H5N1

Migration and outbreaks of vaccine-preventable disease in Europe: A systematic review

Via The Lancet Infectious Diseases: Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review. The summary:

Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. 

We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. 

We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. 

In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. 

A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery.

New arrangement for second dose of measles vaccination under DH's Hong Kong Childhood Immunisation Programme

Via the Centre for Health Protection: New arrangement for second dose of measles vaccination under DH's Hong Kong Childhood Immunisation Programme. Excerpt:

The Department of Health (DH) today (December 23) announced that a new arrangement for measles vaccination under the DH's Hong Kong Childhood Immunisation Programme (HKCIP) will be implemented from January 2, 2020.      

Children in Hong Kong are given the first dose of a combined measles, mumps and rubella (MMR) vaccine when they are 1 year old at the DH's Maternal and Child Health Centres (MCHCs). Under the new arrangement, this will be followed by a second dose of a measles-containing vaccine (i.e. combined measles, mumps, rubella and varicella (MMRV) vaccine) when they are 18 months old at MCHCs instead of receiving the vaccination at Primary One at school under the current practice.      

The new arrangement is applicable to children born on or after July 1, 2018. Those who were born before this date will continue to receive the vaccination concerned at Primary One via the School Immunisation Teams (SITs) of the DH through outreach visits to schools.      

After the implementation of the new measure, the DH will arrange for second doses of a measles-containing vaccine to children according to their date of birth. Detailed arrangements are as follows: 

Children born on or after July 1, 2018 

Those with scheduled appointments at 18 months old for receiving the diphtheria, tetanus, acellular pertussis and inactivated poliovirus vaccine (booster dose) at MCHCs on or after January 2, 2020, will receive the MMRV vaccine on the same day. 

Children born between January 1, 2013, and June 30, 2018 

As in previous years, these children will receive the MMRV vaccine at Primary One via the SITs through outreach visits to schools.

More than 18 million children in Uganda to be immunized against measles, rubella and polio in mass campaign

Via WHO AFRO: More than 18 million children in Uganda to be immunized against measles, rubella and polio in mass campaign.

Kampala, 15 October 2019 – Uganda is set to immunize more than 18 million children against measles and rubella, which amounts to 43% of the country’s population. Among them, 8.2 million children younger than 9 months, or 20.5% of the population, will also receive the oral polio vaccine. 

Uganda has experienced measles outbreaks across numerous districts in the past three years. At the same time, polio remains a daunting threat, given evidence of vaccine-derived strains circulating in neighbouring countries. 

The five-day mass immunization campaign, funded by the Government of Uganda; GAVI, the Vaccine Alliance; the United Nations Children’s Fund; and the World Health Organization (WHO); intends to tackle these three public health challenges. 

The campaign, to be conducted in schools for the first three days and in communities for the last two days, targets all children younger than 15 years, whether previously immunized or not, in order to interrupt circulation of these diseases. The campaign will be a launch pad to introduce the measles-rubella vaccine into the country’s routine immunization schedule. 

“This campaign does NOT replace the routine immunization schedule. Parents, caregivers and all concerned must ensure that all children receive and complete all the vaccines specified on our immunization schedule after the campaign,” said Dr Jane Ruth Aceng, Uganda Minister of Health.  

The mass campaign provides opportunity to intensify sensitization of communities on measles, rubella and polio as well as disease surveillance and to investigate any unreported but suspected cases of these diseases. This is particularly important because of the declining trend in routine immunization coverage in the country.  

“This is an extremely important exercise,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “It represents an impressive level of commitment to health care that we need more than ever across the African Region to prevent deaths, disease and suffering and to avoid unnecessary expenditure when caring for people who are sick.” 

The Government of Uganda acknowledges the importance of immunization against various diseases to attain Sustainable Development Goal 3, which underlines the need for good health and well-being.  

“We appeal to all parents, caregivers and guardians to take your children younger than 15 years for immunization against measles, rubella and polio during this mass exercise. The Ministry of Health has approved the vaccines to be used, and they are safe, free and effective,” said Dr Yonas Tegegn Woldermariam, WHO Representative in Uganda.  

During the campaign, teams of health workers will set up vaccination service delivery posts across the country, with the objective of attaining more than 95% immunization coverage, which is needed to interrupt the transmission of measles, rubella and polio.

