Ongoing outbreak with well over 4,000 measles cases in Italy from January to end August 2017 - what is making elimination so difficult?

Low Rates of Immunity among Medical Students and Residents in the Era of the Resurgence of Measles

Measles is a highly contagious viral disease spread through respiratory droplets. The number of reported cases increased worldwide in 2023, particularly in the European Region. Italy reported 213 cases in the first quarter of 2024, with most of them in unvaccinated adults aged 15-64. Maintaining high vaccination coverage is essential to prevent outbreaks, especially in healthcare settings where measles transmission is a significant risk. In our study, we collected serological and demographic information from all Italian and foreign medical students and residents (850) who underwent a pre-training assessment at the Tor Vergata Occupational Medicine Service, Rome, between 3 April 2023 and 31 January 2024. Of the 850 students and residents analyzed, we found only 546 (64.2%) with a protective level of IgG antibodies against measles, with a median IgG level of 2.00 AI. A significant proportion of students and residents were serologically non-immune, raising concerns about the potential risk of hospital transmission. To manage this risk, it is important to assess serological levels, vaccinate those with inadequate levels, and promote vaccination in the general population.

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.

A Single-Center Evaluation of Pediatric Measles Cases in Istanbul, Türkiye, in 2019

Although measles can be prevented and eliminated by vaccination, it is a highly contagious viral disease that can lead to serious complications, disability, and death. The aim of this retrospective study was to evaluate the characteristics of measles cases in a single center. All children with clinically suspected measles who attended the Pediatric Clinic at Esenler Maternity and Child Health Hospital in Istanbul, Türkiye, between January 1 and June 30, 2019 were included in the analysis. None of the children with measles were fully vaccinated. The incidence and duration of conjunctivitis were significantly higher in the unvaccinated group than in the partially vaccinated group (P = 0.027 and P = 0.019, respectively). Unvaccinated patients had a significantly lower median leukocyte count (P = 0.019) and significantly higher median C-reactive protein level (P = 0.021). The vitamin A level and leukocyte count were moderately positively correlated (r = 0.698; P = 0.008). Children should be fully vaccinated in order to prevent measles.

Measles vaccine uptake among Italian medical students compared to the pre-COVID-19 era

The COVID-19 pandemic has severely affected health systems worldwide and raised the issue of vaccine hesitancy. In 2022, the World Health Organization reported an outbreak of measles infection among people over 20 years of age in the European Region. Previous studies found low rates of measles immunization among Italian healthcare workers (HCWs) and medical students. Vaccine hesitancy is a relevant cause of low immunization rate among HCWs and the general population. We aim to evaluate the measles vaccine uptake among medical students of a large teaching hospital, compared to the pre-pandemic period. This is a retrospective observational study, that evaluated the immune status and the vaccine acceptance rate for measles in medical students at the University of Tor Vergata, Rome, who underwent occupational health surveillance from 1 January to 1 December 2022. We also compared the data with the results of a pre-pandemic survey conducted in 2018. Vaccine uptake among unprotected medical students was 59.5%. The data showed no significant difference in vaccine uptake compared with the pre-COVID-19 period. Conversely, the rate of serologically immune subjects to measles increased from 89.66% in 2018 to 97.45% in 2022 as a result of the recent mandatory vaccination policy. Despite efforts to tackle vaccine hesitancy during the COVID-19 pandemic, measles vaccine uptake is still low among young adults starting their medical training, and their compliance with free workplace vaccination offers is suboptimal. Occupational health services should raise awareness among workers and work together to implement strategies to achieve comprehensive measles vaccination coverage among occupational health workers.

Serological Evaluation for Measles among Italian and Foreign Medical Students in a University Hospital in Rome

BACKGROUND

Measles infection in the hospital setting is a major issue. Despite the availability of an effective vaccine, measles outbreaks continue to occur in some European countries. We aimed to evaluate the immunological status of medical students attending the Tor Vergata Polyclinic (PTV).

METHODS

Measles antibodies titers were assessed by venipuncture on a sample of 2717 medical students who underwent annual health surveillance visits from January 2021 to March 2023. Subjects showing serum IgG values above 1.0 S/CO were considered serologically protected. Personal data, country of origin, and main demographic characteristic were also collected.

RESULTS

66.7% (1467 Italian and 346 foreign) of medical students showed protective IgG antibodies levels. Female students were serologically immune more frequently than males (68.6% vs. 63.3%; p < 0.01 at Chi2). The mean antibody titer was 1.72 S/CO, significantly higher in females than males (1.67 vs. 1.75, respectively; p < 0.05), and significantly related to age (p < 0.01). Albanian students, who were the largest foreign population in our study, showed a low serological protection rate (40/90: 44.4%).

CONCLUSIONS

The proportion of serologically non-immune students is high, raising concerns about the possible risk of hospital transmission. Substantial differences in the rate of immunity have been found between subjects coming from different parts of Europe and the world. Pre-training assessment of all medical students and vaccination of susceptible individuals is highly recommended, particularly for those from low immunization rate countries.

Prediction of Specific Antibody- and Cell-Mediated Responses Using Baseline Immune Status Parameters of Individuals Received Measles-Mumps-Rubella Vaccine

A successful vaccination implies the induction of effective specific immune responses. We intend to find biomarkers among various immune cell subpopulations, cytokines and antibodies that could be used to predict the levels of specific antibody- and cell-mediated responses after measles-mumps-rubella vaccination. We measured 59 baseline immune status parameters (frequencies of 42 immune cell subsets, levels of 13 cytokines, immunoglobulins) before vaccination and 13 response variables (specific IgA and IgG, antigen-induced IFN-γ production, CD107a expression on CD8+ T lymphocytes, and cellular proliferation levels by CFSE dilution) 6 weeks after vaccination for 19 individuals. Statistically significant Spearman correlations between some baseline parameters and response variables were found for each response variable (p < 0.05). Because of the low number of observations relative to the number of baseline parameters and missing data for some observations, we used three feature selection strategies to select potential predictors of the post-vaccination responses among baseline variables: (a) screening of the variables based on correlation analysis; (b) supervised screening based on the information of changes of baseline variables at day 7; and (c) implicit feature selection using regularization-based sparse regression. We identified optimal multivariate linear regression models for predicting the effectiveness of vaccination against measles-mumps-rubella using the baseline immune status parameters. It turned out that the sufficient number of predictor variables ranges from one to five, depending on the response variable of interest.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Anti-vaccination movements in the world and in Brazil

Over the years, vaccinations have provided significant advances in public health, because they substantially reduce the morbimortality of vaccine-preventable diseases. Nevertheless, many people are still hesitant to be vaccinated. Brazil is a region of many anti-vaccine movements, and several outbreaks of vaccine-preventable diseases, such as yellow fever and measles, have occurred in the country during the last few years. To avoid new outbreaks, immunization coverage must be high; however, this is a great challenge to achieve due to the countless anti-vaccine movements. The World Health Organization has suggested new actions for the next decade via the Immunization Agenda 2030 to control, reduce, or eradicate vaccine-preventable diseases. Nonetheless, the vaccination coverage has decreased recently. To resolve the anti-vaccine issue, it is necessary to propose a long-term approach that involves innovative education programs on immunization and critical thinking, using different communication channels, including social media. Cooperation among biology and health scientists, ethicists, human scientists, policymakers, journalists, and civil society is essential for an in-depth understanding of the social action of vaccine refusal and planning effective education measures to increase the vaccine coverage.

