The economic cost of measles: Healthcare, public health and societal costs of the 2012-13 outbreak in Merseyside, UK

Measles resurgence in Armenia: unmasking health system vulnerabilities and crafting comprehensive eradication strategies - a review

Measles is an acute febrile illness associated with rashes, fever and life-threatening complications. It is a vaccine-preventable disease with the Measles Mumps Rubella(MMR) vaccine but a recent global trend unveils a resurgence of measles in various parts of the world including Armenia. Measles was declared eliminated from Armenia in 2021 before reports of local outbreaks surfaced in 2023. The WHO identified discrepancies in the vaccination coverage during COVID-19. Measles also poses a great financial burden as a public health issue worldwide. Sociocultural factors impacting measles transmission are maternal education, healthcare access, migration, vaccine hesitancy, and socioeconomic status (Table 3). Efforts to control and eradicate measles from Armenia are run by a collaborative approach of national and international health bodies such as United Nations Children's Fund (UNICEF), WHO, Global Vaccine Alliance (GAVI), and the Ministry of Health. Thus, the resurgence of measles can be managed through widespread patient education, innovative approaches, strengthening the healthcare system and addressing vaccine hesitancy, sociocultural barriers, and humanitarian emergencies. This review investigates the complicated dynamics of measles inside Armenia's health system in depth. A thorough examination of measles incidence and immunization patterns highlights the shift from few cases and high vaccination rates to a comeback caused by imported viruses. The causes of its recurrence have been thoroughly investigated, including reduced immunization programs and vaccine hesitancy. The research delves further into the 'One Health' idea, assessing the possibility of interspecies transmission among nonhuman primates and examining the environmental factors that influence measles transmission. Among the challenges are weaknesses within Armenia's health system as well as the possibility of interruptions from the COVID-19 outbreak. In measles vaccination status, the combination of maternal education, postnatal care, and socioeconomic variables exposes the larger drivers at work. The study concludes with a comprehensive set of public health policy recommendations covering vaccination promotion, surveillance, healthcare provider education, public awareness, international collaboration, data analysis, law enforcement, emergency preparedness, research, and coordination. The research sheds light on the tangled web of measles dynamics, health system resilience, and contextual subtleties via this multifaceted approach, inviting readers to investigate the multiple strategies required for eliminating measles in Armenia.

The methodological quality of economic evaluations of measles outbreaks: A systematic review of cost-of-illness studies

OBJECTIVES

To identify the main cost components included in the economic evaluations of measles outbreaks, their items and cost drivers, and evaluate the quality of costing methodology, analyzing the key features that may affect the validity of these studies in countries with different income levels.

METHODS

We systematically searched multiple databases EMBASE, MEDLINE (via PubMed), Biblioteca Virtual em Saúde do Ministério da Saúde (BVS MS), NHS Economic Evaluation Database (NHS EED) and NHS Health Technology Assessment (NHS HTA) (via The Centre for Reviews and Dissemination Library - CRD), and EconLit, SCOPUS, and Web of Science, selecting cost analysis and cost of illness studies (COI) of measles outbreaks. Two independent reviewers screened articles for relevance and extracted the data. The quality of costing methods was assessed using a guide to critical evaluation of COI studies. We performed a qualitative narrative synthesis.

RESULTS

Twenty-two studies were reviewed. Most studies evaluated outbreaks that occurred from 2011 to 2013 and 2017 to 2019. Total costs varied from $40,147 to $39.3 million. Per case cost varied from $168 to $49,439. The main drivers of measles outbreak costs were outbreak response, personnel, and productivity losses. Most studies (20/22) did not report the costing methodology adopted, the degree of disaggregation used in the identification and measurement of resource and costs components and the method for the valuation of resource and cost components.

CONCLUSIONS

The quality of the costing methodology, its transparency and accuracy are essential to the validity of these studies results and their potential use to allocate public health resources in the most efficient manner and to inform measles outbreak control strategies, with rapid and effective response.

