Measles outbreak in the adult age group: Clinical, laboratory, and epidemiological features of the 11 patients admitted to the hospital

The measles virus, also known as the morbillivirus, or MV, is a virus that infects humans. The goal of this research is to assess to adult cases of measles. Eleven patients thought to be confirmed cases of measles were enrolled in the investigation. Following the identification of symptoms of tiredness, fever, and rash in one soldier, the results of 10 more troops from the pertinent military group were assessed. The diagnosis was made based on the presence of serum immunoglobulin M (IgM) and positive polymerase chain reaction (PCR) results. When the control IgM, immunoglobulin G, and PCR findings were evaluated a fortnight after hospitalization, a cluster of 11 incidents was found. It is now necessary to address the issue of the cautious stance towards vaccination or the anti‐vaccination sentiment that has grown increasingly popular, particularly in light of the COVID‐19 pandemic, for both our nation and the entire world.


| INTRODUCTION
The prototype virus of the measles virus (also known as the morbillivirus, MV) genus is called rubeola, and it is a member of the Paramyxoviridae and Paramyxovirinae families.People and primates are afflicted by the encapsulated virus known as MV, which has a single-stranded, unsegmented negative-polarity RNA genome. 1 Measles is an acute viral illness that is extremely transmissible, affecting people of all ages who are vulnerable, and is the most common cause of death for small children.The virus spreads via the air or by particles that an infected person's mouth, throat, or nose may produce.Although direct contact with contaminated fluids can potentially spread the infection, MV is unable to survive on any surface that could harbor the virus, including skin, hair, clothes, or bedding.This is as heat and ultraviolet light quickly deactivate it. 2spite being a treatable infectious illness that primarily affects children, endemic occurrences of measles have also been reported in adults. 3In their initial 15 years of life, 95%-98% of children experienced measles before vaccinations were developed. 4The measles vaccination is very successful; in fact, it can prevent infection by up to 99% when more than one dose is administered, according to a review of a measles outbreak at a German school. 5ult measles cases frequently result from not receiving the vaccination, incorrect vaccine storage, or a lack of protective antibodies.Clinical signs of measles comprise a runny nose, conjunctivitis, coughing, high fever, and maculopapular rash.Usually, the illness manifests as a fever and rash.The respiratory system and core neurological systems are typically impacted by unexpected issues, which can result in further problems like pneumonia, blindness, and brain damage. 6The maculopapular rash usually starts on the skin of the face and head and then converges to the trunk and limbs.The normal incubation time for measles is 7-21 days.Instances of measles are infectious for 4 days before rash onset and for 4 days following rash resolution.Measles typically presents as a minor childhood sickness, but, in adults, it can cause problems that contribute to a more serious clinical presentation. 4cording to estimates from the World Health Organization (WHO), every year between 2012 and 2014, some 115 000 peoplemostly children under the age of five-died or were subject to lasting consequences from measles. 7 the Netherlands (2499 cases), and the United Kingdom (1900 cases). 8,9ere are limited studies on measles in adults, investigating complications, hospitalizations, and clinical and laboratory findings.
This study aims to assess the laboratory, clinical, and epidemiological evidence, along with the contact tracing strategy, in adult measles cases at the Military Unit in Edirne Center.In addition, the manuscript can contribute to literature by including epidemiological data on reported measles outbreaks before, during, and after the Covid-19 pandemic.Measles available at: http://www.cdc.gov/vaccines/pubs/survmanual/chpt07-measles.pdf);measles is categorized as a "maculopapular rash that occurs after a few days of prodromal findings such as cough, fever, runny nose, starting from the face and spreading to the body and extremities, and the presence of conjunctivitis"

| RESULTS
Eleven patients confirmed to have had measles were enrolled in the research.All patients were men.The mean age was 22.0 ± 1.95 years (range: minimum: 20, maximum: 25).Each instance was tracked in the clinic and all patients were hospitalized.The index case was the patient first diagnosed.The patient, a soldier, arrived at the military unit in Edirne from Manisa 9 days before acquiring measles, according to the findings of the filiation inquiry.Ten of the soldiers who were sampled had positive results for measles IgM, urine, and swab PCR.

| Clinical manifestations
While high fever, malaise, headache, maculopapular broad rash, and joint pain were present in around half of the cases, 30% of patients also had signs such as a sore throat and conjunctivitis, and tonsillopharyngitis.Pneumonia was detected in just one instance.A maculopapular rash that started on the face and moved to the trunk was found in the cases (Figure 2).According to Table 1, none of the cases had lung rales, photophobia, nausea-vomiting, or Koplik's spot symptoms (Table 1).

| Laboratory tests
Aside from ELISA and PCR, other results showed an increase in CRP in two instances, leukopenia in a single instance, and increases in ALT The IgG1 value was found to be positive in only three cases, but after a fortnight, it was found to be positive in every case.There was only one instance that tested positive in the control PCR, indicating 100% consistency in the PCR urine and swab data (Table 2).Hospital stays for patients ranged from 3 to 7 days.
The registration and card data did not support the vaccination information.Of the nine, three said they had received their vaccinations, and the other was unsure.Aside from the index case, no other issues arose.It was discovered that the patients' measles status had no bearing on their place of birth.

