Ongoing measles outbreak in Switzerland: results from November 2006 to July 2007
JL Richard (jean-luc.richard@bag.admin.ch), V Masserey Spicher
Division of Communicable Diseases, Swiss Federal Office of Public Health, Bern, Switzerland
Introduction
After some sporadic cases and small outbreaks (43 cases) during the first semester of 2006, and a four month period of low measles activity (three cases), an outbreak of measles was detected in the canton of Lucerne in November 2006. From then until 17 July 2007, 483 cases were reported by physicians or laboratories for the whole country. This is ten times more than the average number of cases reported for the corresponding period over the past eight years (mandatory surveillance of measles was introduced in 1999). Of these, 279 cases (58%) occurred in the canton of Lucerne. The incidence for the whole country and all ages, calculated for the eight-month period from November 2006 to July 2007, was 6.5 cases per 100,000 inhabitants. For children under the age of 16 years living in the canton of Lucerne, it was 343 per 100,000.
Outbreak description
The first five known cases, who were eight to nine year-old children living in the town of Lucerne, fell ill almost simultaneously in mid-November. Four of them reported an exposure at school. The origin of the outbreak is unknown. Since then, the disease has spread to the neighbouring countryside; further outbreaks were reported in other cantons: Bern (especially in the area of Biel) in February (68 cases), Geneva in March and again in May (37 cases), and Zug in April (26 cases). These outbreaks are still ongoing. Of 26 cantons, 19 reported at least one measles case. No epidemiological links between the outbreaks have been confirmed, but 27 viral strains obtained from the saliva of cases from different parts of the country – including the first cases in Lucerne – belonged to the D5 genotype. The only exception was one B3 virus that was probably imported from Italy. Exactly the same D5 sequences were recently identified in a Japanese student visiting Canada, and D5 measles viruses were involved in a large outbreak in Japanese universities last spring, suggesting a possible importation of measles from Japan to Switzerland [1,2]. The monthly number of cases has been increasing steadily over this eight-month period, reaching a maximum of 108 cases in June (Figure 1).
Most cases (57%) have been confirmed, either by a positive IgM or PCR result (45% of the total cases), or by an epidemiological link with a laboratory confirmed case (12% of the total cases). Thirty-four percent of the cases fulfilled only the clinical case definition (fever and rash, as well as cough or rhinitis or conjunctivitis), whereas in 9% of the cases, clinical data were not yet available or did not completely fulfil the case definition.
Fifty-three percent of cases were males. Figure 2 shows the age distribution of the cases. Half of them were aged between five and 14 years. The median age was 10 years.
Six percent of the 445 cases for whom a detailed questionnaire had been submitted were vaccinated against measles (18 with one dose and nine with two doses), 87% were unvaccinated, and the vaccination status of the remaining 7% was unknown. There were 43 cases (10%) requiring hospitalisation. Among 445 cases for whom information about complications was available, four cases were reported with encephalitis (1%), all among children, 29 cases with pneumonia (7%, median age 10 years), and 31 cases with otitis media (7%). No deaths were reported.
Control measures
Various measures were taken by the cantonal medical authorities to control this outbreak. They included targeted information, such as letters to the parents in the implicated schools and day-care centres, letters to the doctors of the affected areas, as well as general information through the media and the Bulletin of the Federal Office of Public Health [3,4]. This information contained recommendations to check the vaccination status of children and young adults and to complete immunisation if necessary. In specific cases, contact tracing was carried out to prevent (vaccination or administration of immunoglobulin) and detect new cases. In at least two cantons, non-immune siblings of the index cases were asked to stay at home, in order to limit the transmission to schools.
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Discussion
Measles is a highly contagious disease, with a secondary attack rate of over 90% among non-immune contacts. During this outbreak, a large variety of different settings for transmission were identified, such as families, schools, an anthroposophic boarding school, day-care centres, ski camps, sport clubs, a military accommodation facility, a cinema, planes, an airport, and 'measles parties' (voluntary exposure of children to an infected person).
