Measles among migrants in the European Union and the European Economic Area

Measles Outbreak in Socioeconomically Diverse Sections: A Review

Measles outbreaks among socioeconomically weaker sections constitute a significant public health challenge. The objective is to highlight the specific vulnerabilities and contributing factors that make these communities more susceptible to measles outbreaks. Socioeconomically weaker sections, often characterized by poverty, inadequate healthcare access, overcrowding, and suboptimal immunization rates, face heightened risks of measles outbreaks. These outbreaks occur due to various interrelated factors, including limited healthcare infrastructure, low vaccine coverage, a lack of awareness about vaccination benefits, and difficulties in accessing healthcare services. The effects of measles outbreaks in socioeconomically disadvantaged areas are critical. Particularly among vulnerable groups, including newborns, expectant mothers, and malnourished people, measles increases morbidity and mortality. There is also a considerable financial impact on the healthcare system and the afflicted families. Measles outbreaks in these populations must be addressed using a diversified strategy. In order to improve vaccine coverage through targeted immunization programs, raise community vaccination awareness, and address social determinants of health, efforts should concentrate on bolstering the healthcare infrastructure. Effective epidemic control and prevention depend on coordinated efforts by healthcare practitioners, legislators, local leaders, and public health groups. Healthcare systems can lessen the impact of measles in socioeconomically disadvantaged areas and strive toward attaining equitable health outcomes for all populations by addressing the socioeconomic variables that lead to the vulnerability of measles.

Migration and infant immunization timeliness in New Zealand: Evidence from the Growing Up in New Zealand study

BACKGROUND

Migration has been recognized as an important determinant of child health outcomes including childhood vaccination status. This paper aims to examine the association between parental migration status and a less studied aspect of child immunization outcomes, namely timeliness, within the context of New Zealand (NZ), a country characterized by a substantial proportion of its resident population born overseas. Additionally, the study explored the impact of residential duration on children's immunization timeliness.

METHODS

The data was taken from a large, representative population-based cohort study in NZ (Growing Up in NZ study). A total of 6156 children and their parents, comprising 2241 foreign-born and 3915 NZ-born mothers and a sub-group of their partners were included in the analysis. The survey data was linked with the National Immunization Register dataset. Timely immunization was defined as receiving two vaccines at each scheduled vaccination point (at six-week, three-month, and five-month, totaling six doses of vaccines) within 30 days of their due date. We examined the associations between parental migration status, maternal residential duration, and child immunization timeliness while controlling for socio-economic variations. The results were presented as adjusted odds ratios (AORs) with 95 % confidence intervals (CIs).

RESULTS

The findings revealed that after adjustment for socioeconomic differences, children of foreign-born mothers exhibited higher odds of receiving all six studied vaccine doses on time compared to children of native-born mothers (AOR 1.51, 95 %CI:1.27-1.78). Similarly, having a foreign-born father was also significantly associated with timely completion of all six vaccine doses. Children of recent immigrants who had resided in the country for less than five years demonstrated higher odds of timely vaccination of all six vaccine doses compared to children of settled immigrants who had lived in the country for five or more years (AOR 1.65, 95 %CI: 1.25-2.19).

CONCLUSION

This study revealed a significant pattern in NZ where immigrants exhibited higher rates of timely immunization for their children compared to native-born parents. However, the findings also underscore the importance of providing support to settled immigrants, as their children experienced declines in timely vaccination rates compared to children of recent immigrants and even those born to NZ-born parents.

Knowledge and attitudes of healthcare personnel about vaccination of migrant and refugee children and adolescents

Background

The number of migrants to Greece has increased considerably the last decade. This study assessed the knowledge and attitudes of healthcare personnel (HCP) toward vaccination of newly-arrived children and adolescents in the Aegean islands, a major port of entry of migrants and refugees to Europe.

Methods

The study was conducted from September 2020 to January 2021. All (166) HCP employed in the public health sector of the Aegean islands were invited to participate. A structured questionnaire was used to collect demographic data and data about their knowledge and attitudes toward vaccinations for migrant and refugees.

Results

A total of 120 HCP participated (72 % response rate), including 54 (45 %) physicians, 43 nurses (35.8 %), and 23 health visitors (19.2 %). Sixty-seven (55.8 %) HCP were aware of the national vaccination guidelines. Health visitors had higher rates of knowledge about the national vaccination guidelines, compared with nurses and physicians (87% versus 44,2% and 51,9%; p-value-0.001). Overall, 73 (60.8 %) HCP were aware of vaccinations during the first examination upon arrival. Primary-healthcare physicians were more likely to be aware about the time of vaccine administration compared with hospital-based physicians (74 % versus 50 %; p-value = 0.006). Out of 120 HCP, 45 % knew that vaccination guidelines apply to all newly-arrived migrant and refugees and 65 % that vaccinations are free-of-charge. Overall, 67.5 % of participants supported no serology testing before vaccination, 21.8 % were against free-of-charge vaccinations, and 55 % recommended only priority vaccinations.

Conclusions

There is a need to increase HCP' awareness and knowledge through training programs and tailored protocols focusing on vaccinations for newly-arrived migrant and refugee children and adolescents in order to promote effective vaccination of this vulnerable population.

Exploring Vaccination Challenges among Syrian Refugees in Jordan: Insights from Camps and Communities, and Perceived Parental Barriers to Childhood Vaccination Uptake

PURPOSE

To identify and understand the multifaceted barriers faced by Syrian refugees when seeking vaccination services for their children.

METHODS

A survey questionnaire was administered through structured interviews to a sample of Syrian refugees residing inside the Al-Zaatari camp and in various urban areas across Jordanian communities. This process utilized a multi-stage sampling approach, beginning with a random selection from clusters or strata, and then employing convenience sampling within each to select participants. The survey covered demographics, barriers to vaccination, and vaccine hesitancy.

RESULTS

A total of 332 participants completed the survey with a mean age of 32.7 ± 10 years ranging from 18 to 67. More than half of the sample (59%) had an education of 11th grade or less. Sociodemographic disparities regarding barrier perception were evident among participants. Middle-aged adults (older than 32), males, and those with a monthly income less than USD 200 had scored significantly higher on barrier perceptions across all categories (p < 0.05). In-camp residents were less likely to face vaccination barriers compared to those living outside the camps (p < 0.001). Psychological antecedents of vaccine assessments showed that younger individuals had significantly higher scores in complacency, calculation, and constraints (p < 0.05). Participants with lower income had lower constraints and calculation scores (p < 0.05). In-camp residents had significantly higher scores in complacency, constraints, and calculation constructs compared outside camps counterparts (p < 0.05). Participants with no formal education had higher scores in complacency and constraints, and those with less than a 12th-grade education and higher education degrees scored significantly higher on the collective responsibility construct (p < 0.05).