| DISCUSSION
The Relating to the number of measles cases, Turkey leads the WHO European Region, based on the WHO Epidemiology Summary Report. 12[15] WHO Global Health Observatory Data shows that the number of reported measles cases worldwide between 2017 and 2021 is as follows: 173 457, 360 296, 873 022, 159 073, 123 174.At the start of the pandemic, there were 873 022 cases in 2019, which decreased by approximately 80% and 85% in 2020 and 2021, respectively.In Turkey, 2904 cases were reported in 2019, with no reported cases in the following 2 years during the pandemic. 16 this research, we investigated the clinical, laboratory, and demographic aspects of an epidemic that was discovered in 11 soldiers between 20 and 25 years of age in an Erdine military unit in 2023.The use of just males for the research is consistent with previous investigations and helps to explain why outbreaks are more common in military settings. 17ly the index case developed pneumonia, which is thought to be the most significant adverse effect of measles cases.Fragkou et al., 18 in an investigation on the risk factors behind pneumonia, showed that the male gender, older age, high CRP, and low lymphocyte count were strongly associated with the development of pneumonia.The fact that no pneumonia problems arose may be related to the young age of our cases, that only two of them had elevated CRP, and that one of them had leukopenia.None of the patients had diarrhoea, which is said to be the second most frequent measles consequence and is typically seen in children. 19The Joint pain 5 (45.5) Note: Blood antibody and PCR tests in measles patients: IgM1 and IgG1 are the results of measles antibody testing performed on the first blood samples taken from all the cases.PCR testing was also performed on nasopharyngeal swabs and urine samples.The results of IgM2 and IgG2 were obtained again from blood samples that were taken once more, 2 weeks later.A nasopharyngeal or urine sample was used for a single PCR that was performed as a control.
Early on in an epidemic, serological testing is the most employed approach due to its efficiency, speed, affordability, and dependability. 21 far as test efficacy is concerned, prior research matching IgM testing to reference reverse transcriptase PCR based assays reports sensitivity ranging from 89.9% and 98.8% and specificity between 92.5% and 97.9%. 22For quick identification following immunization and diagnostics, the use of PCR is essential.PCR helps avoid public health interventions and saves time and money when managing epidemics.Furthermore, a variety of analyzes can expedite epidemic solutions in epidemiologically connected epidemics. 23llowing the direction of the Public Health Institution, regular vaccinations may be advised in situations when vaccine knowledge is limited, given the significance of military forces in the management of epidemic diseases.Reduced routine immunization rates and skipped make-up vaccinations in 2020 (as a result of COVID-19) could lead to an increase in measles and yellow fever prevalence in some countries. 24rthermore, as an additional consequence of the COVID-19 pandemic, it Every year, almost 20 million people contract the measles worldwide.The disease has not been totally eliminated and has resurfaced, causing outbreaks in a number of wealthy nations in spite of a more than 90% decline in its European frequency.The number of confirmed cases of measles (644) in the United States following the disease's 2000 eradication was reached after an epidemic that began in Disneyland Park and expanded to other states in December 2014.Nonetheless, this statistic pales in comparison to the data gathered from thirty European Union and European Economic Area nations.The countries with the highest numbers of measles cases in 2013 were Germany (1772), Italy (2216),

A
total of 11 cases were assessed in the present investigation.The patients received treatment at the Edirne State Hospital emergency room between April 10 and April 24, 2023, and exhibited symptoms consistent with measles, had a PCR test result of +, or had measles immunoglobulin M (IgM) + present in their serum.The patients' data were tracked from the moment of their admittance to the time they were released.This research has been designed as a retrospective study using epidemiological planning techniques.The Department of Health and Human Services' measles case definition and the Centers for Disease Control and Prevention's (CDC) criteria were used to determine the diagnosis of standard measles.
scheme, they found 57 close contacts, all of whom were isolated and given precautions for protection.The first patient at the Edirne State Hospital Emergency Clinic was evaluated, and it was found that he may have been in touch with up to 250 soldiers.The appropriate military group was alerted.The Community Health Center then contacted 250 potential contacts, assessed the troops' immunization status, and administered measles vaccinations to anybody who had not had them.After the initial case's diagnosis, 365 personnel stationed at the same barracks received vaccinations.A total of 680 patients were medically evaluated during the measles pandemic, and 59 of those considered clinically compatible had samples of their blood, urine, and nasopharynx submitted to the reference laboratory.Laboratory tests revealed the presence of measles in 11 out of 59 samples.In this investigation, 11 soldiers in the same group serving in the military and within the ages of 20 and 26 were found to have measles (Figure 1).A form was completed for these individuals, and their details, symptoms, test verification results, and vaccination history were forwarded to the Provincial Health Directorate.The infectious diseases ward served as an isolation area for hospitalized patients.While they stayed in five separate wards within a shared military unit, the soldiers with measles shared communal spaces.The final diagnosis was made based on the presence of serum IgM and positive PCR results from nasopharyngeal swabs and urine.Both measles IgM and immunoglobulin G (IgG) antibody presence were determined by ELISA tests, and measles RT-PCR tests were conducted at the Public Health Reference Laboratory (Istanbul) following the manufacturer's instructions for the commercial kits.The patient's aspartate transaminase (AST), alanine transaminase, C-Reaktif Protein (CRP), platelet (PLT), white blood cell and lymphocyte counts were also noted.The SPSS 20.0 software was used to analyze the collected data.For every variable, descriptive statistics are available.

