Measles cases hit record high in the European Region

Over 41 000 children and adults in the WHO European Region have been infected with measles in the first 6 months of 2018. The total number for this period far exceeds the 12-month totals reported for every other year this decade. So far, the highest annual total for measles cases between 2010 and 2017 was 23 927 for 2017, and the lowest was 5273 for 2016. Monthly country reports also indicate that at least 37 people have died due to measles so far this year.

“Following the decade’s lowest number of cases in 2016, we are seeing a dramatic increase in infections and extended outbreaks,” says Dr Zsuzsanna Jakab, WHO Regional Director for Europe. “We call on all countries to immediately implement broad, context-appropriate measures to stop further spread of this disease. Good health for all starts with immunization, and as long as this disease is not eliminated we are failing to live up to our Sustainable Development Goal commitments.”

Seven countries in the Region have seen over 1000 infections in children and adults this year (France, Georgia, Greece, Italy, the Russian Federation, Serbia and Ukraine). Ukraine has been the hardest hit, with over 23 000 people affected; this accounts for over half of the regional total. Measles-related deaths have been reported in all of these countries, with Serbia reporting the highest number of 14.

 

Uneven progress towards measles and rubella elimination

According to the latest assessment by the European Regional Verification Commission for Measles and Rubella Elimination (RVC), released today, 43 of the Region’s 53 Member States have interrupted the endemic spread of measles and 42 have interrupted rubella (based on 2017 reporting).

At the same time, the RVC expressed concerns about inadequate disease surveillance and low immunization coverage in some countries. It also concluded that chains of measles transmission continued for more than 12 months in some countries that had interrupted the endemic spread of the disease, reverting their status back to endemic.

“This partial setback demonstrates that every person who is not immune remains vulnerable no matter where they live, and every country must keep pushing to increase coverage and close immunity gaps, even after achieving interrupted or eliminated status,” says Dr Nedret Emiroglu, Director of the Division of Health Emergencies and Communicable Diseases at the WHO Regional Office for Europe.

 

Measles can be stopped

The measles virus is exceptionally contagious and spreads easily among susceptible individuals. To prevent outbreaks, at least 95% immunization coverage with 2 doses of measles-containing vaccine is needed every year in every community, as well as efforts to reach children, adolescents and adults who missed routine vaccination in the past.

While immunization coverage with 2 doses of measles-containing vaccine increased from 88% of eligible children in the Region in 2016 to 90% in 2017, large disparities at the local level persist: some communities report over 95% coverage, and others below 70%.

WHO is working closely with Member States currently facing outbreaks to implement response measures, including enhanced routine and supplemental immunization as well as heightened surveillance to quickly detect cases. WHO is also working with other countries to attain the 95% threshold.

“At this midterm juncture for the European Vaccine Action Plan, we must celebrate our achievements while not losing sight of those who are still vulnerable and whose protection requires our urgent and ongoing attention,” concludes Dr Jakab. “We can stop this deadly disease. But we will not succeed unless everyone plays their part: to immunize their children, themselves, their patients, their populations – and also to remind others that vaccination saves lives.”

All 53 countries in the Region will review midterm progress towards the goals of the European Vaccine Action Plan at the 68th session of the WHO Regional Committee for Europe, taking place in Rome, Italy, on 17–20 September 2018.

DIPHTHERIA

Diphtheria is an acute infectious disease caused by Corynebac-terium diphtheriae.The microorganism produces an exotoxin which is responsible for the resulting pathologic process. The disease is characterized clinically by a sore throat and a membrane which may cover the tonsils, pharynx and larynx.

Epidemiologic factors. The highest seasonal incidence occurs during the autumn and winter months.

Diphtheria is acquired by contact with either a case or carrier, the microorganisms being disseminated by the acts of coughing, sneezing or talking.

Pathogenesis and Pathology. Virulent diphtheria bacilli lodge in the nasopharynx of a susceptible individual. Bacterial growth taking place in the secretions and epithelial debris, a toxin is elaborated and absorbed by the local mucous membrane. The toxic effect on the cells causes tissue necrosis. In addition to the necrosis, an inflammatory and exudative reaction is also induced by the toxin. The necrotic epithelial cells, leucocytes, red cells, ftorinous material, diphtheria bacilli, and other bacterial inhabitants of the nasopharynx — all these elements combine to form the typical “membrane”. It sloughs off during the recovery period.

Clinical Manifestations. Diphtheria develops after a short incubation period of 2 to 4 days. For clinical purposes it is convenient to classify the disease in accordance with the anatomic location of the membrane. The following types of diphtheria may occur: (1) tonsillar (faucial), (2) laryngeal or laryngotracheal, (3) nasal and 4) nonrespiratory types including skin wounds, conjunctival and genital lesions.

Diagnosis. An early diagnosis of diphtheria is essential because delay of administration of antitoxin may impose a serious risk on the patient. The diagnosis of diphtheria must be made clinically.

The bacteriologic confirmation by means of culture is of the greatest importance. The method of accelerated bacteriological diagnosis when the material secured with the aid of a specially prepared moist tampon is placed in a thermostat for 4—6 hours should be more widely employed. A tellurium test has been recently employed as a method of rapid diphtheria diagnosis.

