Assessing the risk of measles resurgence in a highly vaccinated population: Belgium anno 2013.

Despite long-standing two-dose measles-mumps-rubella (MMR) vaccination, measles outbreaks still occur in highly vaccinated European populations. For instance, large measles outbreaks occurred in France (2008­13), the United Kingdom (2012­13) and the Netherlands (2012). Based on a multicohort model approach, using spatial serological survey data, MMR vaccination coverage data and data on social contacts, we found effective reproduction numbers significantly higher than 1 for measles in Belgium. This indicates that at one of the expected re-introductions, a measles outbreak is likely to spread, especially when it occurs during school term. The predicted average effective reproduction number increased over a 30-year time span from 1.3 to 2.2 and from 1.9 to 3.2 for basic reproduction numbers of 12 and 18, respectively. The expected relative measles incidence was highest in infants under one year of age, in adolescents and young adults. In conclusion, gradually increasing proportions of susceptible adolescents and young adults provide through their highly active social life an avenue for measles to resurge in large outbreaks upon re-introduction in Belgium, especially during school terms. Infants form an important vulnerable group during future measles outbreaks.

Rotavirus vaccination coverage and adherence to recommended age among infants in Flanders (Belgium) in 2012.

In Belgium, rotavirus vaccination has been recommended and partially reimbursed since October 2006. Through a retrospective survey in 2012, we estimated the coverage rate of the rotavirus vaccination in Flanders among infants born in 2010. Using a standardised questionnaire, 874 families were interviewed at home, collecting information on demographic characteristics, socio-economic background and documented vaccination history (updated from medical files and vaccination database, if needed). Adherence to the recommended age for vaccination (8, 12 and 16 weeks) was also assessed. The coverage rate for two doses of rotavirus vaccination was 92.2% (95% confidence interval: 90.2-93.8). Respectively 31.7% and 10.1% of the children received their first and second dose at the recommended age. Incomplete vaccination was often a deliberate choice of the parents. Only eight children (1%) were vaccinated after the maximum age of 26 weeks. Factors identified by multiple logistic regression as related to incomplete vaccination were: living in the province of Antwerp, unemployed mother, and three or more older siblings in the household. Four years after introduction, the coverage rates were surprisingly high for a vaccine that is not fully reimbursed and not readily available in the vaccinator's fridge, which is the case for the other recommended infant vaccines.

A cohesive European policy for hepatitis B vaccination, are we there yet?

Despite the availability of safe and effective hepatitis B virus (HBV) vaccines for more than 30 years, the burden of hepatitis B disease is still substantial. In 1992, the WHO recommended the inclusion of HBV vaccination in all national vaccination programmes. As of 2012, 47 of the 53 European countries (89%) had implemented a universal hepatitis B vaccination programme. The most recent countries to follow the recommendation were Ireland (in 2008) and the Netherlands (in 2011). Still, six countries (Denmark, Finland, Iceland, Norway, Sweden and the UK) adopt risk-group-targeted vaccination only, instead of adding a universal vaccination programme. However, changing demography, increasing immigration and the current vaccine costs make the cost­benefit ratios in these remaining low endemicity countries strongly in favour of universal HBV vaccination. Global efforts, including a cohesive European vaccination policy, are essential to control and prevent hepatitis B.

Human leptospira isolates circulating in Mayotte (Indian Ocean) have unique serological and molecular features.

Leptospirosis is one of the most widespread zoonoses in the world. However, there is a lack of information on circulating Leptospira strains in remote parts of the world. We describe the serological and molecular features of leptospires isolated from 94 leptospirosis patients in Mayotte, a French department located in the Comoros archipelago, between 2007 and 2010. Multilocus sequence typing identified these isolates as Leptospira interrogans, L. kirschneri, L. borgpetersenii, and members of a previously undefined phylogenetic group. This group, consisting of 15 strains, could represent a novel species. Serological typing revealed that 70% of the isolates belonged to the serogroup complex Mini/Sejroe/Hebdomadis, followed by the serogroups Pyrogenes, Grippotyphosa, and Pomona. However, unambiguous typing at the serovar level was not possible for most of the strains because the isolate could belong to more than one serovar or because serovar and species did not match the original classification. Our results indicate that the serovar and genotype distribution in Mayotte differs from what is observed in other regions, thus suggesting a high degree of diversity of circulating isolates worldwide. These results are essential for the improvement of current diagnostic tools and provide a starting point for a better understanding of the epidemiology of leptospirosis in this area of endemicity.

Emergence of dengue virus serotype 3 on Mayotte Island, Indian Ocean.

A serosurvey carried out in 2006 in Mayotte, a French overseas collectivity in the Indian Ocean, confirmed previous circulation of dengue virus (DENV) on the island, but since the set up of a laboratory-based surveillance of dengue-like illness in 2007, no case of DENV has been confirmed. In response to an outbreak of DENV-3 on Comoros Islands in March 2010 surveillance of dengue-like illness in Mayotte was enhanced. By September 15, 76 confirmed and 31 probable cases of DENV have been identified in Mayotte. In urban and periurban settings on the island, Aedes albopictus is the predominant Aedes species, but Ae. aegyptii remains the most common species in rural areas. Given the epidemic potential of dengue virus in Mayotte, adequate monitoring including early detection of cases, timely investigation and sustained mosquito control actions remain essential.

[Malaria in France: Mainland and territories]. / Le paludisme en France : métropole et outre-mer.

