Measles in Europe: an epidemiological assessment

Do We Relatively or Absolutely Overestimate Rare Events?

How good are we at estimating the frequency of rare events? Previous evidence has been mixed: While some studies report well-calibrated frequency judgments, others found rare events to be overestimated. We examined whether the distinctiveness of a rare event fosters overestimation. Distinctiveness may result from exceptional valence, statistical infrequency, or the joint occurrence of two distinct features. Such paired distinctiveness has been found to be particularly salient. We conducted two experiments to investigate the impact of paired distinctiveness and valence on frequency estimations of rare events by combining two paradigms from the decision-making literature and the social psychology literature on stereotypes. The results indicate that rarity alone does not necessarily result in overestimation; rather, the combination of statistical infrequency and small sample sizes (i.e., paired distinctiveness) led participants to overestimate the frequency of a rare event. We were able to rule out alternative explanations such as regression to the mean, but the exact role of outcome valence needs further investigation.

Dramatic change in public attitudes towards vaccination during the 2009 influenza A(H1N1) pandemic in France

We investigated the potential impact of the 2009 influenza A(H1N1) pandemic on attitudes towards vaccination among people aged 18 to 75 years and living in metropolitan France. We used data from three national telephone surveys conducted on representative samples in 2000, 2005 and 2010 (n=12,256, n=23,931, n=8,573 respectively). In France, unfavourable attitudes towards vaccination in general dramatically increased from 8.5% in 2000 and 9.6% in 2005 to 38.2% in 2010. In 2010, among respondents who held unfavourable attitudes towards vaccination, 50% mentioned specifically their opposition to the influenza A(H1N1) vaccine. The sociodemographic profile associated with these attitudes also changed greatly. In particular, unfavourable attitudes towards vaccination in general became significantly more frequent among less educated people in 2010. These attitudes were also correlated with vaccination behaviours. For example, parents who were unfavourable towards vaccination in general were more likely to report that they had at least one child who did not get the measlesmumps- rubella vaccine. As this shift in attitude may have a significant impact on future vaccination coverage, health authorities should urgently address the vaccine confidence gap.

Lack of herd immunity against measles in individuals aged <35 years could explain re-emergence of measles in Catalonia (Spain)

OBJECTIVES

The objective of this study was to assess the association between lack of herd immunity in some population groups and the re-emergence of measles in Catalonia in 2006.

METHODS

Herd immunity was considered established in the different population groups when the prevalence of positive serological results to measles was higher than the herd immunity threshold of 90%. The Chi-square test and the odds ratio were used to assess the association between lack of herd immunity and measles cases in the outbreak of 2006-2007.

RESULTS

Herd immunity was not established against measles in individuals aged 0-14 years and 25-34 years, as the prevalence of positive serological results was <90% in these groups. In the measles outbreak of 2006-2007, 91% of cases occurred in age groups without herd immunity, and only 9% of cases occurred in age groups with herd immunity (p<0.001). The odds ratio for the association between lack of herd immunity and measles cases in the outbreak of 2006-2007 was 104 (p<0.001).

CONCLUSION

Lack of herd immunity in individuals aged<35 years could be one of the factors underlying the re-emergence of measles in Catalonia.

Measles outbreak in Macedonia: epidemiological, clinical and laboratory findings and identification of susceptible cohorts

OBJECTIVES

Despite a 92-99% national vaccination coverage since 2000, the former Yugoslav Republic of Macedonia experienced a large measles outbreak between 2010 and 2011. Here we investigate the characteristics of patients hospitalized during this outbreak at the Clinic of Infectious Diseases in Skopje.

METHODS

Epidemiological, clinical and laboratory data of 284 measles patients, including 251 from Skopje (43.80% of the 573 reported cases) and 33 from elsewhere in Macedonia were collected.

RESULTS

The most affected age groups were children up to 4 years of age and adolescents/adults of 15 years and older. Most patients were unvaccinated (n=263, 92.61%) and many had non-Macedonian nationalities (n=156, 54.93%) or belonged to the Roma ethnicity (n=73, 25.70%). Bronchopneumonia and diarrhea were the most common complications. Eighty-two out of 86 tested patients (95.35%) had measles-specific IgM antibodies. The outbreak was caused by the measles variant D4-Hamburg.

CONCLUSIONS

The epidemic identified pockets of susceptibles in Skopje and indicated that additional vaccination opportunities in particular for people with non-Macedonian nationality and traveler communities are warranted to ensure efficient measles control in Macedonia. The high attack rate among children of less than 1 year suggests that vaccination before 12 months of age should be considered in high risk settings.

