The clinical significance of measles: a review

Streptococcal Infection as a Major Historical Cause of Stuttering: Data, Mechanisms, and Current Importance

Stuttering is one of the most well-known speech disorders, but the underlying neurological mechanisms are debated. In addition to genetic factors, there are also major non-genetic contributions. It is here proposed that infection with group A beta-hemolytic streptococcus (GAS) was a major underlying cause of stuttering until the mid-1900s when penicillin was introduced in 1943. The main mechanism proposed is an autoimmune reaction from tonsillitis, targeting specific molecules, for example within the basal ganglia. It is here also proposed that GAS infections may have continued to cause stuttering to some extent, to the present date, though more rarely. If so, early diagnosis of such cases would be of importance. Childhood cases with sudden onset of stuttering after throat infection may be particularly important to assess for possible GAS infection. The support for this hypothesis primarily comes from three lines of argument. First, medical record data from the 1930s strongly indicates that there was one type of medical event in particular that preceded the onset of childhood stuttering with unexpected frequency: diseases related to GAS throat infections. In particular, this included tonsillitis and scarlet fever, but also rheumatic fever. Rheumatic fever is a childhood autoimmune sequela of GAS infection, which was a relatively widespread medical problem until the early 1960s. Second, available reports of changes of the childhood prevalence of stuttering indicate striking parallels between stuttering and the incidence of rheumatic fever, with: (1) decline from the early 1900s; (2) marked decline from the introduction of penicillin in the mid 1940s; and (3) reaching a more stable level in the 1960s. The correlations between the data for stuttering and rheumatic fever after the introduction of penicillin are very high, at about 0.95. Third, there are established biological mechanisms linking GAS tonsillitis to immunological effects on the brain. Also, a small number of more recent case reports have provided further support for the hypothesis linking stuttering to GAS infection. Overall, it is proposed that the available data provides strong evidence for the hypothesis that GAS infection was a major cause of stuttering until the mid-1900s, interacting with genetic predisposition.

Rubeola keratitis emergence during a recent measles outbreak in New Zealand

INTRODUCTION Measles is a highly contagious disease caused by the rubeola virus. It can result in ocular complications such as conjunctivitis and keratitis, which will be encountered in general practice. Cases usually resolve without sequelae, but may progress to corneal perforation if left untreated. AIM We present two cases of rubeola keratitis secondary to measles infection. METHODS This report is about a retrospective review of data from two patients who presented to the eye department with rubeola keratitis in the midst of the recent measles outbreak in New Zealand. RESULTS Both patients presented with decreased visual acuity approximately 2 weeks after being diagnosed with measles. One of them was unvaccinated, whereas the other had no documentation of previous vaccination. Both were healthy and immunocompetent individuals. There was no evidence of corneal perforation or retinopathy on examination. Both patients regained their baseline visual acuity after treatment with fluorometholone eye drops. DISCUSSION Despite the existence of a safe and effective vaccine, there were more than 2000 cases of measles in the recent outbreak in New Zealand. The lack of vaccination is one of the primary causes of rubeola keratitis. These cases highlight the effects of measles infection from an ophthalmology perspective and reinforce the paramount importance of getting vaccinated.

Measuring the Benefits of Mass Vaccination Programs in the United States

Since the late 1940s, mass vaccination programs in the USA have contributed to the significantly reduced morbidity and mortality of infectious diseases. To assist the evaluation of the benefits of mass vaccination programs, the number of individuals who would have suffered death or permanent disability in the USA in 2014, had mass vaccination never been implemented, was estimated for measles, mumps, rubella, tetanus, diphtheria, pertussis, polio, Haemophilus influenzae type b (Hib), hepatitis B, varicella, and human papillomavirus (HPV). The estimates accounted for mortality and morbidity trends observed for these infections prior to mass vaccination and the impact of advances in standard of living and health care. The estimates also considered populations with and without known factors leading to an elevated risk of permanent injury from infection. Mass vaccination prevented an estimated 20 million infections and 12,000 deaths and permanent disabilities in 2014, including 10,800 deaths and permanent disabilities in persons at elevated risk. Though 9000 of the estimated prevented deaths were from liver cirrhosis and cancer, mass vaccination programs have not, at this point, shown empirical impacts on the prevalence of those conditions. Future studies can refine these estimates, assess the impact of adjusting estimation assumptions, and consider additional risk factors that lead to heightened risk of permanent harm from infection.

A Review of Measles Outbreak Cost Estimates From the United States in the Postelimination Era (2004-2017): Estimates by Perspective and Cost Type

Despite the elimination of measles in the United States (US) in the year 2000, cases continue to occur, with measles outbreaks having occurred in various jurisdictions in the US in 2018 and 2019. Understanding the cost associated with measles outbreaks can inform cost-of-illness and cost-effectiveness studies of measles and measles prevention. We performed a literature review and identified 10 published studies from 2001 through 2018 that presented cost estimates from 11 measles outbreaks. The median total cost per measles outbreak was $152 308 (range, $9862-$1 063 936); the median cost per case was $32 805 (range, $7396-$76 154) and the median cost per contact was $223 (range, $81-$746). There were limited data on direct and indirect costs associated with measles. These findings highlight how costly measles outbreaks can be, the value of this information for public health department budgeting, and the importance of more broadly documenting the cost of measles outbreaks.

A Major Regional Measles Outbreak: Description of Hospitalized Cases in 2017-2018 at Bordeaux University Hospital, France

Background

Measles remains endemic worldwide, despite current vaccination recommendations, and is associated with high morbidity and mortality rates. We describe all cases hospitalized in Bordeaux University Hospital (BUH), the starting point of a national significant measles outbreak in 2017–2018.

Methods

In this retrospective study, we included all patients hospitalized in BUH from September 1, 2017, to May 31, 2018. Inclusion criteria were age >1 year, clinical symptoms, and biological confirmation by measles immunoglobulin M or measles reverse transcription polymerase chain reaction positivity.

Results

We included 171 patients. Most patients were immunocompetent; only 19% had preexisting medical histories. Most patients had rash and fever (97%), but some cases were atypical and difficult to diagnose. Köplik’s spots were reported in 66 cases (38%). The most frequent biological markers were blood inflammation markers (96%) and lymphopenia (81%). Unexpectedly, we found hyponatremia (<135 mmol/L) in 40% of patients. We identified peaks in January and March, corresponding to 76 D8 genotypes and 28 B3 strains. The following complications were reported in 65 patients (38%): pneumonia, hepatitis, and keratitis; 10 had neurological symptoms. One patient had Guillain-Barré syndrome, and a young immunocompromised patient died from measles inclusion-body encephalitis. Most of the patients (80%) had not been correctly vaccinated, including 28 health care workers. Some patients (n = 43, 25%) developed measles despite having plasma IgG. These included 12 possible vaccination failure cases.

Conclusions

During the BUH outbreak, measles was often complicated and sometimes atypical. Vaccination coverage was dramatically insufficient. We also describe vaccination failure cases that must be better investigated.

Effects of a measles outbreak on vaccination uptake

This paper explores the effects of a measles outbreak on vaccination uptake in Austria, using administrative data with individual-level information on childhood vaccinations. I define a treatment group of children affected by the outbreak, and compare them with a control group of earlier-born children who are unaffected. Twelve months after the outbreak, the vaccination rate of the treatment group is 2.5 (first dose of the measles, mumps and rubella vaccine) and 4 (second dose) percentage points higher than the corresponding rates of the control group. The results do not indicate that families at increased risk respond more strongly, suggesting that the outbreak changed the perceived value of vaccinations across the whole population. Findings also reveal heterogeneity in the response of families based on the parents' level of education, indicating that parents with higher education levels absorb new information more rapidly.

