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In document EDITORIAL TEAM (pahina 30-36)

From 30 April to 30 September 2012 there were 59 124 acute admissions to ADHB and CMDHB hospitals. A total of 4417 (7.5%) patients with suspected respiratory infections were assessed. Of these, 2023 (45.8%) met the SARI case definition. Of the 1430 SARI cases from whom nasopharyngeal specimens were collected, 324 (22.7%) had influenza viruses.

A small proportion of influenza-positive cases (7.1%, 21/294) were identified from patients with onset in the past seven to 10 days, so the case definition was expanded to onset within the past 10 days for subsequent study years (2013–2016). A small proportion (8.8%, 37/419) of influenza-positive cases was from non-SARI cases tested for clinical purposes.


Value of SARI surveillance

Hospital-based SARI surveillance has been implemented and fully functioning in New Zealand since 30 April 2012. WHO is encouraging Member States to establish SARI surveillance that meets WHO global standards.2 To our knowledge, New Zealand is among the first developed countries to do this, providing better understanding of the epidemiology, transmission and impact of influenza locally and globally.

New Zealand’s existing hospital-based disease surveillance is well suited to strategic surveillance functions.16 However, such systems are not suited to control-focused surveillance where it is necessary to identify and respond in a timely manner to individual

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Hospital-based surveillance for severe acute respiratory infections, New Zealand Huang et al

All authors participated in designing and establishing SARI surveillance and revising the manuscript critically for intellectual content. All authors have given final approval of the version to be published.


1. Ortiz JR et al. Strategy to enhance influenza surveillance worldwide. Emerging Infectious Diseases, 2009, 15:1271–

1278. doi:10.3201/eid1508.081422 pmid:19751590

2. WHO Global Epidemiological Surveillance Standards for Influenza. Geneva, World Health Organization, 2013 (http://www.


manual/en/index.html, accessed 5 May 2014).

3. Baker MG et al. Pandemic influenza A(H1N1)v in New Zealand:

the experience from April to August 2009. Eurosurveillance:

European Communicable Disease Bulletin, 2009, 14(34):

pii:19319. pmid:19712648

4. Huang QS et al. Influenza surveillance and immunisation in New Zealand, 1997–2006. Influenza and Other Respiratory Viruses, 2008, 2:139–145. pmid:19453466

5. Baker MG et al. Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study. Lancet, 2012, 379:1112–1119. doi:10.1016/S0140- 6736(11)61780-7 pmid:22353263

6. The SHIVERS Project - Study overview. New Zealand, Institute of Environmental Science and Research, 2011 (http://www.esr.

cri.nz/competencies/shivers/Pages/StudyOverview.aspx, accessed 5 May 2014).

7. Lopez L, Wood T, Huang QS. Influenza surveillance in New Zealand, 2012 and 2013 (https://surv.esr.cri.nz/virology/

influenza_annual_report.php, accessed 6 May 2014).

8. Grant CC et al. Risk factors for community-acquired pneumonia in pre-school-aged children. Journal of Paediatrics and Child Health, 2012, 48:402–412. doi:10.1111/j.1440-1754.2011.02244.x pmid:22085309

9. Williamson DA et al. Surveillance for influenza using hospital discharge data may underestimate the burden of influenza-related hospitalization. Infection control and hospital epidemiology: the official journal of the Society of Hospital Epidemiologists of America, 2012, 33(10): 1064–1066.

10. Shu B et al. Design and performance of the CDC real-time reverse transcriptase PCR swine flu panel for detection of 2009 A (H1N1) pandemic influenza virus. Journal of Clinical Microbiology, 2011, 49:2614–2619. doi:10.1128/JCM.02636- 10 pmid:21593260

11. Szewczuk E et al. Rapid semi-automated quantitative multiplex tandem PCR (MT-PCR) assays for the differential diagnosis of influenza-like illness. BMC Infectious Diseases, 2010, 10:113.

doi:10.1186/1471-2334-10-113 pmid:20459845

12. WHO Global Influenza Surveillance Network. Manual for the laboratory diagnosis and virological surveillance of influenza.

Geneva, World Health Organization, 2011, p. 153.

13. Heim A et al. Rapid and quantitative detection of human adenovirus DNA by real-time PCR. Journal of Medical Virology, 2003, 70:228–239. doi:10.1002/jmv.10382 pmid:12696109

14. Lu X et al. Real-time reverse transcription-PCR assay for comprehensive detection of human rhinoviruses. Journal of Clinical Microbiology, 2008, 46:533–539. doi:10.1128/JCM.01739-07 pmid:18057136

15. Code of Health and Disability Services Consumers’ Rights.

Auckland, Health and Disability Commissioner, 2009

surveillance for hospitalized inpatients, it is limited to quantify the impact of these specific risk factors for SARI-related influenza infections without their baseline distributions. Consequently, it is necessary to identify a suitable comparison/control population. During 2013, a hospital-based control population without respiratory illness will be added to investigate specific risk factors for influenza and other respiratory diseases.

