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      Occurrence of measles in a country with elimination status: Amplifying measles infection in hospitalized children due to imported virus

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          Abstract

          The Republic of Korea declared measles elimination in 2006. However, a measles outbreak occurred in 2013. This study aimed to identify the epidemiological characteristics of the sources of infection and the pattern of measles transmission in 2013 in South Korea. We utilized surveillance data, epidemiological data, immunization registry data, and genetic information. We describe the epidemiological characteristics of all measles case patients (sex, age distribution, vaccination status, sources of infection) as well as details of the outbreak (the pattern of transmission, duration, mean age of patients, and generation time). In 2013, a total of 107 measles cases were notified. Most patients were infants (43.0%) and unvaccinated individuals (60.7%). We identified 4 imported and 103 import-related cases. A total of 105 cases were related to four outbreaks that occurred in Gyeongnam, northern Gyeonggi, southern Gyeonggi, and Seoul. The predominant circulating genotype was B3 type, which was identified in the Gyeongnam, northern Gyeonggi, and southern Gyeonggi outbreaks. The B3 type had not been in circulation in South Korea in the previous 3 years; virologic evidence suggests that these outbreaks were import-related. Most measles cases in South Korea have been associated with imported measles virus. Although Korea has maintained a high level of herd immunity, clustering of susceptible people can cause such measles outbreaks.

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          Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States.

          Measles was declared eliminated from the United States in 2000 but remains endemic worldwide. In 2005, a 17-year-old unvaccinated girl who was incubating measles returned from Romania, creating the largest documented outbreak of measles in the United States since 1996. We conducted a case-series investigation, molecular typing of viral isolates, surveys of rates of vaccination coverage, interviews regarding attitudes toward vaccination, and cost surveys. Approximately 500 persons attended a gathering with the index patient one day after her return home. Approximately 50 lacked evidence of measles immunity, of whom 16 (32 percent) acquired measles at the gathering. During the six weeks after the gathering, a total of 34 cases of measles were confirmed. Of the patients with confirmed measles, 94 percent were unvaccinated, 88 percent were less than 20 years of age, and 9 percent were hospitalized. Of the 28 patients who were 5 to 19 years of age, 71 percent were home-schooled. Vaccine failure occurred in two persons. The virus strain was genotype D4, which is endemic in Romania. Although containment measures began after 20 persons were already infectious, measles remained confined mostly to children whose parents had refused to have them vaccinated, primarily out of concern for adverse events from the vaccine. Seventy-one percent of patients were from four households. Levels of measles-vaccination coverage in Indiana were 92 percent for preschoolers and 98 percent for sixth graders. Estimated costs of containing the disease were at least 167,685 dollars, including 113,647 dollars at a hospital with an infected employee. This outbreak was caused by the importation of measles into a population of children whose parents had refused to have them vaccinated because of safety concerns about the vaccine. High vaccination levels in the surrounding community and low rates of vaccine failure averted an epidemic. Maintenance of high rates of vaccination coverage, including improved strategies of communication with persons who refuse vaccination, is necessary to prevent future outbreaks and sustain the elimination of measles in the United States. Copyright 2006 Massachusetts Medical Society.
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            Factors determining prevalence of maternal antibody to measles virus throughout infancy: a review.

            The effectiveness of vaccination against measles, the leading cause of vaccine-preventable deaths in infants globally, is greatly impacted by the level of maternal antibody to measles virus (or "measles maternal antibody"; MMA) during infancy. Variation in the prevalence of maternal antibody to measles virus between infant populations across countries and sociodemographic strata is poorly understood. We reviewed the literature on the prevalence of MMA, focusing on 3 principal determinants: starting level of maternal antibody, placental transfer of maternal antibody, and rate of decay of maternal antibody after birth. Our review identified placental transfer as an important determinant, with greater efficiency found in studies performed in developed countries. Placental transfer was influenced by gestational age, human immunodeficiency virus infection, and malaria. Antibody levels in mothers varied widely between countries, although predictably according to vaccination status within populations. Rates of antibody decay across studies were similar. Future studies should evaluate the utility of the cord blood level of MMA as a predictor of vaccine efficacy in infancy; inclusion of World Health Organization international reference sera will facilitate comparisons. Greater understanding of the determinants of the prevalence of MMA will help national policy makers determine the appropriate age for measles vaccination.
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              The correlation between infectivity and incubation period of measles, estimated from households with two cases.

