Measles in the United Kingdom: can we eradicate it by 2010?
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38989.445845.7C (Published 26 October 2006) Cite this as: BMJ 2006;333:890
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
It is worth noting that one of the common symptoms in the prodromal
phase in children is quite profuse epistaxes. This was quite common
during epidemics
Competing interests:
None declared
Competing interests: No competing interests
We are grateful to Asaria and MacMahon for their excellent summary of
information relating to measles.[1]
There have been measles outbreaks in the Netherlands, Ireland, USA
and Canada, and Italy.[2-6] In the United Kingdom, there was an outbreak
of measles in South Yorkshire this year, with 97 suspected and at least 37
confirmed cases reported.[7]
There has also been an outbreak of measles in Surrey. The first
confirmed case occurred in a child in January 2006. An increase in the
number of measles cases notified to the Surrey & Sussex Health
Protection Unit (HPU) was noticed during the week of 13 March, 2006, and
an initial outbreak meeting was convened on 16 March, 2006.
By the end of August 2006, the HPU had received a total of 280
notifications of measles in Surrey residents, with 111 confirmed or
epidemiologically linked cases. This compares with a total of 6 cases in
the county during 2005.
24 cases of measles were admitted to hospital, and there were 4
confirmed cases in healthcare workers. 16 doses of human normal
immunoglobulin (HNIG) were required as post exposure prophylaxis for
vulnerable contacts.
The outbreak control team worked with local health visitors and GP
practices to carry out sensitive contact tracing, and to implement
measures to reduce further spread. Such measures included immunisation of
contacts with MMR (as post exposure prophylaxis when this could be done
within 72 hours of exposure), or treatment with HNIG for: pregnant
contacts, immunocompromised contacts, contacts aged 6-9/12, or those aged
less than 6/12 with mothers deemed not to be immune to measles.
The HPU also sent out letters to all schools in Surrey, to the PCT,
and liaised with Occupational Health for the acute trust and PCT. We also
gained some attention from the media, which we used to raise awareness of
the need for vaccination.
The HPU has developed an algorithm for the management of measles in
Primary Care (which we are unable to add to this "rapid response", but
which is included in a document which can be downloaded from our
website).[8] This algorithm, based on the ‘Green Book’[9], was used by
the HPU, and local General Practices, during the recent outbreak.
One of our cases was a young mother with a baby aged under 6 months.
Despite having been given HNIG, the baby subsequently developed measles.
It has hitherto been assumed that most mothers would be immune to measles
through natural illness or vaccination, and that babies under the age of
six months would be protected by maternal antibodies. This can no longer
be assumed, as measles has been uncommon in the UK for so many years.
Babies under 6 months should be offered HNIG if the mother is thought
unlikely to be immune.
REFERENCES
1. Asaria P, MacMahon E. Measles in the United Kingdom: can we
eradicate it by 2010? Br Med J 2006;333(7574):890-895.
http://bmj.bmjjournals.com/cgi/content/extract/333/7574/890?ehom
2. Fitzpatrick M. MMR: risk, choice, chance. Brit Med Bull
2004;69:143-53.
3. Landen MG, Beller M, Funk E, Rolka HR, Middaugh J. Measles
Outbreak in Juneau, Alaska, 1996: Implications for Future Outbreak Control
Strategies. Pediatrics 1998;102(6):e71-.
http://pediatrics.aappublications.org/cgi/content/abstract/102/6/e71
4. Anonymous. Measles Outbreak Among School-Aged Children -- Juneau,
Alaska, 1996 MMWR - Morbidity & Mortality Weekly Report
1996;45(36):777-80. http://www.cdc.gov/mmwr/preview/mmwrhtml/00043622.htm
5. Duclos P, Redd SC, Varughese P, Hersh BS. Measles in adults in
Canada and the United States: implications for measles elimination and
eradication. Int. J. Epidemiol. 1999;28:141-6.
http://ije.oxfordjournals.org/cgi/content/abstract/28/1/141
6. Filia A, Curtale F, Kreidl P, Morosetti G, Nicoletti L, Perrelli
F, et al. Cluster of measles cases in the Roma/Sinti population, Italy,
June-September 2006. Eurosurveillance, 2006.
http://www.eurosurveillance.org/ew/2006/061012.asp#2
7. Anonymous. Outbreak of measles in Doncaster. Communicable Disease
Report Weekly 2006;16(15):3-4.
