Association between meteorological variations and the superspreading potential of SARS-CoV-2 infections.

BACKGROUND: While many investigations examined the association between environmental covariates and COVID-19 incidence, none have examined their relationship with superspreading, a characteristic describing very few individuals disproportionally infecting a large number of people. METHODS: Contact tracing data of all the laboratory-confirmed COVID-19 cases in Hong Kong from February 16, 2020 to April 30, 2021 were used to form the infection clusters for estimating the time-varying dispersion parameter (kt), a measure of superspreading potential. Generalized additive models with identity link function were used to examine the association between negative-log kt (larger means higher superspreading potential) and the environmental covariates, adjusted with mobility metrics that account for the effect of social distancing measures. RESULTS: A total of 6,645 clusters covering 11,717 cases were reported over the study period. After centering at the median temperature, a lower ambient temperature at 10th percentile (18.2 °C) was significantly associated with a lower estimate of negative-log kt (adjusted expected change: -0.239 [95 % CI: -0.431 to -0.048]). While a U-shaped relationship between relative humidity and negative-log kt was observed, an inverted U-shaped relationship with actual vapour pressure was found. A higher total rainfall was significantly associated with lower estimates of negative-log kt. CONCLUSIONS: This study demonstrated a link between meteorological factors and the superspreading potential of COVID-19. We speculated that cold weather and rainy days reduced the social activities of individuals minimizing the interaction with others and the risk of spreading the diseases in high-risk facilities or large clusters, while the extremities of relative humidity may favor the stability and survival of the SARS-CoV-2 virus.

Association of nirmatrelvir-ritonavir with post-acute sequelae and mortality in patients admitted to hospital with COVID-19: a retrospective cohort study.

BACKGROUND: Studies have established the short-term efficacy of nirmatrelvir-ritonavir in managing COVID-19, yet its effect on post-COVID-19 condition, especially in patients admitted to hospital, remains understudied. This study aimed to examine the effect of nirmatrelvir-ritonavir on post-COVID-19 condition among patients admitted to hospital in Hong Kong. METHODS: This retrospective cohort study used real-world, territory-wide inpatient records, vaccination records, and confirmed COVID-19 case data from the Hong Kong Hospital Authority and Department of Health, The Government of the Hong Kong Special Administrative Region. Patients aged 18 years and older who tested positive for SARS-CoV-2 between March 11, 2022, and Oct 10, 2023, and who were admitted to hospital with COVID-19 were included. The treatment group included patients prescribed nirmatrelvir-ritonavir within 5 days of symptom onset, excluding those prescribed molnupiravir within 21 days, and the control group had no exposure to either nirmatrelvir-ritonavir or molnupiravir. The outcomes were post-acute inpatient death and 13 sequelae (congestive heart failure, atrial fibrillation, coronary artery disease, deep vein thrombosis, chronic pulmonary disease, acute respiratory distress syndrome, interstitial lung disease, seizure, anxiety, post-traumatic stress disorder, end-stage renal disease, acute kidney injury, and pancreatitis). These outcomes were evaluated starting at 21 days after the positive RT-PCR date in each respective cohort constructed for the outcome. Standardised mortality ratio weights were applied to balance covariates, and Cox proportional hazards regression was used to investigate the relationship between nirmatrelvir-ritonavir and outcomes. FINDINGS: 136 973 patients were screened for inclusion, among whom 50 055 were eligible and included in the analysis (24 873 [49·7%] were female and 25 182 [50·3%] were male). 15 242 patients were prescribed nirmatrelvir-ritonavir during acute COVID-19 and 23 756 patients were included in the control group; 11 057 patients did not meet our definition for the exposed and unexposed groups. Patients were followed up for a median of 393 days (IQR 317-489). In the nirmatrelvir-ritonavir group compared with the control group, there was a significantly lower hazard of post-acute inpatient death (hazard ratio 0·62 [95% CI 0·57-0·68]; p<0·0001), congestive heart failure (0·70 [0·58-0·85]; p=0·0002), atrial fibrillation (0·63 [0·52-0·76]; p<0·0001), coronary artery disease (0·71 [0·59-0·85]; p=0·0002), chronic pulmonary disease (0·68 [0·54-0·86]; p=0·0011), acute respiratory distress syndrome (0·71 [0·58-0·86]; p=0·0007), interstitial lung disease (0·17 [0·04-0·75]; p=0·020), and end-stage renal disease (0·37 [0·18-0·74]; p=0·0049). There was no evidence indicating difference between the groups in deep vein thrombosis, seizure, anxiety, post-traumatic stress disorder, acute kidney injury, and pancreatitis. INTERPRETATION: This study showed extended benefits of nirmatrelvir-ritonavir for reducing the risk of post-acute inpatient death as well as cardiovascular and respiratory complications among patients admitted to hospital with COVID-19. Further research is essential to uncover the underlying mechanisms responsible for these observed negative associations and to devise effective strategies for preventing the onset of post-acute sequelae. FUNDING: Health and Medical Research Fund, Research Grants Council theme-based research schemes, and Research Grants Council Collaborative Research Fund.