Measles resurgence in the USA: How international travel compounds vaccine resistance

Via The Lancet Infectious Diseases: Measles resurgence in the USA: how international travel compounds vaccine resistance. Excerpt:

Hotez and colleagues' recent article highlights the increasing frequency of vaccine-preventable disease cases in Europe and the USA caused by very visible anti-vaccine movements. The most troubling aspect of this development is the global increase in measles cases. From Jan 1, 2019, to April 26, 2019, the USA reported 704 confirmed measles cases spanning 22 states, compared with 372 reported cases in 2018, 120 in 2017, 86 in 2016, 188 in 2015, and 667 in 2014. Therefore, only 4 months into 2019 the number of cases reported is already the highest since measles was declared officially eliminated in the US in 2000. 

These high numbers show that the USA still remains at risk for large measles epidemics such as those recently seen in Europe. Two main factors are believed to contribute to the resurgence of measles cases in the USA: reintroduction of the virus at individual localities through travel from countries experiencing outbreaks and low vaccination rates fueled by non-medical exemptions (NMEs). The analysis we present confirms the hypothesis that these two factors are the most salient ones for the outbreaks of measles in the USA in 2019. This hypothesis allows a predictive risk analysis to identify which US regions are most at risk. The seriousness of this risk is underscored by the ease of transmission of measles, which is caused by the highly contagious measles morbillivirus that is capable of airborne spread. 

We explain this risk using a quantitative model that identifies the US counties with the highest risk of a measles outbreak in 2019. This spatial relative risk profile at a county resolution for the USA is derived from a multiplicative risk function that compounds four factors: international air travel volume to the destination county, NME rates in the county, county population, and the incidence rate of the measles outbreak at travel origin. The model uses county level NME rates if available; otherwise, it relies on state averages for NME rates or estimated vaccination rates. A detailed description of the data and methods used are available in the appendix. Our risk measure can be interpreted as the expected relative size of a measles outbreak in a county. 

The results of the predictions are shown in the figure and listed in the appendix. The results of our calculation are spatially consistent with the reported measles cases in the USA (last comparison made April 15, 2019): counties we identify or those immediately adjacent to them have reported measles cases in 2019. According to the Centers for Disease Control and Prevention and various state health departments, at least 45 USA counties have reported measles cases in 2019 and 30 of these are either included in the top 25 at-risk counties identified in figure 1 or spatially adjacent to one of the top 25 counties. 

Our results correctly predicted the areas in Washington, Oregon, and New York that have had major measles outbreaks. Brooklyn, New York, which has reported over 300 cases, is adjacent to Queens, New York, which ranked fourth. Multnomah, Oregon is ranked 13th, and adjacent to Clark, Washington with 73 cases. San Mateo, California, ranked 19th has had an outbreak with four cases; adjacent Santa Clara has also reported four cases, and adjacent Santa Cruz and San Francisco have also each reported one case. Several Texas counties are identified as being at an elevated risk of measles. Harris, Texas has had the biggest outbreak so far with four cases and is ranked ninth in our predictions. Another seven counties in Texas have reported cases, which are all in close proximity to either Tarrant, Texas (ranked 12th) or Travis, Texas (ranked 22nd).

Further, each of the USA counties listed in the appendix that have not yet had a measles outbreak in 2019 (as of April 15) either lies adjacent to a county that has or is served by a major international airport and is thus at risk of imported measles cases resulting in a local outbreak. Besides Travis, Texas these include Maricopa, Arizona, Clayton Georgia, Honolulu, Hawaii, Wayne, Michigan, Salt Lake, Utah, Hennepin, Minnesota, Suffolk, Massachusetts, Loudon, Virginia, San Diego, California, and multiple counties in Florida. These counties should be targeted for enhanced surveillance and enhanced vaccination efforts. 

Lastly, using the proposed analysis, we can specify the set of countries that contribute most to measles risk across the USA. The top countries ordered by risk posed are: Ukraine, Mexico, Cuba, Israel, Japan, Thailand, and Philippines. Surveillance should also be directed towards those counties with the high incoming passenger volume from these countries. Additionally, we should consider measures to improve public health in these countries— for instance, foundations that are committed to global health enhancement could allocate funding for vaccination efforts in these countries. 

Perhaps the most important implication of our results (appendix) is to suggest enhanced surveillance in counties such as Cook, Illinois, and Los Angeles, California, which have each so far only reported one case of measles in 2019 but, because of the presence of major international airports, could serve as the fulcrum of continuous importation of the measles virus into the USA.

