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Niculae CM, Matoru RM, Brîndușe O, Ioniță AV, Gorea ME, Țîrlescu LG, Constantin RA, Moroti R, Hristea A. High rates of hepatic involvement associated with new epidemic measles strains in Romania. J Med Virol 2024; 96:e70001. [PMID: 39387349 DOI: 10.1002/jmv.70001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 09/09/2024] [Accepted: 10/01/2024] [Indexed: 10/15/2024]
Abstract
Similar to other European countries, a measles epidemic dominated by D8 genotype strains is ongoing since 2022 in our country. Recent reports of liver involvement associated with new measles virus (MeV) strains are scarce. The aim of the study was to compare the clinical characteristics between hospitalized patients with measles from the current epidemic and those from the previous outbreak and to analyze the risk factors associated with hepatic involvement. Data were collected retrospectively for all consecutive adult ( ≥18 years old) patients admitted between October 2022-April 2024 and January 2018-December 2019. A number of 228 patients from the current and 130 from the previous MeV epidemic were included. The main statistically significant differences were those regarding hepatic involvement (77.2% vs. 45.4%, p < 0.001) and significant hepatocellular injury (23.6% vs. 10.7%, p = 0.003). Compared to cases without liver involvement (123), patients with hepatocytolysis (235) had a higher prevalence of keratoconjunctivitis (42.5% vs. 28.4%, p = 0.01), thrombocytopenia (47.6% vs. 34.9%, p = 0.02), severe lymphopenia (51% vs. 35.7%, p = 0.007) and high fibrinogen levels (58.7% vs. 47.1%, p = 0.04). MeV strains from the 2022-2024 epidemic were the strongest predictors of hepatic involvement in the multivariable analysis (odds ratio = 4.3, 95% confidence interval: 2.5-7.4, p < 0.001). The mortality rate of patients with hepatocellular injury was 1.2%. The current measles epidemic is dominated by high rates of hepatic involvement compared to the previous outbreak. Although not associated with a significant mortality, the potential change in MeV hepatotropism could have important clinical implications and warrants further monitoring.
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Affiliation(s)
- Cristian-Mihail Niculae
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
| | - Raluca-Mihaela Matoru
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
| | - Oana Brîndușe
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
| | - Andrei-Valentin Ioniță
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Internal Medicine Department, Coltea Clinical Hospital, Bucharest, Romania
| | - Maria-Evelina Gorea
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
| | - Laura-Georgiana Țîrlescu
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
| | - Rareș-Alexandru Constantin
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
| | - Ruxandra Moroti
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
| | - Adriana Hristea
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Infectious Diseases Department, National Institute for Infectious Diseases, Bucharest, Romania
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Ferrari C, Somma G, Caputi V, Treglia M, Pallocci M, Cenko F, Buonomo E, Carestia M, Di Giampaolo L, Olesen OF, Coppeta L. Low Rates of Immunity among Medical Students and Residents in the Era of the Resurgence of Measles. Pathogens 2024; 13:784. [PMID: 39338975 PMCID: PMC11435405 DOI: 10.3390/pathogens13090784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Revised: 09/04/2024] [Accepted: 09/10/2024] [Indexed: 09/30/2024] Open
Abstract
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.
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Affiliation(s)
- Cristiana Ferrari
- PhD Program in Social, Occupational and Medico-Legal Sciences, Department of Occupational, Medicine, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (G.S.); (V.C.); (M.T.); (M.P.); (L.C.)
| | - Giuseppina Somma
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (G.S.); (V.C.); (M.T.); (M.P.); (L.C.)
| | - Vittorio Caputi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (G.S.); (V.C.); (M.T.); (M.P.); (L.C.)
| | - Michele Treglia
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (G.S.); (V.C.); (M.T.); (M.P.); (L.C.)
| | - Margherita Pallocci
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (G.S.); (V.C.); (M.T.); (M.P.); (L.C.)
| | - Fabian Cenko
- Faculty of Medicine, Catholic University of “Our Lady of Good Counsel”, 1000 Tirana, Albania; (F.C.); (E.B.); (M.C.)
| | - Ersilia Buonomo
- Faculty of Medicine, Catholic University of “Our Lady of Good Counsel”, 1000 Tirana, Albania; (F.C.); (E.B.); (M.C.)
| | - Mariachiara Carestia
- Faculty of Medicine, Catholic University of “Our Lady of Good Counsel”, 1000 Tirana, Albania; (F.C.); (E.B.); (M.C.)
| | - Luca Di Giampaolo
- Department of Occupational Medicine, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy;
| | - Ole F. Olesen
- European Vaccine Initiative, Universitätsklinikum Heidelberg (Heidelberg University Hospital), Voßstraße 2, 69115 Heidelberg, Germany;
| | - Luca Coppeta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy; (G.S.); (V.C.); (M.T.); (M.P.); (L.C.)
