have not been in school because that helped to spread the disease all the human secretions are going to transmit the disease then when we talk the virus is going to be alive for two hours in the air up in the air then you can get that virus from the air from somebody coughing then we try to do as much as possible the measurements to prevent the spread after disease at times you see not mmm the fact that you cover your face when you are copying it is one important thing as well not shaking hands it is another thing that we can it is just little by little that we try to that's why health care workers are at risk and have to be careful about those areas and handling and secretions and patients it is difficult yes ma'am she is asking the question about if you have some hereditary disease or are immune disease it will be at risk of having vaccinations that will be solved case-by-case individually you have to ask your doctor and you always are ahead of time just of my questions wait a minute and then you will see your answer over here but that's excellent look when to call a doctor I'm gonna tell you dr. Guzman I'm gonna call you with my phone yes it is an aunt phone I don't know if it's related to just am over here dr. Guzman now the questions are yours thank you doctor mumble thank you look apart for your excellent presentation so let's continue with with one more portion corresponding to what happened I don't know what I did I pushed the wrong button I'm sorry for that you always happen it's part of the show okay okay when when you should call the doctor well call the doctor right away if you think that your child has signs and symptoms similar similar to me so what is the issue the issue is have we mentioned to you before is that any every most of the people the vital DC I don't have missiles okay most of the viral diseases cooking that can affect the respiratory tract will have a similar a similar let's let me use this word a similar beginning so congestion of the oral cavity congestion of the conjunctiva somebody has about the conjunctiva the conjunctiva is a little layer a tiny layer that covered the the outer portion of that I don't have the code right so you have to call the doctor if you are if you know you perfectly know that somebody who is around your child or your family is running on measles it's a very important thing for you to know if your child is an infant is you have to even be more careful about it so I should yes okay please remember I'm sorry your name is Miss Estella is asking but we have a child the signs and symptoms will be similar to in that the symptoms that can occur in adulthood well every single one of the viruses have a certain pattern and when we are talking about pattern is the beginning a I mean the signs and symptoms that B are at the beginning of the disease in the middle of the disease and at the end of the disease yes the answer is yes the thing is and I want to clarify this most of the viruses who affect o who are in classically affecting take the respiratory system will be will be having in the first week to the half of the second week same signs and symptoms that's why some is confusing for for the mom or the father or the person chart of the child so to to realize if that child who might be in touch with somebody contaminated with the missile disease if that that girl that boy is beginning on or is running on the problem well but there was a portion of doctor love did I answer your question man okay thank you so uh one one very important thing for you to know if if you are 100 percent clear that your child is affected by an autoimmune disease and and remember that for the one so I have a students here and you have to know that out immune diseases are diseases that most of the times are produced by certain cells that are affecting areas areas of the same body but in most of the treatments for those diseases will be medicines that will be regulating will be regulating and will be controlling the response of the immune system and that's why there are more pro-life of having a any kind of contamination well there are some other diseases like is the case of TB for the ones who are not familiar with the abbreviation tuberculosis tuberculosis is weird we are pleased to know that to work you loss is a disease that is partially partially and look at my fingers partially eradicated so we still have some cases in certain areas of the United States a but but we have to know that is produced by a bacteria that affects affects the mainly the lungs and can be also disseminated disseminated I'm sorry in the medicines to to treat those this that that is specific disease will also depress the immune system of the patient Oh as you may understand cancer so cancer is a it is today is considered as a chronic disease and most of the medicines who are who are applied to different different kind of varieties of cancer will be press as well in the first stage the immune disease the immune system well as you may observe we have a the source of information the Health Department of the state of Florida CDC and alone a lot of more of searches for you for us to try to transmit the most clear and precise information to all of you we're insisting so we are trying to make you make people understand how important is to know about the diseases so at the very end at the very end the decision of being vaccinated or not is so personal we don't have regulations we don't not we don't have a strict laws that you that force the the mother or the father to to take the kids to be vaccinated our our goal is you to be informed our goal is you to know how important is to know about the complications not a tradition and you have to understand that a missiles under the age of five and after the age of 25 will be even more severe that in the in the amount of popular in the population that ranges in between the age of five to twenty five so does it does the way the immune system works well I have the great pleasure now to invite miss Megan gunky so a is from the Bureau of IBM epidemiology so well thank you for coming and I appreciate your presence today thank you all right perfect hi everybody my name is Megan gunky I work for the Florida Department of Health at the State Office in the view of Epidemiology like dr. who's been introduced I have worked for the state this summer will be eight years I've