Figure 1
Figure 1 provides an overview of the work plan for disease outbreak management and prevention implemented by the Provincial Health Directorate Identification Team and the Edirne State Hospital Infectious Diseases Service.The Provincial Health Directorate of the Turkish Public Health Institution oversees the management of epidemic diseases in the Turkish Armed Forces.The typical explanations for phrases used in measles reporting are listed below: Clinical description of measles: Follows the measles' clinical description; A fever over 38°C, a broad maculopapular rash, runny nose, cough, or conjunctivitis.Possible case: Case matches clinical description.Definite case: (a) Laboratory results confirm diagnosis.IgM and PCR positivity were examined concurrently.(b) A likely case epidemiologically linked to a certain case.

11 F I G U R E 1
Possible cases, definite cases, and measles elimination program of filiation team.and AST in three instances.Two weeks thereafter, control samples (portrayed as IgM2, IgG2, and Control PCR) were utilized to corroborate the IgM and PCR findings obtained from urine and oropharyngeal swab specimens employed in measles diagnosis.Just two of the patients had positive baseline IgM1 values; however, three of the prior negative cases had positive IgM2 values within 2 weeks.
global measles eradication program led by the WHO has resulted in a significant reduction in the total number of measles-related deaths.From 535 thousand in 2000 to 139 thousand in 2010. 10In 2000 and 2019, the prevalence of the first dose delivery of measlescontaining vaccines rose from 72% to 86% globally.However, in the COVID-19 pandemic, this figure plummeted to 81%, according to the CDC's 2000-2022 Report on Worldwide Progress in Combating Measles.This has been the lowest rate of vaccinations since 2008.First dose distribution reached 83% in 2022 and, between 2000 and 2022, vaccinations circumvented almost 57 million measles fatalities.However, due to factors such as the COVID-19 epidemic and a rise in anti-vaccine sentiment, vaccination rates have started to fall, leaving millions of children unvaccinated. 11 laboratory results, which can differ based on a patient's immunization history, consistently display a trend in our research.Determining the protective effect of IgG1 positive was difficult due to the patients' ages, which made it difficult to obtain data regarding previous vaccinations.Similarly, in a medical context, a sharp and sudden increase in neutralization and virus-specific IgG levels may indicate reinfection.20

F I G U R E 2
Maculopapular rash of index case.Diffuse maculopapular rash on the abdominal area.T A B L E 1 Clinical manifestations and laboratory tests.
is claimed that vaccination rates, particularly for children, are still inadequate because of the interruption of regular preventative medical care and the rise in vaccine refusal and/or opposition brought on by conversations about the COVID-19 vaccine.Worldwide preliminary data for the first 3 months of 2020 shows a significant decline in the number of children immunized against diphtheria, tetanus, and pertussis.25Twenty-one different investigations looked at the effect of low vaccination rates on historical disease epidemiology (pre-COVID), as reported by Hamson et al.The most significant of these effects include polio, measles, infections linked to pneumococci, and other infectious disorders.Measles, pneumococcal illness, polio, and other infectious disease vaccination rates are poor because of vaccination interruptions in service and a growing resistance to vaccines.Concerns about vaccine safety as well as philosophical and non-medical exclusions are part of the anti-vaccine mindset.Despite the National Immunization Program's existence, research has revealed low vaccination rates with no apparent cause.26Catch-up vaccination is indeed crucial to ensure that individuals receive the necessary vaccines according to their age and health status.It helps fill immunity gaps and provides protection against diseases like measles and rubella.The WHO's Measles and Rubella Strategic Framework 2021-2030 emphasizes the importance of implementing effective catch-up vaccination programs to bridge these immunity gaps and improve overall public health.27Since 1998, in Turkey, the development of herd immunity has been hindered by the notable reduction in measles cases following the administration of two vaccine doses, given in the ninth month of the birth and during the first year of primary education.It is understood that every case, with the exception of two cases, has had their second dose of the vaccine, given their age.The patients' remarks have been taken into consideration after their lack of vaccination cards prevented a measles diagnosis from being made.This implies they may not have had a vaccination, may have received a single dosage, or that the vaccine's cold chain may have been disrupted during administration.Considering to measles cases in adults, in the case of a single-dose vaccine, it is possible that the level of protection provided by antibodies may decrease over time.To address these issues, it may be necessary to consider booster doses or catch-up vaccination strategies to help maintain adequate levels of immunity and ensure long-term protection against the disease.5 | CONCLUSIONA cluster of 11 cases was identified based on the patients' ages and interactions with one another.The soldiers scheduled for vaccinations did not have their vaccination records from the time The T A B L E 2 Clinical manifestations and laboratory tests.