Measles In Italy Research Articles

Who is at risk for measles in Italy? Continued measles outbreaks in 2019 and barriers to elimination

Who is at risk for measles in Italy? Continued measles outbreaks in 2019 and barriers to elimination

Who is at risk for measles in Italy? Continued measles outbreaks in 2019 and barriers to elimination

Abstract Background Measles is a highly contagious vaccine preventable disease that can lead to serious complications, including death. All five regions of the World Health Organization have set targets to eliminate measles. In Italy, measles vaccination was introduced in 1976, with sustained low uptake in the 1980s and 1990s. Uptake improved in subsequent years but never reached 95% coverage required for elimination. Two doses of measles-mumps-rubella (MMR) vaccine are recommended (at 12-15 months and 5-6 years respectively). Since July 2017, MMR vaccine has become mandatory for all children up to 16 years of age. Large outbreaks continue to occur, with over 8.000 cases reported in 2017-2018. Methods We analysed measles cases reported to the national integrated measles and rubella surveillance system during January 1 - December 31, 2019. Results From 1 January to 31 December 2019, 1,627 cases (87% laboratory-confirmed), were reported from all 21 administrative regions. National incidence was 27 cases/million. Overall, 86% of cases were unvaccinated. Median age was 30 years but the highest incidence was in infants below one year of age. Ninety-six cases were reported amongst healthcare workers and transmission in the healthcare setting was frequent. Overall, 31% of cases reported complications, including three cases of encephalitis (in two adults and one child) and one death in an adult patient. Complications were more frequent in cases ≥20 years of age compared to younger patients. Forty-six percent of cases were hospitalised. Conclusions The median age of cases has increased further in 2019 compared to 2017 (27 years) and 2018 (28 years). The proportions of complicated and hospitalised cases are high, this may be due to the high median age of cases but also to underreporting from general practitioners who are likely to see milder cases. Wide immunity gaps among adults (including healthcare workers) and nosocomial transmission are major challenges to measles elimination in Italy. Key messages Measles is still endemic in Italy and large outbreaks continue to occur, with a significant public health impact. Wide immunity gaps among adults (including healthcare workers) and nosocomial transmission are major challenges to measles elimination in Italy.

Burden of measles using disability-adjusted life years, Umbria 2013-2018.

Background and aim:The low measles vaccination coverage contributes to the re-emerging of measles in Italy. This study aimed to estimate the measles burden, expressed in Disability Adjusted Life Years (DALYs), in Umbria, for the period 2013-2018.Methods:Data on measles cases in Umbria were obtained from the MoRoNet. While data related to the resident population, were obtained from the website of the National Institute of Statistics. The estimated DALYs was calculated using the Burden of Communicable Diseases in Europe toolkit. The results are expressed in DALYs per year, per case and per 100,000 subjects, for acute illness and for sequelae.Results:The estimated incidence in mean for the entire period was 52.50 cases per year. Resulting in an average loss of 3.10 DALYs per year.Conclusions:The data obtained from this analysis provide important information on the impact of measles in the Umbria region, and offer useful data to the Health Authorities that can be used to reduce measles incidence in the region.

Recurrence of measles in central Italy: the experience of a hospital in Rome

Measles continue to be a major public health issue worldwide with high morbidity and mortality rates. The disease is still endemic in Europe and during 2017 a vast outbreak was described in Italy, Romania and Hungary, which led to thousands of new cases and several deaths. In Italy, 3931 confirmed cases of measles were reported to the Italian national surveillance system from many Italian administrative regions; Lazio, in central Italy, exhibited the highest number of infected patients 1322 (33.63%) and as well as the highest incidence. In this study, we describe the results of a retrospective analysis, carried out during 2016 and 2017, concerning the measles antibody prevalence in patients and healthcare workers attending the Sant’Andrea Hospital of Rome (Lazio). A total of 94 patients (median 30 years of age) were screened in 2016, and 316 (median 40 years of age) during 2017, with an increase of 236% compared to previous year. During 2017, 41 confirmed cases of measles were reported while none in 2016 (P<0.007), and we found a suboptimal immunization coverage in our cohort of patients. Furthermore, measles surveillance of Sant’Andrea healthcare workers during the study period involved 208 personnel units (median >47 years of age) and only one confirmed measles infection was recorded in 2017. These results suggest that there is still an unvaccinated portion of the adult population, who sustain the endemic circulation of measles in Italy. In addition to reach herd immunization on children of 2 years old, catch-up vaccination campaign targeting adult population in Italy and other European countries needs to be implemented to prevent future measles outbreak.

