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Published Date: 2008-05-17 18:00:21
Subject: PRO/EDR> Measles - Spain, USA
Archive Number: 20080517.1654

MEASLES - SPAIN, USA
********************
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In this update:
[1] Measles - Algeciras, Spain
{2] USA - Arizona ex Switzerland
[3] Measles - USA, Jan - Apr 2008 update

******
[1] Measles - Algeciras, Spain
Date: Fri 15 May 2008
Source: Eurosurveillance, Volume 13, Issue 20, 15 May 2008 [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18872>

An outbreak of measles in Algeciras, Spain, 2008
------------------------------------------------
On 4 Feb 2008, the Andalusian Epidemiological Surveillance Ne2rk (SVEA) was
notified of 2 epidemiologically linked cases of measles. By 18 Apr 2008, a
total of 142 suspected cases of measles had been reported from Algeciras, a
town in the south of Spain, with a population of about 110 000 inhabitants.
Of the 142 reports, 57 cases were confirmed, 61 are still under
investigation, and in 24 cases measles was ruled out by laboratory
investigation.

Background
----------
Over the past few years, several European countries have notified measles
outbreaks, some affecting the general public and others limited to specific
population groups [1]. In Andalusia, Spain, a Plan of Action for Measles
Elimination was approved in 2001 [2], following the recommendations of the
World Health Organization (WHO) [3] with the objective of eliminating
indigenous measles by the year 2005. The 2 strategic goals of the plan are
the enhancement of the epidemiological surveillance system to facilitate
early detection of cases and transmission control, and the increase in
vaccination coverage in order to improve population immunity.

Consequently, since 2001, there has been an obligation to urgently notify
cases of measles, within 24 hours, as well as to carry out the
epidemiological survey, to obtain samples for the laboratory, and to take
action on all possible contacts of every suspected measles case.

The Andalusia Vaccination Calendar includes 2 doses of measles, mumps, and
rubella (MMR) vaccine: at the ages of 15 months and 3 years. In 2007, the
MMR vaccine coverage for the 1st dose was 96.5 per cent in Andalusia, and
98.7 per cent in Algeciras.

Outbreak description
--------------------
The 1st 2 cases notified on 4 Feb 2008 were young adults belonging to the
crew of a shipping company covering the Algeciras-Tangiers route.
Subsequently, a 3rd primary case was notified in another adult living in a
different place from the 1st 2, who had travelled to the north of Morocco
via the Tarifa-Tangiers ferry. The 1st 2 cases were associated with 8
secondary cases in their working and family environments. The 3rd case
caused no secondary cases.

Between 12 and 19 Feb 2008, 4 cases were reported, and between 24 Feb 2008
and the 9 Mar 2008 a further 9 cases were notified. From 11 Mar 2008 a
growing number of cases had been registered. To date, 25 per cent of all
cases (37/142) have been shown to be epidemiologically related and belong
to 11 different clusters.

Thus far, the outbreak has been restricted to the town of Algeciras (where
75 per cent of the cases have been reported) and the nearby municipalities.
The incidence of measles in the area reached nearly 50 cases per 100 000
inhabitants.

The age of the cases ranged from 5 months to 41 years. The highest numbers
of cases and highest incidence rates were reported in age groups considered
to be most susceptible to measles: children younger than 2 years old and
adults between 20 and 39 years old. [These data are presented as a table
and a figure in the original text]. About half of the cases were female. 4
patients required hospital treatment. The complications notified have been
diarrhoea, otalgia, and bronchitis.

In keeping with the case classification proposed by the Spanish Measles
Elimination Plan [4], 57 cases have been confirmed up to now: 45 by
laboratory, 11 by epidemiological link, and one by being clinically
compatible. For 61 cases the investigations are still under way and in 24
cases laboratory analysis ruled out measles.

In samples taken from at least 29 patients, including case 3
epidemiologically unrelated to the 2 primary bases, a D4 measles virus
genotype has been isolated, which would suggest a common origin of the
outbreak. The D4 genotype isolated is a strain with an identical sequence
to that identified in the United Kingdom in 2007 which has been circulating
now for more than a year and is related to cases in other European
countries and in Israel and America. Of the confirmed cases, 1.4 per cent
had been vaccinated previously. Among the unvaccinated cases one was an
emergency doctor who subsequently refused to be vaccinated when offered the
vaccine as part of control measures.