Effectiveness of BNT162b2 and Sinovac vaccines against the transmission of SARS-CoV-2 during Omicron-predominance in Hong Kong: A retrospective cohort study of COVID-19 cases.

BACKGROUND: In 2022, SARS-CoV-2 Omicron variants circulated globally, generating concerns about increased transmissibility and immune escape. Hong Kong, having an infection-naive population with a moderate 2-dose vaccine coverage (63% by the end of 2021), experienced a COVID-19 epidemic largely seeded by Omicron BA.2 variants that led to the greatest outbreak in the region to date. Little remains known about the protection of commonly-administered vaccines against transmission of Omicron BA.2 variants. METHODS: In this retrospective cohort study, we identified 17 535 laboratory-confirmed COVID-19 cases using contact tracing information during the Omicron-predominant period between January and June 2022 in Hong Kong. Demographic characteristics, time from positive test result to case reporting, isolation, or hospital admission, as well as contact tracing history and contact setting were extracted. Transmission pairs were reconstructed through suspected epidemiological links according to contact tracing history, and the number of secondary cases was determined for each index case as a measurement for risk of transmission. The effectiveness of mRNA vaccine (BNT162b2) and inactivated vaccine (Sinovac) against transmission of BA.2 variants was estimated using zero-inflated negative binomial regression models. RESULTS: Vaccine effectiveness against transmission for patients who received the 2-dose BNT162b2 vaccine was estimated at 56.2% (95% CI: 14.5, 77.6), 30.6% (95% CI: 13.0, 44.6), and 21.3% (95% CI: 2.9, 36.2) on 15 - 90, 91 - 180, and 181 - 270 days after vaccination, respectively, showing a significant decrease over time. For 3-dose vaccines, vaccine effectiveness estimates were 41.0% (95% CI: 11.3, 60.7) and 41.9% (95% CI: 6.1, 64.0) on 15 - 180 days after booster doses of Sinovac and BNT162b2, respectively. Although significant vaccine effectiveness was detected in household settings, no evidence of such protective association was detected in non-household settings for either Sinovac or BNT162b2. CONCLUSION: Moderate and significant protection against Omicron BA.2 variants' transmission was found for 2 and 3 doses of Sinovac or BNT162b2 vaccines. Although protection by 2-dose BNT162b2 may evidently wane with time, protection could be restored by the booster dose. Here, we highlight the importance of continuously evaluating vaccine effectiveness against transmission for emerging SARS-CoV-2 variants.

Relationship between antidepressants and severity of SARS-CoV-2 Omicron infection: a retrospective cohort study using real-world data.

Background: Few studies have used real-world data to evaluate the impact of antidepressant use on the risk of developing severe outcomes after SARS-CoV-2 Omicron infection. Methods: This is a retrospective cohort study using propensity-score matching to examine the relationship between antidepressant use and COVID-19 severity. Inpatient and medication records of all adult COVID-19 patients in Hong Kong during the Omicron-predominated period were obtained. Severe clinical outcomes including intensive care unit admission and inpatient death after the first positive results of reverse transcription polymerase chain reaction as well as a composite outcome of both were studied. Cox proportional hazard models were applied to estimate the crude and adjusted hazard ratios (HR). Findings: Of 60,903 hospitalised COVID-19 patients admitted, 40,459 were included for matching, among which 3821 (9.4%) were prescribed antidepressants. The rates of intensive care unit admission, inpatient death, and the composite event were 3.9%, 25.5%, and 28.3% respectively in the unexposed group, 1.3%, 20.0%, and 21.1% respectively in the exposed group, with adjusted HR equal to 0.332 (95% CI, 0.245-0.449), 0.868 (95% CI, 0.800-0.942), and 0.786 (95% CI, 0.727-0.850) respectively. The result was generally consistent when stratified by selective serotonin reuptake inhibitors (SSRIs) and non-SSRIs. Antidepressants with functional inhibition of acid sphingomyelinase activity, specifically fluoxetine, were also negatively associated with the outcomes. The effect of antidepressants was more apparent in female and fully vaccinated COVID-19 patients. Interpretation: Antidepressant use was associated with a lower risk of severe COVID-19. The findings support the continuation of antidepressants in patients with COVID-19, and provide evidence for the treatment potential of antidepressants for severe COVID-19. Funding: This research was supported by Health and Medical Research Fund [grant numbers COVID190105, COVID19F03, INF-CUHK-1], Collaborative Research Fund of University Grants Committee [grant numbers C4139-20G], National Natural Science Foundation of China (NSFC) [71974165], and Group Research Scheme from The Chinese University of Hong Kong.