CONCLUSIONS

Efforts to promote vaccination among refugees should consider the specific challenges faced by this population, including financial barriers, healthcare access inequalities, and the impact of living arrangements. Public health strategies should address not only individual and psychological factors but also the physical and logistical challenges in obtaining vaccines.

Access to Vaccination for Newly Arrived Migrants: Developing a General Conceptual Framework for Understanding How to Improve Vaccination Coverage in European Countries

Objectives: Access to vaccination for newly arrived migrants (NAMs) is a relevant concern that requires urgent attention in EU/EEA countries. This study aimed to develop a General Conceptual Framework (GCF) for understanding how to improve vaccination coverage for NAMs, by characterizing and critically analyzing system barriers and possible strategies to increase vaccination. Methods: A theoretical conceptualization of the GCF was hypothesized based on conceptual hubs in the immunization process. Barriers and solutions were identified through a non-systematic desktop literature review and qualitative research. The GCF guided the activities and facilitated the integration of results, thereby enriching the GCF with content. Results: The study explores the vaccination of NAMs and proposes strategies to overcome barriers in their vaccination process. It introduces a framework called GCF, which consists of five interconnected steps: entitlement, reachability, adherence, achievement, and evaluation of vaccination. The study also presents barriers and solutions identified through literature review and qualitative research, along with strategies to enhance professionals' knowledge, improve reachability, promote adherence, achieve vaccination coverage, and evaluate interventions. The study concludes by recommending strategies such as proximity, provider training, a migrant-sensitive approach, and data collection to improve vaccination outcomes for NAMs. Conclusion: Ensuring equitable access to healthcare services, including vaccination, is crucial not only from a humanitarian perspective but also for the overall public health of these countries.

Prevalence and management of rubella susceptibility in healthcare workers in Italy: A systematic review and meta-analysis

Introduction

In the pre-vaccination era, all adults acquired immunity status due to natural infections during childhood and adolescence, whereas universal mass vaccination has changed the seroepidemiology of rubella among adults, showing lack of immunity in some subgroups. National and international guidelines recommend evaluating all healthcare workers (HCWs) for their immune status to rubella and possibly vaccinating those who are seronegative. We conducted a systematic review and meta-analysis to estimate the susceptibility rate to rubella among HCWs in Italy and to explore possible options for the management of those found to be susceptible.

Methods

Eight studies were included in the meta-analysis, selected from scientific papers available in the MEDLINE/PubMed and Google Scholar (till page 10) databases between January 1, 2015 and November 30, 2021. The following terms were used for the search strategy: (sero* OR seroprevalence OR prevalence OR susceptibilit* OR immunit* OR immunogenict*) AND (healthcare worker* OR health personnel OR physician* OR nurse OR student*) AND (rubella OR german measles OR TORCH) AND (Italy)

Results

The prevalence of rubella-susceptible HCWs was 9.0 % (95 %CI: 6.4–12.1 %). In a comparison of female vs. male serosusceptible HCWs, the RR was 0.67 (95 %CI = 0.51–0.88). Occupational medicine examinations for rubella screening with possible subsequent vaccination of seronegatives and exclusion of susceptible HCWs from high-risk settings were common management strategies.

Conclusions

HCWs susceptible to rubella are an important epidemiological concern in Italy, and efforts to identify and actively offer the vaccine to this population should be increased.

Immunization Catch-Up for Newly Arrived Migrants in France: A Cross-Sectional Study among French General Practitioners

Background: Migrants often undergo an incomplete vaccination program in regards to the French recommendations. The aim of this study was to evaluate the practices of French General Practitioners’ (GPs) in terms of catch-up vaccination. Methods: A cross-sectional study was carried-out in 2017–2018 in France. An online questionnaire was disseminated by email through scholarly societies to GPs involved in the care and the vaccination of migrants. Analyses included univariate and multivariate analysis with a logistic regression model. Results: A total of 216 GPs completed the survey. A majority identified themselves with an average level regarding the prevention of infectious diseases among migrant populations (56.7%) and confirmed this is part of their daily practice (83.3%). The majority of respondents do not perform more than two injections on the same day. When compared to GPs working in health centres, those with a private practice are more likely to report returning to a full primary vaccination schedule (adjusted OR = 2.90, 95% CI [1.29–6.53]). Aside from the serology for hepatitis B and to a lesser extent for measles, other pre-vaccination serologies were not frequently used by GPs. When a migrant declares to be up-to-date with his immunisations, only 56.5% of doctors consider this information reliable. Conclusions: This study clarified the vaccination practices of GPs receiving migrant patients in consultation and showed its heterogeneity. An important need for benchmarks has been identified and these results were used for the elaboration of the French guidelines on vaccines catch-up.

Review of the measles epidemic in children from Central Eastern Europe in the third millennium

Measles is an extremely contagious viral disease. Even though a safe vaccine exists for this disease, it remains one of the leading causes of mortality and morbidity in infants and young children. We aimed to create a retrospective descriptive study in which to analyze the evolution of the measles epidemic at the European level. The documentation was carried out using European Centre for Disease Prevention and Control (ECDC) and World Health Organization (WHO) statistics. At the same time, we present the epidemic's evolution in Romania, using data provided by the Romanian National Institute of Public Health and Ministry of Health. European statistical data indicate a high number of patients diagnosed with measles both among children and adults. All European countries benefit from the measles vaccination in the form of the measles-mumps-rubella (MMR) trivaccine included in their National Vaccination Programme. The vaccination schedule varies from country to country. In the vaccination scheme, most European countries include two doses of the MMR vaccine among the pediatric population. Romania registered a limited number of cases of measles between 1980 and 2015 following the introduction of the measles vaccination in the National Vaccination Programme. Since 2005, the Romanian vaccination schedule includes two doses of MMR trivaccine, administered at 12 months and at 6-7 years. After 2015, as a result of a significant decrease in the number of vaccinated children, Romania is facing a major increase in the cases of measles. Consecutively, a measles epidemic was declared in 2016 and an additional dose of mandatory MMR trivaccine was introduced at the age of 9 months. After 4 years of this schedule of administration, starting with August 2020, the additional dose of MMR administered during infancy has been discontinued. We propose an analysis of the factors that influenced the downward evolution of the measles epidemic in Romania at the beginning of the third millennium. Issues related to the limitation of interpersonal contact in the context of the social distancing imposed by the Sars-CoV-2 virus pandemic are discussed. We consider necessary a detailed documentation of the percentage of new disease cases that will appear in the pediatric population in the near future, in the context of the resumption of daily activity after the reopening of nurseries, kindergartens and schools.

