Morbidity and Mortality Weekly Report

Weekly / Vol. 68 / No. 48 December 6, 2019

Progress Toward Regional Measles Elimination — Worldwide, 2000–2018

Minal K. Patel, MD1; Laure Dumolard, PhD1; Yoann Nedelec, MPH1; Samir V. Sodha, MD1; Claudia Steulet1; Marta Gacic-Dobo, MSc1;
Katrina Kretsinger, MD1; Jeffrey McFarland, MD2; Paul A. Rota, PhD3; James L. Goodson, MPH2

In 2010, the World Health Assembly (WHA) set the fol- are needed to strengthen routine immunization systems,
lowing three milestones for measles control to be achieved close historical immunity gaps, and improve surveillance. To
by 2015: 1) increase routine coverage with the first dose of achieve measles elimination, all communities and countries
measles-containing vaccine (MCV1) among children aged need coordinated efforts aiming to reach ≥95% coverage with
1 year to ≥90% at the national level and to ≥80% in every 2 doses of measles vaccine (3).
district, 2) reduce global annual measles incidence to less
than five cases per 1 million population, and 3) reduce global Immunization Activities
measles mortality by 95% from the 2000 estimate* (1). In WHO and the United Nations Children’s Fund (UNICEF)
2012, WHA endorsed the Global Vaccine Action Plan,† with use data from administrative records and vaccination cover-
the objective of eliminating measles§ in five of the six World age surveys reported annually to estimate MCV1 and sec-
Health Organization (WHO) regions by 2020. This report ond dose (MCV2) coverage through routine immunization
updates a previous report (2) and describes progress toward services.¶ During 2000–2018, estimated MCV1 coverage
WHA milestones and regional measles elimination during increased globally from 72% to 86% (Table), although cover-
2000–2018. During 2000–2018, estimated MCV1 coverage age has remained at 84%–86% since 2010, with considerable
increased globally from 72% to 86%; annual reported measles regional variation. Since 2016, MCV1 coverage has remained
incidence decreased 66%, from 145 to 49 cases per 1 million relatively constant in the African Region (AFR) (74%–75%),
population; and annual estimated measles deaths decreased the Eastern Mediterranean Region (EMR) (82%–83%), and
73%, from 535,600 to 142,300. During 2000–2018, measles the South-East Asia Region (SEAR) (88%–89%); and it
vaccination averted an estimated 23.2 million deaths. However,
¶ For MCV1, among children aged 1 year or, if MCV1 is given at age ≥1 year,
the number of measles cases in 2018 increased 167% globally among children aged 24 months. For MCV2, among children at the recommended
compared with 2016, and estimated global measles mortality age for administration of MCV2, per the national immunization schedule. WHO/
has increased since 2017. To continue progress toward the UNICEF estimates of national immunization coverage are available at https://
www.who.int/immunization/monitoring_surveillance/data/en.
regional measles elimination targets, resource commitments
* The coverage milestone is to be met by every country, whereas the incidence
and mortality reduction milestones are to be met globally. INSIDE
† The Global Vaccine Action Plan is the implementation plan of the Decade of
1112 Progress Toward Measles Elimination — China,
Vaccines, a collaboration between WHO; UNICEF; the Bill and Melinda Gates
Foundation; the National Institute of Allergy and Infectious Diseases; the
January 2013–June 2019
African Leaders Malaria Alliance; Gavi, the Vaccine Alliance; and others to 1117 Vital Signs: Status of Human Immunodeficiency Virus
extend the full benefit of immunization to all persons by 2020 and beyond. In Testing, Viral Suppression, and HIV Preexposure
addition to 2015 targets, it also set a target for measles and rubella elimination
in five of the six WHO regions by 2020. https://www.who.int/immunization/
Prophylaxis — United States, 2013–2018
global_vaccine_action_plan/en; https://apps.who.int/gb/ebwha/pdf_files/ 1124 QuickStats
wha65/a65_22-en.pdf.
§ Measles elimination is defined as the absence of endemic measles virus
transmission in a region or other defined geographic area for ≥12 months, in Continuing Education examination available at
the presence of a high-quality surveillance system that meets targets of key https://www.cdc.gov/mmwr/cme/conted_info.html#weekly.
performance indicators.

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

has remained constant since 2008 in the European Region In 2018, approximately 346 million persons received measles
(EUR) (93%–95%) and in the Western Pacific Region (WPR) vaccination during 45 supplementary immunization activities
(95%–97%). Estimated MCV1 coverage in the Region of the (SIAs)†† in 37 countries; India’s 2018 SIA accounted for 47% of
Americas (AMR) decreased from 92% in 2016 to 88% in 2017 all persons vaccinated in SIAs worldwide. An additional 13 million
and increased to 90% in 2018. persons were vaccinated during measles outbreak response activities.
Globally, 118 (61%) countries achieved ≥90% MCV1 cov-
erage in 2018, an increase from 86 (45%) countries in 2000, Reported Measles Incidence
but a decrease from 126 (65%) countries during 2012–2013. In 2018, all 194 WHO member countries conducted
In 2018, MCV1 coverage was ≥95% nationally in 78 (40%) measles surveillance, and 191 (98%) had access to standard-
countries and ≥80% in all districts in 57 (29%) countries.** In ized quality-controlled laboratory testing through the WHO
2018, 19.2 million infants worldwide did not receive MCV1 Global Measles and Rubella Laboratory Network. However,
through routine immunization services. The six countries with surveillance remains weak in many countries, and only 84
the most unvaccinated infants were Nigeria (2.4 million), India (55%) of 152 countries that reported surveillance indicators
(2.3 million), Pakistan (1.4 million), Ethiopia (1.3 million), achieved the sensitivity indicator target of ≥2 discarded measles
Indonesia (1.2 million), and the Philippines (0.7 million). and rubella§§ cases per 100,000 population.
Estimated MCV2 coverage increased globally from 18% in
2000 to 69% in 2018, largely because of an increase in the †† Supplementary immunization activities (SIAs) generally are carried out using
number of countries providing MCV2 from 98 (51%) in 2000 two target age ranges. An initial, nationwide catch-up SIA focuses on all children
aged 9 months–14 years, with the goal of eliminating susceptibility to measles
to 171 (88%) in 2018 (Table). Four countries (Bolivia, the in the general population. Periodic follow-up SIAs then focus on all children
Dominican Republic, Honduras, and the Solomon Islands) born since the last SIA. Follow-up SIAs generally are conducted nationwide
introduced MCV2 in 2018. every 2–4 years and focus on children aged 9–59 months; their goal is to
eliminate any measles susceptibility that has developed in recent birth cohorts
due to low MCV coverage and to protect children who did not respond to
** In 2000, 191 countries were requested to report to WHO; by 2018, 194 MCV1. Data on SIAs by country are available at https://www.who.int/
member states were requested to report because of the creation of new immunization/monitoring_surveillance/data/Summary_Measles_SIAs.xls?ua.
countries. For district level coverage, only countries that reported data are in §§ A discarded case is defined as a suspected case that has been investigated and
the numerator, whereas the denominator is all WHO countries in that year determined not to be measles or rubella using 1) laboratory testing in a
(191–194) regardless of whether they reported data. proficient laboratory or 2) epidemiological linkage to a laboratory-confirmed
outbreak of a communicable disease that is not measles or rubella. The
discarded case rate is used to measure the sensitivity of measles surveillance.

The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
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MMWR Editorial and Production Staff (Weekly)
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Patricia Quinlisk, MD, MPH

1106 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

TABLE. Estimates of coverage with the first and second doses of measles-containing vaccine administered through routine immunization
services, reported measles cases and incidence, and estimated measles cases and deaths,* by World Health Organization (WHO) region —
worldwide, 2000 and 2018
% of Cumulative
reporting no. of
% countries Estimated measles
WHO region/ countries with No. of Measles % measles deaths
Year (no. of % with ≥90% % <5 measles reported incidence Estimated no. Estimated no. mortality averted by
countries in MCV1† MCV1 MCV2† cases per measles per of measles cases of measles deaths reduction, vaccination,
region) coverage coverage coverage 1 million cases§ 1 million§,¶ (95% CI) (95% CI) 2000–2018 2000–2018
African
2000 (46) 53 9 5 8 520,102 836 10,723,800 345,600 85 12,146,900
(7,718,000–17,119,100) (236,300–562,100)
2018 (47) 74 30 26 47 125,426 118 1,759,000 52,600
(1,141,200–6,002,100) (32,000–173,400)
Americas
2000 (35) 93 63 65 89 1,754 2 8,770 (4,400–35,100) NA** NA 97,100
2018 (35) 90 57 82 91 16,327 24 83,500 (41,800–334,200) NA
Eastern Mediterranean
2000 (21) 71 57 28 17 38,592 90 2,427,900 37,900 −29 2,820,600
(1,503,800–3,892,900) (21,700–64,000)
2018 (21) 82 57 74 35 64,722 93 2,852,700 49,000
(2,293,700–4,265,200) (36,700–72,500)
European
2000 (52) 91 62 48 45 37,421 50 860,176 400 50 95,600
(227,200–6,668,300) (100–2,200)
2018 (53) 95 89 91 34 82,523 98 861,800 (71,100–6,480,300) 200
(0–1,800)
South-East Asia
2000 (10) 63 30 3 0 78,558 51 11,411,900 141,700 72 6,825,400
(8,764,600–15,572,100) (100,100–199,600)
2018 (11) 89 82 80 36 34,741 18 3,803,800 39,100
(2,856,700–6,702,900) (24,800–76,000)
Western Pacific
2000 (27) 85 48 2 30 177,052 105 2,786,500 10,000 87 1,213,200
(1,923,900–22,167,600) (5,200–74,200)
2018 (27) 95 59 91 77 29,497 15 408,400 1,300
(42,500–16,753,800) (100–2,786,500)
Total
2000 (191) 72 45 18 38 853,479 145 28,219,100 535,600 73 23,198,800
(20,141,900–65,455,000) (363,400–901,700)
2018 (194) 86 61 69 54 353,236 49 9,769,400 142,300
(6,446,900–40,538,500) (93,600–387,900)
Abbreviations: CI = confidence interval; MCV1 = first dose of measles-containing vaccine; MCV2 = second dose of measles-containing vaccine; NA = not applicable;
UNICEF = United Nations Children’s Fund.
* Mortality estimates for 2000 might be different from previous reports. When the model used to generate estimated measles deaths is rerun each year using new
WHO/UINICEF estimates of national immunization coverage (WUENIC) data, as well as updated surveillance data, adjusted results for each year, including the
baseline year, are also produced and updated.
† Coverage data: WUENIC. Geneva, Switzerland, World Health Organization; 2019. https://www.who.int/immunization/monitoring_surveillance/data/en.
§ Reported measles cases (2018) from World Health Organization. Geneva, Switzerland, World Health Organization; 2019. https://apps.who.int/immunization_
monitoring/globalsummary/timeseries/tsincidencemeasles.html.
¶ Cases per 1 million population; population data from United Nations, Department of Economic and Social Affairs, Population Division, 2019. Any country not
reporting data on measles cases for that year was removed from both the numerator and denominator.
** Estimated measles mortality was too low to allow reliable measurement of mortality reduction.