Severe Measles Infection: The Spectrum of Disease in 36 Critically Ill Adult Patients

France has recently witnessed a nationwide outbreak of measles. Data on severe forms of measles in adults are lacking. We sought to describe the epidemiologic, clinical, treatment, and prognostic aspects of the disease in adult patients who required admission to an intensive care unit (ICU). We performed a retrospective analysis of a cohort of 36 adults admitted to a total of 64 ICUs throughout France for complications of measles from January 1, 2009, to December 31, 2011. All cases of measles were confirmed by serologic testing and/or reverse transcription polymerase chain reaction.The cohort consisted of 21 male and 15 female patients, with a median age of 29.2 years (25th-75th interquartile range [IQR], 27.2-34.2 yr) and a median Simplified Acute Physiology Score (SAPS II) of 13 (IQR, 9-18). Among the 26 patients whose measles vaccination status was documented, none had received 2 injections. One patient had developed measles during childhood. Underlying comorbid conditions included chronic respiratory disease in 9 patients, immunosuppression in 7 patients, and obesity in 3 patients, while measles affected 5 pregnant women.Respiratory complications induced by measles infection led to ICU admission in 32 cases, and measles-related neurologic complications led to ICU admission in 2 cases. Two patients were admitted due to concurrent respiratory and neurologic complications.Bacterial superinfection of measles-related airway infection was suspected in 28 patients and was documented in 8. Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS). Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases. Five patients died, all of whom were severely immunocompromised.On follow-up, 1 patient had severe chronic respiratory failure related to lung fibrosis, and 2 patients had mild lower limb paraparesis along with bladder dysfunction, both of which were ascribable to measles-induced encephalitis and myelitis. Among the 5 pregnant patients, the course of measles infection was uneventful, albeit 1 patient underwent emergent cesarean delivery because of fetal growth restriction.Measles is a disease with protean and potentially deceptive clinical manifestations, especially in the immunocompromised patient. Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality. In contrast with the usually benign course of the disease in immunocompetent patients, measles occurring in immunocompromised patients gives rise to lethal complications including ARDS, with or without bacterial superinfection. Other patients potentially at high risk for severe measles are young adults and pregnant women. Measles pneumonitis may predispose to air leak disease in patients using mechanical ventilation. To date, vaccination remains the most potent tool to control measles infection.

Antibiotics for preventing complications in children with measles

BACKGROUND

Measles is the leading killer among vaccine-preventable diseases; it is responsible for an estimated 44% of the 1.7 million vaccine-preventable deaths among children annually.

OBJECTIVES

To assess the effects of antibiotics given to children with measles to prevent complications and reduce pneumonia, other morbidities and mortality.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (1966 to May week 4, 2013) and EMBASE (1980 to May 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing antibiotics with placebo or no treatment, to prevent complications in children with measles.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

Seven trials with 1263 children were included. The methodological quality of most studies was poor. Only two studies were randomized, double-blind trials. There was variation in antibiotics used, their doses, schedule and evaluation of outcome. Pooled study data showed that the incidence of pneumonia was lower in the treatment group compared to the control group. However, the difference was not statistically significant. Of the 654 children who received antibiotics, 27 (4.1%) developed pneumonia; while out of 609 children in the control group, 59 (9.6%) developed pneumonia (odds ratio (OR) 0.35; 95% confidence interval (0.12 to 1.01). The one trial that showed an increase in the rate of pneumonia with antibiotics was conducted in 1942 and compared oral sulfathiazole with symptomatic treatment. If the results of this trial are removed from the meta-analysis, there is a statistically significant reduction in the incidence of pneumonia in children receiving antibiotics (OR 0.26; 95% CI 0.12 to 0.60). The incidence of other complications was significantly lower in children receiving antibiotics: purulent otitis media (OR 0.34; 95% CI 0.16 to 0.73) and tonsillitis (OR 0.08; 95% CI 0.01 to 0.72). There was no difference in the incidence of conjunctivitis (OR 0.39; 95% CI 0.15 to 1.0), diarrhea (OR 0.53; 95% CI 0.23 to 1.22) or croup (OR 0.16; 95% CI 0.01 to 4.06). No major adverse effects attributable to antibiotics were reported.

AUTHORS' CONCLUSIONS

The studies reviewed were of poor quality and used older antibiotics. This review suggests a beneficial effect of antibiotics in preventing complications such as pneumonia, purulent otitis media and tonsillitis in children with measles. On the basis of this review, it is not possible to recommend definitive guidelines on the type of antibiotic, duration or the day of initiation. There is a need for more evidence from high-quality RCTs to answer these questions.

Cross-sectional surveys of measles antibodies in the Jiangsu Province of China from 2008 to 2010: the effect of high coverage with two doses of measles vaccine among children

BACKGROUND

Changes in the epidemiological characteristics of measles since 2007 appeared in the Jiangsu province. Although the reported coverage with two doses of measles vaccine was greater than 95% in most regions of the province, measles incidence remained high across the whole province. Cross-sectional serological surveys of measles antibodies in the Jiangsu province of China were conducted from 2008 to 2010 to assess and track population immunity.

