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Published Date: 2018-04-15 21:44:44
Subject: PRO/EDR> Measles update (24): Europe, Mexico, South America, USA, Pacific
Archive Number: 20180415.5748939
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

In this update:
[1] Spain (Valencia)
[2] Estonia (Saaremaa): travel related

Mexico and South America
[3] Mexico (Federal District / Baja California)
[4] Brazil (Roraima)

[5] Missouri (Kansas City)

[6] Australia (Sydney): genotype comment
[7] Philippines (Manila)

[1] Spain (Valencia)
Date: Thu 15 Mar 2018 10:45
Source: Levante [edited] as reported in ProMED -ESP Vol 8, Issue 65 - Mar 15 [in Spanish, trans. KS, edited]

A total of 2 unvaccinated minors with measles, admitted to the Hospital de Manises last February [2018], are the center of the outbreak of the infectious disease that has been reported at the hospital and that already affects 11 people, although the figure could increase to 16.

This was confirmed yesterday [Wed 14 Apr 2018] by sources from the Ministry of Health and the hospital management who emphasized that they are applying "all preventive and control measures" issued by the General Directorate of Public Health, which intervened before the outbreak was announced last [Fri 13 Apr 2018]. That day, [Fri 9 Mar 2018], the infection of an employee who came to the Emergency Department on [Thu 15 Mar 2018] with symptoms had already been confirmed; another worker had been dismissed (on Wed 14 Mar 2018) and a 3rd employee had also gone to the ER with the same symptoms, for which he was admitted.

Although the CSI-F union had spoken of 9 infected in the outbreak (4 workers and 5 neighbors), the fact is that already 11 people and 5 other cases are "under study", according to health sources.

Another 5 cases under study
The figure could "easily increase," according to union sources in the hospital, as workers who were diagnosed at the end of the week "had been working all week." These are doctors (one from the Emergency Department) and 2 caretakers "who have been in contact with many people in the hospital," they added.

To prevent contagion, Public Health is reviewing an average of "125 contacts for each of the infected" and on [Mon 12 Mar 2018] "600 doses" of vaccine were sent to the hospital to initiate the vaccination of some of the employees, which began to first thing in the afternoon.

The CSI-F union has criticized the criteria established by Public Health, which only require vaccination "for all those born before 1980" when the triple virus had not been generalized "although 2 of the 4 affected partners were born later, in 1981 and 1985".

This differentiation according to date of birth was not liked among the staff because "there are people who 1st want to be tested to see if they have antibodies before being vaccinated, and others, not included under the guidelines, who want to be vaccinated, and are not being allowed". Measles is a virus that is easily spread by air, so measures such as the use of masks have also been imposed.

Communicated by
Kathryn Soderholm

[A Healthmap/ProMED of Spain can be found at]

[2] Estonia (Saaremaa): travel related
Date: Sat 14 Apr 2018 09:35
Source: Err [edited]

A man who had returned from an overseas trip and a woman with whom he came in contact were diagnosed with measles in Saaremaa this week [week of Sun 8 Apr 2018].

This year [2018], 4 cases of measles have been diagnosed in Estonia, which in 2016 had been listed by the World Health Organization (WHO) as among the countries which had eliminated endemic measles. Last month [March 2018], an unvaccinated child contracted the disease on an overseas trip; their mother caught it in turn upon their return to Estonia.

It is not currently known whether the woman to contract measles this week [week of Sun 8 Apr 2018] was vaccinated or not; the man had been vaccinated with only 1 of 2 doses of the measles vaccine.

In the course of the Health Board's epidemiological study, persons who have been in contact with the 2 individuals as well as their vaccination status were determined. Those who have come in contact with them were also advised regarding the nature of the disease, prevention measures as well as vaccination.

Last week [week of Sun 1 Apr 2018], a case of rubella was diagnosed in Rapla County as well. The previous 2 instances of rubella in Eesti were recorded in 2013.

Measles and rubella are considered highly contagious diseases, but the modern measles, mumps and rubella (MMR) vaccine is over 95 percent effective in preventing measles and rubella.

According to the immunization schedule in Estonia, children are administered the 1st dose of the MMR vaccine at 1 year of age and the 2nd dose at age 13. The MMR vaccine is free for children in Estonia.

Measles symptoms
Some of the earliest symptoms in the onset of measles include fever, malaise, cough, runny nose, conjunctivitis and light sensitivity. A few days later, the signature rash appears, which begins behind the ears and spreads to the face and neck before covering the entire body. A measles patient is contagious beginning 4 -- 5 days before and for up to 5 days following the onset of the rash.