Sex and age as determinants of the seroprevalence of anti-measles IgG among European healthcare workers: A systematic review and meta-analysis

INTRODUCTION

The international literature shows good evidence of a significant rate of measles susceptibility among healthcare workers (HCWs). As such, they are an important public health issue.

METHODS

We conducted a systematic review and meta-analysis to estimate the prevalence of susceptible HCWs in EU/EEA countries and in the UK and to explore the characteristics (sex and age differences) and management of those found to be susceptible.

RESULTS

Nineteen studies were included in the meta-analysis. The prevalence of measles-susceptible HCWs was 13.3% (95 %CI: 10.0-17.0%). In a comparison of serosusceptible female vs. male HCWs, the RR was 0.92 (95 %CI = 0.83-1.03), and in a comparison of age classes (born after vs. before 1980) the RR was 2.78 (95 %CI = 2.20-3.50). The most recent studies proposed the mandatory vaccination of HCWs.

DISCUSSION

According to our meta-analysis, the prevalence of serosusceptible European HCWs is 13%; HCWs born in the post-vaccination era seem to be at higher risk. Healthcare professionals susceptible to measles are a serious epidemiological concern. Greater efforts should therefore be made to identify those who have yet to be vaccinated and actively encourage their vaccination.

Themes Surrounding COVID-19 and Its Infodemic: Qualitative Analysis of the COVID-19 Discussion on the Multidisciplinary Healthcare Information for All Health Forum

Background

Healthcare Information for All (HIFA) is a multidisciplinary global campaign consisting of more than 20,000 members worldwide committed to improving the availability and use of health care information in low- and middle-income countries (LMICs). During the COVID-19 pandemic, online HIFA forums saw a tremendous amount of discussion regarding the lack of information about COVID-19, the spread of misinformation, and the pandemic’s impact on different communities.

Objective

This study aims to analyze the themes and perspectives shared in the COVID-19 discussion on English HIFA forums.

Methods

Over a period of 8 months, a qualitative thematic content analysis of the COVID-19 discussion on English HIFA forums was conducted. In total, 865 posts between January 24 and October 31, 2020, from 246 unique study participants were included and analyzed.

Results

In total, 6 major themes were identified: infodemic, health system, digital health literacy, economic consequences, marginalized peoples, and mental health. The geographical distribution of study participants involved in the discussion spanned across 46 different countries in every continent except Antarctica. Study participants’ professions included public health workers, health care providers, and researchers, among others. Study participants’ affiliation included nongovernment organizations (NGOs), commercial organizations, academic institutions, the United Nations (UN), the World Health Organization (WHO), and others.

Conclusions

The themes that emerged from this analysis highlight personal recounts, reflections, suggestions, and evidence around addressing COVID-19 related misinformation and might also help to understand the timeline of information evolution, focus, and needs surrounding the COVID-19 pandemic.

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.

Seroepidemiology of Measles, Mumps, Rubella and Varicella in Italian Female School Workers: A Cross-Sectional Study

BACKGROUND

Determining the proportion of susceptible workers can represent a first step to the biological risk assessment related to measles, mumps, rubella and varicella exposure. This study aimed to assess the immunity against measles, mumps, rubella and varicella viruses in a cohort of female school workers.

METHODS

A cross-sectional seroepidemiological study in a sample of 263 school workers undergoing routine annual workplace health surveillance program was conducted. As part of the health surveillance program, serum samples were collected and tested for measles, mumps, rubella and varicella IgG antibodies.

RESULTS

Overall seropositivity was 90.5%, 85.2%, 94.7% and 97.3% for measles, mumps, rubella and varicella, respectively. In relation to mumps occupation-specific seropositivity, a statistically significant difference was observed, showing the lowest prevalence of protected individuals in other occupation groups. Moreover, in relation to rubella, school workers born in Centre Italy had the lowest seropositivity of protective antibodies and the difference between groups was statistically significant. Measles and rubella seropositivity showed a significant decrease after 2015.

CONCLUSIONS

This study showed a relevant proportion of school workers susceptible to the aforementioned diseases. These results highlighted the need for proper health surveillance and immunological controls in school workers, especially for females, and provided useful insights to policymakers to select effective strategies aimed at containing the risk of vaccine-preventable diseases at schools.

The role of maturity in adolescent decision-making around HPV vaccination in France

Mothers are often responsible for vaccination decisions in the household. However, their confidence in certain vaccines such as Human Papillomavirus (HPV) vaccines is eroding in some countries. France is one of the countries with the lowest HPV vaccine uptake in Europe, with parents delaying or refusing the vaccine for their adolescent daughters due to safety- and effectiveness-related concerns. Although parental consent is required for vaccination, adolescents' involvement in HPV vaccination decision-making could improve vaccine uptake, with self-consent procedures already introduced in some countries. Adolescents' capacity to engage in decision-making is influenced by their maturity and autonomy in health. This study explored the role of maturity in decision-making around HPV vaccination in France through qualitative interviews with adolescent girls (n = 24) and their mothers (n = 21) and two focus groups with adolescent girls (n = 12). A codebook approach to thematic analysis revealed that adolescent girls' involvement in HPV decision-making is a process that evolved with maturity. As adolescents progressed towards maturity at different speeds, some expressed childlike traits such as impulsive decisions and others described more rational, reflective decision-making. Despite these differences, most adolescents in this study described a passive role in HPV vaccination decision-making, following their parents' lead. However, their expressed desire for information and involvement in discussions indicates that their lack of engagement may not only be due to a lack of maturity but also a result of mothers and doctors excluding them from getting involved. Furthermore, as health behaviours are shaped during adolescence, the influence of vaccine hesitant mothers on their daughters' own views and beliefs could be significant, together with exposure to regular controversies in the mainstream media. Individualised approaches to engage adolescents in decision-making around their own health are needed, for example through strengthening discussions and information around HPV vaccination with parents and doctors.

Molecular Epidemiology of Measles in California, United States-2019

In 2019, the United States (US) experienced the highest number of measles importations and cases in the postelimination era. More than a quarter of imported cases entered the US through California. Measles surveillance efforts in California resulted in the identification of 26 importations, 6 outbreaks, and 72 cases in 2019. Only genotype B3 and D8 measles strains were detected. Genotype-specific differences were noted in the incidence of vaccine failures, hospitalizations, and severe complications among cases. A targeted whole genome sequencing approach provided higher-resolution discrimination between epidemiologically linked and sporadically introduced strains than conventional N450 sequencing. Our report underscores the importance of ensuring appropriate measles vaccination status, especially prior to international travel to measles-endemic regions, and highlights the value of a strong measles surveillance system in minimizing outbreaks and preserving measles elimination status in the US.