worked in public health I started at the county and then now I work for the State Health Department currently in my current position I'm a regional which means that I assist 18 counties in the Panhandle with investigating diseases and handling outbreaks one of my other duties is actually as case reviewer for measles for the whole state so I'm what some would call this expert in measles for the state of Florida and I've been doing that for a few years now so I want to thank all the other doctors about presenting kind of about the disease I'm gonna go from the perspective of the health department and what we when we're dealing kind of with measles and what we have available to assist in those investigations so like I said I'm gonna go over a little bit about measles in Florida reporting requirements laboratory testing and then investigations so this graphic right here is showing over the last ten years so 1998 to 2018 the number of measles cases specifically in Florida you can see we've definitely had unfortunately kind of an upward trend which mimics obviously the national numbers that we saw earlier today now specifically last year which is our last year of complete data we had 15 cases reported in Florida residents this mostly was consistent consisted of 11 cases that were actually connected to 2 small outbreaks the rest were sporadic cases 6 out of the 15 cases were acquired outside the United States or were acquired by someone that else that had traveled and brought it back the rest were locally acquired unfortunately I will say that none of the 15 cases were vaccinated so that's something to keep in mind there was an additional four cases that was investigated that were not our residents but we're visiting Florida while they were infectious so you have to realize Florida touristy state we get a lot of people coming here visiting family going to Disney World you know all that fun stuff and the diseases unfortunately don't stop at the border so you know if they come here and they're sick and it's something of public health concern we're gonna be following up and we're gonna be hopefully preventing further spread of that disease so so you know yes we have the 15 cases but we're going to be looking at those others as well now 2019 I pulled this graphic actually from our vaccine preventable disease report so far this year we've only had two cases which compared to last year obviously is a lot less both cases were acquired outside of the US and neither of them had documentation of vaccine on board so we are only halfway through the year so there definitely can be more but so far we're only at 2 so we're glad obviously but we're working hard now reporting requirements what is that so the CDC has a list of what they call nationally notifiable diseases and this list includes a variety of diseases that they want to know about in that earlier presentation you saw CDC numbers of kind of for the whole US and so every state is required to report to them now each individual state can add on other diseases as they see fit that they feel like is important for that state in addition to the nationally notifiable diseases and so in the state of Florida this is our report of what we call a reportable disease list so written into Florida Statute 60 43 practitioners and laboratory ins are required by law to report these diseases and it's everything from STDs to Lyme disease to Salmonella – of course measles now you can see there's different colors so the black color is looking at next business day so if someone diagnosed somebody with something they need to report with in the next business day the blue is upon diagnosis 24/7 so every county health department as well as the State Health Department has a 24/7 access line basically phone line for reporting of these diseases and the reason for that is because there's some public health intervention or things that we need to do and we need to do it quickly so we need to know if it's a Saturday night we need to know about it now the red is the highest level and that's 24/7 upon suspicion so that doesn't mean you necessarily have a positive test but you suspect it and measles is one of those there's other things like anthrax and and different things but it's basically ones that as soon as you suspect it we want to know about it because we're gonna do some follow-up related to that and we may need to you know do some things no matter what kind of time of day or night it is unfortunately so this is a little flyer that we've produced that has gone out to providers it's just a quick little kind of graphic that helps to determine if you should be suspecting measles so we kind of have the identify isolate inform so identify so we've already kind of talked about the symptoms of looking for you know the Kafka Raisa the conjunctivitis the rash that starts on the hairline moves their way down also looking at risk factors do they have travel internationally to a maybe a state that has now bright going on do they have vaccine on board or contact with someone that they know is ill you want to immediately isolate that person because again it's very contagious and so the less people that are exposed the better obviously and then the next thing would be to call your County Health Department we have some lovely representatives in the back margin and they they're the ones that you need to call because they're gonna and they're gonna be asking you for information of you know the inference we just talked about what are their symptoms what are their risk factors they are the boots on the ground investigators of these cases and so they're going to be the ones that you need to call now once they've been notified is the next step is is this really a case and how do we do that laboratory testing so it was already brought up obviously about serology but there are other options as well so respiratory and urine can be taken and we can do PCR which is polymerase chain reaction basically it's looking for the DNA of the virus in the respiratory specimens or the urine specimens unfortunately it's not available commercially it's only available at our Bureau of Public Health Labs and it is also available at CDC it's the preferred specimen because a majority of the population is vaccinated so it's slightly more accurate but obviously serum is an option as well and it is available at most commercial