No 28-33 - 2017

Measles case in West Zealand

Statens Serum Institut has detected a measles case in a younger person residing in West Zealand.

The person returned to Denmark after staying in Poland in July 2017, and had measles detected at Holbæk Hospital in a sample taken on 4 August 2017. The person has immigrated to Denmark, and the person’s vaccination status is uncertain. The Danish Patient Safety Authority, Division for Supervision and Guidance East, was informed as soon as a positive diagnostic had been reached and has implemented relevant preventive measures.

Physicians, particularly in West Zealand, are encouraged to be extra attentive to the diagnosis in weeks to come. It is important that any person who is suspected of having measles avoids being in waiting rooms with other patients as measles is extremely infectious.

This is the second measles case observed in 2017. The first case was also travel-related, as the person had become infected during a vacational stay in Thailand, EPI-NEWS 11/17. This new case once again underlines that all non-immune travellers to areas with a measles risk should have received measles vaccination prior to their departure (in the form of the MMR vaccine).

Europe has experienced a large outbreak of measles in the course of 2017. Romania and Italy have seen a considerable number of cases, but all EU/EEA countries have reported cases this year, except for Latvia, Lichtenstein, Malta and Norway.

See the latest update from the ECDC

Sampling

On suspicion of measles, the following samples should be taken:

1. A blood sample for IgM/IgG antibody determination. IgM antibodies may be confirmed by rash.
2. Pharyngeal swab and urine for virus detection (PCR). The greatest possibility for detecting measles virus is in the early phases of the disease course, but the virus is frequently detectable for several weeks after the acute disease occurs. A negative finding does not exclude measles.

We request that all measles-positive samples be sent to the National WHO Reference Laboratory for Morbilli and Rubella, Section for Virology Surveillance and Research, Statens Serum Institut, for characterisation which is free of charge.

On suspicion of measles disease, it is important that the diagnostics and work-up are performed as rapidly as practically possible with a view to isolation and treatment of the patient and tracking and treatment of anyone who has become exposed to infection.

Serological detection is insufficient for measles diagnostics, and antigen detection by PCR is a requirement. The National WHO Reference Laboratory for Measles and Rubella at Statens Serum Institut (SSI) handles the characterisation (typing and sequencing) of all measles antigen-positive samples in Denmark. As rapid characterisation of the measles virus is important in relation to infection tracing, all suspected as well as all measles antigen-positive samples should be forwarded hereto as quickly as is practically possible.

We recommend contact by phone to the virologist in charge at the SSI (in the daytime pho.: 40336379, after 15.30 to the epidemiologist on call pho.: 41317404) to inform the laboratory that samples are underway to avoid any unnecessary delay of the diagnosis.

For further details, please see the SSI's measles theme page.

Vaccination and prophylaxis following exposure

The primary form of prevention is MMR vaccination. MMR vaccination is normally offered to all children at 15 months and 4 years of age. As post-exposure prophylaxis (PEP), MMR vaccination may be given to non-immune contacts within 3 days and normal human immunoglobulin within 6 days after certain exposure to infection. Certain exposure is defined as contact with a laboratory-confirmed or epidemiologically linked MMR case. Delimitation of the contacts needing PEP is done by the on-duty physician at the Danish Patient Safety Authority, Division for Supervision and Guidance (formerly the Medical Officers of Health). Expenses are covered by the regional authorities.

For more details on post exposure prophylaxis, please see here.

Notification

Confirmed cases of measles are notifiable in writing (on Form 1515) to the Danish Patient Safety Authority, Division for Supervision and Guidance East/North/South as well as to Statens Serum Institut. In view of the limited window for post-exposure prophylaxis, it may nevertheless be expedient to contact the local Supervision and Guidance unit as soon as the test results arrive to ensure that delimitation of any contacts needing PEP may be established without delay.

