Communicable Disease Threats Report 28 Sep 2013

COMMUNICABLE DISEASE THREATS REPORT
CDTR Week 39, 22-28 September 2013

All users
This weekly bulletin provides updates on threats monitored by ECDC.
I. Executive summary
EU Threats
Measles - Multistate (EU) - Monitoring European outbreaks
Opening date: 9 February 2011 Latest update: 26 September 2013 Measles, a highly transmissible vaccine-preventable disease, is still endemic in many countries of Europe due to a decrease in the uptake of immunisation. The 30 EU/EEA countries reported 8 643 cases of measles during August 2012 to July 2013. France, Germany, Italy, Romania, Spain, the Netherlands and the United Kingdom accounted for 95% of the cases in the last 12-month period. Update of the week The outbreaks in the Netherlands and in Germany are still on-going. In the neighbouring countries there are outbreaks in the Russian federation, Turkey and Georgia.
West Nile virus - Multistate (Europe) - Monitoring season 2013

Opening date: 3 June 2013 Latest update: 26 September 2013 West Nile fever (WNF) is a mosquito-borne disease which causes severe neurological symptoms in a small proportion of infected people. During the transmission season between June and November, ECDC monitors the situation in EU Member States and neighbouring countries in order to inform blood safety authorities regarding WNF-affected areas and identify significant changes in the epidemiology of the disease. During the 2012 season, 244 probable and confirmed cases were reported in the EU, and 693 cases in neighbouring countries. Update of the week During the past week, 20 new cases were detected in the EU: three from Greece, thirteen from Italy and four from Romania. In neighbouring countries, 28 new cases were reported, all from Serbia.
Rubella - Multistate (EU) - Monitoring European outbreaks

Opening date: 7 March 2012 Latest update: 3 July 2013 Rubella, caused by the rubella virus and commonly known as German measles, is usually a mild and self-limiting disease and is an infection which often passes unnoticed. The main reason for immunising against rubella is the high risk of congenital malformations associated with rubella infection during pregnancy. All EU Member States recommend vaccination against rubella with at least two doses of vaccine for both boys and girls. The vaccine is given at the same intervals as the measles vaccine as part of the MMR vaccine. Update of the week Since the last update no new outbreaks were detected.
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European Centre for Disease Prevention and Control (ECDC) Postal address: ECDC 171 83 Stockholm, Sweden Visiting address: Tomtebodavgen 11a, Solna, Sweden www.ecdc.europa.eu Epidemic Intelligence duty email: support@ecdc.europa.eu
Week 39, 22-28 September 2013
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Non EU Threats
Poliovirus - Israel- Detection of WPV1 in environmental samples and healthy individuals
Opening date: 19 August 2013 Latest update: 26 September 2013 EU/EEA countries, as well as the rest of the WHO European Region, have been polio-free since 2002. Wild polio virus type 1 (WPV1) has been isolated in sewage and in the faeces of asymptomatic carriers in Israel in samples collected from 3 February to 25 August 2013. Detection of WPV in environmental samples is a signal of WPV transmission and consequently of concern and highlights the potential for re-establishing transmission in Europe. Update of the week During the week leading up to 26 September 2013, no new positive poliovirus samples have been detected in Israel.
Middle East respiratory syndrome- coronavirus (MERS CoV) - Multistate

Opening date: 24 September 2012 Latest update: 26 September 2013 Between April 2012 and 26 September 2013, 133 laboratory-confirmed cases, including 60 deaths, of acute respiratory disease caused by Middle East respiratory syndrome coronavirus (MERS-CoV), have been reported by national health authorities. MERS-CoV is genetically distinct from the coronavirus that caused the SARS outbreak. To date, all cases have either occurred in the Middle East or have had direct links to a primary case infected in the Middle East. Update of the week Between 19 and 26 September, three new cases, including two deaths have been reported by the national health authorities of the Kingdom of Saudi Arabia. WHO has confirmed a death of a previously reported case from Qatar. Two secondary cases in Italy are now re-classified as probable cases. The WHO Emergency Committee has again concluded in a teleconference meeting held on 25 September 2013 that "conditions for a Public Health Emergency of International Concern have not at present been met".
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II. Detailed reports

Measles - Multistate (EU) - Monitoring European outbreaks
Opening date: 9 February 2011 Latest update: 26 September 2013
Epidemiological summary
EU Member States
The Netherlands update