laboratories specifically when I'm saying respiratory specimen I'm talking about a swab so you know the icky thing where the doctor goes in sticks it in the back ear throat and it scratches a little bit and that needs to go in viral transport media you want to collect the samples as soon as possible after the rash onset preferably within three days and it can be detected 10 to 14 days after that onset and we have had cases where we've done that it needs to be refrigerated and then we would test it at our state lab urine specimens 10 to 15 ml of urine in a leak-proof container again collecting as soon as possible after rash and then again it can be detected up to 10 to 14 days after that onset now serum specimens we had already talked about that briefly you want to collect it in tubes without any additives typically they call it a red top or a tiger top tube I have a picture of one kind of up there the thing to keep to note with this that up to 20% of tests may have false negatives if collected within 72 hours of rash onset hence why it's not exactly the most ideal way to test and it really should only be used for onion you noise patients with clinically compatible illness because we can get false results with serology unfortunately and then IgG that typically is used to look for immunity but we can technically use that to see if there's a rise in that after kind of onset of symptoms but it begins later than the IgM the IgM is definitely the more acute which you are you discussed briefly the thing that I'll say overall about this – it's not just about accuracy it's also about timeliness testing for serology can often take a few days to get the results back whereas PCR if we're running it at our state lab if margery in the back gets a call about you know a measles case and and she's talking with us and talking with the lab you overnight that specimen or even drive it over to the state lab we can get it done I would say I don't say 24 hours but within 48 hours typically it gets there in the morning the lab techs pull it we have an answer before the end of the day and you know the reason why that's important is as we talked about kind of getting post-exposure prophylaxis and being able to prevent further spread spread and understanding you know what's going on so musil's investigations why are we concerned with it and what do we do so if we identify a case we get a positive at our lab and we know it's a confirmed case what are we gonna do we need to create a list of individuals that were exposed to that case we're looking at household contacts who's in the house we're looking at you know they obviously probably went to the doctor so health care facilities you know school work other activities do they go to the gym do they go to the store do they go to a birthday party where were they it was talked about earlier that the infectious period is four days before – four days after rash onset so we're looking for that nine day period where have they been who have they been in contact with and we're gonna take that group of people and we're gonna prioritize follow-up depending upon their immunity status or their risk of severe disease and so you can see here we have four priority areas that they're not immune and they have a high risk they're not immune and not at risk immune status unknown or considered immune so how do we assess immunity so basically we consider you immune if you were born before 1957 what does that mean not that you were born in 1957 1956 and older because essentially the disease was so common during that time period that most people got the disease therefore they have their own natural immunity because of that now in terms of actually getting the vaccine one or two doses of MMR documented healthcare workers must have two documented doses I believe there was a question earlier about requirements so absolutely every facility is different on what they require however in terms of an investigation and if we had a case in a hospital facility if someone doesn't have documented two dose or documented immunity we request that they're pulled from work until they can show that documentation and so it's just for your safety patient safety that sort of thing so just something to keep in mind now you're considered not immune if you've never received any doses of the MMR obviously we talked about the infant's under age 12 months because they can't get the vaccine and so you're severely immunocompromised individuals so immune status unknown they tend to fall into that if they're not sure they don't know we don't have record of it we can get an IgG titer just to see if they have that level of immunity or not it's just another way to figure out what's going on now post exposure prophylaxis this is really the reason why timely reporting timely follow-up is so important so we did that assessment we found all the people that were exposed and now we're determining who's at risk we're taking that risk group and if there's people that are not immune that can get protected in a timely manner we're gonna recommend that so if someone that is 12 months or older so not the babies that isn't vaccinated they can get the MMR within 72 hours of initial exposure that's why that time frame of getting the test results back quickly is important because 72 hours is going to go very quickly so we want to make sure that we get that information back as soon as possible now immune globulin this is another option this is specifically for those that are under 12 months or who are immunocompromised or like the pregnant women maybe that don't have evidence of immunity this has a little bit longer time period thankfully it's within six days of exposure and so again it's not indicated for anyone that can actually receive the MMR but it's another option for those that can't and this is just the different types of IG so there's IG IV and then there's IG IM and there's different individuals that are it's more appropriate for basically and that decision would be up to their medical provider to determine where if they feel like it's necessary or not that's all I really have you know again from the health department's perspective our goal is to stop further spread and the thing to keep in mind is you know we're trying to prevent those secondary cases and getting that post exposure prophylaxis and individuals that need it as well as