Description of two measles outbreaks in the Lazio Region, Italy (2006-2007). Importance of pockets of low vaccine coverage in sustaining the infection

Steroid use in measles: A retrospective cohort study during the 2017 outbreak in tertiary referral center, Rome and Latina, Italy

INTRODUCTION

Since early January 2017, a new measles outbreak in Italy has been observed. The aim of the study was to compare features between adults and children measles cases and evaluate the effect of steroid treatment on the above parameters.

METHODS

A retrospective multicenter, descriptive study was performed. We analyzed all patients admitted to the Department of Public Health and Infectious Diseases, Sapienza University, Rome and Latina, from January 2017 to December 2017 and discharged with diagnosis of measles.

RESULTS

We identified 113 patients discharged with the diagnosis of measles infection cases of which 59 adults and 54 children (≤16 years). In adult population 32 patients (54 %) were males, with a median age of 30.5 years old and all unvaccinated (100 %). Keratoconjunctivitis 30 (50 %) was the most frequent complication. In pediatric population 27 (50 %) patients were males, with a median age of 3 years old. Information on measles vaccination status was available for only 21 (38.8 %) of cases. Keratoconjunctivitis 40 (74 %) was the most frequent complication. Analyzing the differences between adult and pediatric patients we found that children were significantly more likely to have keratoconjunctivitis and diarrhea as complications than adults in which the rate of thrombocytopenia and hepatitis was highest. Thirty-nine adult subjects (66 %) have been treated with systemic corticosteroids.

CONCLUSIONS

Pediatric patients differ from adults in complications and liver involvement. Regarding steroids use, although there is no clear indication of steroid use during measles, there is no evidence of a worse outcome in our cases series.

Evolving measles status and immunization policy development in six European countries

Developing and implementing new immunization policies in response to shifting epidemiology is a critical public health component. We adopted a mixed-methods approach (via narrative literature review [101 articles] and 9 semi-structured interviews) to evaluate policy development in response to shifting measles epidemiology in six European countries (Italy, Belgium, Germany, Romania, UK, and Ukraine); where policies and strategies have evolved in response to country-specific disease and vaccination patterns. Periodic outbreaks have occurred in all countries against a background of declining measles-containing-vaccine (MCV) uptake and increasing public vaccine hesitancy (with substantial regional or social differences in measles burden and vaccine uptake). Health-care worker (HCW) vaccine skepticism is also seen. While many outbreaks arise or involve specific susceptible populations (e.g., minority/migrant communities), the broader pattern is spread to the wider (and generally older) population; often among incompletely/non-vaccinated individuals as a legacy of previous low uptake. Immunization policy and strategic responses are influenced by political and social factors, where public mistrust contributes to vaccine hesitancy. A strong centralized immunization framework (allied with effective regional implementation and coherent political commitment) can effectively increase uptake. Mandatory vaccination has increased childhood MCV uptake in Italy, and similar benefits could be anticipated for other countries considering vaccine mandates. Although possible elsewhere, socio-political considerations render mandating impractical in other countries, where targeted immunization activities to bolster routine uptake are more important. Addressing HCW skepticism, knowledge gaps, improving access and increasing public/community engagement and education to address vaccine hesitancy/mistrust (especially in communities with specific unmet needs) is critical.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 138 studies (23,480,668 participants). Fifty-one studies (10,248,159 children) assessed vaccine effectiveness and 87 studies (13,232,509 children) assessed the association between vaccines and a variety of harms. We included 74 new studies to this 2019 version of the review. Effectiveness Vaccine effectiveness in preventing measles was 95% after one dose (relative risk (RR) 0.05, 95% CI 0.02 to 0.13; 7 cohort studies; 12,039 children; moderate certainty evidence) and 96% after two doses (RR 0.04, 95% CI 0.01 to 0.28; 5 cohort studies; 21,604 children; moderate certainty evidence). The effectiveness in preventing cases among household contacts or preventing transmission to others the children were in contact with after one dose was 81% (RR 0.19, 95% CI 0.04 to 0.89; 3 cohort studies; 151 children; low certainty evidence), after two doses 85% (RR 0.15, 95% CI 0.03 to 0.75; 3 cohort studies; 378 children; low certainty evidence), and after three doses was 96% (RR 0.04, 95% CI 0.01 to 0.23; 2 cohort studies; 151 children; low certainty evidence). The effectiveness (at least one dose) in preventing measles after exposure (post-exposure prophylaxis) was 74% (RR 0.26, 95% CI 0.14 to 0.50; 2 cohort studies; 283 children; low certainty evidence). The effectiveness of Jeryl Lynn containing MMR vaccine in preventing mumps was 72% after one dose (RR 0.24, 95% CI 0.08 to 0.76; 6 cohort studies; 9915 children; moderate certainty evidence), 86% after two doses (RR 0.12, 95% CI 0.04 to 0.35; 5 cohort studies; 7792 children; moderate certainty evidence). Effectiveness in preventing cases among household contacts was 74% (RR 0.26, 95% CI 0.13 to 0.49; 3 cohort studies; 1036 children; moderate certainty evidence).  Vaccine effectiveness against rubella, using a vaccine with the BRD2 strain which is only used in China, is 89% (RR 0.11, 95% CI 0.03 to 0.42; 1 cohort study; 1621 children; moderate certainty evidence).  Vaccine effectiveness against varicella (any severity) after two doses in children aged 11 to 22 months is 95% in a 10 years follow-up (rate ratio (rr) 0.05, 95% CI 0.03 to 0.08; 1 RCT; 2279 children; high certainty evidence). Safety There is evidence supporting an association between aseptic meningitis and MMR vaccines containing Urabe and Leningrad-Zagreb mumps strains, but no evidence supporting this association for MMR vaccines containing Jeryl Lynn mumps strains (rr 1.30, 95% CI 0.66 to 2.56; low certainty evidence). The analyses provide evidence supporting an association between MMR/MMR+V/MMRV vaccines (Jeryl Lynn strain) and febrile seizures. Febrile seizures normally occur in 2% to 4% of healthy children at least once before the age of 5. The attributable risk febrile seizures vaccine-induced is estimated to be from 1 per 1700 to 1 per 1150 administered doses. The analyses provide evidence supporting an association between MMR vaccination and idiopathic thrombocytopaenic purpura (ITP). However, the risk of ITP after vaccination is smaller than after natural infection with these viruses. Natural infection of ITP occur in 5 cases per 100,000 (1 case per 20,000) per year. The attributable risk is estimated about 1 case of ITP per 40,000 administered MMR doses. There is no evidence of an association between MMR immunisation and encephalitis or encephalopathy (rate ratio 0.90, 95% CI 0.50 to 1.61; 2 observational studies; 1,071,088 children; low certainty evidence), and autistic spectrum disorders (rate ratio 0.93, 95% CI 0.85 to 1.01; 2 observational studies; 1,194,764 children; moderate certainty). There is insufficient evidence to determine the association between MMR immunisation and inflammatory bowel disease (odds ratio 1.42, 95% CI 0.93 to 2.16; 3 observational studies; 409 cases and 1416 controls; moderate certainty evidence). Additionally, there is no evidence supporting an association between MMR immunisation and cognitive delay, type 1 diabetes, asthma, dermatitis/eczema, hay fever, leukaemia, multiple sclerosis, gait disturbance, and bacterial or viral infections.  AUTHORS' CONCLUSIONS: Existing evidence on the safety and effectiveness of MMR/MMRV vaccines support their use for mass immunisation. Campaigns aimed at global eradication should assess epidemiological and socioeconomic situations of the countries as well as the capacity to achieve high vaccination coverage. More evidence is needed to assess whether the protective effect of MMR/MMRV could wane with time since immunisation.

