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Rapid Responses: Rapid Responses published:
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Measles: Vaccination the strategy for Eradication
- Pushpa Ranjan Wijesinghe, Thushanthi Sandhya Wijesinghe (31 October 2006)
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Clarification from the authors
- Eithne MacMahon, Perviz Asaria (31 October 2006)
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Measles situation in Surrey
- Peter M English, Nicola Lang, Anna Raleigh, Kevin Carroll, and Margot Nicholls (31 October 2006)
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Diagnosis
- Patrick G Beauchamp (31 October 2006)
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The surgical importance of MMR vaccine coverage.
- Masoom Muttalib (6 November 2006)
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Pushpa Ranjan Wijesinghe, Public Health Practitioner Epidemiological Unit,Ministry of Health, Sri Lanka, Thushanthi Sandhya Wijesinghe
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Editor, We read the article titled “Measles in the United Kingdom: can we eradicate it by 2010? “by Perviz Asaria, and Eithne MacMahon with interest . The authors highlight the need to achieve and maintain high levels of vaccination coverage throughout Europe if the 2010 goal for elimination is to be met against the background of renewed threat of endemic measles in UK. We specially paid our attention to this challenge from the preventive perspective of measles in the article as Public Health Practioners from a developing country. In 1999-2000, we too faced a large outbreak of measles in Sri Lanka which, according to the WHO’s classification of measles situation, fell into the category of countries, which have a better measles immunisation coverage and a better position to improve surveillance (1). As pointed out by the authors, children less than 12 months are at particular risk. The highest morbidity rate (114/100000 population), in the Sri Lankan outbreak, was observed among children less than 9 months (1) suggesting the waning passive immunity in infancy. The age at which routine immunisation is carried out is another factor which adds susceptibles to measles as a result of primary vaccine failure. As pointed out in your article, MMR at 12-15 months is recommended for routine immunisation. However, it has been suggested to shift the vaccination to 12 months for reduction of the pool of susceptibles as proportion of anti-body positive children is low among those aged 9-12 months (2). We routinely immunize children with measles vaccination at 9 months in Sri Lanka, as recommended by the WHO. with a sero conversion rate of about 85% at this age (3). Shifting this age to 12 months has been suggested to enhance the effectiveness of the measles vaccine in the background of reduced transmission after a “catch-up” campaign following the outbreak in 2000 (1). Currently, a second dose of measles (MR) is given in Sri Lanka, at the age of three years though, the ideal age for this would have been 18 months. Another issue that may affect the susceptibility of infants to measles is the relatively short period of the passive immunity of children born to an increasing proportion of women with vaccine induced immunity (4). In our context, as the Measles immunization programme was initiated in 1985, the majority of women currently in the childbearing age have not had natural infection in their life time. As such, the duration of the passive immunity is expected to be low among those who were born to these mothers exposed to measles immunisation from 1985 onwards. As Azaria and McMahon suggested children and adults who have not received two doses are not protected. In our scenario, a “catch-up campaign” covered those in the age group 1-14 years and 15-24 years. This provided the opportunity to give the second dose to those who under the previous EPI schedule received only one dose at 9 months from 1985 and the other group which was not exposed at all to the vaccination when it was initiated in 1985. The effectiveness of this measure to reduce the measles transmission to lower levels was reflected during the mass displacement of people due to Asian Tsunami. Mass immunisation against measles was not adopted by the Epidemiological Unit and contrary to predictions by the WHO, measles was not a problem among clusters of displaced individuals in the aftermath of the Tsunami (5). In conclusion, in unison with authors, it must be stated, that achieving high coverage and maintenance of vaccination remains the key to elimination of measles. REFERENCES: 1. Puvimanasinghe JPA, Arambepola CK, Abeysinghe MRN, Rajapakse LC, Kulathilake TA. Measles outbreak in Sri lanka,1999-2000. Journal of Infectious Diseases. 2003;187 (supl. 1): 241-45. 2. Nicoara C, Zach K, Trachsel D, German D, Matter L. Decay of passively acquired maternal antibodies against measles, mumps, and rubella viruses. Clin.Diagn.Lab. Immunol. 1999:6:868-71. 3. Epidemiological Unit. Immunization hand book. National Expanded Programme for Immunization. . Colombo 4. Brugha R, Ramsay M, Forsey T, Brown D. A study of maternally derived measles antibody in infants born to naturally infected women and vaccinated women. Epidemiol. Infect.1996;117:519-24 5. Anonymous. Disease control in Tsunami affected areas: key to success. Weekly Epidemiological Report (Sri Lanka). 2005; 32 (4). Also available at URL : http:// www.epid.gov.lk/pdf/VOL%2032%20NO%2004%20.pdf Competing interests: None declared |