Comparing the incubation period, serial interval, and infectiousness profile between SARS-CoV-2 Omicron and Delta variants.

In January 2022, the SARS-CoV-2 Omicron variants initiated major outbreaks and dominated the transmissions in Hong Kong, displacing an earlier outbreak seeded by the Delta variants. To provide insight into the transmission potential of the emerging variants, we aimed to compare the epidemiological characteristics of the Omicron and Delta variants. We analyzed the line-list clinical and contact tracing data of the SARS-CoV-2 confirmed cases in Hong Kong. Transmission pairs were constructed based on the individual contact history. We fitted bias-controlled models to the data to estimate the serial interval, incubation period and infectiousness profile of the two variants. Viral load data were extracted and fitted to the random effect models to investigate the potential risk modifiers for the clinical viral shedding course. Totally 14 401 confirmed cases were reported between January 1 and February 15, 2022. The estimated mean serial interval (4.4 days vs. 5.8 days) and incubation period (3.4 days vs. 3.8 days) were shorter for the Omicron than the Delta variants. A larger proportion of presymptomatic transmission was observed for the Omicron (62%) compared to the Delta variants (48%). The Omicron cases had higher mean viral load over an infection course than the Delta cases, with the elder cases appearing more infectious than the younger cases for both variants. The epidemiological features of Omicron variants were likely an obstacle to contact tracing measures, imposed as a major intervention in settings like Hong Kong. Continuously monitoring the epidemiological feature for any emerging SARS-CoV-2 variants in the future is needed to assist officials in planning measures for COVID-19 control.

Estimation of Vaccine Effectiveness of CoronaVac and BNT162b2 Against Severe Outcomes Over Time Among Patients With SARS-CoV-2 Omicron.

Importance: Few studies have evaluated the waning of vaccine effectiveness against severe outcomes caused by SARS-CoV-2 Omicron infection. Hong Kong is providing inactivated and mRNA vaccines, but the population had limited protection from natural infections before the Omicron variant emerged. Objective: To examine the change in vaccine effectiveness against hospitalization and mortality due to the Omicron variant over time. Design, Setting, and Participants: This case-control study included adults with SARS-CoV-2 Omicron variant infection who died or were hospitalized in Hong Kong from January 1 to June 5, 2022 (ie, case participants), and adults with SARS-CoV-2 Omicron, sampled from the public health registry during the study period (ie, control participants), who were matched to case participants by propensity score. Exposures: Vaccination status of the individuals. Main Outcomes and Measures: Estimated vaccine effectiveness against death, death or hospitalization, and death among hospitalized patients. Vaccine effectiveness was calculated as 1 - adjusted odds ratio obtained by conditional logistic regression adjusted with covariates for each period following vaccination. Results: There were 32 823 case participants (25 546 [77.8%] ≥65 years; 16 930 [47.4%] female) and 131 328 control participants (100 041 [76.2%] ≥65 years; 66 625 [46.6%] female) in the sample analyzed for the death or hospitalization outcome. Vaccine effectiveness against death or hospitalization was maintained for at least 6 months after the second dose of both CoronaVac (74.0%; 95% CI, 71.8%-75.8%) and BNT162b2 (77.4%; 95% CI, 75.5%-79.0%) vaccines. Vaccine effectiveness against death in those aged 18 to 49 years was 86.4% (95% CI, 85.8%-87.0%) and 92.9% (95% CI, 92.6%-93.2%) for those receiving 2 doses of CoronaVac and BNT162b2, respectively, while for patients aged 80 years or older, it dropped to 61.4% (95% CI, 59.8%-63.2%) and 52.7% (95% CI, 50.2%-55.6%) for CoronaVac and BNT162b2, respectively. Nevertheless, overall vaccine effectiveness against death at 4 to 6 months after the third dose was greater than 90% for CoronaVac, BNT162b2, and the mixed vaccine schedule (eg, mixed vaccines: vaccine effectiveness, 92.2%; 95% CI, 89.2%-95.1%). Conclusions and Relevance: While vaccines were generally estimated to be effective against severe outcomes caused by SARS-CoV-2 Omicron infection, this analysis found that protection in older patients was more likely to wane 6 months after the second dose. Hence, a booster dose is recommended for older patients to restore immunity. This is especially critical in a setting like Hong Kong, where third-dose coverage is still insufficient among older residents.