METHODS

Measles-specific IgG levels were measured in serum samples using ELISA. GMTs and seroprevalence with 95% CIs were calculated by region, gender, and age. ANOVA and χ(2) tests were used to test for statistically significant differences between groups for GMT levels and seroprevalence, respectively.

RESULTS

Seroprevalence showed a significantly increasing trend annually (CMH χ(2) = 40.32, p<0.0001). Although the seroprevalence among children aged 2-15 years was consistently over 95%, vaccine-induced measles antibodies may wane over time. Measles seropositivity in the Jiangsu province was 91.7% (95% CI: 90.1-93.2%) in 2010. Among adults aged 15 to 29-year-olds, the seropositivity rate was 88.4% (95% CI: 82.7-92.8%).

CONCLUSIONS

Vaccination strategies may need to be adjusted depending on the individual age and regions, particularly individuals between the ages of 8 months-14 years old and 20-29 years old. Additional SIAs are likely required to eliminate measles in China.

Waning of maternal antibodies against measles, mumps, rubella, and varicella in communities with contrasting vaccination coverage

BACKGROUND

The combined measles, mumps, and rubella (MMR) vaccine has been successfully administered for >20 years. Because of this, protection by maternal antibodies in infants born to vaccinated mothers might be negatively affected.

METHODS

 A large cross-sectional serologic survey was conducted in the Netherlands during 2006-2007. We compared the kinetics of antibody concentrations in children and women of childbearing age in the highly vaccinated general population with those in orthodox Protestant communities that were exposed to outbreaks.

RESULTS

 The estimated duration of protection by maternal antibodies among infants in the general population, most of whom were born to vaccinated mothers, was short: 3.3 months for measles, 2.7 months for mumps, 3.9 months for rubella, and 3.4 months for varicella. The duration of protection against measles was 2 months longer for infants born in the orthodox communities, most of whom had unvaccinated mothers. For rubella, mothers in the orthodox communities had higher concentrations of antibodies as compared to the general population.

CONCLUSION

 Children of mothers vaccinated against measles and, possibly, rubella have lower concentrations of maternal antibodies and lose protection by maternal antibodies at an earlier age than children of mothers in communities that oppose vaccination. This increases the risk of disease transmission in highly vaccinated populations.

Epidemiology of two large measles virus outbreaks in Catalonia: what a difference the month of administration of the first dose of vaccine makes

Measles cases in the European Region have been increasing in the last decade; this illustrates the challenge of what we are now encountering in the form of pediatric preventable diseases. In Catalonia, autochthonous measles was declared eliminated in the year 2000 as the result of high measles-mumps-rubella vaccine (MMR) coverage for first and second dose (15 mo and 4 y) since the mid-1990s. From then on, sporadic imported cases and small outbreaks appeared, until in 2006-2007 a large measles outbreak affecting mostly unvaccinated toddlers hit the Barcelona Health Region. Consequently, in January 2008, first dose administration of MMR was lowered from 15 to 12 mo of age. A new honeymoon period went by until the end of 2010, when several importations of cases triggered new sustained transmission of different wild measles virus genotypes, but this time striking young adults. The aim of this study is to show the effect of a change in MMR vaccination schedule policy, and the difference in age incidence and hospitalization rates of affected individuals between both outbreaks.   Epidemiologic data were obtained by case interviews and review of medical records. Samples for virological confirmation and genotyping of cases were collected as established in the Measles Elimination plan guidelines. Incidence rate (IR), rate ratio (RR) and their 95% CI and hospitalization rate (HR) by age group were determined. Statistic z was used for comparing proportions. Total number of confirmed cases was 305 in the 2010 outbreak and 381 in the 2006-2007 outbreak; mean age 20 y (SD 14.8 y; 3 mo to 51 y) vs. 15 mo (SD 13.1 y; 1 mo to 50 y). Highest proportion of cases was set in ≥ 25 y (47%) vs. 24.2% in 2006 (p < 0.001). Differences in IR for ≤ 15 mo (49/100,000 vs. 278.2/100,000; RR: 3,9; 95%CI 2,9-5.4) and in overall HR 29.8% vs. 15.7% were all statistically significant (p < 0.001). The change of the month of age for the administration of the first MMR dose proved successful to protect infants. Yet, given the current epidemiological situation, continued awareness and efforts to reach young adult population, especially those at high risk of infection and transmission such as healthcare workers and travelers, are needed to stop the spread of the virus when importations occur.

