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Published Date: 2007-04-04 21:00:02
Subject: PRO/EDR> Measles - Italy (Apulia)
Archive Number: 20070404.1146

MEASLES - ITALY (APULIA)
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Date: Thu 5 Apr 2007
From: ProMED-mail <promed@promedmail.org>
Source: Eurosurveillance weekly releases 2007, Vol. 12, Issue 4 [edited]
<http://www.eurosurveillance.org/ew/2007/070405.asp#4>

An outbreak of measles in Apulia, Italy, November 2006 to January 2007
-----------------------------------------------
Between 19 Nov 2006 and 9 Jan 2007, an outbreak of measles with 18
cases was reported in the region of Apulia in southeastern Italy. A
case of measles was defined as a case that met the clinical case
definition (clinical picture compatible with measles, i.e. a
generalized rash lasting more than 3 days and a temperature of >38.0
C as well as one or more of the following symptoms: cough, coryza,
Koplik's spots, conjunctivitis) [1].
A confirmed case of measles was defined either as a case that was
laboratory-confirmed (by detection of IgM type antibodies against
measles virus, positive PCR), or as a case that met the clinical case
definition and was epidemiologically linked to a laboratory-confirmed
case.
Outbreak description
--------------------
The 1st reported case was a 6-year-old boy who presented with fever
(>38 C), rhinitis, conjunctivitis, coryza and cough on 19 Nov 2006,
and was hospitalized on 22 Nov 2006. On 24 Nov 2006, he developed a
mild rash. On 24 Nov 2006, a classmate of the 1st reported case
presented with the same symptoms and enanthema (mucosal rash), but he
was not hospitalized. Between the 1st and the 2nd reported cases
(similar onset of symptoms), it was not possible to identify the
index case. One more measles case with onset of symptoms on 27 Nov
2006 was reported in another town in the same province. This was an
11-year-old cousin of the 1st reported case. The 2 had met and spent
some time together on 20 Nov 2006. None of these 3 cases could be
laboratory-confirmed.
From 28 Nov 2006 to 9 Jan 2007, a further 15 measles cases were
reported in the same town in which the 1st and 2nd cases had
occurred. Seven of the affected patients attended the same school,
and the remaining 8 lived in the same neighborhood. However, it was
not possible to establish any contact between them.
All cases occurred during an 8-week period. The epidemic curve for
the outbreak from November 2006 to January 2007 shows the number of
total and laboratory-confirmed measles cases by week of onset
[illustrated by a figure in the original text].
Only 12 of the 18 cases were initially reported to the local and
regional public health authorities. Ten patients were hospitalized.
None of the affected 18 patients had ever been vaccinated against
measles. The average age was 6.4 years (DS = +or- 4.6; median = 5.5;
range: 9 months to 15 years). [The age distribution of cases is
illustrated by a figure in the original text.].
Laboratory results
------------------
Eight cases were laboratory-confirmed by the regional reference
laboratory in Bari. The link between these cases was established
through genotyping of the virus. Measles virus (MV) detection was
performed by a nested RT-PCR on 8 cases. The 456-bp segment of the N
gene of these MV strains was used for genotyping according to the
standard protocol. The N gene sequences of the viruses from the
outbreak were identical and belonged to genotype B3, never previously
identified in Italy [2-4].
Control measures
----------------
In response to the outbreak, active surveillance was set up. All
susceptible contacts and all susceptible children from 2 to 10 years
of age resident in the town and its vicinity were vaccinated with a
1st dose of MMR, if previously unvaccinated, or a 2nd dose if they
had already received one dose.
An extensive catch-up vaccination campaign was conducted in order to
immunize susceptible children with the combined measles-mumps-rubella
(MMR) vaccine as soon as possible. As a result, 1251 children were
vaccinated between 12 Jan and 1 Mar 2007, which corresponds to 12.3
percent of the population aged 2 to 10 years. Coverage rates for a
1st dose of MMR increased from 59.6 percent to 63.2 percent and for a
2nd dose increased from 37.2 percent to 46.3 percent in the targeted
age group.
Discussion
----------
As a result of the large outbreak of measles in Italy in 2002-2003
[5] and the implementation of the National Elimination Plan for
Measles and Congenital Rubella starting in 2003 [6-7], the incidence
of measles infections in Apulia fell to less than one per 100 000
inhabitants in the last 2 years.
