Skip to main content Accessibility help
×
Home

Measles outbreak from Hong Kong International Airport to the hospital due to secondary vaccine failure in healthcare workers

  • Vincent C.C. Cheng (a1) (a2), Shuk-Ching Wong (a2), Sally C.Y. Wong (a1), Siddharth Sridhar (a3), Jonathan H.K. Chen (a1), Cyril C.Y. Yip (a1), Derek L.L. Hung (a1), Xin Li (a1), Vivien W.M. Chuang (a4), Owen T.Y. Tsang (a5), Gibson K.S. Woo (a6), Shuk-Kwan Chuang (a7) and Kwok-Yung Yuen (a3)...

Abstract

Objective:

To report an outbreak of measles with epidemiological link between Hong Kong International Airport (HKIA) and a hospital.

Methods:

Epidemiological investigations, patients’ measles serology, and phylogenetic analysis of the hemagglutinin (H) and nucleoprotein (N) genes of measles virus isolates were conducted.

Results:

In total, 29 HKIA staff of diverse ranks and working locations were infected with measles within 1 month. Significantly fewer affected staff had history of travel than non–HKIA-related measles patients [10 of 29 (34.5%) vs 28 of 35 (80%); P < .01]. Of 9 airport staff who could recall detailed exposure history, 6 (66.7%) had visited self-service food premises at HKIA during the incubation period, where food trays, as observed during the epidemiological field investigation, were not washed after use. Furthermore, 1 airport baggage handler who was admitted to hospital A before rash onset infected 2 healthcare workers (HCWs) known to have 2 doses of MMR vaccination with positive measles IgG and lower viral loads in respiratory specimens. Infections in these 2 HCWs warranted contact tracing of another 168 persons (97 patients and 71 HCWs). Phylogenetic comparison of H and N gene sequences confirmed the clonality of outbreak strains.

Conclusion:

Despite good herd immunity with overall seroprevalence of >95% against measles, major outbreaks of measles occurred among HKIA staff having daily contact with many international pssengers. Lessons from severe acute respiratory syndrome (SARS) and measles outbreaks suggested that an airport can be a strategic epidemic center. Pre-exanthem transmission of measles from airport staff to HCWs with secondary vaccine failure poses a grave challenge to hospital infection control.