The current ongoing outbreak clearly shows that measles is not only a childhood disease: 28% of the cases were 16 years-old or older. With one patient out of 10 hospitalised, sometimes with severe complications, it also shows that measles, even in children, cannot be considered a mild disease. Two groups were involved in particular: children and teenagers whose parents did not wish them to be vaccinated, and to a lesser extent, young adults who were not immunised because they were born before the introduction of a general measles vaccination programme and who had not been infected during childhood due to an already reduced circulation of the virus. The first recommendation for measles vaccination dates from 1976, but an active promotion campaign for measles, mumps, and rubella (MMR) vaccination was started only in 1987.
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The best protection against measles and its complications remains the widespread vaccination of young children. In Switzerland, this vaccination is voluntary and reimbursed by mandatory private health insurance. It includes two doses of MMR vaccine, one at the age of 12 months and another at the age of 15 to 24 months [5]. A catch-up vaccination is recommended for anyone under the age of 40 who has no documented vaccination, or no reliable history of having had measles or specific antibodies. Despite a slight increase in recent years, the measles vaccination coverage in Switzerland remains significantly below the 95% necessary for measles elimination [6] .The coverage for one dose is about 86% at two years of age (78% in the canton of Lucerne), 89% at school entry and 95% at the age of 16 years. Overall it reaches only 70 to 75% for the second dose.
In addition to this insufficient vaccination coverage, the frequent lack of appropriate measures to control sporadic cases and beginning outbreaks (there is no national plan of action for measles elimination yet) still allows measles outbreaks to occur in Switzerland, sometimes with large numbers of patients: 6,400 estimated cases in 1997, 613 reported cases in 2003 [7], and 483 cases so far this year. Thus, under the current conditions, it is unlikely that the WHO’s goal to eliminate measles from Europe will be achieved by 2010.
References:
International Society for Infectious Diseases, ProMED-mail. Measles - Canada ex Japan: suspected. Published on 01-June-2007. Available from: http://www.promedmail.org
Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo. Measles update in Japan as of end of week 25 (24 June 2007). Available from: http://idsc.nih.go.jp/disease/measles_e/idwr200725.html
Shang Meier H. Zwei Masernausbrüche mit bisher 32 Fällen im Kanton Luzern / Deux flambées de rougeole dans le canton de Lucerne avec 32 cas jusqu'ŕ présent. [In German and French]. Bull BAG/OFSP 2007; N° 1/2: 10-11. Available from: http://www.bag.admin.ch/themen/medizin/00682/00684/01087/index.html?lang=de
Delaporte E, Wyler-Lazarevic CA, Sudre P. Outbreak of measles in Geneva, Switzerland, March-April 2007. Euro Surveill 2007;12(05):E070510.2. Available from: http://www.eurosurveillance.org/ew/2007/070510.asp#2
Office fédéral de la santé publique et Commission fédérale pour les vaccinations. Plan de vaccination suisse 2007. [In French]. Directives et recommandations N° 8. 2007. Available from: http://www.bag.admin.ch/themen/medizin/00682/00685/02112/index.html?lang=fr
Bundesamt für Gesundheit und Eidgenössische Kommission für Impffragen. Schweizerischer Impfplan 2007. [In German]. Richtlinien und Empfehlungen Nr. 8. Available from: http://www.bag.admin.ch/themen/medizin/00682/00685/02112/index.html?lang=de
World Health Organization. Eliminating measles and rubella and preventing congenital rubella infection, WHO European Region strategic plan 2005–2010. 2005. Available from: http://www.euro.who.int/document/E87772.pdf
Richard JL, Zimmermann HP. Recent increase in measles in children and teenagers in Switzerland. Euro Surveill 2003; 7(23):E030605.1. Available from: http://www.eurosurveillance.org/ew/2003/030605.asp#1
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