ORIGINAL ARTICLE

Epidemiologic and laboratory surveillance of the measles outbreak in the

Federation of Bosnia and Herzegovina, February 2014–April 2015

I. Salimovi
c-Besi 
c1, M. Seremet1
, J. M. Hübschen8, M. Hukic2,3, N. Tihic6, S. Ahmetagic7, Z. Delibegovic6, A. Pilav4,
c5, J. Ravlija5, C. P. Muller8 and A. Dedeic-Ljubovic1
M. Mulaomerovi
1) Department of Clinical Microbiology, University Clinical Centre Sarajevo, 2) Department of Genetics and Bioengineering, International Burch University,
Ilidza, 3) Department of Medical Sciences, Academy of Sciences and Arts of Bosnia and Herzegovina, 4) Department for Public Health, Monitoring and Evaluation,
Federal Ministry of Health, 5) Department of Epidemiology, Institute for Public Health of Federation Bosnia and Herzegovina, Sarajevo, Bosnia and
Herzegovina, 6) Department of Microbiology, Polyclinic of Laboratory Diagnostics, 7) Department for Infectious Diseases, University Clinical Center Tuzla, Tuzla,
Bosnia and Herzegovina and 8) Department of Infection and Immunity, WHO European Regional Reference Laboratory for Measles and Rubella, Luxembourg
Institute of Health, Esch-sur-Alzette, Luxembourg

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.
© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Keywords: Bosnia and Herzegovina, measles, measles–mumps–rubella (MMR) vaccine, outbreaks, vaccine-preventable diseases, vaccines
and immunization
Original Submission: 8 October 2015; Revised Submission: 18 January 2016; Accepted: 19 February 2016
Editor: L. Kaiser
Article published online: 27 February 2016

Corresponding author: I. Salimovic-Besic, University Clinical
Centre Sarajevo, Department of Clinical Microbiology, Bolnicka 25,
71000 Sarajevo, Bosnia and Herzegovina
E-mail: irma.salimovic_besic@yahoo.com
Introduction
Measles is a highly contagious viral disease caused by the
measles virus, which belongs to the genus Morbillivirus within
the family Paramyxoviridae [1]. A characteristic rash develops
several days after infection in the face and the upper neck and
gradually spreads to the rest of the body. In some cases measles

