Public health responses during measles outbreaks in elimination settings: Strategies and challenges

In late September 2016, the Americas became the first region in the world to have eliminated endemic transmission of measles virus. Several other countries have also verified measles elimination, and countries in all six World Health Organization regions have adopted measles elimination goals. The public health strategies used to respond to measles outbreaks in elimination settings are thus becoming relevant to more countries. This review highlights the strategies used to limit measles spread in elimination settings: (1) assembly of an outbreak control committee; (2) isolation of measles cases while infectious; (3) exclusion and quarantining of individuals without evidence of immunity; (4) vaccination of susceptible individuals; (5) use of immunoglobulin to prevent measles in exposed susceptible high-risk persons; (6) and maintaining laboratory proficiency for confirmation of measles. Deciding on the extent of containment efforts should be based on the expected benefit of reactive interventions, balanced against the logistical challenges in implementing them.

Seroepidemiology and phylogenetic characterisation of measles virus in Ireland, 2004-2013

BACKGROUND

Ireland is classified as an area of high measles incidence. A World Health Organisation-European Region strategic plan exists for measles elimination by 2015.

OBJECTIVES

To retrospectively investigate measles outbreaks using all patient samples (sera and oral fluid) received for measles laboratory diagnosis and characterise the genetic diversity of circulating measles genotypes in Ireland.

STUDY DESIGN

704 cases of acute measles infection as determined by the presence of measles specific IgM in sera and oral fluids were confirmed at the National Virus Reference Laboratory. Measles positive samples (n=116) were examined by genotyping, sequence analysis and phylogenetic characterisation.

RESULTS

Three measles outbreaks occurred over the study period: 2004, 2009/2010 and 2011. Measles IgM positivity ranged from 22-29% in outbreak years to 5-10% in the intervening years. Age profile analysis revealed that whereas individuals >10 years accounted for only 8% of cases in the 2004 outbreak, this increased to 33% and 29% in the 2009/2010 and 2011 outbreaks, respectively. The <1 year cohort accounted for 18-20% of cases in all outbreaks. Phylogenetic analysis demonstrated both indigenous transmission and also importation events. Clade D viruses were exclusively found circulating in Ireland, with autochthonous transmission of diverse genotype D4 strains associated with large outbreaks across Europe. More recently, genotype D8 was identified and these were associated with importation events.

CONCLUSIONS

This study provides a comprehensive genetic analysis of circulating measles genotypes in Ireland and discriminated between indigenous and imported viral strains. Notably, an increase in laboratory-confirmed measles cases in the greater than 10 years of age group was seen over the study period. This information is valuable to inform vaccination strategies with a focus on those populations who remain susceptible to measles infection.

Implementation of a national measles elimination program in Iran: Phylogenetic analysis of measles virus strains isolated during 2010-2012 outbreaks

Measles virus (MV) causes small and large outbreaks in Iran. Molecular assays allow identifying and the sources of measles imported from neighboring countries. We carried out a phylogenetic analysis of measles virus circulating in Iran over the period 2010-2012. Specimens from suspected cases of measles were collected from different regions of Iran. Virus isolation was performed on urine and throat swabs. Partial nucleoprotein gene segments of MV were amplified by RT-PCR. PCR products of 173 samples were sequenced and analyzed. The median age of confirmed cases was 2 years. Among all confirmed cases, 32% had unknown vaccination status, 20% had been vaccinated, and 48% had not been vaccinated. Genotypes B3 and D8 (for the first time), H1 and D4 were detected mainly in unvaccinated toddlers and young children. Genotype B3 became predominant in 2012 and was closely related to African strains. H1 strains were also found in small and large outbreaks during 2012 but were not identical to Iranian H1-2009 strains. A majority of the Iranian D4 strains during 2010-2012 outbreaks were linked to the D4 strain identified in the Pakistan in 2007. We identified a single case in 2010 belonging to D8 genotype with 99.7% identity to Indian isolates. Although the vaccination program is currently good enough to prevent nationwide epidemics and successfully decreased measles incidence in Iran, the fraction of protected individuals in the population was not high enough to prevent continuous introduction of cases from abroad. Due to increasing number of susceptible individuals in some areas, sustained transmission of the newly introduced viral genotype remains possible.

Efficient surveillance of pig populations using oral fluids

Currently virus surveillance in swine herds is constrained by the cost-effectiveness and efficiency of sampling methods. The objective of this study was to assess the value of using oral fluids collected by barn personnel as a method of surveillance based on PCR testing. Approximately 12,150 pigs in 10 wean-to-finish barns on 10 farms were monitored for the presence of porcine circovirus type 2 (PCV2), porcine reproductive and respiratory syndrome virus (PRRSV), influenza A virus (IAV), and Torque teno virus genogroups 1 (TTV1) and 2 (TTV2) by sampling oral fluid specimens. Oral fluid samples were collected from 6 pens at each site starting at the time of pig placement (∼3 weeks of age) and continuing thereafter at 2-week intervals for a period of 18 weeks. Data were analyzed both on a pen basis and barn basis. Overall, 508 (85%) samples were positive for PCV2, 73 (12%) for PRRSV, 46 (8%) for IAV, 483 (81%) for TTV2, and 155 (26%) for TTV1 during the study period. The estimated arithmetic means of the quantitative PCR-positive oral fluids for PCV2, PRRSV, and IAV were 1×10(4.62), 1×10(4.97), and 1×10(5.49)per ml. With a single exception, all barns were positive for PCV2 and TTV2 at every sampling point in the study. Virus detection varied among barns, particularly for IAV and PRRSV. The pen level, cumulative distribution of agent combinations between all 10 barns were statistically different. The most commonly observed patterns were PCV2+TTV2 (239 pen samples, 40%), PCV2+TTV1+TTV2 (88 pen samples, 15%), and PCV2 alone (66 pen samples, 11%). This "proof-of-concept" project showed that a variety of viruses could be detected either intermittently or continuously in pig populations and demonstrated that barn herd virus status is highly variable, even among barns in the same production system. Oral fluid sampling is a promising approach for increasing the efficiency and cost effectiveness of virus surveillance in swine herds.

Diagnosis of mediterranean visceral leishmaniasis by detection of leishmania antibodies and leishmania DNA in oral fluid samples collected using an Oracol device

Current methods for diagnosis of visceral leishmaniasis (VL) require invasive sampling procedures such as visceral aspiration and/or blood drawing. The use of diagnostic tests using oral fluid, which is easier to collect, would be more simple and practical for VL diagnosis, especially under field conditions. Oral fluids from 37 VL patients and 40 healthy controls were collected using Oracol devices. Blood samples and oral fluid specimens from both groups were analyzed by recombinant protein K39 (rK39) enzyme-linked immunosorbent assay and quantitative real-time PCR. Detection of antibodies in the oral fluid had a sensitivity of 100% and a specificity of 97.5%. Antibody levels measured in serum and oral fluid showed a significant positive correlation (ρ = 0.655 and P = 0.01). Detection of Leishmania DNA in oral fluid had a sensitivity of 94.6% and a specificity of 90%. The median parasite load estimated in blood was 133 parasites/ml (interquartile range [IR], 10 to 1,048), whereas that in oral fluid specimens was 3 parasites/ml (IR, 0.41 to 92). However, there was no significant linear relationship between parasite loads assessed in the two biological samples (ρ = 0.31 and P = 0.06). VL diagnosis based on specific antibody detection and Leishmania DNA identification using oral fluid samples was equivalent in accuracy to that using blood and therefore is promising for clinical use.

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.