Boccuzzi E.

Bozzola E.

Di Camillo C.

Lancella L.

Villani A

Vittucci A. C.

English

LETTER TO THE EDITOR Open AccessMeasles lessons in an anti-vaccination era:public health is a social duty, not a politicaloptionL. Lancella1, C. Di Camillo1* , A. C. Vittucci1, E. Boccuzzi2, E. Bozzola1 and A. Villani1AbstractBackground: Measles virus, member of the genus Morbillivirus in the family Paramyxoviridae, is a highlycontagious human pathogen. An effective live-attenuated vaccine is available and its use has the potentialto eradicate the disease from the human population. Although the vaccine was introduced in nationalvaccination schedules, several measles outbreaks have occurred because of insufficient vaccination coverage.Since early January 2017, a new outbreak of measles in Italy has been observed.Methods: We analyzed all the patients admitted to the Emergency Department of Bambino Gesù ChildrenHospital of Rome from the 1st of January 2017 to the end of May 2017 and discharged with diagnosis ofsuspected or confirmed measles or admitted to the Pediatric and Infectious Disease Unit. For each confirmedcase, demographic data, vaccination history, exposure to source case, clinical presentation, date of onset ofsymptoms, hospitalization, laboratory test results, complications and therapy were collected.Results: From the 1st of January 2017 to the 31st of May 2017, we enrolled 139 patients who were conducted to theEmergency Department of Bambino Gesù Children’s Hospital because of measles: 33 patients were discharged withthe diagnosis of suspected measles by clinical manifestations; 33 discharged with the diagnosis of confirmed measlesby laboratory tests and 73 were admitted to the Pediatric and Infectious Disease Unit. Seven patients, who wereexposed to mothers with measles, were admitted to receive treatment with Measles Immune Globulin intravenously.Among the 66 patients admitted to the hospital with measles, 31 cases (47%) occurred in unvaccinated individualswho were age-eligible for measles vaccination; 29 (44%) were infants too young to be vaccinated; only five patients(8%) received one dose of measles-containing vaccine.Out of the 66 patients, 35 (53%) developed complications. Acute respiratory failure was the most reported complications(20%). Death, due to multiorgan failure by measles, occurred in one 9-girl-year-age patient with genetic disorders whowas unvaccinated.Conclusions: Measles still represents a serious public health problem worldwide. Vaccination against measles is safe,effective, and cost-effective.High vaccination coverage (>95%) with two doses of measles vaccine is crucial to elimination. Health care professionalsplay an important role in vaccination uptake and prevention of measles spread during an outbreak.Keywords: Measles, Vaccination, Public health* Correspondence: chiara.dicamillo@opbg.net1General Pediatric and Infectious Disease Unit, Bambino Gesù Children’sHospital, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, ItalyFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Lancella et al. Italian Journal of Pediatrics  (2017) 43:102 DOI 10.1186/s13052-017-0420-6ManuscriptMeasles still represents a serious public health problemworldwide. It is a highly contagious infectious diseasewith severe complications: pneumonia, laryngotracheo-bronchitis, otitis media, diarrhea, hepatitis, keratocon-junctivitis, encephalitis, seizures and subacute sclerosingpanencephalitis [1].It is still responsible for more than 100,000 deathsevery year [2]. An effective live-attenuated vaccine isavailable and its use has the potential to eradicate thedisease from the human population [3].Although the vaccine was introduced in national vac-cination schedules 20 years ago, several outbreaks haveoccurred because of insufficient vaccination coverage inthe European Region [4].Since early January 2017, a new outbreak of measles inItaly has been observed: 2851 new cases were reported,73% with age > 15 years and 27% pediatric patients; amongthose, 168 patients were <1 years old. Two hundred andtwenty-four cases were healthy professionals. Most of thecases (89%) were unvaccinated; 6% received just one dose.Complications were reported by 35% of patients [5].In Italy, measles is a disease subject to mandatorynotification, and according to the routine procedure,physicians must report suspected measles case totheir Local Health Units within 48 h of diagnosis. Atthe time of the study, vaccination for measles-mumps-rubella in a two-dose at 13–15 months and at5–6 years of age respectively, is strongly recom-mended but not mandatory.From the 1st of January 2017 to the 31st of May2017, 139 patients (75 males, median age 3.82 years,range 16 days-20 years) were conducted to theEmergency Department of Bambino Gesù Children’sHospital because of measles: 33 patients (24%) weredischarged with diagnosis of suspected measles byclinical manifestations; 33 (24%) discharged with diag-nosis of confirmed measles by laboratory tests and 66(48%) were admitted