Eurosurveillance Weekly, funded by Directorate General Health and Consumer Protection of the
European Commission, is also available on the world wide web at <http://www.eurosurv.org/>. If you have
any questions, please contact Birte Twisselmann <firstname.lastname@example.org>, +44 (0)20-8200 6868
extension 4417. Neither the European Commission nor any person acting on its behalf is liable for any use
made of the information published here.
Eurosurveillance Weekly: Thursday 25 January 2001. Volume 5, Issue 4
1. Update on the MMR vaccine controversy in the UK
2. Outbreak of tuberculosis in Denmark
3. Surveillance of Lyme borreliosis in Germany, 1999
4. Leptospirosis outbreak in Eco Challenge 2000 participants – update
Update on the MMR vaccine controversy in the UK
New data on the uptake of the combined measles, mumps, and rubella (MMR) vaccine in the United
Kingdom (UK) (1) show that coverage at 2 years of age is 88%, the level to which it fell in late 1998 (from
a high of 92% in early 1995) after a paper that alleged a link between MMR, autism, and inflammatory
bowel disease was published (2). Extensive epidemiological studies since then have found no evidence of
such a link (3, 4).
UK news media have again focused on MMR in the past fortnight, prompted by a review written by two of
the authors of the 1998 Lancet paper (5). The review claims that the original prelicensing studies of MMR
vaccine were too small and that follow up was too short. The review is, however, highly selective in its
choice of studiessummarised, having excluded a key study from Finland (6). In addition, the reanalysis of
the early studies is significantly flawed and contains several basic errors.(7, 8) The review neglects to
acknowledge that MMR was introduced into the UK 16 years after routine use began in the United States
and several years after it was introduced in many other European countries, by which stage extensive
postmarketing surveillance data were available.
In the light of public interest, the UK government this week (backed by several professional bodies)
announced a campaign to restore confidence in MMR vaccine. The campaign coincides with the
publication of further evidence from Finland of the safety of MMR vaccine (9). This Finnish study involved
a 14 year follow up of 1.8 million children vaccinated with MMR but identified no cases of autism
associated with the vaccination and no cases of ulcerative colitis, Crohn's disease, or other chronic
disorder of the gastrointestinal tract.
MMR vaccine is now used in more than 35 countries, including most of those in Europe, and knowledge of
its high level of safety is based on the use of over 250 million doses. One of the suggestions from the
main author of the review is that it would be safer for preschool children to be given six widely spaced
injections of individual measles, mumps, and rubella vaccines rather than the two MMR injections (2).
There are good reasons why this would not be in the interests of individual children or the wider
community (10). The strategy would leave children unprotected against measles, mumps, or rubella for
months and herd immunity for these diseases would be jeopardised. Recent experience of measles in the
Netherlands and Ireland and of rubella in Greece (11-13) show how suboptimal herd immunity allows the
resurgence of measles and measles deaths or congenital rubella. There is now much more evidence of
the safety of MMR vaccine than there is for the safety of the single vaccines, so doctors cannot
recommend them as a safer option. A current vaccination ‘myth’ in the UK – that single vaccines are used
in Europe and France – is often cited. Single measles vaccine is licensed in France, but this is related to a
legal requirement for infants attending nursery care to be protected against measles even though they are
younger than the age when MMR is given. Less than 0.5% of children in France receive single antigen
measles vaccine, and the proportion is dropping. Japan, the only country worldwide known to be using
single measles, mumps, and rubella vaccines does so because it has no licensed MMR vaccine. It
stopped using a vaccine containing the Urabe strain of mumps vaccine in 1993 (vaccines containing
Urabe have stopped being used in Europe in 19XX). Unlike Europe, the United States, and Australasia
Japan has not licensed alternative MMRs. It now has endemic measles and rubella circulation and has
reported 79 deaths from measles between 1992 and 1997.
