Measles in the 21st Century, a Continuing Preventable Risk to Travelers: Data From the GeoSentinel Global Network

Epidemiological features and risk factors for measles and rubella in Taiwan during 2011 to 2020

The risk of geographic transmission of infectious diseases due to air travel varies greatly. Our aim is to survey empirical data that provide a retrospective historical perspective on measles and rubella. This study used the open data website provided by the Taiwan Centers for Disease Control (TCDC) to extract the reported numbers of measles and rubella case between 2011 and 2020. There were 306 cases of measles and 135 cases of rubella. The incidence of measles and rubella per million population were 0 to 6.0 and 0 to 2.6, respectively. There was a gradual increase in the numbers of cases in those aged 20-39 years, and distinct duration patterns. It indicated that the risk of contracting rubella has significantly decreased in the last 5 years. Measles cases aged 20 to 39 years accounted for 72.5% of all cases. Rubella cases aged 20 to 39 years accounted for 59.3% of all cases. The male and residency in the Taipei metropolitan area or northern area were identified as potential risk factors for measles and rubella. Coverage with the first dose of the measles, mumps and rubella (MMR) vaccine in Taiwan increased from 97.31% to 98.86%, and the uptake rate of the second dose of the MMR vaccine increased from 95.73% to 98.39% between 2010 and 2020. Furthermore, the numbers of imported cases of measles (n = 0) and rubella (n = 0) reported during the coronavirus disease 2019 (COVID-19) pandemic were lower than those from 2011 to 2019. Measles and rubella cases were imported most frequently from Cambodia and Vietnam. This study represents the first report of confirmed cases of acquired measles and rubella from surveillance data of the TCDC between 2011 and 2020, also demonstrates that the numbers of cases of measles and rubella significantly decreased in Taiwan during the COVID-19 pandemic.

Safety of measles, rubella and mumps vaccines in adults: a prospective cohort study

BACKGROUND

In recent years, multiple outbreaks of measles associated with vaccine hesitancy occurred in high-income countries, where measles incidence had previously been low. Most safety data about the measles, mumps and rubella (MMR) vaccine are derived from studies conducted among children, whereas evidence regarding the safety profile of the vaccine in adults is scarce.

METHODS

In 2017, during an outbreak of measles in Europe, Israeli travellers to high-risk locations who were incompletely vaccinated, were urged to complete the two MMR vaccination schedule before their travel. In this prospective cohort study, we analysed adverse events (AEs) of MMR and MMRV (measles, mumps, rubella and varicella) vaccines among these travellers. All participants were followed up using structured questionnaires 2-4 weeks after vaccination.

RESULTS

Seven hundred and eighty-five adult travellers whose median age was 49.2 years were vaccinated and followed up. Any AEs were reported by 25.2% of all participants; 11.6% reported local AEs, and 18.6% reported systemic AEs, none of which were severe. In general, AEs were much more common among female travellers (19.4% of males vs 30.1% of females (P < 0.001)). Local AEs, overall systemic AEs, headache and arthralgia were much more common among females, whereas rates of general malaise and fever were not statistically different between genders. We did not observe any significant differences in the rates of total, local or systemic AEs between the MMR and MMRV vaccines. Higher rates of systemic AEs were observed among participants who were younger and probably immunized once with MMR compared to older vaccines immunized once to measles only and to those who were never immunized.

CONCLUSIONS

The current study demonstrated low rates of systemic AEs and no serious AEs following either MMR or MMRV administration. More AEs were reported among females, and rates of AEs were similar after either MMR or MMRV.

Catch-up immunization for adolescents and young adults during pre-travel consultation in Japan

Rubella and measles outbreaks in adults occur because of unimmunized or partially immunized status. Travel clinics play an important role in catch-up measles, rubella, mumps, and varicella immunization for adults. We evaluated the need for catch-up measles, rubella, mumps, and varicella immunization by young adults at our travel clinic. This retrospective observational study was conducted at the National Center for Global Health and Medicine from June 1, 2017 to May 31, 2018. Adults aged 16-49 years who received pre-travel consultation and had childhood immunization records were included. Individuals who fully or partially received planned measles, rubella, mumps, and varicella catch-up immunization were classified as "immunized." We calculated the proportion of "immunized" individuals and analyzed the factors associated with catch-up measles, rubella, mumps, and varicella immunization at pre-travel consultation using logistic regression analysis. Overall, 3,456 individuals received pre-travel consultations during the study period; 827 (336 men, median age 22 years) had childhood immunization records. The most common trip purposes were study (33%) and tourism (24%). The most common destination was Asia (39%). Catch-up immunization of any measles, rubella, mumps, and varicella vaccine was needed by 755 individuals. After consultation, 20-46% of these participants who needed catchup immunization received at least one dose of immunization. Factors that are negatively associated with measles, rubella, mumps, and varicella catch-up immunization were tourism (odds ratio 0.37 to 0.58), yellow fever vaccination (0.45 to 0.50) (excluding varicella), and each disease history (0.13 to 0.40) (excluding rubella and varicella). Further studies are needed to identify barriers to catch-up immunization.