What are the challenges in the vaccination of migrants in Norway from healthcare provider perspectives? A qualitative, phenomenological study

BACKGROUND

Migrant populations in the European Union (EU) suffer a disproportionate burden of infectious diseases and may be particularly vulnerable due to poor conditions in countries of origin or throughout transit to the host country. Given the rising level of migration into Europe, the vaccination of migrant populations has become a key priority, with European countries committing to equitably extending the benefits of vaccination to all. However, in Norway, little is known about the vaccination of migrant populations.

OBJECTIVE

The aim of this qualitative research study was to explore the process of vaccinating migrant populations in Norway and elucidate any challenges as perceived by healthcare providers. This involved exploring the challenges faced by healthcare providers in delivering vaccinations to migrants as well as potential barriers faced by migrants in accessing vaccinations in Norway, from the perspectives of healthcare providers.

METHODS

In June 2019, the authors conducted semi-structured interviews with seven healthcare providers who are involved in vaccinating migrants in South-Eastern and Western Norway. This included healthcare providers working in general practice, public health and infectious disease clinics, migrant health clinics, and local public health institutes.

RESULTS

An inductive, exploratory analysis identified key themes that were reviewed and analysed in light of existing literature. According to the informants, the Childhood Immunisation Programme is effective in including migrant children within the national vaccination schedule. However, gaps in vaccination appear to exist with regards to adult migrants as well as working migrants. There is currently no consistent or structured approach to vaccinating adult migrants in Norway, including no guidelines from governing bodies on how to organise vaccination to adult migrants in municipalities. Furthermore, reasons why adult vaccination is not prioritised were provided, such as tuberculosis screening and treatment taking precedence and the common assumption among healthcare providers that vaccinations are dealt with in childhood.

CONCLUSION

The development of equitable immunisation programmes requires an understanding of the multifactorial barriers to immunisation, such as those posed by policies, structures and governance bodies, or lack thereof. It also entails understanding the administration of such policies and the perspectives of those who are responsible for the delivery of vaccination, namely healthcare providers. This qualitative research study demonstrated that challenges exist in the vaccination of migrants in Norway and that they are coherent with those experienced throughout the EU, principally the presence of gaps in vaccinating adult migrants, working migrants and internal EU migrants. This research provides direction for future investigations and highlights the need for the inclusion of migrant status in the Norwegian Immunisation Registry.

Interventions to reduce the burden of vaccine-preventable diseases among migrants and refugees worldwide: A scoping review of published literature, 2006-2018

BACKGROUND

Disparities in vaccine-preventable disease (VPD) burden and immunisation coverage between migrants and refugees and their host populations have been described in numerous countries worldwide. Effective strategies are required to reduce the health disparities and immunisation inequities experienced by migrants and refugees.

METHODS

Using Arksey and O'Malley's framework, we conducted a scoping review to identify available literature on interventions aimed at reducing VPD burden among migrants and refugees worldwide. We searched for relevant empirical, peer-reviewed literature published in English between 2006 and 2018 using MEDLINE, Ovid EMBASE, CINAHL, Sociological Abstracts, and Web of Science databases. Relevant information from the studies, including intervention type, details and outcomes, were charted in Microsoft Excel and results were summarised using a descriptive analytical method.

RESULTS

Seventy studies met the inclusion criteria. The number of published studies increased over the years. The majority of studies were conducted in high-income countries. More studies were conducted among migrants (not including refugees) (n = 48, 66%) than specifically among refugees (n = 25, 34%). Interventions were implemented in a variety of settings, including health care (n = 31, 42%), community (n = 29, 39%), off-shore (n = 7, 9%), national (n = 4, 5%), school (n = 2, 3%), and workplace (n = 1, 1%). Studies reported interventions focused at the individual (to facilitate uptake of health services) (n = 4, 5%), community (to raise awareness) (n = 25, 34%), provider (to offer health services) (n = 12, 16%) and/or system (to increase compliance with recommendations) (n = 33, 45%) level. To be effective, interventions were designed to overcome commonly identified barriers to accessing services related to language, culture, distance and cost. Engagement with community members and organisations was an effective way to co-design interventions that address migrants' specific needs.

CONCLUSIONS

Studies emphasised the importance of interventions that address the heterogeneity within and between migrant and refugee populations. Considerable variation in practice remains, therefore more evaluation of interventions is needed to inform policy and programme decision-making.

Utility of the Tétanos Quick Stick® in the vaccine catch-up of adult migrants without proof of prior vaccination

BACKGROUND

Unknowing immunity status make migrants vaccine catch-up difficult. The interest of using a rapid tetanus immunotest as the Tétanos Quick Stick® (TQS®) to assess immunity status against tetanus has been evaluated in emergency rooms and it is now commonly used. The study aim was to evaluate TQS® as a tool for migrants' vaccine catch-up.

METHODS

From December 2018 to February 2019, a prospective study was performed and included consecutively migrants who attented to the primary medicine outconsultation of a health care centre in Paris. Migrants above 18, without any records of tetanus immunization were included and a TQS® was performed during a medical consultation. Adapted vaccine catch-up was then proposed. Immunity against tetanus among migrants, factors associated with positive TQS® and costs savings were evaluated.

RESULTS

TQS® test was positive for 32% of the 310 included patients. In the univariable analysis, factors associated to the presence of a positive TQS® test were a female gender (OR = 1.69 CI95% [1.02-2.80]) and an urban living in the country of origin (OR = 1.79 CI95% [1.07-3.02]). In the multivariable analysis, these factors were not significantly associated to a positive TQS®. Anamnesis was not correlated to the immunity status: only 26% of the migrants who reported vaccinations in childhood, adolescence and adulthood had a positive TQS® test. The use of TQS® test allowed savings of 6,522 US$ as compared to the immediate catch-up strategy for the 310 patients.

CONCLUSION

The TQS® test is an acceptable, simple, rapid and cost saving test that could find a place in the migrants' vaccine catch-up.

