An outbreak of measles among a travelling community

[Gert van der Hoek]

MEASLES - NORWAY EX UNITED KINGDOM (ENGLAND)
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Date: Thu 24 May 2007

Source: Eurosurveillance weekly release 2007; 12(5) [edited]
http://www.eurosurveillance.org/ew/2007/070524.asp#


An outbreak of measles among a travelling community from England in
Norway: a preliminary report

------------------------------------------------------------------------------------------------
Between 7 and 14 May 2007, Nasjonalt Folkehelseinstitutt (the
Norwegian Institute of Public Health, NIPH) was notified of 6 cases
of measles, all occurring in a group of families from England staying
at camping sites in Norway.

Epidemiology of measles in Norway
---------------------------------
Measles is no longer considered an endemic disease in Norway [1].
Except for one imported case earlier this year [2007], there have
been no cases of measles reported in Norway since 2004, when 7 cases,
also imported, were notified. The last cases of measles of probably
endemic origin in Norway were in 1999. Measles is a notifiable
disease in Norway and every case is to be reported individually by
both clinicians and laboratories. In addition, the disease is subject
to immediate early warning to local and health authorities and the
24/7 doctor on call at the NIPH.

MMR [measles, mumps, rubella] vaccine is included in the national
vaccination programme and children are vaccinated at 15 months and 12
years of age. The vaccination coverage for the 1st dose of MMR was 86
percent in 2003, but has increased to 91 percent for 2006. The
coverage for the 2nd dose was 91 percent in both 2003 and 2006.
Vaccination is also recommended for non-immune persons within 72
hours of being been exposed to measles.

Outbreak description
--------------------
On 7 May 2007, the NIPH received a laboratory report indicating
measles in a 7-month-old girl (case no. 1) admitted to Stavanger
University Hospital in the southwestern part of the country.
Following up this report, we learned that the child had onset of
fever on 27 Apr 2007, and was examined at the hospital outpatient
department the following day. Due to worsening of her condition, she
was admitted to the paediatric department on 1 May 2007, and then
developed a rash and was isolated. The measles diagnosis was
confirmed by a positive IgM test in serum.

The patient was the child of an English family staying in a caravan
at a camping site in the municipality of Sola, adjacent to Stavanger.
According to the mother, the child had been in contact with a child
with measles in England shortly before they travelled to Norway. The
Municipal Medical Officer in Sola was notified by the hospital and
the NIPH. He visited the camping site and found 3 to 4 English
families staying there on vacation. Two children of these families,
aged 5 (case no. 3) and 9 years (case no. 4), had fallen ill on 8 May
2007, and had been to an outpatient clinic. They were later confirmed
as having measles based on serology test of serum. They were
unvaccinated. The remaining 7 children of the English families at the
camping site had been vaccinated, according to their parents.

On 10 May 2007, the NIPH was notified by St. Olav University Hospital
in Trondheim, a city in central Norway (at least 16 hours drive from
Stavanger), of a case of measles in a child 15 months of age (case
no. 2). The child fell ill on 4 May 2007, with fever and diarrhoea
and a rash developed on 7 May 2007. The child was admitted to the
paediatric ward on 8 May 2007, and isolated the following day. The
child was a cousin of the 1st case in Stavanger, and had been staying
at the same camping site in Sola at the time when the 1st patient
fell ill. The family had later gone with their caravan to a camping
site in the municipality of Malvik, near Trondheim. The child had not
been vaccinated against measles. According to her father, who also
was not vaccinated, the girl and her brother of 4 years had not been
vaccinated because the parents feared serious side effects.

On 12 May 2007, the father (case no. 5) of the child in Trondheim
(case no. 2) also came down with fever. He became so affected that he
was admitted to St. Olavs Hospital on 15 May 2007. The brother of
case no. 2 also fell ill with fever on 13 May 2007 and had developed
a rash when he was seen by a doctor on 17 May 2007. He was also
admitted to St. Olav Hospital on 18 May 2007. The diagnoses for all 3
cases of this family were confirmed by PCR [polymerase chain
reaction] in throat swab and serology in serum.