Clin Microbiol Infect 2016; 22: 563.e1–563.e7

© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved
http://dx.doi.org/10.1016/j.cmi.2016.02.005
563.e2 Clinical Microbiology and Infection, Volume 22 Number 6, June 2016
can cause serious complications, including pneumonia, ear in-
fections, blindness, encephalitis and severe diarrhoea [1].
The World Health Organization (WHO) currently recog-
nizes eight clades of measles virus and 24 genotypes (A, B1–B3,
C1, C2, D1–D11, E, F, G1–G3, H1 and H2) [2]. Sequence
variants within genotypes provide a more sensitive epidemio-
logic surveillance of measles strains [2].
Immunoprophylaxis is the best protection against measles
and its complications, and the benefit of vaccination by far
exceeds its potential adverse effects. In the Federation of Bosnia
and Herzegovina (FB&H), children have been vaccinated against
measles since 1970, and since 1981 the combined measles–
mumps–rubella (MMR) vaccine is in use, as recommended by
the WHO. The first dose is normally given at 12 months of age
and the second dose at the age of 6 years (http://www.zzjzfbih.
ba/wp-content/uploads/2014/02/VODI%C4%86-ZA-NAD-
ZOR-NAD-MORBILIMA.pdf) [3]. In 2013, 17 825 children up
to 2 years of age in FB&H received the first and 17 754 children
at the age of 6 years received the second dose of MMR vaccine,
and no adverse effects or serious complications were reported
(http://www.zzjzfbih.ba/wp-content/uploads/2014/02/VODI%
C4%86-ZA-NADZOR-NAD-MORBILIMA.pdf).
In recent years FB&H has faced several outbreaks of vaccine-
preventable diseases. In 2009–2010 a rubella epidemic involved
1900 cases [4]. This was followed by an epidemic of mumps in
2010–2012 with 7895 reported cases [5,6] and a measles
outbreak in 2014–2015. After the last measles outbreak in
FB&H in 2007 caused by genotype D4 [7] until the beginning of
2014 (February) only sporadic cases of measles were reported
(http://www.zzjzfbih.ba/page/6/?s=morbili).
The purpose of this article is to describe the ongoing measles
outbreak in FB&H combining both epidemiologic and labora-
tory data. The causes of the outbreak as well as potential
measures to prevent future outbreaks of vaccine-preventable
diseases in FB&H are discussed.
Methods
Case investigation
Clinical case definition of suspected measles involved any per-
sons with fever along with generalized maculopapular rash, and
cough, coryza or conjunctivitis [8]. Suspected cases are re-
ported by medical doctors to the Institute for Public Health of
FB&H, which collects all relevant patient information. Between
February 2014 and April 2015 epidemiologic data of 4649
clinically suspected measles cases were collected (http://www.
zzjzfbih.ba/morbili/). The vaccination status of patients was
obtained from their medical records or, if unavailable for adults,
was recorded during anamnesis. Attack rates, expressing the
© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 22, 563.e1–563.e7
CMI
number of cases within the total population in a given area
during a defined period of the outbreak, were calculated for
each canton and the entire FB&H [8].
Sample collection
Between 1 February 2014 and 30 April 2015 a total of 281
patient sera and 44 nasopharyngeal swab samples were
received for laboratory analysis. Sera only were available from
254 patients, swabs only from 17 patients and paired serum and
nasopharyngeal swabs from 27 patients. Thus, overall, 298 pa-
tients were laboratory investigated. Their average age was
17.86 years (range <1–68 years). A single blood sample was
taken at first contact with a healthcare provider and, as rec-
ommended, within 28 days after rash onset [8]. The swabs
were obtained within 7 days of rash onset from patients hos-
pitalized at University Clinical Centre Sarajevo (Sarajevo
Canton), University Clinical Center Tuzla (Tuzla Canton) or
Cantonal Hospital Zenica (Zenica-Doboj Canton). One serum
sample and a nasopharyngeal swab were collected from a pa-
tient with meningitis hospitalized at the University Clinical
Center Tuzla but originating from outside of FB&H (District
Brcko).
Serology
Routine laboratory confirmation of suspected cases was based
on detection of measles-specific immunoglobulin (Ig) M anti-
bodies performed either at the University Clinical Centre
Sarajevo, Department for Clinical Microbiology or University
Clinical Center Tuzla, Polyclinic of Laboratory Diagnostics,
Department of Microbiology, using a commercial indirect
enzyme immunoassay kit (Enzygnost Anti-Measles Virus/IgM;
Siemens, Marburg, Germany) and the fully automated instru-
mentation system BEP 2000 Advance (Siemens, Marburg,
Germany). Serologic results were expressed as the difference in
absorbance ΔA multiplied by the correction factor (ΔA nomi-