Countries report the number of incident measles cases¶¶ decreased 59%, from 853,479 in 2000 to 353,236 in 2018,
to WHO and UNICEF annually using the Joint Reporting and measles incidence decreased 66%, from 145 to 49 cases
Form.*** During 2000–2018, the number of reported cases per million population (Table). However, compared with the
reported number of cases (132,413) and incidence (19 cases
¶¶ https://apps.who.int/immunization_monitoring/globalsummary/timeseries/
per million) in 2016, both cases and incidence increased in 2018,
tsincidencemeasles.html; data reported here as of July 15, 2019. Only countries
that reported data are in the numerator, whereas the denominator is all WHO
the highest levels since 2011 (Figure 1). Compared with 2016,
countries in that year (191–194) regardless of whether they reported data. the number of measles cases increased 167% globally, including
*** https://www.who.int/immunization/monitoring_surveillance/routine/ increases of 246% in AFR, 16,732% in AMR, 931% in EMR,
reporting/en/.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1107
 Morbidity and Mortality Weekly Report

1,791% in EUR, and 26% in SEAR.††† In WPR, the number Korea, Oman, Singapore, Switzerland, and Timor-Leste were
of measles cases decreased 49%, primarily because of decreased verified as having achieved elimination during 2018. No AFR
cases in China. In 2018, five (3%) of 179 reporting countries country had yet been verified as having eliminated measles. In
(Democratic Republic of the Congo, Liberia, Madagascar, the AMR, a region that had achieved verification of measles
Somalia, and Ukraine) had measles incidences >600 per million elimination in 2016, endemic measles transmission was rees-
and accounted for 45% (157,239 cases) of all reported cases tablished in Venezuela in 2018 and in Brazil in 2019. In EUR,
worldwide. The percentage of reporting countries with annual endemic measles transmission was reestablished during 2018
measles incidence of <5 cases per million population increased in Albania, Czechia, Greece, and the United Kingdom.
from 38% (64 of 169) in 2000 to 70% (125 of 178) in 2016,
Discussion
then decreased to 54% (96 of 179) in 2018 (Table) (Figure 1).
Genotypes of viruses isolated from measles cases were During 2000–2018, increased coverage with MCV1 and
reported by 95 (73%) of 131 countries reporting at least one MCV2, widespread SIAs, and other elimination efforts con-
measles case in 2018. Among the 24 recognized measles virus tributed to a 66% decrease in reported measles incidence, a
genotypes, 11 were detected during 2005–2008, eight during 73% reduction in estimated measles mortality, and a reduction
2009–2014, six in 2016, five in 2017, and four in 2018 (4). in the number of circulating measles virus genotypes world-
In 2018, among 7,155 reported virus sequences, 3,011 (42%) wide. Despite this progress, the 2015 global milestones were
were genotype B3; 20 (0.3%) were D4; 3,774 (53%) were D8; not met: MCV1 coverage has stagnated for nearly a decade,
and 350 (5%) were H1. MCV2 coverage is only 69%, and suboptimal surveillance
limits data-driven actions. Reported measles incidence has
Measles Case and Mortality Estimates increased in five regions since 2016 and estimated global
A previously described model for estimating measles cases measles mortality has increased since 2017. Increased measles
and deaths was updated with new measles vaccination cover- cases and outbreaks occurred mostly among unvaccinated
age data, case data, and United Nations population estimates persons, including school-aged children and young adults.
for all countries during 2000–2018, enabling derivation of a The causes of the measles resurgence during 2017–2018 are
new series of disease and mortality estimates (5). For countries multifactorial and vary by country. Large sustained outbreaks
with anomalous estimates in previous iterations, the model was in a few countries with weak immunization systems accounted
modified slightly to generate mortality estimates consistent with for most reported measles cases during this time. In addition,
observed case data. Based on the updated data, the estimated unidentified or unaddressed immunity gaps in older children
number of measles cases decreased 65%, from 28,219,100 and adults, because of historically weak routine immunization
(95% confidence interval [CI]  =  20,141,900–65,455,000) programs and inadequate SIA coverage, led to sustained trans-
in 2000 to 9,769,400 (95% CI = 6,446,900–40,538,500) in mission in some countries that previously had low incidence
2018. During this period, estimated measles deaths decreased or had eliminated measles (6). As well, international travel
73%, from 535,600 (95% CI = 363,400–901,700) to 142,300 by infected persons, including both unimmunized foreign
(95% CI = 93,600–387,900) (Table) (Figure 2). During 2000– visitors and unimmunized residents traveling abroad and
2018, compared with no measles vaccination, measles vac- returning home, facilitated international spread of measles.
cination prevented an estimated 23.2 million deaths globally. For example, in 2018, Israel experienced nearly 100 measles
importations from multiple countries including Philippines,
Regional Verification of Measles Elimination Ukraine, and the United Kingdom; and importations from
By the end of 2018, 82 (42%) countries had been veri- Israel and Ukraine led to outbreaks in the United States (7).
fied as having eliminated measles. Austria, Bahrain, North Sustaining elimination in the face of frequent importations
and gaps in vaccination coverage presents challenges. For
††† Twenty-five countries did not report case data in 2000: Algeria, Austria, example, after having experienced >100 importations in
Belgium, Comoros, Equatorial Guinea, Fiji, Finland, Germany, Guinea- 2018 as a consequence of inadequate vaccination coverage,
Bissau, Ireland, Libya, Mauritania, Monaco, Montenegro, North Korea,
Samoa, Saudi Arabia, Seychelles, Slovenia. Solomon Islands, South Sudan.
endemic measles virus transmission has been reestablished in
Switzerland, Timor-Leste, Tuvalu, and Yemen. Sixteen countries did not the United Kingdom. Countries such as Cambodia, which,
report case data in 2016: Belgium, Cabo Verde, Cook Islands, Haiti, Ireland, through sustained efforts, identified and closed immunity
Italy, Kiribati, Marshall Islands, Monaco, Morocco, Mozambique, Niue,
Samoa, Singapore, Tuvalu, and Vanuatu. Fifteen countries did not report gaps to achieve elimination, but which border countries with
case data in 2018: Belarus, France, Israel, Kuwait, Luxembourg, Marshall ongoing endemic transmission, must remain vigilant to iden-
Islands, Mauritius, Montenegro, Nauru, Niue, North Macedonia, Palau, tify and stop measles outbreaks rapidly. Before international
Seychelles, Tuvalu, and United States. Countries do not provide WHO with
their reasons for not reporting case data. travel, travelers from all countries should ensure they have

1108 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

FIGURE 1. Reported measles incidence per 1 million persons — worldwide, 2000, 2016, and 2018

2000

≥25 per 1 million

5–<25 per 1 million
>0–<5 per 1 million
0 per 1 million
Not reported
Not applicable

2016

2018

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1109
 Morbidity and Mortality Weekly Report

FIGURE 2. Estimated annual number of measles deaths, with and without vaccination programs — worldwide, 2000–2018*

2.5

Estimated measles deaths in absence of vaccination

Estimated measles deaths with vaccination

2.0
No. of measles deaths (millions)

1.5

1.0

0.5

0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Year
* Deaths prevented by vaccination are estimated by the area between estimated deaths with vaccination and those without vaccination (cumulative total of 23.2 million
deaths prevented during 2000–2018). Error bars represent upper and lower 95% confidence limits around the point estimate.

