Daniel Sagebiel

Further efforts needed to achieve measles elimination in Germany: results of an outbreak investigation

OBJECTIVE To determine morbidity and costs related to a large measles outbreak in Germany and to identify ways to improve the countrys national measles elimination strategy. METHODS We investigated a large outbreak of measles in the federal state of North Rhine-Westphalia (NRW) that occurred in 2006 after 2 years of low measles incidence (< 1 case per 100,000). WHOs clinical case definition was used, and surveillance data from 2006 and 2001 were compared. All cases notified in Duisburg, the most severely affected city, were contacted and interviewed or sent a questionnaire. Health-care provider costs were calculated using information on complications, hospitalization and physician consultations. FINDINGS In NRW, 1749 cases were notified over a 48-week period. Compared with 2001, the distribution of cases shifted to older age groups (especially the 10-14 year group). Most cases (n = 614) occurred in Duisburg. Of these, 81% were interviewed; 15% were hospitalized and two died. Of the 464 for whom information was available, 80% were reported as unvaccinated. Common reasons for non-vaccination were parents either forgetting (36%) or rejecting (28%) vaccination. The average cost per measles case was estimated at 373 euros. CONCLUSION An accumulation of non-immune individuals led to this outbreak. The shift in age distribution has implications for the effectiveness of measles control and the elimination strategy in place. Immediate nationwide school-based catch-up vaccination campaigns targeting older age groups are needed to close critical immunity gaps. Otherwise, the elimination of measles in Germany and thus in Europe by 2010 will not be feasible.

Large measles outbreak at a German public school, 2006.

Background: In 2006, a large measles outbreak (n = 614) occurred in Duisburg city, Germany, with 54% of cases aged >9 years. An investigation was launched to determine reasons for the resurgence of measles, assess vaccination coverage and vaccine effectiveness (VE). Methods: A retrospective cohort-study was undertaken at a Duisburg public school affected early in the outbreak. We distributed questionnaires to all 1250 students aged 10–21 years and abstracted vaccination records. Cases were identified according to a standard clinical case definition. Results: Questionnaires were returned by 1098 (88%) students. Vaccination records were abstracted from 859 students, of whom 820 (95.4%) had received at least one, 605 (70.4%) 2, and 39 (4.5%) no dose(s) of measles-containing vaccine (MCV). Coverage with 2 doses was higher in younger students. We identified 53 cases (attack rate = 5%). Measles-virus sequencing revealed genotype D6. After excluding students vaccinated in 2006 and those with a history of measles, the attack rate was 53% in unvaccinated students, 1.0% in students with one, and 0.4% in those with 2 MCV-doses. VE was 98.1% (95% CI: 92–100%) in students with one and 99.4% (95% CI: 97–100%) with 2 MCV-doses. Based on observed attack rates in vaccinated and unvaccinated students with vaccination records and in students without vaccination records, one-dose-coverage among all participating students was estimated at 91%. Conclusions: VE was high. Vaccination coverage was, however, insufficient to prevent the outbreak. Immunization gaps were found especially in older students. To prevent further outbreaks and to achieve the goal of measles elimination in Germany, vaccination coverage must be increased.

A comparative examination of tuberculosis immigration medical screening programs from selected countries with high immigration and low tuberculosis incidence rates

BackgroundTuberculosis (TB) in migrants is an ongoing challenge in several low TB incidence countries since a large proportion of TB in these countries occurs in migrants from high incidence countries. To meet these challenges, several countries utilize TB screening programs. The programs attempt to identify and treat those with active and/or infectious stages of the disease. In addition, screening is used to identify and manage those with latent or inactive disease after arrival. Between nations, considerable variation exists in the methods used in migration-associated TB screening. The present study aimed to compare the TB immigration medical examination requirements in selected countries of high immigration and low TB incidence rates.MethodsDescriptive study of immigration TB screening programsResults16 out of 18 eligible countries responded to the written standardized survey and phone interview. Comparisons in specific areas of TB immigration screening programs included authorities responsible for TB screening, the primary objectives of the TB screening program, the yield of detection of active TB disease, screening details and aspects of follow up for inactive pulmonary TB. No two countries had the same approach to TB screening among migrants. Important differences, common practices, common problems, evidence or lack of evidence for program specifics were noted.ConclusionsIn spite of common goals, there is great diversity in the processes and practices designed to mitigate the impact of migration-associated TB among nations that screen migrants for the disease. The long-term goal in decreasing migration-related introduction of TB from high to low incidence countries remains diminishing the prevalence of the disease in those high incidence locations. In the meantime, existing or planned migration screening programs for TB can be made more efficient and evidenced based. Cooperation among countries doing research in the areas outlined in this study should facilitate the development of improved screening programs.