Mitigating Vaccine Hesitancy and Building Trust to Prevent Future Measles Outbreaks in England

Measles, a highly infectious respiratory viral infection associated with severe morbidity and mortality, is preventable when coverage with the highly effective measles, mumps and rubella vaccine (MMR) is ≥95%. Vaccine hesitancy is responsible for measles outbreaks in countries where measles had previously been eliminated, including in England, and is one of the ten threats to global public health identified by the World Health Organization (WHO). Official administrative 2012-2021 data on measles incidence and MMR coverage in England were reviewed alongside a scoping literature review on factors associated with MMR uptake in England. Whilst measles incidence has reduced significantly since 2012, sporadic measles outbreaks in England have occurred with geographic disparities and variations in MMR coverage. Over the last decade, MMR uptake has fallen across all regions with no area currently reaching the WHO target of 95% coverage of both doses of MMR necessary for herd immunity. Factors associated with MMR coverage overlap with the 3C (convenience, complacency and confidence) model of vaccine hesitancy. The COVID-19 pandemic has reinforced pre-existing vaccine hesitancy. Increasing MMR uptake by reducing vaccine hesitancy requires allocated funding for area-based and targeted domiciliary and community-specific immunisation services and interventions, public health catch-up campaigns and web-based decision aid tools.

Second-dose measles vaccination and associated factors among under-five children in urban areas of North Shoa Zone, Central Ethiopia, 2022

Introduction

Measles remain a leading cause of vaccine-preventable infant mortality. In Africa, about 13 million cases and 6,50,000 deaths occur annually, with Sub-Saharan Africa having the highest morbidity and mortality. Ethiopia launched second-dose measles vaccination into the routine immunization program in the second year of life in 2019. However, little has been known about the coverage of the second-dose measles vaccine. Therefore, the purpose of this study was to assess the level of second-dose measles vaccine uptake and associated factors in North Shoa Zone, Central Ethiopia.

Objective

To assess second-dose measles vaccination and associated factors among under-five children and to identify reasons for not being vaccinated in urban areas of North Shoa Zone, Central Ethiopia, 2022.

Method

A community-based cross-sectional study was conducted from 1 February to 15 March 2022. The sample size was 410, and it was allocated proportionally to each kebelle. The study units were selected consecutively. The data were collected using structured interviewer-administered questionnaires. Four nurses were used as data collectors. Data were coded manually and entered into Epi-data Version 4.4.2.1. Frequency and cross-tabs were used for data cleaning. Data were analyzed using SPSS Version 21 software. Multicollinearity and model goodness-of-fit tests were checked. A multivariable logistic regression model at 95% CI was used to identify factors associated with the dependent variable.

Result

The response rate was 90.7%. The level of second-dose measles vaccination among children in urban areas of North Shoa Zone was 42.5% [95% CI (36.8, 47.3)]. Maternal age of ≤ 25 years [AOR = 9.12: 95% CI (1.97, 42.19)], 26-30 years [AOR = 9.49: 95% CI (2.33, 38.63)], 31-35 years [AOR = 7.87: 95% CI (1.78, 34.79)]; average time mothers had been waiting for vaccination at the health facility [AOR = 3.68: 95% CI (1.33, 10.23)]; awareness about vaccine-preventable diseases [AOR = 4.15: 95% CI (1.53, 11.26)]; and awareness on recommended measles doses [AOR = 17.81: 95% CI (3.91, 81.22)] were identified as factors associated with MCV2 vaccination. The major reason (48.1%) reported by mothers for not vaccinating second-dose measles vaccine was being unaware of the need to return for second-dose measles vaccination.

Conclusion and recommendation

The level of second-dose measles vaccination (MCV2) among children in urban areas of the North Shoa Zone was low. Maternal age, average time mothers had been waiting for vaccination at the health facility, awareness about vaccine-preventable diseases, recommended age for the last vaccination, and recommended measles doses were identified as factors associated with MCV2 uptake. The major reason for not vaccinating MCV2 was a lack of information (unaware of the need to return for MCV2, unaware of the need to return for MCV2, and the place and/or time of immunization unknown). Hence, enhancing awareness about vaccine-preventable diseases, shortening the average time for vaccination at the health facility by half an hour, creating an alerting mechanism for MCV2 appointments, and future studies on the effect of healthcare provider-related factors on MCV2 uptake are recommended.

A systematic literature review to clarify the concept of vaccine hesitancy

Vaccine hesitancy (VH) is considered a top-10 global health threat. The concept of VH has been described and applied inconsistently. This systematic review aims to clarify VH by analysing how it is operationalized. We searched PubMed, Embase and PsycINFO databases on 14 January 2022. We selected 422 studies containing operationalizations of VH for inclusion. One limitation is that studies of lower quality were not excluded. Our qualitative analysis reveals that VH is conceptualized as involving (1) cognitions or affect, (2) behaviour and (3) decision making. A wide variety of methods have been used to measure VH. Our findings indicate the varied and confusing use of the term VH, leading to an impracticable concept. We propose that VH should be defined as a state of indecisiveness regarding a vaccination decision.