been appropriately vaccinated against measles. Progress toward The findings in this report are subject to at least two limita-
measles elimination will regress without a unified effort by all tions. First, large differences between estimated and reported
communities and countries. incidence indicate overall low surveillance sensitivity, making
Evaluations of routine immunization programs to identify comparisons between regions difficult to interpret. Second,
barriers to vaccination indicate that children miss MCV1 and the measles mortality model estimates might be affected by
MCV2 doses for many reasons, including families’ limited biases in model inputs, including vaccination coverage and
awareness of the need for vaccination, limited access to or surveillance data.
financial barriers to receiving vaccination; vaccine stock-outs; The trends of increasing measles incidence and mortality
political instability; and vaccine hesitancy and misinformation. are reversible; however, further progress toward achieving
WHO’s Global Routine Immunization Strategies and Practices elimination goals will require 1) resource commitments to
and The Guide to Tailoring Immunization Programmes pro- strengthen routine immunization systems, close historical
vides guidance on identifying demand and supply barriers to immunity gaps, and improve surveillance to rapidly detect and
routine vaccination and strengthening immunization programs respond to cases, and 2) a new perspective to use measles as
(8,9). Outbreaks should serve as opportunities to investigate a stimulus and guide to improving immunization programs.
underlying causes of undervaccination and to design specific To achieve measles elimination, all communities and countries
routine immunization strengthening activities to prevent future need coordinated efforts aiming to reach ≥95% coverage with
outbreaks. In addition, population immunity gaps should be 2 doses of measles vaccine.
identified through triangulation of data, including surveil- As the period covered by the Global Vaccine Action Plan
lance and vaccination coverage data, and should be targeted 2012–2020 approaches its end, a new vision and strategy for
by vaccination activities. accelerated progress on immunization for 2021–2030 is being

1110 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

References
Summary
1. World Health Organization. Global eradication of measles: report by
What is already known about this topic? the Secretariat. Geneva, Switzerland: World Health Organization; 2010.
In 2012, the World Health Assembly endorsed the Global http://apps.who.int/gb/ebwha/pdf_files/wha63/a63_18-en.pdf
Vaccine Action Plan; countries in all six World Health 2. Dabbagh A, Laws RL, Steulet C, et al. Progress toward regional measles
Organization regions have adopted goals to eliminate measles elimination—worldwide, 2000–2017. MMWR Morb Mortal Wkly Rep
by 2020. 2018;67:1323–9. https://doi.org/10.15585/mmwr.mm6747a6
3. World Health Organization. Global measles and rubella strategic plan,
What is added by this report? 2012–2020. Geneva, Switzerland: World Health Organization; 2012.
During 2000–2018, annual reported measles incidence https://s3.amazonaws.com/wp-agility2/measles/wp-content/
decreased 66%, and annual estimated measles deaths uploads/2017/01/Measles-Rubella-Strategic-Plan.pdf
4. Brown KE, Rota PA, Goodson JL, et al. Genetic characterization of
decreased 73%. Since 2000, measles vaccination has prevented
measles and rubella viruses detected through global measles and rubella
an estimated 23.2 million deaths globally. However, measles elimination surveillance, 2016–2018. MMWR Morb Mortal Wkly Rep
incidence increased in five regions during 2016–2018. 2019;68:587–91. https://doi.org/10.15585/mmwr.mm6826a3
What are the implications for public health practice? 5. Simons E, Ferrari M, Fricks J, et al. Assessment of the 2010 global measles
mortality reduction goal: results from a model of surveillance data. Lancet
To achieve regional measles elimination goals, resource commit- 2012;379:2173–8. https://doi.org/10.1016/S0140-6736(12)60522-4
ments are needed to strengthen routine immunization systems, 6. World Health Organization. Country slides (measles). Geneva,
close immunity gaps, and improve case-based surveillance. Switzerland: World Health Organization; 2019. https://www.who.int/
immunization/monitoring_surveillance/burden/vpd/surveillance_type/
Country_slides_measles.pptx?ua=1
developed by countries and stakeholders (10). Pillars of this 7. Patel M, Lee AD, Clemmons NS, et al. National update on measles cases
evolving strategy include commitment and demand, research and outbreaks—United States, January 1–October 1, 2019. MMWR
and innovation, life course and integration, and supply and Morb Mortal Wkly Rep 2019;68:893–6. https://doi.org/10.15585/
mmwr.mm6840e2
sustainability; all of these are vital to achieving and maintaining 8. World Health Organization. Global routine immunization
measles elimination. This new agenda should be used to secure strategies and practices (GRISP): a companion document to the
the necessary resource commitments to improve coverage and Global Vaccine Action Plan (GVAP). Geneva, Switzerland: World
Health Organization; 2016. https://apps.who.int/iris/bitstream/
equity substantially and, in so doing, further progress toward handle/10665/204500/9789241510103_eng.pdf;jsessionid=C44DB0
achieving the measles elimination goals. 777FEA617956F652845E83415A?sequence=1
Corresponding author: Minal K. Patel, patelm@who.int. 9. World Health Organization Regional Office for Europe. Tailoring
immunization programmes. Copenhagen, Denmark: World Health
1Department of Immunization, Vaccines, and Biologicals, World Health Organization Regional Office for Europe, 2019. http://www.euro.who.
Organization, Geneva, Switzerland; 2Global Immunization Division, Center int/en/health-topics/disease-prevention/vaccines-and-immunization/
for Global Health, CDC; 3Division of Viral Diseases, National Center for publications/2019/tip-tailoring-immunization-programmes-2019
Immunization and Respiratory Diseases, CDC. 10. World Health Organization. Immunization agenda 2030. Geneva,
Switzerland: World Health Organization; 2018. https://www.who.int/
All authors have completed and submitted the International immunization/immunization_agenda_2030/en/
Committee of Medical Journal Editors form for disclosure of potential
conflicts of interest. No potential conflicts of interest were disclosed.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1111
 Morbidity and Mortality Weekly Report

Progress Toward Measles Elimination — China, January 2013–June 2019

Chao Ma, PhD1; Lance Rodewald, MD1; Lixin Hao, PhD1; Qiru Su, PhD1; Yan Zhang, PhD2; Ning Wen, MPH1; Chunxiang Fan, MPH1;
Hong Yang, MPH1; Huiming Luo, MPH1; Huaqing Wang, PhD1; James L. Goodson, MPH3; Zundong Yin, PhD1; Zijian Feng, MPH1

In 2005, the World Health Organization (WHO) Western national Expanded Program on Immunization (EPI). In 1986,
Pacific Region countries, including China, resolved to eliminate the schedule was changed to include 2 MCV doses, with the
measles by 2012 or as soon as feasible thereafter (1). As of 2018, first dose given at age 8 months and the second at age 7 years
nine* of the 37 Western Pacific Region countries or areas† had (the age of administration of the second dose was lowered to
eliminated§ measles. China’s Measles Elimination Action Plan 18 months in 2005, as recommended in WHO guidelines).**
2006–2012 included strengthening routine immunization; Administrative coverage, calculated as the number of vaccine
conducting measles risk assessments, followed by supplementary doses administered divided by estimated target population,
immunization activities (SIAs) with measles-containing vaccine is assessed monthly at the township level (the lowest admin-
(MCV) at national and subnational levels; strengthening surveil- istrative level), aggregated to the national level using vaccine
lance and laboratory capacity; and investigating and responding administration and target population data reported by EPI
to measles outbreaks. Most recently, progress toward measles clinics, and reported annually to WHO and the United Nations
elimination in China was described in a 2014 report document- Children’s Fund (UNICEF). During 2013–2018, annual esti-
ing measles elimination efforts in China during 2008–2012 and mates of coverage with the first MCV dose (MCV1) and the
a resurgence in 2013 (2). This report describes progress toward second dose (MCV2) were both 99%. In 2016, among the
measles elimination in China during January 2013–June 2019.¶ 40,787 townships in China’s 31 mainland provinces, 40,089
Measles incidence per million persons decreased from 20.4 in (98%) reported >90% MCV2 coverage by age 3 years. In 2010,
2013 to 2.8 in 2018; reported measles-related deaths decreased a nationwide SIA was conducted, during which 103 million
from 32 in 2015 to one in 2018 and no deaths in 2019 through children received MCV regardless of previous vaccination his-
June. Measles elimination in China can be achieved through tory. Each province then used a measles risk assessment tool
strengthening the immunization program’s existing strategy developed by the Chinese Center for Disease Control and
by ensuring sufficient vaccine supply; continuing to improve Prevention (China CDC) to determine the need for additional
laboratory-supported surveillance, outbreak investigation and selective or nonselective follow-up SIAs in their jurisdiction.
response; strengthening school entry vaccination record checks; During 2013–2018, 56.9 million children and adults were
vaccinating students who do not have documentation of receipt vaccinated in these follow-up SIAs. During this time, the
of 2 doses of measles-rubella vaccine; and vaccinating health care risk assessment–based SIA target population sizes decreased
professionals and other adults at risk for measles. approximately sixfold, from 23 million in 2013 to 3 million
in 2018. To ensure that school children are protected from
Immunization Activities vaccine-preventable diseases, China has had a national require-
China introduced measles vaccine in 1965 and implemented ment since 2005 that vaccination status is checked upon entry
nationwide measles vaccination in 1978 with the start of the to kindergarten and primary school; children with missing vac-
cine doses are referred to EPI clinics for catch-up vaccination.
* Australia, Brunei, Cambodia, Hong Kong (China), Macao (China), Japan, Although the school entry record check is required, receiving
New Zealand, South Korea, and Singapore. missing vaccine doses is not mandatory, and unvaccinated
† The Western Pacific Region, one of the six regions of WHO, consists of 37
countries and areas with a population of almost 1.9 billion, including American children are not excluded from school.
Samoa (USA), Australia, Brunei, Cambodia, China, Cook Islands, Federated
States of Micronesia, Fiji, French Polynesia (France), Guam (USA), Hong Kong
(China), Japan, Kiribati, Laos, Macao (China), Malaysia, Marshall Islands,
Measles Surveillance Activities
Mongolia, Nauru, New Caledonia (France), New Zealand, Niue, Northern Measles has been nationally notifiable since the 1950s, with
Mariana Islands (USA), Palau, Papua New Guinea, Philippines, Pitcairn Islands aggregated data reported annually to the National Notifiable
(UK), Samoa, Singapore, Solomon Islands, South Korea, Tokelau (New
Zealand), Tonga, Tuvalu, Vanuatu, Vietnam, and Wallis and Futuna (France). Disease Reporting System (NNDRS). In 1997, China devel-
§ Measles elimination is defined as the absence of endemic measles virus
oped a case-based, laboratory-supported measles surveillance
transmission in a defined geographical area (e.g., region or country) for
≥12 months with a well-performing surveillance system.
system, initially in selected provinces and in parallel with
¶ Population of 1.4 billion, not including Hong Kong Special Administrative NNDRS. The two surveillance systems were unified in 2009.
Region, Macao Special Administrative Region, and Taiwan.
** https://www.who.int/immunization/documents/positionpapers/en/.