Increasing childhood vaccination coverage of the refugee and migrant population in Greece through the European programme PHILOS, April 2017 to April 2018

Via Eurosurveillance: Increasing childhood vaccination coverage of the refugee and migrant population in Greece through the European programme PHILOS, April 2017 to April 2018. The abstract:

After the 2016 Balkan route border closures, vaccination of refugee children in Greece was mainly performed by non-governmental organisations. Activities varied between camps, resulting in heterogeneity of vaccination coverage (VC). 

In April 2017, the European programme ‘PHILOS - Emergency health response to refugee crisis’ took over vaccination coordination. Interventions were planned for the first time for refugee children in the community and unaccompanied minors at safe zones. From April 2017–April 2018, 57,615 vaccinations were performed against measles-mumps-rubella (MMR) (21,031), diphtheria-tetanus-pertussis (7,341), poliomyelitis (7,652), pneumococcal disease (5,938), Haemophilus influenzae type b (7,179) and hepatitis B (8,474). 

In April 2018, the vaccination status of children at camps (reception and identification centres and community facilities such as hostels/hotels were excluded) was recorded and VC for each disease, stratified by dose, nationality and camp size, was calculated. 

More than 80% of the children received the first MMR dose, with VC dropping to 45% for the second dose. For all other vaccines, VC was < 50% for the first dose in children aged 0–4 years and < 25% for the second dose. Despite challenges, PHILOS improved planning and monitoring of vaccination activities; however, further efforts towards improving VC in refugee children are needed.

Mandatory vaccination: Suited to enhance vaccination coverage in Europe?

An editorial in Eurosurveillance: Mandatory vaccination: suited to enhance vaccination coverage in Europe? Excerpt:

Vaccines are one of the most successful medical measures that save millions of human lives every year. With the implementation of routine immunisation programs, high and maintained vaccination coverages for many vaccine-preventable diseases—such as those against poliomyelitis or diphtheria—have been reached in most European countries and many others. Although vaccine acceptance is often high within the general population, even in countries with high vaccination coverage a significant number of children and adults are not sufficiently vaccinated because of missed opportunities or various concerns and misperceptions. 

The reasons for this ‘vaccine hesitancy’ are multifactorial, complex and vary across vaccines, time and countries/regions, and are influenced by factors such as complacency (not perceiving disease as high risk and vaccination as necessary), convenience and constraints (practical barriers), and confidence (lack of trust in safety and effectiveness). As a result, vaccination coverages against highly contagious pathogens such as measles virus are not sufficient to prevent outbreaks and infectious disease spread in many countries today.  

Despite the World Health Organization (WHO)’s goal to eliminate measles, a constant increase in measles cases has occurred in recent years. In 2018, more than 82,500 people in 47 of the 53 countries in the WHO European Region were infected with measles, leading to 72 deaths. These numbers were the highest in a decade. They were three times higher than in 2017 and 15 times higher than in 2016, when numbers were at a record low. 

In 2019, the situation seems to be even worse, indicating that current plans of action in the affected areas are insufficient to stop measles circulation. This is evidenced by the fact that the estimated coverage with the second dose of a measles-containing vaccine is far below the necessary 95% to achieve herd/population immunity in several European countries. 

In order to maintain or improve the population immunity acquired by vaccination, several countries are currently revisiting their strategies and discussing changes in vaccination policies, with a focus on either educating the population and giving individuals freedom of choice or implementing mandatory vaccination to ensure high coverage rates. 

With increasing calls to introduce mandatory vaccination programs, intense debates on their effectiveness have also started in several European countries. There are concerns that mandatory vaccination may lead to opposing attitudes and even less vaccine uptake, particularly in those with existing critical attitudes towards vaccines; nonetheless, other studies have disproved that implementation of compulsory vaccination led to opposing attitudes and/or had negative effects. 

However, it is indisputable that with any changes in vaccination policies, intensified information strategies are necessary to improve trust, rectify perceived risks and improve access and affordability of vaccines. Moreover, it is important to note that mandatory vaccination can follow different routes depending on a country’s specific social and cultural backgrounds, as well as epidemiological situations. 

Consideration of these factors can lead to implementing temporary or permanent vaccine mandates for certain vaccines (such as measles/measles-mumps-rubella (MMR) partial compulsory vaccination), for all vaccines included in a national vaccination program or for selected target groups, such as infants and children before entrance in educational settings or certain occupational groups, such as healthcare workers (HCW).  