Treatment. It is necessary to isolate the patient at once. Diphtheria antitoxin must be given promptly and in adequate dosage. In severe toxic forms of diphtheria it is advisable in addition to the serum to administer intravenously a hypertonic glucose solution, give the patients vitamins in the form of nicotinic acid and ascorbic acid for a period of 2—3 weeks, some authors recommending administration of atrychnine from the 1-st days of the disease. Bed rest is very important. Other supportive measures include maintenance of hydration, a high caloric liquid or soft diet rich in vitamins, aspirin or codeine for sore throat and malaise. The patient must gargle his throat several times a day with a 2% boric acid solution. The patient’s room must be aired.

Patients with laryngeal diphtheria require special treatment. In very advanced cases with severe symptoms of growing asphyxia, if there is increasing restlessness, irritability and anxiety, associated with progressive respiratory distress, a tracheotomy is indicated for the relief of obstruction. It should be performed before the child becomes cyanotic and exhausted.

Prognosis and Complications. In spite of the low fatality rate sudden death may be caused by a variety of unpredictable events, such as (1) the sudden complete obstruction of the airway by a detached piece of membrane, (2) the development of myocarditis and heart failure, and (3) the late occurrence of the respiratory paralysis due to phrenic nerve involvement. Patients surviving following myocarditis and neuritis, the recovery is a rule.

Immunity. For determining immune status the Shick test is useful. Active immunity may be induced by either an attack of diphtheria or more commonly today by inoculations of diphtheria toxoid. Immunity following an attack of diphtheria may be either permanent or temporary; recurrent attacks of the disease are not unusual. The widespread and routine immunization of infants and children having had a profound effect on the immune status of the population at large, the incidence of diphtheria among inoculated children is lower, and the disease runs a milder course.

 

WHOOPING COUGH (PERTUSSIS)

Whooping cough is a common acute infection of childhood, highly contagious. It is caused by the Bordutellia Pertussis. The illness is characterized by a catarrhal period of nonspecific respiratory symptoms progressing to the stage of paroxysmal cough, accompanied by the typical inspiratory whoop and vomiting. It may be complicated by potentially serious involvement of the respiratory tract and the central nervous system.

Epidemiologic Factors. The disease may strike at any time of the year. Although no age is exempt from pertussis, most people have the disease in early life. Transmission is likely to occur by direct contact with an infected person (coughing, sneezing, talking). The disease is communicable from its very first days to four weeks afrer onset of typical paroxysms.

Clinical Manifestaions. The incubation period is about 7 days, seldom shorter — from 2 to 4 days, or longer — up to 21 days.

The clinical course of whooping cough is divided into 3 stages — catarrhal, paroxysmal and convalescent. The.catarrhal stage lasts for about 1 or 2 weeks. It begins with the symptoms of an upper respiratory infection or common cold. The child may appear listless and irritable. Sometimes the only manifestation is a dry hacking cough. After about a week the cough, instead of improving, gradually becomes more severe and it begins to occur in paroxysms. The paroxysmal stage lasts, as a rule, 4 to 6 weeks. The cough now comes in explosive bursts. A series of 5 to 10 short, rapid coughs are given on one expiration, followed by a sudden inspiration, associated with a characteristic sound or whoop. During the attack the child’s face becomes red or cyanotic, the eyes bulge, the tongue protrudes. Vomiting frequently follows the attack. In severe cases young unimmunized infants may stop breathing during an attack (apnea).The attacks occur more frequently at night and in a stuffy room than in one well aired or out of doors.

The convalescent stage is marked by cessation of whooping and vomiting. Little by little the number and severity of paroxysms decrease.

Diagnosis. The clinical diagnosis is made by the paroxysmal nature of the cough, the red or cyanotic appearance of the child during an attack and the associated vomiting. During the catarrhal stage it is usually impossible to differentiate pertussis on clinical grounds from the common cold, bronchitis or acute respiratory disease. At this time Bordutellia pertussis can be isolated from the nasopharynx. The white blood test may also help the diagnosis. High white blood counts with a predominance of lymphocytes are characteristic of whooping cough.

Treatment. There is no specific drug to stop the attacks. Modern cough suppressing remedies may be administered in severe cases.

Whooping cough can be effectively treated with antibiotics. The sooner one of these antibiotics is used, the better the results. The course of antibiotics treatment averages 8—12 days. Rest in bed is indicated as long as fever is present. The room should be well aired. It is important to maintain proper nutrition. The diet must be adequate, rich in vitamins, especially vitamin С. The patient should be separated from other people.

Complications. The commonest and usually the most severe complication is pneumonia. Stop of breathing during an attack is very dangerous in young children. Otitis media, atelectasis may often occur.

Immunity. As a rule, one attack of whooping cough is followed by life-long immunity. Second attacks of pertussis are rare.

Prophylaxis. Children should be immunized at the age of 5-6 months with a pertussis - diphtheria vaccine.