Travel-related infections presenting in Europe: A 20-year analysis of EuroTravNet surveillance data

Background

Disease epidemiology of (re-)emerging infectious diseases is changing rapidly, rendering surveillance of travel-associated illness important.

Methods

We evaluated travel-related illness encountered at EuroTravNet clinics, the European surveillance sub-network of GeoSentinel, between March 1, 1998 and March 31, 2018.

Findings

103,739 ill travellers were evaluated, including 11,239 (10.8%) migrants, 89,620 (86.4%) patients seen post-travel, and 2,880 (2.8%) during and after travel. Despite increasing numbers of patient encounters over 20 years, the regions of exposure by year of clinic visits have remained stable. In 5-year increments, greater proportions of patients were migrants or visiting friends and relatives (VFR); business travel-associated illness remained stable; tourism-related illness decreased. Falciparum malaria was amongst the most-frequently diagnosed illnesses with 5,254 cases (5.1% of all patients) and the most-frequent cause of death (risk ratio versus all other illnesses 2.5:1). Animal exposures requiring rabies post-exposure prophylaxis increased from 0.7% (1998–2002) to 3.6% (2013–2018). The proportion of patients with seasonal influenza increased from zero in 1998–2002 to 0.9% in 2013–2018. There were 44 cases of viral haemorrhagic fever, most during the past five years. Arboviral infection numbers increased significantly as did the range of presenting arboviral diseases, dengue and chikungunya diagnoses increased by 2.6% and 1%, respectively.

Interpretation

Travel medicine must adapt to serve the changing profile of travellers, with an increase in migrants and persons visiting relatives and friends and the strong emergence of vector-borne diseases, with potential for further local transmission in Europe.

Funding

This project was supported by a cooperative agreement (U50CK00189) between the Centers for Disease Control and Prevention to the International Society of Travel Medicine (ISTM) and funding from the ISTM and the Public Health Agency of Canada.

GeoSentinel: past, present and future†

RATIONALE FOR REVIEW

In response to increased concerns about emerging infectious diseases, GeoSentinel, the Global Surveillance Network of the International Society of Travel Medicine in partnership with the US Centers for Disease Control and Prevention (CDC), was established in 1995 in order to serve as a global provider-based emerging infections sentinel network, conduct surveillance for travel-related infections and communicate and assist global public health responses. This review summarizes the history, past achievements and future directions of the GeoSentinel Network.

KEY FINDINGS

Funded by the US CDC in 1996, GeoSentinel has grown from a group of eight US-based travel and tropical medicine centers to a global network, which currently consists of 68 sites in 28 countries. GeoSentinel has provided important contributions that have enhanced the ability to use destination-specific differences to guide diagnosis and treatment of returning travelers, migrants and refugees. During the last two decades, GeoSentinel has identified a number of sentinel infectious disease events including previously unrecognized outbreaks and occurrence of diseases in locations thought not to harbor certain infectious agents. GeoSentinel has also provided useful insight into illnesses affecting different traveling populations such as migrants, business travelers and students, while characterizing in greater detail the epidemiology of infectious diseases such as typhoid fever, leishmaniasis and Zika virus disease.

CONCLUSIONS

Surveillance of travel- and migration-related infectious diseases has been the main focus of GeoSentinel for the last 25 years. However, GeoSentinel is now evolving into a network that will conduct both research and surveillance. The large number of participating sites and excellent geographic coverage for identification of both common and illnesses in individuals who have traversed international borders uniquely position GeoSentinel to make important contributions of travel-related infectious diseases in the years to come.