to the Pediatric and InfectiousDisease Unit.Furthmore seven patients, six newborns and one un-vaccinated 6 year old girl with metabolic disease, whowere exposed to their mothers with measles, were ad-mitted to receive treatment with Measles ImmuneGlobulin intravenously (Flebogamma DIF 50 mg/ml).None developed measles.For each patient admitted to the hospital, demographicdata, vaccination history, exposure to source case,clinical presentation, date of onset of symptoms,hospitalization, laboratory test results, complications andtherapy were collected.Vaccination status was categorized as fully vaccinated,partially vaccinated, not vaccinated, too young to be vacci-nated or unknown.A source case was defined as a measles- infectedindividual who transmitted the disease to anotherpreviously uninfected individual.Among the 66 patients admitted to the hospital withmeasles, confirmed by laboratory tests, (33 males;median age 3.36 years), the average duration of stay inthe hospital was 7.42 ± 4.42 days (expressed asmedian ± SD). A confirmed case was defined either as alaboratory confirmed case in which measles-specific IgMantibodies were present in serum or in which measlesvirus nucleic acid was detected in urine or bloodsamples by PCR.Thirty one cases (47%) occurred in unvaccinated indi-viduals who were age-eligible for measles vaccination; ofthose, four had a chronic disease (one with Langerhanscell histocytosis, two with genetic disorders and one withcystic fibrosis). Twenty-nine (44%) were infants tooyoung to be vaccinated; only five patients (8%) receivedone dose of measles-containing vaccine. For one patient,vaccination status was unknown. None were vaccinatedwith two doses.In total, 42% of case patients had contact with a sourcecase: of those, 46% were mothers with recent measlesinfection, who did not received vaccination.Out of the 66 patients, 35 (53%) developed complica-tions. Acute respiratory failure was the most reportedcomplication (13 patients, 20%): 5% cases required in-tensive care. Six patients (9%) developed pneumonia.Death, due to multiorgan failure by measles, confirmedon post-mortem examination, occurred in one 9 year oldgirl with genetic disorders (dup7q36) who was unvaccin-ated. This kind of genetic disorder does not represent acondition preventing vaccination.Encephalitis was verified in two patients. After dis-charge, the patients entered follow-up control; untilnow, no neuropsychological sequelae has been detected.Other complications included laryngotracheobronchitis,neutropenia, thrombocytopenia, otitis, diarrhea and facialnerve paralysis. The characteristics of study populationare represented in Table 1.From the 1st of January 2017 to the 31st of May 2017,Italy experienced high measles burden with 2851 casesreported to the measles surveillance system.The present report analyses measles hospitalizationrates in the pediatric population in Bambino GesùChildren’s Hospital of Rome over a 5-month period.In our study, 53% of population developed compli-cations. Acute respiratory failure was reported to bethe most common cause of morbidity among themeasles cases. Intensive care was required by threepatients.Death is reported in one 9 year old girl with geneticdisorder who did not receive vaccination. This deathserves as reminder that this particular category ofLancella et al. Italian Journal of Pediatrics  (2017) 43:102 Page 2 of 4children, the immune-compromised, is at elevate riskof severe measles complications.Therefore it is essential to have a high vaccinationcoverage among them and their contacts.One of the priorities of the health system in Italy is tocontrol the diseases that are preventable through vaccin-ation. For reaching the objective of measles elimination,the vaccination coverage of >95% with two doses ofmeasles vaccine, is required [6]. In Italy, in 2016, vaccin-ation coverage for measles was 87.26% at 24 months ofage and 82.24% at 5–6 years [7]. These values are lowerthan they have been for over a decade and Italy remainsone of the 14 countries in the European Region with on-going endemic transmission [8].Vaccines are among the most effective preventiontools available to clinicians. However, the success of animmunization program depends on high rates of accept-ance and coverage. We believe that recent parental con-cerns about vaccine safety issues, such as a supposedassociation between autism and vaccines, though notverified by scientific evidence, had led increasing num-bers of parents to refuse or delay vaccination for theirchildren [9]. Furthmore parents are concerned that achild’s immune system could be weakened by too manyvaccines, and they believe that it is better to develop im-munity from natural disease than from vaccination;moreover they suppose that the severity of the disease,such as measles, is low [9]. Other groups of parents mayrefuse vaccination due to religious reasons or preferencefor complementary or alternative medicine. Finally someparents, prefer to obtain information from the