Incomplete genetic reconstitution of B cell pools contributes to prolonged immunosuppression after measles

Measles is a disease caused by the highly infectious measles virus (MeV) that results in both viremia and lymphopenia. Lymphocyte counts recover shortly after the disappearance of measles-associated rash, but immunosuppression can persist for months to years after infection, resulting in increased incidence of secondary infections. Animal models and in vitro studies have proposed various immunological factors underlying this prolonged immune impairment, but the precise mechanisms operating in humans are unknown. Using B cell receptor (BCR) sequencing of human peripheral blood lymphocytes before and after MeV infection, we identified two immunological consequences from measles underlying immunosuppression: (i) incomplete reconstitution of the naïve B cell pool leading to immunological immaturity and (ii) compromised immune memory to previously encountered pathogens due to depletion of previously expanded B memory clones. Using a surrogate model of measles in ferrets, we investigated the clinical consequences of morbillivirus infection and demonstrated a depletion of vaccine-acquired immunity to influenza virus, leading to a compromised immune recall response and increased disease severity after secondary influenza virus challenge. Our results show that MeV infection causes changes in naïve and memory B lymphocyte diversity that persist after the resolution of clinical disease and thus contribute to compromised immunity to previous infections or vaccinations. This work highlights the importance of MeV vaccination not only for the control of measles but also for the maintenance of herd immunity to other pathogens, which can be compromised after MeV infection.

Estimating the nationwide transmission risk of measles in US schools and impacts of vaccination and supplemental infection control strategies

BACKGROUND

The spread of airborne infectious diseases such as measles is a critical public health concern. The U.S. was certified measles-free in 2000, but the number of measles cases has increased in recent years breaking the record of the nationwide annual number of cases since 1992. Although the characteristics of schools have made them one of the most vulnerable environments during infection outbreaks, the transmission risk of measles among students is not completely understood. We aimed to evaluate how three factors influence measles transmission in schools: personal (vaccination), social (compartmentalizing), and building systems (ventilation, purification, and filtration).

METHODS

We used a combination of a newly developed multi-zone transient Wells-Riley approach, a nationwide representative School Building Archetype (SBA) model, and a Monte-Carlo simulation to estimate measles risk among U.S. students. We compared our risk results with the range of reported transmission rates of measles in school outbreaks to validate the risk model. We also investigated the effectiveness of vaccination and ten supplemental infection control scenarios for reducing the risk of measles transmission among students.

RESULTS

Our best nationwide estimate of measles transmission risk in U.S. schools were 3.5 and 32% among all (both unvaccinated and immunized) and unvaccinated students, respectively. The results showed the transmission risk of measles among unvaccinated students is > 70 times higher than properly immunized ones. We also demonstrated that the transmission risk of measles in primary schools (assuming teacher self-contained classrooms) is less than secondary schools (assuming departmentalized systems). For building-level interventions, schools with ductless-with-air-filter and ductless-without-air-filter systems have the lowest and highest transmission risks of measles, respectively. Finally, our simulation showed that infection control strategies could cut the average number of infected cases among all students in half when a combination of advanced air filtration, ventilation, and purification was adopted in the modeled schools.

CONCLUSIONS

Our results highlight the primary importance of vaccination for reducing the risk of measles transmission among students. Yet, additional and significant risk reduction can be achieved through compartmentalizing students and enhancing building ventilation and filtration systems.

Cryo-EM structure of the prefusion state of canine distemper virus fusion protein ectodomain

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Expression and purification of prefusion CDV solF in presence of a fusion inhibitor.

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Elucidation of the CDV fusion protein ectodomain by cryo-EM.

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High structural similarity between MeV and CDV solF suggests common fusion mechanisms.

Measles virus (MeV) and canine distemper virus (CDV), two members of the Morbillivirus genus, are still causing important global diseases of humans and animals, respectively. To enter target cells, morbilliviruses rely on an envelope-anchored machinery, which is composed of two interacting glycoproteins: a tetrameric receptor binding (H) protein and a trimeric fusion (F) protein. To execute membrane fusion, the F protein initially adopts a metastable, prefusion state that refolds into a highly stable postfusion conformation as the result of a finely coordinated activation process mediated by the H protein. Here, we employed cryo-electron microscopy (cryo-EM) and single particle reconstruction to elucidate the structure of the prefusion state of the CDV F protein ectodomain (solF) at 4.3 Å resolution. Stabilization of the prefusion solF trimer was achieved by fusing the GCNt trimerization sequence at the C-terminal protein region, and expressing and purifying the recombinant protein in the presence of a morbilliviral fusion inhibitor class compound. The three-dimensional cryo-EM map of prefusion CDV solF in complex with the inhibitor clearly shows density for the ligand at the protein binding site suggesting common mechanisms of membrane fusion activation and inhibition employed by different morbillivirus members.

Cost-effectiveness of measles control during elimination in Ontario, Canada, 2015

BackgroundGiven that measles is eliminated in Canada and measles immunisation coverage in Ontario is high, it has been questioned whether Ontario's measles outbreak response is worthwhile.AimOur objective was to determine cost-effectiveness of measles containment protocols in Ontario from the healthcare payer perspective.MethodsWe developed a decision-analysis model comparing Ontario's measles containment strategy (based on actual 2015 outbreak data) with a hypothetical 'modified response'. The modified scenario assumed 10% response costs with reduced case and contact tracing and no outbreak-associated vaccinations; it was based on local and provincial administrative and laboratory data and parameters from peer-reviewed literature. Short- and long-term health outcomes, quality-adjusted life years (QALYs) and costs discounted at 1.5%, were estimated. We conducted one- and two-way sensitivity analyses.ResultsThe 2015 outbreak in Ontario comprised 16 measles cases and an estimated 3,369 contacts. Predictive modelling suggested that the outbreak response prevented 16 outbreak-associated cases at a cost of CAD 1,213,491 (EUR 861,579). The incremental cost-effectiveness ratio was CAD 739,063 (EUR 524,735) per QALY gained for the outbreak response vs modified response. To meet the commonly accepted cost-effectiveness threshold of CAD 50,000 (EUR 35,500) per QALY gained, the outbreak response would have to prevent 94 measles cases. In sensitivity analyses, the findings were robust.ConclusionsOntario's measles outbreak response exceeds generally accepted cost-effectiveness thresholds and may not be the most efficient use of public health resources from a healthcare payer perspective. These findings should be balanced against benefits of increased vaccine coverage and maintaining elimination status.

Difficulties in diagnosing of measles inclusion body encephalitis in a child with acute lymphoblastic leukemia

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Report of measles inclusion body encephalitis in child with leukemia.

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It is necessary to determine antibodies to measles virus in the cerebrospinal fluid.

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We found intrathecal synthesis of IgG antibodies to measles virus.

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The disease had a dramatic course and ended in death.

The measles epidemic was observed in Ukraine during 20172019. According to WHO, in Ukraine there was registered the highest number of measles cases in Europe during that period [8].

Measles is characterized by an acute course with fever, maculopapular rash, cough, conjunctivitis and can lead to central nervous system complications (encephalitis, encephalomyelitis) and bronchopulmonary system complications (laryngotracheobronchitis, bronchiolitis, pneumonia).

In immunocompetent patients, viremia ends after the end of clinical signs, in contrast to immunosuppressed individuals, who could develop viremia from one month up to a year.

We have described a case of measles inclusion body encephalitis (MIBE) or subacute measles encephalitis (SME) in an unvaccinated child with an acute lymphoblastic leukemia (ALL). The diagnosis was confirmed by the synthesis of IgG antibodies to the measles virus in the cerebrospinal fluid and by the MRI results. The disease had a dramatic course and ended in death.

Effect of vaccination on children’s learning achievements: findings from the India Human Development Survey

Background

Beyond the prevention of illness and death, vaccination may provide additional benefits such as improved educational outcomes. However, there is currently little evidence on this question. Our objective was to estimate the effect of childhood vaccination on learning achievements among primary school children in India.

Methods

We used cohort data from the India Human Development Survey. Vaccination status and confounders were measured among children who were at least 12 months old at baseline in 2004–2005. In 2011–2012, the same children completed basic reading, writing and math tests. We estimated the effect of full vaccination during childhood on learning achievements using inverse probability of treatment-weighted logistic regression models and results reported on the risk difference scale. The propensity score included 33 potential community-, household-, mother- and child-level confounders as well as state fixed effects.

Results

Among the 4877 children included in our analysis, 54% were fully vaccinated at baseline, and 54% could read by the age of 8–11 years. The estimated effect of full vaccination on learning achievements ranged from 4 to 6 percentage points, representing relative increases ranging from 6% to 12%. Bias analysis suggested that our observed effects could be explained by unmeasured confounding, but only in the case of strong associations with the treatment and outcome.