- Faculty of Medicine, Catholic University of “Our Lady of Good Counsel”, 1000 Tirana, Albania; (F.C.); (E.B.); (M.C.)
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Stanescu A, Ruta SM, Cernescu C, Pistol A. Suboptimal MMR Vaccination Coverages-A Constant Challenge for Measles Elimination in Romania. Vaccines (Basel) 2024; 12:107. [PMID: 38276679 PMCID: PMC10819452 DOI: 10.3390/vaccines12010107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
Measles is targeted for elimination since 2001, with a significant reduction in cases recorded worldwide, but outbreaks occur periodically due to immunization gaps. This study analyzes the evolution of vaccination coverage rates (VCRs) in Romania, a EU country with large measles epidemics during the last two decades, including an ongoing outbreak in 2023. Vaccination against measles has been part of the National Immunization Program since 1979, initially as a single dose, and from 1994 onwards it has had two doses. The initially high national VCRs of >97% gradually declined from 2010 onward and remained constantly under 90%, with further decreases during the COVID-19 pandemic. The lowest VCRs for both vaccine doses in the last decade were recorded in 2022 and were 83.4% for the first dose and 71.4% for the second dose, with significant differences among Romania's 42 counties. Several factors contributed to this decline, including failure to attend the general practitioners' offices, increased number of children lost to follow-up due to population movements, missed vaccination opportunities due to temporary medical contraindications, a surge in vaccine hesitancy/refusal, a decreasing number of general practitioners and discontinuities in vaccine supply. The persisting suboptimal VCRs in Romania threaten the progress toward measles elimination.
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Affiliation(s)
- Aurora Stanescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.S.); (A.P.)
- National Institute of Public Health, National Centre for Communicable Diseases Surveillance and Control, 050463 Bucharest, Romania
| | - Simona Maria Ruta
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.S.); (A.P.)
- Department of Viral Emerging Diseases, Stefan. S. Nicolau Institute of Virology, 030304 Bucharest, Romania
| | | | - Adriana Pistol
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.S.); (A.P.)
- National Institute of Public Health, National Centre for Communicable Diseases Surveillance and Control, 050463 Bucharest, Romania
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Lefebvre M, Gross L, Ollivier R, Bailly S, Coste-Burel M, Coutherut J, Dina J. Measles in vulnerable populations: An outbreak in Roma settlements of Loire-Atlantique, France, 2019. J Med Virol 2023; 95:e29321. [PMID: 38108193 DOI: 10.1002/jmv.29321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/07/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
In May 2019, a measles outbreak occurred in the French subregion of Loire-Atlantique, particularly affecting Roma settlements. Various obstacles hindered the implementation of postexposure measures among Roma population, resulting in the spread of the cases to other settlements. Suspected cases of measles were immediately investigated and concerned settlements were visited for measles-mumps-rubella (MMR) vaccination. From July 1 to September 3, 2019, a first and then a second Health Reserve team helped for vaccination on the affected and then also the measles-free settlements. Vaccination uptake was monitored with the use of the department's vaccination center immunization registry. Genotyping of selected samples was performed for comparison with viruses circulating at the same time in France and Romania. As of September 16 2019, 109 cases of measles were confirmed among Roma population, including 99 (91%) children under 15 years. Of the 85 people eligible for vaccination, 60 (71%) had not been vaccinated and 23 (27%) had an unknown vaccination status. Sequence comparison revealed that 28/29 sequenced D8 strains were 100% identical to the strain responsible for a large number of cases throughout France in 2019, and to two sequences reported in Romania among sporadic cases. The vaccination campaign resulted in 1136 people on 35 settlements receiving at least one dose of MMR vaccine and in the increase of one-dose MMR vaccine coverage at 24 months from 43% (23/53) to 91% (48/53). With measles transmission continuing in Europe, efforts must be made to meet immunization coverage targets, particularly in hard-to-reach communities where outbreaks may be difficult to control.
