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MEASLES - GERMANY (LOWER BAVARIA) ex SWITZERLAND

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Between January and June 2007, a total of 90 cases of measles were 

notified in Passau and Rottal-Inn, 2 districts of Lower Bavaria in 

southeast Germany sharing a border with Austria. Almost 30 percent of 

the cases (n=26) attended a local Montessori school frequented by 

pupils from the 2 affected districts and from Austria.



A case was defined as a resident of one of the affected districts 

with onset of symptoms (generalised maculopapular rash lasting 3 or 

coryza, Koplik spots, or conjunctivitis) between 12 January (week 2) 

and 8 May (week 19) 2007. A case was laboratory-confirmed by 

significantly increased measles-specific IgM antibody titres or by 

detection of measles virus (MV) nucleic acid.



Outbreak description

--------------------

Between week 5 (end of January) and week 22 (end of May) of 2007, a 

total of 90 cases of measles were notified to the District Health 

Authorities (DHA) in Passau and Rottal-Inn. The 2 primary cases (aged 

7 months and 3 years) developed measles in mid-January [2007] after a 

trip to Switzerland where, according to their mother, they had been 

in contact with measles-infected individuals. However, since they did 

not consult a physician during the course of the disease, they were 

not notified to the health authorities until 2 months later. In late 

January and early February [2007], 4 contacts from their family and 

neighbourhood aged 9-16 years fell ill with measles. Of these 4 

cases, 2 attended the above-mentioned Montessori school. From there, 

the outbreak spread to 7 other schools and one kindergarten. An 

institution was considered affected by the outbreak when there were 

at least 2 cases from different families.



[The original text provides a figure showing the course of the 

outbreak by week of onset of symptoms and by week of notification.] 

notified in week 11 [12-18 Mar 2007]. Comparison of the 2 datasets 

highlights the delay between onset of disease and case notification, 

amounting to 3 weeks at the outset of the outbreak. The majority of 

2007] and 16 [16-22 Apr 2007] (n=70, 86 percent). The outbreak peaked 

in week 12 [19-25 Mar 2007] with 14 new cases. Only 4 cases fell ill 

after week 16 [16-22 Apr 2007]. The numbers of new cases decreased 

after the start of the Easter holidays in week 14 [2-8 Apr 2007].



Case description

----------------

Cases were between one month (no laboratory confirmation, 

epidemiological link with 16-year-old sister also not 

laboratory-confirmed) and 27 years of age with more than half in the 

early school age, that is, 6-11 years (n=53, 59 percent) (Figure 2). 

55 cases were female (61 percent). The median age was 9 years for both sexes.



According to the vaccination history, as many as 81 cases (90 

percent) were without protection provided by vaccination at the time 

of infection and no case had received 2 doses of measles vaccine 

[data tabulated in the original text.]. It should be noted, however, 

that 2 cases were below one year of age, that is, below the 

recommended age for measles vaccination.



A total of 6 cases (7 percent, aged 16 months to 27 years) required 

reaction to penicillin that he had received for suspected scarlet 

fever. A 16-month-old boy suffered from fever and conjunctivitis, and 

was treated in an Austrian hospital close to the German-Austrian 

as pneumonia, otitis media, and encephalitis) have been reported.



Laboratory results

------------------

A total of 22 cases (24 percent, aged 16 months to 27 years) had 

laboratory confirmation for measles. 20 cases were serologically 

confirmed; 2 of them, however, had received measles vaccination 

within 14 days prior to laboratory diagnosis, so a positive antibody 

titre due to the vaccination cannot be excluded. The remaining 2 

cases had laboratory confirmation by detection of MV nucleic acid 

performed at the National Reference Centre (NRC) for Measles, Mumps, 

Rubella at the Robert Koch Institute (RKI). Molecular typing of the 

MV detected in these samples showed genotype D5. Sequential typing 

revealed a genome sequence identical to that of the main MV strain 

linked to the current large outbreak in Switzerland (1).



Public health measures

----------------------

The DHA focused on case ascertainment, contact tracing, and a 

comprehensive information campaign for the general public. Press 

statements and written information distributed to the heads of 

schools and day-care facilities and to physicians in the affected 

region included information on the current measles outbreak, on 

protective measures including vaccination, and on the legislation 

concerning measles and the attendance of schools and day-care 

facilities. The DHA sporadically checked vaccination records in 

schools and day-care facilities. Parents of non- or partially 

vaccinated children were advised to complete their child's 

vaccination schedule. However, the number of resulting vaccinations is unknown.