Control measures
----------------
The following steps have been taken to control the outbreak: respiratory
isolation of the cases during the infectious period; vaccination or
administration of immunoglobulin to susceptible contacts, with close
surveillance at work, schools, nurseries, and health centres; vaccination
of infants aged between 6 and 15 months; vaccination of health workers;
distribution of information to doctors on the progress of the outbreak,
insisting upon the necessity of considering measles as a differential
diagnosis on adult rashes, urgent notification of cases and compliance with
the established action protocols with contacts.

[byline: J Nieto-Vera 1, J Masa-Calles 2, J Davila 1, J Molina-Font 3, M
Jiménez 3, V Gallardo-Garcia 4, JM Mayoral-Cortes 4
1 Andalusian Health Service, Algeciras, Cadiz, Spain; 2 Epidemiology Field
Training Programme, National Epidemiological Centre, ISCIII, Madrid, Spain;
3 Provincial Health Council, Regional Ministry of Health, Cadiz, Spain; 4
Regional Ministry of Health of the Government of Andalusia, Seville, Spain]

References
1. Muscat M, Bang H, Glismann S. Measles is still a cause for concern in
Europe. Euro Surveill. 2008; 13(16): pii=18837. Available from
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18837>
2. Plan de Accion para la Eliminacion del Sarampion en Andalucia. Direccion
General de Salud Publica y Participacion. Consejeria de Salud. Seville, 2001.
3. Strategic plan for measles and congenital rubella infection in the
European Region of WHO. Copenhagen, World Health Organization, 2002.
Available from
<http://www.euro.who.int/InformationSources/Publications/Catalogue/20051123_1>.

4. Amela C, Pachon I. La Vigilancia Epidemiologica del Sarampion en el
contexto del "Plan de accion para la eliminacion del sarampion en Espana"
Bol Epidemiol Semanal 2000; 8 (16);169-80. Available from
<http://cne.isciii.es>

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[The significance of this report is the considerable penetration of measles
into a population with a high level of acceptance of MMR vaccine. The case
of the emergency unit physician who declined vaccination is an illustration
of the difficulty in achieving complete population coverage.

The HealthMap/ProMED-mail interactive map of Spain at
<http://healthmap.org/promed?v=40.2,-3.6,5> can be accessed to locate
Algeciras in the Bay of Gibraltar. - Mod.CP]

******
{2] USA - Arizona ex Switzerland
Date: Fri 16 May 2008
Source: KSWT News, Associated Press report [edited]
<http://www.kswt.com/Global/story.asp?S=8338352&nav=menu613_2_6>

Measles outbreak spreads to Pinal County, infant sickened
---------------------------------------------------------
Health officials in Pinal County, AZ, say a measles outbreak in Pima County
has now spread north. Pinal County issued a health advisory Friday [15 May
2008] saying a 9 month old child in San Manuel has been diagnosed with the
highly contagious disease. Pima County health officials have been trying to
stop the spread of measles since a case 1st was reported in February 2008.
There have been 21 confirmed cases in that county and vaccinations clinics
are being held 6 days a week.

Measles is most severe in infants and children and can cause death in rare
cases. It is spread through direct contact and through droplets in the air.

Pinal County officials are now urging parents of children between 6 months
and 11 months to make sure their children have been vaccinated.

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[This outbreak originated by a visitor from Switzerland has not yet been
extinguished. The number of cases in the outbreak has risen from 16 to 21
since the last report on 1 May 2008: see Measles - USA (03): (AZ)
20080501.1498.