Refugee and Migrant Children’s Mental Healthcare: Serving the Voiceless, Invisible, and the Vulnerable Global Citizens

Millions of children are on the run worldwide, with many unaccompanied children and adolescents undertaking risky journeys to flee war, adverse circumstances, and political persecution. The grueling journey and multiple stressors faced by the refugee children, both accompanied and unaccompanied during the pre-migration, migration, and in the country of destination, increase their risk for psychiatric disorders and other medical conditions. Unaccompanied refugee migrant children have higher prevalence of mental health disorders than accompanied refugee peers. Long after reaching the host country, the refugee, migrant, and asylum-seeking juveniles continue to face adversities in the form of acculturation. In assessing medical fitness and healthcare mediations for refugees and migrant children, special consideration should be given to certain areas such as their distinct history, whether they are with their family or separated or unaccompanied, and whether they have been peddled or have been left behind.

Pediatric measles cases by residence status in Tel Aviv, Israel

BACKGROUND

Measles is a vaccine-preventable infectious disease whose outbreaks generally originate from exposure to populations with low vaccination coverage.

METHODS

This study compared the rates and morbidity of measles cases in the district of Tel-Aviv during two outbreaks (2012 and 2018-2019) by citizenship and geographic location.

RESULTS

There were 67 pediatric cases reported in 2012 and 222 in 2018-2019. Cases were more likely to have pneumonia in 2012 as compared to in 2018-2019 (58.2% versus 6.3%) and less likely to report a single vaccination dose (9.5% versus 22.8%, respectively). In 2012, the majority of cases were among children without legal residence (CWLR), while in 2018-2019, they were the minority of cases (N = 54, 80.6% versus N = 51, 23.0%, respectively). In both outbreaks, CWLR were more likely to be less than one year old (the recommended age for the first dose of measles vaccination), unvaccinated or with unknown vaccine status, to be treated in a tertiary care center, and to have pneumonia than children with Israeli citizenship (CC). In both outbreaks, CWLR lived in a concentrated neighborhood in Southern Tel Aviv.

CONCLUSION

While the two measles outbreaks differed in overall morbidity, in both outbreaks CWLR presented with a more severe clinical presentation and were less likely to be vaccinated (in part due to their younger age) than CC. The geographically concentration of CWLR was distinct from that of the CC in both outbreaks. Healthcare professionals should promote vaccination uptake and increase parents' awareness to early signs of the disease.

Health conditions of migrants landed in north-eastern Sicily and perception of health risks of the resident population

OBJECTIVES

In Italy, a recent irregular movement of people raised concerns among the host population on possible introduction of diseases that have long been controlled in the host countries. This study evaluates the health conditions of illegal immigrants landed on the north-eastern Sicilian territory, to provide information on the clinical and epidemiologic burden of infectious diseases among migrants and how the local population feel about these landings.

STUDY DESIGN

The study design is a cross-sectional study.

METHODS

The study considered all migrants landed illegally in the city of Messina, Sicily, between January 2014 and July 2018. Analysing the data of hospital admissions and disease notifications, we calculated the frequency of infectious diseases among migrant population. Furthermore, through a survey conducted by a well-known online newspaper, we analysed the perception that the local population has about the health risk represented by migrants.

RESULTS

In the considered five-year period, 108 landings, for a total of 38,608 migrants occurred at the Messina port. The percentage of hospitalisation was rather low (3.5%), and it concerned mainly pregnant women. The notifications of infectious diseases were contained, with exception of scabies and tuberculosis. Finally, from the online survey, resulted that there is a large part of local population that considers migrants a potential danger to community health.

CONCLUSIONS

Our data show that the presence of migrants should not have to date any impact on the health conditions of the resident population. However, monitoring over time the health of migrants and screening for infectious diseases as soon as possible after landing are advantageous for both migrants and host country.

Infectious disease outbreaks among forcibly displaced persons: an analysis of ProMED reports 1996-2016

Background

The United Nations Refugee Agency (UNHCR) estimates the number of forcibly displaced people increased from 22.7 million people in 1996 to 67.7 million people in 2016. Human mobility is associated with the introduction of infectious disease pathogens. The aim of this study was to describe the range of pathogens in forcibly displaced populations over time using an informal event monitoring system.

Methods

We conducted a retrospective analysis of ProMED, a digital disease monitoring system, to identify reports of outbreak events involving forcibly displaced populations between 1996 and 2016. Number of outbreak events per year was tabulated. Each record was assessed to determine outbreak location, pathogen, origin of persons implicated in the outbreak, and suspected versus confirmed case counts.

Results

One hundred twenty-eight independent outbreak events involving forcibly displaced populations were identified. Over 840,000 confirmed or suspected cases of infectious diseases such as measles, cholera, cutaneous leishmaniasis, dengue, and others were reported in 48 destination countries/territories. The average rate of outbreak events concerning forcibly displaced persons per total number of reports published on ProMED per year increased over time. The majority of outbreak events (63%) were due to acquisition of disease in the destination country.

Conclusion

This study found that reports of outbreak events involving forcibly displaced populations have increased in ProMED. The events and outbreaks detected in this retrospective review underscore the importance of capturing displaced populations in surveillance systems for rapid detection and response.

Infectious Diseases among Refugee Children

In recent years, there has been a substantial increase in refugee and asylum-seeking adults, adolescents and children to high-income countries. Infectious diseases remain the most frequently identified medical diagnosis among U.S.-bound refugee children. Medical screening and immunization are key strategies to reduce the risk of infectious diseases in refugee, internationally adopted, and immigrant children. Notable infectious diseases affecting refugee and other newly arriving migrants include latent or active tuberculosis, human immunodeficiency virus type 1 (HIV), hepatitis B, hepatitis C, vaccine-preventable diseases, malaria, and other parasitic infections. The U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics have published guidelines for health assessment of newly arriving immigrant, refugee, and internationally adopted children. Although, data on the health risks and needs of refugee exists in some high-income countries, there is an urgent need to develop robust evidence-informed guidance on screening for infectious diseases and vaccination strategies on a broader scale to inform national policies. Innovative approaches to reach migrant communities in the host nations, address health and other complex barriers to improve access to high-quality integrated health services, and strong advocacy to mobilize resources to improve health, safety, and wellbeing for refugee children and their families are urgent priorities.

Measles in Zhejiang, China, 2004-2017: Population Density and Proportion of Floating Populations Effects on Measles Epidemic

The target of eliminating measles has not been achieved, and measles has resurged in Zhejiang, China, since 2013. In this study, we hypothesized that population density and the proportion of the floating population were the potential causes of measles persistence in Zhejiang. Measles cases in Zhejiang from 2004 through 2017 were analyzed using data from the National Notifiable Diseases Reporting System (NNDRS). Reported measles incidence and annual incidence by age were described. Spearman correlation coefficients were used to assess correlations between measles incidence and population density and the proportion of floating population. A total of 48,648 measles cases were reported during the 14-year period. Two large measles epidemics occurred in 2005 (14,317 cases, incidence of 29.38/100,000) and 2008 (12,782 cases, incidence of 25.26/100,000). A higher proportion of cases occurred in young adults aged 20 to 34 years and infants under 1 year of age. A positive correlation was observed between measles incidence and either population density or proportion of inter-provincial floating populations. In general, Zhejiang suffers from a high incidence of measles partly because of its high population density and the low vaccination rates among inter-provincial floating populations. To meet the target of measles elimination, convincing susceptible young adults and migrant children to get vaccinated remains a critical issue.