The case report form captures information by interviewing patients/caregivers through their recall, which generates bias. An important example is influenza vaccination status, which is crucial for estimating vaccine effectiveness. The Ministry of Health in New Zealand plans to add influenza vaccination to its national immunization register in 2014, providing more accurate vaccination history for SARI cases than patient/caregiver recall.

Confl icts of interests

None declared.


The SHIVERS project is funded by US CDC (1U01IP000480-01). The hospital-based surveillance is a key component of the SHIVERS project. The project is a five-year research cooperative agreement between ESR and US CDC’s National Center for Immunization and Respiratory Diseases Influenza Division.


The SHIVERS project is a multicentre and multidisciplinary collaboration. Special thanks to these collaborating organizations for their commitment and support: ESR, ADHB, CMDHB, University of Otago, University of Auckland, US CDC and WHO Collaborating Centre at St Jude Children’s Research Hospital in Memphis, USA. Special thanks to: the research nurses at ADHB; the research nurses at CMDHB; staff of the WHO National Influenza Centre, ESR; the Health Intelligence Team, ESR; staff of the ADHB laboratory and CMDHB laboratory; IT staff and SARI surveillance participants. Also, a special thanks to Dr Dean Erdman from Gastroenteritis and Respiratory Viruses Laboratory Branch, US CDC, who provided the real-time PCR assay for non-influenza respiratory viruses. Support in kind was provided by the Ministry of Health.

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Huang et al Hospital-based surveillance for severe acute respiratory infections, New Zealand

17. Murray EL et al. What are the most sensitive and specific sign and symptom combinations for influenza in patients hospitalized with acute respiratory illness? Results from western Kenya, January 2007–July 2010. Epidemiology and Infection, 2013, 141:212–222. doi:10.1017/S095026881200043X pmid:22417876

(http://www.hdc.org.nz/the-act--code/the-code-of-rights, accessed 5 May 2014).

16. Baker MG, Easther S, Wilson N. A surveillance sector review applied to infectious diseases at a country level. BMC Public Health, 2010, 10:332. doi:10.1186/1471-2458-10-332 pmid:20540772

Brief Report

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a Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan.

b Department of Virology 3, National Institute of Infectious Diseases, Tokyo, Japan.

Submitted: 1 April 2014; Published: 16 May 2014 doi: 10.5365/wpsar.2014.5.2.001

Ongoing increase in measles cases

following importations, Japan, March 2014:

times of challenge and opportunity

Takuri Takahashi,a Yuzo Arima,a Hitomi Kinoshita,a Kazuhiko Kanou,a Takehito Saitoh,a Tomimasa Sunagawa,a Hiroaki Ito,a Atsuhiro Kanayama,a Ayako Tabuchi,a Kazutoshi Nakashima,a Yuichiro Yahata,a Takuya Yamagishi,a Tamie Sugawara,a Yasushi Ohkusa,a Tamano Matsui,a Satoru Arai,a Hiroshi Satoh,a Keiko Tanaka-Taya,a Katsuhiro Komase,b Makoto Takedab and Kazunori Oishia

Correspondence to Yuzo Arima (e-mail: arima@niid.go.jp).


ince late 2013 through March 2014, Japan experienced a rapid rise in measles cases. Here, we briefly report on the ongoing situation and share preliminarily findings, concerns and challenges and the public health actions needed over the coming months and years.

Measles is a notifiable disease in Japan based on nationwide case-based surveillance legally requiring physicians to report all clinically diagnosed and laboratory-confirmed cases within seven days, but preferably within 24 hours. After a large outbreak in 2007–2008 (more than 11 000 cases reported in 2008 alone) and a goal of elimination by April 2015, a catch-up programme using the bivalent measles-rubella (MR) vaccine was offered for grades seven and 12 (ages 12–13 and 17–18 years) from April 2008 through March 2013. During this period, there was an estimated 97% decline in measles notifications, and the cumulative number of reported cases has been steadily declining over the last five years (732 cases in 2009, 447 cases in 2010, 439 cases in 2011, 293 cases in 2012 and 232 cases in 2013). However, since late 2013 through March 2014, the country experienced a resurgence only a year after a large rubella outbreak.1,2 During epidemiologic week 48 of 2013 to week 10 of 2014, as of 13 March 2014, 183 measles cases were reported (141 laboratory-confirmed, 26 clinically diagnosed and 16 laboratory-confirmed modified measles cases);

92 of the cases were male (50%) with a median age of 12 years (range four months to 52 years). Cases have been reported throughout Japan.3 While no deaths from measles were reported, a case of encephalitis associated with measles infection occurred.3 With 171 cases reported

during weeks 1–10 of 2014 (relative to 158 cases in 2009, 89 cases in 2010, 73 cases in 2011, 74 cases in 2012 and 52 cases in 2013 for weeks 1–10 for each respective year) there is concern that the declining trend will likely be reversed this year.

