Wednesday, 29th of July 2015 |
EXTENSIVE NOSOCOMIAL TRANSMISSION OF MEASLES ORIGINATING IN CRUISE SHIP PASSENGER, SARDINIA, ITALY, 2014
(http://wwwnc.cdc.gov/eid/article/21/8/14-1105_article#comment )
Antonietta Filia , Antonino Bella, Giovanna Cadeddu, Maria Rafaela Milia, Martina Del Manso, Maria Cristina Rota, Fabio Magurano, Loredana Nicoletti, and Silvia Declich
Author affiliations: Istituto Superiore di Sanità, Rome, Italy (A. Filia, A. Bella, M. Del Manso, M.C. Rota, F. Magurano, L. Nicoletti, S. Declich); Local Health Unit 7, Carbonia, Sardinia, Italy (G. Cadeddu, M.R. Milia)
Abstract
We report a measles outbreak in Sardinia, Italy, that originated in a cruise ship passenger. The outbreak showed extensive nosocomial transmission (44 of 80 cases). To minimize nosocomial transmission, health care facilities should ensure that susceptible health care workers are vaccinated against measles and should implement effective infection control procedures.
Measles is a highly infectious acute viral disease that can cause severe complications. It is transmitted by direct contact with large respiratory droplets and by the airborne route. This disease will develop in ≈90% of susceptible close contacts of infectious persons. We report a large outbreak of measles in Sardinia, Italy, that originated from a reported outbreak on a cruise ship (1) and showed extensive nosocomial transmission.
A rash developed in the index case-patient (an unvaccinated woman) on February 23, 2014, nine days after she disembarked the cruise ship on which she had traveled during February 6–14, and returned to Sardinia. While infectious, she was seen in the emergency department (ED) of a local hospital, where she was admitted for 3 days for laboratory-confirmed measles. The index case-patient transmitted the infection to 6 persons: a coworker (onset of rash March 6), 1 adult relative (onset of rash March 10), 1 adult visitor to the ED in which the index case-patient sought medical care (onset of rash March 11), and 3 health care workers (HCWs) in the same hospital (onset of rash March 2, 10, and 11).
Transmission continued in families, work settings, and the hospital setting. As of July 2014, a total of 136 cases from the cruise ship outbreak were reported to the national measles surveillance system in Italy, of which 80 were from the secondary outbreak described in this report (Figure). The remaining 56 cases include 28 primary cases (crew and passengers) and 28 secondary cases; 39 of 56 case-patients were Italian and 17 were of foreign origin. One other secondary outbreak linked to the cruise ship has been reported (2).
Classification of measles cases was based on European Union 2012 case definitions (3). A probable case-patient was any person meeting clinical criteria for measles and having an epidemiologic link to the outbreak who did not undergo laboratory testing. A confirmed case-patient was any person with an epidemiological link to the outbreak meeting clinical criteria and having laboratory evidence of infection (positive IgM serologic result or identification of measles virus RNA by PCR). A nosocomial case-patient was defined as any person with measles who had contact with a probable or confirmed case-patient in the hospital (including the waiting area of the ED) 7–21 days before rash onset and had no other source identified. An HCW was any hospital staff or other worker who had regular contact with patients, including clinicians, nurses, students in these disciplines, paramedical professionals, social workers, ambulance workers, porters, and other hospital support staff.
Median age of 80 case-patients was 26 years (range 8 months–55 years); 50 (62.5%) were female. Vaccination status was known for 76/80 (95.0%) patients, of whom 74 (97.4%) were unvaccinated and 2 (2.6%). had received only 1 dose of measles vaccine. Forty-one (51.3%) patients reported >1 complication, and 19 (23.8%) reported >2 complications (Table(http://wwwnc.cdc.gov/eid/article/21/8/14-1105-t1)). Thirty-five (44.9%) of 78 patients were hospitalized, including 2 patients admitted to the intensive care unit for respiratory insufficiency. In addition, 14 patients were seen in the ED.