CVD Risk Factors in the Ukrainian Roma and Meta-Analysis of Their Prevalence in Roma Populations Worldwide

The Roma population suffers from severe poverty, social exclusion, and some of the worst health conditions in the industrialized world. Herein, we report on cardiovascular disease (CVD) risk factors in the Ukrainian Roma and present a meta-analysis of the prevalence of CVD risk factors in 16 Roma populations worldwide. The meta-analyses of CVD risk factors in Roma (n = 16,552) vs. non-Roma majority population of the same country (n = 127,874) included publicly available data. Ukrainian field survey included 339 adults of both sexes and outcomes of interest were hypertension, body mass index (BMI), smoking, education, and employment status. Furthermore, 35.7% of the Ukrainian Roma were hypertensive, 69.3% unemployed, and 48.4% never went to school. Ukrainian Roma women were more likely to be underweight and more prone to be hypertensive, with odds of hypertension increasing with age, BMI, and positive smoking status. Meta-analyses showed that, in comparison with non-Roma worldwide, the Roma bear significantly higher risk factor loads related to smoking (OR = 2.850), diabetes (OR = 1.433), abdominal obesity (OR = 1.276), and metabolic syndrome (OR = 1.975), with lower loads for hypertension (OR = 0.607) and BMI ≥ 25 kg/m² (OR = 0.872). To conclude, the CVD risk factors which are more common in Roma than in the majority population may reflect their poor health-related behaviors and inadequate access to health education.

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review

Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery.

American and Canadian veterinarians' perceptions on dog and cat core vaccination rates and the impact of the human medicine anti-vaxx movement on veterinary medicine

An electronic survey was distributed to assess American and Canadian veterinarians' perceptions on dog and cat vaccination rates. The top veterinarian concerns for vaccinating a healthy adult dog were anaphylaxis, soreness at the injection site, and lethargy; for cats, these concerns included vaccine-associated sarcoma, lethargy, and soreness at injection site. Veterinarians reported that the most common concerns mentioned by reluctant or resistant clients to vaccinating their dogs or cats were beliefs that vaccinations are costly and unnecessary or may lead to chronic or severe illness. There was a positive correlation between an organized anti-vaxx movement against mandatory vaccination for children in their community and the number of vaccine resistant or concerned clients. That the number of resistant clients was associated with the presence of an organized anti-vaxx movement implies that the human anti-vaxx movement is impacting pet owners' views on companion animal vaccinations.

Measles Outbreak in a Roma Community in the Eastern Region of Slovakia, May to October 2018

Background

Despite the effective National Immunization Programme of Slovakia, some population groups are incompletely vaccinated or unvaccinated. We aimed to describe the measles outbreak spread in Eastern Slovakia between May and October 2018, affecting the Roma communities in relation to the existing immunity gaps.

Methods

We defined a group of persons living in socially closed communities with low vaccination coverage.

Results

Of 439 measles cases (median age: 10 years), 264 (60.1%) were vaccinated, 137 (31.2%) received two doses and 127 (28.9%) one dose of measles vaccines, 155 (35.3%) were unvaccinated and 20 (4.6%) had an unknown vaccination status. Samples from 102 patients (with two-dose vaccination status) were additionally tested for antibodies against rubella and mumps. Of 102 cases, 68 (66.7%) cases had a positive IgM and 23 (22.5 %) IgG antibodies against measles. For rubella, only 20 (19.6%) cases had seropositive IgG levels, for mumps higher positivity was detected in 60 persons (58.8%). We could detect only a small percentage with positive serology results of rubella IgG antibodies across all age groups. We have assumed that rubella antibodies had to be produced following the vaccination. Their absence in the cases with two doses of MMR suggests that these vaccines could not have been administrated despite the fact that this data was included in the medical records. Sequential analysis of two samples showed measles genotype B3.