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Eithne MacMahon, Consultant Virologist and Honorary Senior Lecturer Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, Perviz Asaria
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Our clinical review, published in the 28 October 2006 issue, was to have been entitled 'Measles in the United Kingdom: here today, gone tomorrow?' Instead, due to an editorial decision taken without consulting us, the article has appeared with the title 'Measles in the United Kingdom: can we eradicate it by 2010?' Unfortunately, the published title is in error. As indicated in Box 1, 'eradication' is a specific epidemiological term indicating the worldwide elimination of an infection. To date, only smallpox has been eradicated. To use 'eradicate' in the context of the United Kingdom is thus incorrect. The front cover statement 'Measles is back in the UK. High levels of vaccination are needed to eradicate it by 2010' is also misleading. Reduced MMR uptake in the United Kingdom has led to sporadic outbreaks in recent years and the renewed threat of endemic measles. Outbreaks have also occurred in other European countries. High levels of vaccination need to be achieved and sustained throughout Europe to reach the WHO target of elimination of measles from the European region by the 2010. Eradication of measles worldwide is the ultimate goal. Competing interests: EMM has received sponsorship from Aventis Pasteur (MSD) towards attending conferences in the past five years. |
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Peter M English, Consultant in Communicable Disease Control Surrey & Sussex HPU, Cedar Court, Leatherhead, KT22 9RX, Nicola Lang, Anna Raleigh, Kevin Carroll, and Margot Nicholls
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We are grateful to Asaria and MacMahon for their excellent summary of information relating to measles.[1] There have been measles outbreaks in the Netherlands, Ireland, USA and Canada, and Italy.[2-6] In the United Kingdom, there was an outbreak of measles in South Yorkshire this year, with 97 suspected and at least 37 confirmed cases reported.[7] There has also been an outbreak of measles in Surrey. The first confirmed case occurred in a child in January 2006. An increase in the number of measles cases notified to the Surrey & Sussex Health Protection Unit (HPU) was noticed during the week of 13 March, 2006, and an initial outbreak meeting was convened on 16 March, 2006. By the end of August 2006, the HPU had received a total of 280 notifications of measles in Surrey residents, with 111 confirmed or epidemiologically linked cases. This compares with a total of 6 cases in the county during 2005. 24 cases of measles were admitted to hospital, and there were 4 confirmed cases in healthcare workers. 16 doses of human normal immunoglobulin (HNIG) were required as post exposure prophylaxis for vulnerable contacts. The outbreak control team worked with local health visitors and GP practices to carry out sensitive contact tracing, and to implement measures to reduce further spread. Such measures included immunisation of contacts with MMR (as post exposure prophylaxis when this could be done within 72 hours of exposure), or treatment with HNIG for: pregnant contacts, immunocompromised contacts, contacts aged 6-9/12, or those aged less than 6/12 with mothers deemed not to be immune to measles. The HPU also sent out letters to all schools in Surrey, to the PCT, and liaised with Occupational Health for the acute trust and PCT. We also gained some attention from the media, which we used to raise awareness of the need for vaccination. The HPU has developed an algorithm for the management of measles in Primary Care (which we are unable to add to this "rapid response", but which is included in a document which can be downloaded from our website).[8] This algorithm, based on the ‘Green Book’[9], was used by the HPU, and local General Practices, during the recent outbreak. One of our cases was a young mother with a baby aged under 6 months. Despite having been given HNIG, the baby subsequently developed measles. It has hitherto been assumed that most mothers would be immune to measles through natural illness or vaccination, and that babies under the age of six months would be protected by maternal antibodies. This can no longer be assumed, as measles has been uncommon in the UK for so many years. Babies under 6 months should be offered HNIG if the mother is thought unlikely to be immune. REFERENCES 1. Asaria P, MacMahon E. Measles in the United Kingdom: can we eradicate it by 2010? Br Med J 2006;333(7574):890-895. http://bmj.bmjjournals.com/cgi/content/extract/333/7574/890?ehom 2. Fitzpatrick M. MMR: risk, choice, chance. Brit Med Bull 2004;69:143-53. 