title: Obstacles in measles elimination: an in-depth description of a measles outbreak in Ghent, Belgium, spring 2011.
abstract: BACKGROUND
  From Mid-February to April 2011 one of the largest measles-outbreak in Flanders, since the start of the 2-dose vaccination scheme in 1995, took place in Ghent, Belgium. The outbreak started in a day care center, infecting children too young to be vaccinated, after which it spread to anthroposophic schools with a low measles, mumps and rubella vaccination coverage. This report describes the outbreak and evaluates the control measures and interventions.
  
  
  METHODS
  Data collection was done through the system of mandatory notification of the public health authority. Vaccination coverage in the schools was assessed by a questionnaire and the electronic immunization database 'Vaccinnet'. A case was defined as anyone with laboratory confirmed measles or with clinical symptoms and an epidemiological link to a laboratory confirmed case. Towards the end of the outbreak we only sought laboratory confirmation for persons with an atypical clinical presentation or without an epidemiological link. In search for an index patient we determined the measles IgG level of infants from the day care center.
  
  
  RESULTS
  A total of 65 cases were reported of which 31 were laboratory confirmed. Twenty-five were confirmed by PCR and/or IgM. In 6 infants, too young to be vaccinated, only elevated measles IgG levels were found. Most cases (72%) were young children (0-9 years old). All but two cases were completely unimmunized. In the day care center all the infants who were too young to be vaccinated (N=14) were included as cases. Thirteen of them were laboratory confirmed. Eight of these infants were hospitalized with symptoms suspicious for measles. Vaccination coverage in the affected anthroposophic schools was low, 45-49% of the pupils were unvaccinated. We organized vaccination campaigns in the schools and vaccinated 79 persons (25% of those unvaccinated or incompletely vaccinated).
  
  
  CONCLUSIONS
  Clustering of unvaccinated persons, in a day care center and in anthroposophic schools, allows for measles outbreaks and is an important obstacle for the elimination of measles. Isolation measures, a vacation period and an immunization campaign limited the spread of measles within the schools but could not prevent further spread among unvaccinated family members. It was necessary to raise clinicians' awareness of measles since it had become a rare, less known disease and went undiagnosed.
authors.affiliation: Scientific Institute of Public Health, Brussels, Belgium. Toon.Braeye@wiv-isp.be.
authors.forename: Toon
authors.initials: T
authors.lastname: Braeye
authors.forename: Martine
authors.initials: M
authors.lastname: Sabbe
authors.forename: Veronik
authors.initials: V
authors.lastname: Hutse
authors.forename: Wim
authors.initials: W
authors.lastname: Flipse
authors.forename: Lina
authors.initials: L
authors.lastname: Godderis
authors.forename: Geert
authors.initials: G
authors.lastname: Top