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Affiliation(s)
- M Lefebvre
- Infectious Disease Department, Nantes University Hospital and Inserm CIC 1413, Nantes University, Nantes, France
- Center for Prevention of Infectious and Transmissible Diseases, Nantes University Hospital, Nantes, France
| | - L Gross
- Regional Health Agency in Pays de la Loire, Nantes, France
| | - R Ollivier
- Santé publique France, Regional Office in Pays de la Loire, Nantes, France
| | - S Bailly
- Center for Prevention of Infectious and Transmissible Diseases, Nantes University Hospital, Nantes, France
| | - M Coste-Burel
- Virology Department, Nantes University Hospital, Nantes, France
| | - J Coutherut
- Center for Prevention of Infectious and Transmissible Diseases, Nantes University Hospital, Nantes, France
| | - J Dina
- Department of Virology, Normandie Univ, UNICAEN, CHU de CAEN Normandie, Virology Department, INSERM UMR 1311, DYNAMICURE, Caen, France
- CHU de CAEN Normandie, National Reference Center for Measles, Mumps and Rubella viruses, Caen, France
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Radoi CL, Zlatian O, Balasoiu M, Giubelan L, Stoian AC, Dragonu L, Neacsu A, Iliescu DG. Seroprevalence of Infections with TORCH Agents in Romania: A Systematic Review. Microorganisms 2023; 11:2120. [PMID: 37630680 PMCID: PMC10459641 DOI: 10.3390/microorganisms11082120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
Maternal-fetal infectious pathology-notably the TORCH panel (Toxoplasma gondii, rubella, Cytomegalovirus, and herpes simplex viruses)-critically impacts maternal and neonatal health. This review collates data on the seroprevalence of IgG and IgM antibodies against TORCH agents in Romanian women, aiming to discern regional and population differences and identify risk factors. Twenty studies were included in the review, revealing variable seroprevalence rates across the country. Regions such as Moldavia and Banat showed higher anti-T. gondii IgG seroprevalence rates than Bihor, with notable declines in Banat. Rural, older, and multiparous women showed elevated T. gondii IgG rates. Anti-rubella vaccine introduction significantly reduced the prevalence of anti-rubella IgG antibodies, but recent vaccination coverage decreases raise concerns. CMV and HSV seroprevalence varied geographically, with rural areas generally showing higher CMV rates and HSV influenced by factors like education level and number of sexual partners. Concurrent seroprevalence of multiple TORCH components in some cases underscores potential common risk factors. This study highlights the importance of continuous monitoring and preventive measures such as vaccinations and awareness campaigns to mitigate the health impact on the pregnant population.
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Affiliation(s)
- Cristiana Luiza Radoi
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (C.L.R.); (A.N.)
| | - Ovidiu Zlatian
- Medical Laboratory, County Clinical Emergency Hospital of Craiova, 200349 Craiova, Romania;
- Microbiology Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Maria Balasoiu
- Medical Laboratory, County Clinical Emergency Hospital of Craiova, 200349 Craiova, Romania;
- Microbiology Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Lucian Giubelan
- Infectious Diseases Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (L.G.); (A.C.S.); (L.D.)
- “Victor Babes” Infectious Diseases and Pneumophtisiology Clinical Hospital, 200515 Craiova, Romania
| | - Andreea Cristina Stoian
- Infectious Diseases Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (L.G.); (A.C.S.); (L.D.)
| | - Livia Dragonu
- Infectious Diseases Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (L.G.); (A.C.S.); (L.D.)
- “Victor Babes” Infectious Diseases and Pneumophtisiology Clinical Hospital, 200515 Craiova, Romania
| | - Alexandru Neacsu
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania; (C.L.R.); (A.N.)
| | - Dominic Gabriel Iliescu
- Obstetrics and Gynecology Department, County Clinical Emergency Hospital of Craiova, 200349 Craiova, Romania;
- Obstetrics and Gynecology Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Lazar M, Pascu C, Roșca M, Stănescu A. Ongoing measles outbreaks in Romania, March 2023 to August 2023. Euro Surveill 2023; 28:2300423. [PMID: 37650907 PMCID: PMC10472751 DOI: 10.2807/1560-7917.es.2023.28.35.2300423] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 09/01/2023] Open
Abstract
Measles cases have recently been increasing in Romania, with 460 confirmed cases by August 2023. From March 2023, measles cases increased, and outbreaks were recorded in Cluj, Bistrita Nasaud, Sibiu and Mures counties. New D8 virus variants were identified, different from the variants detected in Romania before the COVID-19 pandemic. We here provide epidemiological and molecular data on the current increase in measles cases in the context of the measles elimination process in the World Health Organization European Region.