A rapid risk analysis tool to prioritise response to infectious disease outbreaks

Epidemics are influenced by both disease and societal factors and can grow exponentially over short time periods. Epidemic risk analysis can help in rapidly predicting potentially serious outcomes and flagging the need for rapid response. We developed a multifactorial risk analysis tool 'EpiRisk' to provide rapid insight into the potential severity of emerging epidemics by combining disease-related parameters and country-related risk parameters. An initial set of 18 disease and country-related risk parameters was reduced to 14 following qualitative discussions and the removal of highly correlated parameters by a correlation and clustering analysis. Of the remaining parameters, three risk levels were assigned ranging from low (1) moderate (2) and high (3). The total risk score for an outbreak of a given disease in a particular country is calculated by summing these 14 risk scores, and this sum is subsequently classified into one of four risk categories: low risk (<21), moderate risk (21-29), high risk (30-37) and extreme risk (>37). Total risk scores were calculated for nine retrospective outbreaks demonstrating an association with the actual impact of those outbreaks. We also evaluated to what extent the risk scores correlate with the number of cases and deaths in 61 additional outbreaks between 2002 and 2018, demonstrating positive associations with outbreak severity as measured by the number of deaths. Using EpiRisk, timely intervention can be implemented by predicting the risk of emerging outbreaks in real time, which may help government and public health professionals prevent catastrophic epidemic outcomes.

Measles, mumps, rubella prevention: how can we do better?

INTRODUCTION

Measles, mumps, and rubella incidence decreased drastically following vaccination programs' implementation. However, measles and mumps' resurgence was recently reported, outbreaks still occur, and challenges remain to control these diseases.

AREAS COVERED

This qualitative narrative review provides an objective appraisal of the literature regarding current challenges in controlling measles, mumps, rubella infections, and interventions to address them.

EXPERT OPINION

While vaccines against measles, mumps, and rubella (including trivalent vaccines) are widely used and effective, challenges to control these diseases are mainly related to insufficient immunization coverage and changing vaccination needs owing to new global environment (e.g. traveling, migration, population density). By understanding disease transmission peculiarities by setting, initiatives are needed to optimize vaccination policies and increase vaccination coverage, which was further negatively impacted by COVID-19 pandemic. Also, awareness of the potential severity of infections and the role of vaccines should increase. Reminder systems, vaccination of disadvantaged, high-risk and difficult-to-reach populations, accessibility of vaccination, healthcare infrastructure, and vaccination services management should improve. Outbreak preparedness should be strengthened, including implementation of high-quality surveillance systems to monitor epidemiology. While the main focus should be on these public health initiatives to increase vaccination coverage, slightly more benefits could come from evolution of current vaccines.

Classification of unlabeled online media

This work investigates the ability to classify misinformation in online social media networks in a manner that avoids the need for ground truth labels. Rather than approach the classification problem as a task for humans or machine learning algorithms, this work leverages user-user and user-media (i.e.,media likes) interactions to infer the type of information (fake vs. authentic) being spread, without needing to know the actual details of the information itself. To study the inception and evolution of user-user and user-media interactions over time, we create an experimental platform that mimics the functionality of real-world social media networks. We develop a graphical model that considers the evolution of this network topology to model the uncertainty (entropy) propagation when fake and authentic media disseminates across the network. The creation of a real-world social media network enables a wide range of hypotheses to be tested pertaining to users, their interactions with other users, and with media content. The discovery that the entropy of user-user and user-media interactions approximate fake and authentic media likes, enables us to classify fake media in an unsupervised learning manner.

The Changing Global Epidemiology of Measles, 2013-2018

BACKGROUND

Measles incidence and mortality rates have significantly decreased since vaccine introduction. Despite this progress, however, there has been a global resurgence of measles. To understand the current global epidemiology, we analyzed measles surveillance data.

METHODS

We analyzed data on measles cases from 2013-2018 reported to the World Health Organization. Univariate analysis was undertaken based on age, vaccination history, onset year, World Health Organization region, and World Bank income status for the country where the case was reported, and a surrogate indicator of the historical strength of the country's immunization program. Annual incidence and a 2013-2018 mean country incidence per million were calculated.

RESULTS

From 2013 through 2018, there were 899 800 reported measles cases, of which 57% occurred unvaccinated or undervaccinated persons, with an unknown vaccination history in another 30%. Lower-middle-income countries accounted for 66% of cases, 23% occurred in persons ≥15 years of age. In countries with stronger historical vaccination programs and higher country income, case patients had higher median ages.

CONCLUSIONS

Although most measles case patients are <15 years of age, an age shift is seen in countries with a higher income or a stronger historical vaccination program. Countries must strengthen immunization programs to achieve high vaccination coverage; some must undertake strategies to reach persons ≥15 years of age and close immunity gaps.

Parental trust and beliefs after the discovery of a six-year-long failure to vaccinate

BACKGROUND

In Italy vaccine hesitancy worsened after a failure to vaccinate episode that took place in Friuli Venezia-Giulia Region until early 2017 which undermined herd immunity by leaving unprotected more than 5,444 children.

METHODS

Between May and June 2017, 2,557 parents were surveyed at the local vaccination clinic where they were invited within the subsequent extraordinary vaccination campaign. The aim of the survey was to evaluate whether the multi-channel extraordinary vaccination campaign had reached the target population and to know parental beliefs and trusted sources of information after the failure to vaccinate event.

RESULTS

While 279 parents were non-hesitant (10.9%) and 1,491 hesitant acceptors (58.3%), just 38 (1.5%) refused to have their children revaccinated. Overall, the most consulted sources of information were print media (18.8%), physicians (16.0%), relatives and friends (12.1%). The majority of parents considered vaccination as a fundamental practice (73.9%), but many were worried about potential side effects (38.8%) or doubtful about the effectiveness of some vaccines (11.0%). According to parents, 19.7% of them (57) changed their opinion about vaccines after the Codroipo case.

CONCLUSIONS

After the Codroipo case, most parents chose to have their children re-vaccinated and just a little proportion refused the re-administration of vaccines. More studies are needed to confirm the importance of a coherent multi-channel communication strategy using both traditional and new media in order to counteract vaccine hesitancy.

Measles epidemic in pediatric population in Greece during 2017-2018: Epidemiological, clinical characteristics and outcomes

Background and aim

A measles outbreak occurred in Greece during 2017–2018 affecting mainly pediatric population. The aim of the study was to describe the epidemiological and clinical characteristics of the cases diagnosed in the major pediatric tertiary hospital of Athens, where 26.5% of national pediatric measles cases were diagnosed and treated.