There is no treatment for the disease itself; only symptoms can be treated. Complications can include pneumonia, middle ear infections and inflammation of the brain.

[Byline editor: Aili Vahtla]

Communicated by:
ProMED-mail from HealthMap Alerts

[According to, despite the fact that a number of serious infectious diseases have been beaten due to vaccination [in Estonia], there has been a steady increase in the number of parents refusing vaccination and number of children being left unprotected from various diseases.

"While the percentage of refusals in relative to the total number of vaccinations isn't high -- 3-3.9 percent in 2016 -- the steady increase of those refusing and the steady growth in the number of children being left unprotected from a number of infectious diseases is worrisome," said Director General of the Health Board Tiiu Aro.

For example, at the end of 2016, 95.4 percent of children ages 1-14 were vaccinated against measles, mumps and rubella (MMR).

"Considering the World Health Organization's (WHO) recommended level of vaccination for halting the spread of diseases, which is 95 percent, we should be satisfied, however the coverage level among children up to 2 years of age was 93.2 percent, which means that we did not achieve the recommended level of coverage," Aro noted.

As of the end of 2016, a total of 7481 children were unvaccinated against MMR, over 60 percent of whom live in Tallinn.

A Healthmap/ProMED of Estonia can be found at] - Mod LK

Mexico and South America
[3] Mexico (Federal District / Baja California)
Date: Fri 16 Mar 2018 13:38 PM CST
Source: Noticeros as reported in ProMED-ESP - Vol 8, Issues 66 - Mar 16 [edited]

The Ministry of Health (Ssa), identified at least 3 cases of measles in Mexico City, while the 4th was reported in Baja California, according to local sources.

According to the National Epidemiological Surveillance System (Sinave), which belongs to the Ssa, one of the cases reported in the capital is that of a 39-year-old Italian woman who has been living in Mexico City for just over a decade.

The Sinave reported that the woman had symptoms of infection such as fever, maculopapular rash (rashes that do not rise above the surface of the skin), cough and inflammation of the mucosa of the nose.

The 2nd case corresponds to a 1-year-old child who had not been vaccinated. The child is the son of the Italian woman and had not yet received the vaccine that protects him from the disease due to his young age.

A woman of 48 years, who works caring for the child, was the 3rd case reported in the Mexican capital, while the 4th case, reported in Baja California, is that of a person who had left on a trip recently.

Pablo Kuri Morales, undersecretary of Prevention and Health Promotion of the Ssa, reported that the Italian woman could have contracted the disease due to their place of work, the Italian Embassy in Mexico, where she could have come in contact with an infected Italian visitor.

Kuri Morales indicated that there was an outbreak of measles in Italy, so it was likely that a visitor to the embassy carried the virus that causes the infection.

The undersecretary also indicated that in Mexico the disease is controlled and that the virus does not circulate in the country, so the 4 confirmed cases are not part of an epidemic.

When the 3 cases in the Mexico City were reported, Ssa personnel initiated an epidemiological fence in the Benito Juarez, Tlalpan and Coyoacan delegations, to detect other contagions of the disease, which have not been reported.

According to the Ssa, the last autochthonous case of measles was recorded 23 years ago.

Between 1997 and 2017, only 176 cases of measles have been registered, all, according to Kuri Morales, imported or associated with imported cases, as in the case of the Italian citizen and the inhabitant of Baja California.

Communicated by
Kathryn Soderholm

[A Healthmap/ProMED of Mexico can be found at]

[4] Brazil (Roraima)
Date: Fri 16 Mar 2018 14h03
Source: Globo as reported in ProMED-ESP - Vol 8, Issues 66 - Mar 16 [in Spanish, trans. KS, edited]

The number of reported cases of measles in Roraima has reached 50 since the 1st case, on [Tue 13 Feb 2018], was identified in Boa Vista. This weekend [Sat-Sun 17-18 Mar 2018] alone, 11 new suspected cases were registered. So far, 14 cases have been confirmed and 36 are still under investigation.

The updated data were released on [Mon 14 Mar 2018] by the State Department of Health (Sesau). All confirmed cases were recorded in Venezuelans ranging in age from 7 months -- 18 years.

The coordinator general of Health Surveillance, Daniela Souza, explained that all 11 new suspects were admitted to health units with symptoms of measles.

Of these, 7 were recorded in Warao Indians in the municipality of Pacaraima, a city bordering Venezuela. These were the earliest records of the disease outside the capital.

Most of the patients are people who have recently arrived from Venezuela, according to the coordinator general. The age range of reported patients varies from 3-month-old infants -- 33-year-old adults.