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Affiliation(s)
- Mihaela Lazar
- Cantacuzino National Military Medical Institute for Research and Development, Bucharest, Romania
| | - Cătălina Pascu
- Cantacuzino National Military Medical Institute for Research and Development, Bucharest, Romania
| | - Maria Roșca
- National Centre for Communicable Diseases Surveillance and Control, National Institute of Public Health, Bucharest, Romania
| | - Aurora Stănescu
- National Centre for Communicable Diseases Surveillance and Control, National Institute of Public Health, Bucharest, Romania
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Ene L, Duiculescu D, Radoi R, Lazar M, Tardei G, Ungureanu E, Ruta S, Vinters HV, Letendre S, Grant I, Ellis RJ, Achim CL. Subacute myoclonic measles encephalitis - An opportunistic HIV-associated infection. Front Cell Neurosci 2023; 17:1113935. [PMID: 37082207 PMCID: PMC10110848 DOI: 10.3389/fncel.2023.1113935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/13/2023] [Indexed: 04/07/2023] Open
Abstract
Introduction An unusual cluster of myoclonic epilepsy was observed in a Romanian pediatric HIV cohort concurrent with measles outbreaks. We describe this particular form of subacute measles encephalitis (SME) in a group of HIV-infected children and adolescents with severe immunosuppression. Methods This is a single-center study, starting in 1997 and covering 4 measles outbreaks in Romania. The presumptive diagnosis of subacute myoclonic measles encephalitis (SMME) was based on: (1) epidemiological data, previous measles episode or presumed contact with measles virus (MV), (2) clinical presentation with initial localized myoclonic jerks with rapid extension and subsequent motor deficit with preserved mental status, and (3) neuroimaging studies revealing cortical gray matter lesions. Definitive diagnosis was based on a neuropathological exam and immunohistochemistry of brain tissues, and measles RNA detection in the cerebrospinal fluid (CSF). Results Thirty-six patients were diagnosed with a particular form of SME during consecutive measles outbreaks in Romania: 1996-1998 (22); 2005-2008 (12); 2010-2011 (1) and 2016-2018 (1). Most children were born in the late 80s and had parenterally acquired HIV infection in early childhood. Before the episode of SMME, 11 patients had confirmed measles, while the rest, without typical rash, had a respiratory tract infection and/or presumed previous measles contact. In all patients, the clinical onset was sudden, with unilateral myoclonus. MRI findings revealed mainly focal cortical gray matter lesions. Neurologic symptoms progressed rapidly to coma and death in most patients. Three patients survived SMME, they had higher CD4 count at onset, slower progression of neurological symptoms, and benefit of immune recovery with cART. Immunocytochemistry studies revealed MV in the brain with a pattern suggesting an ascending viral neural infection. MV was isolated from CSF in 7 out of 8 patients. Sequence analysis of MV RNA from both nasopharyngeal swabs and CSF was available for one patient with similar N-450 strain characteristics. Conclusion During an outbreak of measles, neurological manifestations, especially myoclonus in immunosuppressed patients, can be related to measles even in the absence of an acute episode. This particular form of subacute myoclonic measles encephalitis is an opportunistic fatal disease. Immune recovery due to effective antiretroviral treatment might increase survival.
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Affiliation(s)
- Luminita Ene
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Dan Duiculescu
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Roxana Radoi
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | | | - Gratiela Tardei
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Eugenia Ungureanu
- “Dr. Victor Babes” Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Simona Ruta
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Ştefan S. Nicolau Institute of Virology, Bucharest, Romania
| | - Harry V. Vinters
- University of California, Los Angeles, Los Angeles, CA, United States
| | - Scott Letendre
- University of California, San Diego, La Jolla, CA, United States
| | - Igor Grant
- University of California, San Diego, La Jolla, CA, United States
| | - Ronald J. Ellis
- University of California, San Diego, La Jolla, CA, United States
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Dube E, Pistol A, Stanescu A, Butu C, Guirguis S, Motea O, Popescu AE, Voivozeanu A, Grbic M, Trottier MÈ, Brewer NT, Leask J, Gellin B, Habersaat KB. Vaccination barriers and drivers in Romania: a focused ethnographic study. Eur J Public Health 2022; 33:222-227. [PMID: 36416573 PMCID: PMC10066483 DOI: 10.1093/eurpub/ckac135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In 2016-18, a large measles outbreak occurred in Romania identified by pockets of sub-optimally vaccinated population groups in the country. The aim of the current study was to gain insight into barriers and drivers from the experience of measles vaccination from the perspectives of caregivers and their providers. METHODS Data were collected by non-participant observation of vaccination consultations and individual interviews with health workers and caregivers in eight Romanian clinics with high or low measles vaccination uptake. Romanian stakeholders were involved in all steps of the study. The findings of this study were discussed during a workshop with key stakeholders. RESULTS Over 400 h of observation and 161 interviews were conducted. A clear difference was found between clinics with high and low measles vaccination uptake which indicates that being aware of and following recommended practices for both vaccination service delivery and conveying vaccine recommendations to caregivers may have an impact on vaccine uptake. Barriers identified were related to shortcomings in following recommended practices for vaccination consultations by health workers (e.g. correctly assessing contraindications or providing enough information to allow an informed decision). These observations were largely confirmed in interviews with caregivers and revealed significant knowledge gaps. CONCLUSIONS The identification of key barriers provided an opportunity to design specific interventions to improve vaccination service delivery (e.g. mobile vaccination clinics, use of an electronic vaccination registry system for scheduling of appointments) and build capacity among health workers (e.g. guidance and supporting materials and training programmes).