Methods

This is a retrospective study of children 0–16 years old, who presented at the emergency department and/or were hospitalized with clinical presentation compatible with measles and diagnosis was confirmed with molecular detection of the measles RNA in pharyngeal swabs. Epidemiological, clinical and laboratory characteristics were retrieved from medical records and analyzed.

Results

A total of 578 children with measles were identified during the study period. 322 (55.7%) were male with median age 36 months (range:1–193), while the largest number of documented cases (251; 43.4%) were children aged 1–5 years. Most children (429/578; 74.2%) belonged to the Roma minority and only 64 (11.1%) had Greek origin. 497 (91.5%) children were unvaccinated and 37 (6.8%) were partially vaccinated with measles vaccine. Hospitalization was required for 342 (59.2%) children, whereas one or more complications were reported in 230 (67.2%) of them. Most frequent complications were elevated transaminases (139; 40.6%), acute otitis media (72; 21%), dehydration (67; 19.6%) and pneumonia (58; 16.9%). 11 children (3.2%) required intensive care admission for altered mental status/status epilepticus (3), sepsis (2) and ARDS (6). 119/342 (34.8%) children were treated with antibiotics because of possible or confirmed bacterial coinfection. One death was reported, concerning an 11-month-old unvaccinated infant, with underlying dystrophy, who died of sepsis.

Conclusion

Measles is not an innocent viral infection, as it is still characterized by high morbidity and complications rates. Unvaccinated or partially vaccinated populations could trigger new outbreaks, resulting in significant cost in public health. To avoid future measles outbreaks, high vaccination coverage should be achieved, as well as closing immunity gaps in the population and ensuring high-quality measles surveillance.

Lower Rate of Seropositivity to Measles Among Young Healthcare Personnel in New York City

We examined the prevalence of measles antibody among 12 349 newly hired HCP between 2009 and 2019. Younger HCP were significantly more likely to have no immunity. Compared with a 92.2% seropositive rate among 1057 persons hired at age >50 years, only 84.4% of approximately 10 000 HCP aged <40 years had protective antibody.

Practice nurses' perceptions of their immunization role and strategies used to promote measles, mumps, and rubella vaccine uptake in 2014 - 2018: A qualitative study

AIM

The aim of this study was to explore which aspects of their role practice nurses perceive to be most influential and the strategies they employ to promote the MMR vaccine.

DESIGN

Qualitative study employing in depth interviews.

METHOD

Fifteen London based practice nurses, nine in 2014 and six in 2018, took part in semi-structured interviews that were audio recorded and transcribed verbatim. Qualitative content analysis was used to systematically manage, analyse, and identify themes.

RESULTS

Analysis of data identified aspects of their role practice nurses perceived to be most influential (the themes) including: promoting vaccination, assisting parents' to make informed decisions, and provided insight into how they used specific strategies to achieve these in practice. These themes were consistent over both phases of the study.

CONCLUSION

The findings provide an understanding of: (i) the practice nurses perceptions of the most important aspects of their role when promoting the measles, mumps, and rubella vaccine; and (ii) the strategies they implemented in practice to achieve these. The latter included assisting parents in their immunization decisions and was facilitated by practice nurses engaging with parents to provide relevant evidence to address parent queries, dispel misconceptions and tailor strategies to promote the measles, mumps, and rubella vaccine.

IMPACT

This study addresses the paucity of literature available that specifically explores practice nurses' perceptions of their role concerning the measles, mumps, and rubella vaccine. The findings reveal how practice nurses promote the measles, mumps, and rubella vaccine by identifying strategies to enable parents to make informed decisions. At a time of an increasing incidence of measles, practice nurses have an important public health role in achieving herd immunity levels for measles, mumps, and rubella.

Clustering of susceptible individuals within households can drive measles outbreaks: an individual-based model exploration

When estimating important measures such as the herd immunity threshold, and the corresponding efforts required to eliminate measles, it is often assumed that susceptible individuals are uniformly distributed throughout populations. However, unvaccinated individuals may be clustered in a variety of ways, including by geographic location, by age, in schools, or in households. Here, we investigate to which extent different levels of within-household clustering of susceptible individuals may impact the risk and persistence of measles outbreaks. To this end, we apply an individual-based model, Stride, to a population of 600,000 individuals, using data from Flanders, Belgium. We construct a metric to estimate the level of within-household susceptibility clustering in the population. Furthermore, we compare realistic scenarios regarding the distribution of susceptible individuals within households in terms of their impact on epidemiological measures for outbreak risk and persistence. We find that higher levels of within-household clustering of susceptible individuals increase the risk, size and persistence of measles outbreaks. Ignoring within-household clustering thus leads to underestimations of required measles elimination and outbreak mitigation efforts.

Measles outbreak in Dubrovnik-Neretva County, Croatia, May to June 2018

In May 2018, measles was introduced in the Dubrovnik region by an adult who recently travelled to Kosovo*. Control measures and an outbreak investigation were implemented: 15 epidemiologically-linked cases met the outbreak case definition of a visitor/resident of Dubrovnik-Neretva County with laboratory-confirmed measles and symptom onset beginning on May 19. New cases were identified through hospitals and primary care physicians. Throat swabs, urine and/or serum samples were collected from outbreak cases. RT-PCR detection of viral RNA and IgM/IgG was used to confirm infection. The median age of cases was 33 years, with one 8 month-old infant. Vaccination status was unknown for 9 cases, three were unvaccinated, one case had history of one dose and two cases reported receiving two doses of measles-containing vaccine. There were 11 hospitalisations and one person developed pneumonia. Control teams undertook an extensive search of contacts and implemented a range of control measures. Despite the outbreak occurring at the beginning of the summer tourism season, it was contained and did not spread to neighbouring regions. With continuing measles transmission in Europe, even small outbreaks create a burden on the health system in countries which have eliminated measles, and illustrate the importance of maintaining high immunisation coverage.

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.

Spatiotemporal Distribution and Genetic Characterization of Measles Strains Circulating in Greece during the 2017-2018 Outbreak

Between May 2017 and November 2018, Greece has experienced a severe measles outbreak with a total of 3258 cases reported, after reaching its goal of eliminating measles since 2014-2015. In this study, we aimed to investigate the origin and the dispersal patterns of the measles strains that circulated in Greece during this outbreak and to identify possible transmission patterns of measles virus (MeV) in the country. Of the 832 measles suspect cases referred to the National Measles and Rubella Reference Laboratory for MeV RNA detection, 131 randomly selected positive samples, representative of the temporal and spatial distribution of the laboratory-confirmed measles cases in Greece, were processed for genotypic identification by an RT-PCR amplification of a 598 bp fragment containing the 450 bp hypervariable region of the measles virus N gene. Phylogenetic analysis was carried out by the approximate maximum likelihood method (ML) under the generalized time-reversible (GTR + cat) model. All samples analyzed were found to belong to genotype B3. Comparative analysis with other European and reference measles strains revealed three separate major clusters and other multiple viruses circulating simultaneously in Greece. They were all isolated from three main community groups, Greek-Roma children, non-minority Greek nationals and immigrants/refugees, a finding that is in accordance with what was also observed in the last two measles outbreaks in 2005-2006 and 2010-2011. Notably, for one of the three clusters, no similarity was detected with previously reported prototype strains. Our results indicate the need for a more intensive vaccination program against measles amongst minority populations and in refugee hot-spots as well as the importance of molecular surveillance as a tool for monitoring measles outbreaks.