'I don't think anybody explained to me how it works': qualitative study exploring vaccination and primary health service access and uptake amongst Polish and Romanian communities in England

OBJECTIVES

This study explored vaccination attitudes and behaviours among Polish and Romanian communities, and related access to primary healthcare services.

DESIGN

A qualitative study using in-depth semistructured interviews with Polish and Romanian community members (CMs) and healthcare workers (HCWs) involved in vaccination in areas with large Polish and Romanian communities. CMs discussed their vaccination attitudes and their experiences of accessing vaccinations in England. HCWs shared their experiences in vaccinating Polish and Romanian communities.

SETTING

Recruitment focused on three geographical areas in England with large Polish and Romanian populations (in London, Lincolnshire and Berkshire).

PARTICIPANTS

20 Polish and 10 Romanian CMs, and 20 HCWs. Most CMs were mothers or pregnant women and were recruited from London or Lincolnshire. HCWs included practice nurses, health visitors and school nurses recruited from the targeted geographical areas.

RESULTS

Although most CMs reported vaccinating according to the UK schedule, obstacles to vaccination were highlighted. CMs experienced difficulties navigating and trusting the English primary healthcare system, and challenges in accessing credible vaccination information in Polish and Romanian. CM vaccination expectations, largely built on knowledge and experiences from Poland and Romania, were often unmet. This was driven by differences in vaccination scheduling and service provision in England, such as nurses delivering vaccines instead of doctors. CMs reported lower acceptance of the influenza vaccine, largely due to perceptions around the importance and efficacy of this vaccine. HCWs reported challenges translating and understanding vaccination histories, overcoming verbal communication barriers and ensuring vaccination schedule completeness among families travelling between England and Poland or Romania.

CONCLUSIONS

This study identified vaccination uptake and delivery issues and recommendations for improvement. HCWs should discuss health service expectations, highlight differences in vaccination scheduling and delivery between countries, and promote greater understanding of the English primary healthcare system in order to encourage vaccination in these communities.

Immunisation of migrants in EU/EEA countries: Policies and practices

In recent years various EU/EEA countries have experienced an influx of migrants from low and middle-income countries. In 2018, the "Vaccine European New Integrated Collaboration Effort (VENICE)" survey group conducted a survey among 30 EU/EEA countries to investigate immunisation policies and practices targeting irregular migrants, refugees and asylum seekers (later called "migrants" in this report). Twenty-nine countries participated in the survey. Twenty-eight countries reported having national policies targeting children/adolescent and adult migrants, however vaccinations offered to adult migrants are limited to specific conditions in seven countries. All the vaccinations included in the National Immunisation Programme (NIP) are offered to children/adolescents in 27/28 countries and to adults in 13/28 countries. In the 15 countries offering only certain vaccinations to adults, priority is given to diphtheria-tetanus, measles-mumps-rubella and polio vaccinations. Information about the vaccines given to child/adolescent migrants is recorded in 22 countries and to adult migrants in 19 countries with a large variation in recording methods found across countries. Individual and aggregated data are reportedly not shared with other centres/institutions in 13 and 15 countries, respectively. Twenty countries reported not collecting data on vaccination uptake among migrants; only three countries have these data at the national level. Procedures to guarantee migrants' access to vaccinations at the community level are available in 13 countries. In conclusion, although diversified, strategies for migrant vaccination are in place in all countries except for one, and the strategies are generally in line with international recommendations. Efforts are needed to strengthen partnerships and implement initiatives across countries of origin, transit and destination to develop and better share documentation in order to guarantee a completion of vaccination series and to avoid unnecessary re-vaccination. Development of migrant-friendly strategies to facilitate migrants' access to vaccination and collection of vaccination uptake data among migrants is needed to meet existing gaps.

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.

Children on the move in Europe: a narrative review of the evidence on the health risks, health needs and health policy for asylum seeking, refugee and undocumented children

BACKGROUND

Europe has experienced a marked increase in the number of children on the move. The evidence on the health risks and needs of migrant children is primarily from North America and Australia.

OBJECTIVE

To summarise the literature and identify the major knowledge gaps on the health risks and needs of asylum seeking, refugee and undocumented children in Europe in the early period after arrival, and the ways in which European health policies respond to these risks and needs.

DESIGN

Literature searches were undertaken in PubMed and EMBASE for studies on migrant child health in Europe from 1 January 2007 to 8 August 2017. The database searches were complemented by hand searches for peer-reviewed papers and grey literature reports.

RESULTS

The health needs of children on the move in Europe are highly heterogeneous and depend on the conditions before travel, during the journey and after arrival in the country of destination. Although the bulk of the recent evidence from Europe is on communicable diseases, the major health risks for this group are in the domain of mental health, where evidence regarding effective interventions is scarce. Health policies across EU and EES member states vary widely, and children on the move in Europe continue to face structural, financial, language and cultural barriers in access to care that affect child healthcare and outcomes.

CONCLUSIONS

Asylum seeking, refugee and undocumented children in Europe have significant health risks and needs that differ from children in the local population. Major knowledge gaps were identified regarding interventions and policies to treat and to promote the health and well-being of children on the move.

Measles and rubella seroimmunity in newly arrived adult immigrants in Sweden

BACKGROUND

International migrants could be considered as a risk group for being susceptible to vaccine preventable diseases such as measles and rubella. However, data on immunity in different migrant groups are scarce. Apart from asylum seekers and refugees, other immigrant groups might also be at risk. We have examined measles and rubella specific IgG antibodies among newly arrived adult immigrants in Skåne region in southern Sweden. In contrast to children, adult immigrants are not offered catch-up vaccinations after arrival.

METHODS

Stored serum samples from 989 asylum seekers and 984 pregnant women from the antenatal screening program, who had recently settled in Sweden, were analyzed for specific measles and rubella IgG-antibodies. Sex, age, reason for screening and geographic origin were variables entered into a multivariate regression model.