Since May 2013 and as of 25 September 2013, the National Institute for Public Health and the Environment (RIVM) reported 1 540 cases of measles. The actual number of cases is estimated to be much higher. So far there have been 90 cases of pneumonia, one case of encephalitis, and 82 hospital admissions. Most measles cases are unvaccinated (96%) and are in the age group 4-12 years (59%). There are 11 health care workers among the cases. Of these, nine are unvaccinated and two persons are vaccinated with two doses. A recent survey found that in the Netherlands religious belief was, by far, the most common (93.6%) reason given for not getting vaccinated.
Germany update
Measles outbreaks continue in Germany. According to the Federal Ministry of Health, the number of reported measles cases this year have been nearly ten times as high as the whole of last year. As of 11 September 2013, there have been 1 520 reported cases. Most cases occurred in Bavaria, followed by Berlin and North Rhine and Westphalia.
Italy - update
The media report that the number of reported measles cases in the Milan area has reached 350 (compared to 20 cases during the whole of 2012). Most cases are adults, between 20 and 40 years of age. Rest of the world
Turkey
Turkey has reported 6 547 cases during the first half of 2013, particularly in its southern provinces. This is a nearly 20-fold increase compared to last year when 349 cases were reported.
Russian federation
In Astrakhan, there is an on-going measles outbreak involving students at the State Medical Academy and their contacts. So far, as of 18 September, 37 cases have been reported. According to the Ministry of Health in the Astrakhan region, the primary case was a student from Dagestan. There is an on-going mass vaccination of students and teachers in the institution. There is also an outbreak of measles in Kazan, the capital of the Republic of Tatarstan with 26 cases. During the first seven months of 2013, there were 720 cases of measles in 40 regions of the Republic of Tatarstan.
The U.S.
According to a recent Morbidity and Mortality Weekly Report there have been 159 cases of measles in 16 states during 1 January 24 August 2013. Eighty-two percent of the cases were unvaccinated persons. Of those who were unvaccinated, 92 (79%) had philosophical objections to vaccination. Of the 159 cases, 99% were import-associated, 50% of the importations were from the WHO European Region. Publications WHO has published:
Guidelines for measles and rubella outbreak investigation and response in the WHO European Region and a Measles and rubella elimination 2015 - package for accelerated action: 2013 2015
Web sources: ECDC measles and rubella monitoring | ECDC/Euronews documentary | WHO Epidemiological Briefs | MedISys Measles page | EUVAC-net ECDC | ECDC measles factsheet | RIVM
ECDC assessment
The transmission season for measles persists in Europe. However, although there have been several outbreaks during this season, the number of aggregated cases is lower than in the previous year. The largest outbreaks have been in Wales and the Netherlands. In the EU neighbourhood, large outbreaks affecting Georgia and Turkey give cause for concern. The target year for measles elimination in Europe is 2015. The current outbreaks suggest that endemic measles transmission
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continues in many EU Member States and the prospect of achieving the 2015 objective is diminishing. During the period August 2012-July 2013, 11 of the 30 EU/EEA countries met the elimination target of less than one case of measles per million population.
Actions
ECDC monitors measles transmission and outbreaks in the EU and neighbouring countries in Europe on a monthly basis through enhanced surveillance and epidemic intelligence activities. Elimination of measles requires consistent vaccination coverage above 95% with two doses of measles vaccine in all population groups, strong surveillance and effective outbreak control measures.
West Nile virus - Multistate (Europe) - Monitoring season 2013