Measles Outbreak in a High-Income Country: Are Pediatricians Ready?

BACKGROUND

Measles is a highly communicable infection with potentially severe complications. It is rarely reported in high-income countries and the limited awareness and experience of pediatricians may result in misdiagnosis. The present study aimed at investigating physician's ability and timing to reach diagnosis during a recent outbreak in Italy.

METHODS

The Italian Society for Pediatric Infectious Diseases conducted a retrospective, multicenter study in children hospitalized for measles between 1 January 2016 and 30 August 2017 in secondary and tertiary care hospitals. The appropriateness of diagnosis at admission, the time to reach clinical diagnosis, and serological confirmation of measles were recorded.

RESULTS

At hospital admission, measles was misdiagnosed in 101 (40.5%) of the 249 children (median age, 14.5 months) enrolled. The appropriate diagnosis increased from 30% to 72.5% during the period of observation (P < .001). A greater chance of receiving an appropriate diagnosis was demonstrated in children who reported a contact with measles (odds ratio [OR], 5.2; 95% confidence interval [CI], 3.0-9.2) or in those seen in institutions that managed more cases (OR, 7.39; 95% CI, 3.22-16.9; P = .0001). In contrast, children with underlying chronic conditions had a higher risk of misdiagnosis (appropriate diagnosis OR, 0.19; 95% CI, 0.10-0.33). The mean time from the onset of symptoms to clinical diagnosis was 4.55 ± 2.2 days and to serological confirmation was 7.0 ± 3.4 days.

CONCLUSIONS

Measles is frequently misdiagnosed in low-prevalence settings. Specific measures to increase pediatricians' awareness about vaccine-preventable infections need to be implemented.

Transient indicators of tipping points in infectious diseases

The majority of known early warning indicators of critical transitions rely on asymptotic resilience and critical slowing down. In continuous systems, critical slowing down is mathematically described by a decrease in magnitude of the dominant eigenvalue of the Jacobian matrix on the approach to a critical transition. Here, we show that measures of transient dynamics, specifically, reactivity and the maximum of the amplification envelope, also change systematically as a bifurcation is approached in an important class of models for epidemics of infectious diseases. Furthermore, we introduce indicators designed to detect trends in these measures and find that they reliably classify time series of case notifications simulated from stochastic models according to levels of vaccine uptake. Greater attention should be focused on the potential for systems to exhibit transient amplification of perturbations as a critical threshold is approached, and should be considered when searching for generic leading indicators of tipping points. Awareness of this phenomenon will enrich understanding of the dynamics of complex systems on the verge of a critical transition.

Immunity to measles in Italian children and adolescents: a persistent problem in view of measles elimination

BACKGROUND

Despite efforts to increase coverage by two doses of measles vaccine in Italy, measles continues to circulate, with over 13 000 cases of disease since 2013. This study aimed to evaluate immunity to measles in Italian children and adolescents.

METHODS

A total of 378 serum samples from subjects aged 9 months-18 years were collected in Northern, Central and Southern regions of Italy between 2012 and 2016. Specific IgG antibodies against measles were measured by a commercial ELISA kit.

RESULTS

The frequency of IgG-positive samples ranged from 10.5% in infants under 1 year to 98.3% in children aged 6-7 years. The frequency of IgG was 72.2% in subjects aged 1-2 years, 85.6% in those aged 3-5 years and 88.3 and 86.8% in those aged 8-10 and 11-18 years, respectively. In Northern Italy, IgG prevalence was consistent with data on vaccination coverage, whereas some differences were observed in samples from subjects aged more than 8 years in Central and Southern Italy.

CONCLUSIONS

Our findings confirm that a large proportion of children and adolescents in Italy are still susceptible to measles. While data on first- and second-dose measles vaccination are essential, they are not sufficient to identify susceptible population cohorts to be targeted by vaccination.

Complications and risk factors for severe outcome in children with measles

OBJECTIVE AND DESIGN

Risk factors for severe measles are poorly investigated in high-income countries. The Italian Society for Paediatric Infectious Diseases conducted a retrospective study in children hospitalised for measles from January 2016 to August 2017 to investigate the risk factors for severe outcome defined by the presence of long-lasting sequelae, need of intensive care or death.

RESULTS

Nineteen hospitals enrolled 249 children (median age 14.5 months): 207 (83%) children developed a complication and 3 (1%) died. Neutropaenia was more commonly reported in children with B3-genotype compared with other genotypes (29.5% vs 7.7%, p=0.01). Pancreatitis (adjusted OR [aOR] 9.19, p=0.01) and encephalitis (aOR 7.02, p=0.04) were related to severe outcome in multivariable analysis, as well as C reactive protein (CRP) (aOR 1.1, p=0.028), the increase of which predicted severe outcome (area under the receiver operating characteristic curve 0.67, 95% CI 0.52 to 0.82). CRP values >2 mg/dL were related to higher risk of complications (OR 2.0, 95% CI 1.15 to 3.7, p=0.01) or severe outcome (OR 4.13, 95% CI 1.43 to 11.8, p<0.01).

CONCLUSION

The risk of severe outcome in measles is independent of age and underlying conditions, but is related to the development of organ complications and may be predicted by CRP value.

Childhood vaccinations: knowledge, attitudes and practices of paediatricians and factors associated with their confidence in addressing parental concerns, Italy, 2016

Background

Paediatrician recommendations are known to influence parental vaccine decisions.

Aim

Our aim was to examine vaccination knowledge, attitudes and practices among paediatricians in Italy and identify factors associated with their confidence in addressing parental questions.

Methods

An electronic questionnaire survey was conducted from February to March 2016, among a sample of Italian paediatricians.

Results

The survey was completed by 903 paediatricians (mean age: 56 years). Of 885 who responded to the specific question, 843 (95.3%) were completely favourable to vaccinations. Sixty-six per cent (570/862) felt sufficiently knowledgeable about vaccinations and vaccine-preventable diseases to confidently discuss them with parents. Paediatricians who were male, who were 55 years or older, who had participated in training courses in the last 5 years, who reported that taking courses and reading the scientific literature had contributed to their knowledge, or who had implemented vaccination promotion activities, felt more knowledgeable than other paediatricians. When asked to rate their level of agreement with statements about vaccine safety and effectiveness, only 8.9% (80/903) responded fully as expected. One third (294/878) did not systematically verify that their patients are up to date with the immunisation schedule. Only 5.4% (48/892) correctly identified all true and false contraindications.

