Further efforts needed to achieve measles elimination in Germany: results of an outbreak investigation

Measles outbreak in Semuto Subcounty, Nakaseke District, Uganda, June-August 2021

Background

Semuto Subcounty reported rubella/measles outbreaks in January 2020 and June-August 2021. This study investigated the outbreak in 2021 to determine the scope, and the factors associated with transmission.

Methods

A probable case was defined as a resident of Semuto Subcounty with acute onset of fever and a generalized maculopapular rash with either cough/cold or red eyes from 1 June to 31 August 2021. A confirmed case was defined as a probable case with a blood sample positive for measles-specific IgM. A village-matched case-control study was conducted with 30 cases and 122 controls (1:4 ratio). A control was defined as an individual aged 6 months-9 years, sampled at random, with no signs or symptoms of measles from 1 June to 31 August 2021, residing in the same village as the matched case. Adjusted Mantel-Haenszel odds ratios (ORMH) and confidence intervals (CIs) were calculated.

Results

Of the 30 cases (27 probable and three confirmed), 16 (53%) were male. The subcounty attack rate (AR) was 3.2/1000. Children aged 5-9 years were the most affected (AR 5.0/1000). Twenty-two (79%) cases and 116 (97%) controls had ever received measles vaccine (ORMH 0.13, 95% CI 0.03-0.52). Interaction with symptomatic persons at water collection points (ORMH 4.4, 95% CI 1.6-12) and playing at community playgrounds (ORMH 4.2, 95% CI 1.7-11) increased the odds of infection.

Conclusions

Socializing/congregating at water collection points and community playgrounds facilitated the transmission of measles in this outbreak.

Thoughts, beliefs and concepts concerning infectious childhood diseases of physicians practicing homeopathic, anthroposophic and conventional medicine - a qualitative study

Background

Physicians who include complementary medicine in their practice are thought to have an understanding of health and disease different from that of colleagues practicing conventional medicine. The aim of this study was to identify and compare the thoughts and concepts concerning infectious childhood diseases (measles, mumps, rubella, chickenpox, pertussis and scarlet fever) of physicians practicing homeopathic, anthroposophic and conventional medicine.

Methods

This qualitative study used semistructured interviews. Participating physicians were either general practitioners or pediatricians. Data collection and analysis were guided by a grounded theory approach.

Results

Eighteen physicians were interviewed (6 homeopathic, 6 anthroposophic and 6 conventional). All physicians agreed that while many classic infectious childhood diseases such as measles, mumps and rubella are rarely observed today, other diseases, such as chickenpox and scarlet fever, are still commonly diagnosed. All interviewed physicians vaccinated against childhood diseases. A core concern for physicians practicing conventional medicine was the risk of complications of the diseases. Therefore, it was considered essential for them to advise their patients to strictly follow the vaccination schedule. Homeopathic-oriented physicians viewed acute disease as a biological process necessary to strengthen health, fortify the immune system and increase resistance to chronic disease. They tended to treat infectious childhood diseases with homeopathic remedies and administered available vaccines as part of individual decision-making approaches with parents. For anthroposophic-oriented physicians, infectious childhood diseases were considered a crucial factor in the psychosocial growth of children. They tended to treat these diseases with anthroposophic medicine and underlined the importance of the family’s resources. Informing parents about the potential benefits and risks of vaccination was considered important.

All physicians agreed that parent-delivered loving care of a sick child could benefit the parent-child relationship. Additionally, all recognized that existing working conditions hindered parents from providing such care for longer durations of time.

Conclusions

The interviewed physicians agreed that vaccines are an important aspect of modern pediatrics. They differed in their approach regarding when and what to vaccinate against. The different conceptual understandings of infectious childhood diseases influenced this decision-making. A survey with a larger sample would be needed to verify these observations.

Measles vaccination among children in border areas of Yunnan Province, Southwest China

BACKGROUND

Border areas are at high risk of measles epidemics. This study aimed to evaluate the effectiveness of the implementation of the routine two-dose measles containing vaccine (MCV) program in border counties of Southwest China.

METHODS

Data used in the study were derived from a cross-sectional survey among 1,467 children aged 8 to 84 months from five border counties of Yunnan Province, Southwest China in 2016. The participants were recruited using a multistage sampling method. Primary guardians of the children were interviewed to collect information on vaccination history, socio-economic status, and knowledge about immunization. Both coverage and timely coverage for the first (MCV1) and the second (MCV2) dose of MCV were calculated. The Kaplan-Meier method was performed to estimate the cumulative coverage of MCV, and Log-rank tests were adopted to compare the differences across counties and birth cohorts. Univariate and multivariate logistic regression models were used to investigate the predictors of delayed MCV1 vaccination.

RESULTS

The coverage for MCV1 and MCV2 were 97.5% and 93.4%, respectively. However, only 63.8% and 84.0% of the children received MCV1 or MCV2 on time. Significant differences in the cumulative coverage were detected across counties and birth cohorts. Results of the multivariate logistic regression analysis indicated that children whose primary guardian knew the schedule of MCV were less likely to receive MCV1 late (OR = 0.63, P<0.01). For the guardians, doctors at vaccination units were the primary and also the most desired source of vaccination information.

CONCLUSIONS

Although the coverage for MCV is high in border areas of Southwest China, the timeliness of MCV vaccination seems suboptimal. Tailored information from local health professionals may help to reduce untimely vaccination.