Dining-Out Behavior as a Proxy for the Superspreading Potential of SARS-CoV-2 Infections: Modeling Analysis.

BACKGROUND: While many studies evaluated the reliability of digital mobility metrics as a proxy of SARS-CoV-2 transmission potential, none examined the relationship between dining-out behavior and the superspreading potential of COVID-19. OBJECTIVE: We employed the mobility proxy of dining out in eateries to examine this association in Hong Kong with COVID-19 outbreaks highly characterized by superspreading events. METHODS: We retrieved the illness onset date and contact-tracing history of all laboratory-confirmed cases of COVID-19 from February 16, 2020, to April 30, 2021. We estimated the time-varying reproduction number (Rt) and dispersion parameter (k), a measure of superspreading potential, and related them to the mobility proxy of dining out in eateries. We compared the relative contribution to the superspreading potential with other common proxies derived by Google LLC and Apple Inc. RESULTS: A total of 6391 clusters involving 8375 cases were used in the estimation. A high correlation between dining-out mobility and superspreading potential was observed. Compared to other mobility proxies derived by Google and Apple, the mobility of dining-out behavior explained the highest variability of k (ΔR-sq=9.7%, 95% credible interval: 5.7% to 13.2%) and Rt (ΔR-sq=15.7%, 95% credible interval: 13.6% to 17.7%). CONCLUSIONS: We demonstrated that there was a strong link between dining-out behaviors and the superspreading potential of COVID-19. The methodological innovation suggests a further development using digital mobility proxies of dining-out patterns to generate early warnings of superspreading events.

Changes in Measles Seroprevalence in China After the Launch of Two Provincial Supplementary Immunization Activities During 2009 to 2013.

BACKGROUND: Supplementary immunization activities (SIAs) have been demonstrated being effective in reducing measles incidence within a short period of time in China, but the effects are short-lived if there is no follow-up SIA with high routine immunization coverage. OBJECTIVES: To assess the change in measles seroprevalence from 2009 to 2013 after the launch of 2 large-scale SIAs within the period. METHODS: Three population-based cross-sectional serologic surveys of measles antibodies were conducted in 2009, 2011 and 2013 in Zhejiang, a province in eastern China, with serologic samples collected from 1541, 896 and 1474 subjects, respectively. The serum levels of immunoglobulin G antibodies were measured by enzyme-linked immunosorbent assay. RESULTS: We found that the seropositivity rate among infants 0-7 months of age, a group having no vaccination benefit, was below 80% throughout the study period. In addition, the seropositivity rate among adults 30-49 years of age decreased significantly from 96.0% (95% confidence interval: 93.7%-98.3%) in 2011 to 88.5% (95% confidence interval: 84.3%-92.8%) in 2013. CONCLUSION: We showed that large-scale SIAs were effective, but their effects were not long lasting. Given the drop in seropositivity among adults, their susceptibility should be carefully monitored. While older individuals could benefit from the immunization activities, children who were too young to be vaccinated still have a weak seropositivity profile and the optimal age for the administration of the first dose of vaccine should be reconsidered.

Epidemiological changes in measles infections in southern China between 2009 and 2016: a retrospective database analysis.