Conclusions

The majority of paediatricians in Italy are favourable to vaccination but gaps were identified between their overall positive attitudes and their knowledge, beliefs and practices. Targeted interventions are needed aimed at increasing paediatricians’ confidence in addressing parents’ concerns, strengthening trust towards health authorities and improving systems barriers.

Spatiotemporal distribution and determinants of measles incidence during a large outbreak, Italy, September 2016 to July 2018

Background

Measles is still endemic in Italy and outbreaks are frequent. From 2016 to 2018, more than 7,000 measles cases were reported to the national integrated measles and rubella surveillance system, the largest outbreak since implementation of this system.

Aim

We aimed to describe the characteristics and spatiotemporal distribution of measles cases in Italy and explore determinants of incidence at municipality level.

Methods

We performed a retrospective observational study, mapping by municipalityall measles cases reported to the national surveillance system with symptom onset between 1 September 2016 and 31 July 2018. We also analysed measles–mumps-rubella (MMR) vaccination coverage (VC) data (2000–2017) for the first and second dose, collected from the Ministry of Health. We used regression analysis to explore factors associated with measles incidence at municipality level.

Results

We analysed 7,854 cases, 3,927 (50%) female. Median age was 26 years; 475 cases (6%) were younger than 1 year. The outbreak occurred in two epidemic waves. The first started in central/northern regions (end of 2016), the second (mostly within 2018) was concentrated in southern regions. In 2016 and 2017, national VC was below 95% for both MMR doses. In 2017, only one region reported VC above 95% for the first dose. At municipality level, incidence was associated with higher urbanisation, less deprivation and fewer adults.

Conclusion

The spread of measles between September 2016 and July 2018 in Italy indicates the need to improve VC and to explore further how societal and other parameters might be linked to incidence.

Knowledge, attitudes and practices about vaccination in Trentino, Italy in 2019

Introduction: Vaccination is among the most important areas of progress in the worldwide history of public health. However, a crescent wave of anti-vaccine groups has grown in Western countries, especially in Italy, in the last two decades. Our aim was to evaluate adult's hesitancy and knowledge about vaccines and related diseases in Trentino-Alto Adige -the Italian region with the lowest vaccination coverages. Methods: We administered self-answered structured questionnaires in three malls in the Trentino province in June 2019. We collected demographic data and information on knowledge about vaccines, infectious diseases and attitude in seeking health information. We utilized a descriptive and multivariate analysis to investigate factors associated with vaccine hesitancy. Results: We collected 567 questionnaires, 18% of the people interviewed were hesitant toward vaccination and 16% were against mandatory vaccination. In the multivariate analysis a poor level of information, being younger than 60 years and being against compulsory vaccination were associated with vaccine hesitancy. Regarding information about vaccines, 76.5% of the people relied on physicians, and/or 49% navigated the internet, while social media are used by 16% of the study population. Though 41.5% searched information on official sites, only 14% knew the website VaccinarSì and 4.7% had visited it. Discussion: Compared to a previous study conducted in all of Italy except Trentino Alto Adige, the level of vaccination hesitancy was higher. It is important to utilize health professionals, the internet and especially social media to spread scientific information about vaccination.

How do Twitter users react to TV broadcasts dedicated to vaccines in Italy?

BACKGROUND

Social media monitoring during TV broadcasts dedicated to vaccines can provide information on vaccine confidence. We analyzed the sentiment of tweets published in reaction to two TV broadcasts in Italy dedicated to vaccines, one based on scientific evidence [Presadiretta (PD)] and one including anti-vaccine personalities [Virus (VS)].

METHODS

Tweets about vaccines published in an 8-day period centred on each of the two TV broadcasts were classified by sentiment. Differences in tweets' and users' characteristics between the two broadcasts were tested through Poisson, quasi-Poisson or logistic univariate regression. We investigated the association between users' characteristics and sentiment through univariate quasi-binomial logistic regression.

RESULTS

We downloaded 12 180 tweets pertinent to vaccines, published by 5447 users; 276 users tweeted during both broadcasts. Sentiment was positive in 50.4% of tweets, negative in 37.7% and neutral in 10.1% (remaining tweets were unclear or questions). The positive/negative ratio was higher for VS compared to PD (6.96 vs. 4.24, P<0.001). Positive sentiment was associated to the user's number of followers (OR 1.68, P<0.001), friends (OR 1.83, P<0.001) and published tweets (OR 1.46, P<0.001) and to being a recurrent user (OR 3.26, P<0.001).

CONCLUSIONS

Twitter users were highly reactive to TV broadcasts dedicated to vaccines. Sentiment was mainly positive, especially among very active users. Displaying anti-vaccine positions on TV elicited a positive sentiment on Twitter. Listening to social media during TV shows dedicated to vaccines can provide a diverse set of data that can be exploited by public health institutions to inform tailored vaccine communication initiatives.

The Impact of Chemotherapy after Pediatric Malignancy on Humoral Immunity to Vaccine-Preventable Diseases

Background/Aim

The antibody titer of vaccine-preventable diseases in pediatric patients who underwent chemotherapy was assessed in order to evaluate the seroprotection after treatment and the feasibility and the efficacy of a policy of revaccination.

Methods

Serum antibody titers of 55 patients for hepatitis B (HBV), rubella, varicella-zoster (VZV), measles, mumps, polio viruses, Clostridium tetani (C. tetani) and Streptococcus pneumoniae (S. pneumoniae) were analysed.

Results: After chemotherapy, a lack of protective antibody titers against HBV, rubella, VZV, measles, mumps, polio viruses, C. tetani, and S. pneumoniae was found in 53%, 45%, 46%, 46%, 43%, 21–26%, 88% and 55% of patients, respectively. In 49 of 55 patients who were tested both before and after chemotherapy for at least a pathogen, the loss of immunity for HBV, rubella, VZV, measles, mumps, polio viruses and C. tetani was respectively 39%, 43%, 38%, 42%, 32%, 33%, and 80%. A low number of B-lymphocytes was associated with the loss of immunity against measles (p=0.04) whereas a high number of CD8+ T-lymphocytes was associated with the loss of immunity against VZV (p=0.03). A single booster of vaccine dose resulted in a seroprotection for HBV, rubella, VZV, measles, mumps, polio viruses, C. tetani and S. pneumoniae in 67%, 83%, 80%, 67%, 33%, 100%, 88% and 67% of patients, respectively.

Conclusions

We confirm that seroprotection for vaccine-preventable diseases is affected by treatment for pediatric malignancy. A single booster dose of vaccine might be a practical way to restore vaccine immunity in patients after chemotherapy.