D Day
Sat was the 'D Day' of the vaccination campaign against measles carried out in Roraima. Two days after the campaign, Sesau said it had not yet counted how many people had been immunized throughout the state.

According to the municipality of Boa Vista, 20 431 people were reached in the municipality, of which 9693 were already vaccinated. Only the 10 601 who had not been previously vaccinated received the dose.

The vaccination campaign was brought forward across the state to prevent an outbreak of the disease. The expectation is that by [Tue 10 Apr 2018], 420 000 Venezuelans and Brazilians will be immunized.

Measles in Roraima
Since 2015, Roraima has received an increasing influx of Venezuelan immigrants. The city of Boa Vista estimates that they already have 40 000 living in the capital. Many come to the state in search of food and work, but the need for medical care is behind other immigrants.

The 1st suspected case of measles was recorded in a Venezuelan immigrant baby on [Tue 13 Feb 2018]. The patient lived with her family in a square in the center of Boa Vista.

An analysis made by the Oswaldo Cruz Foundation (Fiocruz) has confirmed that the virus circulating in the state originates in Venezuela. Before the campaign, about 2000 immigrants had already been immunized in the streets, squares and shelters of the state.

[Byline: Inae Brandao]
Communicated by
Kathryn Soderholm

[A Healthmap/ProMED of Brazil can be found at]

[5] Missouri (Kansas City)
Date: Thu 12 Apr 2018 5:19 PM
Source: KMBZ [edited]

A case of measles has been confirmed in Kansas City that is not connected to a recent outbreak in Johnson County and other nearby counties

A case of The Kansas City Health Department is also confirming a previously reported Kansas City case was not related to current Kansas outbreak of measles.

The Missouri Department of Health and Senior Services (DHSS) is working with the KCHD to notify people who may have been exposed to measles.

Known locations where exposures may have occurred can be found by going to the URL above.

Communicated by:
ProMED-mail from HealthMap Alerts

[A healthmap/ProMED of United States can be found at and of Missouri, United States at 

[6] Australia (Sydney): genotype comment
Date: Sun 15 Apr 2018
From: Ian Carter <>

Measles in Sydney
Measles genotype data is lacking in recent posts. In the last month [March 2018] we have had 2x genotype B3 cases in Sydney. Others?

Ian Carter
Westmead Hospital Sydney

[ProMED thanks Dr. Carter for his comment on the measles genotype from the Australian cases. He raises an important point that reports do not include the genotype, mostly because they are not reported by the source articles. While there are no known biologic differences among genotypes, they are sensitive indicators of spatial and temporal transmission pathways.

Wild-type measles viruses have been divided into distinct genetic groups (genotypes) based on the nucleotide sequences of their hemagglutinin (H) and nucleoprotein (N) genes, which are the most variable genes on the viral genome. Vaccine strains Moraten, Edmonston, Zagreb are all genotype A.

Suggested further reading to understand the implications of the different genotypes is:
Rota PA et al., Global Distribution of Measles Genotypes and Measles Molecular Epidemiology.
The Journal of Infectious Diseases, Volume 204, Issue suppl_1, 1 July 2011, Pages S514-S523,

I also suggest this Review of the temporal and geographical distribution of measles virus genotypes 1951 - 2004 by the Victorian Infectious Disease Research Laboratory (

Although measles virus (MV) is serologically monotypic, the genetic characterization of wild-type viruses has identified eight clades (A - H), which have been divided into 22 genotypes and one proposed genotype. Clades B, C, D, G and H each contain multiple genotypes (B1 - 3, C1 - 2, D1 - 10, G1 - 3, H1 - 2) while clades A, E and F each contain a single genotype (A, E, F). The sequences of the vaccine strains indicate that the wild type viruses from which they were derived were all members of genotype A.

There are no known biological differences between viruses of different genotypes. Specific measles genotypes are not associated with differences in severity of disease, likelihood of developing severe sequela such as subacute sclerosing panencephalitis or inclusion body encephalitis, or variability in sensitivity of laboratory diagnosis.

Analysis of the variability in the nucleotide sequences of wild-type MVs has enabled the use of molecular epidemiologic techniques for measles surveillance. Genetic characterization of viral isolates or RT-PCR products is the only laboratory test that can differentiate between vaccine-associated cases and wild-type infection.

In 1998, the World Health Organization (WHO) recommended a standard protocol for the designation of measles genotypes. The minimum amount of sequence data required to assign a virus to a genotype are the 450 nucleotides encoding the carboxy terminus of the N protein. The entire sequence of the coding region of the H gene should be obtained from representative isolates

The purpose of this summary is to collate all available reports of MV genotypes and to standardize the published genotype nomenclature, according to the current WHO criteria, with the aim of giving a comprehensive overview of the distribution of MV genotypes in the prevaccine and postvaccine eras.