Copyright

Corresponding author

Author for correspondence: Kwok-Yung Yuen, E-mail: kyyuen@hku.hk

References

Hide All
1. Moss, WJ. Measles. Lancet 2017;390:24902502.
2. Seroprevalence rates of measles virus antibodies. Centre for Health Protection. Department of Health. The Government of the Hong Kong Special Administrative Region. https://www.chp.gov.hk/en/statistics/data/10/641/701/3536.html. Accessed May 18, 2019.
3. Jost, M, Luzi, D, Metzler, S, Miran, B, Mutsch, M. Measles associated with international travel in the region of the Americas, Australia and Europe, 2001–2013: a systematic review. Travel Med Infect Dis 2015;13:1018.
4. Bitzegeio, J, Majowicz, S, Matysiak-Klose, D, Sagebiel, D, Werber, D. Estimating age-specific vaccine effectiveness using data from a large measles outbreak in Berlin, Germany, 2014/15: evidence for waning immunity. Euro Surveill 2019;24.
5. Nic Lochlainn, L, Mandal, S, de Sousa, R, et al. A unique measles B3 cluster in the United Kingdom and The Netherlands linked to air travel and transit at a large international airport, February to April 2014. Euro Surveill 2016;21.
6. Coleman, MS, Burke, HM, Welstead, BL, et al. Cost analysis of measles in refugees arriving at Los Angeles International Airport from Malaysia. Hum Vaccin Immunother 2017;13:10841090.
7. Vega, JS, Escobedo, M, Schulte, CR, et al. Notes from the field: measles transmission at a domestic terminal gate in an international airport—United States, January 2014. MMWR Morb Mortal Wkly Rep 2014;63:1211.
8. Banerjee, E, Hickman, C, Engels, K, Kenyon, C, for the Centers for Disease Control and Prevention. Notes from the field: measles transmission in an international airport at a domestic terminal gate—April–May 2014. Morb Mortal Wkly Rep 2015;64:679.
9. Watanabe, A, Kobayashi, Y, Shimada, T, et al. Exposure to H1 genotype measles virus at an international airport in Japan on 31 July 2016 results in a measles outbreak. West Pac Surveill Response J 2017;8:3739.
10. Botelho-Nevers, E, Gautret, P, Biellik, R, Brouqui, P. Nosocomial transmission of measles: an updated review. Vaccine 2012;30:39964001.
11. Cheng, VC, Lau, SK, Woo, PC, Yuen, KY. Severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection. Clin Microbiol Rev 2007;20:660694.
12. Cheng, VC, Tai, JW, Wong, LM, et al. Prevention of nosocomial transmission of swine-origin pandemic influenza virus A/H1N1 by infection control bundle. J Hosp Infect 2010;74:271277.
13. Cheng, VC, To, KK, Tse, H, Hung, IF, Yuen, KY. Two years after pandemic influenza A/2009/H1N1: what have we learned? Clin Microbiol Rev 2012;25:223263.
14. Cheng, VC, Chan, JF, To, KK, Yuen, KY. Clinical management and infection control of SARS: lessons learned. Antiviral Res 2013;100:407419.
15. Cheng, VC, Tai, JW, Lee, WM, et al. Infection control preparedness for human infection with influenza A H7N9 in Hong Kong. Infect Control Hosp Epidemiol 2015;36:8792.
16. Cheng, VC, Lee, WM, Sridhar, S, Ho, PL, Yuen, KY. Prevention of nosocomial transmission of influenza A (H7N9) in Hong Kong. J Hosp Infect 2015;90:355356.
17. Ventilation for acceptable indoor air quality. Standard 62.1 of The American Society of Heating, Refrigerating and Air-Conditioning Engineers website. https://ashrae.iwrapper.com/ViewOnline/Standard_62.1-2016, Published 2016. Accessed May 18, 2019.
18. Outbreak of measles infection at airport concluded. The Government of the Hong Kong Special Administrative Region website. https://www.info.gov.hk/gia/general/201905/17/P2019051700868.htm. Accessed May 18, 2019.
19. van Binnendijk, RS, Hahne, S, Timen, A, et al. Air travel as a risk factor for introduction of measles in a highly vaccinated population. Vaccine 2008;26:57755777.
20. Anderson, RM, May, RM. Directly transmitted infections diseases: control by vaccination. Science 1982;215:10531060.
21. Moss, WJ, Strebel, P. Biological feasibility of measles eradication. J Infect Dis 2011;204 suppl 1:S47S53.
22. Measles in Japan from 1st to 7th epidemiological week, 2019 (as of February 20, 2019). National Institute of Infectious Diseases website. https://www.niid.go.jp/niid/en/survei/2292-idwr/idwr-article-en/8654-idwrc-1907.html. Accessed Jun 29, 2019.
23. Remington, PL, Hall, WN, Davis, IH, Herald, A, Gunn, RA. Airborne transmission of measles in a physician’s office. JAMA 1985;253:15741577.
24. Bloch, AB, Orenstein, WA, Ewing, WM, et al. Measles outbreak in a pediatric practice: airborne transmission in an office setting. Pediatrics 1985;75:676683.
25. Bischoff, WE, McNall, RJ, Blevins, MW, et al. Detection of measles virus RNA in air and surface specimens in a hospital setting. J Infect Dis 2016;213:600603.
26. Cheng, VCC, Wong, SC, Wong, SCY, Yuen, KY. Directly observed hand hygiene—from healthcare workers to patients. J Hosp Infect 2019;101:380382.
27. Haralambieva, IH, Kennedy, RB, Ovsyannikova, IG, Whitaker, JA, Poland, GA. Variability in humoral immunity to measles vaccine: new developments. Trends Mol Med 2015;21:789801.
28. Defay, F, De Serres, G, Skowronski, DM, et al. Measles in children vaccinated with 2 doses of MMR. Pediatrics 2013;132:e1126e1133.
29. Rosen, JB, Rota, JS, Hickman, CJ, et al. Outbreak of measles among persons with prior evidence of immunity, New York City, 2011. Clin Infect Dis 2014;58:12051210.
30. Hahne, SJ, Nic Lochlainn, LM, van Burgel, ND, et al. Measles outbreak among previously immunized healthcare workers, The Netherlands, 2014. J Infect Dis 2016;214:19801986.
31. Haralambieva, IH, Ovsyannikova, IG, O’Byrne, M, Pankratz, VS, Jacobson, RM, Poland, GA. A large observational study to concurrently assess persistence of measles specific B-cell and T-cell immunity in individuals following two doses of MMR vaccine. Vaccine 2011;29:44854491.
32. Mathias, RG, Meekison, WG, Arcand, TA, Schechter, MT. The role of secondary vaccine failures in measles outbreaks. Am J Public Health 1989;79:475478.
33. Cardemil, CV, Dahl, RM, James, L, et al. Effectiveness of a third dose of MMR vaccine for mumps outbreak control. N Engl J Med 2017;377:947956.
34. Marlow, MA, Marin, M, Moore, K, Patel, M. CDC Guidance for use of a third dose of MMR vaccine during mumps outbreaks. J Public Health Manag Pract 2019. doi: 10.1097/PHH.0000000000000962.
35. Fiebelkorn, AP, Coleman, LA, Belongia, EA, et al. Measles virus neutralizing antibody response, cell-mediated immunity, and immunoglobulin G antibody avidity before and after receipt of a third dose of measles, mumps, and rubella vaccine in young adults. J Infect Dis 2016;213:11151123.
36. Basu, S, Giri, P, Adisesh, A, Mc, NR. Healthcare workers and measles-mumps-rubella (MMR) status: how worried should we be about further outbreaks? Epidemiol Infect 2014;142:16881694.
37. Shakoor, S, Mir, F, Zaidi, AK, Zafar, A. Hospital preparedness in community measles outbreaks-challenges and recommendations for low-resource settings. Emerg Health Threats J 2015;8:24173.
38. Centers for Disease C, Prevention. Hospital-associated measles outbreak—Pennsylvania, March–April 2009. Morb Mortal Wkly Rep 2012;61:3032.
39. Porretta, A, Quattrone, F, Aquino, F, et al. A nosocomial measles outbreak in Italy, February–April 2017. Euro Surveill 2017;22.
40. Baxi, R, Mytton, OT, Abid, M, et al. Outbreak report: nosocomial transmission of measles through an unvaccinated healthcare worker-implications for public health. J Public Health (Oxf) 2014;36:375381.
Type Description Title
WORD
Supplementary materials

Cheng et al. supplementary material
Cheng et al. supplementary material

 Word (15 KB)
15 KB

Measles outbreak from Hong Kong International Airport to the hospital due to secondary vaccine failure in healthcare workers

  • Vincent C.C. Cheng (a1) (a2), Shuk-Ching Wong (a2), Sally C.Y. Wong (a1), Siddharth Sridhar (a3), Jonathan H.K. Chen (a1), Cyril C.Y. Yip (a1), Derek L.L. Hung (a1), Xin Li (a1), Vivien W.M. Chuang (a4), Owen T.Y. Tsang (a5), Gibson K.S. Woo (a6), Shuk-Kwan Chuang (a7) and Kwok-Yung Yuen (a3)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed