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Published Date: 2010-07-29 21:00:09
Subject: PRO/EDR> Measles - Europe: re-emergence
Archive Number: 20100729.2548

MEASLES - EUROPE: RE-EMERGENCE
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****A measles outbreak with more than 20 000 reported cases has been
taking place in Bulgaria since April 2009 and clusters of cases have
been reported from several countries in Europe in 2009 and 2010
[Poland, Slovenia, Ireland, Italy, Germany] -- see report below.****

Date: Thu 29 Jul 2010
Source: Eurosurveillance, Volume 15, Issue 30 [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19629>

Ongoing measles outbreak in Greece, January to July 2010
-----------------------------------------------
By D Pervanidou 1, E Horefti 2, S Patrinos 1, T Lytras 1, E
Triantafillou 1, A Mentis 2, S Bonovas 1, T Panagiotopoulos 1,3

1 Department of Surveillance and Intervention, Hellenic Centre for
Disease Control and Prevention, Athens, Greece
2 National Measles Reference Laboratory, Hellenic Pasteur Institute,
Athens, Greece
3 Department of Child Health, National School of Public Health, Athens, Greece

Summary

A measles outbreak (126 reported cases to date) has been ongoing in
Greece, since January 2010, originally related to the recent outbreak
in Bulgaria. Cases are mostly unvaccinated, and mainly belong to 3
groups: Roma population of Bulgarian nationality, Greek Roma
population, and Greek non-minority population. In these population
groups, 67 percent, 95 percent, and 25 percent of cases respectively
were children aged 0-14 years. Measures were taken to raise clinical
awareness and vaccination of specific population groups was
undertaken. Policies are necessary to increase routine vaccination
uptake of hard-to-reach groups.

Background

Measles is still present in Europe, causing severe complications and
deaths in children [1,2]. Despite a large decline in measles incidence
in the past decade in Europe, the World Health Organization (WHO)
target to eliminate measles in Europe by 2010 does not seem feasible
[2]. A measles outbreak with more than 20 000 reported cases has been
taking place in Bulgaria since April 2009 [3,4], and clusters of cases
have been reported from several countries in Europe in 2009 and 2010
[5-9].

Measles is a notifiable disease in Greece; the European Union (EU)
case definition of 2008 is used [10]. Overall, measles incidence has
been steadily declining in Greece during the past 25 years. The last
measles outbreaks occurred in Greece in 1996 and in 2005 and 2006

The 2-5-year measles epidemic cycles previously observed ended after
the 1996 measles outbreak. The last outbreak, in 2005-2006, had mainly
affected unvaccinated Roma children aged 0-14 years, older teenagers
and young adults from the non-minority general population who were
either unvaccinated or had had one dose of measles-containing vaccine,
and unvaccinated or incompletely vaccinated immigrants [11].

Ongoing measles outbreak in Greece

A total of 126 measles cases have been reported to the Hellenic Centre
for Disease Control and Prevention through the mandatory notification
system by 25 Jul 2010 (rate 1.1 cases per 100 000 population). The 1st
case was notified on 29 Jan 2010.

Case classification: 77 (61 percent) of 126 reported cases were
laboratory-confirmed (by serology and/or by PCR). 31 cases (25
percent) were classified as probable (cases meeting the clinical
criteria with an epidemiological link). 18 cases (14 percent) were
classified as possible (cases meeting the clinical criteria).

Laboratory investigation: So far, measles virus genotype D4 was
identified in all 19 cases genotyped by the National Measles Reference
Laboratory (Hellenic Pasteur Institute). Nine of these cases are of
Bulgarian nationality (Roma), 9 are of Greek nationality (6 of them
are Roma) and one case is of Albanian nationality. Genotyping is in
process for more cases.

Nationality / high-risk populations: 36 (29 percent) of 126 reported
cases belonged to Roma communities of Bulgarian nationality, mostly
families of seasonal workers in Greece (usually living in poor
conditions). 87 cases (69 percent) were persons of Greek nationality,
43 (34 percent) of whom belonged to the Greek Roma community. Seven
cases (6 percent) were healthcare workers. Three (2 percent) cases
were persons of other nationalities (one immigrant from Albania, one
tourist from Denmark and one from France).

Progress of the outbreak over time: During the 1st 7 weeks of the
outbreak, the majority of cases were of Bulgarian nationality. In the
following weeks, cases of Greek nationality were reported as well, and
after week 21/2010, the majority of cases belonged to Greek Roma
communities [data illustrated graphically in the original text].

Age distribution: 78 (62 percent) of 126 reported cases were children
aged 0-14 years, with the largest number of cases (n=34, 27 percent)
in the age group of 1-4 years. Ten cases (8 percent) were younger than
one year. The majority of measles cases of Bulgarian nationality were
children 0-14 years (67 percent), mainly children aged 0-4 years (42
percent). Almost all cases in the Greek Roma population were children
aged 0-14 years (95 percent), half of whom were 0-4 years-old. The
majority of cases from the non-minority Greek population were young
adults older than 20 years (66 percent).

Vaccination status: Information on vaccination status was reported by
physicians who got this information from children's health booklets,
or by parents or patients themselves. Of the 106 measles cases with
known vaccination status, 93 cases (88 percent) were reported as
unvaccinated. 13 cases (12 percent) were vaccinated for measles, all
of them of Greek nationality (12 cases from the non-minority general
population and one from the Roma community). Nine cases were reported
to have had one dose of measles vaccine (the case from the Roma
community was vaccinated 7 days before disease onset), and 4 cases
were vaccinated with an unspecified number of doses.

History of recent travel abroad: Information on recent travel abroad
(within 3 weeks before onset of symptoms) was available for 114 of the
126 cases. 104 cases (91 percent) had no history of recent travel
abroad, including 22 cases of Bulgarian nationality. Ten cases (9
percent) had a history of recent travel: 8 cases had recently
travelled to Bulgaria (6 persons of Bulgarian nationality, one Roma
person of Greek nationality and one of Danish nationality), one case
to France (person of French nationality), and another one had an
unknown travel itinerary.

Hospitalisation, complications and outcome: Of the 125 cases with
known hospitalisation status, 83 (66 percent) were hospitalised. Of
125 measles cases with known complication status, complications were
reported in 31 (25 percent) of the cases. Complications included
pneumonia (18 cases), otitis media (7 cases), laryngitis and/or
bronchitis (6 cases). Measles was complicated by meningitis in one
male aged 29 years, whose vaccination status was unknown. No death has
been reported.

Geographical distribution: The 1st measles clusters were reported from
the district of Ilia in southwestern Greece (a total of 30 cases, most
of them in 3 villages) and from the island of Crete (6 cases from the
district of Chania and 13 cases from the district of Heraklion, 10 of
them from one village). No connection was identified between the
clusters in Ilia, Chania and Heraklion. As of 25 Jul 2010, measles
cases have been reported from 21 of the 52 districts of the country,
without any apparent geographical pattern. Clusters have been reported
in Greek Roma camps (33 cases from 8 clusters in Greek Roma camps) and
in villages where Roma of Bulgarian nationality stay (26 cases from 5
villages). The largest reported cluster had 13 cases (12 cases from
one village, most of them relatives, and one healthcare worker) all
belonging to the Greek non-minority population. Only 2 of the clusters
were directly related to imported cases with recent travel history
abroad. Of infants und!
er one year, half (5/10) were part of family clusters, and one was
part of a community cluster.

Control measures

The following public health measures were implemented. All regional
and local public health authorities, physicians and other healthcare
workers in the public and private sector in Greece were informed about
this outbreak and the outbreak in Bulgaria, and about the appropriate
investigation and management of measles cases and their contacts
(isolation of cases, contact tracing and vaccination of susceptible
contacts). Guidelines for measles control were distributed to
healthcare staff and are available on the website of the Hellenic
Centre for Disease Control and Prevention (<http://www.keelpno.gr>).
Furthermore, physicians were alerted to increase their awareness for
measles cases and to strengthen surveillance and to complete routine
immunisation of children, adolescents and young adults in the wider
community, according to the national immunisation schedule. In
addition, vaccination campaigns of population groups with low vaccine
coverage were organised in the country, with!
priority to high risk communities (mainly Roma) in affected areas.

Discussion and conclusions

This is a preliminary report of an ongoing measles outbreak in Greece,
based on national surveillance data. The 1st cases and clusters were
among persons of Bulgarian nationality, probably related to the
measles outbreak in Bulgaria which started in April 2009 [3]. However,
the high proportion of Greek nationals, mainly from Roma communities,
underlines that despite the high national immunisation coverage with
measles-mumps-rubella (MMR) vaccine, pockets of unvaccinated
populations still exist.

Vaccination with 2 doses of MMR vaccine has been included in the
national immunisation schedule in Greece since 1991. According to the
national immunisation schedule, vaccination with the 1st dose of MMR
is recommended at the age of 12-15 months and with the 2nd dose at the
age of 4-6 years. Immunisation coverage with MMR is high in children
in Greece, but less than optimal in adolescents and young adults. In
some population groups (e.g. Greek Roma), vaccination coverage is low.
According to the last national study on vaccination coverage, carried
out in 2006, about 99 percent of 1st grade school children (about 6
years old) were immunised with one dose of a measles-containing
vaccine, and 77 percent with 2 doses. In Roma children, coverage was
82 percent and 45 percent respectively, but this refers to Roma
children going to school and may represent an overestimation of the
coverage of all Roma children. In 9th grade school children (about 14
years-old), coverage with one dose!
of a measles-containing vaccine was 92 percent, and 80 percent with
2 doses [12].