Conclusion

These results support the hypothesis that vaccination has lasting effects on children’s learning achievements. Further work is needed to confirm findings and elucidate the potential mechanisms linking vaccines to educational outcomes.

Spatiotemporal distribution and determinants of measles incidence during a large outbreak, Italy, September 2016 to July 2018

Background

Measles is still endemic in Italy and outbreaks are frequent. From 2016 to 2018, more than 7,000 measles cases were reported to the national integrated measles and rubella surveillance system, the largest outbreak since implementation of this system.

Aim

We aimed to describe the characteristics and spatiotemporal distribution of measles cases in Italy and explore determinants of incidence at municipality level.

Methods

We performed a retrospective observational study, mapping by municipalityall measles cases reported to the national surveillance system with symptom onset between 1 September 2016 and 31 July 2018. We also analysed measles–mumps-rubella (MMR) vaccination coverage (VC) data (2000–2017) for the first and second dose, collected from the Ministry of Health. We used regression analysis to explore factors associated with measles incidence at municipality level.

Results

We analysed 7,854 cases, 3,927 (50%) female. Median age was 26 years; 475 cases (6%) were younger than 1 year. The outbreak occurred in two epidemic waves. The first started in central/northern regions (end of 2016), the second (mostly within 2018) was concentrated in southern regions. In 2016 and 2017, national VC was below 95% for both MMR doses. In 2017, only one region reported VC above 95% for the first dose. At municipality level, incidence was associated with higher urbanisation, less deprivation and fewer adults.

Conclusion

The spread of measles between September 2016 and July 2018 in Italy indicates the need to improve VC and to explore further how societal and other parameters might be linked to incidence.

The Effects of Pre-Existing Antibodies on Live-Attenuated Viral Vaccines

Live-attenuated vaccines (LAVs) have achieved remarkable successes in controlling virus spread, as well as for other applications such as cancer immunotherapy. However, with rapid increases in international travel, globalization, geographic spread of viral vectors, and widespread use of vaccines, there is an increasing need to consider how pre-exposure to viruses which share similar antigenic regions can impact vaccine efficacy. Pre-existing antibodies, derived from either from maternal–fetal transmission, or by previous infection or vaccination, have been demonstrated to interfere with vaccine immunogenicity of measles, adenovirus, and influenza LAVs. Immune interference of LAVs can be caused by the formation of virus–antibody complexes that neutralize virus infection in antigen-presenting cells, or by the cross-linking of the B-cell receptor with the inhibitory receptor, FcγRIIB. On the other hand, pre-existing antibodies can augment flaviviral LAV efficacy such as that of dengue and yellow fever virus, especially when pre-existing antibodies are present at sub-neutralizing levels. The increased vaccine immunogenicity can be facilitated by antibody-dependent enhancement of virus infection, enhancing virus uptake in antigen-presenting cells, and robust induction of innate immune responses that promote vaccine immunogenicity. This review examines the literature on this topic and examines the circumstances where pre-existing antibodies can inhibit or enhance LAV efficacy. A better knowledge of the underlying mechanisms involved could allow us to better manage immunization in seropositive individuals and even identify possibilities that could allow us to exploit pre-existing antibodies to boost vaccine-induced responses for improved vaccine efficacy.

Inpatient morbidity and mortality of measles in the United States

Background

Measles is an extremely contagious, vaccine-preventable infection that was officially declared eradicated in the US in 2000. However, measles outbreaks are increasingly occurring in the US. Measles cases have considerable morbidity requiring hospitalization, yet little is known about hospitalization and complications from measles in recent years.

Objectives

To analyze the frequency, predictors, costs and other outcomes of hospitalization for measles in the US.

Methods

The 2002–2016 Nationwide Inpatient Sample, containing a 20% sample of US hospitalizations (n = 96,568,625), was analyzed. Measles and comorbidities were defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) or ICD-10-CM codes. Multivariable survey logistic regression and linear regression models controlling for sociodemographic demographic factors were constructed to understand associations with organ-specific complications, and cost of care and length of stay, respectively.

Results

Overall, 1,018 measles hospitalizations occurred in 2002–2016, and hospitalizations increased over time. In multivariable logistic regression models, measles was associated with higher odds of gastrointestinal, hematologic, infectious, neurologic, ophthalmologic, pulmonary, and renal complications, with the strongest association observed with encephalitis (39.84 [16.51–96.12], P<0.0001). Increased length of stay (LOS) and similar cost of care (mean [95% CI]; 4.8 [4.4–5.4]; $7,438 [$6,446-$8,582]) were observed versus (vs.) all other admissions (4.5 [4.4–4.5]; P<0.01; $7,854 [$7,774-$7,935], P>0.05). There were 34 deaths in hospitalized measles patients; inpatient mortality was numerically higher in those with vs. without measles (proportion ± SEM: 3.3±1.2% vs. 2.3±0.01%, P = 0.333).

Limitations

Lack of outpatient or prescription data.

Conclusions

Measles continues to pose a substantial and preventable health care burden, with serious complications, hospitalization and inpatient mortality. Further studies are needed to improve the prevention and management of measles.

Vaccines for measles, mumps, rubella, and varicella in children

BACKGROUND

Measles, mumps, rubella, and varicella (chickenpox) are serious diseases that can lead to serious complications, disability, and death. However, public debate over the safety of the trivalent MMR vaccine and the resultant drop in vaccination coverage in several countries persists, despite its almost universal use and accepted effectiveness. This is an update of a review published in 2005 and updated in 2012.

OBJECTIVES

To assess the effectiveness, safety, and long- and short-term adverse effects associated with the trivalent vaccine, containing measles, rubella, mumps strains (MMR), or concurrent administration of MMR vaccine and varicella vaccine (MMR+V), or tetravalent vaccine containing measles, rubella, mumps, and varicella strains (MMRV), given to children aged up to 15 years.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 5), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to 2 May 2019), Embase (1974 to 2 May 2019), the WHO International Clinical Trials Registry Platform (2 May 2019), and ClinicalTrials.gov (2 May 2019).

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), prospective and retrospective cohort studies (PCS/RCS), case-control studies (CCS), interrupted time-series (ITS) studies, case cross-over (CCO) studies, case-only ecological method (COEM) studies, self-controlled case series (SCCS) studies, person-time cohort (PTC) studies, and case-coverage design/screening methods (CCD/SM) studies, assessing any combined MMR or MMRV / MMR+V vaccine given in any dose, preparation or time schedule compared with no intervention or placebo, on healthy children up to 15 years of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the methodological quality of the included studies. We grouped studies for quantitative analysis according to study design, vaccine type (MMR, MMRV, MMR+V), virus strain, and study settings. Outcomes of interest were cases of measles, mumps, rubella, and varicella, and harms. Certainty of evidence of was rated using GRADE.