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 Morbidity and Mortality Weekly Report

Every suspected case is investigated by county-level China Consultations with international partners, including CDC,
CDC staff members using a standardized, in-person question- WHO, UNICEF, the World Bank, the Japan International
naire; outbreaks are investigated and reported by local China Cooperation Agency, and the Measles & Rubella Initiative§§
CDC staff members as needed. China’s Measles Laboratory have helped guide activities. Research and evaluation have
Network comprises 31 provincial laboratories and one national also provided valuable information for measles elimination.
laboratory that has been accredited by WHO as a Regional MCVs used in China were found to be highly immunogenic
Reference Laboratory since 2003†† (3). Rubella case-based in infants aged 8 months, and coadministration of Japanese
surveillance was integrated into the measles surveillance system encephalitis vaccine did not reduce measles seroconversion rates
in 2014. Since 2011, measles surveillance in China has met or (6). In a Chinese study of risk factors for measles in children
exceeded WHO surveillance quality criteria (4). aged 8 months–14 years after a nationwide SIA, the estimated
measles vaccine effectiveness among children was >95%, and
Measles Incidence and Epidemiologic being unvaccinated was the leading risk factor for infection
Characteristics (7). In addition, hospitals were important sites of measles virus
From 2013 to 2014, measles incidence per million persons transmission, and internal migration was associated with risk
increased from 20.4 to 38.8; incidence subsequently declined for measles acquisition (7). In a 2013 assessment of vaccination
each year, reaching 2.8 in 2018 (Table). Among confirmed coverage in China during an outbreak following a nationwide
cases reported during 2013–2018, the case count among SIA, administrative vaccination coverage might have overesti-
infants aged <8 months (younger than the routinely recom- mated coverage by 5%–10% (8). Finally, application of false
mended age for MCV1) decreased from 8,448 (31%) in 2013 contraindications to vaccination led to missed opportunities
to 532 (14%) in 2018 (Figure). Among the 1,839 measles cases to immunize some children against measles (9).
reported in the first half of 2019, 109 (5.9%) were among Research and evaluation have led to action. In 2015, the
infants aged <8 months, 965 (52.5%) were among children Chinese Ministry of Health recommended measles vaccina-
aged 8 months–14 years, and 765 (41.6%) were among persons tion for hospital professionals, and in 2017, China CDC and
aged ≥15 years. During 2013–2018, the number, size, and WHO hosted an international consultation to improve cov-
duration of measles outbreaks decreased steadily. Until 2019, erage assessment methods. Immunogenicity results provided
almost all (98.9%) cases that had a measles virus genotype result evidence of adequate seroconversion when MCV1 is given
were found to be the indigenous genotype H1. However, in at age 8 months, satisfying the WHO evidence requirement
the first half of 2019, this pattern changed: 82% of genotyped for routine MCV1 administration before age 9 months. EPI
measles viruses were found to be import-associated genotypes clinics are now directed to vaccinate migrant children after
B3 or D8 (Table) (5). 3 months of residence.
Mathematical modeling has also proven useful. A metapopu-
Discussion lation measles virus transmission model that estimated the
Progress toward measles elimination in China has been basic reproduction number for measles to be 18 nationwide
considerable. Measles cases, incidence, and outbreaks were all indicated that by 2014, the effective reproduction number was
at historically low levels in 2017 and 2018 and have decreased 2.3 and was <1 in 14 provinces (10). The model predicts that
further through June 2019. Measles deaths are now rare in this measles will eventually be eliminated by the current strategy
country of 1.4 billion persons, with just one measles-associated and that measles elimination can be accelerated by vaccinating
death reported in the last 18 months. middle school and high school students lacking evidence of
Laboratory-supported surveillance is critical for guiding receipt of 2 MCV doses.
measles elimination activities and strengthening routine The global nature of measles virus transmission is evident in
immunization. Outbreak investigations have identified gaps the patterns of measles virus importations and exportations.
in population immunity that are addressed with follow-up China’s measles surveillance system detects imported cases, and
immunization activities and program strengthening. The other countries have detected importations from China. For
risk assessment–based SIA target population sizes markedly example, during January 2016–June 2019, CDC detected only
decreased during 2013–2018, providing indirect evidence of one importation from China into the United States, compared
strengthened routine immunization service delivery. with six, four, and five such importations each year during
§§ The Measles & Rubella Initiative is a partnership established in 2001 as the Measles
†† https://www.who.int/immunization/monitoring_surveillance/burden/
Initiative, spearheaded by the American Red Cross, CDC, the United Nations
laboratory/measles/en/.
Foundation, UNICEF, and WHO. https://measlesrubellainitiative.org/.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1113
 Morbidity and Mortality Weekly Report

TABLE. Epidemiologic characteristics of reported measles, cases, outbreaks, and isolate genotypes — China, January 2013–June 2019
Year
Characteristic 2013 2014 2015 2016 2017 2018 Jan–Jun 2019
Measles incidence, 20.42 38.84 31.09 18.11 4.31 2.84 1.27
cases per million
population*
No. of 31 total 1 0 0 2 4 5 NA
provinces with
incidence <1 per
million population
No. of measles cases 27,646 52,628 42,361 24,820 5,941 3,940 1,839
Age group distribution, no. (%)
<8 mos 8,448 (30.6) 11,193 (21.3) 10,575 (24.9) 4,652 (18.7) 950 (16.0) 542 (13.8) 109 (5.9)
8–23 mos 8,227 (29.8) 11,928 (22.7) 10,070 (23.8) 5,910 (23.8) 1,786 (30.0) 1,231 (31.2) 530 (28.8)
2–6 yrs 2,890 (10.4) 4,554 (8.6) 3,933 (9.3) 2,521 (10.2) 866 (14.6) 554 (14.1) 233 (12.7)
7–14 yrs 648 (2.3) 1,696 (3.2) 1,313 (3.1) 971 (3.9) 445 (7.5) 273 (6.9) 202 (11)
≥15 yrs 7,433 (26.9) 23,257 (44.2) 16,470 (38.9) 10,766 (43.4) 1,894 (31.9) 1,340 (34.0) 765 (41.6)
No. of vaccine doses received by measles patients aged 8 mos–14 yrs†
0 7,636 (64.9) 10,964 (60.3) 9,158 (59.8) 5,332 (56.7) 1,146 (37.0) 629 (30.5) 127 (14.6)
1 1,889 (16.1) 2,947 (16.2) 2,725 (17.8) 1,865 (19.8) 945 (30.5) 749 (36.4) 311 (35.9)
≥2 724 (6.1) 1,577 (8.7) 1,453 (9.5) 1,128 (12.0) 495 (16.0) 551 (26.8) 340 (39.2)
Unknown 1,516 (12.9) 2,690 (14.8) 1,980 (12.9) 1,077 (11.5) 511 (16.5) 129 (6.3) 89 (10.3)
Laboratory- 96.3 96.3 96.3 96.1 85.6 96.5 92.6
confirmed (%)
Male sex (%) 59.8 56.5 56.2 55.2 57.2 57.6 56.5
No. of measles- 24 28 32 18 5 1 0
related deaths
Measles deaths per 0.018 0.020 0.023 0.013 0.004 0.001 0
million population
Administrative 99.6 99.9 99.4 99.4 99.4 99.2 NA
MCV2 coverage (%)
No. of persons 22.67 12.81 9.12 4.06 5.44 2.84 NA
vaccinated in SIAs
(million)
No. of outbreaks 109 283 329 230 38 37 18
reported§
No. of outbreak- 436 2,080 1,847 1,235 238 158 83
related cases
Median no. of cases 2 (2–29) 3 (2–271) 2 (2–278) 4 (2–122) 3 (2–59) 3 (2–29) 3 (2–14)
per outbreak
(range)
Median outbreak 8 (1–44) 7 (1–158) 8 (1–245) 85 (1–65) 13 (1–44) 11 (1–28) 9 (1–35)
duration, days
(range)
Measles virus H1 (2,208); B3 (3); H1 (4,872); B3 (10); H1 (3,948); D9 (1) H1 (2,467); D8 (3) H1 (400); B3 (1); H1 (155); B3 (3); H1 (24); B3 (18);
genotypes D8 (51); D9 (47) D8 (3); D9 (9); G3 (1) D8 (10) D8 (8) D8 (91)
(no. identified)¶
Abbreviations: MCV = measles-containing vaccine; MCV2 = second dose of MCV; NA = not available; SIA = supplementary immunization activity.
* Incidence for January–June 2019 is annualized.
† No. of doses of MCV received by patient as of date of measles illness onset.
§ In China, a measles outbreak is defined as the occurrence, within a 10-day period, of either two or more confirmed measles cases in a village, district, school, or
similar unit or five or more confirmed measles cases in a township.
¶ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0218782.

