MEASLES OUTBREAK IN A HIGH-INCOME
COUNTRY: ARE PEDIATRICIANS READY?
Group 1 / BIOSTATISTICS AND EPIDEMIOLOGY /
INTRODUCTION
Measles
• Highly communicable, viral disease (severe complications).
• Still an important cause of morbidity (illness/disease) and
mortality (death) with 140,000 deaths annually.
• Infection is rarely reported in countries where vaccination
is in immunization plan but due to the reduction of
immunization coverage, outbreaks have been reported in
recent years in countries where the measles was
considered eliminated.
o Meaning, gamay ra ang cases of measles to countries
nga strong ang vaccination plan.
o When we say “reduction of immunization”, let us consider
those from the third-world countries, like the Philippines.
- We can’t say naman nga there are only a few vaccines
gyud, it’s just that due to “financial constraints”, the
distribution of vaccines will be impacted like madugay
or gamay lang gyud ang ma distribute.
o So due to these happenings, outbreaks are reported for
the past few years in countries nga gituohan nato nga
“wala nay cases of measles”/
• In 2015, the World Health Organization (WHO) proposed a
plan to eradicate measles in Europe.
o The goal was not met as evidenced by the 2017 report of
nearly 13,000 cases in Europe.
• From the reports, infants and preschool-aged children
had the highest incidence rates.
• Some factors why children are susceptible to measles:
o Immature Immune System
- The immune system strengthens with age as children
are exposed to various pathogens and develop
immunity.
o Vaccination Schedule
- Measles vaccination typically begins at around 1 year
of age, with a second dose given later in childhood.
- Until children receive the full course of measles
vaccines, they remain susceptible to the virus.
o Malnutrition
- Children often have weakened immune systems.
Methods
• Used a retrospective, multicenter, observational study.
o Retrospective Study
- Researchers examined existing records rather than
starting a new study and collecting new data.
o Multicenter Study
- The study involves multiple secondary and tertiary
hospitals in Italy. Thus, a broader representation of the
population and increases the generalizability of the
study findings.
o Observational Study
- The researchers likely observed the progression of the
disease, recorded symptoms, and analyzed relevant
information without introducing any interventions.
• What are collected?
o Patient’s demographic data
o Presence of underlying chronic conditions
o Date and ward at hospital admission and discharge
o Initial diagnosis at admission
o Clinical presentation
o Time to read clinical diagnosis (time between symptom
onset and clinical suspect)
o Serological confirmation of measles (time between
symptom onset and availability of serological results).
• All data were extracted manually from medical records
by a single person at each center.
• The data were recorded in a standardized Microsoft Excel
dataset.
• Biologic Samples: Centralized to the National Reference
Laboratory for Measles and Rubella of the Italian Institute of
Health (Rome) for confirmation and molecular genetic
characterization by polymerase chain reaction (PCR).
Scope and Limitation
• Scope
o Children and adolescents aged <18 years and
hospitalized for clinical and laboratory-confirmed
measles infection were included in the study.
- Those with presence of clinical feature for measles.
- Those who are positive with immunoglobulin M
antibodies by ELISA Test.
• Limitations
o Children treated at home and seen in the emergency
room
Statistical Analyses
• Results were compared using the t test or Mann-Whitney
nonparametric test, as appropriate.
o T-Test
- Used to compare the means of two groups.
- Determine whether a process or treatment actually has
an effect on the population.
o Mann-Whitney Test
- Used to compare two sample means that come from
the same population, and used to test whether two
sample means are equal or not.
- Usually used when the data is ordinal or when the
assumptions of the t-test are not met.
• Categorical Variables were reported as frequencies and
percentages then compared using Fisher’s exact test.
o Fisher’s exact test
- Determines whether a statistically significant
association exists between two categorical variables.
Results
• 249 children (14.5 months/1 year and 2 and a half months):
total samples
o 170 (68.2%) children: had a known contact with measles
o 37 (14.8%) children: received 1 dose of vaccination
o 2 (0.8%) children: received 2 doses of vaccination
Discussions
• Despite the availability of an effective and safe vaccine,
measles is spreading throughout Europe due to inadequate
immunization coverage.
• The pediatricians’ ability to reach an appropriate
clinical diagnosis may have been affected by several
factors.
o (1) Children with a household/school contact with
measles commonly had appropriate and faster diagnosis
after hospital admission.
• The absolute chance of receiving an appropriate diagnosis
of measles was higher for children seen in institutions that
managed more cases.
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• Rate of Misdiagnosis: Higher in children with chronic • But there might be reasons for vaccine hesitancy of the
illnesses. people:
o A longer hospital stay compared to healthy patients o Misinformation
indicated that the presence of fever and/or skin rash was o Distrust in the healthcare system
likely due to other etiologies and required extensive o Fear of side effects
diagnostic workup. o Religious beliefs
• TAKE NOTE: o Complacency
o The measles epidemic in Italy in 2017–2018, which o Limited access to healthcare services
resulted in over 8000 cases and almost 15 deaths, had
alarming consequences due to a lack of clinical skills in POSSIBLE QUESTIONS
early diagnosis and communication, political debate Why did you choose to focus on the measles outbreak
among "no vax" (no vaccination) groups, and the delay in in a high-income country for your study?
enforcing immunization.