Thirty-four cases (42.5%) were laboratory confirmed; the remaining 46 cases were classified as probable. Measles virus genotype B3 was identified in 7 cases, and phylogenetic analysis showed that viral sequences were identical to each other and to those obtained from the cruise ship outbreak (2,4) (measles nucleotide surveillance [MeaNS] database accession nos. 62563, 62564, 67009, 67016, 62565, 67017, and 67020). Nosocomial cases included HCWs (n = 15; 18.8%) and persons infected in the waiting area of the ED or in a hospital ward (n = 29; 36.2%). Six additional case-patients were infected by an HCW in a family setting.
Local health authorities conducted case investigations, including active case finding by regular visits/phone calls to the hospital, and contact tracing and vaccination of susceptible contacts. Hospital directors were contacted by local health authorities to inform them of measles transmission in the hospital. No data were available for vaccination coverage among HCWs because this information is not routinely obtained. An information circular that invited susceptible staff to receive measles vaccine and consent/dissent forms were distributed in the affected wards (ED, intensive care unit, medicine). However, participation has been negligible: only 2 of 114 HCWs agreed to be vaccinated.
Clinical and genotype data suggest that the index case-patient for this outbreak was infected during the cruise, either onboard or in 1 of the cities visited during the cruise (5). The index case-patient triggered an outbreak with extensive spread, which highlights the ease with which measles is transmitted in various settings, especially the hospital setting, which accounted for 44 (55%) of the cases.
Nosocomial transmission of measles has been frequently reported and has a major role in the epidemiology of this disease, especially in industrialized countries (6,7). As described in this outbreak, nosocomial transmission can lead to measles in HCWs, other patients at the hospital, and susceptible hospital visitors. Measles is one of the most contagious viral diseases and patients frequently visit hospitals or health care facilities for diagnosis and management, which might lead to nosocomial transmission if appropriate infection control measures are not immediately instituted (8).
The potential for airborne transmission of measles in waiting areas of health care facilities is higher than for other airborne infections, such as tuberculosis and influenza, and persons might become infected after a relatively short exposure time (9). Also, measles virus can survive for up to 2 hours in the air or on objects and surfaces, which indicates that a susceptible person can be infected even after an infected person has left the area (10,11). Infectivity of measles is greatest during the 3 days before the onset of rash, when the disease might not be suspected (12).
The consequences of measles transmission in a health care setting are serious because the infection might be transmitted to immunocompromised patients, young children, pregnant women, or other persons at high risk for severe complications. More than 50% of the case-patients in the described outbreak reported complications, and respiratory insufficiency developed in 2 patients. In addition to illness and death attributable to measles, nosocomial transmission also leads to major use of resources for evaluating and containing an outbreak (11).
Measles is effectively prevented by a 2-dose vaccination, and a key preventative measure against nosocomial transmission is vaccination of HCWs (13). In Italy, measles vaccine is recommended for all susceptible HCWs. However, HCWs are not required to show evidence of measles immunity for employment. Analysis of national measles surveillance data for Italy during October 2010–December 2011 showed that HCWs accounted for 11.6% of reported case-patients for whom information on occupation was recorded (14).
In addition to maintaining high coverage of vaccination in the community, ensuring that susceptible HCWs are vaccinated against measles, and maintaining a complete staff immunity database, it is essential that isolation protocols and infection control guidelines be in place in hospitals to minimize nosocomial spread of infection. Infection control measures should include maintaining a high level of awareness among staff, excluding exposed susceptible HCWs from work during the measles incubation period; immediately isolating suspected case-patients who come to an ED or any outpatient waiting area, contacting persons known to be exposed in hospital or outpatient (including ED) settings, offering postexposure vaccination to susceptible persons, and strengthening surveillance for nosocomially acquired cases (7,10,11,15). Stronger recommendations and guidelines are needed at the national level and in Europe.