Conclusion

This outbreak can outline the existence of a vulnerable group of the Roma. Low vaccinate coverage represents a serious public health threat.

Measles among healthcare workers in Italy: is it time to act?

Vaccination of healthcare workers (HCWs) against measles is strongly recommended in Europe. In this study, we examined the impact of measles on Italian HCWs by systematically and quantitatively analyzing measles cases involving HCWs over time and by identifying the epidemiological characteristics of the respective measles outbreaks. We retrieved data on measles cases from the Italian national integrated measles and rubella surveillance system from January 2013 to May 2019. Additionally, we performed a systematic review of the literature and an analysis of the measles and rubella aggregate outbreaks reporting forms from 2014 to 2018. Our review suggests that preventing measles infection among HCWs in disease outbreaks may be crucial for the elimination of measles in Italy. National policies aiming to increase HCW immunization rates are fundamental to the protection of HCWs and patients, will limit the economic impact of outbreaks on the institutions affected and will help achieve the elimination goal.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Vaccine Hesitancy: A Growing Concern

Vaccines are one of the great achievements of medical science. They have eradicated or drastically reduced the incidence of once common diseases. It is estimated that vaccines save between 2 and 6 million lives each year, but 1.5 million more lives could be saved if coverage was increased. Vaccine hesitancy, defined by the World Health Organization as "the reluctance or refusal to vaccinate despite the availability of vaccines", is a barrier to increasing coverage that has received a great deal of attention from the media and public health academics in recent years. It is argued that many parents are reluctant to vaccinate their children because of concerns about vaccine safety, despite reassurances from doctors and public health authorities. Vaccine hesitancy is a particularly big problem in high-income countries. Observers have noted that the internet and social media play an important role in spreading fears about vaccine safety. It is, however, important to understand how the wider social and political context has influenced concerns about vaccine safety. Vaccine hesitancy appears to be one aspect of a broader breakdown in trust between some sections of the population on the one hand, and elites and experts on the other.

Assessment of Economic Burden of Concurrent Measles and Rubella Outbreaks, Romania, 2011-2012

We estimated the economic impact of concurrent measles and rubella outbreaks in Romania during 2011–2012. We collected costs from surveys of 428 case-patients and caretakers, government records, and health staff interviews. We then estimated financial and opportunity costs. During the study period, 12,427 measles cases and 24,627 rubella cases were recorded; 27 infants had congenital rubella syndrome (CRS). The cost of the outbreaks was US $9.9 million. Cost per case was US $439 for measles, US $132 for rubella, and US $44,051 for CRS. Up to 36% of households needed to borrow money to pay for illness treatment. Approximately 17% of patients continued to work while ill to pay their treatment expenses. Our key study findings were that households incurred a high economic burden compared with their incomes, the health sector bore most costs, and CRS costs were substantial and relevant to include in rubella outbreak cost studies.

Austerity, measles and mandatory vaccination: cross-regional analysis of vaccination in Italy 2000-14

Background

Italy has experienced a resurgence in measles since 2015. Although much emphasis has been placed on the role of individuals opting out of vaccination, here we test the hypothesis that large budget reductions in public health spending were also a contributing factor.

Methods

Multi-variate statistical models were used to assess the relationship between measles, mumps and rubella (MMR) coverage and real public health expenditure per-capita across Italy's 20 regions covering the period 2000-14.

Results

Between 2010 and 2014 Italy's public health expenditure fell by over 2%, although varying among regions. Fixed effects models estimate that each 1% reduction in per-capita public health expenditure was associated with a decrease of 0.5 percentage points (95% CI: 0.36-0.65 percentage points) in MMR coverage, after adjusting for time and regional-specific time trends. The consequences can be illustrated by comparing two regions, Lazio, where public health spending fell by 5% and MMR coverage by over 3 percentage points, and Sardinia, a historically deprived region, where public health spending partly rose and MMR rates remained approximately steady.

Conclusion

Adoption of austerity policies in the Italian health system was found to be significantly associated with declining vaccination rates for MMR. However, the recent introduction of mandatory vaccination for Italian children may help counteract this trend.

Impact of vaccination programs against measles, varicella and meningococcus C in Italy and in Tuscany and public health policies in the last decades

The World Health Organization (WHO) has established specific targets for control, elimination or eradication of some vaccine preventable infectious diseases, which were periodically updated. In Italy, WHO recommendations have been endorsed and implemented over time, through the national and regional health prevention plans. The aim of the study was to assess the impact of the immunization practices against measles, varicella and Neisseria meningitidis type C (Men C) in Italy and in Tuscany Region, during the last decades, by analyzing national and regional surveillance databases. Benefits of vaccination strategies were discussed from different points of view (clinical, epidemiological, economic, ethical, social and communicative). The implementation of measles, varicella and Men C vaccination, caused a considerable decrease of incidence rates over the years in Italy and in Tuscany too. However, in the last years, notifications of measles and Men C cases in subjects not targeted by immunization campaigns, in Italy and in Tuscany, are a cause for concern for public health and for the achievement of the elimination goals. Achieving and maintaining high vaccine coverage guarantees a decrease in the incidence of serious diseases and their clinical and economic consequences, but it is necessary to strengthen surveillance system of infectious diseases in order to monitor epidemiological trends. Moreover, outreach campaigns are necessary to raise awareness in the general population and create the culture of prevention with the same nationwide health goals for all.

Under-vaccinated groups in Europe and their beliefs, attitudes and reasons for non-vaccination; two systematic reviews

BACKGROUND

Despite effective national immunisation programmes in Europe, some groups remain incompletely or un-vaccinated ('under-vaccinated'), with underserved minorities and certain religious/ideological groups repeatedly being involved in outbreaks of vaccine preventable diseases (VPD). Gaining insight into factors regarding acceptance of vaccination of 'under-vaccinated groups' (UVGs) might give opportunities to communicate with them in a trusty and reliable manner that respects their belief system and that, maybe, increase vaccination uptake. We aimed to identify and describe UVGs in Europe and to describe beliefs, attitudes and reasons for non-vaccination in the identified UVGs.