1. CDSC. COVER programme: July to September 2000. Commun Dis Rep CDR Wkly [serial online] 2001 [cited 25 January
2001]; 11(4): immunisation. Available from <http://www.phls.co.uk/publications/CDRelectronic/CDR weekly/CDR
2. Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, et al. Ileal-lymphoid-nodular hyperplasia, non-
specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351: 637-641. (http://www.thelancet.com/)
3. Taylor B, Farrington CP, Petropoulos M-C, Favot-Mayaud I, Li J, Waight P, Miller E. Autism and measles, mumps and
rubella vaccine: no epidemiological evidence of a causal association. Lancet 1999; 353: 2026-9.
4. Nicoll A, Elliman D, Ross, E. MMR vaccination and autism 1998. Deja vu – pertussis and brain damage 1974. BMJ 1998;
316: 715-6. (http://www.bmj.com/cgi/content/full/316/7133/715)
5. Wakefield AJ, Montgomery SM. Measles, mumps, rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol
Rev 2000; 19: 265-83.
6. Peltola H, Heininen OI. Frequency of true adverse reactions to measles-mumps-rubella vaccine. Lancet 1986; I: 939-42.
7. Miller E, Andrews N. Vaccines and vaccine safety. Comments on ‘Measles, mumps, rubella vaccine: through a glass,
darkly’ by Wakefield and Montgomery. Public Health Laboratory Service, 2001.
8. Elliman H, Bedford H. MMR vaccine – the saga continues. BMJ 2001; 322: 183-4. (http://www.bmj.com/)
9. Patja A, Davidkin I, Kurki T, Kallio MJ, Valle M, Peltola H. Serious adverse events after measles-mumps-rubella
vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-34. (http://www.pidj.com/)
10. Public Health Laboratory Service electronic news bulletin. Why is MMR preferable to single vaccines?
11. van Steenbergen J, Langendam M, Woonink F. Measles in the Netherlands. Eurosurveillance Weekly 1999; 3: 990930.
12. Cronin M, O’Connell T. Measles outbreak in the Republic of Ireland. Eurosurveillance Weekly 2000; 4: 000210.
13. Panagiotopoulos T, Antonaidou I, Valassi-Adam E. Increase in congenital rubella occurrence after immunisation in
Greece: retrospective survey and systematic review. BMJ 1999; 3: 1462-7.
Reported by Mary Ramsay (email@example.com), Immunisation Division, and Angus Nicholl
(firstname.lastname@example.org), Public Health Laboratory Service Communicable Disease Surveillance Centre,
Outbreak of tuberculosis in Denmark
The investigation of a case of tuberculosis (TB) in a young Danish national serviceman has so far
revealed two further cases of TB in Denmark, according to the latest issue of the national surveillance
bulletin, EPI-NEWS (1). Fourteen of the other 37 people in the same detachment examined at the
barracks were Mantoux positive, an unusually high proportion for Denmark.
In August 2000 a national serviceman at a military installation in South Zealand was diagnosed with open
pulmonary TB. He had sought medical advice because he had been coughing for six months, latterly with
green sputum, and was now unable to keep up with the other soldiers on training runs. The initial
diagnosis was made by chest radiography, followed by the identification of acid fast bacilli on sputum
The patient belonged to a detachment of 38 personnel aged 19 to 25 years, divided into two equal squads
that were housed in dormitories of 100 bunk beds 165 cm apart. Contact tracing was conducted, and the
37 contacts as well as two officers were Mantoux tested; two of these received BCG. Fourteen people
were Mantoux positive; 10 of those shared the patient’s dormitory, three the adjacent dormitory, and one
was a member of the other squad. Subsequent chest radiographs showed that one person sharing the
patient’s dormitory had lung changes compatible with active TB, and further investigation showed this
person to have infectious TB.
A parallel investigation of the index patient’s family showed that a 1 year old child had also developed TB.