For example, in France three mandatory vaccines (against diphtheria, tetanus and poliomyelitis (DTP)) co-existed with eight recommended vaccines (against MMR, pertussis, Streptococcus pneumoniae, hepatitis B (HepB), Neisseria meningiditis serogroup C (MenC) and Haemophilus influenza (Hib)) for routine childhood immunisation up until 2017. However, misperceptions in the population, i.e. that non-mandatory vaccines are less valuable, optional or not as safe and effective as the mandatory ones, resulted in insufficient and stagnating vaccine coverages of the recommended vaccines. This growing vaccine hesitancy, as well as large outbreaks and deaths from measles, led to a change in French policy to extend the mandates to all 11 childhood vaccines.  

Italy has had a similar situation, where four mandatory vaccines were in place already before 2017 (against poliomyelitis, tetanus, diphtheria and HepB). The coverage for vaccination against measles, mumps and rubella dropped country-wide from 90% to 87% between 2000–16. This, together with large measles outbreaks, led the government to extend the existing vaccine mandates to 10 mandatory vaccines (hexavalent vaccine against DTPert (pertussis)-poliomyelitis-Hib-HepB, as well as MMR and Varicella (V) vaccine) in 2017, whereas vaccination against Men C, S. pneumoniae and rotavirus remained recommended vaccines.  

The current issue of Eurosurveillance presents articles from France and Italy on approaches and experiences after the extension of mandatory vaccination. While an article in last week’s issue of Eurosurveillance by Mathieu et al describes the population’s general attitude towards mandatory vaccination shortly before implementation of extended vaccination mandates in France, the rapid communication by Lévy-Bruhl et al. in this issue evaluates the effects of mandatory vaccination on vaccine coverage 2 years after its implementation. D’Ancona et al., also in this issue, depict challenges in Italy in the year following the introduction of the new mandate and how these are being addressed.

Uganda: Government warns against mass immunisation sabotage

Via New Vision: Govt Warns Against Mass Immunisation Sabotage. Excerpt:

KAMPALA - The Government has warned cultural and religious leaders against sabotaging the upcoming mass immunisation exercise against measles and rubella, both caused by a virus. 

Health minister Dr Ruth Aceng, who voiced the warning, said culprits will be prosecuted. 

“Government will take action against cultural and religious leaders who will interfere with the mass immunisation exercise, according to the law. We have no choice but to implement the law,” she told a meeting of Resident District Commissioners (RDCs) in Kampala on Thursday. 

It was an engagement and sensitisation meeting on a planned campaign against meales and rubella, also known as German measles.  

Both are highly contagious diseases, transmitted in similar ways. Measles is spread through droplets from the nose, mouth or throat of infected persons while rubella is transmitted in airborne droplets when infected people sneeze or cough.    

President Yoweri Museveni assented into law the Immunization Act 2017, which makes it mandatory for every child to be immunised and a requirement for school enrolment.  

Dr. Aceng cited districts such as Kamuli, Kaabong and Napak, where in 2014, some of the cultural and religious leaders campaigned against a mass immunisation exercise against polio due to cultural and religious beliefs. 

She said there not be a repeat of that.  

The upcoming mass immusation exercise is scheduled for September in all the 136 districts for children between 9 months and 15 years of age.

Canada: How measles outbreak spurred renewed interest in national vaccine registry

Via CBC News: How measles outbreak spurred renewed interest in national vaccine registry. Excerpt:

As Colin Duggan and his wife were getting ready to take their 18-month-old daughter to get vaccinated, they realized they didn't know their own immunization history. 

Over the years, Duggan has moved around, living in Nova Scotia, Ontario and the United States. When it came to finding his vaccination records, he was at a loss.  

"We asked our nurse practitioner if that was something we could do again, and she said, 'Better safe than sorry,'" he said. 

That day, the entire family rolled up their sleeves and received their shots for measles, mumps and rubella.  

A central database 

Creating a central place for people to look up their records is just one part of a long list of reasons why public health advocates have spent more than two decades calling for a national immunization registry. 

Those calls have been renewed recently with an outbreak of measles in Saint John. 

One of those patients had visited a hospital in Halifax for treatment of something unrelated to measles. Because of that, all cleaners, doctors and nurses had to be tested to see if they were immune before they could return to work.

