Caring for Rohingya Refugees With Diphtheria and Measles: On the Ethics of Humanity.

Hundreds of thousands of Rohingya refugees arrived in Bangladesh within weeks in fall 2017, quickly forming large settlements without any basic support. Humanitarian first responders provided basic necessities including food, shelter, water, sanitation, and health care. However, the challenge before them-a vast camp ravaged by diphtheria and measles superimposed on a myriad of common pathologies-was disproportionate to the resources. The needs were endless, resources finite, inadequacies abundant, and premature death inevitable. While such confines force unimaginable choices in resource allocation, they do not define the humanitarian purpose-to alleviate suffering and not allow such moral violations to become devoid of their horrifying meaning. As humanitarian workers, we maintain humanity when we care, commit, and respond to moral injustices. This refusal to abandon others in desperate situations is an attempt to rectify injustices through witnessing and solidarity. When people are left behind, we must not leave them alone.

Responding to measles outbreaks in underserved Roma and Romanian populations in England: the critical role of community understanding and engagement.

Since 2016, the European Region has experienced large-scale measles outbreaks. Several measles outbreaks in England during 2017/18 specifically affected Romanian and Romanian Roma communities. In this qualitative interview study, we looked at the effectiveness of outbreak responses and efforts to promote vaccination uptake amongst these underserved communities in three English cities: Birmingham, Leeds and Liverpool. Semi-structured in-depth interviews were conducted with 33 providers involved in vaccination delivery and outbreak management in these cities. Interviews were analysed thematically and factors that influenced the effectiveness of responses were categorised into five themes: (1) the ability to identify the communities, (2) provider knowledge and understanding of the communities, (3) the co-ordination of response efforts and partnership working, (4) links to communities and approaches to community engagement and (5) resource constraints. We found that effective partnership working and community engagement were key to the prevention and management of vaccine-preventable disease outbreaks in the communities. Effective engagement was found to be compromised by cuts to public health spending and services for underserved communities. To increase uptake in under-vaccinated communities, local knowledge and engagement are vital to build trust and relationships. Local partners must work proactively to identify, understand and build connections with communities.

Community-Oriented Epidemic Preparedness and Response to the Jerusalem 2018-2019 Measles Epidemic.

Measles epidemics are still a public health challenge worldwide, necessitating a rapid response. The Jerusalem District Health Office applied a community-oriented intervention during the 2018-2019 epidemic (2150 notified cases). Program development targeted the socioeconomic and cultural characteristics of high-incidence Jewish ultraorthodox communities. Health care and community collaboration led to coverage rates of measles vaccination increasing from 80% to 95% within three months and a significant decline in incidence. Epidemic preparedness calls for maintaining the infrastructure of countermeasures combined with sustaining immunization coverage.

Preliminary findings indicate nosocomial transmission and Roma population as most affected group in ongoing measles B3 genotype outbreak in Bulgaria, March to August 2017.

From March to August 2017, 165 measles cases were reported from three regions in Bulgaria. The age range was 0-55 years and 66% of the cases were under 9 years. The Roma population was disproportionally affected (89% of cases), 41% cases were unvaccinated and in 24 cases there was nosocomial transmission mostly in paediatric departments. A child under 12 months of age died. Control measures have been taken and the investigation is still ongoing.

Measles in Italy: Co-circulation of B3 variants during 2014.

In 2013, the majority of the WHO/EUR countries reported an annual incidence of >1 case per one million population indicating that the elimination target is far from being met. Thus, there is the urgent need to uncover and analyze chains of measles virus (MV) transmission with the objective to identify vulnerable groups and avoid possible routes of introduction of MV variants in the European population. The analysis of molecular epidemiology of MV B3 strains identified in 2014 has shown that four different variants co-circulated in Italy, including the strain that caused a cruise-line ship outbreak at the beginning of the year.

Outbreak of a new measles B3 variant in the Roma/Sinti population with transmission in the nosocomial setting, Italy, November 2015 to April 2016.

A measles outbreak occurred from November 2015 to April 2016 in two northern Italian regions, affecting the Roma/Sinti ethnic population and nosocomial setting. Overall, 67 cases were reported. Median age of 43 cases in three Roma/Sinti camps was four years, nosocomial cases were mainly adults. The outbreak was caused by a new measles virus B3.1 variant. Immunisation resources and strategies should be directed at groups with gaps in vaccine coverage, e.g. Roma/Sinti and healthcare workers.

Measles outbreak among Roma people in Wroclaw, Poland, 2012.