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Affiliation(s)
- Eve Dube
- Direction des risques biologiques et de la santé au travail, Institut National de Santé Publique du Québec, Québec, QC, Canada.,Axe maladies infectieuses et immunitaires, Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,Vaccine Acceptance and Demand, Vaccine Acceptance Research Network, Sabin Vaccine Institute, Washington, DC, USA
| | - Adriana Pistol
- Centre for Communicable Disease Surveillance and Control, National Institute of Public Health Romania, Bucharest, Romania
| | - Aurora Stanescu
- Centre for Communicable Disease Surveillance and Control, National Institute of Public Health Romania, Bucharest, Romania
| | - Cassandra Butu
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | | | - Oana Motea
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | - Anca Elvira Popescu
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | | | - Miljana Grbic
- World Health Organization (WHO) Country Office in Romania, Bucharest, Romania
| | - Marie-Ève Trottier
- Direction des risques biologiques et de la santé au travail, Institut National de Santé Publique du Québec, Québec, QC, Canada
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - Julie Leask
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Bruce Gellin
- Vaccine Acceptance and Demand, Sabin Vaccine Institute, Washington, DC, USA
| | - Katrine Bach Habersaat
- Vaccine-Preventable Diseases and Immunization, World Health Organization (WHO) Behavioural and Cultural Insights unit and WHO Europe, Copenhagen, Denmark
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Measles and Rubella Incidence and Molecular Epidemiology in Senegal: Temporal and Regional Trends during Twelve Years of National Surveillance, 2010-2021. Viruses 2022; 14:v14102273. [PMID: 36298828 PMCID: PMC9607477 DOI: 10.3390/v14102273] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/24/2022] [Accepted: 10/07/2022] [Indexed: 11/16/2022] Open
Abstract
We investigated the epidemiology of measles and rubella infections in Senegal based on data from twelve consecutive years of laboratory-based surveillance (2010−2021) and conducted phylogenetic analyses of circulating measles viruses. Sera from measles-suspected cases were collected and tested for measles and rubella-specific IgM antibodies using enzyme-linked immunosorbent assays (ELISA). Throat swabs were collected from patients with clinically diagnosed measles for confirmation by reverse-transcription polymerase chain reaction (RT-PCR) and viral genotyping. Among 8082 laboratory-tested specimens from measles-suspected cases, serological evidence of measles and rubella infection was confirmed in 1303/8082 (16.1%) and 465/6714 (6.9%), respectively. The incidence of rubella is now low—0.8 (95% CI 0.4−1.3) cases per million people in 2021—whereas progress towards measles pre-elimination targets (<1.0 case per million people per year) appears to have stalled; there were 10.8 (95% CI 9.3−12.5) cases per million people in 2021. Phylogenetic analyses revealed that all Senegalese measles strains belonged to genotype B3. The rubella virus sequence obtained in this study was consistent with genotype 1C. Our national surveillance data suggest that despite their low incidence both measles and rubella remain endemic in Senegal with a concerning stagnation in the decline of measles infections that represents a significant challenge to the goal of regional elimination.