Opening date: 3 June 2013 Latest update: 26 September 2013
As of 27 September 2013, 187 human cases of West Nile fever have been reported in the EU and 464 cases in neighbouring countries since the beginning of the 2013 transmission season. EU Member States
Croatia
Croatia has recorded 11 cases of WNV so far this year. Ten new probable cases were reported last week, one case from Medimurska county and nine cases from the Zagrebacka county, an area with one previous case report. In addition, the first probable case reported in Zagrebacka County on 23 August 2013 is now a confirmed case. For the remaining cases, final laboratory confirmation results are still pending. The city of Zagreb has been identified as the possible place of infection of three already reported cases.
Greece
Eighty-one cases of West Nile virus (WNV) have been reported in Greece. The regions affected are Attiki (35), Imathia (2), Kavala (10), Thessaloniki (6), Xanthi (16), Kerkyra (1), Serres (5) Ileia (1), Pella (4) and one case was reported in the previous week where the place of infection is not available at the moment.
Italy
Italy has reported 59 cases of WNV. The provinces affected are Modena (15), Rovigo (9), Verona (6), Reggio Emilia (5), Mantova (5), Bologna (2), Padova (1), Ferrara (5), Parma (3), Cremona (2) and newly affected areas Treviso (4) and Venezia (2).
Hungary
Hungary has reported 18 cases so far this year. The counties affected are: Fejer (2), Pest (3), Komaron (1), Bks (2), Budapest (3), Csongrd (2), Hajd-Bihar (2), Jsz-Nagykun-Szolnok (1), Heves (1) and Bcs-Kiskun (1).
Romania
Romania has reported 18 cases of WNV. The counties affected are Braila (4), Ialomita (3), Iasi (2), Galati (2), Constanta (2), Tulcea (1), Bucuresti (2) and the newly affected counties Ilof (1) and Mures (1).
Spain
On 19 September 2013, the Andalusia Ministry of Agriculture in Spain detected two horses with West Nile encephalitis in the newly affected province of Huelva. Neighbouring countries
Bosnia and Herzegovina

One case of WNF has been reported in Tuzlansko-podrinjski canton.
Israel
Fifty-six cases of WNV have been reported in Israel. The affected districts are Central (27), Haifa (17), Tel Aviv (11) and the newly affected Southern district (1)
Montenegro
Montenegro has reported two cases so far this year. One case in Podgorica region, an area suspected to be affected last year. The second case was recorded this week in the newly affected Cetinje region.
Serbia
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Serbia has reported 238 cases of WNF from eight districts: Grad Beograd (144), Podunavski (13), Sremski (9), Juzno-backi (4), Juzno-banatski (40), Kolubarski (10), Macvanski (3) Branicevski district (2), Jablancki (1), Srednje-banatski (4), Severno-banacki (3) Moravicki (2), Severno-banatski (1), Zapadno-backi (1), and one case in the newly affected Zlatiborski district.
the former Yugoslav Republic of Macedonia

One case has been reported in Kocani (Eastern Macedonia).
Russia
Russia has reported 165 cases of WNF from ten oblasts and one republic in Russia: Adygeya oblast (1), Astrakhanskaya oblast (61), Lipetskaya oblast (2), Rostovskaya oblast (8), Samarskaya oblast (9), Saratovskaya oblast (28), Volgogradskaya oblast (48), Voronezhskaya oblast (3), Belgorodskaya oblast (2) Kaluzhskaya oblast (1), Omskaya oblast (1) and the newly affected Orenburgskaya oblast (1).
Ukraine
The first case for this year was reported in Zhytomyrs ka oblast. Websources: ECDC West Nile fever risk maps | ECDC West Nile fever risk assessment tool | Volgograd oblast | Serbia MoH | Macedonian PH Institute | Croatia PHI | Israel MoH |
ECDC assessment
The 2013 season is progressing in comparable fashion to previous years in the EU and neighbouring countries. West Nile fever in humans is a notifiable disease in the EU. The implementation of control measures are considered important for ensuring blood safety by the national health authorities when human cases of West Nile fever occur. According to the EU blood directive, efforts should be made to defer blood donations from affected areas with ongoing virus transmission to humans.
Actions
ECDC produces weekly West Nile fever risk maps during the transmission season to inform blood safety authorities regarding affected areas. ECDC published a West Nile fever risk assessment tool on 3 July 2013.
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ECDC
Rubella - Multistate (EU) - Monitoring European outbreaks