Dr. Filia is a medical epidemiologist in the Infectious Diseases Epidemiology Unit of the National Health Institute, Rome, Italy. Her primary research interests are vaccine-preventable diseases, elimination of measles and congenital rubella, and tuberculosis.
Acknowledgments
We thank the hospital staff and staff in regional and local health authorities in Sardinia, Italy, for investigating and reporting cases to the national integrated measles–rubella surveillance system.
This study was supported by the Italian Ministry of Health (National Centre for Disease Prevention and Control Project).
References
Figure
Table
Suggested citation for this article: Filia A, Bella A, Cadeddu G, Milia MF, Del Manso M, Rota MC, et al. Extensive nosocomial transmission of measles originating in cruise ship passenger, Sardinia, Italy, 2014. Emerg Infect Dis. 2015 Jun [date cited]. http://dx.doi.org/10.3201/eid2108.141105
Assessment of Immune Status Against Measles, Mum ...
Assessment of Immune Status Against Measles, Mumps, and Rubella in Young Kuwaitis: MMR Vaccine Efficacy. Madi N, Altawalah H, Alfouzan W ...2017 M&RI Partners Meeting Presentations
The global Measles and Rubella Initiative meeting was held in Washington DC on 7th and 8th Sept. 2017. The meeting which was hosted by American Red Cr ...STORIES OF LIFE IN A CHANGING WORLD Scientists Cr ...
STORIES OF LIFE IN A CHANGING WORLD Scientists Crack a 50-Year-Old Mystery about the Measles Vaccine Worth a little pain? Back in 1990 a school bo ...20 most consulted measles and rubella articles in ...
Dear AllToday we share a review of the year 2016 regarding measles and rubella items posted on our web page. We shared articles on topics ranging from ...Region of the Americas is declared free of measles ...
More information on this great milestone can be found on url link belowhttp://www.paho.org/hq/index.php?option=com_content&view=article&id=125 ...Progress Toward Regional Measles Elimination — W ...
Progress Toward Regional Measles Elimination — Worldwide, 2000–2014 Morbidity and Mortality Weekly Report Best read, with ta ...Health Equity Initiative, New York, NY, 25-26 Febr ...
Health Equity Initiative, Summit, NYC, 25-26 February 2016 For details, consult http://www.healthequityinitiative.org/hei/programs/summit/REQUEST FOR PROPOSAL: MEASLES VACCINATION UNDER 9 ...
1 REQUEST FOR PROPOSAL: Measles Vaccination Under 9 Months of Age APPLICATION SUBMISSION DATE: January 26, 2015 1. In ...CARTOON CHARACTERS JOIN THE FIGHT AGAINST MEASLES
[source] Measles and Rubella Initiative[|source]Thanks to reader Jane Wachira for pointing out the following weblink. Measles eradication consists not ...I LOVE/HATE THIS GLOBAL VACCINATION COVERAGE GRAPH ...
[source]Rosling s FactPod[|source]This video from Hans Rosling explaining what he loves with global measles vaccination coverage trends namely rapid i ...POWER POINT PRESENTATIONS FROM THE 13TH ANNUAL ADV ...
[source]Measles and Rubella Initiative[|source]The Measles and Rubella Initiative has spent much effort fighting for its cause by means of widespread ...CALLING THE SHOTS
[source]PBS Network[|source]"VACCINES -- CALLING THE SHOTS" This TV program, broadcast on the PBS network, looks at the commonest arguments by anti-v ...COMBATING HEALTHCARE CORRUPTION AND FRAUD WITH IMP ...
[source]BMC International Health and Human Rights[|source]Corruption is a serious threat to global health outcomes, leading to financial waste and adv ...CORRUPTION KILLS: ESTIMATING THE GLOBAL IMPACT OF ...
[source]PLoS One[|source]Many countries still have high levels of child mortality, particularly in sub-Saharan Africa and South Asia, and in recent ye ...READY OR NOT: RESPONDING TO MEASLES IN THE POSTELI ...