"It's on everybody's mind in public health, in all the provinces and territories, and at the federal government," said Dr. Gaynor Watson-Creed, deputy chief medical officer of health for Nova Scotia. 

"I think the big advantage for a national registry is that allows us to see how well we're doing at reaching unimmunized populations and bringing their immunizations up to date. And that gives us a sense as to how protected we are against some of the most serious vaccine preventable diseases."  

While Watson-Creed said the desire is there, a national registry would force public health officials to sort through some significant hurdles.  

Each jurisdiction follows its own system when it comes to vaccines. There are different types of shots, some are given on different schedules.  "It would require 13 provinces to have the same approach." 

There are, however, hints that it's possible. Eight provinces and territories have opted to use the same program, Panorama, to digitally track their public health records.

UK: MMR vaccination call following high numbers of measles cases

A May 24 news release from Public Health England: MMR vaccination call following high numbers of measles cases. Excerpt:

Public Health England (PHE) is calling for all parents to get their children vaccinated against measles, mumps and rubella (MMR) when the vaccine is offered, or for them to take it up now if they didn’t have it at the scheduled time.  

In the first quarter of 2019, there were 231 confirmed cases of measles. This figure is slightly lower compared to the same quarter last year. As measles is highly infectious, anyone who has not received 2 doses of MMR vaccine is at risk, particularly unvaccinated people travelling to countries where there are currently large outbreaks of measles.  

The recent measles cases are primarily occurring in under-vaccinated communities, particularly those with links to other countries with ongoing measles outbreaks. There has also been some spread into the wider population, such as those who may have missed out on the MMR vaccine when they were younger.  

In the final quarter of 2018, 94.9% of eligible children aged 5 received the first dose of MMR. To achieve herd immunity for measles, at least 90 to 95% of the population need to be fully protected. 

One dose of the MMR vaccine is about 90 to 95% effective at preventing measles. After a second dose, the level of protection is around 99%. 

Coverage of the second dose is at 87.4% for children aged 5, for this reason PHE is urging those who have only had one dose to ensure they are fully vaccinated with 2 doses.  

This quarter, 795 cases of mumps have also been confirmed. No new cases of rubella were reported.

The measles crisis in Europe—the need for a joined-up approach

A letter in The Lancet: The measles crisis in Europe—the need for a joined-up approach.

Measles elimination in Europe is in crisis. More than 80 000 confirmed cases were reported in 2018 in the 53 countries in the WHO European Region, the highest figure for 20 years. 14 countries in the region reported more than 500 confirmed cases, including four countries that were previously deemed to have eliminated measles (Greece, Albania, Israel, and the UK), meaning interrupted transmission for 3 years. New strategies are urgently needed to put measles elimination in Europe back on track. 

In theory, controlling measles should be straightforward. Two doses of the measles, mumps, and rubella (MMR) vaccine provide highly efficacious protection that is long lasting. Yet, in practice, achieving elimination has proven challenging. One of the most contagious diseases, measles can strike susceptible pockets even if vaccination coverage on a national level is high. 

Although asserting elimination status for individual nations might serve as a motivational tool, countries can experience large outbreaks even after several years of interrupted transmission. Countries such as Greece, Germany, and Kyrgyzstan reported consistently high MMR uptake over the past decade but are still experiencing outbreaks. Moreover, outbreaks do not occur in isolation: they traverse country borders, sometimes lasting years, and affecting different countries at different times. 

In light of these issues, there is a need to link efforts across the continent. The Pan American Health Organization4 interrupted measles transmission in the early 2000s through combined strategies, including high routine immunisation, catch-up campaigns during periods of low transmission, and follow-up campaigns ensuring high levels of immunity at the age of school entry, all applied uniformly across the Americas. 

Applying a similar joined-up approach in Europe would serve the dual purpose of increasing immunity in the general population while reducing the chance of imported cases reaching susceptible pockets. 

Epidemiological investigation would also benefit from combined efforts. Linking genetic and case data to better understand chains of transmission has proven successful for other diseases and might reveal the interconnectivity of measles across Europe. Subnational seroprevalence studies could be used to better identify pockets of susceptibles. Improved vaccine supply, advocacy, and communication to population groups found to be most at risk could help increase immunity to the levels required. 

Such efforts would come at a fraction of the cost of responding to outbreaks. The Americas have shown that elimination of measles is feasible through a combination of political willpower, targeted interventions, and concerted effort. If Europe can sustain a similar approach, it might still follow suit.