METHODS

We defined a UVG as a group of persons who share the same beliefs and/or live in socially close-knit communities in Europe and who have/had historically low vaccination coverage and/or experienced outbreaks of VPDs since 1950. We searched MEDLINE, EMBASE and PsycINFO databases using specific search term combinations. For the first systematic review, studies that described a group in Europe with an outbreak or low vaccination coverage for a VPD were selected and for the second systematic review, studies that described possible factors that are associated with non-vaccination in these groups were selected.

RESULTS

We selected 48 articles out of 606 and 13 articles out of 406 from the first and second search, respectively. Five UVGs were identified in the literature: Orthodox Protestant communities, Anthroposophists, Roma, Irish Travellers, and Orthodox Jewish communities. The main reported factors regarding vaccination were perceived non-severity of traditional "childhood" diseases, fear of vaccine side-effects, and need for more information about for example risk of vaccination.

CONCLUSIONS

Within each UVG identified, there are a variety of health beliefs and objections to vaccination. In addition, similar factors are shared by several of these groups. Communication strategies regarding these similar factors such as educating people about the risks associated with being vaccinated versus not being vaccinated, addressing their concerns, and countering vaccination myths present among members of a specific UVG through a trusted source, can establish a reliable relationship with these groups and increase their vaccination uptake. Furthermore, other interventions such as improving access to health care could certainly increase vaccination uptake in Roma and Irish travellers.

Measles Cases in Children Requiring Hospital Access in an Academic Pediatric Hospital in Italy, 2008-2013

BACKGROUND

The Lazio region is one of the Italian regions where sustained measles transmission continues to occur. We investigated measles cases reported by the emergency department (ED) of the largest pediatric hospital in Italy, located in Lazio.

METHODS

We reviewed clinical records of all measles cases from 0 to 18 years of age evaluated in the ED in 2008-2013. We compared demographic and clinical characteristics of patients admitted to the inpatient setting with those of patients discharged home to assess possible determinants of hospital admission.

RESULTS

Of 248 patients with measles evaluated in the ED, 113 (45.6%) were admitted as inpatients. The number of measles cases peaked in 2011 (N = 122; 49.2%), when epidemics were reported in Lazio. Median age was 2.7 years (range: 21 days to 17.9 years), and 31 patients (13%) had an underlying chronic illness. The strongest independent predictor of hospitalization was having an underlying chronic illness [adjusted odd ratio (OR): 9.87; 95% confidence interval: 3.13-31.13]. Other factors independently and significantly associated with higher risk of hospitalization were taking medications at the time of ED visit, being younger than 1 year of age and having altered liver enzyme values. Eighty-five percent of children >15 months of age who were hospitalized were not vaccinated. One hundred six hospitalized children (94%) had at least 1 measles complication; 1 child required intensive care for respiratory insufficiency.

CONCLUSIONS

Hospitalizations of children with measles continue to occur in European areas where elimination has not been achieved. Children with chronic diseases represent a vulnerable population that is at higher risk of hospitalization.

The measles outbreak in Bulgaria, 2009-2011: An epidemiological assessment and lessons learnt

Measles re-emerged in a nationwide outbreak in Bulgaria from 2009 to 2011 despite reported high vaccination coverage at national level. This followed an eight-year period since the last indigenous cases of measles were detected. The Bulgarian National Centre of Infectious and Parasitic Diseases collated measles surveillance data for 2009-2011. We analysed data for age group, sex, ethnicity, diagnosis confirmation, vaccination, hospitalisation, disease complications, and death and describe the outbreak control measures taken. The outbreak started in April 2009 following an importation of measles virus and affected 24,364 persons, predominantly Roma. Most cases (73%) were among children < 15 years old. Vaccination status was available for 52% (n = 12,630) of cases. Of children 1-14 years old, 22% (n = 1,769) were unvaccinated and 70% (n = 5,518) had received one dose of a measles-containing vaccine. Twenty-four measles-related deaths were reported. The Roma ethnic group was particularly susceptible to measles. The magnitude of the outbreak resulted primarily from the accumulation of susceptible children over time. This outbreak serves as a reminder that both high vaccination coverage and closing of immunity gaps across all sections of the population are crucial to reach the goal of measles elimination.

Molecular detection and genetic characterization of circulating measles virus in northern Italy

BACKGROUND

Laboratory diagnosis of measles virus (MV) infection and genetic characterization of circulating MV play an essential role in measles surveillance, allowing proper interventions to interrupt endemic transmission.

OBJECTIVES

We describe results obtained using serological and molecular methods to confirm MV infection among suspected cases reported in a large region in the north of Italy during 2010-2014 and the genotyping of the MV strains detected.

STUDY DESIGN

Three hundred seventy-two samples (361 urine and 11 oral fluids) were tested for MV-RNA detection. In 281 cases, the serological results for MV-IgM detection were also available.

RESULTS

A total of 276 cases were classified as confirmed measles and MV-RNA detection resulted positive for 239/276 cases. Nucleotide sequence analysis revealed sporadic cases of genotypes D9 and different circulations of endemic MV strains (D8, D4 and B3).

CONCLUSIONS

This data suggests that there is still an unvaccinated part of the population maintaining the endemic circulation of MV in Italy.

Molecular Characterization of Wild Type Measles Virus from Adult Patients in Northern China, 2014

OBJECTIVES

In this study, we studied the N and H genes from wild type measles viruses (MeVs) isolated during the 2013-2014 outbreak.

