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Home Eurosurveillance Weekly Release  2006: Volume 11/ Issue 8 Article 2
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Eurosurveillance, Volume 11, Issue 8, 23 February 2006
Articles

Citation style for this article: Georgakopoulou T, Grylli C, Kalamara E, Katerelos P, Spala G, Panagiotopoulos T. Current measles outbreak in Greece. Euro Surveill. 2006;11(8):pii=2906. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2906

Current measles outbreak in Greece

T Georgakopoulou, C Grylli, E Kalamara, P Katerelos, G Spala, T Panagiotopoulos (tpan@keel.org.gr)

Hellenic Centre for Disease Control and Prevention, Athens, Greece

Since November 2005, there has been an outbreak of measles in Greece. Sporadic cases began to appear in September 2005.

Between 1 September 2005 and 12 February 2006, 171 cases of measles were reported, of which 53 (31%) have been laboratory confirmed (by detection of measles IgM), 99 (58%) are probable cases (clinical criteria according to case definition [1]), and 19 (11%) are still awaiting laboratory confirmation (figure 1).

Figure 1. Notified cases of measles by week of symptom onset, Greece, 1 September 2005 - 12 February 2006.

Cases were reported from 14 of the 52 districts of Greece (figure 2), and 159/171 patients (93%) are from northern Greece. Eighty eight cases (52%) are in males. About half (45%) of the patients are aged 0-4 years, 16% are aged 5-9 years, 15% are aged 10-19; and 25% are aged 20 or older, most of these being young adults.

Figure 2. Notified cases of measles by district, Greece, 1 September 2005 – 12 February 2006.

Ninety four patients (55%) belong to Roma (gypsies) families and 25 (15%) to immigrant families; 52 cases (30%) belong to the non-minority general population, most of whom (71%) are 15 years old or more. Of 110 patients with known vaccination status, 98 (89%) were unvaccinated for measles and 12 (11%) had had one dose of measles-containing vaccine Eight cases made up two hospital clusters (four cases in each). One hundred and three patients (60%) were admitted to hospital, and 27 (16%) had complications (mainly pneumonia and bronchiolitis), all of whom have recovered. Results of virus isolation and molecular typing, which are being carried out at the Hellenic Pasteur Institute, are pending.

Measles is a notifiable disease in Greece, and is under surveillance through a sentinel physician system with both private and public sector physicians. In both systems the EU case definition is used [1]. Laboratory surveillance of the disease is carried out through the national reference laboratory for measles in Greece (Medical Microbiology Laboratory, Hellenic Pasteur Institute).

Measures taken to control the outbreak include:

  • campaigns to vaccinate children between 0-14 years old in Roma communities (estimated total population in Greece, 200 000)with MMR in affected districts as a priority (carried out since December 2005), and in the whole country subsequently
  • recommendations to start vaccination of all infants at the age of 6 months in affected districts
  • alerting physicians and the general public to the need for all children, adolescents and high-risk young adults to be vaccinated with two doses of measles containing vaccine,
  • asking health professionals to enhance surveillance, and be aware of vaccination requirements and prophylactic measures in healthcare settings

Discussion
Measles vaccination was introduced in Greece in the early 1970s, when vaccines became commercially available, and vaccination at the age of 15 months was introduced in the national immunisation schedule in 1981; measles-mumps-rubella vaccine (MMR) was introduced in 1989. Vaccination with a second dose of MMR at the age of 11-12 years was introduced in the national immunisation schedule in 1991, and in 1999 this dose was shifted to 4-6 years.

According to several local studies carried out in 2003-2005 in different parts of Greece, vaccination coverage of preschool children, schoolchildren and adolescents with one dose of measles containing vaccine is >95% in the non-minority population, and 80%-90% in children of immigrant families. Vaccination coverage with two doses is about 60-80% for the general child population [2]. Older studies have shown that cohorts of young adults have much lower vaccination coverage, particularly with two doses of measles containing vaccine (86% and 37% of 14 year olds in a national study conducted in 1997 were vaccinated with one and two doses respectively) [3].

Vaccination coverage of Roma children has been found to be very low (2%-12% in studies of the period 2003-2005) [2], and although a number of vaccination campaigns have taken place in this group since these studies were made, vaccination coverage probably still remains very low.

Overall, measles incidence has been steadily declining in Greece during the past 25 years. The current outbreak is the first observed in Greece since 1996. The 1996 outbreak was much smaller than previous outbreaks, and after it ended the 2-5 year epidemic cycles previously observed (Figure 3).

Figure 3.
Notified cases of measles per 100 000 population, Greece, 1957-2005.


Conclusions
This is the first outbreak of measles in Greece since 1996. It has mainly affected three groups of the population: the majority of patients are unvaccinated Roma children aged 0-14 years, primarily of preschool age. The second group is older teenagers and young adults from the non-minority general population who were either unvaccinated or had had one dose of measles containing vaccine. Unvaccinated or incompletely vaccinated immigrants, without any particular age pattern, are the third group affected. The large majority of cases occurred in northern Greece.

References:
  1. Commission Decision of 19 March 2002 laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council (2002/253/EC). Official Journal of the European Communities 3/4/2002; L 86/44.
  2. Hellenic Centre for Disease Control and Prevention. Report on outbreak of measles in Greece since September 2005. Athens, January 2006. [In Greek].
  3. Panagiotopoulos T, Valassi-Adam E, Sarafidou E, Mandeki A, Stratiki Z, Benos A, Adamidis D, Koutis A, Lionis C. National study on immunisation coverage. Archives of Hellenic Medicine 1999; 16:154-62. [In Greek].

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