Nonrenewable energy-environmental and health effects on human capital: empirical evidence from Pakistan

This research work reconnoiters the impact of nonrenewable energy (NRE) consumptions, environmental pollution, and mortality rate on human capital in the presence of economic growth and two common diseases, measles and tuberculosis (TB) in Pakistan. The study uses data from 1995 to 2017 and employs the Autoregressive Distributive Lag (ARDL) model to investigate cointegration and long-run dynamics. Results indicate that nonrenewable energy (oil, coal, and gas) increase air pollution, measles, TB cases, and mortality rate, which affect the human capital in Pakistan. The results of the ARDL confirm the long-run and short-run effects of fossils fuels, air pollution, and diseases on human capital. The results of the Granger Causality confirm the feedback hypothesis between nonrenewable consumption and human capital, between air pollution and human capital. Measles and TB diseases Granger cause human capital. The study recommends some essential points for energy management, environmental management, and diseases control programs to uplift the human capital in Pakistan.

Measles Resurgence in Europe: Migrants and Travellers are not the Main Drivers

Measles is a highly transmissible viral infection that may lead to serious illness, lifelong complications, and death. As there is no animal reservoir for measles, measles resurgence is due to human movement of viremic persons. Therefore, some have blamed the enormous migration into Europe in the past 5 years for the measles resurgence in this region. We set out to determine the main driver for measles resurgence in Europe by assessing vaccine coverage rates and economic status in European countries, number of migrants, and travel volumes. Data on measles vaccine coverage rates with two vaccine doses of measles, mumps and rubella (MMR) [Measles Containing Vaccine (MCV)2] and total number of measles cases in 2017 for Europe, including Eastern European countries, were obtained, in addition to Gross Domestic Product (GDP), and number of migrants and tourist arrivals. The outcome measured, incidence of measles per 100,000, was log transformed and subsequently analyzed using multiple linear regression, along with predictor variables: number of international migrants, GDP per capita, tourist arrivals, and vaccine coverage. The final model was interpreted by exponentiating the regression coefficients. Incidence of measles was highest in Romania (46.1/100,000), followed by Ukraine (10.8/100,000) and Greece (8.7/100,000). MCV2 coverage in these countries is less than 84%, with lowest coverage rate (75%) reported in Romania. Only vaccine coverage appears to be the significant predictor in the model (p < 0.001) for incidence of measles even after adjusting for international migrants, international tourist arrivals, and GDP per capita. With one unit increase in vaccination coverage, the incidence of measles decreased by 18% [95% confidence interval (CI): 10-25]. Our results showed that number of migrants and international tourist arrivals into any of the European countries were not the drivers for increased measles cases. Countries with high vaccine coverage rates regardless of economic status did not experience a resurgence of measles, even if the number of migrants or incoming travellers was high. The statistically significant sole driver was vaccine coverage rates. These analyses reemphasize the importance of strategies to improve national measles vaccination to achieve coverage greater than 95%.

Clinical Characteristics of Measles in Previously Vaccinated and Unvaccinated Patients in California

Background

Measles vaccine failure was first described in 1972. Over the next 20 years, vaccine failure was extensively studied, but during the last 25 years few investigations have been performed. We describe the clinical characteristics of measles in previously vaccinated and unvaccinated patients in California.

Methods

All confirmed measles cases reported to the California Department of Public Health from 1 January 2000 through 31 December 2015 were reviewed. Clinical characteristics (rates of hospitalization, cough, coryza, conjunctivitis, and fever) were compared between the previously unvaccinated, those who had had 1 dose of vaccine, and those who had had ≥2 doses of measles vaccine.

Results

There were 232 confirmed measles cases in whom vaccination status was verified; 80% were unvaccinated, 9% had had 1 dose of measles vaccine, and 11% had had ≥2 doses of measles vaccine. Subjects who had had ≥2 doses of measles vaccine had lower rates of hospitalization, cough, coryza, conjunctivitis, and fever than subjects who had 1 dose of measles vaccine or who were unimmunized.

Conclusions

Vaccine failure measles cases were less ill than cases that occurred in unvaccinated patients. Nevertheless, these cases still required the same amount of public health effort in tracing contacts as in cases who were unvaccinated.

The rise in travel-associated measles infections-GeoSentinel, 2015-2019

The global threat of measles in recent years affects international travelers, and is acquired in both endemic and outbreak settings. The number of measles cases reported to GeoSentinel has risen each year since 2015 and demonstrates a high median age, short travel duration, and low measles vaccination coverage.

Characteristics and preparation of the last-minute traveler: analysis of vaccine usage in the Global TravEpiNet Consortium

BACKGROUND

Last-minute travellers (LMTs) present challenges for health care providers because they may have insufficient time for recommended vaccinations or pre-travel preparation. Our objective was to obtain a better understanding of LMTs in order to help travel medicine providers develop improved strategies to decrease the number of LMTs and potentially reduce travel-related morbidity.