The following report presented as part [3] of this post provides an update
of the current measles situation in the United States up to 25 Apr 2008. -
Mod.CP]

******
[3] Measles - USA, Jan - Apr 2008 update
Date: Fri 9 May 2008
Source: MMWR Morb Mortal Wkly Rep 2008: 57(18): 494-8, May 9 [edited]
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5718a5.htm>

Measles -- United States, 1 Jan 2008 -- 25 Apr 2008
---------------------------------------------------
Measles, a highly contagious acute viral disease, can result in serious
complications and death. As a result of a successful United States
vaccination program, measles elimination (that is, interruption of endemic
measles transmission) was declared in the US in 2000 (1). The number of
reported measles cases has declined from 763 094 in 1958 to fewer than 150
cases reported per year since 1997 (1). During 2000-2007, a total of 29 -
116 measles cases (mean: 62, median: 56) were reported annually. However,
during 1 Jan 2008 - 25 Apr 2008, a total of 64 confirmed measles cases were
preliminarily reported to CDC, the most reported by this date for any year
since 2001. Of the 64 cases, 54 were associated with importation of measles
from other countries into the US, and 63 of the 64 patients were
unvaccinated or had unknown or undocumented vaccination status. This report
describes the 64 cases and provides guidance for preventing measles
transmission and controlling outbreaks through vaccination, infection
control, and rapid public health response.

Because these cases resulted from importations and occurred almost
exclusively in unvaccinated persons, the findings underscore the ongoing
risk for measles among unvaccinated persons and the importance of
maintaining high levels of vaccination.

Measles cases in the US are reported by state health departments
preliminarily to CDC, and confirmed cases are reported officially via the
National Notifiable Disease Surveillance System, using standard case
definitions and case classifications. Cases are considered importation
associated if they are 1) acquired outside the US (that ia, international
importation) or 2) acquired inside the US and either epidemiologically
linked via a chain of transmission to an importation or accompanied by
virologic evidence of importation (that is, a chain of transmission from
which a measles virus is identified that is not endemic in the US). Other
cases in the US are classified as having an unknown source.

During 1 Jan 2008 - 25 Apr 2008, a total of 64 preliminary confirmed
measles cases were reported from the following areas: New York City (22
cases), Arizona (15), California (12), Michigan and Wisconsin (4 each),
Hawaii (3), and Illinois, New York state, Pennsylvania, and Virginia (one
each) (Figure). Patients ranged in age from 5 months to 71 years; 14
patients were aged <12 months, 18 were aged 1-4 years, 11 were aged 5-19
years, 18 were aged 20-49 years, and 3 were aged >50 years, including one
US resident born before 1957.

14 (22 per cent) patients were hospitalized; no deaths were reported.
Transmission occurred in both health-care and community settings. One of
the 44 patients for whom transmission setting was known was an unvaccinated
health care worker who was infected in a hospital. 17 (39 per cent) were
infected while visiting a health care facility, including a child aged 12
months who was exposed in a physician's office when receiving a routine
dose of measles, mumps, and rubella (MMR) vaccine.

54 (84 per cent) of the 64 measles cases were importation associated: 10
(16 per cent) of the 64 were importations (5 in visitors to the US and 5 in
US residents traveling abroad) from Switzerland (3), Israel (3), Belgium
(2), and India and Italy (one each); 29 (45 per cent) cases were
epidemiologically linked to importations; and 15 (23 per cent) cases had
virologic evidence of importation. The remaining 10 (16 per cent) cases
were from unknown sources; however, all occurred in communities with
importation-associated cases. Specimens from 14 patients were genotyped at
CDC, and 4 different genotypes were identified: 3 from Arizona (genotype
D5), 3 from California (D5), 5 from New York City (one in a case
epidemiologically linked to an imported case from Belgium and 4 in cases in
communities where importations from Israel had occurred; all D4), 2 from
Wisconsin (H1), and one from Michigan (D5).

56 of the 64 measles cases reported in 2008 have occurred in 5 outbreaks
(defined as 3 or more cases linked in time or place). In New York City, an
outbreak of 22 cases has been reported, including 4 importations and 18
other cases (10 importation associated). In Arizona, 15 cases have been
reported; the index patient was an unvaccinated adult visitor from
Switzerland. In San Diego, California, 11 cases have been reported, and an
additional case spread to Hawaii; the index patient in the San Diego
outbreak was an unvaccinated child who had traveled to Switzerland. In
Michigan, 4 cases have been reported; the index patient was an unvaccinated
youth aged 13 years with an unknown source of infection. In Wisconsin, 4
cases have been reported; the index patient was a person aged 37 years with
unknown vaccination status who likely was exposed to a Chinese visitor with
measles-compatible illness.