Outbreak of measles in Central and Eastern Cheshire, UK, October 2008-February 2009

We describe the largest outbreak of measles in Central and Eastern Cheshire (North West England) since the MMR vaccine was introduced in 1988, the majority of cases were not vaccinated and more than 20% of the cases belonged to the travelling community. Over 4 months,147 clinical cases of measles were notified locally to the Cheshire & Merseyside Health Protection Unit (CMHPU). Of these, 67 (45.6%) were laboratory confirmed, 42 (28.6%) were negative, and one was equivocal, leaving 23 probable and 14 possible cases. The primary case was probably an 8-year-old unvaccinated travelling child, symptomatic on 1 October 2008. Measles spread locally and within school-aged children until early February 2009. Most of Central and Eastern Cheshire, including 23 educational institutions (playgroups, nurseries, primary schools, secondary schools, colleges), were affected, showing that there were enough susceptible/unvaccinated children to sustain an outbreak. Nearly a quarter of the confirmed cases (15/67, 22.4%) were aged <13 months and too young to be vaccinated under the UK immunization schedule. This outbreak is a reminder of the importance of achieving herd immunity to prevent spread and protect those at risk of severe illness or complications. There were no fatalities in this outbreak and no significant complications were reported.

DHEA inhibits measles virus through a mechanism independent of its ability to modulate the Raf/MEK/ERK signaling pathway

Aim: Despite the existence of an effective vaccine, measles infection is still frequent in many developing countries with reduced health infrastructure, and it is one of the major causes of child death globally. In the past decade numerous outbreaks have occurred in developed countries, giving a fresh impetus to antiviral research against measles virus. The aim of this study was to investigate the antiviral activity of the natural steroid hormone DHEA against measles virus and the role of the Raf/MEK/ERK signaling pathway in viral multiplication and DHEA’s antiviral activity. Materials & methods: The antiviral activity of DHEA and two ERK modulators, UO126 and anisomycin, was determined using a virus yield reduction assay. Furthermore, we studied DHEA’s virucidal activity and the viral multiplication step affected by the compound. The effect of virus infection on the Raf/MEK/ERK pathway and the activity of those compounds against measles virus spread and induced cytopathic effect were studied using western blot and indirect immunofluorescence. Results & conclusion: We found that DHEA and UO126 are active against measles virus and that they are able to diminish virus-induced cytopathic effects. Also, our study showed that early events in the viral multiplication cycle trigger ERK activation, suggesting that DHEA, a Raf/MEK/ERK modulator, may not exert its antiviral activity through the modulation of this pathway. Our results may provide a first step in the development of new antiviral agents against measles virus.

Epidemic trend of measles in Shandong Province, China, 1963-2005

OBJECTIVES

Although measles is a vaccine-preventable infectious disease and the measles vaccine is safe and effective, it still poses a serious threat to the health of children and susceptible populations in China every year. This study aimed to investigate the epidemiological characteristics of measles in Shandong Province, China, including its spatial distribution pattern, in order to have a precise prediction of measles epidemics for better public health strategic planning and resource allocation.

STUDY DESIGN

Longitudinal data study.

METHODS

This study was based on the surveillance data set of measles from all 17 regions (cities) in Shandong Province between 1963 and 2005. Geographical Information Systems and piecewise exponential smoothing of logarithmic transformed data were applied with consideration of the spatial and temporal features of the data. The parameters of epidemic peaks were estimated by filtering off the drifting long-term trends.

RESULTS

Measles presented in almost all regions in Shandong Province with different spatial distribution over the 43-year study period. The incidence of measles was very high in the pre-vaccination period, with an average incidence of 617.61/100,000 population in 1963. With the implementation of vaccination, the average incidence of measles decreased to 3.63/100,000 population in 2005, the periodicity died out and the trend remained at a stable low level. Outbreaks have been reported recently.

CONCLUSIONS

This study identified the effects of different strategies on the incidence of measles observed in Shandong, China, and will provide valuable information to assist local and national public health policy making. There are still some challenges to improve vaccination coverage and efficacy in order to eliminate measles in China. Strengthening surveillance will be essential in the framework of the anticipated global elimination campaign for measles.

Vaccine-preventable diseases and their prophylaxis

Global uptake of new vaccines shapes the epidemiology of infections, and in turn this changing epidemiology guides vaccine development. Once introduced, surveillance and monitoring of the impact of vaccines on disease and adverse events is vital for further development. This article reviews the use of vaccines as part of routine health care, vaccines that may be required for entry into a destination country, and vaccines that are recommended because of risk during travel. Considerations and advances in the vaccination of travelers are addressed.

Timing of measles immunization and effective population vaccine coverage

OBJECTIVE

To describe measles vaccination patterns in a cohort of Swiss children aged up to 3 years insured with a single health insurer.

METHODS

A dynamic cohort study evaluating measles immunizations patterns in children born between 2006 and 2008 was conducted. Time-to-event analysis was used to describe timing of measles immunization. Effective vaccine coverage was calculated by using an area under the curve approach.