KEY FINDINGS
1. Accurate Diagnosis
How does the measles outbreak in a high-income
• Diagnosis is more accurate if the individual in contact to
country compare to outbreaks in low-income
someone has measles.
countries?
o This is because their symptoms were more noticeable, so
the doctors were more alert to the possibility of measles.
- Maka contribute narin ang hospitals dealing with more
measles kay most likely ang staff nila kay more
experienced in recognizing the symptoms and better
Why do you think a significant number of children with
procedures in place for identifying and diagnosing
measles in your study had a known contact with the
measles.
disease despite the availability of an effective vaccine?
o On the other hand, those individuals who did not have
contact with someone diagnosed with measles, they were
LESS likely to receive an accurate diagnosis.
- I think ang implication here kay there was no known
exposure to a confirmed case of measles, so Can you discuss the implications of the observed
healthcare workers might have faced greater complications, especially encephalitis?
challenges sa pag identify ng disease.

2. Most Patients in the Study Were Not Fully-

Vaccinated
• This lack of proper vaccination contribute to the spread of In your opinion, what measures should be taken to
disease. ensure broader coverage of immunization, especially
• Not vaccinated = higher risk of infection, more susceptible in the context of ongoing outbreaks?
to the virus and making it easier for measles to circulate
within the population and potentially lead to outbreaks.

3. Impact of Awareness
• Early stages of the outbreak = less awareness, leading to How effective are campaigns in preventing and
a lower rate of correct diagnosis. controlling measles outbreaks, based on your
o But later on, more cases were identified, thus, the findings?
pediatricians became more familiar with the symptoms
and clinical presentation of measles.
- So the more experience pediatricians gained during
the outbreak, the battery they became at recognizing In what ways can public health campaigns address
and correctly diagnosing cases of measles. and influence public perception to encourage
vaccination?
4. Challenges
• Measles was uncommon in Italy
• Delayed diagnosis
o So like, if ang doctor di ka identify sa case quickly, then
What role did the ELISA test and molecular tests play
di ma isolate properly or promptly ang infected individual.
in the study, and how did it contribute to the
- What happens is mag continue ang spread sa diagnosis of measles?
population.
o The slower detection of measles cases contributed to a
wider spread of the illness, making it more challenging to
control and contain the outbreak.
• Impact of the anti-vaccination movement How can ongoing professional development programs
o Since some people were unwilling to get vaccinated, so contribute to improving pediatricians' awareness of
ang remaining portion of the population were more vaccine-preventable infections?
susceptible to measles.
o If more people were not hesitant about getting vaccines,
the spread of measles could be significantly reduced, and
outbreaks could be prevented.

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