63 of the 64 patients were unvaccinated or had unknown or undocumented
vaccination status, and one patient had documentation of receiving 2 doses
of MMR vaccine. None of the 5 patients who were visitors to the US had been
vaccinated. Among the 59 patients who were US residents, 13 were aged <12
months and too young to be vaccinated routinely, 7 were children aged
12--15 months and had not yet received vaccination, 21 were children aged
16 months-19 years, including 14 (67 per cent) who claimed exemptions
because of religious or personal beliefs (Table). Among the 18 patients
aged >20 years, 14 had unknown or undocumented vaccination status, 2 had
claimed exemptions and acquired measles in Europe, one had evidence of
immunity because of birth before 1957, and one had documentation of
receiving 2 doses of MMR vaccine.

Of the 5 US residents with measles who were vaccine eligible and had
traveled abroad, all were unvaccinated. One was a child aged 15 months who
was not vaccinated before travel, and 2 were adults who were unvaccinated
because of personal belief exemptions. For 2 adults, the reason for not
being vaccinated was unknown.

[byline: SB Redd, PK Kutty, AA Parker, CW LeBaron, AE Barskey, JF Seward,
et al, Div of Viral Diseases, National Center for Immunization and
Respiratory Diseases, CDC]

MMWR editorial note
-------------------
Although ongoing measles transmission was declared eliminated in the US in
2000 (1) and in the World Health Organization (WHO) Region of the Americas
in 2002 (2), about 20 million cases of measles occur each year worldwide.
The 2008 upsurge in measles cases serves as a reminder that measles is
still imported into the US and can result in outbreaks unless population
immunity remains high through vaccination. Among the 64 confirmed measles
cases, prior vaccination could be documented for only one person.

Before introduction of measles vaccination in 1963, about 3 to 4 million
persons had measles annually in the US; about 400-500 died, 48 000 were
hospitalized, and 1000 developed chronic disability from measles
encephalitis (1). Even after elimination of endemic transmission in 2000,
imported measles has continued to create a substantial US public health
burden; of the 501 measles cases reported during 2000-2007, one in 4
patients was hospitalized, and one in 250 died (1).

Thus far in 2008, 5 US residents and 5 visitors have been documented as
acquiring measles abroad. Of these 10 persons, 9 acquired measles in the
WHO European Region. These importations likely are related to an increase
in 2008 in measles activity in Europe. In Switzerland, about 2250 measles
cases have been reported since November 2006. The Swiss measles outbreak
started in Lucerne, where the measles vaccination coverage level in
children is 78 percent, and spread across the country, predominantly
affecting children aged 5-15 years who were unvaccinated because of
parental opposition to vaccination. In Israel (which is included in the WHO
European Region), a measles outbreak with about 1000 cases is ongoing
(Ministry of Health, Israel, unpublished data, 2008), and measles
transmission is occurring in other European countries, predominantly among
populations opposed to vaccination. This situation prompted travel advisory
notices to be issued in the US and Europe.

Health care providers should advise patients who travel abroad of the
importance of measles vaccination and should consider the diagnosis of
measles in persons with clinically compatible illness who have traveled
abroad recently or have had contact with travelers.

The limited size of recent measles outbreaks in the US has resulted from
highly effective measles and MMR vaccines, pre-existing high vaccination
coverage levels in preschool and school-aged children, and a rapid and
effective public health response. All children should receive 2 doses of
MMR vaccine, with the 1st dose recommended at age 12-15 months and the
second dose at age 4-6 years. Unless they have other documented evidence of
measles immunity, all adults should receive at least 1 dose. 2 doses are
recommended for international travelers aged >12 months, health care
personnel, and students at secondary and postsecondary educational
facilities. Infants aged 6-11 months should receive 1 dose before travel
abroad (3). During a measles outbreak, the vaccination response should be
guided by the epidemiology of the outbreak and the outbreak setting and
might include offering 1 dose of measles or MMR vaccine to infants aged
6-11 months, offering the 2nd dose to preschool-aged children provided that
28 days have elapsed since the 1st dose, and recommending 1 dose to health
care workers born before 1957 unless they show other evidence of immunity.