Large measles outbreak introduced by asylum seekers and spread among the insufficiently vaccinated resident population, Berlin, October 2014 to August 2015

The largest measles outbreak in Berlin since 2001 occurred from October 2014 to August 2015. Overall, 1,344 cases were ascertained, 86% (with available information) unvaccinated, including 146 (12%) asylum seekers. Median age was 17 years (interquartile range: 4–29 years), 26% were hospitalised and a 1-year-old child died. Measles virus genotyping uniformly revealed the variant ‘D8-Rostov-Don’ and descendants. The virus was likely introduced by and initially spread among asylum seekers before affecting Berlin’s resident population. Among Berlin residents, the highest incidence was in children aged < 2 years, yet most cases (52%) were adults. Post-exposure vaccinations in homes for asylum seekers, not always conducted, occurred later (median: 7.5 days) than the recommended 72 hours after onset of the first case and reached only half of potential contacts. Asylum seekers should not only have non-discriminatory, equitable access to vaccination, they also need to be offered measles vaccination in a timely fashion, i.e. immediately upon arrival in the receiving country. Supplementary immunisation activities targeting the resident population, particularly adults, are urgently needed in Berlin.

Se requerirá un mayor esfuerzo para eliminar el sarampión en Alemania: resultados de la investigación de un brote

Background Germany, with 82 million inhabitants, is committed to the WHO goal of eliminating indigenous measles transmission in the European Region by 2010. (1,2) WHO recommends that at least 95% of children receive two doses of a measles-virus-containing vaccine (MVCV)--the first at 12 months of age and the second before school entry, (2) and that older children who are susceptible also be targeted for a two-dose vaccination. (2) A nationwide two-dose routine measles vaccination schedule was implemented in Germany in 1991. (3) Since 2001, the first dose has been recommended at 11-14 months and the second at 15-23 months of age. (3) Childhood vaccination is usually performed by paediatricians of general practitioners and is free of charge. Vaccinations are not mandatory in Germany, but status is routinely documented from vaccination cards presented at school entry examinations. In 2001, measles became a notifiable disease in Germany, which resulted in strengthened surveillance. The number of measles cases notified in Germany decreased from 6037 in 2001 to a historical low of 122 in 2004. (4) In 2005, a resurgence was observed due to outbreaks in two states (776 cases). The highest attack rate occurred in children aged 1-4 years in Hesse and 5-9 years in Bavaria. (4) In 2006, a large outbreak occurred in the densely-populated state of North Rhine-Westphalia (NRW), with 18 million inhabitants. The epidemiological distribution of measles in Germany is a determinant of measles elimination in Europe because Germany has the largest population in the European Union; regions with high population densities; and geographic, economic and migrational characteristics conducive to measles importation and exportation. (4-6) In a school-based retrospective cohort study during the initial phase of the 2006 outbreak, we demonstrated a vaccine effectiveness of 98.1% in students with one MVCV dose and of 99.4% with two doses. (7) Low or diminishing vaccine effectiveness in older age groups was thus ruled out as an explanation for the outbreak. Here we describe the NRW outbreak in detail, present outbreak-related morbidity and costs in Duisburg (the most severely affected city in NRW), and identify areas for improvement in the national measles elimination strategy. Methods Case definition A case was defined as a person with generalized maculopapular rash [greater than or equal to] 3 days), fever and either cough, coryza of conjunctivitis. (2) Cases that occurred less than one maximum incubation period (18 days) apart in the same city or district were considered to be epidemiologically linked and related to the outbreak. Data collection District public health offices routinely notify measles cases to the Robert Koch Institute (RKI) in Berlin via their state authority. We analysed data from all measles cases during the NRW outbreak and compared the age distribution of these cases with data from 2001. We compared district-level measles vaccination coverage at school entry from 1995 and 2005. (8) All notified patients in Duisburg were contacted to be interviewed with a standardized questionnaire that covered demographic characteristics, clinical symptoms, date of rash onset, measles vaccination status, reasons for non-vaccination, physician consultations and hospitalization, as well as contact details relevant for disease transmission. Interviews were conducted face to face during home visits or by telephone through staff from the district public health office, the state public health institute or the RKI. If at least three attempts to contact the patient by telephone failed, the questionnaire was mailed. Parents were interviewed if the patient was