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Penedos AR, Fernández-García A, Lazar M, Ralh K, Williams D, Brown KE. Mind your Ps: A probabilistic model to aid the interpretation of molecular epidemiology data. EBioMedicine 2022; 79:103989. [PMID: 35398788 PMCID: PMC9006250 DOI: 10.1016/j.ebiom.2022.103989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 02/18/2022] [Accepted: 03/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background Assessing relatedness of pathogen sequences in clinical samples is a core goal in molecular epidemiology. Tools for Bayesian analysis of phylogeny, such as the BEAST software package, have been typically used in the analysis of sequence/time data in public health. However, they are computationally-, time-, and knowledge-intensive, demanding resources that many laboratories do not have available or cannot allocate frequently. Methods To evaluate a faster and simpler alternative method to support the routine interpretation of sequence data for epidemiology, we obtained sequences for two regions in the measles virus genome, N-450 and MF-NCR, from patient samples of genotypes B3, D4 and D8 taken between 2011 and 2017 in the UK and Romania. A mathematical model incorporating time, possible shared ancestry and the Poisson distribution describing the number of expected substitutions at a given time point was developed to exclude epidemiological relatedness between pairs of sequences. The model was validated against the commonly used Bayesian phylogenetic method using an independent dataset collected in 2017–19. Findings We demonstrate that our model, using time and sequence information to predict whether two samples may be related within a given time frame, minimises the risk of erroneous exclusion of relatedness. An easy-to-use implementation in the form of a guide and spreadsheet is provided for convenient application. Interpretation The proposed model only requires a previously calculated substitution rate for the locus and pathogen of interest. It allows for an informed but quick decision on the likelihood of relatedness between two samples within a time frame, without the need for phylogenetic reconstruction, thus facilitating rapid epidemiological interpretation of sequence data. Funding This work was funded by the United Kingdom Health Security Agency (UKHSA). The World Health Organization European Regional Office funded Aurora Fernández-García and Mihaela Lazar training visits to UKHSA.
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11
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Vojtek I, Larson H, Plotkin S, Van Damme P. Evolving measles status and immunization policy development in six European countries. Hum Vaccin Immunother 2022; 18:2031776. [PMID: 35180372 PMCID: PMC9009904 DOI: 10.1080/21645515.2022.2031776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Heidi Larson
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Stanley Plotkin
- University of Pennsylvania School of Medicine, Doylestown, PA, USA.,Vaxconsult, Doylestown, PA, USA
| | - Pierre Van Damme
- Centre for the Evaluation of Vaccination, Vaccine & Infectious Diseases Institute, University of Antwerp, Antwerp, Belgium
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12
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Davitoiu AM, Spatariu L, Plesca DA, Dimitriu M, Cirstoveanu CG, Chindris S. Review of the measles epidemic in children from Central Eastern Europe in the third millennium. Exp Ther Med 2021; 22:816. [PMID: 34131439 PMCID: PMC8193220 DOI: 10.3892/etm.2021.10248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022] Open
Abstract
Measles is an extremely contagious viral disease. Even though a safe vaccine exists for this disease, it remains one of the leading causes of mortality and morbidity in infants and young children. We aimed to create a retrospective descriptive study in which to analyze the evolution of the measles epidemic at the European level. The documentation was carried out using European Centre for Disease Prevention and Control (ECDC) and World Health Organization (WHO) statistics. At the same time, we present the epidemic's evolution in Romania, using data provided by the Romanian National Institute of Public Health and Ministry of Health. European statistical data indicate a high number of patients diagnosed with measles both among children and adults. All European countries benefit from the measles vaccination in the form of the measles-mumps-rubella (MMR) trivaccine included in their National Vaccination Programme. The vaccination schedule varies from country to country. In the vaccination scheme, most European countries include two doses of the MMR vaccine among the pediatric population. Romania registered a limited number of cases of measles between 1980 and 2015 following the introduction of the measles vaccination in the National Vaccination Programme. Since 2005, the Romanian vaccination schedule includes two doses of MMR trivaccine, administered at 12 months and at 6-7 years. After 2015, as a result of a significant decrease in the number of vaccinated children, Romania is facing a major increase in the cases of measles. Consecutively, a measles epidemic was declared in 2016 and an additional dose of mandatory MMR trivaccine was introduced at the age of 9 months. After 4 years of this schedule of administration, starting with August 2020, the additional dose of MMR administered during infancy has been discontinued. We propose an analysis of the factors that influenced the downward evolution of the measles epidemic in Romania at the beginning of the third millennium. Issues related to the limitation of interpersonal contact in the context of the social distancing imposed by the Sars-CoV-2 virus pandemic are discussed. We consider necessary a detailed documentation of the percentage of new disease cases that will appear in the pediatric population in the near future, in the context of the resumption of daily activity after the reopening of nurseries, kindergartens and schools.