METHODS

Clinical samples were collected, and the genotyping, phylogenetic analysis were performed.

RESULTS

The vaccination rate of the study population was 4%. Genotype H1a was the predominant genotype. Wild type viruses were classified into clusters A and B, C and may have different origins. N-450 sequences from wild type viruses were highly homologous with, and likely evolved from MeVs circulating in Tianjing and Henan in 2012. MVs/Shenyang.CHN/18.14/3 could have evolved from MeVs from Liaoning, Beijing, Hebei, Heilongjiang, Henan, Jilin, and Tianjin. Our data suggested that one or more of the same viruses circulated between Beijing, Shenyang, Hong Kong, Taiwan and Berlin.

CONCLUSIONS

Important factors contributing to outbreaks could include weak vaccination coverage, poor vaccination strategies, and migration of adult workers between cities, countries, and from rural areas to urban areas.

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

Aims: Progress towards meeting the goal of measles elimination in the EU and the European Economic Area (EEA) by 2015 is being obstructed, as some children are either not immunized on time or never immunized. One group thought to be at increased risk of measles is migrants; however, the extent to which this is the case is poorly understood, due to a lack of data. This paper addresses this evidence gap by providing an overview of the burden of measles in migrant populations in the EU/EEA. Methods: Data were collected through a comprehensive literature review, a country survey of EU/EEA member states and information from measles experts gathered at an infectious disease workshop. Results: Our results showed incomplete data on measles in migrant populations, as national surveillance systems do not systematically record migration-specific information; however, evidence from the literature review and country survey suggested that some measles outbreaks in the EU/EEA were due to sub-optimal vaccination coverage in migrant populations. Conclusions: We conclude that it is essential that routine surveillance of measles cases and measles, mumps and rubella (MMR) vaccination coverage become strengthened, to capture migrant-specific data. These data can help to inform the provision of preventive services, which may need to reach out to vulnerable migrant populations that currently face barriers in accessing routine immunization and health services.

Prevalence of measles virus-specific IgG antibodies according to vaccination schedule in medical students of Padua University

Aims: The goal of the present study was to establish the efficacy of the measles vaccine and the validity of the vaccination schedule adopted in Italy. Materials & methods: The following procedures are adopted: analyze the compliance to the vaccination schedule; assess the seroprevalence of measles antibodies according to the year of birth and the number of doses; and investigate the persistence of positive antibodies post-vaccination. We gathered and elaborated data of both vaccination history and seroprevalence against measles in a large population of students (4195) belonging to the Medical School of Padua University (Italy). Results: Our results reveal a requirement for a two-dose vaccination schedule to ensure protection from the disease. Nevertheless, these results clearly indicate that the percentage of seropositivity reached using the two-dose strategy is below the percentage (95%) that ensures optimal population immunity. Conclusion: It is uncertain whether immune coverage persists when circulating antibodies vanish, but two vaccine doses should prevent disease outbreaks.

Hospital preparedness in community measles outbreaks-challenges and recommendations for low-resource settings

We have reviewed various strategies involved in containment of measles in healthcare facilities during community outbreaks. The strategies that are more applicable to resource-poor settings, such as natural ventilation, mechanical ventilation with heating and air-conditioning systems allowing unidirectional air-flow, and protection of un-infected patients and healthcare workers (HCWs), have been examined. Ventilation methods need innovative customization for resource-poor settings followed by validation and post-implementation analysis for impact. Mandatory vaccination of all HCWs with two doses of measles-containing vaccine, appropriate post-exposure prophylaxis of immunocompromised inpatients, and stringent admission criteria for measles cases can contribute toward reduction of nosocomial and secondary transmission within facilities.

Determinants of childhood vaccination completion at a peri-urban hospital in Kenya, December 2013 -January 2014: a case control study

INTRODUCTION

Vaccine preventable diseases account for about 17% of deaths among children below five years in Kenya. Immunization is one the most cost-effective ways of reducing child mortality and morbidity worldwide. In Kenya, national full vaccination coverage today stands at above 80%. However there continue to be pockets of low full vaccination coverage like the catchment area of Alupe Sub-District Hospital which pose a threat to the rest of the country.

METHODS

This was a case-control study at Alupe Sub-District Hospital, Western Kenya. Sixty one (61) cases and 122 controls were sampled from the facility maternal and child health register by systematic random sampling and traced to their households. Cases were defined as children 12-23 months resident in Kenya who received at least one infant vaccine at the facility but were not fully vaccinated at the time of the study, while controls were children 12-23 months who were fully vaccinated by the time of the study. Pretested structured questionnaires were used for data collection. Data entry and analysis was done using Epi-Info 3.5.4 statistical software.

RESULTS

Independent determinants of infant vaccination completion were the child's age < 18 months (AOR 4.2(1.8-9.6), p < 0.01), maternal age < 25 years (AOR 2.5(1.1-5.0), p = 0.03), maternal tetanus toxoid vaccination status < 2 TT doses (AOR 2.5(1.2-5.4), p < 0.02) and late receipt of BCG [AOR 3.2(1.4-7.3), p = 0.005).

CONCLUSION

Strategies to increase full vaccination should target young mothers especially during antenatal period.

Spotlight on measles in Italy: why outbreaks of a vaccine-preventable infection continue in the 21st century

Measles is a serious infectious disease that can lead to significant morbidity and mortality. Remarkable progress has been made through measles vaccination in reducing the number of people dying from measles. In the last years, concerns about the safety of vaccines have led to decline in immunization coverage rates and new outbreaks of measles in many European countries, including Italy. We believe that it is important to reinforce the message that measles vaccine is safe and highly effective through appropriate information campaigns and public awareness.

