Epidemiologic and laboratory surveillance of the measles outbreak in the Federation of Bosnia and Herzegovina, February 2014–April 2015

Abstract

A measles outbreak with two epidemic waves involving 4649 probable and laboratory-confirmed cases was recorded in six out of ten cantons of the Federation of Bosnia and Herzegovina between February 2014 and April 2015. The majority of the patients had never received measles vaccination (3115/4649, 67.00%), and the vaccination status of another 23% was unknown (1066/4649). A total of 281 blood samples were tested serologically. Virus detection was performed using 44 nasopharyngeal swabs. About 57% (161/281) of the laboratory-investigated sera were immunoglobulin M positive, and 95% (42/44) of the swabs were reverse transcriptase-PCR positive. Phylogenetic analysis of sequences obtained from 30 swab samples showed circulation of two variants of genotype D8, but no genotype D4 strains as detected in 2007. Similar involvement of all age groups indicates a problem with vaccine refusal resulting from antivaccination activities in addition to gaps in immunization coverage during the war and postwar period (1992-1998). Differences in ethnicity, vaccine coverage, compliance with review policies of vaccination records and potentially also travel habits may partially explain why only six of ten cantons were affected by the outbreak. The second epidemic wave may in part be due to large-scale migrations due to catastrophic floods in 2014. As a result of the epidemic, 6- to 12-month-old children may now be vaccinated against measles during outbreaks, and public health recommendations for interventions have been strengthened. Additional efforts are required to implement the measures throughout the cantons.

Challenges to Achieving Measles Elimination, Georgia, 2013–2018

“…The experience in Georgia demonstrates that without adequate and timely response, substantial susceptibility to measles can persist in settings with historically suboptimal coverage even after large-scale outbreaks, thus leaving room for future outbreaks. A similar pattern was observed in Ukraine and in Bosnia and Herzegovina, where, in the absence of appropriate response, the historically underimmunized birth cohorts were affected by repeated outbreaks of measles ( 22 – 27 ). In contrast, those countries in the former Soviet Union and Eastern Europe that successfully implemented wide-age SIAs, achieved elimination or substantial reduction of measles incidence for prolonged periods ( 4 , 28 , 29 ).…”

Epidemiological, clinical and laboratory characteristics of the measles resurgence in the Republic of Serbia in 2014-2015

“…Most of them were students born in B&H during the war or post-war period (1992–1998) who were unvaccinated or had an unknown vaccination status. At the time of the introduction, a large measles outbreak caused mainly by the “Rostov on Don” variant of genotype D8 was ongoing in B&H [21,22]. The same virus variant was also responsible for most cases linked to the 2014/2015 measles resurgence in Serbia (77.4%, n = 106 of the 137 sequences obtained in total) and to an outbreak in Germany [23–25], where an unvaccinated Roma child from Srem (MVs/Sremska_Mitrovica.SRB/49.14, Fig 2) was probably exposed.…”

Large measles outbreak introduced by asylum seekers and spread among the insufficiently vaccinated resident population, Berlin, October 2014 to August 2015

“…This variant was detected in Berlin during the entire outbreak period and had previously been found during a large outbreak in Bosnia and Herzegovina (February 2014 to April 2015). Forty-five cases had variants deviating in the 450 nt region by 1–2 nt from D8-Rostov-Don (10 variants, Figure 3 ) [ 22 ]. One variant detected in Berlin from December 2014 to May 2015 (MVs/Berlin.DEU/01.15) was also found in the course of the aforementioned outbreak (MVs/Lukavac.BIH/05.15) [ 22 ].…”

“…Several lines of evidence indicate that measles was introduced by and initially spread among asylum seekers: firstly, the index case occurred in an asylum seeker who had symptoms upon arrival in Berlin, after travelling from Bosnia and Herzegovina where a large measles outbreak was ongoing at that time [ 22 ]. Subsequent cases occurred predominantly among asylum seekers (often from Bosnia and Herzegovina) that acquired infection in Berlin.…”