A table showing genotypes by year can be found at the URL above

A Healthmap/ProMED of Australia can be found at].

[7] Philippines (Manila)
Date: Fri 13 Apr 2018
Source: Outbreak News Today [edited]

The U.S. Embassy Manila issued a health alert [Fri 13 Apr 2018] for US citizens living in or traveling to the Philippines due to a measles outbreak being reported throughout the country.

This follows a travel notice issued by the Centers for Disease Control and Prevention [Wed 11 Apr 2018].

According to Philippines health officials, in the current measles outbreak, data from the Epidemiology Bureau (EB) showed that there were 4168 measles cases reported nationwide from 01 Jan -- 26 Mar [2018]. Out of the 4168 reported cases, 723 were laboratory-confirmed measles with a total of
13 deaths. Most of the confirmed cases came from regions XI- Davao (27.73 percent), ARMM (21.59 percent), IX- Zamboanga Peninsula (14.32 percent), XII-SOCCSKSARGEN (10.45 percent), and X- Northern Mindanao (10 percent).

U.S. Embassy Manila recommends that U.S. citizens living in or traveling to the Philippines should make sure they are vaccinated against measles with the MMR (measles, mumps, and rubella) vaccine and to avoid contact with people who are sick.

[Byline: Robert Herriman]

Communicated by:
ProMED-mail from HealthMap Alerts

[A Healthmap/ProMED of Philippines can be found at ]

See Also

Measles update (23): Asia, Pacific, Europe, USA, Africa 20180413.5743280
Measles update (22): USA, South America, Europe, Pacific, epi update, comment 20180409.5734358
Measles update (21): WHO, South America, Europe, Asia, Pacific, Africa 20180406.5728515
Measles update (20): Europe, Pacific, Americas 20180331.5720595
Measles update (19): Pacific, Americas, Europe, Asia 20180324.5706015
Measles update (18): USA, Asia, Europe, South America, WHO, PAHO 20180318.5694434
Measles update (17): Asia, Pacific, Africa, Europe 20180314.5684766
Measles update (16): Asia & Pacific, Europe, South America 20180307.5672342
Measles update (15): Europe, Asia, Pacific 20180304.5663849
Measles update (14): Europe, Asia and Pacific, USA 20180228.5655543
Measles update (13): Europe (France), USA (TX) 20180224.5648197
Measles update (12): Africa, Europe, North America, Pacific 20180218.5634900
Measles update (11): Pacific, Europe, USA 20180214.5627038
Measles update (10): Europe, Pacific, South America, USA 20180210.5620572
Measles update (09): Europe, Caribbean, Central America 20180205.5606548
Measles update (08): Asia, Central America, North America, Europe 20180201.5600423
Measles update (07): Africa, USA, Caribbean, Canada, Europe 20180128.5589231
Measles update (06): Americas, Europe, Asia/Pacific 20180123.5576951
Measles update (05): Europe, Pacific-Asia, USA 20180118.5566770
Measles update (04): Europe, USA 20180115.5561190
Measles update (03): Europe, Pacific, USA 20180112.5556312
Measles update (02): Europe, South America 20180109.5547446
Measles update (01): Asia, Europe 20180105.5540575
Measles update (58): Australia, Sweden, Serbia, Nepal 20171229.5526586
Measles update (57): South America, Europe 20171213.5501019
Measles update (56): Greece, UK, PAHO, USA, Australia 20171205.5485332
Measles update (55): South America, US, Europe, Africa 20171129.5472558
Measles update (54): Asia, South America, Europe 20171113.5441554
Measles update (53): Africa, Asia, Southeast Asia, Eastern Europe 20171110.5435068
Measles update (52): Africa, Europe 20171103.5423266
Measles update (51): Pacific, Asia, Europe 20171021.5395632
Measles update (50): USA, Europe, Pacific 20171017.5384584
Measles update (40): Africa, Europe 20170812.5244541
Measles update (30) 20170603.5080696
Measles update (20) 20170415.4972251
Measles update (10) 20170303.4874401
Measles update (05): India (BN) New Zealand ex Singapore, USA (NJ) 20170129.4801137
Measles update (04): Australia (VI, NS), USA (CA), Netherlands 20170123.4784372
Measles update (03): Pakistan (BA), Australia (NS), Switzerland 20170112.4761857
Measles update (02): Australia (NS), Romania (TM), USA (CA) 20170106.4747028
Measles update (01): USA (CA), Sudan (SK) 20170103.4740174
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