Among the 183 cases, 52 (28%) had recent overseas travel histories within three weeks before onset with the majority coming from the Philippines (n = 41), where measles cases began increasing in October–November 2013.4 Among the 105 cases that were genotyped since week 48 of 2013, the majority were B3 (n = 99), a genotype that had not been detected in Japan until 20134,5 and the sole genotype detected in the Philippines in 2013 (n = 33).4 Among the 41 cases with recent travel history to the Philippines, 39 were B3, one D9 and another unknown. Based on the available epidemiologic and genetic information, the recent increase since late November 2013 appears to be linked to the Philippines.4,6,7 Other countries have also reported genotype B3 measles cases in travellers returning from the Philippines since late 2013, including Australia, Canada, Italy, New Zealand, the United Kingdom, and the United States.8–10 Importantly, while transmission occurred locally in 128 of the cases (70%) during week 48 of 2013 to week 10 of 2014, the change in the proportion and rate of imported cases over time has reflected the evolving epidemiologic situation in Japan.

Prior to the increase in notification rates, the proportion of cases believed to have been infected overseas was low at 7% (15/204) during weeks 1–47 of 2013, then rose to 52% (42/81) during week 48 of 2013 to week three of 2014 and then declined to 11% (10/92) during weeks 1–10 of 2014. While the notification rate of

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Takahashi et al Increase of measles cases in Japan, 2014

unlikely to be differentially associated with importation status or with temporality and thus unlikely to alter our qualitative interpretation. Although clinicians may have tended to suspect measles for those with overseas travel, the fact that the recent increase was mostly due to cases without such travel supports the notion of a true increase due to ongoing locally acquired transmissions.

The measles situation in Japan warrants both timely and sustained public health response. Continued vigilance for imported cases is imperative, and at the same time there is a need to be alert against secondary transmission and respond rapidly to each suspected case. With Japan’s announcement in 2013 easing visa requirements for visitors from South-East Asia12 and with Tokyo’s Haneda Airport increasing international flights,13 the risk of importation will increase. Thus, sustained and routine measles vaccination, with high coverage to maintain herd immunity is essential. Travellers overseas should also ensure that they are vaccinated to prevent importation in the first place. MR vaccine is the ideal strategy to prevent infection from both viruses and prevent potentially severe outcomes such as measles encephalitis and congenital rubella syndrome.

Japan’s National Institute of Infectious Diseases, Ministry of Health, Labour and Welfare and other partners are actively communicating these key messages via the Internet, television and newspapers to the general public and to the medical and public health communities.3 overseas-acquired cases rose and then declined during

these respective periods, the rate for locally acquired cases continued to rise. Thus, while the recent increase began with overseas-acquired cases, the majority of the latest cases, also genotype B3, likely emerged as ongoing, locally acquired transmissions (Figure 1).

In addition to family clusters, at least 22 cases were believed to have been infected nosocomially, and school- associated transmissions also emerged. Similarly, further transmissions from overseas-acquired cases associated with travel to the Philippines have been reported from the United Kingdom,8 the United States,9,11 and in the Mediterranean.10

Notably, among the 183 cases, 146 (80%) had either no or unknown history of measles vaccination.

While nearly a quarter of the affected were aged one year or below (those not yet ready for vaccination and with waning maternal immunity), the large number of unvaccinated older paediatric and young adult cases are believed to have contributed to the ongoing transmission.

Our preliminary findings point toward both the relative overall effectiveness of measles vaccination and that pockets of unvaccinated/susceptible populations remain, sustaining transmission following importation.

While there are limitations in the reported surveillance data, including potential underreporting and misdiagnosis, such missing or misclassified cases are

Figure 1. Number of reported measles cases by onset by epidemiologic week, Japan, January 2013 to March 2014

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10

2013 2014

Number of reported cases

Onset by epidemiologic week and year Overseas-acquired n = 67 Locally acquired n = 310

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Increase of measles cases in Japan, 2014 Takahashi et al

idsc/idwr/diseases/rubella/rubella2014/rube14-10.pdf, accessed 21 March 2014.)