In 1999, the MMR vaccine administered at the age of 12 months was
added to the vaccination schedule in the region of Apulia. Since
2005, the 1st dose of MMR has been given at the age of 15 months and
the 2nd dose to children 5-6 years old. A catch-up vaccination with 2
doses of the MMR vaccine has been added to the list of routine
vaccinations for still-susceptible boys and girls at 11 to 12 years.
In 2005, the coverage rate for the 1st dose of MMR in the 2003 birth
cohort was 80.6 percent in the town in which the outbreak here
described took place, and 88.9 percent in the rest of Apulia.
Therefore, the target MMR coverage for the WHO European Region (>95
percent for both doses) has not yet been reached.
Genotyping revealed that an apparently imported MV of genotype B3 was
responsible for the observed outbreak. B3 viruses are still
endemically circulating and widely distributed in Africa. Several
importations of B3 into Europe and the USA have recently been
reported [11]. In order to reach the goal set by the World Health
Organization to eliminate measles from the European Region by the
year 2010 (8-10), strengthened active surveillance by laboratory
confirmation of every measles case and high vaccination coverage need
to be achieved and maintained in countries with low incidence of
measles.
[By R Prato1, M Chironna2, G Caputi1, A Sallustio2, D Martinelli2, A
Falco2, C A Germinario <c.germinario@igiene.uniba.it>2]
1. Dipartimento di Scienze Mediche e del Lavoro, Sezione di Igiene
Universita di Foggia; Osservatorio Epidemiologico Regione Puglia
(Department of Medical Sciences, Section of Hygiene, University of
Foggia; Apulia Regional Epidemiological Observatory), Foggia, Italy
2. Dipartimento di Scienze Biomediche e Oncologia Umana, Sezione di
Higiene, Universita di Bari; Osservatorio Epidemiologico Regione
Puglia, (Department of Biomedical Sciences, Section of Hygiene,
University of Bari; Apulia Regional Epidemiological Observatory),
Bari, Italy)
References
-----------
(1) Commission Decision of 19 Mar 2002 laying down case definitions
for reporting communicable diseases to the Community network under
Decision No 2119/98/EC of the European Parliament and of the Council.
Official Journal of the European Communities 2002; L 86/44.
(2) Riddell MA, Rota JS, Rota PA. Review of the temporal and
geographical distribution of measles virus genotypes in the
prevaccine and postvaccine eras. Virol. J., 2005, 2: 87.
(3) Bellini WJ, Rota PA. Genetic diversity of wild-type measles
viruses: implications for global measles elimination programs. Emerg.
Infect. Dis. 1998, 4: 29-35.
(4) World Health Organization. New genotype of measles virus and
update on global distribution of measles genotype. Wkly. Epidemiol.
Rec. 2005, 80:347-351.
(5) Lopalco PL, Prato R, Pastore R, Martinelli D, Caputi G,
Germinario C. Epidemiological analysis of measles in the Apulian
region based on the use of current data sources. Journal of
Preventive Medicine and Hygiene 2005; 46: 132-138.
(6) Manfredi P, Williams JR, Ciofi degli Atti ML, Salmaso S. Measles
elimination in Italy: project impact of the National Elimination
Plan. Epidemiol Infect 2005, 133: 87-97.
(7) Bonanni P, Bechini A, Boccalini S, Peruzzi M, Tiscione E,
Boncompagni G, Mannelli F, Salmaso S, Filia A, Ciofi degli Atti M.
Progress in Italy in control and elimination of measles and
congenital rubella. Vaccine 2007, doi:10.1016/j.vaccine.2007.01.019.
(8) Spika J. Measles elimination 2010 target: the need to meet the
specific risk group. Euro Surveill 2006;11(10):202-2
<http://www.eurosurveillance.org/em/v11n10/1110-221.asp>.
(9) WHO Europe: Eliminating measles and rubella and preventing
congenital rubella infection: WHO European Region Strategic Plan
2005-2010
<http://www.euro.who.int/Document/E87772.pdf>.
(10) EUVAC: Measles surveillance annual report 2005
<http://www.euvac.net/graphics/euvac/pdf>.
(11) Rota J, Lowe L, Rota P, Bellini W, Redd S, Dayan G et al.
(2006). Identical genotype B3 sequences from measles patients in 4
countries, 2005. Emerg Infect Dis 12(11), 1779-1781.
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