RESULTS

In the study cohort, 62.6% of 13-month-old children were up-to-date for the first measles immunization (recommended at 12 months of age). Approximately 59% of 25-month-old children were up-to-date for the second measles immunization (recommended at 15-24 months of age). Most doses were delivered during months in a child's life when well-child visits are recommended (eg, 12 months of age). For second measles vaccine dose, accelerations in vaccine delivery occurred at time points for well-child visits during the months 19 and 25 of age but with lower final uptake than for the first measles vaccine dose. Until their second birthday, children in our cohort spent on average 177 days and 89 days susceptible to measles due to policy recommendations and additional delays, respectively. In a group of children aged 6 months to 2 years reflecting the age distribution in our cohort, effective vaccine coverage was only 48.6%.

CONCLUSIONS

Timing and timeliness of measles immunizations influence effective population vaccine coverage and should be routinely reported in addition to coverage whenever possible. Proposed timing and relation of recommended vaccinations to well-child visits could be relevant aspects in optimizing measles vaccine coverage to reach measles elimination.

Fever with rash in patients returning from popular tourist resort Phuket, Thailand: dengue--or measles?

We report three recent cases of measles in travelers to a popular vacation resort, Phuket, Thailand, two initially diagnosed clinically as dengue, one as drug reaction. In countries with no indigenous measles, clinicians may no longer recognize the disease. When left misdiagnosed, the patients continue to be potential transmitters.

Measles outbreak in Europe: susceptibility of infants too young to be immunized

As women vaccinated against measles transfer low amounts of antibodies, an increasing number of infants lack early protection through maternal antibodies until being immunised themselves. This paper reviews the literature on disease burden of measles in the population too young to be immunized according to the respective national recommendations during recent outbreaks in EU and EEA/EFTA countries. In addition, specific control strategies adopted to protect this young population are reviewed. Pubmed, Unbound Medline, Web of Knowledge and the Eurosurveillance database were searched using MESH terms: measles and epidemiology, measles and infants, prevalence of measles, measles and outbreaks and measles and epidemic. Additionally, data from Euvac.net and ECDC were consulted. Databases were searched from January 2001 to September 2011. Fifty-three papers were included in the analysis. The percentage of all measles cases during outbreaks affecting young infants ranged from 0.25% to 83.0%. Specific control strategies were adopted: e.g. administration of the first or second vaccine dose earlier than recommended. Infants younger than 12 months are often involved in measles outbreaks, and advancing the first vaccine dose could reduce the burden of disease. However, immunization before 9 months of age is not systematically recommended because of dysmature humoral immune responses of infants. High coverage and timely administration of the recommended series of vaccines are the most important measures to decrease measles incidence and measles circulation and protect vulnerable infants from infection.

Recent resurgence of measles in a community with high vaccination coverage

Even though 2-dose measles vaccination coverage rate was maintained at more than 95%, the largest measles outbreaks since 1996 still occurred in Wuhu city, P R China. A total of 916 cases were reported during 2005-2010. The annual incidence was 6.7 cases per 100,000 population with the peak incidence of 17.6 cases per 100,000 population in 2008. The highest age-specific incidence rate was 222.1 per 100,000 population and occurred in infants aged between 8 and 12 months; the second was 151.9 per 100,000 population in infants aged <8 months. Also, 200 cases occurred in those aged to 22 to 30 years old, accounting for 21.8% of total cases, with the age-specific incidence being 12.8 per 100,000 population. The characteristics related to age distribution have changed in recent measles outbreaks. It underlines the need for vaccination of susceptible young adults and timely administration of the first dose of the measles vaccine.

Exposure of California kindergartners to students with personal belief exemptions from mandated school entry vaccinations

OBJECTIVES

Personal belief exemptions (PBEs) from mandated school entry vaccinations have increased in California over the past decade. Infectious disease outbreaks in the state may be associated with the aggregation of intentionally unvaccinated children within schools. We sought to quantify the exposure of California kindergartners to children with PBEs at school.

METHODS

We used cross-sectional California Department of Public Health data on 3 kindergarten cohorts to define and calculate multiple measures of exposure to children with exemptions, including interaction and aggregation indices, for the state as a whole (2008-2010) and by county (2010).

RESULTS

In 2010, the PBE rate in California was 2.3 per 100 students, and the school PBE rate for the average kindergartner with a PBE was 15.6 per 100. More than 7000 kindergartners in California attend schools with PBE rates greater than 20 per 100, including 2700 kindergartners with PBEs. Exposure measures vary considerably across counties.

CONCLUSIONS

Our results suggest increasing levels of exposure among kindergarten students in California to other kindergartners with PBEs. Our data provide a concrete set of metrics through which public health and education officials can identify high-risk areas as targets for policy and programmatic interventions.