RESULTS

There were considerable differences in seroimmunity to measles with regard to geographic origin (44-97%). Measles seroimmunity gaps were most prominent in immigrants from some European regions such as the Baltic countries, the former Yugoslavia and the Newly Independent States and Russia. Seroprotection for rubella varied less between geographic regions (90-99%).

CONCLUSION

Susceptibility to measles among adult immigrants arriving in Sweden varies considerably depending on their geographic origin. Vaccinations against measles and rubella should be offered to groups of immigrants who might be incompletely immunized.

National approaches to the vaccination of recently arrived migrants in Europe: A comparative policy analysis across 32 European countries

BACKGROUND

Migrants may be underimmunised and at higher risk of vaccine-preventable diseases, yet there has been no comprehensive examination of what policies are currently implemented across Europe targeting child and adult migrants. We analysed vaccination policies for migrants in 32 EU/EEA countries and Switzerland.

METHODS

Using framework analysis, we did a comparative analysis of national policies and guidelines pertaining to vaccination in recently arrived migrants through a systematic guideline and literature review and by approaching national experts.

RESULTS

Six (18.8%) of 32 countries had comprehensive policies specific to the vaccination of migrants (two focused only on child migrants, four on both adults and children). Nineteen (59.4%) countries applied their national vaccination schedule for migrant vaccinations, predominantly focusing on children; and five (15.6%) countries had circulated additional migrant-specific resources to relevant health-care providers. In six (18.8%) countries, policies on migrant vaccination focused on outbreak-specific vaccines only. In ten (31.3%) countries, policies focused on priority vaccinations, with polio being the vaccine most commonly administered and heterogeneity noted in vaccines recommended to adults, adolescents, and children. Eighteen (56.3%) countries recommended that an individual should be considered as unvaccinated where vaccination records were missing, and vaccines re-administered. Nine (28.1%) countries reported that specific vaccinations were mandatory.

CONCLUSION

There is considerable variation in policies across Europe regarding approaches to vaccination in adult and child migrants, and a lack of clarity on optimum ways forward, what vaccines to offer, with a need for robust research in this area. More emphasis must be placed on ensuring migrant-specific guidance is disseminated to front-line healthcare professionals to improve vaccine delivery and uptake in diverse migration populations across the region.

Divergent approaches in the vaccination of recently arrived migrants to Europe: a survey of national experts from 32 countries, 2017

BackgroundMigrants within the European Union and European Economic Area (EU/EEA) may be underimmunised and lack documentation on previous vaccinations. We investigated approaches to vaccination in recently arrived adult and child migrants, and guideline availability and implementation. Methods: Between March and May 2017, a national vaccination expert from every EU/EEA country and Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results: We approached 32 countries (response rate 100%). Although 28 experts reported vaccination guidance at national level, specific guidelines for recently arrived migrants were only available in six countries and not consistently implemented. Twenty-three countries administered vaccinations during on-arrival health checks. Most experts recommended multiple vaccination opportunities be made available: at point of entry (n = 13) or at holding level (reception centres, migrant camps, detention centres) (n = 21). In 30 countries, child migrants without evidence of previous vaccination were re-vaccinated according to the national schedule. Diphtheria-pertussis-tetanus and polio vaccinations were given to migrant children in all countries, measles-mumps-rubella (MMR) in 31 countries, hepatitis B vaccination in 25. Low levels of catch-up vaccination were reported in adult migrants, with only 13 countries offering MMR and 10 countries charging fees. Conclusion: Existing guidance is often not migrant-specific and may not be applied in practice; clarification is needed on which vaccines should be given. Strategies are needed specifically for catch-up vaccination in adult migrants. Vaccinations should be offered in multiple settings, free of charge, with sufficient guidance and training provided to front-line healthcare professionals.

Interventions to Improve Vaccination Uptake and Cost Effectiveness of Vaccination Strategies in Newly Arrived Migrants in the EU/EEA: A Systematic Review

Newly arrived migrants to the EU/EEA (arrival within the past five years), as well as other migrant groups in the region, might be under-immunised and lack documentation of previous vaccinations, putting them at increased risk of vaccine-preventable diseases circulating in Europe. We therefore performed a systematic review conforming to PRISMA guidelines (PROSPERO CRD42016045798) to explore: (i) interventions that improve vaccine uptake among migrants; and (ii) cost-effectiveness of vaccination strategies among this population. We searched MEDLINE, Embase, CINAHL, and Cochrane Database of Systematic Reviews (CDSR) between 1 January 2006 to 18 June 2018. We included three primary intervention studies performed in the EU/EEA or high-income countries and one cost effectiveness study relevant to vaccinations in migrants. Intervention studies showed small but promising impact only on vaccine uptake with social mobilization/community outreach, planned vaccination programs and education campaigns. Targeting migrants for catch-up vaccination is cost effective for presumptive vaccination for diphtheria, tetanus, and polio, and there was no evidence of benefit of carrying out pre-vaccination serological testing. The cost-effectiveness is sensitive to the seroprevalence and adherence to vaccinations of the migrant. We conclude that scarce but direct EU/EEA data suggest social mobilization, vaccine programs, and education campaigns are promising strategies for migrants, but more research is needed. Research should also study cost effectiveness of strategies. Vaccination of migrants should continue to be a public heath priority in EU/EEA.

Impact of the Refugee Crisis on the Greek Healthcare System: A Long Road to Ithaca

Greece is the country of "Xenios Zeus", the Ancient Greek god of foreigners and hospitality; however, it is also the main point of entry to Europe. Since the beginning of 2014, 1,112,332 refugees crossed the borders of Greece. Overall, 33,677 children and adolescent refugees sought asylum in Greece from 2013 to 2017, while 57,042 refugees are currently being hosted. The rapid entry of refugees into Greece raised the critical issue of health policy. The Greek National Health Service (NHS) faces many challenges. Adequate economic and human support is essential if this situation is to be managed successfully. However, Greece still bears the burden of the economic downturn since 2009. In fact, the crisis led to shortages in crucial equipment, and unmet health needs for both locals and refugees. The NHS deals with traumatic experiences, as well as cultural and linguistic differences. Overcrowded reception centers and hotspots are highly demanding and are associated with severe disease burden. This highlights the importance of guidelines for medical screening, healthcare provision, and a well-managed transition to definitive medical facilities. Furthermore, non-governmental organizations make an essential contribution by ensuring appropriate support to refugee minors, especially when they experience poor access to the NHS.