2013–2015, respectively, supporting the understanding that to medical attention, and some medically attended cases might
cooperation among countries in fighting measles can benefit not be reported.
all countries. China is approaching measles elimination, but the high
The findings in this report are subject to at least two limita- transmissibility of measles virus, the size and density of
tions. First, administrative coverage can be affected by inaccu- China’s population, and the persistence of global measles virus
rate population estimates leading to under- or overestimates of transmission mean that measles will continue to be detected
coverage (8). Second, despite meeting WHO Western Pacific in China for years to come. Elimination can be achieved
Region surveillance quality indicators, surveillance might with an updated action plan that includes ensuring sufficient
underestimate incidence because not all measles patients come vaccine supply, continuing to improve laboratory-supported

1114 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

FIGURE. Confirmed measles cases,* by age group — China, January 2013–June 2019
12,000
≥15 years
8 months–14 years
10,000 <8 months

8,000
No. of cases

6,000

4,000

2,000

0
Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct
2013 2014 2015 2016 2017 2018 2019

Year and month

* Confirmed cases include those that are laboratory-confirmed, epidemiologically linked to a laboratory-confirmed case, or clinically compatible.

1National Immunization Program, Chinese Center for Disease Control and

Summary Prevention; 2World Health Organization Western Pacific Regional Office,
What is already known about this topic? Regional Reference Measles and Rubella Laboratory, National Institute for Viral
Disease Control and Prevention, Chinese Center for Disease Control and
China has historically had high measles incidence and many Prevention; 3Global Immunization Division, Center for Global Health, CDC.
associated deaths. A comprehensive measles elimination plan
during 2006–2012 substantially reduced measles incidence; All authors have completed and submitted the International
however, a resurgence occurred during 2013–2015. Committee of Medical Journal Editors form for disclosure of potential
conflicts of interest. No potential conflicts of interest were disclosed.
What is added by this report?
In China, measles surveillance, outbreak response, research, and References
program evaluation were used to strengthen routine immuniza-
1. World Health Organization. Fifty-sixth session of the Regional Committee
tion and target immunization activities for eliminating measles. for the Western Pacific. Summary record of the eighth meeting. Resolution
Measles incidence declined from 31 per million in 2015 to 2.8 in WPR/RC56.R8. Measles elimination, hepatitis B control, and
2018; only one measles-associated death has been reported poliomyelitis eradication. Manila, Philippines: World Health Organization;
during 2018–June 2019. 2005. http://www.wpro.who.int/hepatitis/2005_measles_elimination_
What are the implications for public health practice? hepatitisbcontrol.pdf
2. Ma C, Hao L, Zhang Y, et al. Monitoring progress towards the elimination
The World Health Organization–recommended strategy to of measles in China: an analysis of measles surveillance data. Bull World
eliminate measles can be effective, including in large, densely Health Organ 2014;92:340–7. https://doi.org/10.2471/BLT.13.130195
populated countries like China. 3. Xu W, Zhu Z, Jiang X, et al. Establishment and running status of measles
laboratory network in China [Chinese]. Chin J Vaccin Immun
2006;12:1–6.
surveillance and outbreak response, strengthening the school- 4. Ma C, Su Q, Wen N, et al. Evaluation of measles surveillance system
entry vaccination record check, vaccinating students lacking performance in China, 2015–2016 [Chinese]. Chin J Vaccin Immun
2018;24:141–5.
documentation of receipt of at least 2 doses of measles/rubella 5. Wang H, Zhang Y, Mao N, et al. Molecular characterization of measles
vaccine, and vaccinating health care professionals and other viruses in China: circulation dynamics of the endemic H1 genotype from
adults at risk for measles. Data sharing and cooperation among 2011 to 2017. PLoS One 2019;14:e0218782. https://doi.org/10.1371/
countries and international organizations will continue to journal.pone.0218782
6. Li Y, Chu SY, Yue C, et al. Immunogenicity and safety of measles-rubella
be critically important in the global effort to eliminate and vaccine co-administered with attenuated Japanese encephalitis SA 14-14-2
eventually eradicate measles. vaccine in infants aged 8 months in China: a non-inferiority randomised
Corresponding author: Lixin Hao, haolx@chinacdc.cn. controlled trial. Lancet Infect Dis 2019;19:402–9. https://doi.
org/10.1016/S1473-3099(18)30650-9

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1115
 Morbidity and Mortality Weekly Report

7. Hao L, Ma C, Wannemuehler KA, et al. Risk factors for measles in children 9. Su Q, Zhang Y, Ma Y, et al. Measles imported to the United States by
aged 8 months–14 years in China after nationwide measles campaign: a children adopted from China. Pediatrics 2015;135:e1032–7. https://
multi-site case-control study, 2012–2013. Vaccine 2016;34:6545–52. doi.org/10.1542/peds.2014-1947
https://doi.org/10.1016/j.vaccine.2016.02.005 10. Hao L, Glasser JW, Su Q, et al. Evaluating vaccination policies to accelerate
8. Ma C, Li F, Zheng X, et al. Measles vaccine coverage estimates in an measles elimination in China: a meta-population modelling study. Int J
outbreak three years after the nation-wide campaign in China: implications Epidemiol 2019;48:1240–51. https://doi.org/10.1093/ije/dyz058
for measles elimination, 2013. BMC Infect Dis 2015;15:23. https://doi.
org/10.1186/s12879-015-0752-z

1116 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

Vital Signs: Status of Human Immunodeficiency Virus Testing,

Viral Suppression, and HIV Preexposure Prophylaxis —
United States, 2013–2018
Norma S. Harris, PhD1; Anna Satcher Johnson, MPH1; Ya-Lin A. Huang, PhD1; Dayle Kern, MA1; Paul Fulton2; Dawn K. Smith, MD1;
Linda A. Valleroy, PhD1; H. Irene Hall, PhD1

On December 3, 2019, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr).

Abstract
Background: Approximately 38,000 new human immunodeficiency virus (HIV) infections occur in the United States
each year; these infections can be prevented. A proposed national initiative, Ending the HIV Epidemic: A Plan for
America, incorporates three strategies (diagnose, treat, and prevent HIV infection) and seeks to leverage testing, treatment,
and preexposure prophylaxis (PrEP) to reduce new HIV infections in the United States by at least 90% by 2030. Targets
to reach this goal include that at least 95% of persons with HIV receive a diagnosis, 95% of persons with diagnosed HIV
infection have a suppressed viral load, and 50% of those at increased risk for acquiring HIV are prescribed PrEP. Using
surveillance, pharmacy, and other data, CDC determined the current status of these three initiative strategies.
Methods: CDC analyzed HIV surveillance data to estimate annual number of new HIV infections (2013–2017); estimate
the percentage of infections that were diagnosed (2017); and determine the percentage of persons with diagnosed HIV
infection with viral load suppression (2017). CDC analyzed surveillance, pharmacy, and other data to estimate PrEP
coverage, reported as a percentage and calculated as the number of persons who were prescribed PrEP divided by the
estimated number of persons with indications for PrEP.
Results: The number of new HIV infections remained stable from 2013 (38,500) to 2017 (37,500) (p = 0.448). In
2017, an estimated 85.8% of infections were diagnosed. Among 854,206 persons with diagnosed HIV infection in
42 jurisdictions with complete reporting of laboratory data, 62.7% had a suppressed viral load. Among an estimated
1.2 million persons with indications for use of PrEP, 18.1% had been prescribed PrEP in 2018.
Conclusion: Accelerated efforts to diagnose, treat, and prevent HIV infection are needed to achieve the U.S. goal of at
least 90% reduction in the number of new HIV infections by 2030.

Introduction medications (tenofovir and emtricitabine), has been found to

Since 2013, progress in reducing the number of new be highly effective in preventing acquisition of HIV infection
human immunodeficiency virus (HIV) infections has stalled (4). PrEP coverage has increased in recent years; however,
at approximately 38,000 new infections occurring each year coverage among persons at risk for exposure remains low
(1). Infections are preventable. Persons who are aware that (5). In February 2019, a new national initiative, Ending the
they have HIV infection and maintain a suppressed viral load HIV Epidemic: A Plan for America, was proposed. The plan
(<200 copies of HIV RNA per mL) have effectively no risk of calls for intensified efforts to diagnose, treat, and prevent
sexually transmitting the virus to HIV-negative partners (2). HIV infections in the United States, with an overall goal of
Nevertheless, 38% of new HIV infections are transmitted reducing new infections by at least 90% by 2030 (6). Use of
from persons with HIV infection who are unaware of their PrEP is a major component of the prevention strategy and is
infection. Further, 43% of new HIV infections are transmit- indicated for men and women with sexual or injection drug
ted from persons who have received a diagnosis but are not use behaviors that increase their risk for acquiring HIV (7).
receiving HIV medical care, and 20% of new HIV infections To focus national and local prevention efforts on eliminating
are transmitted from persons receiving medical care for HIV, HIV, CDC analyzed surveillance, pharmacy, and other data
but who are not virally suppressed (3). Preexposure prophylaxis to determine the status of these strategies (diagnose, treat, and
(PrEP), a daily oral pill that includes two HIV antiretroviral prevent HIV infections) at the national and state levels.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1117
 Morbidity and Mortality Weekly Report