Measles outbreak investigation process in low- and middle-income countries: a systematic review of the methods and costs of contact tracing

Aim

The occurrence of measles outbreaks has increased, and previously measles-free countries are experiencing a resurgence, making measles elimination by 2020 unlikely. Therefore, outbreak prevention and rapid response strategies will need to be intensified. This systematic review therefore examines whether contact tracing (CT) as compared to no CT is an effective means of reducing measles spread during outbreaks in low- and middle-income countries (LMICs).

Subject and methods

A systematic review was conducted by searching six databases (CINAHL, Global Health, Medline, Cochrane Library, Web of Science and PubMed). The 17 included articles were appraised using the Critical Appraisal Skills Programme checklists and analysed using a narrative synthesis.

Results

CT is often used alongside mass communication strategies and hospital record checks. Interviewing measles cases to identify contacts, and considering everyone who has shared a space with a case as a contact are common CT methods. Also, CT can be done backwards and/or forwards with the measles case as the focal point of the investigation process. The cost per case of an outbreak response dominated by CT is high especially in terms of labour for the health sector and productivity losses for households. However, overall outbreak expenditure can be low if CT results in fewer and less severe measles cases and a short outbreak duration.

Conclusion

CT data as a standalone and comparative active surveillance approach in LMICs is scarce. If CT is initiated early, it can prevent large outbreaks, thereby reducing the economic burden of measles and drive LMICs towards measles elimination.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-021-01590-2.

Economic and Behavioral Influencers of Vaccination and Antimicrobial Use

Despite vast improvements in global vaccination coverage during the last decade, there is a growing trend in vaccine hesitancy and/or refusal globally. This has implications for the acceptance and coverage of a potential vaccine against COVID-19. In the United States, the number of children exempt from vaccination for “philosophical belief-based” non-medical reasons increased in 12 of the 18 states that allowed this policy from 2009 to 2017 (1). Meanwhile, the overuse and misuse of antibiotics, especially in young children, have led to increasing rates of drug resistance that threaten our ability to treat infectious diseases. Vaccine hesitancy and antibiotic overuse exist side-by-side in the same population of young children, and it is unclear why one modality (antibiotics) is universally seen as safe and effective, while the other (vaccines) is seen as potentially hazardous by some. In this review, we consider the drivers shaping the use of vaccines and antibiotics in the context of three factors: individual incentives, risk perceptions, and social norms and group dynamics. We illustrate how these factors contribute to the societal and individual costs of vaccine underuse and antimicrobial overuse. Ultimately, we seek to understand these factors that are at the nexus of infectious disease epidemiology and social science to inform policy-making.

Health and economic costs of an import-initiated measles outbreak in an international border area of Yunnan Province

BACKGROUND

Measles outbreaks often require labor- and resource-intense response. A border-area measles outbreak occurred in Yunnan province that required outbreak response immunization for its containment. We report results of our investigation into the outbreak and the health sector costs of the response activities, with the goal of providing evidence for policy makers when considering the full value of vaccines and of measles elimination.

METHODS

We conducted case investigations to determine sources of infection and routes of transmission. Costs of outbreak response activities incurred by health sector were determined through retrospective interviews and record reviews of staff.

RESULTS

In total, 67 measles cases were confirmed, including 4 cases imported from Myanmar. Among the 33 cases aged between 8 months and 14 y old, 22 (66∙7%) had received 2 doses of MCV; 2 (6∙0%) had received 1 dose of MCV; 9 (27∙3%) had not received MCV. The first 4 cases had been infected in Myanmar, and we identified 8 transmission clusters with a total of 62 cases. Transmission among Yunnan province residents occurred in schools, family settings, and at gatherings. The overall cost to control the outbreak was $214,774, for a per-case cost of $3,206. The outbreak response vaccination campaign accounted for 64% of the total outbreak costs.

CONCLUSIONS

Despite high population immunity among Yunnan province children and adolescents, an import-related measles outbreak occurred among individuals who were not vaccinated or had vaccine failure in the across-border area. The economic cost of the outbreak was substantial. Investment in a sensitive measles surveillance system to detect outbreaks in a timely manner, maintaining high population immunity to measles, and reinforcing cross-border collaboration with neighboring countries support achieving and sustaining measles elimination in the border areas of China.

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 descriptive analysis of an outbreak of measles and a multilevel mixed-effects analysis of factors associated with case isolation in healthcare settings, London (February-June 2016)

OBJECTIVES

We described the epidemiology and healthcare exposures during a measles outbreak in London and identified factors associated with isolation on arrival to healthcare premises.