Discussion

----------

The measles outbreak described here originated in a population of 

non-immunised pupils of a Montessori school, and lasted for over 4 

months (week 2 [8-14 Jan] to week 19 [7-13 May], 2007). Presumably, 

the control measures implemented by the DHA, the limited number of 

susceptible individuals in the region, and the Easter holidays (weeks 

14-15 [2-15 Apr 2007]), which limited the contacts among pupils and 

children in day-care facilities, all contributed to the end of the outbreak.



It is possible that a large number of infections could have been 

prevented by stricter and timelier public health interventions, 

including an on-site vaccination offer. However, this was not 

feasible mainly due to delay between onset of disease and case 

notification especially at the beginning of the outbreak. A 

pre-requisite for early outbreak detection is case notification by 

health professionals and by heads of schools and day-care facilities. 

The latter would have been particularly important in this outbreak 

since the primary cases and their contacts did not consult physicians.



In 2005, vaccination coverage with at least 2 doses of measles 

vaccine was 70 percent among first graders (5-7 years) in both 

affected districts. Coverage with at least one dose was 94 percent 

and 92 percent in the districts of Passau and Rottal-Inn, 

respectively (2). The figures only represent pupils with available 

vaccination records (approx. 90 percent in both districts) and are 

probably an overestimation of the true vaccination coverage. However, 

the figures are higher than for the whole of Bavaria. This shows that 

gaps in vaccination coverage are likely to exist in subpopulations 

with a sceptical attitude towards measles vaccination like the 

families of Montessori school pupils in this outbreak. Actions aiming 

at a further increase of measles vaccination coverage should 

especially target these sub-populations and their physicians.



The MV strain identified during this outbreak was not only found in 

Switzerland. Further epidemiological investigations and genotyping 

allow us to reconstruct a chain of infection from Switzerland via 

Bavaria to Austria, Lower Saxony in northern Germany, and Denmark 

(detailed results to be published soon). The outbreak described in 

this paper occurred in an area close to the German-Austrian border 

where residents of both countries consult physicians on both sides of 

the border, according to proximity to their place of residence. To 

measles reported in 2007 to the Austrian National Reference 

Laboratory for Measles, Mumps, Rubella) were linked to the Bavarian 

outbreak (personal communication with Professor Heidemarie Holzmann, 

3 Oct 2007). However, since the reporting of cases among residents of 

a foreign country is not mandatory for German and Austrian 

physicians, active case finding would be needed to better assess the 

size of the outbreak. This demonstrates the need of an 

institutionalised approach to exchange of information on infectious 

diseases across international borders, if the World Health 

Organization (WHO) goal of measles elimination by 2010 is to be achieved.



The article is adapted from (3).



We thank the staff members of the District Health Authorities of 

Passau and Rottal-Inn for providing the data.



Bayern 4/2006 [in German]. Available at

1. Halbjahr 2007 [in German]. Epidemiologisches Bulletin, 14. 

September 2007/Nr. 37. Available at



Siedler/4, MS Ludwig/5, R Fischer/5, W Hautmann/5

1. Robert Koch Institute, Department for Infectious Disease 

Epidemiology, Berlin, delegated to Bavarian Health and Food Safety 

Authority, Oberschleissheim, Germany. 2. Postgraduate Training for 

Applied Epidemiology (PAE, German FETP). 3. Robert Koch Institute, 

National Reference Centre for Measles/Mumps/Rubella, Berlin, Germany. 

4. Robert Koch Institute, Department for Infectious Disease 

Epidemiology, Berlin, Germany. 5. Bavarian Health and Food Safety 

Authority, Department Health and Nutrition, Oberschleissheim, Germany]



--



[This report highlights continuing problems in eradication of measles 

even in highly immunised populations as a consequence of the 

existence of minorities reluctant to accept vaccination. The spread 

of a single strain of measles virus from Switzerland, via the border 

region of South Germany and Austria to North Germany and eventually 

to Denmark, illustrates the critical need for close international 

collaboration in measles surveillance. - Mod.CP]



[A map of the area is available at



2006

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Measles & SSPE - Germany (Nordrhine-Westfalia) 20060604.1556

Measles - Germany 20060413.1095]

.....................mpp/cp/mj/mpp