http://www.hpa.org.uk/cdr/archives/2006/cdr1506.pdf
8. Carroll K, English PMB, Morgan J, Nicholls M, van den Bosch C.
Control of measles in the event of an outbreak. Leatherhead, Surrey:
Surrey and Sussex Health Protection Unit, 2006:1-10.
http://www.bigfoot.com/~scdcs (follow "Policy and guidance documents")
9. Department of Health, Welsh Office, Scottish Office Department of
Health, DHSS (Northern Ireland). Immunisation against infectious disease:
the 'Green book' draft chapter on Measles (available from website). In:
Department of Health, Welsh Office, Scottish Office Department of Health,
Ireland) DN, editors. London: Department of Health, 2006.
http://www.publications.doh.gov.uk/greenbook/. Last updated: August 2006.
Last accessed: 31 October 2006.
Competing interests:
None declared
Competing interests: No competing interests
Our clinical review, published in the 28 October 2006 issue, was to
have been entitled 'Measles in the United Kingdom: here today, gone
tomorrow?' Instead, due to an editorial decision taken without consulting
us, the article has appeared with the title 'Measles in the United
Kingdom: can we eradicate it by 2010?'
Unfortunately, the published title is in error. As indicated in Box
1, 'eradication' is a specific epidemiological term indicating the
worldwide elimination of an infection. To date, only smallpox has been
eradicated. To use 'eradicate' in the context of the United Kingdom is
thus incorrect.
The front cover statement 'Measles is back in the UK. High levels of
vaccination are needed to eradicate it by 2010' is also misleading.
Reduced MMR uptake in the United Kingdom has led to sporadic outbreaks in
recent years and the renewed threat of endemic measles. Outbreaks have
also occurred in other European countries. High levels of vaccination
need to be achieved and sustained throughout Europe to reach the WHO
target of elimination of measles from the European region by the 2010.
Eradication of measles worldwide is the ultimate goal.
Competing interests:
EMM has received sponsorship from Aventis Pasteur (MSD) towards attending conferences in the past five years.
Competing interests: No competing interests
Editor,
We read the article titled “Measles in the United Kingdom: can we
eradicate it by 2010? “by Perviz Asaria, and Eithne MacMahon with
interest . The authors highlight the need to achieve and maintain high
levels of vaccination coverage throughout Europe if the 2010 goal for
elimination is to be met against the background of renewed threat of
endemic measles in UK.
We specially paid our attention to this challenge from the preventive
perspective of measles in the article as Public Health Practioners from
a developing country. In 1999-2000, we too faced a large outbreak of
measles in Sri Lanka which, according to the WHO’s classification of
measles situation, fell into the category of countries, which have a
better measles immunisation coverage and a better position to improve
surveillance (1).
As pointed out by the authors, children less than 12 months are at
particular risk. The highest morbidity rate (114/100000 population), in
the Sri Lankan outbreak, was observed among children less than 9 months
(1) suggesting the waning passive immunity in infancy. The age at which
routine immunisation is carried out is another factor which adds
susceptibles to measles as a result of primary vaccine failure. As
pointed out in your article, MMR at 12-15 months is recommended for
routine immunisation. However, it has been suggested to shift the
vaccination to 12 months for reduction of the pool of susceptibles as
proportion of anti-body positive children is low among those aged 9-12
months (2).
We routinely immunize children with measles vaccination at 9 months
in Sri Lanka, as recommended by the WHO. with a sero conversion rate of
about 85% at this age (3). Shifting this age to 12 months has been
suggested to enhance the effectiveness of the measles vaccine in the
background of reduced transmission after a “catch-up” campaign following
the outbreak in 2000 (1). Currently, a second dose of measles (MR) is
given in Sri Lanka, at the age of three years though, the ideal age for
this would have been 18 months. Another issue that may affect the
susceptibility of infants to measles is the relatively short period of the
passive immunity of children born to an increasing proportion of women
with vaccine induced immunity (4). In our context, as the Measles
immunization programme was initiated in 1985, the majority of women
currently in the childbearing age have not had natural infection in their
life time. As such, the duration of the passive immunity is expected to be
low among those who were born to these mothers exposed to measles
immunisation from 1985 onwards.