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Affiliation(s)
- Ana-Maria Davitoiu
- Department of Paediatrics, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Paediatrics, 'Dr. Victor Gomoiu' Children Clinical Hospital, 022102 Bucharest, Romania
| | - Luminita Spatariu
- Department of Paediatrics, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Paediatrics, 'Dr. Victor Gomoiu' Children Clinical Hospital, 022102 Bucharest, Romania
| | - Doina-Anca Plesca
- Department of Paediatrics, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Paediatrics, 'Dr. Victor Gomoiu' Children Clinical Hospital, 022102 Bucharest, Romania
| | - Mihai Dimitriu
- Department of Paediatrics, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Catalin Gabriel Cirstoveanu
- Department of Paediatrics, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Neonatal Intensive Care Unit, 'Marie Curie' Emergency Clinical Hospital, 077120 Bucharest, Romania
| | - Sorina Chindris
- Department of Paediatrics, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Paediatrics, 'Dr. Victor Gomoiu' Children Clinical Hospital, 022102 Bucharest, Romania
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13
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Mulchandani R, Sibal B, Phillips A, Suleman S, Banerjee A, Teagle R, Foulkes S, Spence K, Edeghere O. A large outbreak of measles in the West Midlands, England, 2017-2018: descriptive epidemiology, control measures and lessons learnt. Epidemiol Infect 2021; 149:e114. [PMID: 33866992 PMCID: PMC8161374 DOI: 10.1017/s0950268821000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/05/2021] [Accepted: 04/08/2021] [Indexed: 11/16/2022] Open
Abstract
In November 2017, eight confirmed measles cases were reported to Public Health England from a hospital in the West Midlands. A multidisciplinary Incident Management Team (IMT) was established to determine the extent of the problem and coordinate an outbreak response. Between 1 November 2017 and 4 June 2018, a total of 116 confirmed and 21 likely measles cases were linked to this outbreak; just under half (43%) were aged over 15 years of age. Fifty-five of the confirmed cases were hospitalised (48%) and no deaths were reported. At the start of the outbreak, cases were mostly individuals of Romanian origin; the outbreak subsequently spread to the wider population. Over the 8-month response, the IMT conducted the following control measures: extensive contact tracing, immediate provision of post-exposure prophylaxis, community engagement amongst specific high-risk groups, MMR awareness raising including catch-up campaigns and enhanced vaccination services at selected GP surgeries. Key challenges to the effective control measures included language difficulties limiting community engagement; delays in diagnosis, notification and appropriate isolation of cases; limited resources for contact tracing across multiple high-risk settings (including GPs and hospitals) and lack of timely data on vaccine coverage in sub-groups of the population to guide public health action.
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Affiliation(s)
- R. Mulchandani
- UK Field Epidemiology Training Programme (UK-FETP), Public Health England, London, UK
- Field Service Midlands, National Infection Service, Public Health England, Birmingham, UK
| | - B. Sibal
- National Port Health Team, Public Health England, London, UK
| | - A. Phillips
- West Midlands Health Protection Team, Public Health England, Birmingham, UK
| | - S. Suleman
- Field Service Midlands, National Infection Service, Public Health England, Birmingham, UK
| | - A. Banerjee
- Midlands Screening and Immunisation Team, Public Health England, Birmingham, UK
| | - R. Teagle
- Field Service Midlands, National Infection Service, Public Health England, Birmingham, UK
| | - S. Foulkes
- Field Service Midlands, National Infection Service, Public Health England, Birmingham, UK
| | - K. Spence
- West Midlands Health Protection Team, Public Health England, Birmingham, UK
| | - O. Edeghere
- Field Service Midlands, National Infection Service, Public Health England, Birmingham, UK
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14
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Pițigoi D, Săndulescu O, Crăciun MD, Drăgănescu A, Jugulete G, Streinu-Cercel A, Vișan A, Rîciu C, Rafila A, Aramă V, Luminos M, Streinu-Cercel A. Measles in Romania - clinical and epidemiological characteristics of hospitalized measles cases during the first three years of the 2016-ongoing epidemic. Virulence 2021; 11:686-694. [PMID: 32507005 PMCID: PMC7549973 DOI: 10.1080/21505594.2020.1771948] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A large measles epidemic has been ongoing in Romania and many European countries, since 2016. We report case-based surveillance data for all patients (n = 1371) with laboratory-confirmed and epidemiologically-confirmed measles hospitalized in a major infectious diseases hospital in Bucharest Romania during the first three years of the current measles epidemic (July 2016–July 2019). More than half of the patients (57.6%) had ages below 5 years; 6% (n = 82) had preexisting comorbidities. Only 1.5% of the patients had been fully vaccinated, 5.9% had received only one vaccine dose, while 92.8% had not been vaccinated at all against measles. The rate of measles-related complications was 93.4%; complications occurred more frequently among patients who were not eligible for vaccination due to young age or underlying diseases, and among children, who developed pneumonia and enterocolitis more frequently than adults. The median hospital length-of-stay was 6 days. Eight cases (0.6%) required intensive care and mechanical ventilation, and three deaths (0.2%) were recorded. Measles disproportionately affects patient groups who are not eligible for vaccination. During the current epidemic in Romania, 98.5% of the patients hospitalized for measles had not been vaccinated and among these, 75.7% would have been eligible for vaccination. For the remaining pool of unvaccinated children, supplementary immunization activities are urgently needed.
