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Special Measles Issue

Guest editor:

Marta Ciofi Degli Atti

Laboratori of Epidemiology and Biostatistics

Istituto Superiore di Sanita’

Rome

 

In June of this year, Europe was declared to have achieved the elimination of poliomyelitis. Measles is considered the next candidate for elimination. Indeed, measles has several of the prerequisites necessary for elimination: it affects only man, has no environmental or animal reservoir, there are no chronic carriers, and most importantly, there is a safe and effective vaccine available. WHO has established the objective of the elimination of measles in Europe by 2007 (1), although the actual situation in Europe is differs considerably between countries: some have already achieved this objective, while in neighboring countries, measles remains a serious public health problem. Together with Germany, Italy is one of the countries at high risk of measles epidemics given that vaccine coverage remains low and there are therefore a large number of susceptibles (2).

 

The epidemic that has occurred this year in Italy is the direct consequence of this accumulation of susceptibles, and as shown in the articles published in this month’s BEN, the distribution of cases in the country closely reflects the vaccination coverage distribution at provincial and regional level. Within the Campania region in southern Italy, the region most affected by the 2002 measles epidemic, the article by D’Argenio et al demonstrates that in Benevento, the province with the highest vaccine coverage rate, the incidence rate was considerably lower than that observed in other provinces (3). However, within Benevento, vaccination coverage was not uniform across districts, and the authors clearly demonstrate that the incidence by age group was inversely proportional to levels of vaccine coverage. Among the 10-14 year age group, where the vaccine coverage was approximately 30%, the incidence was six times higher than that observed in children 1-4 years of age, where the coverage was higher than 80%. Also in other regions, the correlation between vaccine coverage and incidence is clear: as reported by Di Giovanni et al, in the local health authority of Campobasso in the Molise region of southern Italy, the epidemic was seen primarily in 8 communes, the majority of which had coverage levels below 65%. By contrast, in the article by Grandinori et al in Emilia-Romagna region in northeast Italy, where vaccine coverage was 90% in 2001 and there were no significant differences across the local health authorities, the incidence in the pediatric age group is 8 times lower than that observed in Campania, without large variations across the various authorities. Finally, as demonstrated in the article by Filzoni et al, data from the epidemic in a school in the province of Ascoli Piceno, where measles affected 24% of the non-vaccinated children and none of those who were vaccinated, clearly demonstrates the efficacy of the vaccine.

 

The elimination of measles requires high vaccine coverage in all age groups and special attention to population groups at risk. The experience of providing vaccination in a Gypsy camp in Rome reported by Trinito et al shows the necessity of field intervention and the immediate protective effect of vaccination in a period of high incidence. Furthermore, the closer one comes to elimination, the better the surveillance system and the capacity to investigate epidemics needs to be.  The articles published in this issue demonstrate clearly how important it is to gather data, analyze it, and use it for interventions. Following the epidemic in Benevento, nearly 30% of the susceptible children were vaccinated over a three-month period; in Campobasso, the priority areas were identified for improving the vaccine program, and in Rome, a special vaccination day was established that resulted in coverage of 90% of children in a Gypsy camp. In Emilia-Romagna and Ascoli Piceno, finally, the impact of the vaccine strategy was clearly demonstrated.

 

The epidemic of measles this year caused thousands of illnesses, hundreds of hospitalizations, a dozens of cases of encephalitis, and several deaths. This is a price that for us as a nation is too high to pay. To eliminate measles, it is necessary to vaccinate not only 95% of the children during the second year of life but also older children who have not been vaccinated; only though the development of a national strategies shared by all the actors involved (regions, local health authorities, pediatricians, and general practitioners) will ultimately guarantee success.

 

References

1. Health 21 – the health for all policy for the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1999 (European Health for All Series, No. 6).

2. Salmaso S, Gabutti G, Rota MC, Giordano C, Penna C, Mandolini D, Crovari P, and the Serological Study Group. Pattern of susceptibility to measles in Italy. Bulletin of the World Health Organization, 2000; 78 (8): 950-955.

3. Ciofi degli Atti,ML, S Salmaso, R Pizzuti, P D'Agnese, C Bove, D Protano, A D'Argenzio, M L Trabucco, 2002, Epidemia di morbillo in campania. Aggiornamento. BEN, notiziario ISS 15, 7-8, luglio-agosto.