Effect of vaccination on severity and infectiousness of measles during an outbreak in the Netherlands, 2013-2014

An outbreak of measles in the Netherlands in 2013-2014 provided an opportunity to assess the effect of MMR vaccination on severity and infectiousness of measles.Measles is notifiable in the Netherlands. We used information on vaccination, hospitalisation, complications, and most likely source(s) of infection from cases notified during the outbreak. When a case was indicated as a likely source for at least one other notified case, we defined it as infectious. We estimated the age-adjusted effect of vaccination on severity and infectiousness with logistic regression.Of 2676 notified cases, 2539 (94.9%) were unvaccinated, 121 (4.5%) were once-vaccinated and 16 (0.6%) were at least twice-vaccinated; 328 (12.3%) cases were reported to have complications and 172 (6.4%) cases were hospitalised. Measles in twice-vaccinated cases led less often to complications and/or hospitalisation than measles in unvaccinated cases (0% and 14.5%, respectively, aOR 0.1 (95% CI 0-0.89), P = 0.03). Of unvaccinated, once-vaccinated and twice-vaccinated cases, respectively, 194 (7.6%), seven (5.1%) and 0 (0%) were infectious. These differences were not statistically significant (P > 0.05).Our findings suggest a protective effect of vaccination on the occurrence of complications and/or hospitalisation as a result of measles and support the WHO recommendation of a two-dose MMR vaccination schedule.

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

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

Inferring collective dynamical states from widely unobserved systems

When assessing spatially extended complex systems, one can rarely sample the states of all components. We show that this spatial subsampling typically leads to severe underestimation of the risk of instability in systems with propagating events. We derive a subsampling-invariant estimator, and demonstrate that it correctly infers the infectiousness of various diseases under subsampling, making it particularly useful in countries with unreliable case reports. In neuroscience, recordings are strongly limited by subsampling. Here, the subsampling-invariant estimator allows to revisit two prominent hypotheses about the brain’s collective spiking dynamics: asynchronous-irregular or critical. We identify consistently for rat, cat, and monkey a state that combines features of both and allows input to reverberate in the network for hundreds of milliseconds. Overall, owing to its ready applicability, the novel estimator paves the way to novel insight for the study of spatially extended dynamical systems.

From infectious diseases to brain activity, complex systems can be approximated using autoregressive models. Here, the authors show that incomplete sampling can bias estimates of the stability of such systems, and introduce a novel, unbiased metric for use in such situations.

Modeling the Transmission of Measles and Rubella to Support Global Management Policy Analyses and Eradication Investment Cases

Policy makers responsible for managing measles and rubella immunization programs currently use a wide range of different vaccines formulations and immunization schedules. With endemic measles and rubella transmission interrupted in the region of the Americas, all five other regions of the World Health Organization (WHO) targeting the elimination of measles transmission by 2020, and increasing adoption of rubella vaccine globally, integrated dynamic disease, risk, decision, and economic models can help national, regional, and global health leaders manage measles and rubella population immunity. Despite hundreds of publications describing models for measles or rubella and decades of use of vaccines that contain both antigens (e.g., measles, mumps, and rubella vaccine or MMR), no transmission models for measles and rubella exist to support global policy analyses. We describe the development of a dynamic disease model for measles and rubella transmission, which we apply to 180 WHO member states and three other areas (Puerto Rico, Hong Kong, and Macao) representing >99.5% of the global population in 2013. The model accounts for seasonality, age-heterogeneous mixing, and the potential existence of preferentially mixing undervaccinated subpopulations, which create heterogeneity in immunization coverage that impacts transmission. Using our transmission model with the best available information about routine, supplemental, and outbreak response immunization, we characterize the complex transmission dynamics for measles and rubella historically to compare the results with available incidence and serological data. We show the results from several countries that represent diverse epidemiological situations to demonstrate the performance of the model. The model suggests relatively high measles and rubella control costs of approximately $3 billion annually for vaccination based on 2013 estimates, but still leads to approximately 17 million disability-adjusted life years lost with associated costs for treatment, home care, and productivity loss costs of approximately $4, $3, and $47 billion annually, respectively. Combined with vaccination and other financial cost estimates, our estimates imply that the eradication of measles and rubella could save at least $10 billion per year, even without considering the benefits of preventing lost productivity and potential savings from reductions in vaccination. The model should provide a useful tool for exploring the health and economic outcomes of prospective opportunities to manage measles and rubella. Improving the quality of data available to support decision making and modeling should represent a priority as countries work toward measles and rubella goals.

Large measles epidemic in the Netherlands, May 2013 to March 2014: changing epidemiology

Since the early 1990s, the Netherlands has experienced several large measles epidemics, in 1992–94, 1999–2000 and in 2013–14. These outbreaks mainly affected orthodox Protestants, a geographically clustered population with overall lower measles-mumps-rubella first dose (MMR-1) vaccination coverage (60%) than the rest of the country (> 95%). In the 2013–14 epidemic described here, which occurred between 27 May 2013 and 12 March 2014, 2,700 cases were reported. Several control measures were implemented including MMR vaccination for 6–14-month-olds and recommendations to reduce the risk in healthcare workers. The vast majority of reported cases were unvaccinated (94%, n = 2,539), mostly for religious reasons (84%, n = 2,135). The median age in the epidemic was 10 years, 4 years older than in the previous epidemic in 1999–2000. A likely explanation is that the inter-epidemic interval before the 2013–2014 epidemic was longer than the interval before the 1999–2000 epidemic. The size of the unvaccinated orthodox Protestant community is insufficient to allow endemic transmission of measles in the Netherlands. However, large epidemics are expected in the future, which is likely to interfere with measles elimination in the Netherlands and elsewhere.

A report of outbreaks of measles on the southern coast of Iran from 2009 to 2015

Introduction

Immunogenicity assessment figures of the measles vaccine is approximately 90%, and decreases over time. Therefore, the immunity level of measles vaccine is variable which can result in outbreaks of measles in a population. The aim of current study was to report the outbreaks of measles in Hormozgan province from 2009 to 2015.

Methods

This cross-sectional study was carried out in Hormozgan Province on the southern coast of Iran. The documented data of all cases suspected of measles are included in this study. We used a checklist including gender, age, area, place of residence, contact history, and vaccination status to extract required data. Data was analyzed using IBM SPSS statistics software version 21.0.