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Affiliation(s)
- Daniela Pițigoi
- Department of Epidemiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania.,National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania
| | - Oana Săndulescu
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Infectious Diseases I, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Maria Dorina Crăciun
- Department of Epidemiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Anca Drăgănescu
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania
| | - Gheorghiță Jugulete
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Infectious Diseases, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Anca Streinu-Cercel
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Infectious Diseases I, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Angelica Vișan
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Infectious Diseases, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Claudia Rîciu
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania
| | - Alexandru Rafila
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Microbiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Victoria Aramă
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Infectious Diseases I, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Monica Luminos
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Infectious Diseases, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
| | - Adrian Streinu-Cercel
- National Institute for Infectious Diseases "Prof. Dr. Matei Balș" , Bucharest, Romania.,Department of Infectious Diseases I, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy , Bucharest, Romania
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15
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Chakraborty C, Sharma AR, Bhattacharya M, Sharma G, Saha RP, Lee SS. Ongoing Clinical Trials of Vaccines to Fight against COVID-19 Pandemic. Immune Netw 2021; 21:e5. [PMID: 33728098 PMCID: PMC7937508 DOI: 10.4110/in.2021.21.e5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has developed as a pandemic, and it created an outrageous effect on the current healthcare and economic system throughout the globe. To date, there is no appropriate therapeutics or vaccines against the disease. The entire human race is eagerly waiting for the development of new therapeutics or vaccines against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Efforts are being taken to develop vaccines at a rapid rate for fighting against the ongoing pandemic situation. Amongst the various vaccines under consideration, some are either in the preclinical stage or in the clinical stages of development (phase-I, -II, and -III). Even, phase-III trials are being conducted for some repurposed vaccines like Bacillus Calmette-Guérin, polio vaccine, and measles-mumps-rubella. We have highlighted the ongoing clinical trial landscape of the COVID-19 as well as repurposed vaccines. An insight into the current status of the available antigenic epitopes for SARS-CoV-2 and different types of vaccine platforms of COVID-19 vaccines has been discussed. These vaccines are highlighted throughout the world by different news agencies. Moreover, ongoing clinical trials for repurposed vaccines for COVID-19 and critical factors associated with the development of COVID-19 vaccines have also been described.
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Affiliation(s)
- Chiranjib Chakraborty
- Department of Biotechnology, School of Life Science & Biotechnology, Adamas University, Kolkata 700126, India
- Institute for Skeletal Aging & Orthopedic Surgery, Hallym University-Chuncheon Sacred Heart Hospital, Chuncheon 24252, Korea
| | - Ashish Ranjan Sharma
- Institute for Skeletal Aging & Orthopedic Surgery, Hallym University-Chuncheon Sacred Heart Hospital, Chuncheon 24252, Korea
| | | | - Garima Sharma
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chuncheon, Korea
| | - Rudra P. Saha
- Department of Biotechnology, School of Life Science & Biotechnology, Adamas University, Kolkata 700126, India
| | - Sang-Soo Lee
- Institute for Skeletal Aging & Orthopedic Surgery, Hallym University-Chuncheon Sacred Heart Hospital, Chuncheon 24252, Korea
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16
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Spatiotemporal Distribution and Genetic Characterization of Measles Strains Circulating in Greece during the 2017-2018 Outbreak. Viruses 2020; 12:v12101166. [PMID: 33076287 PMCID: PMC7602502 DOI: 10.3390/v12101166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 01/16/2023] Open
Abstract
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.
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