              The generation time of an infectious disease is the time between infection of a primary case and infection of a secondary case by the primary case. Its distribution plays a key role in understanding the dynamics of infectious diseases in populations, e.g. in estimating the basic reproduction number. Moreover, the generation time and incubation period distributions together characterize the effectiveness of control by isolation and quarantine. In modelling studies, a relation between the two is often not made specific, but a correlation is biologically plausible. However, it is difficult to establish such correlation, because of the unobservable nature of infection events. We have quantified a joint distribution of generation time and incubation period by a novel estimation method for household data with two susceptible individuals, consisting of time intervals between disease onsets of two measles cases. We used two such datasets, and a separate incubation period dataset. Results indicate that the mean incubation period and the generation time of measles are positively correlated, and that both lie in the range of 11-12 days, suggesting that infectiousness of measles cases increases significantly around the time of symptom onset. The correlation between times from infection to secondary transmission and to symptom onset could critically affect the predicted effectiveness of isolation and quarantine. Copyright © 2011 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: Visualization
                Role: Data curationRole: Formal analysisRole: InvestigationRole: SoftwareRole: Visualization
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Visualization
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: Validation
                Role: ConceptualizationRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: Validation
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                15 February 2018
                2018
                : 13
                : 2
                : e0188957
                Affiliations
                [1 ] Division of Vaccine-Preventable Diseases Control and National Immunization Program, Korea Center for Disease Control and Prevention, Cheongju-si, Chungcheongbuk-do, Republic of Korea
                [2 ] Division of Respiratory Viruses, Korea National Institute of Health, Cheongju-si, Chungcheongbuk-do, Republic of Korea
                [3 ] Department of Preventive Medicine, Korea University Medical College, Seongbuk-gu, Seoul, Republic of Korea
                Public Health England, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                [¤a]

                Current address: Division of Influenza Virus, Korea National Institute of Health, Cheongju-si, Chungcheongbuk-do, Republic of Korea

                [¤b]

                Current address: Division of HIV/AIDS & Tuberculosis Control, Korea, Cheongju-si, Chungcheongbuk-do, Republic of Korea

                [¤c]

                Current address: Division of Public Health Preparedness & Response, Korea Center for Disease Control and Prevention, Cheongju-si, Chungcheongbuk-do, Republic of Korea

                Article
                PONE-D-16-42330
                10.1371/journal.pone.0188957
                5813900
                29447169
                e1f6b94d-f474-498c-8e34-0e19ff29009f
                © 2018 Eom et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 24 October 2016
                : 16 November 2017
                Page count
                Figures: 4, Tables: 3, Pages: 13
                Funding
                This article was not funded for research, authorship, and publication.
                Categories
                Research Article
                Biology and life sciences
                Organisms
                Viruses
                RNA viruses
                Paramyxoviruses
                Measles Virus
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Paramyxoviruses
                Measles Virus
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Paramyxoviruses
                Measles Virus
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Paramyxoviruses
                Measles Virus
                Medicine and Health Sciences
                Infectious Diseases
                Viral Diseases
                Measles
                Medicine and Health Sciences
                Epidemiology
                People and places
                Geographical locations
                Asia
                South Korea
                Biology and Life Sciences
                Immunology
                Vaccination and Immunization
                Medicine and Health Sciences
                Immunology
                Vaccination and Immunization
                Medicine and Health Sciences
                Public and Occupational Health
                Preventive Medicine
                Vaccination and Immunization
                Social Sciences
                Sociology
                Education
                Schools
                Medicine and health sciences
                Infectious diseases
                Infectious disease control
                Vaccines
                Viral vaccines
                MMR vaccine
                Biology and life sciences
                Microbiology
                Virology
                Viral vaccines
                MMR vaccine
                Medicine and Health Sciences
                Epidemiology
                Disease Surveillance
                Infectious Disease Surveillance
                Medicine and Health Sciences
                Infectious Diseases
                Infectious Disease Control
                Infectious Disease Surveillance
                Custom metadata
                1. All Korean measles surveillance data is available at http://www.cdc.go.kr/npt/. The all statistics data of Korean notifiable infectious diseases, including measles, can be accessed and queried by anyone. This site is maintained in Korean only. 2. The epidemiologic survey data & personal immunization record can be accessed by the permitted members of Korean Centers Disease Control & Prevention. These data include personal identifications, in which all the epidemiological survey data are encrypted and are stored securely in governmental database. Korean government has enacted a law for protection of personal information (Personal Information Protection Act, PIPA), which is effective from September 2011. The authors originally accessed this data through a partnership between KCDC and Korea University. Interested researchers can request access via public portal: https://www.data.go.kr/main.do?lang=en. 3. The all measles nucleotide data in Korea are sent to WHO's Measles Nucleotide Surveillance system ( http://who-measles.org/Public/Web_Front/epi.php).

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