A measles outbreak that affected mainly the Roma ethnic group has been observed in Wroclaw, southwest Poland, in spring/summer 2012. There were 15 confirmed measles cases occurring among young Roma people aged from 0 to 16 years including a newborn infant, born by a mother who showed measles symptoms immediately after delivery. Measles virus transmission into the general Polish population was restricted to two contact cases. Initiation of the outbreak by MeV importation from Romania has been confirmed by detection of MeV variant "D4-Maramures" circulating in Romania from 2011 to 2012. The outbreak experience highlights once more the still existing prob- lem of immunity gaps in Roma groups moving throughout Europe with a high susceptibility among children and adolescents including young women of child-bearing age.

Measles among U.S.-bound refugees from Malaysia--California, Maryland, North Carolina, and Wisconsin, August-September 2011.

On August 26, 2011, California public health officials notified CDC of a suspected measles case in an unvaccinated male refugee aged 15 years from Burma (the index patient), who had lived in an urban area of Kuala Lumpur, Malaysia, which is experiencing ongoing measles outbreaks. Currently, approximately 92,000 such refugees are living in urban communities in Malaysia. Resettlement programs in the United States and other countries are ongoing. The health and vaccination status of urban refugees are largely unknown.

East African immigrant children in Australia have poor immunisation coverage.

AIM: To provide data on the immunisation status of recently arrived East African children and adolescents in Australia. METHODS: A prospective audit was conducted at a hospital-based paediatric immigrant health clinic, in Melbourne, Australia, over the time period November 2000-January 2002. Study subjects were consecutive children and adolescents born in East Africa, arriving in Australia after January 1998. Vaccination status was ascertained by parent report and review of patient-held records where available, and by serological testing for immunity to hepatitis B, tetanus, diphtheria, rubella and measles. RESULTS: Among 136 participants, 132 (97%) had incomplete or unknown immunisation status based on parent report and vaccination records; written records were available for 5/136 (4%) of participants. Only 21/136 (15%) had serological immunity to all five of measles, rubella, tetanus, diphtheria and hepatitis B, despite a total of 395 visits to vaccine providers by participants since migration. A higher proportion of children had serological immunity to measles (90%) compared to the proportion with serological immunity to rubella (77%), tetanus (61%), diphtheria (45%) and hepatitis B (33%). The predictive value of parent-reported vaccination status for serological immunity was poor. CONCLUSIONS: Paediatric East African immigrants in Victoria are very likely to be inadequately immunised and parent-reported vaccination status does not predict serological immunity. Full catch-up immunisation is recommended where immunisation status is unknown and written records are unavailable. Consideration should be given to policy and program development to provide timely and complete immunisation coverage in this group after arrival in Australia.

Mass immunisation campaign in a Roma settled community created an opportunity to estimate its size and measles vaccination uptake, Poland, 2009.

During a mass immunisation campaign following an outbreak of measles in a Roma community settled in the town of Pulawy, Poland, we performed an estimation of the size of this Roma population and an assessment of its vaccination uptake. We obtained a list of Roma residing in Pulawy from the local municipality and estimated using a simple capture-recapture formula that Pulawy had 377 Roma residents (43% under 20 years old), which was 27% more than the 295 registered at the municipality. During the vaccination campaign, demographic information was recorded that could be linked to information from the municipality list as well as to prior immunisation status. Among the people whose data were recorded during the vaccination campaign, 14% were not registered at the primary healthcare centres, and were therefore deprived of access to healthcare. Among 102 screened subjects under the age of 20 years, 51% were vaccinated according to schedule. Vaccine uptake for the first dose of measles-containing vaccine was 56% (54/96) and for the second dose 37% (18/49). The present study indicates the need to get a better demographic overview of Roma communities living in Poland and to understand the barriers limiting their access to healthcare and social services. Organisation of catch-up immunisations of this vulnerable population is necessary.

Spotlight on measles 2010: A measles outbreak in a Roma population in Pulawy, eastern Poland, June to August 2009.

We describe a local indigenous outbreak of measles in a susceptible Roma community, which occurred in Pulawy, a town of 50,000 citizens in the Lubelskie province (eastern Poland) during summer 2009. From 22 June to 30 August 2009, 32 measles cases were reported, and additionally nine possible cases were actively identified. A mass immunisation campaign was organised to stop measles transmission in the Roma community. Active surveillance of rash-febrile illnesses allowed documentation of the impact of mass immunisation in preventing further measles spread in the Roma community, and the surrounding population of Pulawy.

The tragic 1824 journey of the Hawaiian king and queen to London: history of measles in Hawaii.