(L.K. Knudsen, P.H. Andersen, Department of Infectious Epidemiology and Prevention, T.K. Fischer, L.D. Rasmussen, H.B. Eriksen, Virology Surveillance and Research, G. Ertner, the Danish Patient Safety Authority, Supervision and Guidance East)

New vaccine for meningococcal disease of group B

A new vaccine, Trumenba®, has been approved for prevention of infection with Neisseria meningitidis (meningococci) of group B. Henceforth, this vaccine, like Bexsero®, EPI-NEWS 33/14, will be offered as free post-exposure prophylaxis (PEP) to persons who have been close contacts with a person with group B meningococcal disease. Furthermore, it can also be ordered from the SSI for other patient groups; but in this case, the vaccine is not free.

Trumenba® is marketed in Denmark and can be dispensed freely. As Bexsero® is not marketed in Denmark, an issue permit is needed for the vaccine. Such permit is issued by the Danish Medicines Agency. It is possible to apply for an issue permit for a single patient (individual permit) or for several patients (general permit). If Bexsero® is ordered for other causes, the vaccine must be ordered directly from the SSI Order Office. In any case, a copy of the issue permit must be sent to the Order Office at ordre@ssi.dk before the pharmaceutical can be issued.

Trumenba® is approved as from 10 years of age. Trumemba® is a multi-component protein vaccine containing two meningococcal proteins which are expressed on the surface of 96% of all group B strains in Europe.

The efficacy of the vaccine has not been determined in clinical trials but by studying its ability to form antibodies that have a bactericidal effect on four of the most common European strains of group B. It is assessed that a protective antibody level is achieved in approx. 85% of persons who are vaccinated with Trumenba®.

Vaccination programme

The primary vaccination series may be given as a two-dose or as a three-dose programme. The effects of the two programmes are comparable as they yield nearly the same antibody response once the vaccination series has been concluded. The two-dose programme is administered at a 6-month interval, and in the three-dose programme the two initial doses are given at a minimum interval of 1 month, followed by a third dose no less than 4 months after the second dose.

The three-dose programme with Trumenba® yields protection more rapidly and is recommended for persons who are at an increased risk of invasive meningococcal disease, whereas the two-dose programme is recommended for persons who wish to be protected against invasive meningococcal disease of group B, but who are not at an increased risk.

There are no data on the efficacy of the vaccine in adults above 65 years or in patients with chronic medical conditions or a weakened immune response.

A booster dose may be given after both programmes to persons who remain at risk of invasive meningococcal disease. In the summary of product characteristics, the effect of a booster dose is described 4 years after the primary vaccination series.

The most common adverse effects (may affect more than one in ten people) in clinical trials was tenderness and redness or swelling at the injection site, headache, fatigue, chills, diarrhoea, nausea and muscle and joint pain. The complete list of side effects and limitations appears from the summary of product characteristics.

For newly registered pharmaceuticals, all observed or suspected adverse reactions occurring within a 2-year period from the marketing date shall be reported to the Danish Medicines Agency. The marketing date was 1 June 2017.

Post-exposure prophylaxis

Persons who are to be offered post-exposure prophylaxis (PEP) typically comprise those who are close contacts to a person affected by meningococcal disease, and the Danish Patient Safety Authority decides who such people are. Vaccines for close contacts can be ordered by contacting the Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut.

Persons below 10 years of age will be offered vaccination with Bexsero®, EPI-NEWS 33/14, whereas any other persons will be offered vaccination with Trumenba® as a three-dose programme.

(P. Valentiner-Branth, L.K. Krause, Department of Infectious Disease Epidemiology and Prevention)

SSI Vaccine Day in Copenhagen on 11 September 2017

Now for the fourth time, the SSI invites GPs and practice staff with a healthcare background related to vaccines and vaccination to attend an instructive and educational day focusing on the childhood vaccination programme.

The day will comprise sessions offered by the WHO, the Department of Infectious Disease Epidemiology and Prevention and the Danish Health Authority, among others, and there will be ample opportunity to ask questions and share experiences from clinical practice. This year the day is held at the Hotel Crowne Plaza Copenhagen Towers in Copenhagen.

See the programme and learn how to sign up.

(Department of Infectious Disease Epidemiology and Prevention)

Link to previous issues of EPI-NEWS

16 August 2017