Results

Eight hundred fifty-one suspicious cases of measles were determined from 2006 to 2015. Of those, 135 infected cases were reported. Among patients, 49% were male, 79% were Iranian, 18% were Afghans, and 3 % were Indians or Pakistanis. Also, 31% of cases were reported from Bandar Abbas, 25% were reported from Minab, 18% from Qeshm, 17 % from Jask and other cases were reported from other areas of the Hormozgan Province. Thirty percent of the cases were reported from urban areas.

Conclusion

A high percentage of cases with measles in rural areas were reported in the areas which were covered by complete vaccination. This shows interruption of cold continuum. Also, increasing the number of under one-years-old cases reported, could be due to poor nutritional status of the children and insufficient immunization of mothers. Further studies are required for identifying the causes of cold continuum interruption. Further studies are required for the assessment of immunization in children and mothers and various vaccination protocols.

Epidemiology and economic burden of measles, mumps, pertussis, and varicella in Germany: a systematic review

OBJECTIVES

Despite the availability of vaccines and the existence of public vaccination recommendations, outbreaks of vaccine-preventable childhood diseases still cause public health debate. The objective of this systematic review was to provide an overview of the current epidemiology and economic burden of measles, mumps, pertussis, and varicella in Germany.

METHODS

We systematically reviewed studies published since 2000. The literature search was conducted using PubMed and EMBASE. Also, we used German notification data to give an up-to-date overview of the epidemiology of the four diseases under consideration.

RESULTS

Thirty-six studies were included in our review. Results suggest that there is still considerable morbidity due to childhood diseases in Germany. Studies providing cost estimates are scarce. Comparative analyses of different data sources (notification data vs. claims data) revealed a potential underestimation of incidence estimates when using notification data. Furthermore, several studies showed regional differences in incidence of some of the diseases under consideration.

CONCLUSIONS

Our findings underline the need for improved vaccination and communication strategies targeting all susceptible age and risk groups on a national and local level.

Systematic Review of Health Economic Analyses of Measles and Rubella Immunization Interventions

Economic analyses for vaccine-preventable diseases provide important insights about the value of prevention. We reviewed the literature to identify all of the peer-reviewed, published economic analyses of interventions related to measles and rubella immunization options to assess the different types of analyses performed and characterize key insights. We searched PubMed, the Science Citation Index, and references from relevant articles for studies in English and found 67 analyses that reported primary data and quantitative estimates of benefit-cost or cost-effectiveness analyses for measles and/or rubella immunization interventions. We removed studies that we characterized as cost-minimization analyses from this sample because they generally provide insights that focused on more optimal strategies to achieve the same health outcome. The 67 analyses we included demonstrate the large economic benefits associated with preventing measles and rubella infections using vaccines and the benefit of combining measles and rubella antigens into a formulation that saves the costs associated with injecting the vaccines separately. Despite the importance of population immunity and dynamic viral transmission, most of the analyses used static models to estimate cases prevented and characterize benefits, although the use of dynamic models continues to increase. Many of the analyses focused on characterizing the most significant adverse outcomes (e.g., mortality for measles, congenital rubella syndrome for rubella) and/or only direct costs, and the most complete analyses present data from high-income countries.

The Costs and Valuation of Health Impacts of Measles and Rubella Risk Management Policies

National and global health policymakers require good information about the costs and benefits of their investments in measles and rubella immunization programs. Building on our review of the existing measles and rubella health economics literature, we develop inputs for use in regional and global models of the expected future benefits and costs of vaccination, treatment, surveillance, and other global coordination activities. Given diversity in the world and limited data, we characterize the costs for countries according to the 2013 World Bank income levels using 2013 U.S. dollars (2013$US). We estimate that routine immunization and supplemental immunization activities will cost governments and donors over 2013$US 2.3 billion per year for the foreseeable future, with high-income countries accounting for 55% of the costs, to vaccinate global birth cohorts of approximately 134 million surviving infants and to protect the global population of over 7 billion people. We find significantly higher costs and health consequences of measles or rubella disease than with vaccine use, with the expected disability-adjusted life year (DALY) loss for case of disease generally at least 100 times the loss per vaccine dose. To support estimates of the economic benefits of investments in measles and/or rubella elimination or control, we characterize the probabilities of various sequelae of measles and rubella infections and vaccine adverse events, the DALY inputs for health outcomes, and the associated treatment costs. Managing measles and rubella to achieve the existing and future regional measles and rubella goals and the objectives of the Global Vaccine Action Plan will require an ongoing commitment of financial resources that will prevent adverse health outcomes and save the associated treatment costs.

Vaccines4Kids: Assessing the impact of text message reminders on immunization rates in infants

The purpose of this study was to examine the effect text messages (TM) immunization reminders have on immunization rates in the first 7 months of life. This randomized-control trial enrolled 57 parent/infant dyads and had a 74% completion rate (43) at the end of the study period. The study was approved by Committee on Human Subjects at the University of Hawaii Institutional Board Review. All participants completed a demographics form and a Barriers to Immunization Survey (SHOTS survey) at the start and end of the study. Parents received TM at 4, 7, 12, 15, 20, & 23 weeks of child's age. The intervention group received immunization reminders and the control group received healthy baby messages. In the overall mixed model, between enrollment and 7 months of age, the barriers to immunizations decreased for all parents significantly. There were no significant differences in immunization rates between groups at 7 months of age. Positive responses from regarding TM interventions show this is a promising intervention, but further research is required regarding how to address behavior change and motivation for health prevention behaviors with TM.

Measles incidence and reporting trends in Germany, 2007-2011

Objective

We aimed to quantify progress towards measles elimination in Germany from 2007 to 2011 and to estimate any potential underreporting over this period.