Measles in Italy: Viral strains and crossing borders

In 2017, Italy experienced one of the largest outbreaks of measles in recent years, with 5404 notified cases and 4347 confirmed cases. A further 2029 cases were notified during the first 6 months of 2018, and 1516 of them were laboratory-confirmed. The B3 and D8 genotypes were identified as those responsible for the outbreak. Possible transmission routes can be established by monitoring the circulating measles virus strains in support of the national health authorities to warn people and travellers.

A Note on the Risk of Infections Invading Unaffected Regions.

We present two probabilistic models to estimate the risk of introducing infectious diseases into previously unaffected countries/regions by infective travellers. We analyse two distinct situations, one dealing with a directly transmitted infection (measles in Italy in 2017) and one dealing with a vector-borne infection (Zika virus in Rio de Janeiro, which may happen in the future). To calculate the risk in the first scenario, we used a simple, nonhomogeneous birth process. The second model proposed in this paper provides a way to calculate the probability that local mosquitoes become infected by the arrival of a single infective traveller during his/her infectiousness period. The result of the risk of measles invasion of Italy was of 93% and the result of the risk of Zika virus invasion of Rio de Janeiro was of 22%.

Measles in Italy: Co-circulation of B3 variants during 2014.

In 2013, the majority of the WHO/EUR countries reported an annual incidence of >1 case per one million population indicating that the elimination target is far from being met. Thus, there is the urgent need to uncover and analyze chains of measles virus (MV) transmission with the objective to identify vulnerable groups and avoid possible routes of introduction of MV variants in the European population. The analysis of molecular epidemiology of MV B3 strains identified in 2014 has shown that four different variants co-circulated in Italy, including the strain that caused a cruise-line ship outbreak at the beginning of the year.

Measles in Italy, laboratory surveillance activity during 2010.

The European Regional Office of the World Health Organization (WHO/Europe) developed a strategic approach to stop the indigenous transmission of measles in its 53 Member States by 2015. This study describes the measles laboratory surveillance activity performed by the National Reference Laboratory for Measles and Rubella at the Italian National Institute of Health (Istituto Superiore di Sanità) during 2010. Urine, oral fluid and capillary blood samples from 211 suspected measles cases arrived to the NRL from different regions of Italy for confirmation of the clinical diagnosis. Serological and/or molecular assays were performed; after molecular detection, positive samples were sequenced and genotyped. 85% (180/211) of the specimens were confirmed as measles cases and 139 of these were analyzed phylogenetically. The phylogenetic analysis revealed a co-circulation of D4 and D8 genotypes for the reviewed period.

Measles in Italy, July 2009 to September 2010

Outbreaks of measles continue to occur in Italy, as in other European countries. We present here details of cases reported through the Italian enhanced measles surveillance system from July 2009 to September 2010. In total, 2,151 cases were reported, 42% (n=895) of which were laboratory confirmed. The median age of cases was 18 years and 1,709 of 1,856 cases (92%) were unvaccinated. Many cases with complications were reported (n=305), including three with encephalitis. A total of 652 of 1,822 cases (36%) were hospitalised. Molecular characterisation revealed circulation of a limited number of measles virus genotypes (D4, D8 and B3), which is consistent with the current epidemiology of the disease in Italy. A national measles elimination plan was approved in 2003 with the aim of interrupting endemic measles transmission by 2007. Since elimination was not achieved, the target date was recently moved to 2015. The emphasis of the new elimination plan, approved in March 2011, is on strengthening surveillance, implementing evidence based-interventions to increase measles-mumps-rubella vaccine uptake in children, adolescents and young adults, and implementing communication activities related to the vaccine. The strategies proposed by the plan should be implemented fully and appropriately by all regions in order to meet the elimination goal by 2015.