High number of hospitalisations and non-classical presentations: lessons learned from a measles outbreak in 2017, Belgium

We describe and analyse an outbreak of measles that affected Belgium early 2017. In total, 289 cases were reported, mostly (53%) in people 15 years or older. For 133 (46%) vaccination status was unknown and a further 117 (41%) were not vaccinated. According to national guidelines, 83 of the unvaccinated cases (29% of total cases) should have received minimum one dose of vaccine, but did not. One in five cases (21%) did not present with the classical triad of fever, rash and any of coryza, conjunctivitis or cough. Rash was the most sensitive symptom, being absent in only six cases. A large proportion of cases (125/289, 43%) required hospitalisation. In hospitalised patients, the most commonly observed complications were hepatic disorders (present in 58/125 hospitalised patients, 46%). Thirty-six of the cases (12%) were in healthcare workers and nosocomial spread contributed importantly to the outbreak. Older age at presentation, altered clinical presentations and presence of complications like hepatitis can delay the correct diagnosis of measles. Clinicians should maintain a high index of suspicion in any individual presenting with rash. If the elimination target is to be reached, catch-up vaccination campaigns should be intensified and target young adults and health care workers.

Towards elimination of measles and rubella in Italy: Progress and challenges

INTRODUCTION

In the WHO European Region, endemic transmission of measles and rubella had been interrupted by 37 and 42 of the 53 member states (MSs), respectively, by 2018. Sixteen MSs are still endemic for measles, 11 for rubella and nine for both diseases, the latter including Italy. Elimination is documented by each country's National Verification Committee (NVC) through an annual status update (ASU).

OBJECTIVE

By analysing data used to produce the ASUs, we aimed to describe the advances made by Italy towards elimination of measles and rubella. Moreover, we propose a set of major interventions that could facilitate the elimination process.

METHODS

A total of 28 indicators were identified within the six core sections of the ASU form and these were evaluated for the period 2013-2018. These indicators relate to the incidence of measles/rubella; epidemiological investigation of cases; investigation of outbreaks; performance of the surveillance system; population immunity levels; and implementation of supplemental immunization activities (SIAs).

RESULTS

From 2013 to 2018, epidemiological and laboratory analyses of measles cases in Italy improved substantially, allowing timely investigation in 2017 and 2018 of most outbreak and sporadic cases and identification of the majority of genotypic variants. Moreover, since 2017, vaccination coverage has increased significantly. Despite these improvements, several areas of concern emerged, prompting the following recommendations: i) improve outbreak monitoring; ii) strengthen the MoRoNet network; iii) increase the number of SIAs; iv) reinforce vaccination services; v) maintain regional monitoring; vi) design effective communication strategies; vii) foster the role of general practitioners and family paediatricians.

CONCLUSIONS

The review of national ASUs is a crucial step to provide the NVC with useful insights into the elimination process and to guide the development of targeted interventions. Against this background, the seven recommendations proposed by the NVC have been shared with the Italian Ministry of Health and the Technical Advisory Group on measles and rubella elimination and have been incorporated into the new Italian Elimination Plan 2019-2023 as a technical aid to facilitate the achievement of disease elimination goals.

Evaluation of Immunity to Measles in a Cohort of Medical Students in Rome, Italy

BACKGROUND

Measles is a highly contagious viral disease with serious complications. Currently, in Italy, measles vaccination is not mandatory for health care workers (HCWs) and medical students, and the free offer of the Measles Mumps Rubella (MMR) vaccine is the only national prevention measure to increase the coverage rate among these subjects.

AIMS

The aim of our study was to evaluate the impact on vaccination rate of the National Plan of Vaccine Prevention (NPVP) implemented in 2017.

MATERIAL AND METHODS

This is a retrospective observational study that evaluated the measles-specific IgG immunity status of medical students at the University Tor Vergata of Rome, which underwent occupational health surveillance from 1 January to 31 December 2018.

RESULTS

In 2018, 84 of 319 students (26.30%) were serologically non-immune to measles; among these, 16 (19%) had previously been vaccinated, and 35 of the remaining 68 students accepted the MMR vaccine. Therefore, 33 out of 319 students did not undergo vaccination in 2018. These data are similar to those obtained in the previous year. In the 2017 screening, 84/314 (26.75%) students tested negative at the serological screening, whereas 15/85 (17.8%) among them documented a previous vaccination with two doses of the MMR vaccine; 69 students tested as unprotected. Vaccine compliance was 51.44%.

CONCLUSIONS

No change in vaccination coverage occurred after the introduction of the last NPVP. Further efforts are needed to sensitize target populations about the relevance of vaccination; providing pre-employment screening for measles and free vaccine might be useful for this purpose.

Tackling Biological Risk in the Workplace: Updates and Prospects Regarding Vaccinations for Subjects at Risk of Occupational Exposure in Italy

Occupational activities may expose workers to a variety of risks. Exposure to biological agents constitutes a traditional risk in numerous occupational settings. Legislative Decree (D.Lgs.) 81/2008 constitutes the main Italian legislative basis for the management and the prevention of biological risk in occupational settings and lists the available vaccinations against each single biological agent. The 2017-2019 National Vaccination Prevention Plan (PNPV) identifies some categories of workers for whom specific vaccinations are indicated. In this context, the occupational physician identifies work processes that are at risk-identifying susceptible workers and providing information on health monitoring-and is responsible for ensuring that vaccinations are carried out. Adequate and thorough evaluation of risk are indispensable to appropriate consultation by the occupational physician in order to enable the employer to provide efficacious vaccinations. Close collaboration among the services of occupational medicine, vaccination clinics, and healthcare management together with the implementation of vaccination programs that are agreed upon at the institutional level provides an opportunity to reduce the number of workers who are susceptible to vaccine-preventable diseases, thereby yielding benefits in terms of biological risk management in the workplace and contributing to increasing vaccination coverage rates, which in many cases are currently unsatisfactory.

Measles outbreak linked to insufficient vaccination coverage in Nouvelle-Aquitaine Region, France, October 2017 to July 2018

On 30 October 2017, an outbreak of measles started in the Nouvelle-Aquitaine (NA) region in France among Bordeaux University students before spreading to other regions. Until 1 July 2018, 1,101 cases were reported in NA, including 98 complications and two deaths. Cases were related to clusters (e.g. students, healthcare workers) in 16%; 81% of cases were not vaccinated against measles as recommended. Vaccination coverage above herd immunity threshold remains the main preventative outbreak measure.