Methods

We determined the annual incidence of notified cases of measles – for each year – in northern, western, eastern and southern Germany and across the whole country. We then used measles-related health insurance claims to estimate the corresponding incidence.

Findings

In each year between 2007 and 2011, there were 6.9–19.6 (mean: 10.8) notified cases of measles per million population. Incidence decreased with age and showed geographical variation, with highest mean incidence – 20.3 cases per million – in southern Germany. Over the study period, incidence decreased by 10% (incidence rate ratio, IRR: 0.90; 95% confidence interval, CI: 0.85–0.95) per year in western Germany but increased by 77% (IRR: 1.77; 95% CI: 1.62–1.93) per year in eastern Germany. Although the estimated incidence of measles based on insurance claims showed similar trends, these estimates were 2.0- to 4.8-fold higher than the incidence of notified cases. Comparisons between the data sets indicated that the underreporting increased with age and was generally less in years when measles incidence was high than in low-incidence years.

Conclusion

Germany is still far from achieving measles elimination. There is substantial regional variation in measles epidemiology and, therefore, a need for region-specific interventions. Our analysis indicates underreporting in the routine surveillance system between 2007 and 2011, especially among adults.

The tumor-associated marker, PVRL4 (nectin-4), is the epithelial receptor for morbilliviruses

PVRL4 (nectin-4) was recently identified as the epithelial receptor for members of the Morbillivirus genus, including measles virus, canine distemper virus and peste des petits ruminants virus. Here, we describe the role of PVRL4 in morbillivirus pathogenesis and its promising use in cancer therapies. This discovery establishes a new paradigm for the spread of virus from lymphocytes to airway epithelial cells and its subsequent release into the environment. Measles virus vaccine strains have emerged as a promising oncolytic platform for cancer therapy in the last ten years. Given that PVRL4 is a well-known tumor-associated marker for several adenocarcinoma (lung, breast and ovary), the measles virus could potentially be used to specifically target, infect and destroy cancers expressing PVRL4.

[Measles surveillance in Germany. From sentinel to mandatory surveillance]

From September 1999 to March 2011, sentinel surveillance of measles was conducted by a self-selected sample of private physicians in Germany. From 2001, when mandatory surveillance for measles was established, two surveillance systems worked in parallel. The aim of this article is to summarize the strengths and limitations of sentinel versus mandatory surveillance. Active monthly reporting included case-based questionnaires on patients with (suspected) measles or zeroreporting. For confirmation of measles, the diagnostic patient specimens were sent to regional laboratories for serological tests or to the National Reference Laboratory (NRC). In the NRC in addition to serological tests measles-virus (MV) detection by PCR in urine, throat swabs, and oral fluid (since 2003) as well as MVgenotyping was offered. From January 2000 to December 2010, 934 out of 1,488 participating sentinel-practices did not see any measles case, while 554 reported 3,573 suspected cases. Measles was confirmed by laboratory testing in 801 cases, excluded in 473 cases, and the diagnosis remained uncertain in 215 cases. Of 3,100 analyzed cases, 2,712 (87 %) were unvaccinated, 217 (7 %) and 32 (1 %) were vaccinated with one or two doses, respectively, and for 139 (4 %) cases the vaccination status was unknown. The main reason for not being vaccinated against measles was refusal (n = 1,383). The confirmation rate was lower in the vaccinated than in the unvaccinated patients (19 % vs. 63 %). Since 2006, sentinel-cases have differed from notified cases by region and age. The proportion of sentinel cases from all NRC-investigated cases decreased from more than  50 % (2002) to less than  5 % (since 2007). Sentinel surveillance allowed for the detection of trends, delivered additional information for measles prevention, and played a major role in measles diagnostics. Since mandatory surveillance was established and sentinel surveillance no longer reflected the epidemiologic situation, the latter was abandoned in April 2011.

[Knowledge, attitude, and practice concerning measles vaccination. Approaches for national vaccination education]

Achievement of the goal to eliminate measles by 2015 set by the European region of the World Health Organization (WHO) necessitates an increase in the willingness of German nationals to get vaccinated. To identify influential factors on vaccination behavior as the basis for communication measures specific to target groups, the Federal Centre for Health Education (BZgA) has conducted two representative surveys on attitude, knowledge, and practice concerning vaccination among parents of children between 0 and 13 years as well as among adolescents and adults. The parents' survey (n = 3,002) revealed that more than one-third see measles as a harmless disease. The survey of adolescents and adults (n = 4,483, 16-85 years) also shows that about one-quarter of the interviewees between 16 and 44 years regarded vaccination against measles as not very important. Moreover, 81 % of adults born after 1970 without sufficient existing vaccine protection were not aware of the new measles vaccination recommendation for this age group. Personal consultation with the physician was regarded as the major source of vaccination information in both surveys. About half of all persons interviewed intended to obtain information about vaccinations on the Internet. The results of these studies were used for the development of a nationwide multilevel BZgA campaign on vaccination protection against measles, its goal being to support medical professionals with comprehensive information and to enable adolescents and young adults via different communication measures to make well-informed vaccination decisions.

Measles epidemic from 1951 to 2012 and vaccine effectiveness in Guangzhou, southern China

BACKGROUND

Since the National Expanded Program on Immunization was implemented in China, considerable progress has been made in reducing the incidence of measles. However, the incidence of measles increased again in 2004. Few post-marketing studies on measles vaccine effectiveness were reported in China. In this study, we aimed to describe the measles epidemic and to evaluate the effectiveness of the measles vaccine in Guangzhou, southern China.

METHODS

Based on the surveillance data for measles, we investigated the epidemiology during different periods between 1951 and 2012. We analyzed the clinical characteristics of laboratory-confirmed cases of measles between 2009 and 2012 and conducted a case-control study using test-negative cases as controls. We determined the protective effect of measles vaccine.