The pre-vaccination regional epidemiological landscape of measles in Italy: contact patterns, effort needed for eradication, and comparison with other regions of Europe

BackgroundStrong regional heterogeneity and generally sub-optimal rates of measles vaccination in Italy have, to date, hampered attainment of WHO targets for measles elimination, and have generated the need for the new Italian National Measles Elimination Plan. Crucial to success of the plan is the identification of intervention priorities based upon a clear picture of the regional epidemiology of measles derived from the use of data to estimate basic parameters. Previous estimates of measles force of infection for Italy have appeared anomalously low. It has been argued elsewhere that this results from Italian selective under-reporting by age of cases and that the true measles force of infection in Italy is probably similar to that of other European countries. A deeper examination of the evidence for this conjecture is undertaken in the present paper.MethodsUsing monthly regional case notifications data from 1949 to the start of vaccination in 1976 and notifications by age from 1971–76, summary equilibrium parameters (force of infection (FOI), basic reproductive ratio (R0) and critical vaccination coverage (pc)) are calculated for each region and for each of 5 plausible contact patterns. An analysis of the spectra of incidence profiles is also carried out. Finally a transmission dynamics model is employed to explore the correspondence between projections using different estimates of force of infection and data on seroprevalence in Italy.ResultsFOI estimates are lower than comparable European FOIs and there is substantial regional heterogeneity in basic reproductive ratios; certain patterns of contact matrices are demonstrated to be unfeasible. Most regions show evidence of 3-year epidemic cycles or longer, and compared with England & Wales there appears to be little synchronisation between regions. Modelling results suggest that the lower FOI estimated from corrected aggregate national data matches serological data more closely than that estimated from typical European data.ConclusionResults suggest forces of infection in Italy, though everywhere remaining below the typical European level, are historically higher in the South where currently vaccination coverage is lowest. There appears to be little evidence to support the suggestion that a higher true force of infection is masked by age bias in reporting.

Heterogeneity in regional notification patterns and its impact on aggregate national case notification data: the example of measles in Italy.

BackgroundA monthly time series of measles case notifications exists for Italy from 1949 onwards, although its usefulness is seriously undermined by extensive under-reporting which varies strikingly between regions, giving rise to the possibility of significant distortions in epidemic patterns seen in aggregated national data.ResultsA corrected national time series is calculated using an algorithm based upon the approximate equality between births and measles cases; under-reporting estimates are presented for each Italian region, and poor levels of reporting in Southern Italy are confirmed.ConclusionAlthough an order of magnitude larger, despite great heterogeneity between regions in under-reporting and in epidemic patterns, the shape of the corrected national time series remains close to that of the aggregated uncorrected data. This suggests such aggregate data may be quite robust to great heterogeneity in reporting and epidemic patterns at the regional level. The corrected data set maintains an epidemic pattern distinct from that of England and Wales.

Measles in Italy 2002: studies show correlation between vaccine coverage and incidence

The geographical distribution of measles in Italy during the epidemic that occurred in 2002 (1) closely reflected the vaccination coverage distribution at provincial and regional level. Over recent years there had been an accumulation of susceptible children and adolescents. Estimates of the full impact of the 2002 epidemic are awaited although by July in one region there had been 13 cases of encephalitis and three deaths (1). To eliminate measles in Italy, it will be necessary to vaccinate more than 95% of children with two doses of vaccine and reduce older susceptibles with supplementary “catch-up” vaccination programmes. Also, as elimination gets closer, surveillance and the capacity to investigate epidemics must be improved.