BACKGROUND: The incidence rate of measles in China reached a nadir in 2012 after 2 supplementary immunization activities (SIAs) were undertaken in 2009 and 2010. However, the disease began re-emerging in 2013, with a high prevalence rate observed in 2013-2014 in the southern province of Guangdong. In this study, we assessed the changes that occurred in measles epidemiology during 2009-2016, particularly between 2009 and 2011 (when the influence of the SIAs were in full effect) and between 2012 and 2016 (when this influence subsided). METHODS: Data from 22,362 patients with measles diagnosed between 2009 and 2016, and whose diagnoses were confirmed clinically and/or with laboratory testing, were extracted from the National Infectious Disease Monitoring Information System. Descriptive analyses were performed, and changes in epidemiological characteristics between 2009 and 2011 and 2012-2016 were compared. RESULTS: There was a substantial surge in 0-8-month-old patients after 2012; the incidence rate increased from 4.0 per 100,000 population in 2011 (10.3% of the total) to 280 per 100,000 population in 2013 (32.8% of the total). Patients aged 0-6 years represented 73.4% of the total increase between 2011 and 2013. Compared with 2009-2011, adults aged ≥25 years accounted for a higher proportion of patients in 2013 and after (p < 0.01), and were highest in 2016 (31% of the patient total). CONCLUSION: Despite the remarkable results achieved by SIAs in terms of providing herd immunity, the 2013 resurgence of measles revealed insufficient immunization coverage among children. Therefore routine immunization programs should be strengthened, and supplementary vaccinations targeting adults should also be contemplated.

Latitudes mediate the association between influenza activity and meteorological factors: A nationwide modelling analysis in 45 Japanese prefectures from 2000 to 2018.

BACKGROUND: Cold and dry conditions were well-documented as a major determinant of influenza seasonality in temperate countries but the association may not be consistent when the climate in temperate areas is closer to that in sub-tropical areas. We hypothesized latitudes may mediate the association between influenza activity and meteorological factors in 45 Japanese prefectures. METHODS: We used the weekly incidence of influenza-like illness of 45 prefectures from 2000 to 2018 as a proxy for influenza activity in Japan, a temperate country lying off the east coast of Asia. A combination of generalized additive model and distributed lag nonlinear model was adopted to investigate the associations between meteorological factors (average temperature, relative humidity, total rainfall, and actual vapour pressure, a proxy for absolute humidity) and the influenza incidence. Kendall's tau b (τ) and Spearman correlation coefficient (rs) between latitude and the adjusted relative risk (ARR) of each meteorological factor were also assessed. RESULTS: A higher vapour pressure was significantly associated with a lower influenza risk but the ARR strongly weakened along with a lower latitude (τ = -0.23, p-value = 0.02; rs = -0.33, p-value = 0.03). Lower temperature and lower relatively humidity were significantly associated with higher influenza risks in over 65% and around 40% of the prefectures respectively but the strength and significance of the correlations between their ARRs and latitude were weaker than that from vapour pressure. CONCLUSION: Even though the range of latitudes in Japan is small (26°N-43°N), the relationships between meteorological factors and influenza activity were mediated by the latitude. Our study echoed absolute humidity played a more important role in relating influenza risk, but we on the other hand showed its effect on influenza activity could be hampered in a low-latitude temperate region, which have a warmer climate. These findings thus offer a high-resolution characterization of the role of meteorological factors on influenza seasonality.

Mathematical modelling of the impact of treating latent tuberculosis infection in the elderly in a city with intermediate tuberculosis burden.

Hong Kong is a high-income city with intermediate tuberculosis (TB) burden primarily driven by endogenous reactivations. A high proportion of remote latently infected people, particularly elderly, hinders the effectiveness of current strategies focusing on passive TB detection. In this study, we developed a mathematical model to evaluate the impact of treating latent TB infection (LTBI) in the elderly in addition to current TB control strategies. The model was calibrated using the annual age-stratified TB notifications from 1965-2013 in Hong Kong. Our results showed that at present, approximately 75% of annual new notifications were from reactivations. Given the present treatment completion rate, even if only a low to moderate proportion (approximately 20% to 40%) of elderly people were screened and treated for LTBI, the overall TB incidence could be reduced by almost 50%, to reach the 2025 milestone of the global End TB Strategy. Nevertheless, due to a high risk of hepatotoxicity in elderly population, benefit-risk ratios were mostly below unity; thus, intervention programs should be carefully formulated, including prioritising LTBI treatment for high-risk elderly groups who are closely monitored for possible adverse side effects.

Targeting Adults for Supplementary Immunization Activities of Measles Control in Central China: A Mathematical Modelling Study.