MAIN RESULTS

We included 138 studies (23,480,668 participants). Fifty-one studies (10,248,159 children) assessed vaccine effectiveness and 87 studies (13,232,509 children) assessed the association between vaccines and a variety of harms. We included 74 new studies to this 2019 version of the review. Effectiveness Vaccine effectiveness in preventing measles was 95% after one dose (relative risk (RR) 0.05, 95% CI 0.02 to 0.13; 7 cohort studies; 12,039 children; moderate certainty evidence) and 96% after two doses (RR 0.04, 95% CI 0.01 to 0.28; 5 cohort studies; 21,604 children; moderate certainty evidence). The effectiveness in preventing cases among household contacts or preventing transmission to others the children were in contact with after one dose was 81% (RR 0.19, 95% CI 0.04 to 0.89; 3 cohort studies; 151 children; low certainty evidence), after two doses 85% (RR 0.15, 95% CI 0.03 to 0.75; 3 cohort studies; 378 children; low certainty evidence), and after three doses was 96% (RR 0.04, 95% CI 0.01 to 0.23; 2 cohort studies; 151 children; low certainty evidence). The effectiveness (at least one dose) in preventing measles after exposure (post-exposure prophylaxis) was 74% (RR 0.26, 95% CI 0.14 to 0.50; 2 cohort studies; 283 children; low certainty evidence). The effectiveness of Jeryl Lynn containing MMR vaccine in preventing mumps was 72% after one dose (RR 0.24, 95% CI 0.08 to 0.76; 6 cohort studies; 9915 children; moderate certainty evidence), 86% after two doses (RR 0.12, 95% CI 0.04 to 0.35; 5 cohort studies; 7792 children; moderate certainty evidence). Effectiveness in preventing cases among household contacts was 74% (RR 0.26, 95% CI 0.13 to 0.49; 3 cohort studies; 1036 children; moderate certainty evidence). Vaccine effectiveness against rubella is 89% (RR 0.11, 95% CI 0.03 to 0.42; 1 cohort study; 1621 children; moderate certainty evidence). Vaccine effectiveness against varicella (any severity) after two doses in children aged 11 to 22 months is 95% in a 10 years follow-up (rate ratio (rr) 0.05, 95% CI 0.03 to 0.08; 1 RCT; 2279 children; high certainty evidence). Safety There is evidence supporting an association between aseptic meningitis and MMR vaccines containing Urabe and Leningrad-Zagreb mumps strains, but no evidence supporting this association for MMR vaccines containing Jeryl Lynn mumps strains (rr 1.30, 95% CI 0.66 to 2.56; low certainty evidence). The analyses provide evidence supporting an association between MMR/MMR+V/MMRV vaccines (Jeryl Lynn strain) and febrile seizures. Febrile seizures normally occur in 2% to 4% of healthy children at least once before the age of 5. The attributable risk febrile seizures vaccine-induced is estimated to be from 1 per 1700 to 1 per 1150 administered doses. The analyses provide evidence supporting an association between MMR vaccination and idiopathic thrombocytopaenic purpura (ITP). However, the risk of ITP after vaccination is smaller than after natural infection with these viruses. Natural infection of ITP occur in 5 cases per 100,000 (1 case per 20,000) per year. The attributable risk is estimated about 1 case of ITP per 40,000 administered MMR doses. There is no evidence of an association between MMR immunisation and encephalitis or encephalopathy (rate ratio 0.90, 95% CI 0.50 to 1.61; 2 observational studies; 1,071,088 children; low certainty evidence), and autistic spectrum disorders (rate ratio 0.93, 95% CI 0.85 to 1.01; 2 observational studies; 1,194,764 children; moderate certainty). There is insufficient evidence to determine the association between MMR immunisation and inflammatory bowel disease (odds ratio 1.42, 95% CI 0.93 to 2.16; 3 observational studies; 409 cases and 1416 controls; moderate certainty evidence). Additionally, there is no evidence supporting an association between MMR immunisation and cognitive delay, type 1 diabetes, asthma, dermatitis/eczema, hay fever, leukaemia, multiple sclerosis, gait disturbance, and bacterial or viral infections.

AUTHORS' CONCLUSIONS

Existing evidence on the safety and effectiveness of MMR/MMRV vaccines support their use for mass immunisation. Campaigns aimed at global eradication should assess epidemiological and socioeconomic situations of the countries as well as the capacity to achieve high vaccination coverage. More evidence is needed to assess whether the protective effect of MMR/MMRV could wane with time since immunisation.

A microneedle patch for measles and rubella vaccination: a game changer for achieving elimination

While morbidity and mortality associated with measles and rubella (MR) have dramatically decreased, there are still >100000 estimated deaths due to measles and an estimated 100000 infants born with congenital rubella syndrome annually. Given highly effective MR vaccines, the primary barrier to global elimination of these diseases is low vaccination coverage, especially among the most underserved populations in resource-limited settings. In contrast to conventional MR vaccination by hypodermic injection, microneedle patches are being developed to enable MR vaccination by minimally trained personnel. Simplified supply chain, reduced need for cold chain storage, elimination of vaccine reconstitution, no sharps waste, reduced vaccine wastage, and reduced total system cost of vaccination are advantages of this approach. Preclinical work to develop a MR vaccine patch has proceeded through successful immunization studies in rodents and non-human primates. On-going programs seek to make MR vaccine patches available to support MR elimination efforts around the world.

Art of prevention: The importance of measles recognition and vaccination

Measles is a viral infection that has a characteristic pattern of prodromal symptoms followed by a rash. Previously considered an inevitable childhood condition, measles is known as the "first" classic childhood exanthem. For most children, measles was a one-time, short-term illness; however, some children developed complications that led to severe sequelae and death. The introduction of the measles vaccine dramatically decreased the number of cases, but the current trend against vaccination has caused outbreaks of the condition. We propose the implementation of the AAA approach (assume, advise, and answer) as a way for providers to directly encourage the administration of the vaccine and prevent future cases of measles.

High number of hospitalisations and non-classical presentations: lessons learned from a measles outbreak in 2017, Belgium

We describe and analyse an outbreak of measles that affected Belgium early 2017. In total, 289 cases were reported, mostly (53%) in people 15 years or older. For 133 (46%) vaccination status was unknown and a further 117 (41%) were not vaccinated. According to national guidelines, 83 of the unvaccinated cases (29% of total cases) should have received minimum one dose of vaccine, but did not. One in five cases (21%) did not present with the classical triad of fever, rash and any of coryza, conjunctivitis or cough. Rash was the most sensitive symptom, being absent in only six cases. A large proportion of cases (125/289, 43%) required hospitalisation. In hospitalised patients, the most commonly observed complications were hepatic disorders (present in 58/125 hospitalised patients, 46%). Thirty-six of the cases (12%) were in healthcare workers and nosocomial spread contributed importantly to the outbreak. Older age at presentation, altered clinical presentations and presence of complications like hepatitis can delay the correct diagnosis of measles. Clinicians should maintain a high index of suspicion in any individual presenting with rash. If the elimination target is to be reached, catch-up vaccination campaigns should be intensified and target young adults and health care workers.

Measles: An Overview of a Re-Emerging Disease in Children and Immunocompromised Patients

Despite the availability of a safe and effective vaccine, in 2018, around 350,000 measles cases were reported worldwide, which resulted in an estimate of 142,300 deaths from measles. Additionally, in 2017, global measles cases spiked, causing the death of 110,000 people, mostly children under the age of 5 years and immunocompromised adults. The increase in measles incidence is caused by the ongoing reduction of vaccination coverage. This event has triggered public and scientific interest. For this reason, we reviewed the pathophysiology of measles infection, focusing on mechanisms by which the virus spreads systemically through the host organism. By reaching the lymphocytes from the airways through a "trojan horse" strategy, measles induces an immunosuppression status. H and F glycoproteins, both expressed in the envelope, ensure attachment of the virus to host cells and spreading from one cell to another by binding to several receptors, as described in detail. The severity of the disease depends both on the age and underlying conditions of patients as well as the social and health context in which epidemics spread, and is often burdened by sequelae and complications that may occur several years after infection. Particular attention was paid to special groups that are more susceptible to severe or atypical measles. An overview of microbiology, symptoms, diagnosis, prevention, and treatment completes and enriches the review.

Complications of measles: a case series

Measles, which was once thought to be a disappearing viral infection due to effective vaccination, has been re-emerging globally, with increasing cases in adolescents and adults. This has been attributed to anti-vaccination campaigning in the early 21st century, which has resulted in a drop in overall herd immunity. In this case series we report three patients with complications secondary to measles who presented to a hospital in Malta in 2019. Through this series, we discuss the range of possible complications caused by the measles virus, ranging from mild viraemic symptoms to multiorgan involvement which could possibly lead to high-dependency care and may even be fatal. We also highlight recent global statistics which reflect the exponential increase in the incidence of measles, with a special focus on Europe. It is emphasised that vaccine education and compliance with the two-dose measles vaccine should be implemented worldwide.