All those who were Mantoux positive were offered prophylactic treatment with isoniazid (300 mg daily for
six months) and pyridoxine (50 mg 1-2 time daily for six months). Once the detachment had left, the
dormitory was disinfected and mattresses, curtains, and cleaning rags destroyed.
TB is still a serious disease. Although only a few hundred people are infected with TB in Denmark each
year, the diagnosis must be considered in patients with prolonged cough or unexplained fatigue.
Eurosurveillance Weekly has previously reported on the incidence of TB in Denmark, which is particularly
high in immigrants (2, 3)
1. Statens Serum Institut. Outbreak of tuberculosis. EPI-NEWS 2001; 1-2. (http://www.ssi.dk/en/index.html)
2. White C. High incidence of tuberculosis among immigrant populations in Denmark. Eurosurveillance Weekly 2000; 4:
3. Twisselmann B. Tuberculosis in Denmark. Eurosurveillance Weekly 2000; 4: 001130.
Adapted from reference 1 by Birte Twisselmann (email@example.com), Eurosurveillance editorial
Surveillance of Lyme borreliosis in Germany, 1999
One thousand four hundred and eleven cases of Lyme borreliosis were notified in six German states in
1999, a total 8% lower than in 1998, but still a substantial number of cases of an infectious disease with
serious clinical manifestations.
Lyme borreliosis is not a notifiable disease in Germany, but five of Germany’s 16 states – Brandenburg,
Mecklenburg-Western Pomerania, Saxony, Saxony-Anhalt and Berlin have extended notification systems
which include Lyme borreliosis. Thuringia has a voluntary notification system forof Lyme borreliosis. These
systems make an important contribution to surveillance in Germany. For the six states can be assumed
that about 25 % of all cases are notified .
A total of 1338 of the 1411 cases (95%), were serologically confirmed. Seventy-seven per cent
(1083/1411) of cases presented at an early stage of the infection and were therefore susceptible to
specific treatment. 53% (748/1411) of the cases in 1999 were female. Nine hundred and eighty-one (70%)
of cases were aged 15 to 44 years; 239 (17%) were children and adolescents. One explanation for the
age distribution may be the leisure behaviour of different age groups, which may influence the likelihood of
exposure (more outdoor activities, sport, camping and others). Comparatively few cases in the >65 age
group, possibly because their activities differ and they are less mobile. Eight hundred and thirty-seven
(89%) of patients remembered being bitten by ticks. Around 89% of acute cases occurred from March to
October. The peak (66% of acute cases between May and August) is attributable to periods of maximum
tick activity and summer related leisure behaviour. Several cases were diagnosed only at the later stages
of infection. In these, the onset date – which may have been years ago – cannot be determined.
In 15% (216/1411) of cases the illness presented with non-specific symptoms such as fever, weakness,
myalgias, and swollen lymph nodes. Sixty-seven per cent (939/1411) of all notified cases presented with
skin manifestations. The most important of these is erythema chronicum migrans, which affected 767
patients (54%) in 1999. A red skin rash was reported in 128 cases. Acrodermatitis chronicum migrans as
a late manifestation of borreliosis was observed in 29 patients. Fifteen per cent of cases (206) suffered
central nervous system (CNS) manifestations) – meningitis in 21 (mainly in children aged 5 to 15 years.
Neuropathies and pareses affected 111 cases, including 29 with paresis of the facial nerve. A diagnosis of
neuroborreliosis as a postprimary manifestation of the CNS was made in 13 patients. The joints were
affected in 292 patients (21%) – eight cases had swollen joints and 284 arthritis in the large joints. The
cardiovascular system was affected in 24 cases (11 cases had myocarditis). Two hundred and fifteen
cases (15%) were treated in hospitals.
Lyme borreliosis is a common and potentially serious infectious disease in Germany, but few data about
its incidence, spread, and manifestation are available. The efforts made in some federal states to record
confirmed cases through notification are therefore an important contribution to surveillance in Germany.