Two consecutive measles outbreaks with genotypes D8 and D4 in two mainly unvaccinated communities in Germany

A measles infection in a 13-year-old student from a free progressive school was the index case for an outbreak in Essen in 2010. In this type of school, mainly unvaccinated and measles-susceptible children accumulate. This observation is confirmed by the fact that some of the recent outbreaks originated in such institutions. In Essen, this outbreak was followed by a second smaller outbreak in unvaccinated children and adults in a low socio-economic setting and migration background. Measles were diagnosed clinically and/or were serologically confirmed. Genotyping of measles isolates was performed by PCR and sequencing. Vaccination certificates were checked by the Community Health Centre (CHC) of the City of Essen. Measures to prevent the spread of the infection were implemented and enforced according to the National Protection Against Infection Act (IfSG). In total, 86 cases of measles were notified from March to July 2010. Of all infected patients, 97 % had had no vaccination and 15 % had to be hospitalised. Clinical courses showed the severity of this infection. Epidemiologic evaluation and genotyping of measles virus (MV) detected in Essen revealed the presence of two distinct chains of MV transmission by genotypes D8 and D4 causing two independent outbreaks. The outbreaks were caused by the index cases, and the spread of infection was facilitated by insufficient vaccination coverage in certain groups. Immediate suspension of non-immune children from classes for 2 weeks might have limited the outbreak in the free progressive school. Overall, high measles vaccination coverage in children and adolescents in regular schools in Essen presumably prevented a greater spread of the virus.

Measles virus, immune control, and persistence

Measles remains one of the most important causes of child morbidity and mortality worldwide with the greatest burden in the youngest children. Most acute measles deaths are owing to secondary infections that result from a poorly understood measles-induced suppression of immune responses. Young children are also vulnerable to late development of subacute sclerosing panencephalitis, a progressive, uniformly fatal neurologic disease caused by persistent measles virus (MeV) infection. During acute infection, the rash marks the appearance of the adaptive immune response and CD8(+) T cell-mediated clearance of infectious virus. However, after clearance of infectious virus, MeV RNA persists and can be detected in blood, respiratory secretions, urine, and lymphoid tissue for many weeks to months. This prolonged period of virus clearance may help to explain measles immunosuppression and the development of lifelong immunity to re-infection, as well as occasional infection of the nervous system. Once MeV infects neurons, the virus can spread trans-synaptically and the envelope proteins needed to form infectious virus are unnecessary, accumulate mutations, and can establish persistent infection. Identification of the immune mechanisms required for the clearance of MeV RNA from multiple sites will enlighten our understanding of the development of disease owing to persistent infection.

Vaccination coverage among medical residents in Paris, France

Medical residents are particularly exposed to the risk of occupational infection. We aimed to determine the vaccination coverage in residents with an anonymous self-reporting electronic questionnaire. A total of 250 residents took part in this survey. Vaccination rates were particularly high for mandatory vaccinations (diphtheria, tetanus, poliomyelitis, hepatitis B virus and tuberculosis). Regarding recommended vaccinations (influenza, 45.6%; pertussis, 65.2%; measles, 62.8%; varicella, 62.8%), rates were insufficient to prevent hospital epidemics, but higher than those reported in other healthcare workers. Further immunization programmes should target residents, and not only senior healthcare workers, with a critical role for occupational medicine departments.

Responding to diversity: an exploratory study of migrant health policies in Europe

There has been growing international attention to migrant health, reflecting recognition of the need for health systems to adapt to increasingly diverse populations. However, reports from health policy experts in 25 European countries suggest that by 2009 only eleven countries had established national policies to improve migrant health that go beyond migrants' statutory or legal entitlement to care. The objective of this paper is to compare and contrast the content of these policies and analyse their strengths and limitations. The analysis suggests that most of the national policies target either migrants or more established ethnic minorities. Countries should address the diverse needs of both groups and could learn from "intercultural" health care policies in Ireland and, in the past, the Netherlands. Policies in several countries prioritise specific diseases or conditions, but these differ and it is not clear whether they accurately reflect real differences in need among countries. Policy initiatives typically involve training health workers, providing interpreter services and/or 'cultural mediators', adapting organizational culture, improving data collection and providing information to migrants on health problems and services. A few countries stand out for their quest to increase migrants' health literacy and their participation in the development and implementation of policy. Progressive migrant health policies are not always sustainable as they can be undermined or even reversed when political contexts change. The analysis of migrant health policies in Europe is still in its infancy and there is an urgent need to monitor the implementation and evaluate the effectiveness of these diverse policies.

Measles

Measles is a highly contagious disease caused by measles virus and is one of the most devastating infectious diseases of man--measles was responsible for millions of deaths annually worldwide before the introduction of the measles vaccines. Remarkable progress in reducing the number of people dying from measles has been made through measles vaccination, with an estimated 164,000 deaths attributed to measles in 2008. This achievement attests to the enormous importance of measles vaccination to public health. However, this progress is threatened by failure to maintain high levels of measles vaccine coverage. Recent measles outbreaks in sub-Saharan Africa, Europe, and the USA show the ease with which measles virus can re-enter communities if high levels of population immunity are not sustained. The major challenges for continued measles control and eventual eradication will be logistical, financial, and the garnering of sufficient political will. These challenges need to be met to ensure that future generations of children do not die of measles.