nal value/mean ΔA valueReference P/P). On the basis of the criteria
of the test, the samples were classified as follows: IgM results
were scored as negative (ΔA < 0.100), equivocal
(0.100  ΔA  0.200) or positive (ΔA > 0.200), as recom-
mended by the manufacturer.
Measles virus PCR
Detection of virus RNA was used alone or to complement
serologic testing and was carried out at the University Clinical
Centre Sarajevo. RNA extraction was done according to the
QIAamp Viral RNA Mini kit protocol (Qiagen, Hilden, Ger-
many). For nested reverse transcriptase (RT)-PCR, previously
published primer sets were used (MN1/MN2 and MN3/MN4)
[9], with the difference that reverse transcription and first
round amplification were done in a one-step format.
CMI
Sequence analysis
A total of 30 nasopharyngeal swabs were forwarded to the
WHO European Regional Reference Laboratory for Measles
and Rubella in Luxembourg for sequencing and genotyping.
Sequences were analysed by SeqScape Software 2.5 (Thermo
Fisher Scientific Life Sciences, Waltham, MA, USA), BioEdit
version 7.0.9.0 [10] and molecular evolutionary genetics anal-
ysis (MEGA4) software [11]. Neighbour-joining phylogenetic
trees based on the Kimura two-parameter model were con-
structed using 450 nucleotides coding for the COOH-terminal
150 amino acids of the measles virus nucleoprotein. The rec-
ommended set of reference sequences [2], current sequence
variants of genotype D8 and close BLAST (Basic Local Align-
ment Search Tool) fits of sequences from FB&H were included
in the phylogenetic analysis. All new sequences were submitted
to the MeaNS (http://www.who-measles.org/Public/Web_
Front/main.php) and GenBank databases.
Results
Description of outbreak
The first two measles cases reported from Bugojno beginning
of February 2014 were teenage siblings who had recently
visited Germany [12]. The first laboratory-confirmed measles
case (11 February 2014) linked to the outbreak was an un-
vaccinated 13-year-old girl. The disease spread among school-
children from different municipalities of the Central Bosnia
Canton. Beside this canton, another five cantons of FB&H were
affected: Sarajevo, Una-Sana, Tuzla, Zenica-Doboj and
Herzegovina-Neretva (Fig. 1); a single sporadic case was
recorded in the Posavina Canton. A total of 4649 suspected
cases were reported between 1 February 2014 and 30 April
700
600
500
Number of cases
400
300
200
100
0
Month/Year
FIG. 1. Number of cases by month in six most affected cantons in Federation of Bosnia and Herzegovina.
© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 22, 563.e1–563.e7
Salimovi
c-Besi
c et al. Measles outbreak in FB&H, 2014–2015 563.e3
2015 (Table 1). According to the latest estimation of the
population density (http://www.fzs.ba/Podaci/Brojke2014.pdf)
Central Bosnia Canton had the highest attack rate (1283/
253 149, 0.51%) (Table 1). Two distinct epidemic waves were
observed. The first wave occurred between week 7 (February)
and week 36 (September) of 2014 and the second from week
37 (September) of 2014 to at least week 18 (April) of 2015. A
drop in case numbers was observed in weeks 36 and 37 of
2014, with only 19 cases each (Fig. 1). Central Bosnia and
Sarajevo had the highest numbers of cases during the first
epidemic wave (2063/2407, 85.71%), while during the second
wave mainly the cantons of Una Sana and Tuzla were affected
(1696/2242, 75.64%).
The highest proportion of cases was found in the 15- to 19-
year age group (814/4649, 17.51%) and the lowest in children
under 1 year of age (484/4649, 10.41%) (Fig. 2).
Two-thirds of the patients had never received the measles
vaccine (3115/4649, 67.00%), and the vaccination status of
about one quarter was unknown (1066/4649, 22.92%). About
8% of the patients (376/4649, 8.09%) were immunized with
one dose of measles-containing vaccine, while only about 2%
(92/4649, 1.98%) had received two doses of the MMR vaccine.
Figure 2 suggests that the proportion of patients without
vaccination decreased with age, while the proportion with
unknown vaccination status increased. Children below 1 year
of age are not eligible for vaccination according to the immu-
nization schedule in FB&H, but for some of them (21/484,
4.34%) an unknown status was declared since their vaccination
records were not available. Children aged <6 years were in
principle not eligible for the second dose of vaccine, as indi-
cated by the average percentage of patients with a single vac-
cine dose in the age brackets 1–4 and 5–9 years (10.99 vs.
8.09%, Fig. 2).
Una-Sana Canton
Tuzla Canton
Zenica-Doboj Canton
Central Bosnia Canton
Herzegovina-Neretva
Canton
Sarajevo Canton
FB&H
563.e4 Clinical Microbiology and Infection, Volume 22 Number 6, June 2016 CMI

