Measles Elimination and outbreaks Simon Cottrell and Malorie

Measles (Elimination and outbreaks) Simon Cottrell and Malorie Perry Public Health Wales Vaccine Preventable Disease Programme April 2018

Quiz According to WHO definitions, measles in Wales is: • Endemic? Continuous transmission of indigenous or imported measles virus that persists for a period of 12 months or more in a defined geographical area. • Eliminated? The absence of endemic measles cases in in aadefinedgeographicalareafor fora aperiod of at least 12 12 months, in in thepresence of of aawell-performingsurveillancesystem. • Eradicated? Worldwide interruption of measles transmission in the presence of a verified, wellperforming surveillance system. Measles

Recent measles in Wales 2010 - 2017 Interrupted transmission Measles

Measles in Europe Progress announced in 2017 • Austria, Germany, Kyrgyzstan, Poland, the Russian Federation, Switzerland Turkey have interrupted endemic measles transmission for at least 12 months, bringing the total to 42 countries for the Region • Denmark, Spain, the United Kingdom, Republic of Moldova, Sweden and the former Yugoslav Republic of Macedonia eliminated transmission of measles, bringing the total to 33 countries for the Region Measles

However There is still a way to go • Measles remains one of the most contagious viruses known • Transmitted by direct contact with infectious droplets (airborne through breathing, coughing and sneezing) • Incubation period around 10 days (but can range from 7 to 18), rash usually appears 2 -4 days after then start of symptoms • 10 countries in Europe still have endemic transmission • Outbreaks occur even in countries where measles is eliminated Measles

Measles in Europe 2017 #Measles travels easily across borders, causing outbreaks wherever #vaccine coverage has been low. Monthly overview of cases in 53 countries of Euro region shows over 15, 000 measles cases reported (as at Dec 7 th 2017) http: //bit. ly/2 j 2 v 5 TH #immunize. Europe Source: Vaccine-preventable Diseases and Immunization programme of the WHO Regional Office for Europe www. euro. who. int/immunization Measles

Gwent measles outbreak 2017 MMR coverage in AB UHB 2016 -17 coverage Wales Newport Torfaen MMR 1 in 5 y to 16 y olds 94. 6 (%) 94. 9 (%) 96. 9 (%) MMR 2 in 5 y to 16 y olds 90. 3 (%) 89. 6 (%) 92. 7 (%) MMR 1 at 2 y Measles MMR 2 at 5 y

Gwent measles outbreak 2017 Exposure in a healthcare setting ? Measles ?

Gwent measles outbreak 2017 26 th May to 27 th June Measles

Gwent measles outbreak 2017 6 th July to 12 th August Measles

Gwent measles outbreak 2017 Catch up Measles

Gwent measles outbreak 2017 Summary • • 26 May to 12 Aug 2017 21 cases (17 conf (B 3 genotype), 1 prob, 3 poss) Age 0 to 29 y (Med 11. 5 y), 14/21 school-aged 5 ‘at risk’ 13 unimmunised, 2 x MMR 1, 6 x MMR 2 5 admitted to hospital Two transmission events in Healthcare settings Measles

Gwent measles outbreak 2017 Key outcomes • Generally highly vaccinated population, however: o Some unregistered children unknown to GPs o Some GP Registered children unknown to child health o School nurses not always informed of new starters in school • Measles not always notified • Transmission in healthcare settings • Success of school catch-up sessions Measles

Key features 2016 – 2018 outbreaks, incidents and cases • Confirmed cases almost exclusively children, teenagers and young adults • Spread to those too young to be vaccinated • Transmission in schools • Transmission at festivals • Cases presenting in different healthcare settings and subsequent transmission • Imported cases and cases linked to countries experiencing outbreaks • ‘Off-radar’ children (e. g. unregistered with CHS/ GPs, alternative schooling) • Unvaccinated and vaccinated cases Measles

Vaccine effectiveness The 2017 outbreak • 13 unimmunised, 2 x MMR 1, 6 x MMR 2 • VE (screening method), children aged 2 to 18 in the outbreak area o 92. 8% for Only 1 MMR dose o 96. 0% for two MMR doses • Underestimation due to: o Problems in ascertainment of vaccination status for some children o Potentially higher levels of immunity due to prior measles exposure in one community Measles

Recommendations • MMR status checking and offer at every opportunity • Better (electronic) communication between child-health, GP and local education data systems • Identification of schools at risk • Systems for alerting school-nurses to new entrants • Development of multi-lingual communication lines • Reminding healthcare professionals about measles, infection control and notification protocols Measles

Acknowledgements • Chris Williams, Amy Philips (PHW CDSC) • Richard Roberts, Anne Mc. Gowan, Ember Hilvers (PHW VPDP) • Ceri Harris, Nicola Hathway, Rhianwen Stiff and Heather Lewis, Giri Shankar (PHW Health Protection Team and SPRs) • Catherine Moore and PHW Microbiology • Jane Francis, Mezz Bowley and all Outbreak Control Team members o Aneurin Bevan UHB, the Aneurin Bevan Local Public Health Team, Gwent Local Education Authority, PHW Comms Team • NHS Wales Informatics Service Measles