RESULTS

The highest annual incidence in Guangzhou was 2187.15/100,000 in 1964, and the lowest was 0.32/100,000 in 2011. The average incidence of measles from 1951 to 2012 was 306.27/100,000. There was a significant tendency of decline in recent years. From 2009 to 2012, there are 700 laboratory-confirmed cases were reported with an average onset age of 2.5 (median) years. The non-vaccinated target population (age<8 months and ≥ 15 years) accounted for 56.7% of the cases. The transient (non-resident) population accounted for 51.3% of the cases. Fewer cases were observed in the population targeted for measles vaccine (aged 8 months to 14 years). The effectiveness of a single dose of the measles vaccine was 89.1% (95% confidence interval (CI), 44.5-97.9), and the effectiveness of ≥ 2 doses of the measles vaccine was 97.8% (95% CI, 88.3-99.6) in children aged 8 months to 14 years old.

CONCLUSIONS

There is a significant overall decline in the incidence of measles (including clinical and laboratory confirmed cases) in the measles vaccine targeted population in Guangzhou. Two doses of measles vaccine are more effective than one dose in preventing measles in China. In order to accelerate the elimination of measles, vaccination should also be given to the transient and the non-vaccine targeted population.

The effects of weather conditions on measles incidence in Guangzhou, Southern China

BACKGROUND

Few studies were conducted to examine the effects of weather conditions on the incidence of measles.

METHODS

We used a distributed lag nonlinear model (DLNM) to analyze the relationship between meteorological factors and measles incidence in Guangzhou, China.

RESULTS

Nonlinear effects of temperature and relative humidity on measles incidence were observed. The relative risk (RR) for the measles incidence associated with the 75th percentile of mean temperature (27.9 °C) relative to the median of mean temperature (24.7 °C) was 1.00 (0.86,1.16) for lags 0-10 days. The RR for the measles incidence associated with the 25th percentile of relative humidity (64%) relative to the median of relative humidity (73%) was 1.36 (1.01,1.82) for lags 0-30 days. The wet effects and dry effects were larger in females than in males. The wet effects were generally increased with ages. Significantly negative effects of cold spells on measles incidence were observed.

CONCLUSION

Both hot and cold temperatures result in decreases in the incidence of measles, and low relative humidity is a risk factor of measles morbidity. An increased number of measles cases might occur before and after a cold spell. Our findings highlight the need to pay more attention to the weather transformation and improve the immunity of susceptible population for measles elimination. Catch-up vaccination campaigns should be initiated among young adults.

[Demands and expectations of parents who refuse vaccinations and perspective of health professional on the refusal to vaccinate]

OBJECTIVES

To examine the opinions, beliefs and attitudes about vaccination, of parents who decide not to vaccinate their children. To determine the opinions and attitudes of the health professionals on the behaviour towards childhood vaccination.

METHOD

Qualitative research based on semi-structured interviews and focal groups in Granada, Spain, including parents who chose to not vaccinate their children, and healthcare professionals who can provide a technical point of view. An analysis was made of the semantic content, and answers were categorized in thematic units.

RESULTS

The parents argued on the benefit of suffering vaccine-preventable diseases in a natural way, without non-natural, aggressive or toxic products. Vaccination was considered unnecessary, if given adequate hygienic-sanitary conditions, effectiveness unproven and more dangerous than the diseases they prevent, especially the polyvalent vaccines. They believed that vaccination programs are moved by biased studies and interests other than prevention. Health care professionals believe that they had fears without scientific basis, which requires improving information systems.

CONCLUSIONS

Non-vaccinators are unaware of the benefit/risk ratio between the vaccination and the individual risk for preventable diseases, and ask for informed consent. Health care professionals believe that non-vaccinators' arguments are not correctly contrasted and expose the existence of failures in actual vaccination coverage and information registration systems. It was suggested to centralize registers and compare them in schools, working with local leaders and reporting regularly on the status of vaccine-preventable diseases.

Measles outbreak in Macedonia: epidemiological, clinical and laboratory findings and identification of susceptible cohorts

OBJECTIVES

Despite a 92-99% national vaccination coverage since 2000, the former Yugoslav Republic of Macedonia experienced a large measles outbreak between 2010 and 2011. Here we investigate the characteristics of patients hospitalized during this outbreak at the Clinic of Infectious Diseases in Skopje.

METHODS

Epidemiological, clinical and laboratory data of 284 measles patients, including 251 from Skopje (43.80% of the 573 reported cases) and 33 from elsewhere in Macedonia were collected.

RESULTS

The most affected age groups were children up to 4 years of age and adolescents/adults of 15 years and older. Most patients were unvaccinated (n=263, 92.61%) and many had non-Macedonian nationalities (n=156, 54.93%) or belonged to the Roma ethnicity (n=73, 25.70%). Bronchopneumonia and diarrhea were the most common complications. Eighty-two out of 86 tested patients (95.35%) had measles-specific IgM antibodies. The outbreak was caused by the measles variant D4-Hamburg.

CONCLUSIONS

The epidemic identified pockets of susceptibles in Skopje and indicated that additional vaccination opportunities in particular for people with non-Macedonian nationality and traveler communities are warranted to ensure efficient measles control in Macedonia. The high attack rate among children of less than 1 year suggests that vaccination before 12 months of age should be considered in high risk settings.