prescription for >28 days and for whom TDF/FTC was not
Summary
prescribed for HIV treatment, hepatitis B treatment, or HIV
What is already known about this topic?
postexposure prophylaxis (5,9). NHSS, National Health and
The approximately 38,000 new human immunodeficiency virus Nutrition Examination Survey, and U.S. Census data were
(HIV) infections that occur annually in the United States are
preventable through testing, treatment, and preexposure
used to estimate the number of persons aged ≥16 years with
prophylaxis (PrEP). A proposed initiative seeks to reduce new indications for PrEP (10). PrEP coverage, reported as a per-
infections by at least 90% by 2030. The targets for the initiative centage, was calculated as the number of persons who were
are at least 95% for testing and treatment and 50% for PrEP. prescribed PrEP divided by the estimated number of persons
What is added by this report? who had indications for PrEP. To estimate PrEP coverage by
In 2017, 85.8% of persons with HIV infection had received a race/ethnicity, the proportion among those with recorded race/
diagnosis, and 62.7% of persons with diagnosed HIV infection ethnicity data was applied to those with missing race/ethnicity
had a suppressed viral load. In 2018, PrEP had been prescribed data. Analyses were conducted using SAS statistical software
to 18.1% of persons with indications. (version.9.4; SAS Institute).
What are the implications for public health practice?
Accelerated efforts to diagnose, treat, and prevent HIV infection Results
are urgently needed. The annual number of new HIV infections remained stable
from 2013 (38,500) to 2017 (37,500) (p = 0.448). Among
Methods the estimated 1.2 million persons living with HIV infection
CDC analyzed data reported to the National HIV in 2017, 85.8% (95% confidence interval [CI] = 84.3–87.5)
Surveillance System (NHSS) from the beginning of the had received a laboratory-confirmed diagnosis of HIV
epidemic in the early 1980s through June 2019 from 50 infection. The lowest percentages of diagnosed HIV infec-
states and the District of Columbia (DC) for persons aged tions were among persons aged 13–24 years (54.6%,
≥13 years with diagnosed HIV infection. A CD4-depletion 95% CI  =  52.7–56.7), American Indians/Alaska Natives
model* (8) was applied to NHSS data to estimate 1) the (79.5%, 95% CI  =  58.7–100.0), and heterosexual males
annual number of new HIV infections (2013–2017); 2) the (82.0%, 95% CI  =  76.5–88.3), compared with other age,
total number of persons living with HIV (diagnosed and racial/ethnic, or transmission risk groups. (Table 1). The per-
undiagnosed infection, or prevalence) at year-end 2017; and centage of diagnosed infections ranged from 79.7% in Nevada
3) the percentage of persons with HIV infection who had to 94.4% in New Jersey (Table 2).
received a diagnosis. In 2017, 62.7% of 854,206 persons with diagnosed HIV
NHSS data reported from 41 states and DC that had com- infections in 42 jurisdictions had a suppressed viral load
plete laboratory reporting of viral load test results were used (Table 1). The lowest percentages of persons with viral sup-
to determine two viral suppression measures: viral suppression pression were those aged 13–24 years (56.9%), blacks/African
among persons with diagnosed HIV infection in the jurisdic- Americans (blacks) (57.4%), and males who inject drugs
tion at year-end 2017 and viral suppression within 6 months (52.0%), compared with other age, racial/ethnic, and transmis-
of diagnosis among persons with HIV infection diagnosed sion risk groups. The percentage of persons with a suppressed
during 2017. These 42 jurisdictions represent 89% of persons viral load ranged from 47.0% in South Dakota to 79.6% in
with diagnosed HIV infection in the United States. Iowa (Table 2). The percentage of persons with a suppressed
CDC analyzed national pharmacy data from the IQVIA viral load within 6 months of diagnosis of HIV infection was
Real World Data–Longitudinal Prescriptions database to 61.5 overall and <59% in 12 jurisdictions (Figure).
estimate the number of persons aged ≥16 years who were An estimated 1.2 million persons had indications for PrEP;
prescribed PrEP in 2017 and 2018. The annual number of 12.6% were prescribed PrEP in 2017 and 18.1% in 2018. In
PrEP prescriptions for persons aged ≥16 years was determined 2018, PrEP coverage was three times as high among males
using an algorithm that included persons who had at least one (20.8%) as among females (6.6%) (Table 1). Compared with
tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) other age groups, the lowest PrEP coverage rate was among
persons aged 16–24 years (11.4%). Adjusting for missing
* The first CD4 test result after HIV diagnosis and a CD4-depletion model race/ethnicity, PrEP coverage was 5.9% for blacks, 10.9% for
indicating disease progression or duration after infection were used to estimate
the number of new HIV infections and total prevalence (persons living with
Hispanics/Latinos, and 42.1% for whites. PrEP coverage ranged
diagnosed or undiagnosed infection) among adults and adolescents in the from 5.0% in Wyoming to 41.1% in New York (Table 2).
United States.

1118 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

TABLE 1. Percentage of diagnosed human immunodeficiency virus (HIV) infections, viral suppression among persons with diagnosed HIV
infection, and prescription of preexposure prophylaxis (PrEP) for persons with indications, by demographic and transmission categories —
United States, 2017 and 2018
2017 2018
Diagnosed HIV infection,* Viral suppression,†,§ PrEP coverage,¶,**,††
Characteristic % (95% CI) % %
Sex
Male 84.9 (83.1–86.8) 63.3 20.8
Female 89.1 (86.1–92.3) 60.8 6.6
Age group (yrs)
13–24 54.6 (52.7–56.7) 56.9 11.4
25–34 70.4 (69.4–71.4) 58.1 21.5
35–44 84.5 (83.6–85.4) 60.2 21.9
45–54 92.2 (91.5–92.9) 64.6 17.4
≥55 94.7 (93.9–95.5) 65.5 14.4
Race/Ethnicity
American Indian/Alaska Native 79.5 (58.7–100.0) 62.0 —§§
Asian 83.7 (72.6–98.9) 68.3 —§§
Black/African American 85.5 (83.1–88.0) 57.4 5.9
Hispanic/Latino 83.0 (79.8–86.5) 62.3 10.9
Native Hawaiian/Other Pacific Islander —* 65.0 —§§
White 88.6 (85.8–91.5) 69.3 42.1
Multiple races 86.7 (80.5–94.0) 69.9 —§§
Transmission category
Male-to-male sexual contact 83.7 (81.7–85.8) 65.7 —§§
Injection drug use 93.8 (89.1–99.0) —¶¶ —§§
Male 93.3 (87.0–100.0) 52.0 —§§
Female 94.4 (87.9–100.0) 58.4 —§§
Male-to-male sexual contact and injection drug use 92.0 (85.9–99.0) 63.1 —§§
Heterosexual contact 85.9 (83.0–89.0) —¶¶ —§§
Male 82.0 (76.5–88.3) 57.6 —§§
Female 87.7 (84.4–91.2) 61.8 —§§
Total 85.8*** (84.3–87.5) 62.7*** 18.1
Abbreviation: CI = confidence interval.
* Percentage of diagnosed infections calculated as the number of persons who received a diagnosis of HIV infection divided by the number of persons living with
HIV (diagnosed and undiagnosed; n = 1,153,400). Dash in this column indicates estimate not available for some populations because of high relative standard errors.
† Percentage viral suppression calculated as the number of persons with a viral load test result of <200 copies of HIV RNA per mL at last test divided by the number
of persons living with diagnosed HIV infection (n = 854,206).
§ Includes data for 42 jurisdictions (41 states and District of Columbia) with complete laboratory reporting. These jurisdictions include Alabama, Alaska, California,
Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan,
Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode
Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
¶ PrEP coverage, calculated as the number of persons who were prescribed PrEP (n = 219,691 in 2018) divided by estimated number of persons with indications for
PrEP (n = 1,211,777 in 2017).
** Total includes 1,605 persons prescribed PrEP with unknown jurisdiction and 143,168 persons prescribed PrEP with unknown/unavailable race/ethnicity. PrEP
coverage for race/ethnicity was adjusted applying the distribution of records with known race/ethnicity to records with missing race/ethnicity.
†† Age group for PrEP coverage is 16–24 years.
§§ Dashes indicate data not available. IQVIA data source has incomplete race/ethnicity data and does not collect data on transmission risk category.
¶¶ Percentage viral suppression is presented for each sex within transmission category.
*** Total includes persons with HIV infection attributed to hemophilia, blood transfusion, perinatal exposure, or whose risk factor was not reported or not identified.

Discussion received a diagnosis, 95% of persons with diagnosed HIV

The annual number of new HIV infections has remained infection having a suppressed viral load, and 50% of persons
relatively stable since 2013. In 2017, the percentage of per- with indications for PrEP having been prescribed PrEP (11).
sons with HIV infection whose infection was diagnosed was New infections will occur unless substantial improvements are
86%, a significant increase from 83% in 2010 (1). Overall, made in implementing these three strategies.
in 2017, 63% of persons with diagnosed HIV infection had a In this analysis, the lowest percentages of diagnosed HIV
suppressed viral load, and in 2018, PrEP coverage was low at infection were among young persons (aged 13–34 years),
18%. These findings confirm substantial gaps in diagnosing, American Indians/Alaska Natives, and heterosexual males.
treating, and preventing HIV infection and underscore the The low percentage of diagnosed HIV infection in these
need for expanded efforts. The targets for the proposed ini- three populations might be explained by 1) lower testing
tiative are at least 95% of persons with HIV infection having rates among youths (12), 2) HIV-related stigma and lack of

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1119
 Morbidity and Mortality Weekly Report