Transmission and molecular characterisation of wild measles virus in Romania, 2008 to 2012

Molecular characterisation of measles virus is a powerful tool for tracing transmission. Genotyping may prove the absence of endemic circulation of measles virus, i.e. transmission for more than 12 months, which is one of the criteria for verifying elimination of the disease. We have genetically characterised measles viruses detected in Romania from 2008 to 2012, focusing on the recent outbreaks from 2010 to 2012 that affected mainly groups with limited access to healthcare and schools. The findings emphasise the importance of genotyping during the different phases of an outbreak. A total of 8,170 cases were notified, and 5,093 (62%) of the 7,559 possible cases were serologically confirmed. RT-PCR was performed for 104 samples: from the 101 positive samples obtained from sporadic measles cases or clusters from different counties, 73 were genotyped. Sporadic measles cases associated with D4 and D5 viruses were observed from2008 to 2009. Genotype D4-Manchester was predominant in 2011 and 2012. In addition, the related variant D4-Maramures and MVs/Limoges.FRA/17.10[D4] and a few D4-Hamburg strains were detected. The detection of several distinct MV-D4 genotypes suggests multiple virus importations to Romania. The outbreak associated with D4 genotype is the second largest outbreak in Romania in less than 10 years.

Prevalence of measles antibodies among health care workers in Catalonia (Spain) in the elimination era

BACKGROUND

Interruption of measles transmission was achieved in Catalonia (Spain) in 2000. Six years later, a measles outbreak occurred between August 2006 and June 2007 with 381 cases, 11 of whom were health care workers (HCW).The objective was to estimate susceptibility to measles in HCW and related demographic and occupational characteristics.

METHODS

A measles seroprevalence study was carried out in 639 HCW from six public tertiary hospitals and five primary healthcare areas. Antibodies were tested using the Vircell Measles ELISA IgG Kit. Data were analyzed according to age, sex, type of HCW, type of centre and vaccination history.The odds ratios (OR) and their 95% CI were calculated to determine the variables associated with antibody prevalence. OR were adjusted using logistic regression.Positive predictive values (PPV) and the 95% confidence intervals (CI) of having two documented doses of a measles containing vaccine (MCV) for the presence of measles antibodies and of reporting a history of measles infection were calculated.

RESULTS

The prevalence of measles antibodies in HCW was 98% (95% CI 96.6-98.9), and was lower in HCW born in 1981 or later, after the introduction of systematic paediatric vaccination (94.4%; 95% CI 86.4-98.5) and higher in HCW born between 1965 and 1980 (99.0%; 95% CI 97.0-99.8). Significant differences were found for HCW born in 1965-1980 with respect to those born in 1981 and after (adjusted OR of 5.67; 95% CI: 1.24-25.91).A total of 187 HCW reported being vaccinated: the proportion of vaccinated HCW decreased with age. Of HCW who reported being vaccinated, vaccination was confirmed by the vaccination card in 49%. Vaccination with 2 doses was documented in only 50 HCW, of whom 48 had measles antibodies. 311 HCW reported a history of measles.The PPV of having received two documented doses of MCV was 96% (95% CI 86.3-99.5) and the PPV of reporting a history of measles was 98.7% (95% CI 96.7-99.6).

CONCLUSIONS

Screening to detect HCW who lack presumptive evidence of immunity and vaccination with two doses of vaccine should be reinforced, especially in young workers, to minimize the risk of contracting measles and infecting the susceptible patients they care for.

Antibiotics for preventing complications in children with measles

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

[Measles vaccination campaign among vulnerable populations during the peak of the 2011 epidemic in Marseilles]

BACKGROUND

From 2008 to the end of 2011, Europe experienced a major outbreak of measles. The outbreak hit France especially hard, with measles hotspots in the South-East of France. It is known that people living in precarious socio-economic conditions are more exposed to infectious diseases. Regarding the local situation, the NGO "MdM-Marseille" decided to conduct a vaccination campaign among the Roma community living in camps.

METHODS

The campaign was planned with two injections of a combined measles, mumps and rubella vaccine (MMR) in a one month interval for all young people born since 1980 and over the age of one year, regardless of antecedents. Twenty-four camps were selected. The target population was estimated at 720 people. Each site was the subject of an information visit. A letter was sent to the Prefecture to inform them and ask for a moratorium on evictions for the identified camps.

RESULTS

Between May 15th and September 15th 2011, 326 primary immunizations were performed during 34 visits (covering 45.3% of the target population). Over the same period, almost all the camps were evacuated, forcing teams to stop the vaccination campaign. The second injection campaign covered only 37 persons.

CONCLUSION

The vaccination campaign among Roma populations in Marseilles was organized in a context of a major national outbreak of measles in the general population. Although the Prefecture was informed, camp evictions were not interrupted. This highlights the discrepancy between public health policy and security policy. In the context of an epidemic, innovative actions should be focused on vulnerable populations in partnership with health authorities. The main objective is to find procedures that can protect populations at risk in the event of a health crisis but which are also useful for routine prevention.

Progress in the elimination of measles and congenital rubella in Central Italy

Despite the launch of a WHO European Region strategic plan 2005-2010 for eliminating measles and rubella and preventing congenital rubella (CR) infection, measles and rubella are still circulating in Europe. Increased transmission and outbreaks of measles in Europe were still observed in 2011. In Italy, the objectives of the National Plan (2003-2007) for measles elimination have not yet been achieved. The goal of measles elimination and incidence reduction of CR cases has been postponed to 2015 by the Italian Ministry of Health through the implementation of the new National Plan 2010-2015 which will require (1) the achievement of more than 95% coverage with 1 dose and two doses of measles containing vaccine (MCV), respectively, within 24 mo and within 12 y of age; (2) supplementary vaccination activities aimed at susceptible populations including adolescents, young adults and those at risk (health care and educational workers, military, groups "hard to reach" like nomads); and in addition, (3) reduction to less than 5% in the proportion of susceptible women of childbearing age (especially immigrant women). Experiences at regional level, like in Tuscany, have shown promising results in order to create an integrated surveillance system between regional and local health authorities, university and laboratory and in the future, to validate elimination. Moreover, the evaluation of all preventive activities performed in Tuscany during the last decade, immunization coverage data, sero-epidemiological population profile and incidence of measles and rubella cases has highlighted critical points which should be improved and good practices already implemented which should be maintained in the future in order to reach the new goals.