Measles-associated pneumonia and hepatitis during the measles outbreak of 2018

Background Between 2017 and 2018, Greece experienced a measles outbreak, affecting >3000 patients, most of which were unvaccinated. Measles-associated pneumonia (MAP) is the most common serious compilation of the disease, but very few recent reports regarding its presentation are available. Materials and Methods Between January and May 2018, 11 adult patients presented to our department with acute measles virus infection, hypoxia and findings on chest X-ray. Clinical, laboratory and radiological data were collected and assessed. Nine out of eleven patients had hypoxic respiratory failure. Other complications included hepatitis, cholestasis and myositis, which were observed in the majority of patients. All patients received supplementary oxygen administration, whereas five patients required continuous positive airway pressure ventilation. Scoring of the radiological examinations performed was most notable for the presence of reticular opacities and consolidations. Statistical analysis demonstrated a significant association between PaO2/FiO2 values and the presence of reticular opacities, with PaO2/FiO2 decreasing as the mean value of the reticular opacities score increased (P = .02). Conclusion To our knowledge, this is the first report demonstrating an association between PaO2/FiO2 values and the presence of reticular opacities in patients with MAP. MAP should be suspected in any patient presenting with acute onset hypoxaemia and a reticular pattern on radiological examination, especially in outbreak settings. What is known Measles infections are on the rise in Europe, with epidemics affecting several European countries, resulting from suboptimal immunisation. The most common serious complication of measles is pneumonia, which is more common in adult patients and can cause significant morbidity. It is the most common cause of death due to measles. What is new In this report, we present 11 adults with measles-associated pneumonia, who presented with the combination of acute measles virus infection, hypoxia and findings on chest X-ray. To our knowledge, this is the first report demonstrating an association between the severity of hypoxaemia and the presence of reticular opacities on chest imaging studies.

An evaluation of the clinical features of measles virus infection for diagnosis in children within a limited resources setting

BACKGROUND

Measles is a recurrent health problem in both advanced and developed countries. The World Health Organization (WHO) recommends anti-measles immunoglobulin M (Ig M) as the standard method of detecting the virus; however, many areas still present the inability to perform a serology test of anti-measles IgM. Therefore, a typical clinical feature is necessary to establish the diagnosis of measles. The objective of this study was to evaluate hyperpigmented rash and other clinical features as the diagnostic tools with respect to measles, especially in an outbreak setting.

METHODS

In this observational diagnostic study, the inclusion criteria were as follows: between 6 and 144 months of age, fever, maculopapular rash for 3 days or more, accompanied by a cough, or coryza, or conjunctivitis. Those with a prior history of measles vaccination (1-6 weeks) were excluded, in addition to those with histories of corticosteroid for 2 weeks or more and immunocompromised conditions. The samples were taken from Dr. Soetomo General Academic Hospital in Surabaya, Indonesia. We evaluated the sensitivity, specificity, the positive predictive value, and the negative predictive value of such clinical features. Hyperpigmented rash was validated using Kappa and Mc Nemar tests. Anti-measles Ig M was considered as the gold standard.

RESULTS

This study gathered 82 participants. The clinical manifestations of all subjects included fever, cough, coryza, conjunctivitis, Koplik spots, and maculopapular rash (which turns into hyperpigmented rash along the course of the illness). Most maculopapular rashes turn out to be hyperpigmented (89%). Sensitivity, specificity, positive predictive value, and negative predictive values ​​of the combination of fever, maculopapular rash, and hyperpigmented rash were found to be at 90.7, 28.6, 93.2, and 22.2%, respectively. The Mc Nemar and Kappa tests showed p values of 0.774 and 0.119, respectively.

CONCLUSION

The combination of fever, maculopapular rash, and hyperpigmented rash can be used as a screening tool regarding measles infection in an outbreak setting, which can then be confirmed by anti-measles Ig M. Cough, coryza, and Koplik's spot can be added to this combination, albeit with a slight reduction of sensitivity value.

Prevalence of Maternal Measles Antibody and Its Associated Factors among Infants in Coastal Karnataka, India

BACKGROUND

The current recommendation in India to commence first dose of measles immunization is at 9 months of age. The effectiveness of measles vaccination is greatly impacted by the level of maternal measles antibody (MMA) during infancy.

OBJECTIVES

To find the prevalence of MMA and to study the maternal and infant factors associated with persistence of MMA among the infants in a Indian rural community.

METHODOLOGY

Dried blood spot sample was collected before vaccination among infants aged 9 months and above when they came for first dose of measles vaccine to assess measles-specific maternal IgG antibody titers by enzyme immunoassay. Maternal and child factors influencing persistence of MMA were collected by interviewing the mothers. Association between various factors affecting seropositivity was tested using univariate logistic regression analysis and strength of association is reported as risk ratio with 95% confidence interval.

RESULTS

Based on the qualitative estimation among all the recruited children (250) in the study, 4 (1.6%) infants showed the presence of MMA whereas 25 (10%) of children had MMA on quantitative estimation. The effect of maternal factors, child nutrition, and sociodemographic factors on the presence of MMA was not found to be statistically significant.

CONCLUSION

The prevalence of persistent MMA (IgG titer ≥200 mIU/ml) among the infants aged 9-12 months was 10%. The choice of vaccinating infants at the end of 9 months for the first dose of measles vaccine is justified as the remaining (90%) of infants were susceptible for measles infection at this age.

Fatal rare case of measles complicated by bilateral pulmonary embolism: a case report and short literature review

Different endemic outbreaks of measles have been diagnosed worldwide during the last several years. Some have had severe and fatal complications, possibly because of decreasing vaccination rates. The present case report describes an unvaccinated boy aged 2 years 11 months who was diagnosed with severe measles complicated by pulmonary embolism (PE). Clinical examination revealed a maculopapular rash, hyperemic pharynx, Koplik’s spots, upper respiratory airway obstruction, and tachycardia with no meningeal signs of irritation. Laboratory investigations showed leukocytosis, anemia, normal liver enzyme levels, a moderately high C-reactive protein level (26 mg/L), a high erythrocyte sedimentation rate (65 mm/h), and immunoglobulin M positivity for measles. The patient was treated with antibiotic therapy (meropenem at 20 mg/kg every 8 hours) and supportive measures (anti-inflammatory drugs and intravenous rehydration). On the fourth day of hospitalization, the patient’s general condition became profoundly altered; although cardiorespiratory resuscitation maneuvers were initiated, the child died. Autopsy revealed bilateral pleural effusion with serous citrine fluid, acute purulent bronchopneumonia, bilateral hilar adenopathy, and bilateral PE. Additional research is needed to establish optimal care for pediatric patients with measles, especially when complicated by PE.

Identifying Children With Measles for Isolation in a High-volume Pediatric Emergency Department in Singapore

BACKGROUND

Viral exanthems in the pediatric age group are common. The worldwide increase in the incidence of highly infectious measles and other vaccine-preventable diseases and its impact in emergency departments (EDs) of a cosmopolitan city-state like Singapore are unknown. Our aims were to investigate and describe recent epidemiologic trends of proven measles infection seen in our ED and elucidate risk factors that can potentially impact our ED isolation practice.

METHODS

This is a retrospective observational cohort study on laboratory-confirmed measles infection in patients admitted through our pediatric ED from January 2010 to December 2016.

RESULTS

A total of 277 patients were hospitalized for measles infection during the study period. Of these, 177 patients (63.9%) were not isolated initially at the ED triage and 92 patients (33.2%) were not admitted to isolation wards on admission. Seventy-five patients (27.1%) with microbiologically proven measles had no rash at initial ED presentation. They presented earlier in their illness (3.1 days) compared with an average of 4.8 days for those who had a rash at presentation (P < 0.001). These patients without rash were younger, and most were admitted for poor feeding.

CONCLUSIONS

Our study found that most pediatric patients who required hospitalization presented with nonspecific symptoms at an early phase of illness, making it challenging to adequately isolate patients despite strict isolation policies. This calls for the importance of universal push for global vaccination to increase herd immunity to prevent measles infection.

Missed vaccinations and critical care admission: all you may wish to know or rediscover-a narrative review

Most vaccines are so effective that they could lead to the control/elimination of the diseases they target and directly impact on intensive care admissions or complications. This is best illustrated by the use of vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, zoster, yellow fever, Ebola virus, influenza or measles-but also by third party strategies such as maternal, toddler and care-giver immunization. However, each of these vaccine-induced protection is threatened by insufficient vaccine uptake. Here, we briefly discuss how vaccine hesitancy has led to the resurgence of diseases that were considered as controlled and explore the effect of vaccine-hesitant healthcare workers on nosocomial infections. As intensive care physicians are in charge of polymorbid patients, we briefly summarize the current recommendations for vaccinations in high-risk patients. We finally give some perspective on ongoing research, and discuss how institutional policies and intensive care physicians could play a role in increasing the impact of vaccination, overall and in intensive care units.