TABLE 2. Percentage of diagnosed human immunodeficiency virus (HIV) infections, viral suppression among persons with diagnosed HIV
infection, and prescription of preexposure prophylaxis (PrEP) for persons with indications, by jurisdiction — United States, 2017 and 2018
2017 2018
Diagnosed HIV infection,* Viral suppression,†,§ PrEP coverage,¶,**
Jurisdiction % (95% CI) % %
Alabama 83.9 (72.2–100.0) 57.3 13.2
Alaska —* 78.7 8.3
Arizona 84.7 (74.1–98.8) —§ 13.1
Arkansas 82.2 (66.3–100.0) —§ 12.5
California 85.9 (81.6–90.5) 66.6 21.9
Colorado 85.8 (74.5–100.0) 58.6 13.3
Connecticut 88.6 (75.1–100.0) 66.8 21.3
Delaware 85.5 (64.9–100.0) 67.7 8.7
District of Columbia 88.6 (76.9–100.0) 56.0 36.5
Florida 87.0 (82.3–92.3) 63.0 11.1
Georgia 82.0 (76.0–89.1) 58.3 15.2
Hawaii 85.5 (63.1–100.0) 68.2 12.2
Idaho 96.6 (65.3–100.0)†† —§ 10.0
Illinois 85.6 (77.9–94.9) 53.8 26.8
Indiana 83.8 (71.5–100.0) 61.3 10.1
Iowa 82.3 (61.6–100.0) 79.6 28.1
Kansas 84.0 (63.3–100.0) —§ 13.9
Kentucky 82.7 (68.3–100.0) —§ 9.2
Louisiana 81.2 (71.7–93.7) 64.7 22.8
Maine 85.9 (59.8–100.0) 78.3 11.9
Maryland 86.1 (78.1–95.9) 58.2 14.3
Massachusetts 89.5 (79.6–100.0) 70.9 33.4
Michigan 83.1 (72.2–97.9) 72.2 12.2
Minnesota 84.9 (71.8–100.0) 69.1 15.1
Mississippi 87.9 (73.8–100.0) 49.2 12.9
Missouri 85.2 (73.4–100.0) 66.2 14.2
Montana —* 78.5 6.6
See table footnotes on next page.

access to HIV-related services among American Indians/Alaska Developing or scaling up the implementation of evidence-
Natives (13), and 3) low patient and provider perceived risk for based interventions is also important for improving adherence
HIV acquisition among heterosexuals (14). The percentage of and viral suppression among youths and blacks. For example,
diagnosed HIV infections also varied geographically, possibly one successful approach to improving viral suppression among
reflecting differences in access to and implementation of HIV blacks with HIV infection is an integrated care model that
testing and highlighting the need for developing tailored test- includes collaboration between community pharmacists and
ing strategies (15). CDC recommends routine screening of all HIV medical care providers to develop individualized care
persons aged 13–64 years at least once in their lifetime (16), plans that address HIV treatment challenges (19).
yet recent findings indicate that only 40% of persons aged Since 2012, prompt treatment with antiretroviral therapy
≥18 years in the United States have ever been tested for HIV after diagnosis of HIV infection, regardless of stage of disease,
(15). HIV testing guidelines also recommend at least annual has been recommended (20). Yet only 61.5% of persons with
testing for persons at high risk for acquiring HIV. Accelerating HIV infection diagnosed in 2017 had a suppressed viral load
implementation of HIV testing strategies such as integrated within 6 months of diagnosis. Low viral suppression rates
and routinized HIV screening in health care settings, scaling within 6 months of HIV diagnosis (59%) occurred mainly in
up partner notification, social/sexual network screening, and Southern states, which are already disproportionately affected
mass distribution of HIV self-test kits (15) might facilitate by HIV (1). One study in patients with high rates of mental
early diagnosis. health illness, drug use, and housing instability illustrated suc-
The lowest percentages of viral suppression were found cess in reaching viral suppression within 1 year using multidis-
among young persons, blacks, and heterosexual males. ciplinary care and other support (21). To rapidly improve viral
Adherence to medication is critical to viral suppression. Factors suppression for all populations, additional research is needed
associated with lower adherence or viral suppression include to identify interventions that will achieve viral suppression
young age (17) and, for blacks, include health care coverage, within 6 months of diagnosis, especially among populations
homelessness, and incarceration (18). Expanded efforts must facing severe health and socioeconomic challenges, including
address these and other social and economic barriers to care. homelessness (22).

1120 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

TABLE 2. (Continued) Percentage of diagnosed human immunodeficiency virus (HIV) infections, viral suppression among persons with diagnosed
HIV infection, and prescription of preexposure prophylaxis (PrEP) for persons with indications, by jurisdiction — United States, 2017 and 2018
2017 2018
Diagnosed HIV infection,* Viral suppression,†,§ PrEP coverage,¶,**
Jurisdiction % (95% CI) % %
Nebraska 82.7 (59.8–100.0) 64.2 18.8
Nevada 79.7 (67.4–97.4) —§ 13.5
New Hampshire 85.5 (57.0–100.0)†† 70.3 21.0
New Jersey 94.4 (85.6–100.0) —§ 16.8
New Mexico 81.2 (61.7–100.0) 68.5 12.0
New York 88.3 (84.0–93.0) 63.2 41.1
North Carolina 87.3 (79.0–97.5) 63.2 11.1
North Dakota —* 77.7 14.8
Ohio 83.9 (74.8–95.5) 54.7 11.6
Oklahoma 82.9 (66.8–100.0) 59.0 7.6
Oregon 85.9 (71.4–100.0) 63.7 13.6
Pennsylvania 92.7 (84.6–100.0) —§ 22.9
Rhode Island 84.5 (62.2–100.0) 76.6 18.9
South Carolina 84.1 (73.9–97.5) 66.3 11.7
South Dakota —* 47.0 11.3
Tennessee 84.9 (74.2–99.2) 57.6 11.4
Texas 81.1 (76.3–86.6) 61.3 14.3
Utah 81.9 (61.1–100.0) 62.5 21.9
Vermont 93.0 (59.0–100.0)†† —§ 17.7
Virginia 86.9 (77.5–98.8) 55.2 9.5
Washington 88.3 (76.9–100.0) 78.6 25.0
West Virginia 86.9 (61.4–100.0) 58.9 9.7
Wisconsin 83.7 (68.3–100.0) 74.5 14.3
Wyoming —* 76.8 5.0
Total 85.8 (84.3–87.5) 62.7 18.1
Abbreviation: CI = confidence interval.
* Percentage of diagnosed infections calculated as the number of persons who received a diagnosis of HIV infection divided by the number of persons living with
HIV (diagnosed and undiagnosed). Dashes in this column indicate estimates not available for some jurisdictions because of high relative standard errors.
† Percentage viral suppression calculated as the number of persons with a viral load test result of <200 copies of HIV RNA per mL at last test divided by the number
of persons living with diagnosed HIV infection.
§ Includes data for 42 jurisdictions (41 states and District of Columbia) with complete laboratory reporting. These jurisdictions include Alabama, Alaska, California,
Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan,
Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island,
South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Data were incomplete or not reported for nine
jurisdictions, as indicated by dashes.
¶ PrEP coverage calculated as the number of persons who were prescribed PrEP (in 2018) divided by estimated number of persons with indications for PrEP (in 2017).
** Total includes 1,605 PrEP users with unknown jurisdiction.
†† Estimate does not meet the standard of reliability; use with caution.

In 2019, the United States Preventive Services Task Force in racial/ethnic minority populations has not been equitable.
issued a Grade A recommendation† that clinicians offer Improving PrEP coverage will require targeted improvements
PrEP to persons at substantial risk for HIV acquisition (4). in PrEP awareness, prescribing practices, and use in under-
Overall, PrEP coverage was 9% in 2016 (5) and improved reached demographic groups, especially among young persons,
to 18% in 2018. Similar to earlier findings, PrEP coverage blacks, and Hispanics/Latinos at risk for acquiring HIV. CDC
in this analysis was especially low in young persons (aged has developed a campaign, Prescribe HIV Prevention, which
16–24 years) compared with that in other age groups, and is designed to help clinicians provide PrEP to prevent acquisi-
racial/ethnic and geographic disparities in PrEP prescription tion of HIV (24).
exist (5). In 2018, approximately 43% of HIV diagnoses were The findings in this report are subject to at least three limita-
among blacks, and 26% were among Hispanics/Latinos (23). tions. First, estimation of the number of new infections and
However, PrEP coverage among whites was seven times as high percentage of undiagnosed infections relies on the assumption
as that among blacks and four times as high as that among that persons received no treatment before their first CD4 test.
Hispanics/Latinos, suggesting that PrEP delivery to persons The CD4 counts of persons with evidence of previous anti-
retroviral therapy use or viral suppression are excluded from
† Grade A recommendation is a recommendation with high certainty
the analysis, minimizing the impact of prior treatment on the
that the net benefit of the intervention is substantial. https://www. HIV depletion model. Second, viral suppression measures in
uspreventiveservicestaskforce.org/Page/Name/grade-definitions.

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1121
 Morbidity and Mortality Weekly Report