Molecular epidemiology of measles virus in Italy, 2002-2007

Background

The European Regional Office of the World Health Organization (WHO/Europe) developed a strategic approach to halt the indigenous transmission of measles in its 53 Member States by 2015. In view of the goal of measles elimination, it is of great importance to assess the circulation of wild-type measles virus (MV). Genetic analysis is indispensable to understand the epidemiology of measles.

Methods

Urine and saliva samples were collected between May 2002 and December 2007, in order to find the origins and routes of wild type measles virus circulation. RT-PCR was performed on a total of 414 clinical samples of patients from different Italian regions. The results confirmed the genome presence in 199 samples, out of which 179 were sequenced. The sequences were genotyped by comparing the fragment coding for the carboxyl terminus of the nucleoprotein (450 nucleotides) with that one of the WHO reference strains.

Results

From the year 2002 to the year 2007 phylogenetic analysis of measles sequences showed a predominant circulation of the D7 genotype in the Italian territory for the years 2002–2004. This genotype was replaced by D4 and B3 genotypes in the biennium 2006–2007. During the same period C2, A, D5 and D8 genotypes were also detected.

Conclusions

Genetic characterization of wild-type MV provides a means to study the transmission pathways of the virus, and is an essential component of laboratory-based surveillance. Knowledge of currently circulating measles virus genotype in Italy will help in monitoring the success of the measles elimination programme and will contribute to evaluate the effectiveness of future vaccination campaigns.

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

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

Laboratory diagnosis, molecular characteristics, epidemiological and clinical features of an outbreak of measles in a low incidence population in Australia

BACKGROUND

Prompt and accurate laboratory diagnosis of measles is essential for case detection, outbreak management and ongoing surveillance in low incidence countries. Several disease markers are employed for diagnosis and are important to determine epidemiological and molecular characteristics for future control measures.

OBJECTIVES

To report different disease markers, genotypes and epidemiology of a measles outbreak in Australia, a low incidence country.

STUDY DESIGN

A retrospective descriptive study of the clinical and epidemiological features and laboratory diagnosis in 16 confirmed measles cases using measles serum IgM/IgG, antigen detection (IFA), viral RNA detection by real-time PCR and genotyping results for respiratory and urine specimens processed in one reference laboratory.

RESULTS

Of the 16 confirmed measles cases, 11 were young adults aged between 20-35 years and 15 were not age-appropriately vaccinated. The most common genotype detected was D9 (11/16), followed by D4 (1/16) and D8 (1/16). Two imported cases were from the Philippines (D4) and Italy (D9). Of six disease markers, respiratory swab PCR and serum IgM gave the highest percentage (100%) of positive samples for confirmed cases followed by urine PCR (90.9%), serum PCR (66.6%), urine IFA (54.5%) and respiratory IFA (46.2%).

CONCLUSIONS

Measles should be considered in the differential diagnosis of a presentation with fever and rash, even in countries in the elimination phase of measles control. Genotyping is a powerful molecular-epidemiological tool to assist low incidence countries towards eradication goals. Improving vaccination coverage remains essential, particularly in young adults and travellers.

Vaccines for measles, mumps and rubella in children

BACKGROUND

Mumps, measles and rubella (MMR) are serious diseases that can lead to potentially fatal illness, disability and death. However, public debate over the safety of the trivalent MMR vaccine and the resultant drop in vaccination coverage in several countries persists, despite its almost universal use and accepted effectiveness.

OBJECTIVES

To assess the effectiveness and adverse effects associated with the MMR vaccine in children up to 15 years of age.

SEARCH METHODS

For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, PubMed (July 2004 to May week 2, 2011) and Embase.com (July 2004 to May 2011).

SELECTION CRITERIA

We used comparative prospective or retrospective trials assessing the effects of the MMR vaccine compared to placebo, do nothing or a combination of measles, mumps and rubella antigens on healthy individuals up to 15 years of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed methodological quality of the included studies. One review author arbitrated in case of disagreement.