TABLE 1. Outbreak attack rate estimated for involved cantons of the FB&H during the first and the second wave of the outbreak

No. of cases Attack rate (%) No. of cases Attack rate (%) No. of casesb Attack rate (%)

Canton Population no. a

Outbreak’s first wave Outbreak’s second wave Total

Una-Sana 287 621 151 0.05 546 0.19 697 0.24

Posavina 3896 0 NA 1 0.00 1 0.00
Tuzla 498 911 16 0.00 1150 0.23 1166 0.23
Zenica-Doboj 398 655 142 0.04 138 0.03 280 0.07
Central Bosnia 253 149 1259 0.50 24 0.01 1283 0.51
Herzegovina-Neretva 224 388 35 0.02 36 0.02 71 0.03
Sarajevo 442 669 804 0.18 347 0.08 1151 0.26
FB&H 2 337 200 2407 0.10 2242 0.10 4649 0.20

The attack rate expresses the number of cases among the total population in a given area during a defined period of the outbreak [8].
a
Estimation as of 30th June 2013 (http://www.fzs.ba/Podaci/Brojke2014.pdf).
b
Number of cases until 30th April 2015.

Laboratory results
About 57% (161/281) of the serum samples were IgM positive.
Among all swab samples analysed by RT-PCR, 95.45% (42/44)
were positive. The two negative samples were also negative by
nested PCR. Of the 27 patients with paired serum and swab
samples, 26 were IgM/RT-PCR double positive and 1 was IgM/
nested RT-PCR double negative.
A total of 30 samples (18 from the first wave collected
during 11 February–23 July 2014 and 12 from the second wave
collected during 6 to 21 February 2015) were sequenced
(GenBank accession nos. KR632648–KR632676 and
KR704878).
All sequences belonged to genotype D8. The two sequence
variants differed by two nucleotides in the 450 nucleotide re-
gion of the measles virus N gene. One variant was found in both
the first and second outbreak waves (n = 22) and had previously
been reported from different European countries such as Italy,
Slovenia, Sweden and Austria as well as the United States
(Fig. 3). The second variant (n = 8) was found only during the
second outbreak wave, and no identical strains were identified
by BLAST (Fig. 3). Sequences from Germany and Slovenia
differed by at least one nucleotide from this new variant (Fig. 3).
Discussion
Most patients with measles were not vaccinated or had an
unknown vaccination status. Gaps in the immunization program
in the war (1992–1995) and postwar period (1996–1998) left
many children susceptible to measles, rubella and mumps
[4–6]. At the time of the current outbreak, the war generation
had reached the age of 16 to 23 years, largely falling into the
most affected age bracket. The high incidence in the 1- to 9-
year-old children may be related to the insufficient

Unknown vaccination status 0 doses 1 dose 2 doses

Total 1066 3115 376 92 100% (4649)

≥ 30 years 363 290 42 8 15.12% (703/4649)

20-29 years 216 308 51 14 12.68% (589/4649)

Age group

15-19 years 191 521 71 31 17.51% (814/4649)

10-14 years 100 419 50 16 12.58% (585/4649)

5-9 years 85 500 78 22 14.73% (685/4649)

1-4 years 90 614 84 1 16.97% (789/4649)

< 1 year 21 463 10.41% (484/4649)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Number of cases and percentage