[Hot spot: epidemiology of measles and rubella in Germany and the WHO European region]

The elimination of measles and rubella by 2015 is an important goal set by the World Health Organization European Region (WHO/Europa). Since 1991, the incidence of measles in WHO/Europa declined owing to routine childhood vaccination and supplementary immunization activities in the region. However, in many countries of Western Europe elimination of measles and rubella remains a challenge, and every year there are outbreaks with partly long-lasting transmission chains and dissemination of the virus internationally. In Germany, outbreaks occur because of the high proportion of susceptible individuals in specific population groups. In 2011, over 1,600 cases were reported (19.7 per 1,000,000 inhabitants, data from the Robert Koch Institute) whereas in 2012 only 167 cases were reported to the Robert Koch Institute (2 per 1,000,000 inhabitants). It is unclear whether the declining trend will continue in the following years due to improved vaccination coverage or whether number of cases will rise again because of the accumulation of susceptible groups. In Germany, there are currently no representative, country-wide data on rubella; however, data from the eastern federal states provide important epidemiological insights. Outbreaks are seldom reported, but statutory notification of rubella and congenital rubella syndrome was implemented in March 2013. As a result, it will be possible to better assess the epidemiology of rubella in Germany, although a considerable underreporting of rubella cases is anticipated.

Effectiveness and timing of vaccination during school measles outbreak

Implementing a vaccination campaign during an outbreak can effectively reduce the outbreak size.

Attitudes towards the Eradication of Measles and CAM Orientation of General Physicians. Is There a Direct Link? A Decision Tree Analysis

<b><i>Background: </i></b>The goal of measles eradication is still broadly discussed by health care authorities. Several studies suggest negative attitudes of general physicians (GPs) oriented in complementary and alternative medicine (CAM) with regard to measles eradication. We intended to identify prognostic factors for positive/negative attitudes in a survey of German GPs. <b><i>Methods: </i></b>In 2004, a total of 732 GPs received a questionnaire to evaluate their attitudes towards the eradication of measles asking for age, gender, medical qualification, license by health insurance, CAM orientation, monthly number of early detection checkups, patients per day, appraisal of significance of legal aspects and parents' autonomy. We carried out a QUEST decision tree analysis to identify predictors for a positive/negative attitude towards the eradication of measles. <b><i>Results: </i></b>621 GPs (348 conventional vs. 273 CAM-oriented GPs) sufficiently completed the questionnaire and were included in this analysis. 256 physicians (41%) had a negative attitude towards the eradication of measles. In a 3-level decision tree we found a high number of early detection checkups (U9) in children being the first predictor for a positive attitude, followed in the second node by the CAM orientation. Based on this decision tree only 27 attitudes of GPs (4.4%) were falsely classified as yielding to a kappa index of agreement of k = 0.91 (95% CI: 0.88-0.94). <b><i>Discussion: </i></b>The CAM orientation of the physicians is not the only predictor for positive or negative attitudes towards measles eradication. In particular, the number of early detection checkups of children seems to play a major role in this context. Future research should focus on this aspect.

Effect of thermal environment on the temporal, spatial and seasonal occurrence of measles in Ondo state, Nigeria

We investigated the temporal and spatial dynamics, as well as the seasonal occurrence of measles in Ondo state, Nigeria, to better understand the role of the thermal environment in the occurrence of the childhood killer disease measles, which ranks among the top ten leading causes of child deaths worldwide. The linkages between measles and atmospheric environmental factors were examined by correlating human-biometeorological parameters in the study area with reported clinical cases of measles for the period 1998-2008. We also applied stepwise regression analysis in order to determine the human-biometeorological parameters that lead to statistical changes in reported clinical cases of measles. We found that high reported cases of measles are associated with the least populated areas, where rearing and cohabitation of livestock/domestic animals within human communities are common. There was a significant correlation (P < 0.01) between monthly cases of measles and human-biometeorological parameters except wind speed and vapour pressure. High transmission of measles occurred in the months of January to May during the dry season when human thermal comfort indices are very high. This highlights the importance of the thermal environment in disease demographics since it accounted for more than 40% variation in measles transmission within the study period.

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.

Two consecutive measles outbreaks with genotypes D8 and D4 in two mainly unvaccinated communities in Germany

A measles infection in a 13-year-old student from a free progressive school was the index case for an outbreak in Essen in 2010. In this type of school, mainly unvaccinated and measles-susceptible children accumulate. This observation is confirmed by the fact that some of the recent outbreaks originated in such institutions. In Essen, this outbreak was followed by a second smaller outbreak in unvaccinated children and adults in a low socio-economic setting and migration background. Measles were diagnosed clinically and/or were serologically confirmed. Genotyping of measles isolates was performed by PCR and sequencing. Vaccination certificates were checked by the Community Health Centre (CHC) of the City of Essen. Measures to prevent the spread of the infection were implemented and enforced according to the National Protection Against Infection Act (IfSG). In total, 86 cases of measles were notified from March to July 2010. Of all infected patients, 97 % had had no vaccination and 15 % had to be hospitalised. Clinical courses showed the severity of this infection. Epidemiologic evaluation and genotyping of measles virus (MV) detected in Essen revealed the presence of two distinct chains of MV transmission by genotypes D8 and D4 causing two independent outbreaks. The outbreaks were caused by the index cases, and the spread of infection was facilitated by insufficient vaccination coverage in certain groups. Immediate suspension of non-immune children from classes for 2 weeks might have limited the outbreak in the free progressive school. Overall, high measles vaccination coverage in children and adolescents in regular schools in Essen presumably prevented a greater spread of the virus.

Measles outbreak in an asylum-seekers' shelter in Germany: comparison of the implemented with a hypothetical containment strategy

In order to contain a measles outbreak in a German asylum-seekers' shelter, serological testing of all residents was performed, followed by selective vaccination of those with negative test results/not tested. In this paper we describe the outbreak epidemiologically and then compare the implemented strategy with a hypothetical mass vaccination of all individuals unvaccinated or with unknown vaccination status born after 1970 as recommended by the German Standing Committee on Vaccination in terms of potentially avoided cases, logistics, and costs. Three hundred (70%) residents participated in the serological testing, of which 39 (13%) were seronegative. In total, 144 individuals were eligible for vaccination, while a mass vaccination would have targeted 359 persons. However, serological testing was time- and personnel consuming and revealed several logistical problems. Its costs amounted to €90 000, double that of mass vaccination that additionally might have avoided three of the eight cases. Mass vaccination seems the preferred measure for measles outbreak control in such settings.