It is of concern that the age distribution of cases in the Greek Roma
population (95 percent of cases under 15 years) is similar to the one
observed in many countries in the pre-vaccination era [13]. Children
under the age of one year represented 8 percent of all cases (rate 9.1
per 100 000 population). In some recent outbreaks, the incidence of
measles in this age group was found increased compared to previous
years [14]. The hospitalisation rate we found (66 percent) is similar
to that reported in some recent outbreaks in Europe [3,5] but higher
than in others [6,14], possibly reflecting a greater extent of
underreporting of mild cases.

The occurrence of this outbreak highlights the need to achieve high
vaccination coverage with 2 doses of MMR vaccine through routine
immunisation in the general population (not only among children, but
also among adolescents and young adults) and the need to increase
immunisation coverage in hard-to-reach populations. It is equally
important to have systematic policies that ensure good access to
vaccination services for children in Roma communities in Greece.

References

1.EUVAC NET. Measles surveillance annual report 2009. Copenhagen:
EUVAC NET. Available from:
<http://www.euvac.net/graphics/euvac/pdf/annual_2009.pdf>.
2. Lopalco PL, Martin R. Measles still spreads in Europe: who is
responsible for the failure to vaccinate?. Euro Surveill.
2010;15(17):pii=19557. Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19557>.
3. Marinova L, Muscat M, Mihneva Z, Kojouharova M. An update on an
ongoing measles outbreak in Bulgaria, April-November 2009. Euro
Surveill. 2009;14(50):pii=19442. Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19442>.
4. EUVAC NET. Measles outbreak in Bulgaria: update as of week 28,
2010. Copenhagen: EUVAC NET. Available from:
<http://www.euvac.net/graphics/euvac/outbreak/bulgaria28.html>.
5. Orlikova H, Rogalska J, Kazanowska-Zielinska E, Jankowski T,
Slodzinski J, Kess B, et al. Spotlight on measles 2010: A measles
outbreak in a Roma population in Pulawy, eastern Poland, June to
August 2009. Euro Surveill. 2010;15(17):pii=19550. Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19550>.
6. Gee S, Cotter S, O'Flanagan D, on behalf of the national incident
management team. Spotlight on measles 2010: Measles outbreak in
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from:
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ongoing measles outbreak in a subpopulation with low vaccination
coverage in Berlin, Germany, January-March 2010. Euro Surveill.
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<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19527>.
8. Grgic-Vitek M, Frelih T, Ucakar V, Prosenc K, Tomaia J, Petrovec M,
et al. Spotlight on measles 2010: A cluster of measles in a hospital
setting in Slovenia, March 2010. Euro Surveill. 2010;15(20):pii=19573.
Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19573>.
9. EUVAC NET. Measles outbreaks in Piemonte, Italy between 1 January
2010 and 13 May 2010. Copenhagen: EUVAC NET. Available from:
<http://www.euvac.net/graphics/euvac/outbreak/italy5.html>.
10. European Commission. Commission Decision of 28 April 2008 amending
Decision 2002/253/EC 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. 18.06.2008:L
159. Available from:
<http://ec.europa.eu/health/ph_threats/com/docs/1589_2008_en.pdf>.
11. Georgakopoulou T, Grylli C, Kalamara E, Katerelos P, Spala G,
Panagiotopoulos T. Current measles outbreak in Greece. Euro Surveill.
2006;11(8):pii=2906. Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2906>.
12. Panagiotopoulos T, Georgakopoulou T, Stavrou D, Danis K, Laggas D,
Georgiadou L, et al. Greek national study on vaccination coverage and
occurrence of tuberculosis infection in children, 2006. Athens:
National School of Public Health. 2009 [in Greek].
13. Miller E, Nokes DJ, Anderson RM. Measles, mumps and rubella
vaccination. BMJ. 1992;304(6839):1440-1.
14. Stein-Zamir C, Abramson N, Shoob H, Zentner G. An outbreak of
measles in an ultra-orthodox Jewish community in Jerusalem, Israel,
2007 - an in-depth report. Euro Surveill. 2008;13(8):pii=8045.
Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=8045>.

--
Communicated by:
ProMED-mail <promed@promedmail.org>

[Prior to 2010, the last measles outbreaks occurred in Greece in 1996
and in 2005 and 2006. The resurgence of measles virus infection
appears to be predominantly a consequence of movement from Bulgaria of
migrant workers belonging to the Roma community and subsequent spread
of infection to the indigenous Roma population in Greece. This
situation highlights the need for new initiatives to extend routine
vaccination to segments of the community that are currently hard to
reach.

The HealthMap/ProMED-mail interactive map of Greece can be accessed
at: <http://healthmap.org/r/01Pm>. - Mod.CP]

See Also