Infectious ticks are likely to occur throughout Germany, and it is likely that the situation in the remaining 10
states is similar. Special advice, information, and explanations are necessary for people at risk – in
particular with respect to avoiding exposure, to look for ticks after possible exposition, to remove the tick,
and to contact a doctor in the case of suspect symptoms. Some doctors may be inexperienced in terms of
laboratory diagnoses, interpretation of findings, and treatment.
1. Robert Koch-Institut. Zur Situation bei wichtigen Infektionskrankheiten im Jahr 1999. Teil 6: Zur Lyme-Borreliose in
ausgewählten Bundesländern. Epidemiologisches Bulletin 2000; 50: 396-8.
Reported by Wolf Heiger Mehnert, Wolfgang Kiehl (KiehlW@rki.de), and Heidemarie Kant, Robert Koch-
Institut, Berlin. Translated and adapted from reference 1 by Birte Twisselmann
(firstname.lastname@example.org), Eurosurveillance editorial office.
Leptospirosis outbreak in Eco Challenge 2000 participants – update
In September 2000, Eurosurveillance Weekly reported on an outbreak of leptospirosis among participants
in the Eco Challenge 2000 expedition race (http://www.ecochallenge.com/borneo2000/index.html), which
took place between 20 August and 3 September 2000 (1). Participants included athletes from 26
A recent report in the MMWR provided an update on the investigation of this outbreak, confirmed that
leptospira was the cause of illness, and that water from the Segama River was the primary source of
Cases of febrile illness were identified over the telephone using a questionnaire (response rate 52%;
158/304). A case was defined as an Eco Challenge athlete with acute onset of fever on or after 21 August,
and at least two of the following symptoms: chills, myalgias, headache, diarrhoea, or conjunctivitis. Fifty-
two per cent (83) of the 158 respondents reported chills, 51% (80), myalgias, 48% (76) headache, and
36% (58), diarrhoea. Conjunctivitis, a common finding in infection with leptospira, was reported by 36
(23%) athletes. Arthralgias (47 (30%)), dark urine (44 (28%)), and calf or leg pain (45 (28%)) were also
reported. One hundred and nine athletes reported illness; 68 (44%) had illness that met the case
definition. The median age of cases was 34 years (range 22-50 years); 73% were male. The median
duration of illness was six days (range 1-19); 34% (25) cases were admitted to hospital.
Laboratory evidence for leptospirosis was defined as a positive result for leptospira antibodies by Dip-S-
Ticks or by immunoglobulin M (IgM) enzyme linked immunosorbent assay (ELISA), or a positive culture.
Thirty-two out of 39 ill (acute and convalescent) athletes who provided serum to the Centers for Disease
Control and Prevention (CDC) in Atlanta met the case definition. To identify other causes for febrile
illnesses, four samples positive for leptospirosis were tested for alternative organisms; these were
negative for dengue and for Orientia tsutsugamushi, both of which cause illness clinically similar to
leptospirosis. Further testing of other specimens for these pathogens is being undertaken.
To identify potential exposure risks, information was gathered about participation in various portions of the
race. Significant risk factors on univariate analysis included kayaking, swimming in the Segama River,
potholing, and swallowing water from the Segama River. Stepwise logistic regression showed that
swimming in the river was the only factor significantly associated with illness. Attributable risk for
swimming in the river was 38%. Participants in adventure sports and exotic tourism should be aware of
potential exposure to unusual and emerging infectious agents.
1. Evans M, Baranton G. Leptospirosis outbreak in Eco Challenge 2000 participants. Eurosurveillance Weekly 2000; 4:
2. CDC. Update: Outbreak of acute febrile illness among athletes participating in Eco-Challenge-Sabah 2000 – Borneo,
Malaysia, 2000. MMWR Morb Mortal Wkly Rep 2001; 50(2): 21-4.
Adapted from reference 2 by Birte Twisselmann (email@example.com), Eurosurveillance editorial