Routine immunizations and supplementary immunization activities (SIAs) have significantly improved measles control over the past two decades in China. Progress towards eliminating measles currently faces multiple challenges as the infection age increases, and adult-targeted SIA strategies are being considered. This study developed an age-stratified susceptible-exposed-infectious-recovered model using a recently published contact matrix to depict measles transmissions between individuals in seven age groups. Hubei, a high measles-incidence province in central China, was the selected setting. The baseline scenario was calibrated by fitting with the 2012-2015 age-stratified incidence data. SIAs targeting multiple age groups were simulated. Adult-targeted (>29 years) two-year SIA cycles produced the greatest annual incidence rate decrease, reducing incidences by half over a long timespan with 90% coverage levels. Incidences could remain below 10/100,000 until 2030 if SIAs were provided to individuals ≥6 years old with at least 50% coverage. These findings will help officials prioritize supplementary vaccination strategies. Public health officials in China should consider adult-to-adult transmissions and provide adult-targeted SIAs. Although officials have reported approximately 90% SIA coverage in the past, SIAs for the adult population should be provided on shorter intervals, particularly for the aging population with decreased immunity.

Monitoring the age-specificity of measles transmissions during 2009-2016 in Southern China.

BACKGROUND: Despite several immunization efforts, China saw a resurgence of measles in 2012. Monitoring of transmissions of individuals from different age groups could offer information that would be valuable for planning adequate disease control strategies. We compared the age-specific effective reproductive numbers (R) of measles during 2009-2016 in Guangdong, China. METHODS: We estimated the age-specific R values for 7 age groups: 0-8 months, 9-18 months, 19 months to 6 years, 7-15 years, 16-25 years, 26-45 years, and ≥46 years adapting the contact matrix of China. The daily numbers of laboratory and clinically confirmed cases reported to the Center for Disease Control and Prevention of Guangdong were used. RESULTS: The peak R values of the entire population were above unity from 2012 to 2016, indicating the persistence of measles in the population. In general, children aged 0-6 years and adults aged 26-45 years had larger values of R when comparing with other age groups after 2012. While the peaks of R values for children aged 0-6 years dropped steadily after 2013, the peaks of R values for adults aged 26-45 years kept at a high range every year. CONCLUSIONS: Although the provincial supplementary immunization activities (SIAs) conducted in 2009 and 2010 were able to reduce the transmissions from 2009 to 2011, larger values of R for children aged 0-6 years were observed after 2012, indicating that the benefits of the SIAs were short-lived. In addition, the transmissions from adults aged between 26 and 45 years increased over time. Disease control strategies should target children and adult groups that carry high potential for measles transmission.

Interpreting the transmissibility of measles in two different post periods of supplementary immunization activities in Hubei, China.

Although evidence has shown that supplementary immunization activity (SIA) campaigns greatly reduce the incidence of measles, their effects on disease transmissibility have seldom been monitored. A great decrease in the number of cases may be a false signal of early success towards measles elimination to policy makers. By interpreting the transmissibility in two different post-SIA periods in Hubei, China, the current study showed sustained measles transmissions despite a reduced number of cases. Two population-based cross-sectional serological surveys of measles antibodies were conducted in Hubei province in mid-2010 and mid-2011 after the implementation of SIAs. Immunoglobulin G (IgG) antibodies against measles were measured by enzyme-linked immunosorbent assay (ELISA). Based on the estimated age-specific susceptibility levels, the effective reproduction number (R), a key indicator of disease transmissibility, was determined by the next generation matrix in transmission model. The results revealed an overall IgG seroprevalence of 88.0% (95% confidence interval [CI]: 85.6-90.4%) and 89.6% (95%CI: 88.0-91.2%), respectively, in the two different periods. Comparatively lower seroprevalence rates were observed among children less than 24months of age and young adults 15 to 19years of age in 2011. The Rs were 0.76 and 1.53 for the two study periods. In conclusion, even though the incidence was reduced to below 1/100,000 in both 2010 and 2011, the reproduction number in 2011 indicates a high risk for sustained measles transmission. This finding was potentially due to a lower seropositivity rate among young adults that had not been covered in the first SIA. Thus, implementation of SIA targeted to appropriate age groups is recommended. Regular monitoring of seroprevalence is also suggested to track disease transmissibility and to align SIA with the appropriate age groups.