Table. Case Histories

Case / Age / Sex / Onset / Test / Information

1 / 7 mths / F / 27 Apr / IgM / infected in UK
2 / 15 mths / F / 4 May / PCR, IgM / Cousin of 1
3 / 5 yrs / F / 8 Nay / IgM / Sola camping
4 / 9 yrs / F / 8 May / IgM / Sola camping
5 / 21 yrs / M / 12 May / PCR, IgM / Father of 2
6 / 4 yrs / M / 13 May / PCR IgM / Brother of 2

Public health measures
----------------------
NIPH informed general practitioners and public health officers
through [its] biweekly newsletter MSIS-rapport on 8 May 2007, and
gave more comprehensive information on the website from 11 May 2007.
An early warning was also issued through EWRS [early warning response
system] on 11 May 2007. On 15 May 2007, further information was sent
to all hospitals in the country.

Both the index patient in Stavanger and the 1st patient in Trondheim
had visited outpatient clinics and paediatric wards during their
infectious period. The hospitals could therefore not rule out the
possibility that they might have infected other children. Stavanger
University Hospital posted information to 30-40 families with
children who might have been in contact with the patient. St. Olav
Hospital and the municipal Medical Officer in Trondheim traced
patient contacts and offered vaccine and gammaglobulin. Three
unvaccinated children aged 9-15 months received MMR vaccine and one
child below 9 months of age received gammaglobulin. In addition, 3
adult contacts and 6 health workers received vaccination. So far, no
secondary cases due to contact in the health services have been reported.

The Senior Medical Officers in Malvik, in Sola, and in the city of
Trondheim were involved in contact tracing. The patients in Trondheim
were staying at a camping site in Malvik together with approximately
24 other English families with a total of approximately 75 persons.
MMR vaccine was offered to all members of these families. So far, 15
have accepted and received vaccine, and 2 infants below the age of 9
months have been given gammaglobulin.

International investigation
---------------------------
It is not common to see English families with school-aged children on
camping holidays in Norway at this time of the year, and there were
also indications that the families were reluctant to vaccinate
children. As this suggested that the families were from the
travelling community, we sought more information from the Health
Protection Agency in the United Kingdom (UK). Around 20 cases have
been confirmed so far this year [2007] among travellers from several
sites in the UK, most arising after a large gathering that occurred
in southeast London on 3 Apr 2007. On further interviewing, it
appears likely that the index patient in Stavanger attended this
event early in April 2007. The mother reported hearing that someone
with measles had been at that event, but as the index patient fell
ill on 27 Apr 2007, however, it is likely that she contracted measles
following contact in the UK with other travelling children. These
details of the intermediate cases remain to be investigated.

Travelling communities in the UK report poorer health than comparable
groups of residents from socially deprived inner city areas, other
ethnic minorities and rural residents [2]. Outbreaks of measles have
indicated that they have lower vaccination coverage than the stable population.


Conclusion

----------
Norwegian health authorities are investigating an outbreak of measles
among English nomadic travellers in Norway. The infection is most
likely imported from England and linked to other current clusters in
the UK. So far, no cases in the Norwegian population can be linked to
the outbreak. The investigation of the outbreaks continues and
intensified surveillance during the coming weeks will show if the
outbreak will continue or not. Due to low vaccination coverage and
wide travels, the travelling communities in Europe represent a
particular challenge for the measles elimination campaign [4].

References

1. EUVAC.NET [Epidemiological surveillance and control of
vaccine-preventable diseases in the European Community]
http://www.euvac.net/graphics/euvac/index.html

2. Parry G, Van Cleemput P, Peters J, Walters S, Thomas K, Cooper C:
Health status of Gypsies and Travellers in England. J Epidemiol
Community Health. 2007 Mar; 61(3): 198-204. Available from:
http://jech.bmj.com/cgi/content/full/61/3/198

3. Laboratory confirmed cases of measles, mumps, and rubella, England
and Wales: April to June 2006. Communicable Disease Report Weekly. 28
September 2006; 16; 39. Available from:
http://www.hpa.org.uk/cdr/archives/2006/cdr3906.pdf

4. Filia A, Curtale F, Kreidl P, Morosetti G, Nicoletti L, Perrelli
F, et al: Cluster of measles cases in the Roma/Sinti population,
Italy, June-September 2006. Euro Surveill 2006; 11(10): E061012.2.
Available from: http://www.eurosurveillance.org/ew/2006/061012.asp#2

[Byline: O Lovoll, L Vonen et al]

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Communicated by:
ProMED-mail
promed@promedmail.org

[In Europe in recent times there have been several outbreaks of
infectious disease associated with movement of travellers (Roma
communities and others) where certain population groups have eluded
public health surveillance or actively resisted vaccination. This
Norwegian investigation illustrates both the nature of the problem
and the effectiveness of vaccination in protection of the non-migrant majority.