MAIN RESULTS

We included five randomised controlled trials (RCTs), one controlled clinical trial (CCT), 27 cohort studies, 17 case-control studies, five time-series trials, one case cross-over trial, two ecological studies, six self controlled case series studies involving in all about 14,700,000 children and assessing effectiveness and safety of MMR vaccine. Based on the available evidence, one MMR vaccine dose is at least 95% effective in preventing clinical measles and 92% effective in preventing secondary cases among household contacts.Effectiveness of at least one dose of MMR in preventing clinical mumps in children is estimated to be between 69% and 81% for the vaccine prepared with Jeryl Lynn mumps strain and between 70% and 75% for the vaccine containing the Urabe strain. Vaccination with MMR containing the Urabe strain has demonstrated to be 73% effective in preventing secondary mumps cases. Effectiveness of Jeryl Lynn containing MMR in preventing laboratory-confirmed mumps cases in children and adolescents was estimated to be between 64% to 66% for one dose and 83% to 88% for two vaccine doses. We did not identify any studies assessing the effectiveness of MMR in preventing rubella.The highest risk of association with aseptic meningitis was observed within the third week after immunisation with Urabe-containing MMR (risk ratio (RR) 14.28; 95% confidence interval (CI) from 7.93 to 25.71) and within the third (RR 22.5; 95% CI 11.8 to 42.9) or fifth (RR 15.6; 95% CI 10.3 to 24.2) weeks after immunisation with the vaccine prepared with the Leningrad-Zagreb strain. A significant risk of association with febrile seizures and MMR exposure during the two previous weeks (RR 1.10; 95% CI 1.05 to 1.15) was assessed in one large person-time cohort study involving 537,171 children aged between three months and five year of age. Increased risk of febrile seizure has also been observed in children aged between 12 to 23 months (relative incidence (RI) 4.09; 95% CI 3.1 to 5.33) and children aged 12 to 35 months (RI 5.68; 95% CI 2.31 to 13.97) within six to 11 days after exposure to MMR vaccine. An increased risk of thrombocytopenic purpura within six weeks after MMR immunisation in children aged 12 to 23 months was assessed in one case-control study (RR 6.3; 95% CI 1.3 to 30.1) and in one small self controlled case series (incidence rate ratio (IRR) 5.38; 95% CI 2.72 to 10.62). Increased risk of thrombocytopenic purpura within six weeks after MMR exposure was also assessed in one other case-control study involving 2311 children and adolescents between one month and 18 years (odds ratio (OR) 2.4; 95% CI 1.2 to 4.7). Exposure to the MMR vaccine was unlikely to be associated with autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn's disease, demyelinating diseases, bacterial or viral infections.

AUTHORS' CONCLUSIONS

The design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate. The evidence of adverse events following immunisation with the MMR vaccine cannot be separated from its role in preventing the target diseases.

Spread of measles virus D4-Hamburg, Europe, 2008-2011

A new strain of measles virus, D4-Hamburg, was imported from London to Hamburg in December 2008 and subsequently spread to Bulgaria, where an outbreak of >24,300 cases was observed. We analyzed spread of the virus to demonstrate the importance of addressing hard-to-reach communities within the World Health Organization European Region regarding access to medical care and vaccination campaigns. The D4-Hamburg strain appeared during 2009-2011 in Poland, Ireland, Northern Ireland, Austria, Greece, Romania, Turkey, Macedonia, Serbia, Switzerland, and Belgium and was repeatedly reimported to Germany. The strain was present in Europe for >27 months and led to >25,000 cases in 12 countries. Spread of the virus was prevalently but not exclusively associated with travel by persons in the Roma ethnic group; because this travel extends beyond the borders of any European country, measures to prevent the spread of measles should be implemented by the region as a whole.

Epidemiological and molecular assessment of a measles outbreak in a highly vaccinated population of northeast Italy

Two distinct measles outbreaks, unrelated from the epidemiological point of view but caused by genetically related strains, occurred in the Friuli Venezia Giulia region of northeastern Italy. Forty-two cases were reported during the period April-May 2008. In the first outbreak the index case was a teacher who introduced the virus into the Pordenone area, involving eight adolescents and young adults. The other concomitant outbreak occurred in the city of Trieste with 33 cases. The containment of the epidemics can be explained by the high MMR vaccine coverage in an area where the first dose was delivered to 93·4% and the second dose to 88·3% of the target children. Phylogenetic analysis of 14 measles virus strains showed that they belonged to a unique D4 genotype indistinguishable from the MVs/Enfield.GBR/14.07 strain, probably introduced from areas (i.e. Piedmont and Germany) where this genotype was present or had recently caused a large epidemic.

Isolation and complete nucleotide sequence of the measles virus IMB-1 strain in China

The complete nucleotide sequence of the measles virus strain IMB-1, which was isolated in China, was determined. As in other measles viruses, its genome is 15,894 nucleotides in length and encodes six proteins. The full-length nucleotide sequence of the IMB-1 isolate differed from vaccine strains (including wild-type Edmonston strain) by 4%-5% at the nucleotide sequence level. This isolate has amino acid variations over the full genome, including in the hemagglutinin and fusion genes. This report is the first to describe the full-length genome of a genotype H1 strain and provide an overview of the diversity of genetic characteristics of a circulating measles virus.

Antibiotics for preventing complications in children with measles

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

In this 2008 update we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1) MEDLINE (1966 to January week 1, 2008), EMBASE (1980 to December 2007) and the National Research Register (Issue 3, 2007).

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

Seven trials with 1385 children were included. Pooled study data showed that the incidence of pneumonia was lower in the treatment group compared to the control group. However, the difference was not statistically significant. In children who received antibiotics, 1.9% developed pneumonia, while in the control group 6% developed pneumonia (OR 0.28; 95% CI 0.06 to 1.25). The one trial that showed an increase in the rate of pneumonia with antibiotics was conducted in 1942 and compared oral sulfathiazole with symptomatic treatment. If the results of this trial are removed from the meta-analysis, and the remaining six studies are combined, there is a statistically significant reduction in the incidence of pneumonia in children receiving antibiotics (OR 0.17; 95% CI 0.05 to 0.65). The number needed to treat to prevent one episode of pneumonia is 24 patients. The incidence of other complications was significantly lower in children receiving antibiotics: purulent otitis media (OR 0.34; 95% CI 0.16 to 0.73) and tonsillitis (OR 0.08; 95% CI 0.01 to 0.72). There was no difference in the incidence of conjunctivitis (OR 0.39; 95% CI 0.15 to 1.0), diarrhea (OR 0.53; 95% CI 0.23 to 1.22) or croup (OR 0.16; 95% CI 0.01 to 4.06).

AUTHORS' CONCLUSIONS

This review suggests a beneficial effect of antibiotics in preventing complications such as pneumonia, purulent otitis media and tonsillitis in children with measles. On the basis of this review, it is not possible to give definitive guidelines on the type of antibiotic, duration, or the day of initiation. Use of penicillin or co-trimoxazole may be considered. There is a need to generate more evidence by well planned RCTs to answer these questions.