Epidemiology of measles, mumps and rubella in Italy

A serosurvey for measles, mumps and rubella was conducted in Italy; incidence based on statutory notifications over the last three decades was also calculated. In Italy the diseases followed an endemic-epidemic pattern, with an incidence peak every 2-4 years, and had a limited reduction of incidence attributable to childhood immunization. Lower notification rates were observed in the Southern regions. This is possibly related to greater under notification in the South and is confirmed by our seroprevalence data. Incidence of measles and rubella and proportion of cases among young adults increased significantly in the three decades considered, but not for mumps. Serological data confirmed that these infections are still very frequent in Italy, without significant geographic variation in the country. In the age groups 2-4 and 5-9 years the percentage of individuals still susceptible to each virus was higher than 30%. The proportion of susceptible subjects older than 15 years was similar for the three infections (6.1, 11.7 and 8.8% for measles, mumps and rubella, respectively). The low vaccine coverage for rubella and measles in Italy has so far only partially affected the occurrence of the diseases. No impact of mumps vaccination is visible. The average number of deaths, for each disease, has decreased during the three study periods. Today the priority in Italy is to halt the progressive increase of the mean age of acquisition of the three infections, to eliminate differences in coverage among regions and to conform to European standards. This will be achieved through a combination of increasing MMR vaccine coverage before 2 years of age, implementing vaccination campaigns for low seroprevalence age groups, and/or introducing a second dose of MMR, depending on the level of current MMR coverage.

Pattern of susceptibility to measles in Italy. Serological Study Group.

On the basis of seroprevalence and incidence data we describe the distribution of individuals susceptible and immune to measles in Italy in 1996-97. In regions where vaccination coverage was at least 70%, approximately 10% of 3-year-old children were susceptible to measles, whereas 40% were in this category in regions with lower vaccination coverage. Seroprevalence among children older than 4 years was similar for the two groups of regions; in the age group 20-39 years it was approximately 95%. During 1990-96 in the regions with lower vaccination coverage the incidence was highest among children aged 4-6 years, and the median age of cases was 7 years; in the regions with higher vaccination coverage, however, the incidence remained at around 5% for the age group 4-16 years, and the overall median age was 10 years. These data confirm the partial reduction in measles incidence in Italy, although transmission has still not been interrupted. The size and geographical distribution of the current pool of susceptible individuals can be expected to present an obstacle to measles elimination if appropriate vaccination strategies, such as catch-up campaigns, are not adopted.

Empirical determinants of measles metapopulation dynamics in England and Wales.

A key issue in metapopulation dynamics is the relative impact of internal patch dynamics and coupling between patches. This problem can be addressed by analysing large spatiotemporal data sets, recording the local and global dynamics of metapopulations. In this paper, we analyse the dynamics of measles meta-populations in a large spatiotemporal case notification data set, collected during the pre-vaccination era in England and Wales. Specifically, we use generalized linear statistical models to quantify the relative importance of local influences (birth rate and population size) and regional coupling on local epidemic dynamics. Apart from the proportional effect of local population size on case totals, the models indicate patterns of local and regional dynamic influences which depend on the current state of epidemics. Birth rate and geographic coupling are not associated with the size of major epidemics. By contrast, minor epidemics--and especially the incidence of local extinction of infection--are influenced both by birth rate and geographical coupling. Birth rate at a lag of four years provides the best fit, reflecting the delayed recruitment of susceptibles to school cohorts. A hierarchical index of spatial coupling to large centres provides the best spatial model. The model also indicates that minor epidemics and extinction patterns are more strongly influenced by this regional effect than the local impact of birth rate.

Brill's Disease

BRILL'S disease should be considered as a cause of fever of undetermined origin in a general hospital that draws patients from the foreign-born population. Typhus fever, a scourge of all times and all nations, was first differentiated from measles in Italy by Jerome Cardan in 1536. Bravo, in 1570, and Fracastorius, in 1584, further described the though the cause was not surmised. In 1608 Cober described the Hungarian disease, which was prevalent in that army, and noted the presence of lice infestation among soldiers but did not relate them etiologically to what apparently was epidemic typhus. Five hundred and . . .