Opening date: 7 March 2012 Latest update: 3 July 2013
The 27 EU/EEA countries contributing to enhanced rubella surveillance reported 37 856 cases during the last 12-month period between August 2012 and July 2013. Of the 27 contributing countries, 25 reported data for the entire period. Poland accounted for 99% of all reported rubella cases in the 12-month period.
Web sources:ECDC measles and rubella monitoring | ECDC rubella factsheet | WHO epidemiological brief summary tables | WHO epidemiological briefs
ECDC assessment
As rubella is typically a mild and self-limiting disease with few complications, the rationale for eliminating rubella would be weak if it were not for the virus teratogenic effect. When a woman is infected with the rubella virus within the first 20 weeks of pregnancy, the foetus has a 90% risk of being born with congenital rubella syndrome (CRS), which entails a range of serious incurable illnesses. The increase in the number of rubella cases reported in 2012 and 2013 mainly due to the large outbreaks in Romania and Poland and the potential for an increase in the number of babies born with CRS are cause for concern.
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Actions
ECDC closely monitors rubella transmission in Europe by analysing the cases reported to the European Surveillance System and through its epidemic intelligence activities on a monthly basis. Twenty-four EU and two EEA countries contribute to the enhanced rubella surveillance. The purpose of the enhanced rubella monitoring is to provide regular and timely updates on the rubella situation in Europe in support of effective disease control, increased public awareness and the achievement of the 2015 rubella and congenital rubella elimination target. An ECDC report is available online: Survey on rubella, rubella in pregnancy and congenital rubella surveillance systems in EU/EEA countries
Poliovirus - Israel- Detection of WPV1 in environmental samples and healthy individuals

Opening date: 19 August 2013 Latest update: 26 September 2013
Wild poliovirus type 1 (WPV1) was first isolated from sewage samples collected between 7 and 13 April 2013 in Beer Sheva and Rahat in southern Israel. WPV1-specific analysis of samples indicated WPV1 introduction into that area in early February 2013. WPV1 has been detected in 96 sewage samples from 27 sampling sites all across Israel since then, indicating widespread transmission throughout the country. The strain is related to strains circulating in Pakistan and also to the strain detected in sewage from Cairo in December 2012. It is unrelated to the polioviruses circulating in the Horn of Africa. In addition, as part of subsequent on-going stool sample survey activities, WPV1 has also been isolated in stool samples from 42 asymptomatic carriers. Israel has been free of indigenous WPV transmission since 1988. In the past, WPV has been detected in environmental samples collected in this region between 1991 and 2002 without occurrence of cases of paralytic polio in the area. Three positive samples have also been collected from the West Bank and Gaza (the most recent on 20 August). Previous and subsequent specimens collected through environmental surveillance since 2002 in both Gaza and the West Bank have consistently tested negative for the presence of WPV. No case of paralytic polio has been reported in either Israel or the West Bank and Gaza. Web sources: MoH Israel | WHO DON
ECDC assessment
The World Health Organization (WHO) estimates the risk of further international spread of WPV1 from Israel to remain moderate to high. ECDC, as stated in a recently published risk assessment, considers that there is a risk of importation and re-establishment of WPV into the EU via a recently infected person shedding the virus, if we consider the significant population flow from and to countries where WPV is still circulating, as well as the sub-optimal potential for early detection of the virus in both the environment and the population. The overall threat can be considered to be very low in OPV vaccinees for both poliovirus infection and disease; moderate in IPV-only cohorts for poliovirus infection and low for disease; and high in low or unvaccinated groups for poliovirus infection and moderate for disease. The highest level of risk is posed by the proximity of clustered un- or under-immunised population groups to large populations vaccinated using IPV-only schemes. Sub-optimal hygiene and crowded living conditions may also play a role in facilitating the spread of infection. Web sources: ECDC Risk Assessment|
Actions
Nationwide measures to prevent cases of poliomyelitis and stop the environmental spread of the virus have been adopted in Israel, including a supplementary immunisation activity with bivalent oral polio vaccine (OPV1 and 3) with the aim of boosting
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mucosal immunity levels in cohorts of children nave to OPV in order to rapidly interrupt virus circulation. ECDC supports WHO recommendations that all countries, in particular those with frequent travel and contacts with polio-infected countries, strengthen surveillance for cases of acute flaccid paralysis (AFP), in order to rapidly detect new poliovirus importations and facilitate a rapid response. Countries should also analyse routine immunisation coverage data to identify subnational gaps in population immunity to guide catch-up immunisation activities and thereby minimise the consequences of new virus introduction. Priority should be given to areas at high risk of importations and where OPV3/DPT3 coverage is <80%. All travellers to and from polio-infected areas should be fully vaccinated against polio. Three countries remain endemic for indigenous transmission of WPV: Nigeria, Pakistan and Afghanistan. Additionally, in 2013, the Horn of Africa is affected by an outbreak of WPV . ECDC will close this threat and monitor this event through routine epidemic intelligence activities from 27 September 2013.
Middle East respiratory syndrome- coronavirus (MERS CoV) - Multistate