METHODS

We defined LMTs as travellers with a departure date of 7 days or fewer from the medical encounter. We analysed the characteristics and health preparation of 12 494 LMTs who presented to a network of US clinical practices for pre-travel health advice between January 2009 and December 2015.

RESULTS

LMTs comprised 16% of all travellers. More LMTs than non-LMTs travelled for business or to visit friends and relatives (VFR) (26% vs 16% and 15% vs 8%, respectively; P < 0.0001). More LMTs also travelled for longer than 1 month (27% vs 21%; P < 0.0001) and visited only urban areas (40% vs 29%; P < 0.0001). At least one travel vaccine was deferred by 18% of LMTs because of insufficient time before departure. Vaccines that required multiple vaccinations, such as Japanese encephalitis and rabies, were the most likely to be deferred because of time constraints.

CONCLUSION

Interventions to improve the timing of pre-travel health consultations should be developed, particularly for business and VFR travellers. Recently endorsed accelerated vaccine schedules for Japanese encephalitis and rabies may help some LMTs receive protection against these infections despite late presentation for pre-travel health care.

The Clinical Impact and Cost-effectiveness of Measles-Mumps-Rubella Vaccination to Prevent Measles Importations Among International Travelers From the United States

BACKGROUND

Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States.

METHODS

We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage.

RESULTS

The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage.

CONCLUSIONS

PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage.

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.

Reducing infectious disease inequities among migrants

BACKGROUND

migration has reached unprecedented levels, with 3.6% of the world's population living outside their country of birth. Migrants comprise a substantial proportion of high-income country populations, are at increased risk of a range of infectious diseases, compared to native-born populations and may experience worse health outcomes due to barriers accessing timely diagnoses and treatment. Poor access to essential healthcare services can be attributed to several factors, including language and cultural barriers and lack of specific inclusive health policies.

METHODS

This review draws on evidence from the immigrant health and travel medicine literature, with a focus on infectious disease risks. It presents strategies to reduce barriers to healthcare access through health promotion and screening programs both at the community and clinic level and the delivery of linguistically and culturally competent care. The Methods: Salud Entre Culturas (SEC) 'Health Between Cultures' project from the Tropical Medicine Unit at the Hospital Ramon y Cajal in Madrid is described as an effective model of care.

RESULTS

For those providing healthcare to migrant populations, the use of community-consulted approaches are considered best practice in the development of health education, health promotion and the delivery of targeted health services. At the clinic-level, strategies optimizing care for migrants include the use of bilingual healthcare professionals or community-based healthcare workers, cultural competence training of all clinic staff, the appropriate use of trained interpreters and the use of culturally appropriate health promotion materials.

CONCLUSIONS

Multifaceted strategies are needed to improve access, community knowledge, community engagement and healthcare provider training to provide appropriate care to migrant populations to reduce infectious disease disparities.

Spectrum of illness in migrants to Canada: sentinel surveillance through CanTravNet

BACKGROUND

Due to ongoing political instability and conflict in many parts of the world, migrants are increasingly seeking asylum and refuge in Canada.

METHODS

We examined demographic and travel correlates of illnesses among migrants to Canada to establish a detailed epidemiologic framework of this population for Canadian practitioners. Data on ill-returned Canadian travellers presenting to a CanTravNet site between 1 January 2015 and 31 December 2015 were analyzed.

RESULTS

During the study period, 2415 ill travellers and migrants presented to a CanTravNet site, and of those, 519 (21.5%) travelled for the purpose of migration. Sub-Saharan Africa (n = 160, 30.8%), southeast Asia (n = 84, 16.2%) and south central Asia (n = 75, 14.5%) were the most common source regions for migrants, while the top specific source countries, of 98 represented, were the Philippines (n = 45, 8.7%), China (n = 36, 6.9%) and Vietnam (n = 31, 6.0%). Compared with non-migrant travellers, migrants were more likely to have a pre-existing immunocompromising medical condition, such as HIV or diabetes mellitus (P < 0.0001), and to require inpatient management of their illness (P < 0.0001). Diagnoses such as tuberculosis (n = 263, 50.7%), hepatitis B and C (n = 78, 15%) and HIV (n = 11, 2.1%) were over-represented in the migrant population compared with non-migrant travellers (P < 0.0001). Most cases of tuberculosis in the migrant population (n = 263) were latent (82% [n = 216]); only 18% (n = 47) were active.