Patients with measles frequently seek medical care, and emergency
departments are common sites of measles transmission (4). To prevent
transmission of measles in health care settings, patients should be asked
to wear a surgical mask (if tolerated) for source containment, airborne
infection-control precautions (5) should be followed stringently, and
patients should be placed in a negative air-pressure room as soon as
possible. If a negative air-pressure room is not available, the patient
should be placed in a room with the door closed. Measles cases should be
investigated, patients isolated promptly, and specimens obtained for
laboratory confirmation and viral genoptying. Case contacts without
documented evidence of measles immunity should be vaccinated, offered
immune globulin, or asked to quarantine themselves at home from the 5th day
after their 1st exposure to the 21st day after their last exposure.
Contacts with measles-compatible symptoms should be managed in a manner
that will prevent further spread (3,5).

Health care personnel place themselves and their patients at risk if they
are not protected against measles. In accordance with current
recommendations, health care personnel should have documented evidence of
measles immunity readily available at their work location (3). If this
documentation is not available when measles is introduced, major costs and
disruptions to health care operations can result from the need to exclude
potentially infected staff members and rapidly ensure immunity for others (6).

Many of the measles cases in children in 2008 have occurred among children
whose parents claimed exemption from vaccination because of religious or
personal beliefs and in infants too young to be vaccinated. 48 states
currently allow religious exemptions to school vaccination requirements,
and 21 states allow exemptions based on personal beliefs. During 2002 and
2003, nonmedical exemption rates were higher in states that easily granted
exemptions than states with medium or difficult exemption processes (7); in
such states, the process of claiming a nonmedical exemption might require
less effort than fulfilling vaccination requirements (8).

Although national vaccination levels are high, unvaccinated children tend
to be clustered geographically or socially, increasing their risk for
outbreaks (6,9). An upward trend in the mean proportion of school children
who were not vaccinated because of personal belief exemptions was observed
from 1991 to 2004 (7). Increases in the proportion of persons declining
vaccination for themselves or their children might lead to large-scale
outbreaks in the United States, such as those that have occurred in other
countries (for example, United Kingdom and Netherlands) (10).

Ongoing measles virus transmission has been eliminated in the US, but the
risk for imported disease and outbreaks remains. High vaccination coverage
in the US has limited the spread of imported measles in 2008. Nevertheless,
the measles outbreaks in 2008 illustrate the risk created by importation of
disease into clusters of persons with low vaccination rates, both for the
unvaccinated and those who come into contact with them.

References
1. Orenstein WA, Papania MJ, Wharton ME. Measles elimination in the United
States. J Infect Dis 2004; 189(suppl 1): S1-3.
2. De Quadros CA, Andrus JK, Danovaro-Holliday MC, Castillo-Solorzano C.
Feasibility of global measles eradication after interruption of
transmission in the Americas. Expert Rev Vaccines 2008; 7: 355-62.
3. CDC. Measles, mumps, and rubellavaccine use and strategies for
elimination of measles, rubella, and congenital rubella syndrome and
control of mumps: recommendations of the Advisory Committee on Immunization
Practices (ACIP). MMWR 1998; 47(No.RR-8).
4. Farizo KM, Stehr-Green PA, Simpson DM, Markowitz LE. Pediatric emergency
room visits: a risk factor for acquiring measles. Pediatrics 1991; 87: 74-9.
5. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection
Control Practices Advisory Committee. 2007 guideline for isolation
precautions: preventing transmission of infectious agents in health care
settings. Am J Infect Control 2007; 35(suppl 2): S65-164.
6. Parker AA, Staggs W, Dayan GH, et al. Implications of a 2005 measles
outbreak in Indiana for sustained elimination of measles in the United
States. N Engl J Med 2006; 355: 447-55.
7. Omer SB, Pan WK, Halsey NA, et al. Nonmedical exemptions to school
immunization requirements: secular trends and association of state policies
with pertussis incidence. JAMA 2006; 296: 1757-63.
8. Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarosa EJ.
Processes for obtaining nonmedical exemptions to state immunization laws.
Am J Public Health 2001; 91: 645-8.
9. Smith PJ, Chu SY, Barker LE. Children who have received no vaccines: who
are they and where do they live? Pediatrics 2004; 114: 187-95.
10. CDC. Measles outbreak Netherlands, April 1999 January 2000. MMWR 2000;
49: 299-303.

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