Opening date: 24 September 2012 Latest update: 26 September 2013
As of 26 September 2013, 133 laboratory-confirmed cases of MERS-CoV, including 60 deaths worldwide have been reported by national health authorities. All cases have either occurred in the Middle East or have had direct links to a primary case infected in the Middle East. Saudi Arabia has reported 111 symptomatic or asymptomatic cases including 49 deaths, Jordan two cases, who both died, United Arab Emirates five cases including one fatality and Qatar three cases including two deaths. Twelve cases have been reported from outside the Middle East: in the UK (4), Italy (1), France (2), Germany (2) and Tunisia (3). In France, Tunisia and the United Kingdom, there has been local transmission among patients who have not been to the Middle East but have been in close contact with laboratory-confirmed or probable cases. Person-to-person transmission has occurred both among close contacts and in healthcare facilities. However, with the exception of a possible nosocomial outbreak in Al-Ahsa, Saudi Arabia, secondary transmission has been limited. Sixteen asymptomatic cases were reported by Saudi Arabia and two by the UAE. Seven of these cases were healthcare workers. The Ministry of Health of Saudi Arabia updated its Health Regulations for travellers to Saudi Arabia for the Umrah and Hajj pilgrimage regarding MERS-CoV and now recommends that the elderly, those with chronic diseases, pilgrims with immune deficiency, malignancy and terminal illnesses, pregnant women and children coming for Hajj and Umrah this year should postpone their journey. WHO published a travel advice on MERS-CoV for pilgrimages on 25 July 2013. On 18 September WHO has issued an interim recommendation to laboratories and stakeholders involved in laboratory testing for Middle East respiratory syndrome coronavirus (MERS-CoV). The WHO third meeting of the Emergency Committee was held by teleconference on, 25 September 2013. The Committee concluded that it saw no reason to change its advice to the Director-General. Based on the current information, and using a risk-assessment approach, it was the unanimous decision of the Committee that the conditions for a Public Health Emergency of International Concern (PHEIC) have not at present been met. Web sources: ECDC RRA Update 26 September | ECDC novel coronavirus webpage | WHO | WHO MERS updates | WHO travel health update | WHO Euro MERS updates | CDC MERS | Saudi Arabia MoH | Qatar SCH | Eurosurveillance article | Eurosurveillance article 26 September
ECDC assessment
The continued detection of MERS-CoV cases in the Middle East indicates that there is an ongoing source of infection present in the region. The source of infection and the mode of transmission have not been identified.There is therefore a continued risk of cases occurring in Europe associated with travel to the area. Surveillance for cases is essential, particularly with expected increased travel to Saudi Arabia for the Hajj in October. The risk of secondary transmission in the EU remains low and could be reduced further through screening for exposure among patients presenting with respiratory symptoms and their contacts, and strict implementation of infection prevention and control measures for patients under investigation.
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Actions
The latest ECDC rapid risk assessment was published on 26 September 2013. The results of an ECDC coordinated survey on laboratory capacity for testing the MERS-CoV in Europe were published in EuroSurveillance. ECDC published a Public Health Development on 27 August 2013 regarding the isolation of MERS-CoV from a bat sample. The first 133 cases are described in EuroSurveillance published on 26 September 2013. ECDC is closely monitoring the situation in collaboration with WHO and the EU Member States.
Distribution of confirmed cases of MERS-CoV by month* and place of probable infection, March 2012 - 26 September 2013 (N=133)
ECDC SRS
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Distribution of confirmed cases of MERS-CoV by age and gender, March 2012 - 26 September 2013 (n=128*)
ECDC SRS
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Distribution of MERS-CoV cases by place of reporting as of 26 September 2013

ECDC SRS
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The Communicable Disease Threat Report may include unconfirmed information which may later prove to be unsubstantiated.
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Communicable Disease Threats Report 28 Sep 2013

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COMMUNICABLE DISEASE THREATS REPORT

CDTR Week 39, 22-28 September 2013

West Nile virus - Multistate (Europe) - Monitoring season 2013

Rubella - Multistate (EU) - Monitoring European outbreaks