Exploring immunisation inequities among migrant and refugee children in New Zealand

Migrants may experience immunisation inequities compared with the host population related to barriers with accessing immunisations in their home countries, while migrating and/or post-arrival. This retrospective cohort study explored vaccination rates among migrant and non-migrant children in New Zealand (NZ). Linked de-identified data from various government sources from 1 January 2006 to 31 December 2015 were analysed using Statistic NZ's Integrated Data Infrastructure. Vaccination rates were compared between three cohorts of children aged up to 5 years: foreign-born children who migrated to NZ; children born in NZ of migrant mothers; and a comparator group of children born in NZ to non-migrant mothers. Less than half of foreign-born children (46%) had a record in the NZ National Immunisation Register compared with 95% and 96% among migrant and non-migrant NZ-born children, respectively. Foreign-born migrant children had lower age-appropriate reported vaccination rates by vaccine of interest, ethnicity and visa category compared with NZ-born children. Migrant children from Pacific ethnicities had lower reported coverage than other ethnicities. High rates of not age-appropriately vaccinated were noted among foreign-born children on refugee, Pacific and humanitarian visa schemes. This study highlights possible shortfalls around immunisation data, particularly about recording vaccinations given overseas for foreign-born children, and potential challenges around engagement with immunisation services for migrant children. However, results highlight the successful engagement of quota refugee children as part of NZ's refugee orientation programme. It is important to monitor vaccination coverage by migrant and refugee background to inform improvements to policy and practice for wider population health benefits.

National immunization strategies targeting migrants in six European countries

Over the last three years an unprecedented flow of migrants arrived in Europe. There is evidence that vaccine preventable diseases have caused outbreaks in migrant holding centres. These outbreaks can be favored by a combination of factors including low immunization coverage, bad conditions that migrants face during their exhausting journey and overcrowding within holding facilities. In 2017, we conducted an online survey in Croatia, Greece, Italy, Malta, Portugal and Slovenia to explore the national immunization strategies targeting irregular migrants, refugees and asylum seekers. All countries stated that a national regulation supporting vaccination offer to migrants is available. Croatia, Italy, Portugal and Slovenia offer to migrant children and adolescents all vaccinations included in the National Immunization Plan; Greece and Malta offer only certain vaccinations, including those against diphtheria-tetanus-pertussis, poliomyelitis and measles-mumps-rubella. Croatia, Italy, Malta and Portugal also extend the vaccination offer to adults. All countries deliver vaccinations in holding centres and/or community health services, no one delivers vaccinations at entry site. Operating procedures that guarantee the migrants' access to vaccination at the community level are available only in Portugal. Data on administered vaccines is available at the national level in four countries: individual data in Malta and Croatia, aggregated data in Greece and Portugal. Data on vaccination uptake among migrants is available at national level only in Malta. Concluding, although diversified, strategies for migrant vaccination are in place in all the surveyed countries and generally in line with WHO and ECDC indications. Development of procedures to keep track of migrants' immunization data across countries, development of strategies to facilitate and monitor migrants' access to vaccinations at the community level and collection of data on vaccination uptake among migrants should be promoted to meet existing gaps.

The measles epidemic trend over the past 30 years in a central district in Shanghai, China

Background

Measles vaccination over the past 50 years has greatly reduced the incidence of measles. However, measles among migrants and the resulting changes in epidemiological characteristics have brought new challenges to the elimination of measles. We aim to describe the measles epidemic trend over the past 30 years in a central district in Shanghai, China.

Methods

The present study was conducted in the Jing’an District, which is located in the center of Shanghai. Based on historical surveillance data of measles, we calculated the incidence of measles among local residents and migrants separately. Next, we classified all of the cases of the measles among local residents between 1984 and 2015 into 8 age groups and 5 birth cohorts. Finally, we calculated the measles incidence in each time period by the different age groups and birth cohorts, to understand the measles epidemic trend over past 30 years in the Jing'an District.

Results

A total of 103 cases of measles were reported from the Jing’an District, Shanghai, from 1984 to 2015. For infants less than 1 year of age and adults over 30 years of age, the incidence of measles continued to rise over the past 30 years. For a specific birth cohort, the incidence of measles after measles vaccination declined initially, and was then followed by a rebound.

Conclusions

The incidence of measles in older adults and infants increased in some developed regions, which slows the process of measles elimination. This suggested that the population immunity against measles after measles vaccination would gradually reduce with time. We recommend supplemental immunization against measles in adults in order to reduce the immunity decline, especially for migrants.

Immunization Strategies Targeting Newly Arrived Migrants in Non-EU Countries of the Mediterranean Basin and Black Sea

Background: The World Health Organization recommends that host countries ensure appropriate vaccinations to refugees, asylum seekers and migrants. However, information on vaccination strategies targeting migrants in host countries is limited. Methods: In 2015-2016 we carried out a survey among national experts from governmental bodies of 15 non-EU countries of the Mediterranean and Black Sea in order to document and share national vaccination strategies targeting newly arrived migrants. Results: Four countries reported having regulations/procedures supporting the immunization of migrants at national level, one at sub-national level and three only targeting specific population groups. Eight countries offer migrant children all the vaccinations included in their national immunization schedule; three provide only selected vaccinations, mainly measles and polio vaccines. Ten and eight countries also offer selected vaccinations to adolescents and adults respectively. Eight countries provide vaccinations at the community level; seven give priority vaccines in holding centres or at entry sites. Data on administered vaccines are recorded in immunization registries in nine countries. Conclusions: Although differing among countries, indications for immunizing migrants are in place in most of them. However, we cannot infer from our findings whether those strategies are currently functioning and whether barriers to their implementation are being faced. Further studies focusing on these aspects are needed to develop concrete and targeted recommendations for action. Since migrants are moving across countries, development of on-line registries and cooperation between countries could allow keeping track of administered vaccines in order to appropriately plan immunization series and avoid unnecessary vaccinations.

Migration and infectious diseases

BACKGROUND

Infectious diseases still represent an important cause of morbidity and mortality among foreign-born individuals. The rising migration flows towards Europe throughout the last few years are raising renewed concerns about management issues and the potential associated risk for the native population.

AIMS

To discuss the health implications and challenges related to the four phases of migration, from first arrival to stable resettlement.

SOURCES

Scientific literature and relevant statistical reports.

CONTENT

Although infectious diseases are not a health priority at first arrival, a syndromic screening to identify the most common communicable conditions (pulmonary tuberculosis above all) should be promptly conducted. Reception centres where asylum seekers are gathered after arrival may be crowded, so favouring epidemic outbreaks, sometimes caused by incomplete vaccine coverage for preventable diseases. After resettlement, the prevalence of some chronic infections such as human immunodeficiency virus, viral hepatitis or tuberculosis largely reflects the epidemiological pattern in the country of origin, with poor living conditions being an additional driver. Once resettled, migrants usually travel back to their country of origin without seeking pre-travel advice, which results in a high incidence of malaria and other infections.