CONCLUSIONS

Compared with non-migrant travellers, migrants were more likely to present with a communicable infectious disease, such as tuberculosis, potentially complicated by an underlying immunosuppressing condition such as HIV. These differences highlight the divergent healthcare needs in the migrant population, and underscore the importance of surveillance programmes to understand their burden of illness. Intake programming should be adequately resourced to accommodate the medical needs of this vulnerable population of new Canadians.

Is short-term exposure to ambient fine particles associated with measles incidence in China? A multi-city study

BACKGROUND

China's rapid economic development has resulted in severe particulate matter (PM) air pollution and the control and prevention of infectious disease is an ongoing priority. This study examined the relationships between short-term exposure to ambient particles with aerodynamic diameter ≤2.5µm (PM_2.5) and measles incidence in China.

METHODS

Data on daily numbers of new measles cases and concentrations of ambient PM_2.5 were collected from 21 cities in China during Oct 2013 and Dec 2014. Poisson regression was used to examine city-specific associations of PM_2.5 and measles, with a constrained distributed lag model, after adjusting for seasonality, day of the week, and weather conditions. Then, the effects at the national scale were pooled with a random-effect meta-analysis.

RESULTS

A 10µg/m³ increase in PM_2.5 at lag 1day, lag 2day and lag 3day was significantly associated with increased measles incidence [relative risk (RR) and 95% confidence interval (CI) were 1.010 (1.003, 1.018), 1.010 (1.003, 1.016) and 1.006 (1.000, 1.012), respectively]. The cumulative relative risk of measles associated with PM_2.5 at lag 1-3 days was 1.029 (95% CI: 1.010, 1.048). Stratified analyses by meteorological factors showed that the PM_2.5 and measles associations were stronger on days with high temperature, low humidity, and high wind speed.

CONCLUSIONS

We provide new evidence that measles incidence is associated with exposure to ambient PM_2.5 in China. Effective policies to reduce air pollution may also reduce measles incidence.

Stop measles in Switzerland - The importance of travel medicine

BACKGROUND

In line with the worldwide strive to combat measles, the Swiss Federal Office of Public Heath (FOPH) launched a National Strategy for measles elimination 2011-2015. In this study, we highlight the importance of travel medicine consultations to complement measles vaccination programmes based on data from the Travel Clinic of the University of Zurich.

METHOD

We analysed measles vaccination data from the Zurich Travel Clinic between July 2010 and February 2016 and focused on three groups: (i) all clients who received the measles vaccination, (ii) all clients aged>two years who received the measles vaccination ("catch-up vaccination"), and (iii) all clients aged>two years and born after 1963 ("FOPH recommended catch-up vaccination").

RESULTS

107,669 consultations were performed from 2010 to 2016. In 12,470 (11.6%) of these, a measles vaccination was administered; 90.9% measles vaccinations were given during a pre-travel consultation, and 99.4% were administered to individuals aged>two years ("catch-up vaccinations"). An "FOPH recommended catch-up vaccination" was received by 13.6% of all Zurich Travel Clinic clients aged >2years and born after 1963.

CONCLUSIONS

In this study, we highlight the importance of travel medicine consultations to enhance the measles vaccination coverage in the adult Swiss population.

Comparison of monoplex and duplex RT-PCR assays for the detection of measles virus

Rapid and accurate detection of measles virus is important for case diagnosis and public health management. This study compared the performance of two monoplex RT-PCR reactions targeting the H and N genes to a duplex RT-PCR targeting both genes simultaneously. The duplex simplified processing without compromising assay performance characteristic.

Adverse events following immunization: real causality and myths

INTRODUCTION

To assure the highest safety of immunization programs, detect adverse events following immunization (AEFIs), eliminate concerns, and reduce the risk of low vaccination coverage, authorities in industrialized countries have collected years of reports of suspected AEFIs and have systematically assessed their clinical importance.

AREAS COVERED

In this paper, the methods used to assess vaccine safety and the results obtained by the analysis of reports, studies, and meta-analyses are discussed.

EXPERT OPINION

Severe AEFIs are rare, and all evaluations of safety of vaccines recommended for both children and adults have demonstrated that the advantages of vaccines are always significantly higher than the problems that they cause, and there is no need to modify recommendations. However, the definition of AEFI is dependent on the vaccines themselves, complicating the definition of an AEFI and explaining why doubts and concerns have been raised. Presently, disease epidemiology data collected in healthy people and in subjects with underlying disease, general vaccine coverage, and the vaccination status of subjects with AEFIs are managed by many independent institutions. Only strict co-operation between these institutions will lead to the successful identification of AEFIs and to a reduction of the weight of anti-vaccine arguments.