1. Measles Outbreak in Skopje, Republic of Macedonia, 2014 Erjona Shakjiri 1, D. Kochinski 1, Sh. Memeti 1, B. Aleksoski 1, K. Stavridis 1, V. Mikic 1, G. Boshevska 1, E. Janceska 1, G. Kuzmanovska 1, V. Velikj Stefanovska 2 1 Institute of Public Health of Republic of Macedonia 2 Institute of epidemiology with statistics and medical informatics, Medical Faculty Skopje Funded by the European Union Institute of Public Health of Republic of Macedonia

2. Background Measles is a highly contagious, acute viral illness that can lead to serious complications such as: blindness, encephalitis, severe diarrhoea and dehydration, ear infection, pneumonia and death. It is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretions. No specific antiviral treatment exists for measles virus Vaccine preventable disease In 1980, before widespread vaccination, measles caused an estimated 2.6 million deaths each year In 2013, there were 145 700 measles deaths globally – about 400 deaths every day or 16 deaths every hour. Measles vaccination resulted in a 75% drop in measles deaths between 2000 and 2013 worldwide.

4. Measles in R.Macedonia Measles is a mandatory notifiable disease by law in Macedonia Each year there are sporadic cases Strategy for elimination of measles, rubella and congenital rubella infection. Anti-vaccination movements In last five years R.Macedonia experienced 2 outbreaks

5. Changes in the calendar of immunization related to measles in R.Macedonia Year of vaccine introduction Type of vaccineAgeComment 1972Measles (M)13 months Introduced vaccination against measles I dose monovalent MCV 1983MMR13 months Substitute of monovalent MCV with MMR 1987Measles(M) 7 yearsVaccination with II doses MCV 1997MMR 7 years ( first grade in elementary school) Vaccination with II doses MCV ( MMR) 2010MMR6 years Due to changes in education system

6. Measles incidence in R.Macedonia (1998-2014)

7. Vaccine coverage of measles (1976-2014)

8. Objectives To describe the last measles outbreak in R.Macedonia To assess the vaccination status of cases To provide recommendations for preventing further outbreaks

9. Methods of investigation Descriptive analyses by person, place and time Clinical case definition: a person with maculopapular rash >3 days, fever >38°C and at least one of the following: cough, runny nose, conjunctivitis or Koplik spots after the 1 st of January 2014, in Skopje Lab confirmed cases: A case that meets the clinical case definition and has laboratory-confirmation of measles virus infection. ELISA was used for confirmation Epidemiologically confirmed cases: a patient who meets the clinical case definition and has direct contact with another laboratory-confirmed measles case. Structured questionary to collect data (local epidemiologists)

10. Distribution of cases by age-group and vaccination status, Skopje, January-June 2014( n=112)

11. Age specific attack rate: Skopje, January-June 2014 ( n=112)

12. Epidemic curve by the week of rush onset: notified measles cases, Skopje, January-June 2014 (n=112)

13. Geographical distribution of cases, Skopje, January-June, 2014 (n=112)

14. Distribution of cases by complication, Skopje, January-June (n=112)

15. Outbreak control measures Outbreak control team ( Ministry of health, IPH, CPH)  Case interview  Contact tracing  Immunization advise of cases and contacts  Checking immunization history  Vaccination of susceptible contacts- those not vaccinated or partially vaccinated  Delivery of catch-up vaccination in vaccinational centers  Campaigns for immunization

16. Conclusions second outbreak in the last 5 years children <5 were at higher risk because of not being vaccinated (95%) 17.8 % belong to the age group < 1 year which were at high risk possible due to low levels of maternal antibodies older than 30 years (42.8%) were at higher risk due to lower vaccination coverage and immunization schedule with only one dose of MCV from 1972-1987.

17. Recommendations In case of outbreak, lowering the age for primary vaccination should be considered also as early revaccination of children under five years. Post-exposure guidelines recommend vaccination of contacts with a case of measles when they are unprotected and aged six months or older. Catch-up campaigns Vaccine campaigns

18. Thank you for your attention Funded by the European Union Institute of Public Health of Republic of Macedonia