IMPLICATIONS

Although infectious diseases among migrants are known to have a negligible impact on European epidemiology, screening programmes need to be implemented and adapted to the different stages of the migratory process to better understand the trends and set priorities for action. Appropriate access to care regardless of the legal status is crucial to improve the health status and prevent the spread of contagious conditions.

Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence

The decline of immunization rates in countries of origin of migrants and refugees, along with risky conditions during the journey to Europe, may threaten migrants' health. We performed a systematic review of the scientific literature in order to assess the frequency of vaccine preventable diseases, and vaccination coverage among migrants and refugees in Europe. To this end, Medline and Cochrane databases were considered. After the screening and the selection process, 58 papers were included in the review. We focused on the following vaccine-preventable diseases: hepatitis B, measles, rubella, mumps, tetanus, poliomyelitis, pertussis, diphtheria, meningitis, and varicella. The results were presented as a qualitative synthesis. In summary, several studies highlighted that migrants and refugees have lower immunization rates compared to European-born individuals. Firstly, this is due to low vaccination coverage in the country of origin. Then, several problems may limit migrants' access to vaccination in Europe: (i) migrants are used to move around the continent, and many vaccines require multiple doses at regular times; (ii) information on the immunization status of migrants is often lacking; (iii) hosting countries face severe economic crises; (iv) migrants often refuse registration with medical authorities for fear of legal consequences and (v) the lack of coordination among public health authorities of neighboring countries may determine either duplications or lack of vaccine administration. Possible strategies to overcome these problems include tailoring immunization services on the specific needs of the target population, developing strong communication campaigns, developing vaccination registers, and promoting collaboration among public health authorities of European Countries.

Waning of vaccine-induced immunity to measles in kidney transplanted children

Vaccine-preventable diseases are a significant cause of morbidity and mortality in solid organ transplant recipients who undergo immunosuppression after transplantation. Data on immune responses and long-term maintenance after vaccinations in such population are still limited.We cross-sectionally evaluated the maintenance of immune response to measles vaccine in kidney transplanted children on immunosuppressive therapy. Measles-specific enzyme-linked immunosorbent assay and B-cell enzyme-linked immunosorbent spot were performed in 74 kidney transplant patients (Tps) and in 23 healthy controls (HCs) previously vaccinated and tested for humoral protection against measles. The quality of measles antibody response was measured by avidity test. B-cell phenotype, investigated via flow cytometry, was further correlated to the ability of Tps to maintain protective humoral responses to measles over time.We observed the loss of vaccine-induced immunity against measles in 19% of Tps. Nonseroprotected children showed signs of impaired B-cell distribution as well as immune senescence and lower antibody avidity. We further reported as time elapsed between vaccination and transplantation, as well as the vaccine administration during dialysis are clinical factors affecting the maintenance of the immune memory response against measles.Tps present both quantitative and qualitative alterations in the maintenance of protective immunity to measles vaccine. Prospective studies are needed to optimize the vaccination schedules in kidney transplant recipients in order to increase the immunization coverage over time in this population.

Eradication of measles: remaining challenges

Measles virus (MeV) is an aerosol-borne and one of the most contagious pathogenic viruses known. Almost every MeV infection becomes clinically manifest and can lead to serious and even fatal complications, especially under conditions of malnutrition in developing countries, where still 115,000 to 160,000 patients die from measles every year. There is no specific antiviral treatment. In addition, MeV infections cause long-lasting memory B and T cell impairment, predisposing people susceptible to opportunistic infections for years. A rare, but fatal long-term consequence of measles is subacute sclerosing panencephalitis. Fifteen years ago (2001), WHO has launched a programme to eliminate measles by a worldwide vaccination strategy. This is promising, because MeV is a human-specific morbillivirus (i.e. without relevant animal reservoir), safe and potent vaccine viruses are sufficiently produced since decades for common application, and millions of vaccine doses have been used globally without any indications of safety and efficacy issues. Though the prevalence of wild-type MeV infection has decreased by >90 % in Europe, measles is still not eliminated and has even re-emerged with recurrent outbreaks in developed countries, in which effective vaccination programmes had been installed for decades. Here, we discuss the crucial factors for a worldwide elimination of MeV: (1) efficacy of current vaccines, (2) the extremely high contagiosity of MeV demanding a >95 % vaccination rate based on two doses to avoid primary vaccine failure as well as the installation of catch-up vaccination programmes to fill immunity gaps and to achieve herd immunity, (3) the implications of sporadic cases of secondary vaccine failure, (4) organisation, acceptance and drawbacks of modern vaccination campaigns, (5) waning public attention to measles, but increasing concerns from vaccine-associated adverse reactions in societies with high socio-economic standards and (6) clinical, epidemiological and virological surveillance by the use of modern laboratory diagnostics and reporting systems. By consequent implementation of carefully designed epidemiologic and prophylactic measures, it should be possible to eradicate MeV globally out of mankind, as the closely related morbillivirus of rinderpest could be successfully eliminated out of the cattle on a global scale.

Analysis of measles-related hospitalizations in Tuscany from 2000 to 2014

To evaluate measles incidence and its relevant changes over a 14-year period (2000–2014), we analysed data from the regional hospital discharge database on children and adults hospitalized in Tuscany, Italy. A total of 181 paediatric and 413 adult cases were identified. Despite all the efforts towards regional measles elimination, we observed that the overall measles hospitalization rates for children and adults living in Tuscany globally increased from 0·45 to 0·85/100 000 during the study period (P = 0·001) showing fluctuations due to periodic measles outbreaks. Data stratified by age group showed that the hospitalization rate significantly increased in young adults over the study period, confirming an increase in susceptibility to measles in this subpopulation. Conversely, no statistically significant difference was observed in the hospitalization rate in the other age groups. However, children aged <1 year still exhibit the highest hospitalization rate. Pneumonia represented the most common complication in both the adult and children subsets. No death was reported. Measles still represents a public health problem, and national strategies should be implemented, focusing on emergent susceptible subsets, such as infants and young adults.

Varicella outbreak in Sudanese refugees from Calais

We describe an outbreak of varicella in 31 Sudanese refugees (all except one were male, mean age: 26 ± 1), from the Calais migrant camp and sheltered in a French transit area. The attack rate was 39%. Adults are scantly immunized against varicella zoster virus in East Africa and may be exposed to epidemics once in France.