Combining serological and contact data to derive target immunity levels for achieving and maintaining measles elimination

BACKGROUND

Vaccination has reduced the global incidence of measles to the lowest rates in history. However, local interruption of measles virus transmission requires sustained high levels of population immunity that can be challenging to achieve and maintain. The herd immunity threshold for measles is typically stipulated at 90-95%. This figure does not easily translate into age-specific immunity levels required to interrupt transmission. Previous estimates of such levels were based on speculative contact patterns based on historical data from high-income countries. The aim of this study was to determine age-specific immunity levels that would ensure elimination of measles when taking into account empirically observed contact patterns.

METHODS

We combined estimated immunity levels from serological data in 17 countries with studies of age-specific mixing patterns to derive contact-adjusted immunity levels. We then compared these to case data from the 10 years following the seroprevalence studies to establish a contact-adjusted immunity threshold for elimination. We lastly combined a range of hypothetical immunity profiles with contact data from a wide range of socioeconomic and demographic settings to determine whether they would be sufficient for elimination.

RESULTS

We found that contact-adjusted immunity levels were able to predict whether countries would experience outbreaks in the decade following the serological studies in about 70% of countries. The corresponding threshold level of contact-adjusted immunity was found to be 93%, corresponding to an average basic reproduction number of approximately 14. Testing different scenarios of immunity with this threshold level using contact studies from around the world, we found that 95% immunity would have to be achieved by the age of five and maintained across older age groups to guarantee elimination. This reflects a greater level of immunity required in 5-9-year-olds than established previously.

CONCLUSIONS

The immunity levels we found necessary for measles elimination are higher than previous guidance. The importance of achieving high immunity levels in 5-9-year-olds presents both a challenge and an opportunity. While such high levels can be difficult to achieve, school entry provides an opportunity to ensure sufficient vaccination coverage. Combined with observations of contact patterns, further national and sub-national serological studies could serve to highlight key gaps in immunity that need to be filled in order to achieve national and regional measles elimination.

Measles outbreak in a tertiary level hospital, Porto, Portugal, 2018: challenges in the post-elimination era

A measles outbreak has been occurring in a healthcare setting in Porto, Portugal, since early March 2018, posing public health challenges for a central hospital and the community. Up to 22 April, 96 cases were confirmed, 67 in vaccinated healthcare workers, mostly between 18-39 years old. Following identification of the first cases, control measures were rapidly implemented. Concomitantly, other measles cases were notified in the Northern Region of the country. No common epidemiological link was identified.

Demographics, Complications and Resource Utilization for Patients Hospitalized for Measles Across Us Children's Hospitals

Our objective was to retrospectively describe measles hospitalizations in 52 US children's hospitals. We identified 136 patients hospitalized for measles in 2004-2018; 17% (23/136) had complex chronic conditions, 2 of whom died or were in hospice. Among noncomplex patients only 39% received vitamin A, median length of stay was 3 days and median adjusted estimated costs were $5896.

Molecular characterization and evolutionary dynamics of measles virus sequences isolated from children in Lagos and Ibadan, South Western, Nigeria

Measles infection is endemic in Nigeria, with outbreaks occurring yearly. Genotype B3 is the dominant genotype and the only genotype characterized from Nigeria. The current study investigated the phylogenetic and Bayesian evolutionary dynamics of Nigerian measles virus Nucleoprotein (N) sequences isolated from Lagos and Ibadan, Nigeria. A total of 120 throat swab samples were analysed by RT-PCR and Sanger sequencing. Phylogenetic analysis and Bayesian demographic reconstructions were done using MEGA and BEAST software. Measles RNA positivity was 14.2% (17/120), age range 0-1 recorded the highest rate with 40.83%. Study sequences clustered within clade B3.1. The evolutionary rate of analysed B3 sequences was 1.108×10^-3, higher posterior density HPD interval (1.462×10^-3 - 7.886×10^-4)subs/site/year. The time to most recent common ancestor (T_MRC), was 1991. The Bayesian skyride analysis(BSP) of West African MV cladeB3.1, showed a stable, steady state population demography. This study has reemphasised the dominance of clade B3.1 in Nigeria. We have shown that clade B3.1 was recently introduced into circulation and has a slow population expansion. We advocate for the institution of molecular surveillance country wide in order to help monitor strain diversity and genetic evolution of Measles in Nigeria.

Measles Vaccine Virus RNA in Children More Than 100 Days after Vaccination

Measles vaccines have been in use since the 1960s with excellent safety and effectiveness profiles. Limited data are available on detection of measles vaccine virus (MeVV) RNA in human subjects following vaccination. Available evidence suggests MeVV RNA can be identified up to 14 days after vaccination, with detection beyond this rare. In routine diagnostic testing, we used two real-time reverse transcription-polymerase chain reaction (RT-rPCR) assays targeting M and F genes to identify measles virus (MeV) and MeVV RNA. Confirmatory testing was performed with an N gene RT-rPCR, followed by sequence confirmation of RT-rPCR positives by semi-nested conventional RT-PCR assays targeting portions of the N, H, and L genes. We report detection and confirmation of MeVV RNA from the respiratory tract of 11 children between 100 and 800 days after most recent receipt of measles-containing vaccine. These novel findings emphasize the importance of genotyping all MeV detections and highlight the need for further work to assess whether persistent MeVV RNA represents viable virus and if transmission to close contacts can occur.

Spread of Measles in Europe and Implications for US Travelers

From January 2018 to June 2018, World Health Organization (WHO) European Region countries reported >41 000 measles cases, including 37 deaths, a record high since the 1990s. Low vaccination coverage in previous years is the biggest contributing factor to the increase in cases. The Ukraine reported the majority of cases, but France, Georgia, Greece, Italy, the Russian Federation, and Serbia also reported high case counts. Europe is the most common travel destination worldwide and is widely perceived as being without substantial infectious disease risks. For this reason, travelers may not consider the relevance of a pretravel health consultation, including vaccination, in their predeparture plans. Measles is highly contagious, and the record number of measles cases in the WHO European Region not only puts unvaccinated and inadequately vaccinated travelers at risk but also increases the risk for nontraveling US residents who come into close contact with returned travelers who are ill. The US Centers for Disease Control and Prevention encourage US travelers to be aware of measles virus transmission in Europe and receive all recommended vaccinations, including for measles, before traveling abroad. Health care providers must maintain a high degree of suspicion for measles among travelers returning from Europe or people with close contact with international travelers who present with a febrile rash illness. The current WHO European Region outbreak should serve to remind health care providers to stay current with the epidemiology of highly transmissible diseases, such as measles, through media, WHO, and Centers for Disease Control and Prevention reports and encourage measles vaccination for international travelers.

Observational study of a new strategy and management policy for measles prevention in medical personnel in a hospital setting

BACKGROUND

At the end of March 2018, a clustered outbreak of measles associated with health care workers occurred in northern Taiwan. Prior to this study, the policy for measles vaccination for physicians and nurses in MacKay Memorial Hospital, Taiwan was encouragement of vaccination in medical personnel working in the emergency room or other high risk divisions without prior testing for measles antibody, and vaccination coverage was only 85.3%. It was important to urgently formulate a new strategy to achieve zero tolerance for intra-hospital transmission and epidemic prevention. This study aimed to explore the effectiveness of a new strategy for the prevention of an outbreak of measles.

METHODS

This study was conducted from April 23, 2018 to May 22, 2018 in the MacKay Memorial Hospital, a medical center and tertiary teaching hospital with 2200 beds in northern Taiwan. First-line medical personnel in the hospital underwent a free screening for measles antibody as a new strategy for measles outbreak prevention. Susceptible medical personnel were advised to receive measles vaccination.