A map of Norway showing the location of Stavanger (and adjacent Sola)
and Trondheim can be accessed at
http://www.infoplease.com/atlas/country/norway.html> - Mod.CP]

http://www.promedmail.org/pls/prome..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,37552

 

[Gert van der Hoek]

Re: An outbreak of measles among a travelling community

Outbreak of measles among Irish Travellers in Norway: an update

? L?voll (Oistein.Lovoll@fhi.no)1, L Vonen2, SA Nordb?3, T Vevatne4, E Sagvik5, K Vainio1, S Sandbu1 and P Aavitsland1

1. Folkehelseinstituttet (Norwegian Institute of Public Health, NIPH), Oslo, Norway
2. Malvik Municipality, Norway
3. St Olav University Hospital, Trondheim, Norway
4. Sola Municipality, Norway
5. Trondheim Municipality, Norway

This is an update on the preliminary report [1] of an outbreak of measles in Norway among a travelling community from England.

As of 13 June, 15 cases have been reported. The outbreak is currently confined to several families of Irish Travellers from England who have had contact in two camping sites in Norway.

Most of them are now living in a camp site outside Trondheim in central Norway. The date of onset of symptoms ranges from 27 April to 2 June. So far, 12 cases have been confirmed by PCR, IgM antibodies or both. There are 11 female patients.

Thirteen are children, all unvaccinated, and aged between 7 months and 9 years (two less than one year, four between 1 and 3 years, six between 4 and 5 years, and one aged 9 years). The two other cases are unvaccinated adult members of the Traveller families.

There are currently no indications that the outbreak has spread to the indigenous population in Norway. Only one other case of measles, imported from Pakistan, has been reported in Norway this year.

The virus strain from one of the patients have been sequenced. It was found to be a D4 strain closely matching the measles strain causing the current outbreak among Irish Travellers in the UK [2].

Conclusions

The outbreak in Norway is clearly linked to the ongoing UK outbreak
[2]. The cases in Norway belong to the same community, at least one of the cases visited a gathering of Irish Travellers in south-east London on 3 April 2007, and the Norwegian outbreak strain closely matches the UK one. It is too early to declare the outbreak over so we have to face the following public health challenges:

? Some of the Irish Travellers currently residing in Norway seem to fly back and forth to England from time to time. This poses a risk of exposure to infected Irish Travellers in England and subsequent reimportation, and vice versa, i.e. Travellers from Norway infecting people in England.

? Some of the Irish Traveller families have now moved on from their main camp site in Norway: their whereabouts are not known. Members of these families may be incubating measles. There is a possibility of further contact with non-immune people elsewhere in Norway or neighbouring countries and thus a risk of further spread of the disease.

So far, several non-vaccinated contacts within the Traveller community involved in the outbreak have been given the MMR vaccine. The Traveller community has responded favourably to the Norwegian health authorities' interventions.

On June 14, as this article was being prepared for publication, a suspect case of measles (case no 16) with onset on June 10 was notified to the Norwegian health authorities. The patient is an Irish Traveller child who had recently moved from Trondheim to Bergen, over 700 kilometres away.


References:

L?voll ?, Vonen L, Vevatne T, Sagvik E, Vainio K, Sandbu S, Aavitsland P. An outbreak of measles among a travelling community from England in Norway: a preliminary report. Euro Surveill 2007;12(5):E070524.1.

Available from: http://www.eurosurveillance.org/ew/2007/070524.asp#1
Cohuet S, Morgan O, Bukasa A, Heathcock R, White J, Brown K, Ramsay M,

Gross R. Outbreak of measles among Irish Travellers in England, March to May 2007. Euro Surveill 2007; E070614.1.

Available from: http://www.eurosurveillance.org/ew/2007/070614.asp#1

http://www.eurosurveillance.org/ew/2007/070614.asp#2