The susceptibility of isolated island-based populations to acute infections like measles is well documented, most clearly in Fiji and the Faröe Islands. We review the remarkably tragic 1824 journey of King Kamehameha II and Queen Kamamalu of Hawaii to London and the later enormous impact of measles on Hawaii on first arrival in 1848. The young royalty came to seek an audience with King George IV to negotiate an alliance with England. Virtually the entire royal party developed measles within weeks of arrival, 7 to 10 days after visiting the Royal Military Asylum housing hundreds of soldiers' children. Within the month the king (27) and queen (22) succumbed to measles complications. Their bodies were transported to Hawaii by Right Honorable Lord Byron (Captain George Anson, the poet's cousin). Before 1848 measles was unknown in Hawaii. Several epidemics struck Hawaii in late 1848, beginning with measles and pertussis, then diarrhea and influenza. Measles arrived at this time from California, spreading from Hilo, Hawaii, through all the islands; 10% to 33% of the population died. Subsequent measles epidemics occurred in 1861, 1889 to 1890, 1898, and 1936 to 1937, the latter with 205 deaths. The imported epidemics of infections including measles diminished Hawaii's population from approximately 300,000 at Captain Cook's arrival in 1778 to 135,000 in 1820 and 53,900 in 1876. The measles deaths of the king and queen in London in 1824, likely acquired visiting a large children's home, was a harbinger of the devastating impact of measles upon Hawaiians 24 years later with its first arrival to the Sandwich (Hawaiian) Islands.

Measles outbreak in a French Roma community in the Provence-Alpes-Côte d'Azur region, France, May to July 2017.

OBJECTIVES: To analyse a measles outbreak in a Roma community. METHODS: We describe a community-wide outbreak of genotype D8 measles that took place in southeastern France, between May and July 2017, along with the control measures adopted. RESULTS: We identified a total of eighteen cases, between six months and 24 years old. All cases were unvaccinated or incompletely vaccinated and belonged to a sedentary French Roma community. Most of them (67%) were hospitalised, with three cases (17%) of severe measles including one death of a 16-year-old girl who had previously received oral corticosteroids. The latter was the only lethal case notified in France during the year 2017. Control measures included intensification of surveillance, isolation of cases, and a large vaccination campaign in this Roma community. During the outbreak period, there was no case of healthcare-associated measles transmission. A broad adherence to vaccination through the mediating role of both the chief of the community and the pastor allowed reaching completed vaccination coverage of 90%. CONCLUSIONS: Efforts should be concentrated to enhance access to health services for minorities such as the Roma community characterized by low vaccination coverage. A trustful relationship with leaders of the community is essential to ensure adherence to vaccination. In France, attributable mortality to measles is low and concerns mainly unvaccinated and immunodepressed patients.

[Measles are eliminated in Denmark].

Measles vaccination has led to a significant fall in the number of measles cases and measles-related deaths worldwide. However, many countries still struggle to eliminate the disease. To obtain elimination, a minimum of 95% vaccination coverage for both of the measles, mumps, and rubella (MMR) vaccines is necessary as well as an efficient surveillance system and timely public health response. Presenting data on reported cases and vaccination coverage in the latest 20 years, this article describes how measles are eliminated in Denmark and recommends, how the Danish measles surveillance system can be further improved to maintain the status.

Susceptibility to measles in migrant population: implication for policy makers.

BACKGROUND: Despite a large measles outbreak is taking place in WHO European region, currently no data are available on measles immunization coverage in the asylum seeker and migrants hosted in this area. METHODS: Two hundred and fifty-six migrants upon their arrival in Italy on March, April and May 2016 were screened for measles virus IgG antibodies by chemiluminescence immunoassay (Liaison XL analyzer, Diasorin, Italy). The virus susceptibility in this cohort, the differences between the official country reported and the observed measles immunization coverage and the impact of current measles outbreak on the asylum seekers hosted in the largest Asylum Seeker centres of Italy, were evaluated. RESULTS: The prevalence of subjects with positive result for measles IgG antibodies ranged between 79.9% and 100%. In Senegal, Mali, Nigeria, Pakistan and Bangladesh, the measles IgG seroprevalence observed was greater than the vaccinal coverage reported by WHO after I dose of vaccine. Based on data regarding the II dose coverage, the ASs population presented a seroprevalence greater to that expected. CONCLUSION: On the basis of the results obtained, extraordinary screening and vaccination campaigns in the migrant population, especially in the course of large outbreaks, could represent a resource to reach an adequate measles immunization coverage and to control this infectious disease.

Community-wide measles outbreak in the Region of Madrid, Spain, 10 years after the implementation of the Elimination Plan, 2011-2012.

