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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: [email protected]
Expansion of the
Roman Empire
c.200 AD
Sumeria
c.3000 BC
Greek city states
c.1000 BC
THE URBAN
HEART
OF MEASLES
IRANIAN
PLATEAU
TIBETAN
PLATEAU
GOBI
DESERT
Japan
c.1000 AD ?
Italian city states
c-300 BC
SAHARA DESERT
City states of
the Levant
c.1500 BC
Egyptian
civilisation
c.1000-500 BC
Probable axis of measles expansion
with the evolution of civilisations
Barriers to measles expansion
China: end of the
Han dynasty
2200 BC?
Indus civilisation
c.2500 BC
Ganges
civilisation
c.1000 BC
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
> 90% (91 countries or 47%)
< 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 > 90% coverage of children < 5 yrs
Source: WHO/UNICEF joint reporting form, 2002 & WHO SIA Database, WHO/UNICEF
estimates 2003
data from 192 WHO member states
Measles epidemiology in Italy from
Paediatricians and GPs notifications and
specific mortality in 1980-1997 period.
N. of cases
Vaccination started
N.of deaths
100000
100
90000
N.Cases
N.
casi
90
N.
decessi
N.Deaths
80000
80
70000
70
60000
60
50000
50
40000
40
30000
30
20000
20
10000
10
0
0
60
62
64
66
68
70
72
74
76
78
80
82
84
86
88
90
92
94
96
98
0
Percentages of Italian children (15-24 months) who received measles
vaccine during 1983-2000 period.
%
100
90
80
70
60
50
40
30
20
10
0
anni
years
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.
Incidence of measles in Italian Regions
SPES: Jannuary- August 2002
Jan
May
Feb
Mar
Apr
June
July
Aug
Molecular Epidemiology: an useful method for study
measles epidemiology
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.
A
A
C
H
B
A,D2
G2 C
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
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.
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.
How to Plan, to organize and to carry out the
Italian Measles elimination policy
Experts of Public
Health, working
In the Prevention
Department, and
their scientific
Association
Local Health Agencies
Coordinated by Regional Experts
and Authorities
Universities
Hospitals
Scientific Research Centers
Paediatricians, GPs and
their Scientific Associations
Nurses and
Social workers
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.
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%.
Measles-vaccination coverage of Italian children
0-24 months
ICONA 1998
2000
< 50%
50-75%
>75%
Measles-vaccination coverage of Italian
children 0-24 months (August 2004)
Coverage rates
< 70%
70-85%
> 85%
No data
National mean
coverage rate:
83.6%
Measles-vaccination coverage of Italian
children 0-24 months (August 2004)
Coverage rates
< 70%
70-85%
> 85%
No data
National mean
coverage rate:
83.6%
Causes of refused or delayed MMR
vaccination (font: ICONA, 2003)
5%
non
noto
No data
6%
altro
other
17%
Illness
malattia
opinione
medico
Unfavorable
GP or Pediatricia opinion
18%
18%
ha
giˆ av uintothe
il morb
Measles
past illo
organizzazione
serv
izio
No good organization
of vaccination
services
vTardy
accinerˆ
pitar di
vaccination
5%
25%
3%
3%
vFear
acc.pericolose/inefficaci/
of vaccination
malattia rara
malattia
Measles ispoco
not a pericolosa
severe illness
Give me a gift for a better life:
VACCINE ME!!!!