2. Sugishita Y et al. Ongoing rubella outbreak among adults in Tokyo, Japan, June 2012 to April 2013. Western Pacific Surveillance and Response Journal, 2013, 4:37–41. doi:10.5365/

wpsar.2013.4.2.011 pmid:24319613

3. Infectious Disease Surveillance Center. Measles situation update, epidemiologic week 48, 2013 – epidemiologic week 8, 2014.

Tokyo, Infectious Disease Surveillance Center, National Institute of Infectious Diseases, 2013 (http://www.nih.go.jp/niid/en/all- surveillance/2292-idwr/idwr-article-en/4440-idwrc-1408-en.

html, accessed 20 March 2014).

4. Expanded Programme on Immunization. Measles-Rubella Bulletin. Manila, World Health Organization Regional Office for the Western Pacific, 2014 (http://www.wpro.who.int/immunization/

documents/measles_rubella_bulletin/en/index.html, accessed 20 March 2014).

5. Infectious Disease Surveillance Center, National Institute of Infectious Diseases. An imported case of measles virus genotype B3 infection from Thailand, May 2013-Fukuoka City. Infectious Agents Surveillance Report, 2013, 34:201–202 [in Japanese]

(http://www.nih.go.jp/niid/ja/measles-m/measles-iasrd/3666- pr4012.html, accessed 20 March 2014).

6. Measles situation in the Philippines – FAQs, January 2014.

Manila, World Health Organization Regional Office for the Western Pacific, 2014 (http://www.wpro.who.int/philippines/mediacentre/

features/measles_faq/en/, accessed 19 March 2014).

7. National Epidemiology Center. Disease Surveillance Report:

measles cases in the Philippines - morbidity week 7, February 9–15, 2014. Manila, National Epidemiology Center, Public Health Surveillance and Informatics Division, Department of Health, 2014 (http://nec.doh.gov.ph/images/MEASLES2014/

measlesmw7.pdf, accessed 20 March 2014).

8. Public Health England. Measles cases with links to the ongoing outbreak in the Philippines. Health Protection Report, 2014, 8(10):14 (http://www.hpa.org.uk/hpr/archives/2014/news1014.

htm#mslslnn, accessed 20 March 2014).

9. Measles in the Philippines. Atlanta, Centers for Disease Control and Prevention (CDC), 2014 (http://wwwnc.cdc.gov/travel/notices/

watch/measles-phillipines, accessed 20 March 2014).

10. Lanini S et al. Measles outbreak on a cruise ship in the western Mediterranean, February 2014, preliminary report. Euro Surveillance: European Communicable Disease Bulletin, 2014, 19(10):pii=20735. pmid:24650863

11. Aleccia J. Measles uptick in U.S. linked to Philippines, CDC says. NBC News, 2014, 4 March (http://www.nbcnews.com/

health/health-news/measles-uptick-u-s-linked-philippines-cdc- says-n43541, accessed 18 March 2014).

12. Ministry of Foreign Affairs of Japan [Internet] (http://www.mofa.

go.jp/j_info/visit/visa/index.html, accessed 21 March 2014).

13. Tokyo International Air Terminal. Start date for the expansion of the Tokyo International Air Terminal. Tokyo, Tokyo International Air Terminal, 2014 [in Japanese] (http://www.haneda- airport.jp/inter/info/N0000085/201402251600.pdf, accessed 21 March 2014).

While vaccination rates have vastly improved since 2007–2008, there is a need to better understand those who remain under or unvaccinated.

Japan is responding to a challenging measles situation and is about to enter its historic peak season in the spring. The current situation highlights the importance of both rapid response and routine public health activities. These messages should not be lost, especially at these opportune times. We are actively communicating with our fellow public health and medical practitioners to share timely measles information and re- emphasize the importance of MR vaccination.

Confl icts of interest

None declared.




We thank the staff at local public health centers and prefectural and municipal public health institutes nationwide, notifying physicians and other public health and medical staff who have been responding to the ongoing measles situation. We sincerely appreciate the rapid laboratory diagnosis and reporting by the prefectural and municipal institutes of public health that have allowed for rapid assessments and response.

In addition, we acknowledge the local public health workers who continue to work with dedication not only during acute response times but also during times of peace, implementing and promoting important prevention activities.


1. Infectious Disease Surveillance Center. Cumulative number of rubella cases by week, 2008–2014 (week 1–10). Tokyo, Infectious Disease Surveillance Center, National Institute of Infectious Diseases, 2014 (http://www0.nih.go.jp/niid/

In document EDITORIAL TEAM (pahina 30-36)