We describe a community-wide outbreak of measles due to a D4 genotype virus that took place in the Region of Madrid, Spain, between February 2011 and August 2012, along with the control measures adopted. The following variables were collected: date of birth, sex, symptoms, complications, hospital admission, laboratory test results, link with another cases, home address, places of work or study, travel during the incubation period, ethnic group, and Mumps-Measles-Rubella (MMR) vaccination status. Incidences were calculated by 100,000 inhabitants. A total of 789 cases were identified. Of all cases, 36.0% belonged to Roma community, among which 68.7% were 16 months to 19 y old. Non-Roma cases were predominantly patients from 6 to 15 months (28.1%) and 20 to 39 y (52.3%). Most cases were unvaccinated. We found out that 3.0% of cases were healthcare workers. The first vaccination dose was brought forward to 12 months, active recruitment of unvaccinated children from 12 months to 4 y of age was performed and the vaccination of healthcare workers and of members of the Roma community was reinforced. High vaccination coverage must be reached with 2 doses of MMR vaccine, aimed at specific groups, such as young adults, Roma population and healthcare workers.

Safety of measles-containing vaccines in post-marketing surveillance in Anhui, China.

The safety of measles vaccination is of great interest and importance to public health practice and the general society. We have analyzed the adverse events following immunization (AEFIs) of currently used measles-containing vaccines (including live attenuated measles vaccine, live attenuated measles and rubella combined vaccine, live attenuated measles and mumps combined vaccine, live attenuated Measles, Mumps and Rubella Combined Vaccine) in Anhui Province, China. From 2009 to 2014, 9.9 million doses of measles-containing vaccines were administrated and 1893 AEFIs were found (191.4 per million doses), of which, 33 serious AEFIs (3.3 per million vaccine doses) were reported. 59.4% (1124 cases) were male cases, and 85.1% (1611 cases) occurred in persons aged < 1 year. 93.3% (1766 cases) occurred at the first dose of vaccination and 95.9% (1815 cases) were found within 3 days after vaccination. This study presents up-to-date data and suggests that the measles-containing vaccines used in Anhui Province of China are safe.

Genetically defined race, but not sex, is associated with higher humoral and cellular immune responses to measles vaccination.

In addition to host genetic and environmental factors, variations in immune responses to vaccination are influenced by demographic variables, such as race and sex. The influence of genetic race and sex on measles vaccine responses is not well understood, yet important for the development of much-needed improved measles vaccines with lower failure rates. We assessed associations between genetically defined race and sex with measles humoral and cellular immunity after measles vaccination in three independent and geographically distinct cohorts totaling 2872 healthy racially diverse children, older adolescents, and young adults. We found no associations between biological sex and either humoral or cellular immunity to measles vaccine, and no correlation between humoral and cellular immunity in these study subjects. Genetically defined race was, however, significantly associated with both measles vaccine-induced humoral and cellular immune responses, with subjects genetically classified as having African-American ancestry demonstrating significantly higher antibody and cell-mediated immune responses relative to subjects of Caucasian ancestry. This information may be useful in designing novel measles vaccines that are optimally effective across human genetic backgrounds.

Prevalence of chronic infections and susceptibility to measles and varicella-zoster virus in Latin American immigrants.

BACKGROUND: Large numbers of Latin American immigrants recently arrived in Western Europe. Curative and preventive programmes need to take account of their risk of suffering and transmitting imported chronic infections and of their susceptibility to cosmopolitan infections. We aimed to assess the prevalence and co-occurrence of imported chronic infections among Latin American immigrants, and their susceptibility to highly prevalent cosmopolitan infections. METHODS: Adult participants were recruited in the community and in a primary health centre in Geneva in 2008. Serological tests were performed on stored sera for HIV, HBV, syphilis, Strongyloides stercoralis, Trypanosoma cruzi, varicella and measles. We considered only chronic active infections in the analysis. RESULTS AND DISCUSSION: The 1 012 participants, aged 37.2 (SD 11.3) years, were mostly female (82.5 %) and Bolivians (48 %). Overall, 209 (20.7 %) had at least one and 27 (2.7 %) two or more chronic infections. T. cruzi (12.8 %) and S. stercoralis (8.4 %) were the most prevalent chronic active infections compared to syphilis (0.4 %), HBV (0.4 %) and HIV (1.4 %). Concomitant infections affected 28.2 and 18.5 % of T. cruzi and S. stercoralis infected cases. Bolivian origin (aOR: 13.6; 95 % CI: 3.2-57.9) was associated with risk of multiple infections. Susceptibilities for VZV and measles were 0.7 and 1.4 %, respectively. Latin American immigrants are at risk of complications and possible reactivation of chronic parasitic infections but have overall low risks of chronic viral and syphilitic active infections. CONCLUSIONS: Systematic screening for chronic active parasitic infections is therefore necessary especially among Bolivians. The high protection rate against measles and VZV doesn't require specific preventive interventions.