Who are the children at risk? Lessons learned from measles outbreaks

We investigated a measles outbreak in the Jerusalem district in 2007-2008 (992 cases). Most cases (72·6%) were aged <15 years, 42·9% aged <5 years, and 12·8% were infants aged <1 year. The peak incidence rate was in infants aged 6-12 months (916·2/100 000). This represents a significant shift from former outbreaks in 2003-2004, where the peak incidence was in the 1-4 years age group. Of children aged <5 years the proportion aged 6-12 months tripled (7·7% vs. 25·6%). In a case-control study (74 cases, 148 controls) children who developed measles were less likely to be registered in a well-baby clinic and had lower overall immunization coverage. The differences in proportions for registration, DTaP3 and MMR1 coverage were 35·1%, 48·6% and 80·8%, respectively (all P<0·001). Rising birth order of cases and their siblings was associated with non-registration and non-compliance with MMR immunization. The vulnerability of young infants and the risk markers noted above should be taken into account in planning intervention programmes.

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.

Closer to the goal: efforts in measles elimination in Germany 2010

Increasing 2-dose vaccination coverage has led to an interruption of endemic measles virus circulation in Germany. However, outbreaks after virus importation still occur and contribute to international transmission chains. Between 2003 and 2009, annual measles incidence ranged between 0.2 and 2.8 per 100,000 population. Immunization gaps have been identified especially in secondary-school students and young adults, which is also reflected by a shift in age distribution of reported measles cases toward older age groups. Stronger political commitment and standardized guidelines for outbreak containment were put in place in Germany in the past years, but the last step toward measles elimination cannot be made until the number of susceptible individuals has been further reduced. In addition to routine childhood vaccination, supplementary immunization activities are needed targeting school students and young adults to close critical immunization gaps. Intensification of public awareness and sound information on vaccinations are necessary to convince skeptics and remind the forgetful.

Measles transmission from an anthroposophic community to the general population, Germany 2008

BACKGROUND

In Germany, measles vaccination coverage with two doses is not yet sufficient to prevent regional outbreaks. Among the 16 German federal states, vaccination coverage was lowest in Bavaria with 85% in 2008. From March to mid-April 2008, four neighbouring Bavarian counties reported 55 measles-cases mostly linked to an ongoing measles outbreak in an anthroposophic school in Austria. We investigated this outbreak to guide future public health action.

METHODS

We applied the German national case-definition for measles and collected data using the national surveillance system and a questionnaire. Measles cases with disease onset a maximum of 18 days apart and spatial contact (e.g. same household, same school) were summed up in clusters. Two different interventions, which were implemented in schools and kindergartens in Bavaria, were compared by their impact on the size and duration of measles clusters. Susceptible persons were excluded from schools or kindergartens either with the first (intervention A) or second (intervention B) measles case occurring in the respective institution.

RESULTS

Among the 217 Bavarian measles cases identified from March-July 2008, 28 (13%) cases were attendees of the anthroposophic school in Austria. In total, vaccination status was known in 161 (74%) cases and 156 (97%) of them were not vaccinated. The main factor for non-vaccination was "fear of vaccine-related adverse events" (33%). Twenty-nine (18%) of 161 cases suffered complications. Exclusively genotype D5 was detected. Overall, 184 cases could be epidemiologically grouped into 59 clusters. Of those, 41 clusters could be linked to households and 13 to schools or kindergartens. The effect of intervention A and B was analysed in 10 school or kindergarten clusters. Depending on the respective intervention A or B, the median number of cases per cluster was 3 versus 13 (p = 0.05), and the median duration of a cluster was 3 versus 26 days (p = 0.13).

CONCLUSIONS

Introduction of measles virus into a pocket of susceptible persons (e.g. vaccination opponents or sceptics) may lead to large outbreaks in the general population, if the general population's vaccination coverage is below the WHO recommended level. Education on the safety of measles vaccine needs to be strengthened to increase measles vaccination coverage. Early intervention may limit spread in schools or kindergartens. Suspected measles has to be reported immediately to the local health authorities in order to allow intervention as early as possible.

[Measles in 2010. Knowledge and vaccination status of medical students]

OBJECTIVES

In 2002, the WHO Regional Office for Europe developed a strategic plan for measles in the WHO European Region. WHO recommends that at least 95% of children receive two doses of measles vaccine. This plan targeted the elimination of measles for the year 2010 and is supported by the Federal Republic of Germany.

METHODS

Questionnaire survey, serological tests and check-up of the certificates of vaccination were offered to second year medical students of Goethe University Frankfurt/Main, Germany.

RESULTS

Only 62.3% of medical students had received two doses of measles vaccine. Serological data showed that 23.1% were not immune against measles. Important gaps of knowledge were identified in the knowledge test of the survey; less than one third of the students (n=95/324) were able to answer more than 50% of the questions correctly.

DISCUSSION

The suboptimum measles-vaccination coverage shows that the goal of eliminating measles will not be met across Europe by the target year 2010. Both occupational and public health measures need to make sure that vaccination programs should achieve a minimum of 95% coverage with two doses. In addition, the obligation to notify the authorities even of suspected cases serve the same purpose and measures to improve the knowledge of medical students are required. Consequent surveillance systems are necessary to investigate chains of measles infections. Healthcare workers play a decisive role in this issue.

