Eurosurveillance - Volume 14, Issue 50, 17 December 2009

An increased relative risk of infection with the 2009 pandemic H1N1 influenza virus associated with pregnancy and Indigenous status has been a common finding in many countries. Using publicly available data from May to October 2009 in Australia, we estimated the relative risk of hospitalisation, admission to intensive care unit and death as 5.2, 6.5 and 1.4 respectively for pregnant women, and as 6.6, 6.2 and 5.2, respectively for Indigenous Australians. Pregnancy and Indigenous status were associated with severe influenza. More complete analyses of risks in these groups are required to understand and prevent influenza morbidity and mortality.

Earlier this year, an outbreak of measles was detected in Bulgaria, following an eight–year period without indigenous measles transmission, and continues to spread in the country. By the end of 48 week of 2009 (first week of November), 957 measles cases had been recorded. Most cases are identified among the Roma community living in the north-eastern part of the country. Measles has affected infants, children and young adults. The vaccination campaign that started earlier in the year in the affected administrative regions continues, targeting all individuals from 13 months to 30 years of age who have not received the complete two-dose regimen of the combined measles-mumps-rubella (MMR) vaccination.

From mid-September 2009 to 7 December 2009, 173 cases of mumps have been reported in the Jerusalem District. Most cases (82.1%) were male adolescents (median age 14.5 years) who are students in religious boarding schools. The majority of them (74%) are appropriately vaccinated for their age; 67% had received two doses of mumps-containing vaccine. An epidemiologic connection has been reported with visitors from New York, some of whom had recently had mumps.

We report the first worldwide case of Usutu virus (USUV) neuroinvasive infection in a patient with diffuse large B cell lymphoma who presented with fever and neurological symptoms and was diagnosed with meningoencephalitits. The cerebrospinal fluid was positive for USUV, and USUV was also demonstrated in serum and plasma samples by RT-PCR and sequencing. Partial sequences of the premembrane and NS5 regions of the viral genome were similar to the USUV Vienna and Budapest isolates.

We report a case of Usutu virus (USUV)-related illness in a patient that underwent an orthotropic liver transplant (OLT). Post transplant, the patient developed clinical signs of a possible neuroinvasive disease with a significant loss of cerebral functions. USUV was isolated in Vero E6 cells from a plasma sample obtained immediately before the surgery, and USUV RNA was demonstrated by RT-PCR and sequencing. This report enlarges the panel of emerging mosquito-borne flavivirus-related disease in humans.

Switzerland adheres to the objective of eliminating measles within the European region of the World Health Organization (WHO) by 2010. After several years with a relatively low annual incidence rate (0.3 to 1 case per 100,000 inhabitants), there has been a large epidemic of measles from November 2006 to August 2009. By mid September 2009, 4,415 cases were notified by physicians and laboratories, corresponding to an incidence rate of 15 per 100,000 in 2007 and 29 per 100,000 in 2008; by far the highest rates in Europe. This exceptionally long nationwide epidemic comprised three successive waves, with peaks in August 2007 (171 cases), March 2008 (569 cases) and March 2009 (417 cases). It mainly affected children aged from five to 14 years (48% of cases). Most cases were not vaccinated (93%) or were incompletely vaccinated (5%). In total 656 patients (15%) suffered complications or were hospitalised. Insufficient, spatially heterogeneous immunisation coverage (87% for at least one dose at the age of two years at the national level) has allowed a sequence of numerous outbreaks to occur, despite the gradual strengthening of measures to control the disease. Several exportations to Europe (81 in 2007 and 2008) and to the rest of the world (10 for the whole of the epidemic) have in some instances caused large outbreaks. The epidemic was a threat to the goal of eliminating measles in Switzerland and in Europe. The Federal Office of Public Health (FOPH) and its partners are currently working on a national strategy to eliminate measles.

A cross-sectional study was performed to determine the rubella seroprevalence in 331 children aged between 0 and 59 months in Turkey who were not vaccinated for rubella and lived in the area covered by Dogankent Health Center, a rural area with a large proportion of residents of low socioeconomic status. Rubella seropositivity was found to be low, with 17.5%, increased with age and low socioeconomic level, and was particularly high in children who live in a household with one member going to school, and in children of uneducated parents (p<0.05). The asymptomatic infection rate was 98.3%. There was no significant difference in seropositivity with regards to the gender, history of rubella infection, size of the household, or number of children at home (p>0.05). Rubella vaccine has only been included into the national vaccination programme in the form of the measles-mumps-rubella (MMR) vaccine since 2006 and is performed at the age of 12 months, in the first year of primary school and at the age of about 15 years. In order to eliminate rubella and congenital rubella syndrome, it is necessary that use of MMR vaccine is expanded to include the children born before 2006.

Smallpox was formally declared as eradicated in 1979. Smallpox is the only infectious disease of humans that has ever been eradicated. Poliomyelitis has been eliminated from three of the six World Health Organization (WHO) regions although not all countries within those regions always meet the elimination criteria. Elimination criteria for measles are being discussed. We use poliomyelitis and measles as examples to illustrate our assertion that the current approach to documenting measles elimination relies too heavily on criteria for surveillance quality, disadvantaging countries with long established and relatively inflexible surveillance systems. We propose an alternative approach to documenting measles elimination, with the two key criteria being molecular evidence to confirm the lack of a circulating endemic genotype for at least one year and maintenance of 95% coverage of one dose of measles-containing vaccine, with an opportunity for a second dose. Elimination status should be reviewed annually. We suggest four principles that should guide development of final criteria to document measles elimination: countries that have eliminated measles should be able to meet the elimination criteria; quality surveillance criteria are necessary but not sufficient to define elimination; quality surveillance criteria should be guided by elimination criteria, not the other way around; and elimination criteria should not differ between the WHO regions without good reason.