Dermatological signs and symptoms of measles: a prospective case series and comparison with the literature

BACKGROUND/AIMS

Because of high vaccination rates, population immunity against measles increased in the western world. Nevertheless, outbreaks are still observed. The aim of this article is to document and describe the natural course of dermatological manifestations and compare it with the literature.

METHODS

After detecting a measles index case, the dermatological onset of the disease in the non-vaccinated siblings was prospectively monitored and documented with a digital camera.

RESULTS

Our findings show that dermatological symptoms are only limited consistently from one case to another and described heterogeneously in the literature as well.

CONCLUSION

Dermatological manifestations do not seem conclusive in our clinical data set as well as in the literature. Especially the exact onset of the Koplik spots should be further explored in detail. In future, a larger population should be observed and clinical diagnostics for measles defined.

Who are the children at risk? Lessons learned from measles outbreaks

We investigated a measles outbreak in the Jerusalem district in 2007-2008 (992 cases). Most cases (72·6%) were aged <15 years, 42·9% aged <5 years, and 12·8% were infants aged <1 year. The peak incidence rate was in infants aged 6-12 months (916·2/100 000). This represents a significant shift from former outbreaks in 2003-2004, where the peak incidence was in the 1-4 years age group. Of children aged <5 years the proportion aged 6-12 months tripled (7·7% vs. 25·6%). In a case-control study (74 cases, 148 controls) children who developed measles were less likely to be registered in a well-baby clinic and had lower overall immunization coverage. The differences in proportions for registration, DTaP3 and MMR1 coverage were 35·1%, 48·6% and 80·8%, respectively (all P<0·001). Rising birth order of cases and their siblings was associated with non-registration and non-compliance with MMR immunization. The vulnerability of young infants and the risk markers noted above should be taken into account in planning intervention programmes.

The clinical epidemiology of pediatric patients with measles from 2000 to 2009 in shanghai, china

Measles remains a leading vaccine-preventable cause of child mortality worldwide. The incidence has increased recently in some areas. The authors retrospectively analyzed the epidemiological and clinical characteristics of 2473 measles patients in Shanghai from 2000 to 2009. There were 1909 measles cases during 2005-2009 (group II), whereas only 564 cases were reported during 2000-2004 (group I). In total, 60.87% patients in group II were younger than 9 months, which was significantly higher than that in group I (35.28%; P < .001). More complications, death cases, and less atypical rashes were found in recent years. In addition, 2181 of all the 2473 patients (88.19%) and 1112 of 1328 hospitalized children (83.73%) had not been vaccinated; most of them were immigrants. The results indicated that the rising number of immigrants accounted for the increased measles morbidity in Shanghai. The tendency of more young patients and increased complications suggest that some adjustments might be needed in vaccination administration and therapeutic strategy.

The Swiss National Vaccination Coverage Survey, 2005-2007

OBJECTIVES

We described the results from the Swiss National Vaccination Coverage Survey (SNVCS) 2005-2007, a survey designed to monitor immunization coverage of children and adolescents residing in Switzerland in each canton within a three-year period.

METHODS

The SNVCS is a cross-sectional survey using a two-stage sampling design targeting children aged 2, 8, and 16 years. Families of selected children were contacted by mail and telephone. Coverage was determined via vaccination cards or vaccination summary forms.

RESULTS

A total of 25 out of 26 cantons participated in the survey, with 8,286 respondents for children aged 24-35 months, 10,314 respondents for children aged 8 years, and 9,301 respondents for teenagers aged 16 years. Compared with data from 1999-2003, coverage estimates for toddlers remained unchanged for diphtheria, tetanus, pertussis, poliomyelitis, and Haemophilus influenzae type b vaccines at three doses, but increased five percentage points to 86%-87% for measles-mumps-rubella at one dose and was 71% at two doses. Coverage for measles, mumps, and rubella were 89%-90% at one dose and 75% at two doses for 8-year-olds, and 94% and 76% for the two dosages, respectively, for 16-year-olds. Linguistic region and nationality were highly correlated with being vaccinated against measles for the two younger age groups.

CONCLUSION

Despite the increase in vaccine coverage, measles vaccination is still low, and the World Health Organization goal to eliminate measles by 2010 was not achieved in Switzerland. More efforts are needed by the cantons and the central government to increase vaccination coverage.