RESULTS

A total of 719 first-line medical personnel were enrolled for the general survey. Measles seropositivity was 76.1% (287/377) in the generation born after 1978 (vaccinated), and 96.5% (330/342) in the generation born before 1978 (p < 0.001), while the overall seropositivity was 85.8% (617/719). Vaccination coverage of susceptible personnel under the new strategy reached 86.3% in the first month (88/102) following the survey. At the end of the first month after implementation of the new strategy, 98.1% of the medical personnel were seropositive or revaccinated, and reached 99.4% at the end of the second month.

CONCLUSIONS

In this study, rapid, free antibody screening during a measles outbreak and subsequent vaccination of those susceptible resulted in most of the first-line medical personnel being seropositive or revaccinated. The new strategy was effective, time saving, used little manpower, and of low cost. Screening for measles antibody free of charge followed by vaccination of seronegative medical personnel can be regarded as an effective health management strategy to reduce and prevent the spread of measles infection.

Economic burden and associated factors of measles patients in Zhejiang Province, China

This study aimed to figure out the economic burden of measles patients and explore the associated factors for total cost in measles cases that occurred in the year 2015 from Jiaxing, Jinhua, and Taizhou cities in Zhejiang Province, China. Direct interviews were conducted to collect information on patient expenses during treatment, including outpatient expenses, hospitalization expenses, self-treatment fees, productivity loss, and transportation fees. Descriptive epidemiological methods and chi-square tests were used to assess the direct and indirect cost of measles patients. Ordinal logistic regression was applied to explore the possible factors contributing to cost. A total of 136 measles cases were investigated and the average direct cost, indirect cost, and total cost were #747.14, #520.12, and #1,267.26, respectively. Direct cost accounted for 58.96% of the total cost, which was significantly higher than the indirect cost (P < 0.001). In 2015, 1,386 confirmed cases were reported in the Zhejiang Province, and the overall direct, indirect, and total economic burden reached #1.04 million, #0.72 million, and #1.76 million, respectively. Quality-adjusted life years for measles patient were calculated to be 76.06 in Zhejiang, 2015. Hospitalization, occupation, complication, disease duration, age, and site had a significant influence on the total cost according to ordinal logistic regression, with the maximum contribution from hospitalization. Measles resulted in heavy economic burdens, and local public health departments or community health service centers should spare no effort to maintain a high rate of vaccination coverage and protect susceptible populations.

Knowledge and home treatment of measles infection by caregivers of children under five in a low-income urban community, Nigeria

Background

Despite the availability of a safe and effective vaccine for over 50 years, measles remains a leading cause of death among young children in developing countries.

Aim

This study assessed the knowledge and home treatment of measles by caregivers of children under 5 years.

Setting

Abebi community, Ibadan, Oyo State, Nigeria.

Methods

A descriptive cross-sectional study of 509 caregivers of children aged 6 months to 5 years in a semi-urban community in Ibadan was conducted using a multi-stage sampling method. An interviewer administered structured questionnaire was used to collect information on socio-demographic characteristics, knowledge of aetiology, main symptoms and signs, and home treatment of measles. Chi-square test and logistic regression were used to explore associations at 5% level of significance.

Results

Most of the caregivers were females (96.3%), married (86.1%) and were the biological parents of the children (90.9%). More than half had good knowledge of the cause (59.7%) and main symptoms and signs (52.8%) of measles. However, the composite knowledge was good in 57.6% of caregivers. Over half (54.4%) of the caregivers reported that their children ever had measles. Majority (91.3%) of caregivers whose children had measles gave home treatment, while 24 (8.7%) sought treatment from health facilities alone. There was a significant association between caregivers’ educational status, age, tribe and marital status and their knowledge of measles; however, tribe was the only significant predictor of knowledge after regression analysis. Caregivers from other tribes were 3.3 times more likely to have good knowledge of measles than Yoruba caregivers. Caregivers who were 35 years and older compared to those younger than 35 years (OR: 0.625; 95% CI: 0.425–0.921) and those who were not currently married compared to those married (OR: 0.455; 95% CI: 0.273–0.758) had lower odds of having good knowledge of measles, respectively.

Conclusion

Home treatment by caregivers of children with measles is high. Health education on the cause, prevention and treatment of measles should be provided for caregivers.

Evaluation of a phased pneumococcal conjugate vaccine introduction in Mongolia using enhanced pneumonia surveillance and community carriage surveys: a study protocol for a prospective observational study and lessons learned

Background

Streptococcus pneumoniae causes substantial morbidity and mortality among children. The introduction of pneumococcal conjugate vaccines (PCV) has the potential to dramatically reduce disease burden. As with any vaccine, it is important to evaluate PCV impact, to help guide decision-making and resource-allocation. Measuring PCV impact can be complex, particularly to measure impact on one of the most common and significant diseases caused by the pneumococcus, namely pneumonia. Here we outline the protocol developed to evaluate the impact of 13-valent PCV (PCV13) on childhood pneumonia in Mongolia, and a number of lessons learned in implementing the evaluation that may be helpful to other countries seeking to undertake pneumonia surveillance.

Methods

From 2016 PCV13 was introduced in a phased manner into the routine immunisation programme with some catch-up by the Government of Mongolia. We designed an evaluation to measure vaccine impact in children aged 2–59 months with hospitalised radiological pneumonia as a primary outcome, with secondary objectives to measure impact on clinically-defined pneumonia, nasopharyngeal carriage of S. pneumoniae among pneumonia patients and in the community, and severe respiratory infection associated with RSV and/or influenza. We enhanced an existing hospital-based pneumonia surveillance system by incorporating additional study components (nasopharyngeal swabbing using standard methods, C-reactive protein, risk factor assessment) and strengthening clinical practices, such as radiology as well as monitoring and training. We conducted cross-sectional community carriage surveys to provide data on impact on carriage among healthy children.

Discussion

Establishing a robust surveillance system is an important component of monitoring the impact of PCV within a country. The enhanced surveillance system in Mongolia will facilitate assessment of PCV13 impact on pneumonia, with radiological confirmed disease as the primary outcome. Key lessons arising from this evaluation have included the importance of establishing a core group of in-country staff to be responsible for surveillance activities and to work closely with this team; to be aware of external factors that could potentially influence disease burden estimates; to be flexible in data collection processes to respond to changing circumstances and lastly to ensure a consistent application of the pneumonia surveillance case definition throughout the study period.

Correlates of laboratory-confirmed measles in Japan, 2011-2015

BACKGROUND

With the progressive decline in the incidence of measles in Japan, its diagnosis has become challenging, with fewer physicians having experience in examining measles patients. We aimed to determine the correlates of laboratory-confirmed measles to help physicians improve their measles diagnosis.

METHODS

This study was conducted using the National Epidemiological Surveillance of Infectious Disease (NESID) system data during 2011-2015. Among clinically suspected measles patients reported to NESID, measles virus (MV)-positive patients were compared with MV-negative patients. The odds ratios (OR) and associated 95% confidence intervals (CI) were determined using logistic regression.

RESULTS

A total of 4168 laboratory-tested patients were notified to NESID. We analysed 618 MV-positive patients (median age, 17 years; interquartile range [IQR], 4-30 years) and 600 MV-negative (median age, 10 years; IQR, 1-29 years) patients after excluding those that met the exclusion criteria or were reported during the rubella epidemic period (the 18th epidemiological week of 2012 to the 46th week of 2013). Having an epidemiological link with a measles patient within 14 days of onset (OR, 14.9; 95% CI, 10.0-23.3), a history of recent international travel (OR, 11.7; 95% CI, 6.9-19.9), and unvaccinated/unknown vaccination status for measles-containing vaccine (MCV; OR, 3.7; 95% CI, 2.3-5.7) were significantly associated with MV-positive status. International travel (adjusted OR, 10.2; 95% CI, 5.9-17.7) and unvaccinated/unknown MCV vaccination status (adjusted OR, 5.8; 95% CI, 3.5-9.8) remained significantly associated with MV-positive status after adjusting for age, sex, and each other.

CONCLUSION

In low-incidence Japan, having an epidemiological link, international travel, and lack of MCV vaccination were correlates of laboratory-confirmed measles. The findings of this study could potentially improve the clinical diagnosis of measles, which can lead to more efficient testing and earlier laboratory confirmation.

