Up-date on measles elimination in Italy

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• Up-date on measles elimination in Italy
• Roberto Gasparini
• Department of Health Sciences Genoa University
• Via Pastore, 1 - 16132 Genoa (Italy)
• E-mail address gasparini_at_unige.it

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Expansion of the Roman Empire c.200 AD
Sumeria c.3000 BC
THE URBAN HEART OF MEASLES
Greek city states c.1000 BC
GOBI DESERT
Japan c.1000 AD ?
TIBETANPLATEAU
IRANIANPLATEAU
Italian city states c-300 BC
City states of the Levant c.1500 BC
China end of the Han dynasty 2200 BC?
SAHARA DESERT
Egyptian civilisation c.1000-500 BC
Indus civilisation c.2500 BC
Ganges civilisation c.1000 BC
Probable axis of measles expansion with the
evolution of civilisations Barriers to measles
expansion
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Measles Vaccine

• After the isolation and propagation of measles
  virus in tissue culture by Enders and Peebles in
  1954, vaccine development, testing, and licensure
  quickly followed. After the vaccine containig the
  Edmoston A and B strains many further attenuated
  vaccines have been developed and they are in
  active use worldwide (Schwarz, Moraten,
  Edmoston-Zagreb, ecc).
• Tolerability, safety and effectiveness of Measles
  vaccines are very good.

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Slide Date October 03
Countries implementing measles mortality
reduction strategies
Achieving 90 measles coverage, 2002
gt 90 (91 countries or 47)
lt 90 (100 countries or 52)
No data (1 countries or 1)
Providing 2nd opportunity, 1998-2002
Yes 2nd opportunity (163 countries or 85)
No 2nd opportunity (29 countries or 15)
2nd Opportunity country has implemented a two
dose routine measles schedule and/or within the
last 4 years has conducted a national
immunization campaign achieving gt 90 coverage of
children lt 5 yrs
Source WHO/UNICEF joint reporting form, 2002
WHO SIA Database, WHO/UNICEF estimates 2003 data
from 192 WHO member states
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Measles epidemiology in Italy from Paediatricians
and GPs notifications and specific mortality in
1980-1997 period.
N. of cases
Vaccination started
N.of deaths
N.Cases N.Deaths
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Percentages of Italian children (15-24 months)
who received measles vaccine during 1983-2000
period.

years
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Measles epidemics in Campania Region (Italy) in
2002

• Total cases estimated, in subjects aged 0-14
  years, was 24,000 (2,300/100,000).
• The number of hospitalisations was 368, of which
  63 were cases of pneumonia and 13 encephalytis.
• There were 4 deaths.
• In the other Italian Regions the incidence was
  77/100,000.

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Incidence of measles in Italian RegionsSPES
Jannuary- August 2002
Mar
Jan
Feb
Apr
June
May
July
Aug
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Molecular Epidemiology an useful method for
study measles epidemiology
A

• The measles virus has 6 structrural proteins P,
  L, N, F, H and M. The entire 15,894-nucleotide
  long genome have been sequenced.
• The WHO currently recognize 20 genotypes and one
  proposed genotype of measles virus based on
  phylogenetic analysis of the N gene.

C
A
H
C
G2
B
A,D2
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MOLECULAR EPIDEMIOLOGY OF MEASLES A NEW GENOTYPE
ISOLATED IN 2003 DURING AN OUTBREAK IN LIGURIA

• In spring 2003 in Liguria an outbreak of measles
  was registered with a total of 187 cases the
  highest incidence was in La Spezia
• Out of 16 pharingeal swabs collected, 8 were
  viremic and were characterized by nucleic acid
  sequence analysis of the Nucleoprotein gene (N)
  and the Haemagglutinin gene (H)
• The philogenetic analysis permitted genotyping of
  all 8 and relatediness between the viruses and
  appropriate reference sequences was studied
• Sequences from Liguria formed a distinguished
  cluster from genotypes previously described as
  D7 genotype, even if with a difference of 5 with
  the reference strain
• Molecular epidemiology studies have made a
  significant contributions to the identification
  of source and transmission pathways of the
  measles virus and allowed to clarificate
  epidemiological links during measle outbreaks
  separating indigenous strains from newly imported
  strains

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Rational of Measles vaccination policy

• The basic reproductive rate of infectious
  diseases (R0) is the average number of cases that
  would be expected to spread from a single case in
  a completely susceptible population.
• Measles is a highly infectious disease, and R0
  has been estimated as 12.5 to 18. So, it has been
  estimated that to achive the goal of Measles
  elimination it is necessary that the susceplible
  subjects are not more than 15 at the age 0-5,
  not over 10 between 5 to 9 years children, and
  no more than 5 in subjects over 9 years.

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The goal of Italian plan of measles elimination

• The goal of Italian plan of measles elimination
  is to maintain, after 2007, the measles
  incidence below 1 case per 100,000 inhabitants.

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How to Plan, to organize and to carry out the
Italian Measles elimination policy
Local Health Agencies Coordinated by Regional
Experts and Authorities
Experts of Public Health, working In the
Prevention Department, and their scientific
Association
Universities Hospitals Scientific Research Centers
The departments of Italian Local Health Agency
are the Centers for planning, organizing and
carrying out measles elimination plan. To achieve
the goal it is neccessary that a close
collaboration among experts of Public Health,
Paediatricians, nurses, GPs, and also,
Istitutions as University, Hospital, etc.
Paediatricians, GPs and their Scientific
Associations
Nurses and Social workers
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Measles elimination action plan

• Within 2003 to improve the surveillance system,
  by virus isolation and definition of the clades
  and genotypes too, for identification of cases as
  imported or indigenous.
• Within 2004 increasing coverage of infants until
  85, and improving the informatization of
  vaccination data base.
• Within 2005 implementing the infant measles
  coverage til 90.
• Within 2006 increasing and sustaining high
  routine coverage (95), and achiving a 95
  coverage rate in children aged 3-15 years, and
  maintaining the measles incidence below 1 case
  per 100,000 inhabitants.
• Within 2007 maintaining the children rate
  coverage at 95 or over, and increasing the two
  doses coverage of children aged 5-6 til 90.

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Measles-vaccination coverage of Italian children
0-24 months
ICONA 1998
2000
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Measles-vaccination coverage of Italian children
0-24 months (August 2004)
National mean coverage rate 83.6
Coverage rates lt 70 70-85 gt 85 No data
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Measles-vaccination coverage of Italian children
0-24 months (August 2004)
National mean coverage rate 83.6
Coverage rates lt 70 70-85 gt 85 No data
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Causes of refused or delayed MMR vaccination
(font ICONA, 2003)
No data
other
Illness
Unfavorable GP or Pediatricia opinion
Measles in the past
No good organization of vaccination services
Tardy vaccination
Fear of vaccination
Measles is not a severe illness
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Give me a gift for a better life VACCINE ME!!!!