notifying people that they were exposed is very important now if we get a secondary case that whole process starts over again we're going okay where were you and your 90-day period and finding those contacts and doing the same process again and so yeah I'll take questions yes ma'am yes that's a great question so the PCR that we do at the state lab does not differentiate between the wild or the vaccine strain so if it's someone that we suspect is a vaccine related kind of illness or something like that we can send it off to CDC and what they refer to as a genotype so certain genotypes are considered wild types and then the vaccine has a very specific type so if that's the typing on it then that would be from the vaccine technically so we do work with CDC on that they also do sequencing that would further identify maybe connections to other cases or other countries for instance some of our cases from last year you know looked similar to ones from the Ukraine and then we found out they had Ukraine travel so you know we definitely do further kind of analysis on that and we do work very closely with CDC regarding right so if if it's positive we typically do send a CDC for genotyping so it's pretty much automatic for that I'm right I believe the CDC puts out some information regarding that as well as w-h-o because a lot of it's very interconnected you have to remember you know certain genotypes are more popular in certain places and are connected to outbreak so there are places online that does have that level of detail I'm not sure that we have that available directly through our site but definitely CDC has that information sure her question was related to religious exemptions so state of Florida is one of the states that does have those in place and honestly I'm not sure I'm not part of that conversation directly ideal was kind of more after the disease is here unfortunately uh-huh and so we do have a whole immunization section that deals more with on that side of it and I am NOT a part of that so I'm I'm more on the investigation once the disease unfortunately is here and and preventing further spread obviously so that's definitely a question I think that's happening throughout the US and will probably continue as we get more and more vaccine preventable diseases popping up so a good question so her question was related to the you know 90 X 90 exposure kind of period and how do we actually identify contacts and that's a great question we talked to the people so we talked to them we walk back through steps honestly with the nine day period a lot of times they're sickly so they're not technically doing too much most of the time sometimes they are it depends on how sick they are but so hopefully they have some recollection in terms of working with healthcare facilities because a lot of them obviously have gone to a health care facility they're usually able to pull a client list of who was there that day and then we can start notifying them through that route again it's just working closely with them sometimes we ask people to go back and look at their credit card receipts you know I don't know where I ate but I can pull up my credit card receipt and find out where I went shopping or where I ate that sort of thing so we have different mechanisms to interview and try to get more information from them we do that for other diseases as well quite honestly you know we just were working with the people to jog their memory a little bit and then we go from there so yes ma'am well I believe on the slide that was shown earlier her question was related to the reason for the second MMR so the first MMR is gonna give you 93% effectiveness and dena and the second one brings it up to about 97% so getting that second one is gonna increase your protection basically so we want more protection and that's why certain vaccines you know will have multiple doses so like Hep A is – or Hep B is 3 so depending upon the vaccine you know there's been research done essentially that's you know showing that that is needed or warranted basically to have a better level of protection to protect you from disease oh yes ma'am that was a great question so the the question was related to how do we handle maybe people that can't get out to see the doctor or that sort of thing during an investigation so gotta give a hand to our lovely County Health Department folks they we have vehicles we drive we'll go out and find you well well we'll help with whatever we need if we need to get specimens or if we just you know we've done interviews in person sometimes it's better in person to talk to somebody and get information so we will go out and and that that would be an option correct whatever is needed we'll work them if someone's that ill though we probably want to refer to their physician just to confirm that that's appropriate anytime you're dealing with someone that has any sort of medical condition we are not their provider we are not their doctor we can only provide recommendations so if someone's that ill you know we would want to be working in conjunction with their provider to make sure that they felt like that was appropriate for them other questions comments well I will end it there then here's my contact information if you have any questions and thank you guys [Applause] there's a there's I'm going to widen your your question a little bit more so did your answer I'm sorry so I was thinking about the question I'm sorry for that so and with regard to the the reason why of why to receive a second chance a second shot for you to be even more protected it's directly related to the amount of of exposition to the immune system so at the first the first time you receive the shot you will be is like the face of recognition of the immune system the acquired immune system to the the germ or the microbe or the virus that is is inserted into your body and will the cells of humidity will be mounting an immune response the more you are exposed the more you're exposed they let me describe you this way the bigger the response of the immune system will be for that specific germ so that's why that's why I doing the first shot you get a 93% and even after the second shot you will you get in between 97 to 98 percent of protection the more you are exposed to the disease the more protection you will get

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