STUDY DESIGN

We conducted a cohort study including all confirmed measles cases in London residents from February 1, 2016, to June 30, 2016, and semistructured interviews with two infection prevention and control teams (IPCTs).

METHODS

We described the outbreak and conducted a multilevel mixed-effects analysis to assess the relationship between sociodemographic and clinical factors and isolation on arrival to healthcare premises. We summarised the interviews.

RESULTS

There were 182 cases, mostly aged 17-35 years (46%; 84). Excluding cases younger than one year, 76% (92/120) were unvaccinated, including two healthcare workers. The majority presented with rash (97%; 174), and 42% (70/166) required hospitalisation. Of the recorded cases, 93% of cases (164/178) had visited a healthcare setting during their infectious period (median number of visits = 2). In 33% (59/178) of the visits, the case was isolated on arrival; when not isolated, four healthcare exposures resulted in further transmission. Presenting to the hospital as opposed to a general practitioner (GP) was associated with higher odds of isolation (odds ratio = 2.23, 95% confidence interval = 1.1-4.4) when adjusted for age, gender and presenting with a cough. The IPCT identified measles training using standardised risk assessments by triage nurses in accident and emergency and intelligence regarding measles activity in the community as positive measures to prevent healthcare exposures.

CONCLUSIONS

We recommend opportunistic immunisation of unvaccinated young adults by GPs and that occupational health departments ensure their staff are protected against measles. Raising measles awareness in healthcare settings via training or regular sharing of current measles surveillance activity from public health to the IPCT and GP may improve triage and isolation of cases on arrival to healthcare premises.

Responding to measles outbreaks in underserved Roma and Romanian populations in England: the critical role of community understanding and engagement

Since 2016, the European Region has experienced large-scale measles outbreaks. Several measles outbreaks in England during 2017/18 specifically affected Romanian and Romanian Roma communities. In this qualitative interview study, we looked at the effectiveness of outbreak responses and efforts to promote vaccination uptake amongst these underserved communities in three English cities: Birmingham, Leeds and Liverpool. Semi-structured in-depth interviews were conducted with 33 providers involved in vaccination delivery and outbreak management in these cities. Interviews were analysed thematically and factors that influenced the effectiveness of responses were categorised into five themes: (1) the ability to identify the communities, (2) provider knowledge and understanding of the communities, (3) the co-ordination of response efforts and partnership working, (4) links to communities and approaches to community engagement and (5) resource constraints. We found that effective partnership working and community engagement were key to the prevention and management of vaccine-preventable disease outbreaks in the communities. Effective engagement was found to be compromised by cuts to public health spending and services for underserved communities. To increase uptake in under-vaccinated communities, local knowledge and engagement are vital to build trust and relationships. Local partners must work proactively to identify, understand and build connections with communities.

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.

Preparedness Through Urban Resilience

This book explores the topic of resilience at the city level. The focus is more on outbreak events at the city level, or how cities should prepare and react in facing the larger events of epidemic and pandemic.

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.

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.

Detection of modified measles and super-spreader using a real-time reverse transcription PCR in the largest measles outbreak, Yamagata, Japan, 2017 in its elimination era

We aimed to verify the effectiveness of real-time reverse transcription (rRT) polymerase chain reaction (PCR) for detecting cases of modified measles (M-Me) and for predicting super-spreader candidates through the experience of a measles outbreak dominated by M-Me in Yamagata, Japan, during March-April 2017. We applied rRT-PCR to specimens from 35 cases of M-Me, nine cases of typical measles (T-Me) and nine cases of prodromal stage of T-Me (P-Me). From rRT-PCR among the M-Me cases, peripheral blood mononuclear cells (PBMC) showed the highest positive rate (80.0%), followed by throat swab (48.6%), urine (33.3%) and serum (3.1%). The negative result of PBMC in M-Me cases was recovered by the result of a throat swab. In specimens of PBMC, throat swab and urine, M-Me group showed the significantly higher cycle of threshold (i.e., lower viral load) in the rRT-PCR than T-Me and P-Me groups, respectively. Furthermore, three super-spreaders in T-Me or P-Me showed an extremely low cycle of threshold in their throat swab specimens. rRT-PCR using PBMC and throat swab might be helpful for clinical management and measles control by certain detection of M-Me cases and by predicting super-spreading events resulting from measles cases with the high viral load.