FIG. 2. Measles cases and their vaccination status by age group during epidemic in Federation of Bosnia and Herzegovina, February 2014–April 2015
(n = 4649).
© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 22, 563.e1–563.e7
 MVs/Tuzla.BIH/6.15
MVs/Gradacac.BIH/6.15
MVs/Lukavac.BIH/5.15/2
MVs/Lukavac.BIH/5.15
MVs/Lukavac.BIH/6.15
MVs/Lukavac.BIH/7.15
MVs/Tuzla.BIH/6.15/2
MVs/Lukavac.BIH/6.15/2
MVs/Fuerth.DEU/31.14 D8 KM586153
MVs/Celje.SVN/3.15/2 D8 KP835278
MVs/Hadzici.BIH/23.14
MVs/Sarajevo.BIH/23.14/2
MVs/Sarajevo.BIH/13.14/2
MVs/Florida.USA/12.15 D8 KR914665
MVs/Brcko.BIH/7.15
MVs/Fojnica.BIH/23.14
MVs/Sarajevo.BIH/23.14
MVs/Banovici.BIH/7.15
MVs/Bolzano.ITA/04.15 D8 KR349627
MVs/Sarajevo.BIH/23.14/3
MVs/Tuzla.BIH/7.15
89
MVs/Sarajevo.BIH/30.14/2
MVs/Bugojno.BIH/07.14/2
MVs/Sarajevo.BIH/13.14
MVs/Tuzla.BIH/5.15
MVs/Malmo.SWE/19.15/2 D8 KT099182
MVs/Visoko.BIH/16.14
MVs/Sarajevo.BIH/30.14
MVs/Sarajevo.BIH/13.14/4
99
MVs/Bugojno.BIH/07.14
MVs/Sarajevo.BIH/23.14/4
MVs/Fojnica.BIH/23.14/2
MVs/Visoko.BIH/16.14/2
MVs/NovaGorica.SVN/15.15/2 D8 KR780259
MVs/Sarajevo.BIH/13.14/3
MVs/Bugojno.BIH/07.14/3
98 MVs/Gaenserndorf.AUT/51.13 D8 KJ494386
MVs/Frankfurt Main.DEU/17.11 D8 KF683445
MVi/Villupuram.IND/03.07 D8 FJ765078
99
MVs/Taunton.GBR/27.12 D8 JX984461
94 MVs/Swansea.GBR/4.13 D8 KF214761
MVi/Manchester.GBR/30.94 D8 AF280803
88 MVi/Hulu Langat.MYS/26.11 D8 JX486001
MVi/Menglian.Yunnan.CHN/47.09 D11 GU4405
MVi/Victoria.AUS/16.85 D7 AF243450
78 MVi/Illinois.USA/50.99 D7 AY037020
MVi/Montreal.CAN/0.89 D4 U01976
MVi/Victoria.AUS/12.99 D9 AF481485
MVi/Illinois.USA/0.89/1 D3 U01977
MVi/Palau/0.93 D5 L46758
MVi/Bangkok.THA/0.93/1 D5 AF079555
MVi/Johannesburg.ZAF/0.88/1 D2 U64582
MVi/Kampala.UGA/51.01/1 D10 AY923185
MVi/Bristol.GBR/0.74 D1 D01005
MVi/New Jersey.USA/0.94/1 D6 L46750
81 MVi/Amsterdam.NLD/49.97 G2 AF171232
71 MVi/Gresik.IDN/17.02 G3 AY184217
MVi/Berkeley.USA/0.83 G1 U01974
MVi/Hunan.CHN/0.93/7 H1 AF045212
85 MVi/Beijing.CHN/0.94/1 H2 AF045217
MVs/Madrid.ESP/0.94(SSPE) F X84865
99 MVi/Maryland.USA/0.77 C2 M89921
MVi/Erlangen.DEU/0.90 C2 X84872
MVi/Tokyo.JPN/0.84 C1 AY043459
MVi/Goettingen.DEU/0.71 E X84879
MVi/Maryland.USA/0.54 A U01987
MVi/Libreville.GAB/0.84 B2 U01994
FIG. 3. Phylogenetic tree showing MVi/Yaounde.CMR/12.83 B1 U01998
89
MVi/New York.USA/0.94 B3 L46753
measles viruses involved in outbreak in
74 MVi/Ibadan.NGA/0.97/1 B3 AJ232203
Federation of Bosnia and Herzegovina
during February 2014–April 2015. 0,01

© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 22, 563.e1–563.e7
563.e6 Clinical Microbiology and Infection, Volume 22 Number 6, June 2016
vaccination coverage due to the more recently emerging anti-
vaccination activities in FB&H and abroad [12–14], but also to
the often late and inadequate control measures to primary
outbreaks in school settings [12].
For the successful elimination of measles, a vaccine
coverage of at least 95% is required (http://apps.who.int/iris/
bitstream/10665/44855/1/9789241503396_eng.pdf). In FB&H,
the average coverage rate of MMR1 between 1998 to 2014
was 87.05% (lowest in 1999 with 80.70%; highest in 2007 with
96.20%), and for MMR2 was 83.92% (minimum 53.00% in
2006; maximum 91.90% in 2008) (Institute for Public Health
FB&H, unpublished data). Vaccine coverage is particularly low
in Roma children in B&H [15]: only 22% of 18-month-old
children had received their MMR1 dose, which is recom-
mended at 12 months of age. The Roma population was
affected by the current outbreak, but unfortunately ethnicity
is not recorded in the questionnaires. According to unpub-
lished data, the largest number of Roma live in Tuzla Canton,
followed by Sarajevo Canton, which were two of the three
cantons with the highest incidence rates. Differences in
ethnicity, vaccine coverage, compliance with review policies of
vaccination records and potentially also travel habits may
partially explain why essentially only six of the ten cantons of
FB&H were affected by the outbreak. The second epidemic
wave may be partially explained by large-scale migrations
between May and September 2014 due to catastrophic floods,
in particular in Zenica-Doboj, Tuzla, Una-Sana and Posavina
cantons.
The 92 patients (1.98%) who were fully immunized may have
had primary or secondary vaccine failure [16].
No discrepancy was observed between IgM serology and
nested RT-PCR for 27 patients with paired samples collected
between day 1 and 12 after rash onset. However, the low
overall IgM positivity (56.58%) may be partly the result of
cocirculation of other rash/fever-causing agents such as rubella
virus, parvovirus B19 or human herpesvirus 6. Unfortunately,
data on the differential diagnosis of febrile rash illness were not
available, except for 38 patients, two of whom were IgM pos-
itive for other pathogens (rubella and Coxsackie virus). Because
laboratory request forms are often poorly filled out, it cannot
be completely excluded that a few of the sera were for checking
measles immunity rather than IgM antibodies. Given the huge
extent of the outbreak and the high number of suspected cases,
we do, however, not expect this number to be very high.
Despite the possibility of false-negative IgM results in samples
collected before 72 hours after rash onset, no later samples
were available for investigation.
A total of 30 PCR-positive samples were sequenced and
genotyped. Interestingly, genotype D4, which was present in
© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 22, 563.e1–563.e7
CMI
FB&H during the first quarter of 2007 (MVs/Sarajevo.BIH/
11.07/1) [7], was no longer found in 2014–2015. Instead, all
new sequences belonged to genotype D8, which seems to
have replaced D4 as endemic genotype in FB&H [12]. Geno-
type D8 is currently widespread in Europe and beyond, and
several sequence variants such as Taunton, Villupuram,
Frankfurt Main, Swansea and Hulu Langat have already been
defined (http://www.who-measles.org/Public/Web_Front/main.
php). One of two genotype D8 variants from FB&H had also
been found in several European countries and the United
States and may be part of a larger transmission chain. The
second variant was unique and has not yet been reported from
anywhere else in the world. While epidemiologic evidence
points to an introduction of the first variant from Germany,
members of the FB&H diaspora are known to live in Austria,
Italy, Slovenia, Sweden and the United States, all of which
reported the same sequence variant. All eight sequences of the
second variant were from samples obtained during the second
outbreak wave from the municipalities of Tuzla, Lukavac and
Gradacac (Tuzla Canton). During the second wave, both var-
iants were circulating only in the municipality of Tuzla. Since
only contacts with cases or cities/cantons affected by variant 1
were known, possibly the new variant emerged during the
current epidemic.
Besides the previously described contributions to outbreak
control [12], the Institute for Public Health of FB&H published a
‘Guideline for Measles Surveillance’ for healthcare professionals
(http://www.zzjzfbih.ba/wp-content/uploads/2014/02/VODI%
C4%86-ZA-NADZOR-NAD-MORBILIMA.pdf) to support the
WHO’s measles elimination efforts (http://apps.who.int/iris/
bitstream/10665/44855/1/9789241503396_eng.pdf). Further-
more, according to a recent decree, children from 6 to
12 months of age may be vaccinated against measles in outbreak
situations, provided that they are revaccinated at the age of 15
to 24 months. Immunization against measles and rubella may be
carried out in people aged 15 to 18 years who have not
received two doses of measles- and at least one dose of rubella-
containing vaccine until the age of 14 years. Administration of
one or two doses of monovalent measles vaccine (with an in-
terval of 3 months) or a single dose of monovalent vaccine
against rubella is recommended (http://www.fmoh.gov.ba/
images/federalno_ministarstvo_zdravstva/preporucujemo/
Naredba_imunizacija_21_15.pdf). Other established supple-
mentary immunization activities include vaccination of in-
dividuals who had contacts with measles patients within
72 hours of contact. However, adherence to the recommended
guidelines must be strictly enforced. Despite all these measures,
refusal of vaccines and antivaccination activities will continue to
lead to increasing numbers of susceptible children.
CMI
Conclusions
Awareness campaigns highlighting the benefits of vaccination to
support the implementation of the WHO strategic plan for
2012–2020 for measles and rubella elimination should improve
vaccine coverage and measles control. Since molecular sur-
veillance has shown that endemic genotypes can change rela-
tively quickly, constant monitoring of cases and outbreaks is
necessary, and the timely sharing of data is critical.
In addition to gaps in vaccination coverage during the war
and postwar period (1992–1998), vaccine refusal due to anti-
vaccination activities contributed to the recent measles
outbreak. Differences in ethnicity, vaccine coverage, compli-
ance with review policies of vaccination records and potentially
also travel habits may partially explain why only certain cantons
were affected. Public health recommendations for interventions
have been strengthened, but additional efforts are required to
implement them throughout the cantons.
Transparency Declaration
All authors report no conflicts of interest relevant to this
article.
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