FIGURE. Viral suppression*,†,§ within 6 months of diagnosis of human Accelerated efforts to diagnose, treat, and provide PrEP
immunodeficiency virus (HIV) infection among persons aged while addressing disparities, are urgently needed to reach the
≥13 years — United States,¶ 2017
targets for the Ending the HIV Epidemic: A Plan for America
initiative. These accelerated efforts, along with other prevention
strategies such as quickly responding to increases in diagnoses
of HIV infections, will be needed to meet the ambitious U.S.
goal of at least a 90% reduction in the number of new HIV
infections by 2030.
DC
Corresponding author: Norma S. Harris, nharris@cdc.gov, 404-718-8559.
1Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis,
STD, and TB Prevention, CDC; 2National Center for HIV, Viral Hepatitis,
STD, and TB Prevention, CDC.
All authors have completed and submitted the International
72%–95% Committee of Medical Journal Editors form for disclosure of potential
65%–71% conflicts of interest. No potential conflicts of interest were disclosed.
60%–64%
51%–59% References
Incomplete reporting 1. CDC. Estimated HIV incidence and prevalence in the United States,
Laws do not require 2010–2016. HIV surveillance supplemental report 2019. Vol 24, no. 1.
reporting all results Atlanta, GA: US Department of Health and Human Services, CDC;
2019. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-
Abbreviation: DC = District of Columbia.
* Percentage viral suppression within 6 months of HIV diagnosis, calculated as surveillance-supplemental-report-vol-24-1.pdf
the number of persons with a viral load test result of <200 copies of HIV RNA per 2. CDC. Evidence of HIV treatment and viral suppression in preventing
mL at last test divided by the number of persons with HIV diagnosed in 2017. the sexual transmission of HIV. Atlanta, GA: US Department of Health
Residence was based on residence at the time of diagnosis of HIV infection. and Human Services, CDC; 2018. https://www.cdc.gov/hiv/pdf/risk/
† Total = 61.5%. art/cdc-hiv-art-viral-suppression.pdf
§ Data classified using quartiles.
3. Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI. Vital signs: HIV
¶ Analysis based on data reported from 41 states and DC; data for nine states
transmission along the continuum of care—United States, 2016.
were incomplete or not reported. MMWR Morb Mortal Wkly Rep 2019;68:267–72. https://doi.
org/10.15585/mmwr.mm6811e1
this analysis were based on data from 42 jurisdictions and are 4. Owens DK, Davidson KW, Krist AH, et al.; US Preventive Services Task
therefore not necessarily representative of data on all persons Force. Preexposure prophylaxis for the prevention of HIV infection:
living with diagnosed HIV infection in the United States. US Preventive Services Task Force recommendation statement. JAMA
2019;321:2203–13. https://doi.org/10.1001/jama.2019.6390
Finally, although IQVIA recorded 92% of all prescriptions 5. Huang YA, Zhu W, Smith DK, Harris N, Hoover KW. HIV preexposure
from retail pharmacies in the United States, prescriptions from prophylaxis, by race and ethnicity—United States, 2014–2016. MMWR
closed health care systems (e.g., managed care organizations or Morb Mortal Wkly Rep 2018;67:1147–50. https://doi.org/10.15585/
mmwr.mm6741a3
military health plans) were not included. Therefore, these are 6. Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending
minimum estimates of PrEP coverage. Different data sources the HIV epidemic: a plan for the United States. JAMA 2019;321:844–5.
were used in the numerator and denominator to calculate PrEP https://doi.org/10.1001/jama.2019.1343
7. CDC. Preexposure prophylaxis for the prevention of HIV infection in
coverage. Although the result is expressed as a percentage, it the United States—2017 update. Atlanta, GA: US Department of Health
is unknown whether all persons prescribed PrEP (numerator) and Human Services, CDC; 2018. https://www.cdc.gov/hiv/pdf/risk/
are also contained in the denominator of the estimate of the prep/cdc-hiv-prep-guidelines-2017.pdf
number of persons with indications for PrEP. In addition, 8. Song R, Hall HI, Green TA, Szwarcwald CL, Pantazis N. Using CD4
data to estimate HIV incidence, prevalence, and percent of undiagnosed
only 35% of persons with PrEP prescriptions identified in infections in the United States. J Acquir Immune Defic Syndr
the IQVIA data had race/ethnicity information available. In 2017;74:3–9. https://doi.org/10.1097/QAI.0000000000001151
calculating PrEP coverage, the racial/ethnic distribution of 9. Furukawa NW, Smith DK, Gonzalez CJ, et al. Evaluation of algorithms
used for PrEP surveillance using a reference population from New York
known records was applied to those for which data on race/ City — July 2016–June 2018. Public Health Rep. In press 2019.
ethnicity were missing, which might not be valid. The extent 10. Smith DK, Van Handel M, Grey J. Estimates of adults with indications for
to which the missing race/ethnicity is the same as that for those HIV pre-exposure prophylaxis by jurisdiction, transmission risk group, and
race/ethnicity, United States, 2015. Ann Epidemiol 2018;28:850–857.e9.
with reported race/ethnicity is unknown. Improvements in the https://doi.org/10.1016/j.annepidem.2018.05.003
completeness of race/ethnicity data in prescription databases 11. Stein S. Trump wants 90% drop in new HIV infections, near-universal
are needed to fully describe disparities in PrEP coverage. care. Bloomberg Law Health Law and Business News. October 30,
2019. https://news.bloomberglaw.com/health-law-and-business/
trump-wants-90-drop-in-new-hiv-infections-near-universal-care

1122 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

12. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance— 19. Byrd KK, Hou JG, Bush T, et al. Adherence and viral suppression among
United States, 2017. MMWR Surveill Summ 2018;67(No. SS-8). participants of the patient-centered human immunodeficiency virus
https://doi.org/10.15585/mmwr.ss6708a1 (HIV) care model project: a collaboration between community-based
13. Negin J, Aspin C, Gadsden T, Reading C. HIV among indigenous pharmacists and HIV clinical providers. Clin Infect Dis 2019;ciz276
peoples: a review of the literature on HIV-related behaviour since the April 6, 2019. https://doi.org/10.1093/cid/ciz276
beginning of the epidemic. AIDS Behav 2015;19:1720–34. 20. Panel on Antiretroviral Guidelines for Adults and Adolescents.
14. Pringle K, Merchant RC, Clark MA. Is self-perceived HIV risk Guidelines for the use of antiretroviral agents in adults and adolescents
congruent with reported HIV risk among traditionally lower HIV risk with HIV. Washington, DC: US Department of Health and Human
and prevalence adult emergency department patients? Implications for Services; 2019. https://aidsinfo.nih.gov/contentfiles/lvguidelines/
HIV testing. AIDS Patient Care STDS 2013;27:573–84. https://doi. AdultandAdolescentGL.pdf
org/10.1089/apc.2013.0013 21. Coffey S, Bacchetti P, Sachdev D, et al. RAPID antiretroviral therapy:
15. Pitasi MA, Delaney KP, Brooks JT, DiNenno EA, Johnson SD, Prejean J. high virologic suppression rates with immediate antiretroviral therapy
HIV screening in 50 local jurisdictions accounting for the majority of initiation in a vulnerable urban clinic population. AIDS 2019;33:825–32.
new HIV diagnoses and seven states with disproportionate occurrence https://doi.org/10.1097/QAD.0000000000002124
of HIV in rural areas, 2016–2017. MMWR Morb Mortal Wkly Rep 22. Aidala AA, Wilson MG, Shubert V, et al. Housing status, medical care,
2019;68:561–7. https://doi.org/10.15585/mmwr.mm6825a2 and health outcomes among people living with HIV/AIDS: a systematic
16. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations review. Am J Public Health 2016;106:e1–23. https://doi.org/10.2105/
for HIV testing of adults, adolescents, and pregnant women in health- AJPH.2015.302905
care settings. MMWR Recomm Rep 2006;55(No. RR-14). 23. CDC. Diagnoses of HIV infection in the United States and dependent
17. Zanoni BC, Mayer KH. The adolescent and young adult HIV cascade areas, 2018. HIV surveillance report. Vol. 30. Atlanta, GA: US
of care in the United States: exaggerated health disparities. AIDS Patient Department of Health and Human Services, CDC; 2019. https://www.
Care STDS 2014;28:128–35. https://doi.org/10.1089/apc.2013.0345 cdc.gov/hiv/library/reports/hiv-surveillance.html
18. Beer L, Mattson CL, Bradley H, Skarbinski J; Medical Monitoring 24. CDC. Let’s stop HIV together: prescribe HIV prevention. Atlanta, GA:
Project. Understanding cross-sectional racial, ethnic, and gender US Department of Health and Human Services, CDC; 2019. https://
disparities in antiretroviral use and viral suppression among HIV patients www.cdc.gov/stophivtogether/campaigns/prescribe-hiv-prevention/
in the United States. Medicine (Baltimore) 2016;95:e3171. https://doi. index.html
org/10.1097/MD.0000000000003171

US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / December 6, 2019 / Vol. 68 / No. 48 1123
 Morbidity and Mortality Weekly Report

QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Percentage* of Adults Aged 18–64 Years Who Had Seen or Talked to a

Health Care Professional in the Past 12 Months,† by Race/Ethnicity§ —
National Health Interview Survey, 2012–2013 and 2017–2018¶
100

2012–2013
2017–2018

80

60
Percentage

40

20

0
Total Hispanic White, Black, Asian,
non-Hispanic non-Hispanic non-Hispanic
Race/Ethnicity
* With 95% confidence intervals indicated by error bars.
† Based on a question in the Sample Adult section that asked “About how long has it been since you last saw
or talked to a doctor or other health care professional about your own health? Include doctors seen while a
patient in a hospital.”
§ Categories shown for non-Hispanic respondents are only for those who selected one racial group; respondents
had the option to select more than one racial group. Hispanic respondents might be of any race or combination
of races. Only selected groups are shown in the individual race/ethnicity bars, but total bar shows results for
all adults aged 18–64 years.
¶ Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population
in 2012 and 2013 combined and 2017 and 2018 combined. Estimates are derived from the National Health
Interview Survey Sample Adult component.

The percentage of adults aged 18–64 years who had seen or talked to a health care professional in the past 12 months increased
from 79.3% in 2012–2013 to 82.1% in 2017–2018. There was an increase in the percentage of Hispanic (67.0% to 73.6%), non-
Hispanic white (82.8% to 84.9%), non-Hispanic black (80.0% to 83.2%), and non-Hispanic Asian (75.8% to 78.8%) adults who
had seen or talked to a health care professional in the past 12 months between those two periods. During 2012–2013 as well
as 2017–2018, non-Hispanic white adults were the most likely and Hispanic adults were the least likely to have seen or talked
to a health care professional in the past 12 months.
Source: National Health Interview Survey, 2012, 2013, 2017, and 2018 data. https://www.cdc.gov/nchs/nhis.htm.
Reported by: Michael E. Martinez, MPH, MHSA, bmd7@cdc.gov, 301-458-4758; Tainya C. Clarke, PhD.

1124 MMWR / December 6, 2019 / Vol. 68 / No. 48 US Department of Health and Human Services/Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

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