Estimates of case-fatality ratios of measles in low-income and middle-income countries: a systematic review and modelling analysis

BACKGROUND

In the 21st century, increases in immunisation coverage and decreases in under-5 mortality have substantially reduced the global burden of measles mortality. However, the assessment of measles mortality burden is highly dependent on estimates of case-fatality ratios for measles, which can vary according to geography, health systems infrastructure, prevalence of underlying risk factors, and measles endemicity. With imprecise case-fatality ratios, there is continued uncertainty about the burden of measles mortality and the effect of measles vaccination. In this study, we aimed to update the estimations of case-fatality ratios for measles, to develop a prediction model to estimate case-fatality ratios across heterogeneous groupings, and to project future case-fatality ratios for measles up to 2030.

METHODS

We did a review of the literature to identify studies examining measles cases and deaths in low-income and middle-income countries in all age groups from 1980 to 2016. We extracted data on case-fatality ratios for measles overall and by age, where possible. We developed and examined several types of generalised linear models and determined the best-fit model according to the Akaike information criterion. We then selected a best-fit model to estimate measles case-fatality ratios from 1990 to 2015 and projected future case-fatality ratios for measles up to 2030.

FINDINGS

We selected 124 peer-reviewed journal articles published between Jan 1, 1980, and Dec 31, 2016, for inclusion in the final review-85 community-based studies and 39 hospital-based studies. We selected a log-linear prediction model, resulting in a mean case-fatality ratio of 2·2% (95% CI 0·7-4·5) in 1990-2015. In community-based settings, the mean case-fatality ratio was 1·5% (0·5-3·1) compared with 2·9% (0·9-6·0) in hospital-based settings. The mean projected case-fatality ratio in 2016-2030 was 1·3% (0·4-3·7).

INTERPRETATION

Case-fatality ratios for measles have seen substantial declines since the 1990s. Our study provides an updated estimation of case-fatality ratios that could help to refine assessment of the effect on mortality of measles control and elimination programmes.

FUNDING

Bill & Melinda Gates Foundation.

Epidemiological characteristics and trends of a Nationwide measles outbreak in Mongolia, 2015-2016

Background

Mongolia was one of the four countries that received a measles-elimination certificate from the World Health Organization Regional Office for the Western Pacific in 2014. Following the outbreaks in many countries including China, a large measles outbreak occurred in Mongolia in 2015. This study reports 2015–2016 measles outbreak incidence, mortality, and complications, according to time, geographical distribution, and host characteristics.

Methods

The epidemiological characteristics and trends of measles outbreak were analyzed using the Mongolian national surveillance data reported to the Center for Health Development, Ministry of Health, from January 2015 to December 2016.

Results

In total, 23,464 cases of measles including eight deaths were reported in 2015, and 30,273 cases of measles including 132 deaths were reported in 2016, which peaked in June 2015 and March 2016, respectively. Majority of the cases were reported from Ulaanbaatar (35,397, 65.9%). The highest attack rates were 241 per 10,000 population in Darkhan-Uul aimag, and 263 per 10,000 population in Ulaanbaatar. Measles-related death, nosocomial infection, and complications were most frequent among children aged < 1 year.

Conclusions

Following no reports of measles since 2011, a large nationwide outbreak occurred in Mongolia, despite the high vaccination coverage in the past. The highest incidence rate was reported in Ulaanbaatar city, and Umnugovi aimag in 2015 and Darkhan-Uul aimag in 2016. The most affected age group were aged < 1 year and those aged 15–24 years. Mortality cases were prominent among children aged < 1 year who were not eligible for vaccination. A systematic vaccination strategy is required to prevent another measles outbreak.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6511-0) contains supplementary material, which is available to authorized users.

Sero-Prevalence Surveillance to Predict Vaccine-Preventable Disease Outbreaks; A Lesson from the 2014 Measles Epidemic in Northern Vietnam

Background

During the first half of 2014, a severe outbreak of measles occurred in northern Vietnam, causing 15 033 confirmed cases and 146 deaths.

Methods

To evaluate the population-level seroprevalence of protection against measles in the period before the outbreak, we made use of an existing age-stratified serum bank, collected over the year before the outbreak, between November 2012 and December 2013, from 4 sites across the country (Hanoi, Hue, Dak Lak, and Ho Chi Minh City). Data from the UNICEF’s Multiple Indicator Clustered Surveys (MICS), carried out in Vietnam during the first quarter of 2014, were used to assess the vaccine coverage in 6 ecological regions of Vietnam.

Results

Results revealed a large discrepancy between levels of protection, as estimated from the serology and vaccine coverage estimated by UNICEF’s MICS. Variation in seroprevalence across locations and age groups corresponded with reported numbers of measles cases, most of which were among the 0–2-year-old age group and in the northern part of the country.

Conclusions

Our study presents a strong case in favor of a serosurveillance sentinel network that could be used to proactively tune vaccination policies and other public health interventions.

Burden of measles in Nigeria: a five-year review of casebased surveillance data, 2012-2016

INTRODUCTION

measles is a vaccine preventable, highly transmissible viral infection that affects mostly children under five years. We reviewed surveillance data on measles from Nigeria over a five-year period to highlights its burden and make recommendations for improvements.

METHODS

we conducted a secondary data analysis of measles specific Integrated Disease Surveillance and Response (IDSR) records of all states in Nigeria over a five-year period.

RESULTS

a total of 131,732 cases were recorded between January 2012 and September 2016. Most cases 57,892 (43.95%) were recorded in 2013 while the least 11,061 (8.4%) were recorded in 2012. A total of 817 deaths were recorded, with a case fatality rate (CFR) of 0.62%. The highest CFR (1.43%) was recorded in 2012 while the least CFR (0.44%) was recorded in 2016. Only 8,916 (6.7%) cases were confirmed by laboratory tests. The trend of measles cases followed the same pattern throughout the years under review, with cases peaking at March, then gradually reducing to lowest level at June, which was maintained throughout the rest of the year. States in northern region of Nigeria recorded the highest attack rate (Yobe: 480.29 cases per 100,000 population, Sokoto: 284.63 cases per 100,000 population and Katsina: 246.07 cases per 100,000 population) compared to States in the southern region (Rivers: 11.72 cases per 100,000 population and Akwa Ibom: 13.59 cases per 100,000 population). Conversely, States in the southern region recorded the highest CFR (Ebonyi: 13.43% and Rivers: 3.27%).

CONCLUSION

measles infection remains a burden especially in the northern region of Nigeria. Although measles fatalities declined over the years, laboratory confirmation was sub-optimal. We recommended improvement on routine immunization and strengthening of regional laboratories diagnostic capacities, for successful eradication of measles from Nigeria.

Combating Vaccine Hesitancy: Teaching the Next Generation to Navigate Through the Post Truth Era

Despite scientific evidence supporting the fact that vaccines are fundamental tools for preventing infectious diseases, a percentage of the population still refuses some or all of them. Vaccine hesitancy has become a widespread issue, and its complexity lies in the great variety of factors that can influence decisions about immunization, which are not just vaccine-related concerns, but also involve personal and societal levels. Our research group performed an extensive literature review to analyze: (1) different age groups, their relation to the problem and their characteristics; (2) the most important information (key messages) about immunization that could be used to counteract hesitancy; and (3) best approaches to transmit the messages to the target groups. We propose a long-term approach to overcome vaccine hesitancy that involves the education of children and adolescents on the basics about immunization and critical thinking, using different communication channels.

Vaccines in pediatric transplant recipients-Past, present, and future

Infections significantly impact outcomes for solid organ and hematopoietic stem cell transplantation in children. Vaccine-preventable diseases contribute to morbidity and mortality in both early and late posttransplant time periods. Several infectious diseases and transplantation societies have published recommendations and guidelines that address immunization in adult and pediatric transplant recipients. In many cases, pediatric-specific studies are limited in size or quality, leading to recommendations being based on adult data or mixed adult-pediatric studies. We therefore review the current state of evidence for selected immunizations in pediatric transplant recipients and highlight areas for future investigation. Specific attention is given to studies that enrolled only children.