Closer to the goal: efforts in measles elimination in Germany 2010

Increasing 2-dose vaccination coverage has led to an interruption of endemic measles virus circulation in Germany. However, outbreaks after virus importation still occur and contribute to international transmission chains. Between 2003 and 2009, annual measles incidence ranged between 0.2 and 2.8 per 100,000 population. Immunization gaps have been identified especially in secondary-school students and young adults, which is also reflected by a shift in age distribution of reported measles cases toward older age groups. Stronger political commitment and standardized guidelines for outbreak containment were put in place in Germany in the past years, but the last step toward measles elimination cannot be made until the number of susceptible individuals has been further reduced. In addition to routine childhood vaccination, supplementary immunization activities are needed targeting school students and young adults to close critical immunization gaps. Intensification of public awareness and sound information on vaccinations are necessary to convince skeptics and remind the forgetful.

[Integrated bulletin for the automated surveillance of notifiable communicable diseases in Schleswig-Holstein (IBISSH). A spatiotemporal early warning system]

The program package "Integrated Bulletin for Infectious disease Surveillance for Schleswig-Holstein" (IBIS(SH)) was introduced in 2008 for the automated data analysis of notifiable infectious diseases in Schleswig-Holstein, Germany. The Java-based IBIS(SH) software supports access to the national SurvNet@RKI reporting data via Access and MS SQL. The aim of the IBIS(SH) system is early warning and interpretation of clusters and monitoring of trends. One module of the system permits the analysis of temporal aberration by comparison of data from previous years. The interpretation system is based on the weekly median and on percentile values from previous years. The extent of an aberration is assessed by a five-step score magnitude scale. Another module permits the detection of regional clusters by the weekly assessment of a population-based risk analysis. IBIS(SH) automatically generates tables and graphs for the weekly bulletin and their allocation in the Internet. Data for the most relevant pathogens in Schleswig-Holstein are presented for the year 2009. The performance of the automated temporal and the regional detection systems are compared to outbreak detection by local health authorities.

[Measles in 2010. Knowledge and vaccination status of medical students]

OBJECTIVES

In 2002, the WHO Regional Office for Europe developed a strategic plan for measles in the WHO European Region. WHO recommends that at least 95% of children receive two doses of measles vaccine. This plan targeted the elimination of measles for the year 2010 and is supported by the Federal Republic of Germany.

METHODS

Questionnaire survey, serological tests and check-up of the certificates of vaccination were offered to second year medical students of Goethe University Frankfurt/Main, Germany.

RESULTS

Only 62.3% of medical students had received two doses of measles vaccine. Serological data showed that 23.1% were not immune against measles. Important gaps of knowledge were identified in the knowledge test of the survey; less than one third of the students (n=95/324) were able to answer more than 50% of the questions correctly.

DISCUSSION

The suboptimum measles-vaccination coverage shows that the goal of eliminating measles will not be met across Europe by the target year 2010. Both occupational and public health measures need to make sure that vaccination programs should achieve a minimum of 95% coverage with two doses. In addition, the obligation to notify the authorities even of suspected cases serve the same purpose and measures to improve the knowledge of medical students are required. Consequent surveillance systems are necessary to investigate chains of measles infections. Healthcare workers play a decisive role in this issue.

Lessons learned from a measles outbreak in Antwerp, Belgium 2007-2008

A 2007 to 2008 measles outbreak in Antwerp, Belgium, identified the orthodox Jewish communities as a new risk group. This study analyzes vaccination data of 949 school children of 4 belief systems to assess the completeness and timeliness of their measles-mumps-rubella vaccination. Orthodox Jewish children show a 4-fold lower chance of complete vaccination, a delayed start, and increased temporal spacing of childhood vaccinations. Not only belief issues but difficulties to access the regular vaccination program also seem to be the main reason.

Under-reporting of measles: an evaluation based on data from north rhine-westphalia

BACKGROUND

Eliminating measles in Europe by 2015 is a WHO health goal. In Germany, physicians are legally required to report measles cases, yet it seems likely that reporting is less than universal. The goal of this study is to compare the number of measles cases that are reflected by data from the statutory health insurance (SHI) carriers with the number of physician-reported cases during and after a recent outbreak in the German state of North Rhine-Westphalia (NRW).

METHODS

We analyzed the billing data of SHI carriers relating to measles in 2006 and 2007, as well as the measles cases that were reported in NRW over this period as required by law. We calculated the incidence of measles as the number of measles cases per 100 000 insurees (SHI carrier data) or per 100 000 persons in the overall population (reporting data).

RESULTS

The measles outbreak in the first half of 2006 comprised 1713 measles cases according to the SHI data and 1665 cases that were reported as required by law (ratio, 1.02:1). From mid-2006 to the end of 2007, the SHI data reflected 821 cases, but only 349 cases were reported (ratio, 2.35:1). Younger patients were more commonly found among the cases reflected in the SHI data than among the reported cases.

CONCLUSION

Our study confirms that the system of legally mandated reporting underestimates the true number of measles cases, particularly in times when most cases are sporadic, and particularly in children who are less than 5 years old.