BRONCHITIS

This is probably the most common respiratory disorder of childhood. The inflammation affects the mucosa of the bronchial system. In the majority of cases it is harmless, but in very young patients or those weakened by ill health, it may develop into bronchopneumonia.

Bronchitis may be primary, but is very often an accompaniment of some other infection, as tuberculosis, pneumonia, influenza, whooping-cough, diphtheria. Bronchitis may occur at any age.

Etiology. Bronchitis is due to virus and bacterial infection. The microorganisms most frequently found are the staphylococcus, streptococcus, pneumococcus.

Pathology. Bronchitis is usually part of a general inflammation which may include any or all of the respiratory tract. The infection can begin at any point, and extend down as far as the alveoli, where it results in pneumonia. In a simple case the changes are usually minor: hyperemia of the bronchial mucosa and desquamation of ciliated epithelial cells, with loss of cilia; the mucous glands become distended, the bronchial secretion increases.

Symptoms. The mildest form is confined to the larger tubes. The onset may be sudden or gradual sometimes accompanied by slight fever, from 37.7°C to 38.8°C, during the first day or two usually there are but few general symptoms. Respiration may be accelerated, and is usually audible. There may be either constipation or diarrhea. The child may be restless and irritable, though giving little evidence of being sick. Catarrh of the upper passages may be associated. Usually there is a dry, hoarse cough, either mild or severe, which may interfere with the taking of food. There may be pain under sternum. When the inflammation reaches the intermediate tubes, the fever is usually higher for the first two or three days, after which it gradually declines. Both respiration and pulse are accelerated. In children over three years old bronchitis is not unlike that in adults. There is not the same danger as in infants, of the infection passing over into the smaller bronchi. Often there is no fever, the patient feels well and has a good appetite. The symptoms are cough, which is worse at night and soreness over sternum. The cough is with a small amount of whitish expectoration. The cough usually lasts from one to two weeks. In severe cases older children may complain of headache, chilliness, pain in the back, and a feeling of tightness in the chest.

Expectoration is more profuse, sometimes blood-streaked. Sometimes bronchitis may be more protracted; this is connected with the duration of the primary disease and with domestic conditions, particularly when the child is deprived of fresh air and sunlight for prolonged periods. Such unfavourable factors may lead to a number of complications, such as otitis media, pyelitis, secondary anemia. Bronchopneumonia is the most frequent complication in infants.

Prognosis is good for acute bronchitis; in childhood the conversion to chronic forms is rare. Even in protracted cases uncomplicated by pneumonia complete recovery is often obtained by proper care and improved domestic conditions.

Treatment. Bronchitis usually requires only fresh air, good ventilation of premises, a well-balanced diet. Warm baths are indicated, especially for infants. Mustard plasters and mustard packs are recommended. The symptomatic drugs administered are usually expectorants or, on the contrary, anesthetics to keep the cough down.

ACUTE BRONCHITIS

Acute bronchitis is an acute disease of the bronchi, characterized by an inflammation of their mucous membrane, caused by the chemical and biological extension of irritation from the upper air passages, often following a rhinitis or a laryngotracheitis. The larger bronchi are first affected. Affection of the smaller bronchi may be secondary to affection of the larger tubes. Further spread of the infection may cause bronchopneumonia. The condition is also found in association with influenza, measles, scarlet fever, and some of the other acute febrile diseases.

Symptoms: These are retrosternal pain, hoarseness, cough, and often soreness; there may be a slight rise of temperature, though the temperature often remains normal.

Physical Signs: Inspection of the chest is negative; the trachea and pharynx may be infected. Nothing abnormal is elicited by palpation and percussion, but on auscultation the respiratory murmur may be harsh, and numerous large moist or dry rales are found along the large bronchi, which often disappear after cough and expectoration.

CHRONIC BRONCHITIS

This is a chronic inflammatory condition of the medium sized and small bronchi, associated with destructive changes in the bronchial wall and peribronchial space. As a rule, it is a secondary disease. It is characterized by dyspnea, cough and various types of expectoration.

Most cases of chronic bronchitis occur in those past middle life. In the young it may be caused by some irritating condition within the upper air passages, the trachea or the bronchi, and also by the presence of enlarged tonsils, sinus infections, focal infections, enlarged pendulous uvula, adenoids, congenital malformation of the trachea. A foreign body in the bronchi or lungs may at times be the cause of chronic bronchitis.

Symptoms: These are cough which occurs in paroxysms, copious expectoration, absence of fever, and a history of long-standing cough.

Physical signs: A person suffering from chronic bronchitis is usually emphysematous. Inspection, therefore, will reveal an emphysematous chest. Palpation will give evidence of diminished tactile fremitus throughout the chest. Percussion will elicit a hyperresonant note, except when associated congestion of the bases is present, in which case, impaired resonance or relative dullness is obtained over these areas. On auscultation the examiner will hear low-pitched, prolonged inspiration, accompanied by low-pitched, prolonged wheezy expiration. The rales heard will be large and small, moist and dry. A profusion of all kinds of rales is usually audible in this class of cases, though the rales may disappear temporarily after the secretion has been coughed up.