Internetthan to clinicians [10]. Many of the vaccine concernsidentified among parents can be addressed throughdiscussions with healthcare professionals and publicvaccine information campaigns.Out of the infected people, complications have beendetected in 35% of patients, causing hospitalization anddeath. The decrease in measles immunization representsa problem for the whole Italian community, in particularfor infants too young to be vaccinated or affected byimmunodeficiency.In our study, a substantial number of cases (44%) werein children less than 15 months of age not eligible forvaccination. In addition 46% of patients had beeninfected by mothers who were unvaccinated. Moreoverinfants of mothers who are not immune by naturalinfection become vulnerable at very early age and theyrepresent a category at risk of developing severe or fatalcomplications [2].It is necessary to identify susceptible individuals andconsider undertaking catch-up immunization or sup-plementary immunization activities to close immunitygaps. Additionally measles immunization saves highcosts for the national healthcare system [6]. In fact,measles is associated with direct cost (i.e hospital costfor complicated cases) and indirect cost (i.e. missingwork days of parents).Thus, we conclude that it is important to improve theknowledge and the scientific culture of healthcareprofessionals and all population for reaching adequatevaccination coverage for preventable diseases.AcknowledgementsNot applicable.Availability of data and materialsAt Bambino Gesù Children’s Hospital, Dr. Di Camillo’s repository.Authors’ contributionsLL planned the study. CDC was a major contributor in writing the manuscriptstudy. ACV helped to draft the manuscript. EBozzola, and EBoccuzzi collectedthe clinical information of patients. AV analyzed and interpreted the patientdata regarding the infectious disease. All authors read and approved the finalmanuscript.Table 1 The characteristics of study populationCharacteristics Number of casesPatients 66Male gender 33Median Age (years) 3.82Age group (months)1–15 29> 15 37Contact with source caseYes 27No 39Mothers with measles 13Vaccination statusIneligible (aged <15 months) 29No 31Yes (I dose) 5Unknown 1Length of hospital stay (days) 7.42Complications 35Acute respiratory insufficiency 13Hypertransaminasemia 7Pneumonia 6Encephalitis 2Death 1Others 13TherapyAntibiotics 33Measles Immune Globulin intravenously 2Antiviral 2Lancella et al. Italian Journal of Pediatrics  (2017) 43:102 Page 3 of 4Ethics approval and consent to participateNot applicable. Collected before patient enrollment; availability of data atBambino Gesù Children’s Hospital, Dr. Di Camillo’s repository.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1General Pediatric and Infectious Disease Unit, Bambino Gesù Children’sHospital, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, Italy. 2PediatricEmergency Department, Bambino Gesù Children’s Hospital, IRCCS, PiazzaSant’Onofrio 4, 00165 Rome, Italy.Received: 14 August 2017 Accepted: 6 November 2017References1. Perry RT, Halsey N. The clinical significance of measles: a review. J Infect Dis.2004;189(Suppl 1):S4–16.2. Moss WJ. Measles. Lancet. 2017; https://doi.org/10.1016/S0140-6736(17)31463-0.3. WHO. Measles vaccines: WHO position paper- April 2017. Wkly EpidemiolRec. 2017;92(17):205–27. http://www.who.int/wer4. Datta SS, O’Connor PM, et al. Progress and challenges in measles andrubella elimination in the WHO European region. Vaccine. 2017; https://doi.org/10.1016/j.vaccine.2017.06.042.5. Istituto Superiore di Sanità. Surveillance Measles and Rubella. http://www.epicentro.iss.it/problemi/morbillo/bollettino/Measles_WeeklyReport_N11.pdf.Accessed 6 June 2017.6. Hayman DTS, Marshall JC, French NP, et al. Cost-benefit analyses ofsupplementary measles immunization in the highly immunized populationof New Zealand. Vaccine. 2017;35:4913–22.7. Italian Ministry of Health. Infectious Diseases and vaccinations. Vaccinecoverage. http://www.salute.gov.it. Accessed 8 June 2017.8. World Health Organization Regional Office for Europe (WHO/Europe). FifthMeeting of the European Regional Verification Commission for Measles andRubella Elimination (RVC) 24–26 October 2016. Copenhagen, Denmark.9. Omer SB, Salmon DA, et al. Vaccine refusal, mandatory immunization, and therisks of vaccine-preventable diseases. N Engl J Med. 2009;360(19):1981–8.10. Salmon DA, Moulton LH, et al. Factors associated with refusal of childhoodvaccines among parents of school-aged children: a case-control study. ArchPediatr Adolesc Med. 2005;159:470–6.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Lancella et al. Italian Journal of Pediatrics  (2017) 43:102 Page 4 of 4

Measles lessons in an anti-vaccination era: public health is a social duty, not a political option

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Measles lessons in an anti-vaccination era: public health is a social duty, not a political option

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