Systematic Literature Review on the Spread of Health-related Misinformation on Social Media

Contemporary commentators describe the current period as “an era of fake news” in which misinformation, generated intentionally or unintentionally, spreads rapidly. Although affecting all areas of life, it poses particular problems in the health arena, where it can delay or prevent effective care, in some cases threatening the lives of individuals. While examples of the rapid spread of misinformation date back to the earliest days of scientific medicine, the internet, by allowing instantaneous communication and powerful amplification has brought about a quantum change. In democracies where ideas compete in the marketplace for attention, accurate scientific information, which may be difficult to comprehend and even dull, is easily crowded out by sensationalized news. In order to uncover the current evidence and better understand the mechanism of misinformation spread, we report a systematic review of the nature and potential drivers of health-related misinformation. We searched PubMed, Cochrane, Web of Science, Scopus and Google databases to identify relevant methodological and empirical articles published between 2012 and 2018. A total of 57 articles were included for full-text analysis. Overall, we observe an increasing trend in published articles on health-related misinformation and the role of social media in its propagation. The most extensively studied topics involving misinformation relate to vaccination, Ebola and Zika Virus, although others, such as nutrition, cancer, fluoridation of water and smoking also featured. Studies adopted theoretical frameworks from psychology and network science, while co-citation analysis revealed potential for greater collaboration across fields. Most studies employed content analysis, social network analysis or experiments, drawing on disparate disciplinary paradigms. Future research should examine susceptibility of different sociodemographic groups to misinformation and understand the role of belief systems on the intention to spread misinformation. Further interdisciplinary research is also warranted to identify effective and tailored interventions to counter the spread of health-related misinformation online.

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Studies on health misinformation mainly relate to vaccine and infectious disease.

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Findings show high prevalence and popularity of misinformation on social media.

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Theoretical frameworks are drawn on disparate disciplinary paradigms.

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Studies employed content analysis, social network analysis or experiments.

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More interdisciplinary research needed to understand the susceptibility of users.

Parental vaccination to reduce measles immunity gaps in Italy

High-income countries are experiencing measles reemergence as the result of suboptimal vaccine uptake and marked immunity gaps among adults. In 2017, the Italian Government introduced mandatory vaccination at school entry for ten infectious diseases, including measles. However, sustainable and effective vaccination strategies targeting adults are still lacking. We use a data-driven model of household demography to estimate the potential impact on future measles epidemiology of a novel immunization strategy, to be implemented on top of the 2017 regulation, which consists of offering measles vaccine to the parents of children who get vaccinated. Model simulations suggest that the current vaccination efforts in Italy would not be sufficient to interrupt measles transmission before 2045 because of the frequency of susceptible individuals between 17 and 44 years of age. The integration of the current policy with parental vaccination has the potential to reduce susceptible adults by 17–35%, increasing the chance of measles elimination before 2045 up to 78.9–96.5%.

Measles is one of the world’s most contagious diseases causing thousands of deaths every year, despite a safe and effective vaccine being available since the 1960s. High rates of vaccination – about 95% of each age group – are required to eliminate measles, but national and global health agencies struggle to achieve high vaccination rates because some parents were and still are hesitant to vaccinate their children. As a result, large measles epidemics continue to occur even in countries with well-established vaccination programs.

In Italy, low vaccination rates year after year have resulted in large numbers of unprotected youth and adults. The country has recently introduced mandatory measles vaccination at school entry to improve vaccination coverage among children. Yet a high proportion of measles cases in Italy continue to occur in people over 20 years old, a situation that could be improved by immunization programs targeting adults. One approach would be to take advantage of the compulsory vaccination of children by offering parents the vaccine at the same time.

Marziano et al. used computer modeling to estimate how various vaccination scenarios would affect measles spread in Italy. Their models showed that current vaccination policies targeting school age children would be unlikely to eliminate measles before 2045. On the other hand, if 50% of parents were also vaccinated, elimination could be achieved by 2042, and as early as 2031 if 99% of parents agreed to vaccination.

Marziano et al. show that a parental vaccination campaign could reduce the population of adults susceptible to measles in Italy and help the country stop the spread of the disease. However, more research is needed to assess how feasible and sustainable this policy would be. Additional policies to increase vaccination against measles in adults could also help, but parental vaccination has a key advantage: it does not require active targeting to recruit parents, since they are already immunizing their children.

MMRdb: Measles, mumps, and rubella viruses database and analysis resource

Measles, mumps, and rubella viruses are well known human pathogens that cause mild to severe illnesses. Despite the existence of MMR vaccines since 1971, outbreaks have been largely documented even in highly vaccinated populations. There is a pressing need to develop a resource to monitor genetic and antigenic variations among these viruses. Here, we introduced MMRdb, a web central database and analysis resource for measles, mumps, and rubella viruses. Users can search viruses at gene level and obtain sequence information based on gene product, geographic location, year, or host. The MMRdb also catalogs experimentally verified B cells and T cells antigenic epitopes data. A set of computation tools such as multiple sequence alignment, Geo Chart, and sequence similarity BLAST search has been implemented in a user-friendly database. The main features of this database will assist researchers in monitoring genetics and antigenic variations, tracking geographic spread with regards of sequence information, and facilitate the development of diagnostics, vaccines, and immunotherapeutics. Database URL: http://mmrdb.org.

Cost-effectiveness of workplace vaccination against measles

Measles is one of the most contagious infectious diseases. Measles vaccine, which has been introduced in Italy in 1979, is highly effective in preventing the disease (two-dose vaccine effectiveness is 99%). In 2017, Italy was the second country of EU for number of cases of measles. A study conducted in the same year showed that 22.3% of measles infection happened in hospital settings and 6.6% of cases occurred in HCWs. This risk group showed low rates of adhesion to the vaccination campaign. For this reason, we hypothesized that workplace vaccination could lead to better vaccination rates in HCWs. Moreover, we focused the vaccination campaign on a specific target group composed of HCWs not serologically immune and previously not vaccinated. We analyzed the clinical records of measles-specific IgG antibodies of 2,940 HCWs, that underwent occupational health surveillance between 1 January 2017 and 31 December 2017. 15.3% (450) was seronegative for measles, especially in the age group under 35 years. We compared the costs related to strategies with and without serological screening. Our study confirmed that immunization strategy with pre-vaccination screening was cost-effective compared to the vaccination without screening. In our sample, in fact, administration of two dose vaccine only susceptible HCWs determine a saving of 146,262 €. The vaccination of HCWs remains a topical issue in preventing the transmission of infectious disease in the hospital setting. Due to the cost-effectiveness evaluation, we recommend extending the pre-vaccination screening to identify the real susceptible workers.

Vaccine-preventable diseases and vaccination among Italian healthcare workers: a review of current literature

Protection of healthcare workers (HCWs) from biological hazards in the workplace has the added benefit of contributing to the quality of patient care and patient safety. Vaccinated HCWs act as a barrier against the spread of infections and maintain essential healthcare delivery during outbreaks. In Italy, specific recommendations for vaccination of HCWs are issued by the Ministry of Health within the framework of the National Immunization Prevention Plan. These recommendations provide advice regarding HCW vaccination for hepatitis B, influenza, pertussis, measles, mumps, rubella, varicella and tuberculosis. This paper summarizes the current literature on vaccine-preventable diseases and vaccination among Italian HCWs.