3. Landen MG, Beller M, Funk E, Rolka HR, Middaugh J. Measles Outbreak in Juneau, Alaska, 1996: Implications for Future Outbreak Control Strategies. Pediatrics 1998;102(6):e71-. http://pediatrics.aappublications.org/cgi/content/abstract/102/6/e71 4. Anonymous. Measles Outbreak Among School-Aged Children -- Juneau, Alaska, 1996 MMWR - Morbidity & Mortality Weekly Report 1996;45(36):777-80. http://www.cdc.gov/mmwr/preview/mmwrhtml/00043622.htm 5. Duclos P, Redd SC, Varughese P, Hersh BS. Measles in adults in Canada and the United States: implications for measles elimination and eradication. Int. J. Epidemiol. 1999;28:141-6. http://ije.oxfordjournals.org/cgi/content/abstract/28/1/141 6. Filia A, Curtale F, Kreidl P, Morosetti G, Nicoletti L, Perrelli F, et al. Cluster of measles cases in the Roma/Sinti population, Italy, June-September 2006. Eurosurveillance, 2006. http://www.eurosurveillance.org/ew/2006/061012.asp#2 7. Anonymous. Outbreak of measles in Doncaster. Communicable Disease Report Weekly 2006;16(15):3-4. http://www.hpa.org.uk/cdr/archives/2006/cdr1506.pdf 8. Carroll K, English PMB, Morgan J, Nicholls M, van den Bosch C. Control of measles in the event of an outbreak. Leatherhead, Surrey: Surrey and Sussex Health Protection Unit, 2006:1-10. http://www.bigfoot.com/~scdcs (follow "Policy and guidance documents") 9. Department of Health, Welsh Office, Scottish Office Department of Health, DHSS (Northern Ireland). Immunisation against infectious disease: the 'Green book' draft chapter on Measles (available from website). In: Department of Health, Welsh Office, Scottish Office Department of Health, Ireland) DN, editors. London: Department of Health, 2006. http://www.publications.doh.gov.uk/greenbook/. Last updated: August 2006. Last accessed: 31 October 2006. Competing interests: None declared |
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Patrick G Beauchamp, Retired GP Retired GP
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It is worth noting that one of the common symptoms in the prodromal phase in children is quite profuse epistaxes. This was quite common during epidemics Competing interests: None declared |
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Masoom Muttalib, Specialist Registrar in Surgery formerly Sandwell General Hospital
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EDITOR - The authors describe a subgroup of cohorts who have not received the MMR vaccine and have not developed natural immunity during the time measles was on the wane.(1) This is the same cohort related to the recent mumps epidemic.(2) At a time of mumps resurgence, difficulties in the surgical diagnosis of complications from viral illness become more apparent. Rare surgical manifestations of mumps include macroscopic haematuria (3) and mastitis (4) but are usually preceded by parotitis. Mumps orchitis commonly presents in post-pubertal men and needs to be distinguished from other causes of acute scrotal pain. The absence of preceding parotitis may necessitate surgical exploration to exclude torsion, as ultrasonographic findings are not specific, often showing altered vascularity and abnormal testicular echo texture. The less common mumps pancreatitis needs to be differentiated from other causes of an acute abdomen. Pancreatitis may be the first of manifestation of mumps in the absence of parotitis (5) or even post measles, mumps, and rubella (MMR) vaccination (6) and has led to unnecessary laparotomy. (7) Electrophoresis of amylase isoenzymes (pancreatic and salivary types) may offer clues to the underlying viral cause.(8) (1) Asaria P, MacMahon E. Clinical Review – Measles in the United Kingdom: can we eradicate it by 2010? BMJ 2006; 333: 890-5. (2) Gupta RK, Best J, MacMahon E. Mumps and the UK epidemic 2005. BMJ 2005; 330: 1132-1135. (3) Yildiz N, Yasa O, Celik Y, Baydilli H, Ozcay S. Hematuria with mumps infection. Indian J Pediatr. 2003;70(1):93-4. (4) Happel JS. Mastitis in the male -a rare complication of mumps. BMJ 1965;2(5469):1041. (5) Naficy K, Nategh R, Ghadimi H. Mumps pancreatitis without parotitis. BMJ 1973;1(5852):529. (6) Adler JB, Mazzotta SA, Barkin JS. Pancreatitis caused by measles, mumps, and rubella vaccine. Pancreas 1991;6(4):489-90. (7) Feldman G, Zer M. Infantile acute pancreatitis after mumps vaccination simulating an acute abdomen. Pediatr Surg Int. 2000;16(7):488- 9. (8) Skrha J, Stepan J, Sixtova E. Amylase isoenzymes in mumps. Eur J Pediatr. 1979;132(2):99-105. Competing interests: None declared |
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