As Azaria and McMahon suggested children and adults who have not
received two doses are not protected. In our scenario, a “catch-up
campaign” covered those in the age group 1-14 years and 15-24 years. This
provided the opportunity to give the second dose to those who under the
previous EPI schedule received only one dose at 9 months from 1985 and the
other group which was not exposed at all to the vaccination when it was
initiated in 1985. The effectiveness of this measure to reduce the measles
transmission to lower levels was reflected during the mass displacement of
people due to Asian Tsunami. Mass immunisation against measles was not
adopted by the Epidemiological Unit and contrary to predictions by the
WHO, measles was not a problem among clusters of displaced individuals in
the aftermath of the Tsunami (5). In conclusion, in unison with authors,
it must be stated, that achieving high coverage and maintenance of
vaccination remains the key to elimination of measles.
REFERENCES:
1. Puvimanasinghe JPA, Arambepola CK, Abeysinghe MRN, Rajapakse LC,
Kulathilake TA. Measles outbreak in Sri lanka,1999-2000. Journal of
Infectious Diseases. 2003;187 (supl. 1): 241-45.
2. Nicoara C, Zach K, Trachsel D, German D, Matter L. Decay of
passively acquired maternal antibodies against measles, mumps, and rubella
viruses. Clin.Diagn.Lab. Immunol. 1999:6:868-71.
3. Epidemiological Unit. Immunization hand book. National Expanded
Programme for Immunization. . Colombo
4. Brugha R, Ramsay M, Forsey T, Brown D. A study of maternally
derived measles antibody in infants born to naturally infected women and
vaccinated women. Epidemiol. Infect.1996;117:519-24
5. Anonymous. Disease control in Tsunami affected areas: key to
success. Weekly Epidemiological Report (Sri Lanka). 2005; 32 (4). Also
available at URL : http:// www.epid.gov.lk/pdf/VOL%2032%20NO%2004%20.pdf
Competing interests:
None declared
Competing interests: No competing interests
The surgical importance of MMR vaccine coverage.
EDITOR - The authors describe a subgroup of cohorts who have not
received the MMR vaccine and have not developed natural immunity during
the time measles was on the wane.(1) This is the same cohort related to
the recent mumps epidemic.(2)
At a time of mumps resurgence, difficulties in the surgical diagnosis
of complications from viral illness become more apparent. Rare surgical
manifestations of mumps include macroscopic haematuria (3) and mastitis
(4) but are usually preceded by parotitis.
Mumps orchitis commonly presents in post-pubertal men and needs to be
distinguished from other causes of acute scrotal pain. The absence of
preceding parotitis may necessitate surgical exploration to exclude
torsion, as ultrasonographic findings are not specific, often showing
altered vascularity and abnormal testicular echo texture.
The less common mumps pancreatitis needs to be differentiated from
other causes of an acute abdomen. Pancreatitis may be the first of
manifestation of mumps in the absence of parotitis (5) or even post
measles, mumps, and rubella (MMR) vaccination (6) and has led to
unnecessary laparotomy. (7) Electrophoresis of amylase isoenzymes
(pancreatic and salivary types) may offer clues to the underlying viral
cause.(8)
(1) Asaria P, MacMahon E. Clinical Review – Measles in the United
Kingdom: can we eradicate it by 2010? BMJ 2006; 333: 890-5.
(2) Gupta RK, Best J, MacMahon E. Mumps and the UK epidemic 2005. BMJ
2005; 330: 1132-1135.
(3) Yildiz N, Yasa O, Celik Y, Baydilli H, Ozcay S. Hematuria with
mumps infection. Indian J Pediatr.
2003;70(1):93-4.
(4) Happel JS. Mastitis in the male -a rare complication of mumps.
BMJ 1965;2(5469):1041.
(5) Naficy K, Nategh R, Ghadimi H. Mumps pancreatitis without
parotitis. BMJ 1973;1(5852):529.
(6) Adler JB, Mazzotta SA, Barkin JS. Pancreatitis caused by measles,
mumps, and rubella vaccine. Pancreas 1991;6(4):489-90.
(7) Feldman G, Zer M. Infantile acute pancreatitis after mumps
vaccination simulating an acute abdomen. Pediatr Surg Int. 2000;16(7):488-
9.
(8) Skrha J, Stepan J, Sixtova E. Amylase isoenzymes in mumps. Eur J
Pediatr. 1979;132(2):99-105.
Competing interests:
None declared
Competing interests: No competing interests