Revealing new measles virus transmission routes by use of sequence analysis of phosphoprotein and hemagglutinin genes

With improved measles virus (MV) control, the genetic variability of the MV-nucleoprotein hypervariable region (NP-HVR) decreases. Thus, it becomes increasingly difficult to determine the origin of a virus using only this part of the genome. During outbreaks in Europe and Africa, we found MV strains with identical NP-HVR sequences. However, these strains showed considerable diversity within a larger sequencing window based on concatenated MV phosphoprotein and hemagglutinin genes (P/H pseudogenes). In Belarus, Germany, Russia, and the Democratic Republic of Congo, the P/H pseudogenes provided insights into chains of transmission, whereas identical NP-HVR provided none. In Russia, for instance, the P/H pseudogene identified temporal clusters rather than geographical clusters, demonstrating the circulation and importation of independent variants rather than large local outbreaks lasting for several years, as suggested by NP-HVR. Thus, by extending the sequencing window for molecular epidemiology, a more refined picture of MV circulation was obtained with more clearly defined links between outbreaks and transmission chains. Our results also suggested that in contrast to the P gene, the H gene acquired fixed substitutions that continued to be found in subsequent outbreaks, possibly with consequences for its antigenicity. Thus, a longer sequencing window has true benefits both for the epidemiological surveillance of measles and for the better monitoring of viral evolution.

Low measles seropositivity rate among children and young adults: a sero-epidemiological study in southern China in 2008

To obtain sero-epidemiological profile and develop optimal strategies to promote measles elimination, we conducted a measles seroprevalence study using stratified sampling method in Guangzhou, southern China in 2008. 4036 samples were analyzed by the enzyme-linked immunosorbent assay method and the overall sero-positive rate of measles antibody was 70.6% (95% CI 69.2-72.0%). Positive seroprevalences differed among age groups (P=0.000) and a W-curve distribution was observed. The 15-29 years group had the low positive rate of 58.8% (95% CI 54.9-62.7%). Catch-up vaccination campaigns should be promoted among susceptible population of ≤ 29 year olds including women of childbearing age.

Heterogeneity in vaccination coverage explains the size and occurrence of measles epidemics in German surveillance data

The objective of this study was to characterize empirically the association between vaccination coverage and the size and occurrence of measles epidemics in Germany. In order to achieve this we analysed data routinely collected by the Robert Koch Institute, which comprise the weekly number of reported measles cases at all ages as well as estimates of vaccination coverage at the average age of entry into the school system. Coverage levels within each federal state of Germany are incorporated into a multivariate time-series model for infectious disease counts, which captures occasional outbreaks by means of an autoregressive component. The observed incidence pattern of measles for all ages is best described by using the log proportion of unvaccinated school starters in the autoregressive component of the model.

Estimation of measles vaccine efficacy and critical vaccination coverage in a highly vaccinated population

Measles is a highly infectious disease that has been targeted for elimination from four WHO regions. Whether and under which conditions this goal is feasible is, however, uncertain since outbreaks have been documented in populations with high vaccination coverage (more than 90%). Here, we use the example of a large outbreak in a German public school to show how estimates of key epidemiological parameters such as the basic reproduction number (R(0)), vaccine efficacy (VE(S)) and critical vaccination coverage (p(c)) can be obtained from partially observed outbreaks in highly vaccinated populations. Our analyses rely on Bayesian methods of inference based on the final size distribution of outbreak size, and use data which are easily collected. For the German public school the analyses indicate that the basic reproduction number of measles is higher than previously thought (R(0) = 30.8, 95% credible interval: 23.6-40.4), that the vaccine is highly effective in preventing infection (VE(S) = 0.997, 95% credible interval: 0.993-0.999), and that a vaccination coverage in excess of 95 per cent may be necessary to achieve herd immunity (p(c) = 0.971, 95% credible interval: 0.961-0.978). We discuss the implications for measles elimination from highly vaccinated populations.

[Current vaccination coverage and immunization gaps of children and adolescents in Germany]

Available data show increasing vaccination coverage of children and adolescents in recent years in Germany. Vaccination coverage of children against diphtheria, tetanus, polio and haemophilus influenzae Type b is high. Vaccination gaps exist for pertussis, hepatitis B and for the second measles, mumps and rubella doses. Coverage is still insufficient to achieve effective herd immunity and measles elimination. Data from the representative German Health Interview and Examination Survey for Children and Adolescents reveal that vaccination of infants is markedly delayed compared to recommendations of the German Standing Committee on Vaccination (STIKO). Particularly older children and adolescents are often not fully vaccinated or are even unvaccinated. A high proportion is missing the recommended booster doses against diphtheria, tetanus, pertussis and polio. Vaccination compliance especially regarding completeness and timeliness is lower in western than eastern Germany, as well as in children of vaccine sceptics and foreign-born children. More comprehensive surveillance of vaccination coverage and adverse events following immunization as well as the implementation of a national immunization plan focussing on closure of immunization gaps could lead to improved vaccination coverage.

Measles outbreak linked to a minority group in Austria, 2008

We report on a measles outbreak originating in an anthroposophic community in Austria, 2008. A total of 394 (94·9%) cases fulfilled the outbreak case definition including 168 cases affiliated to the anthroposophic community. The source case was a school pupil from Switzerland. The Austrian outbreak strain was genotype D5, indistinguishable from the Swiss outbreak strain. A school-based retrospective cohort study in the anthroposophic school demonstrated a vaccine effectiveness of 97·3% in pupils who had received a single dose of measles-containing vaccine and 100% in those who had received two doses. The vaccination coverage of the cases in the anthroposophic community was 0·6%. Of the 226 outbreak cases not belonging to the anthroposophic community, the 10–24 years age group was the most affected. Our findings underline the epidemiological significance of suboptimal vaccination coverage in anthroposophic communities and in older age groups of the general population in facilitating measles virus circulation. The findings of this outbreak investigation suggest that the WHO European Region is unlikely to achieve its 2010 target for measles and rubella elimination.