Measles outbreak in EuropeBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3724 (Published 15 June 2011) Cite this as: BMJ 2011;342:d3724
- 1Communicable Disease Surveillance Centre, Public Health Wales, Temple of Peace, Cardiff CF10 3NW, UK
- 2Vaccine Preventable Disease Programme, Public Health Wales, Cardiff
Current outbreaks of measles in Europe are a reminder of the important risks of death and serious morbidity associated with measles. Between 2009 and 2010, cases of measles increased dramatically in Europe, with notifications increasing from 7175 to 30 367.1 In 2010 most reported cases were in Bulgaria (22 005), but there were also 5019 in France, 861 in Italy, 787 in Germany, 406 in Ireland, 397 in the United Kingdom, and 302 in Spain. Of these, 21 877 people were admitted to hospital and 21 died (case fatality 0.69 deaths/1000 reported cases); 71% of people infected were aged under 20 years and 85% were unvaccinated. The World Health Organization has reported outbreaks in 24 European countries already this year.2 There is little sign of a decrease in cases in 2011, and travel has facilitated transmission between countries. From January to March 2011, 9349 cases were reported, and 18 of 32 reporting countries found that the incidence of measles was higher than during the same period in 2010.3
Currently the French outbreak is the largest in Europe and it has not yet peaked. Since it began in 2008, France has reported more than 14 500 cases and five deaths.4 Most people who became infected with measles in France during 2010 to 2011 were older than 10 years, with a third being older than 20 years, which highlights the current risk to unvaccinated teenagers and young adults. Spain is also seeing an outbreak, with 786 cases reported from January to May 2011. The UK Health Protection Agency report 334 confirmed cases in England and Wales up to the end of April, compared with 374 cases during the whole of 2010, down from a peak of 1370 in 2008.5
All countries in the European Union implement a two dose measles, mumps, and rubella (MMR) vaccination schedule, with all first doses given by 18 months of age.6 The age at which the second dose is given varies widely. Many countries do not give the second dose until well after school entry, some after 12 years of age. Those countries with a mean uptake of the MMR vaccine below 90% since 2000 seemed more likely to have a higher incidence of measles in 2010.
The global picture regarding measles is a little more optimistic, although mortality remains high. Over the past 30 years, annual cases of measles reported to WHO by member countries have fallen from 4 211 431 in 1980 to 292 952 in 2010, with rates of infection falling most in African and Western Pacific regions.7 In 2010, 63.7% of the cases reported globally were from the African region, 17.1% were from South East Asia, 14.7% were from the Western Pacific, and 3.6% were from the Eastern Mediterranean. Cases from Europe accounted for 0.9% and cases from the Americas accounted for less than 0.1% of those reported globally. Between 2000 and 2008 annual global mortality related to measles fell by 78%, from an estimated 733 000 to 164 000 deaths.8
The low rates of measles in the American continent show what can be achieved. In the United States measles has been eradicated since the late 1990s (eradication is defined as an absence of endemic transmission and the US has seen an average of 56 cases a year from 2001 to 2008).9 Measles was eradicated in the rest of the American continent in 2002.10 The current 15 year high in US cases is largely accounted for by unvaccinated returning travellers who have become infected in Europe and South East Asia.9
Measles is next in line for global eradication after polio, but it will be at least 10 years until this goal is achieved, and substantial challenges remain.10 Most people who have been infected in the current European outbreak have never been vaccinated with MMR.3 Concern over the vaccine’s safety, which affected its uptake in the UK among those who are now teenagers and young adults, has been shown to be based on discredited and even fraudulent research.11 Measles is highly infectious, with as many as 90% of susceptible contacts becoming infected.9 The characteristic rash appears after seven to 21 days, and unvaccinated travellers infected abroad are likely to import and spread infection during the incubation period. Measles should be suspected in unvaccinated recent travellers with fever, coryza, conjunctivitis, and cough; notification and control measures should be based on suspicion, although laboratory confirmation is also needed.
Rates of measles seroconversion after vaccination are around 90% after a single dose and 99% after two doses.12 WHO recommends 95% uptake of two doses of measles containing vaccine for elimination of the infection in a population, but pragmatically 90% coverage of one dose is the current global minimum target.10 In non-endemic low transmission areas the first dose is ideally given soon after the first birthday (to avoid interference by maternal antibody and to maximise seroconversion) and the second dose before school entry, especially in the context of increased incidence of measles. However, MMR vaccination can be given before the first birthday, routinely at 9 months in high transmission, high mortality areas. In the case of travel to an endemic area it can be given as early as 6 months of age if immediate protection is required, with two further scheduled doses at the recommended ages.12 Given the age distribution of cases in the current European outbreak, we consider that catch-up programmes to immunise unprotected teenagers are essential to control and then eliminate measles in Europe.
Cite this as: BMJ 2011;342:d3724
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; RJR’s department has received small educational grants from GSK and Sanofi Pasteur to support an annual immunisation conference; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not peer reviewed.