[source]Annals of Internal Medicine[|source]Opnion Paper Although endemic measles was eliminated in the United States in 2000, two concurrent measle ...RUBELLA AND CONGENITAL RUBELLA SYNDROME CONTROL AN ...
[source]Morbidity and Mortality Weekly Report (MMWR)[|source]In 2011, the World Health Organization (WHO) updated guidance on the preferred strategy f ...PROGRESS TOWARDS MEASLES ELIMINATION – EASTERN M ...
[source]Weekly Epidemiological Record (WER)[|source]During the period 2008–2012, regional progress towards measles elimination stagnated, and th ...THE IMMUNIZATION PROGRAMME THAT SAVED MILLIONS OF ...
[source]Bulletin of the WHO[|source]In the world vaccination week, the Bulletin of the World Health Organization outlines the history, status and impa ...HEALTH SYSTEM COST OF DELIVERING ROUTINE VACCINATI ...
[source]Bulletin of the WHO[|source]On the eve of the 40th anniversary of launching of the Expanded Programme on Immunization (EPI) in 1974, during th ...World Immunization Week
[source]WHO/IVB Publication[|source]Never miss another jab, The slogan for World Immunization Week 2014 is “Immunize for a healthy future: Know ...Measles: know the risks, check your status, protec ...
[source]WHO/IVB Publication[|source]Measles is a highly contagious, serious disease caused by a virus. In 1980, before widespread vaccination, measles ...THE RIGHTS OF THE UNVACCINATED CHILD: THE LEGAL FR ...
[source]Los Angeles Times[|source]In light of what s starting to look like a surge of measles cases spread by unvaccinated carriers, Hasting ...Consultants: Measles and rubella control/eliminati ...
[source]Technical Network for Strengthening EPI[|source]Announcement solicits interest from potential candidates to act as consultants for WHO through ...PUBLIC HEALTH OFFICIALS MARK 50TH YEAR OF MEASLES ...
[source]Journal of American Medical Association[|source]Until the 1960s, measles was a rite of passage for US children; nearly all had the disease bef ...THE TOLL OF THE ANTI-VACCINATION MOVEMENT, IN ONE ...
[source]Los Angelos Times[|source]Aaron Carroll today offers a graphic depiction of the toll of the anti-vaccination movement. It comes from a Council ...“Can we use $30 of the taxes you’re already pa ...
[source]Annual Letter of BMGF[|source]If you were asked this question today, what answer would you give? Bill and Melinda Gates ask, "Would you check ...REACHING HARD-TO-REACH INDIVIDUALS: NONSELECTIVE V ...
[source]American Journal of Epidemiology[|source]Source: American Journal of Epidemiology The World Health Organization guidelines for response to me ...Rubella and Congenital rubella syndrome control an ...
[source]Weekly Epidemiological Record (WER)[|source]Full text record of Rubella and CRS control/elimination are available at http://www.who.int/wer/20 ...Measles Press Conference at CDC: 50th Anniversary ...
[source]CDC Media Release, 5th Dec[|source]Full text, video and question and answer session for journalists all avalable at http://www.cdc.gov/media/r ...A bibliometric analysis of childhood immunization ...
[source]BMC Medicine[|source]During the past four decades national EPI programs have developed or adapted and implemented a broad range of strategies ...Lessons from the tragic measles outbreak in Samoa
Monday, 9th of March 2020 |
Characterisation of diversity of measles viruses in India: genomic sequencing and comparative genomics studies.
Monday, 9th of March 2020 |
The elimination of measles in Iran
Monday, 9th of March 2020 |
Measles-containing vaccines in Brazil: Coverage,
Monday, 9th of March 2020 |
Measles-containing vaccines in Brazil: Coverage, homogeneity of coverage and associations with contextual factors at municipal level.
Monday, 9th of March 2020 |
Website Views |
47443592 |