Malaria, which was eliminated first from Metropolitan France (mainland and Corsica), then in the French West Indies and the Reunion Island during the 20(th) century, remains endemic in two French territories: French Guiana and the Indian Ocean Mayotte island. Despite differences in the dominating plasmodial species and epidemiological patterns, these two territories have achieved marked quantitative improvements (in the reported number of cases and severe cases) thanks to efforts undertaken over the past decade. The situation, however, remains a concern from a qualitative standpoint with the emergence of resistance to antimalarial drugs and logistical and administrative issues which hinder access to treatment. Although malaria was eradicated in Metropolitan France half a century ago, competent vectors remain present in part or all of these territories and can give rise to limited outbreaks.

[Influenza A (H1N1) 2009 surveillance on Mayotte island: the challenge of setting up a new system facing the pandemic]. / La grippe A (H1N1) 2009 à Mayotte: mise en place d'une surveillance épidémiologique face à la menace de pandémie.

In response to the threat of the pandemic influenza A (H1N1) 2009 virus in Mayotte Island, influenza surveillance needed to be set up in a matter of weeks, to detect the introduction of the pandemic virus and monitor its spread and impact on public health. Surveillance was based on different systems, including a sentinel practitioner network for influenza-like illness, surveillance of the activity at the hospital emergency departments, virological surveillance, surveillance of severe and fatal cases, and data collection on sale of antipyretic and anti-viral drugs. Despite some weaknesses of the surveillance, results showed a good correlation between all systems, describing an epidemic period of approximately 8-9 weeks, with a peak between weeks 37 and 40, followed by a rapid decrease. Besides allowing monitoring and describing the impact of pandemic H1N1 2009 virus in Mayotte, the surveillance system provided an opportunity to create networks and globally strengthened surveillance of infectious diseases in the Island.

Oral fluid for the serological and molecular diagnosis of measles.

OBJECTIVES: Since measles presents mostly in children, a non-invasive sample collection technique such as oral fluid sampling would be very useful in the early detection of measles RNA and antibodies. The aim of this study was to validate the detection of anti-measles IgM and measles virus RNA in oral fluid and to make a comparison with the gold standard methods of ELISA using serum (Enzygnost(®) anti-Measles IgM) and in-house nested reverse transcriptase polymerase chain reaction (RT-PCR) using nasopharyngeal secretions. METHODS: Three samples each from 73 measles-positive and 44 measles-negative subjects (serum, oral fluid, and nasopharyngeal secretions) were analyzed. RESULTS: The anti-measles IgM ELISA (MicroImmune) on oral fluid was validated against the IgM ELISA (Siemens) for serum and this resulted in a sensitivity of 92% and specificity of 100%. A molecular nested RT-PCR using oral fluid was validated against the standard assay on nasopharyngeal secretions and gave a sensitivity of 100% and specificity of 100%. CONCLUSIONS: The results confirm that both serological and molecular oral fluid assays are suitable for routine use. The use of oral fluid samples for the detection of measles virus may encourage patients, general practitioners, and pediatricians to participate in the Belgian measles surveillance system and other epidemiological studies in the framework of the World Health Organization elimination program.

Cost analysis in total hip arthroplasty: experience of a teaching medical center located in Paris.

BACKGROUND: Since the beginning of 2008, the implementation of a 100% activity-based payment system, has made efficiency one of the prime concern for the French health-care providing institutions. We therefore assessed the real cost of a scheduled total hip replacement (THR) ina teaching hospital and compared findings with French national data (and with the Government Healthcare Insurance System allowance). HYPOTHESIS: The study should suggest possible means to optimize organization of management and/or clinicians' practice. MATERIAL AND METHODS: This is a retrospective full-cost economic study. Patients were included only if fulfilling the following criteria: admitted in 2006; classified in Diagnosis-Related Group (DRG) 08C23 V or 08C23W (respectively THR without and with associated comorbidity); treated in a single department; admitted from home; and having undergone a THR (coded as NEKA020 in the french CPT) that same year. Treatment-cost was established on the basis of data collected from two main sources: the Information Systems Medicalization Program (ISMP) data-base, and the finance department data, which were taken into account in line with the French National Costs Study (NCS) structure. RESULTS: The methodology employed here follows the 2006 National Costs Scale structure. Treatment costs (excluding the cost of implantable medical devices or IMDs) were estimated at 8,104.72 EUR for DRG 08C23W and 7,529.19 EUR for DRG 08C23 V. These figures were higher than the rates authorized in 2006 (excluding IMDs), which were 7,677.92 EUR for 08C23W and 6,358.97 EUR for 08C23 V (taking the 7% geographic coefficient into account) and than the 2005 NCS figures (excluding IMDs) of respectively 7,536.13 EUR and 6,083.59 EUR. DISCUSSION: Clinical units and departments need to be able to assess costs for the pathologies they treat, as health-care institutions have to balance their expenditure against their income, which largely comes from their hospital-care activity. The methodology put forward here, of cost comparison according to the NCS structure, enables the total cost to be known. Comparing results (expenditure line by expenditure line) against national data, selectively highlights the areas in which efficiency can be improved. The exactitude of the obtained results remains, however, limited by the rules currently in use at each individual hospital's accounting department. LEVEL OF EVIDENCE: Level IV, retrospective economic and decision analysis study.

An outbreak of measles in orthodox Jewish communities in Antwerp, Belgium, 2007-2008: different reasons for accumulation of susceptibles.

From August 2007 to May 2008, an outbreak of at least 137 cases of measles occurred in some orthodox Jewish communities in Antwerp, Belgium. The outbreak was linked to outbreaks in the same communities in the United Kingdom and in Israel. The reasons for this outbreak were diverse: cultural factors, misinformation on vaccination by some medical doctors and the lack of a catch-up vaccination programme in private Jewish schools. The identification of smaller susceptible groups for measles transmission and vaccination of these groups represent a major challenge for the measles elimination programme.