Cost-benefit analyses of supplementary measles immunisation in the highly immunized population of New Zealand

As endemic measles is eliminated from countries through increased immunisation, the economic benefits of enhanced immunisation programs may come into question. New Zealand has suffered from outbreaks after measles introductions from abroad and we use it as a model system to understand the benefits of catch up immunisation in highly immunised populations. We provide cost-benefit analyses for measles supplementary immunisation in New Zealand. We model outbreaks based on estimates of the basic reproduction number in the vaccinated population (R_v, the number of secondary infections in a partially immunised population), based on the number of immunologically-naïve people at district and national levels, considering both pre- and post-catch up vaccination scenarios. Our analyses suggest that measles R_v often includes or exceeds one (0.18-3.92) despite high levels of population immunity. We calculate the cost of the first 187 confirmed and probable measles cases in 2014 to be over NZ$1 million (∼US$864,200) due to earnings lost, case management and hospitalization costs. The benefit-cost ratio analyses suggest additional vaccination beyond routine childhood immunisation is economically efficient. Supplemental vaccination-related costs are required to exceed approximately US$66 to US$1877 per person, depending on different scenarios, before supplemental vaccination is economically inefficient. Thus, our analysis suggests additional immunisation beyond childhood programs to target naïve individuals is economically beneficial even when childhood immunisation rates are high.

Measles outbreaks in the UK, is it when and where, rather than if? A database cohort study of childhood population susceptibility in Liverpool, UK

OBJECTIVES

There was a large outbreak of measles in Liverpool, UK, in 2012-2013, despite measles, mumps and rubella (MMR) immunisation uptake rates that were higher than the national average. We estimated measles susceptibility of a cohort of children born in Liverpool between 1995 and 2012 to understand whether there was a change in susceptibility before and after the outbreak and to inform vaccination strategy.

DESIGN

Retrospective cohort study.

SETTING

The city of Liverpool, North West UK.

PARTICIPANTS

All children born in Liverpool (72 101) between 1995 and 2012 inclusive who were identified using the Child Health Information System (CHIS) and were still resident within Liverpool in 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated cohort age-disaggregated and neighbourhood-disaggregated measles susceptibility according to WHO thresholds before and after the outbreak for children aged 1-17 years.

RESULTS

Susceptibility to measles was above WHO elimination thresholds before and after the measles outbreak in the 10+ age group. The proportion of children susceptible before and after outbreak, respectively: age 1-4 years 15.0% before and 14.9% after; age 5-9 years 9.9% before and 7.7% after; age 10+ years 8.6% before and 8.5% after. Despite an intensive MMR immunisation catch-up campaign after the 2012-2013 measles outbreak, the overall proportion of children with no MMR remains high at 6.1% (4390/72 351). Across all age groups and before and after the outbreak, measles susceptibility was clustered by neighbourhood, with deprived areas having the greatest proportion of susceptible children.

CONCLUSIONS

The risk of sustained measles outbreaks remains, especially as large pools of susceptible older children will start leaving secondary education and continue to aggregate in higher education, employment and other community settings and institutions resulting in the potential for a propagated measles outbreak.

An expensive adult measles outbreak and response in office buildings during the era of accelerated measles elimination, Beijing, China

BACKGROUND

Few measles outbreaks among adults are reported in China, and outbreak response costs are seldom documented. We report an adult measles outbreak and response in 4 linked office buildings in Beijing and its associated costs.

METHOD

The World Health Organization measles case definitions were used to determine suspected and confirmed measles cases. Surveillance data were used to describe the outbreak, and records and interviews of response staff were used to describe the response. Costs were determined by use of retrospective surveys of cases, review of records, and interviews of staff.

RESULTS

The outbreak lasted 19days, and involved 22 cases aged 23-49years. Nineteen cases had a local household registration. All cases were employed by 8 companies in 4 linked office buildings. Among the 22 cases, 8 had temperature less than 38.5 degree, 18 had no Koplik spots and none had complications or hospitalizations. A total of 7930 contacts were identified, and of these, 6869 were employees in the office buildings. All the child contacts aged 8months-14years had been up-to-date for measles-containing vaccine (MCV); no adult could document their vaccination or measles history. Of contacts, about 96% were offered post-exposure vaccination. The total household costs were $13,298, or $605 per case. Control costs were $384,594, or $17,481 per case. Involved companies paid for 90.7% of control costs.

CONCLUSION

Office buildings provide a mechanism for measles transmission. Timely control activities were challenged by the highly infectious nature of measles and mild presentations of cases. The outbreak response was very costly. Financial support by involved companies can provide needed resources for outbreak management.