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
All rapid responses
In their recent BMJ editorial on the ongoing Measles epidemic in
Europe, Cottrell and Roberts assert that all European Union (EU) member
states implement a two-dose schedule of the measles, mumps and rubella
(MMR) vaccine. They refer to a Vaccine European New Integrated
Collaboration Effort (VENICE) document from April 2007, which includes
data from Romania and Bulgaria. This is intriguing, given that these
two countries only acceded to the EU in January of 2007.
I do not doubt that it is the national policy of every EU member
state to give every child two doses of MMR. However knowing that the EU is
a disparate collection of countries with very different socioeconomic
characteristics, I am sceptical as to what actually happens on the ground
in some EU countries.
The recent fusillade of multi-billion pound EU/International Monetary
Fund (IMF) bailouts to countries such as Portugal, Ireland and Greece
draws one's attention to the economic fragility of some of the EU's 27
Yet the economic woes of bailed-out dependent EU countries distract
us from the relative poverty of the aforementioned newer members of the
EU, such as Bulgaria and Romania. Cottrell and Roberts also refer to the
huge outbreak in Bulgaria in 2009/2010 which has reported the largest
number of cases in the present European measles epidemic.
Various socioeconomic and public health indicators serve to fuel
doubts about the success of immunisation programmes and indeed the general
state of public health in the EU's less affluent member states.
I note that according to the IMF, the Gross Domestic Product (GDP)
per capita of Bulgaria (US$ 6334) and Romania (US$ 7542) is less than that
of some African countries such as Botswana (US$ 7627) and Gabon (US$
In addition, it is of interest that according to the CIA World
Factbook, the infant mortality rates (IMR) of Bulgaria (17.87 deaths per
1000 live births) and Romania (22.90 deaths per 1000 live births) rank 110
and 130 in the world respectively. For comparison the UK's IMR is 4.85
deaths per 1000 live births (world ranking 32) and the EU average IMR is
5.72 deaths per 1000 live births (world ranking 43).
It is also noteworthy that the EU member states with the 5 lowest
life expectancies i.e. Latvia, Romania, Estonia, Bulgaria and Hungary
respectively joined in the Union in the two most recent waves of EU
expansion in 2004 and 2007, respectively.
Finally, I see that according to the World Health Organisation (WHO),
only 88% of Romanians had access to clean running water in 2009.
Furthermore, only 78% of Latvians and 72% of Romanians had access to
These are just some of the indications which suggest to me that the
state of public health of some newer EU member states is less than
optimal. Complete implementation of national immunisation programmes,
challenging enough in a relatively wealth country like Britain, must be
open to question in less well resourced EU member states.
Incomplete implementation of immunisation programmes and
unpredictable resourcing of key public health functions such as
surveillance and outbreak control within the expanded EU maybe
contributing factors to this measles pandemic. The combination of greater
inequality in public health resources and increased freedom of travel
between EU member states may have inadvertently created a permissive
environment for the spread of infectious diseases such as measles.
1. Cottrell S, Roberts J R. Measles outbreak in Europe. BMJ
2. Report on First Survey of Immunisation Programs in Europe 2007:
http://venice.cineca.org/Report_II_WP3.pdf (accessed 28/6/11)
3. Romania and Bulgaria join the EU. BBC News online:
http://news.bbc.co.uk/1/hi/world/europe/6220591.stm (accessed 28/6/11)
4. List of countries by GDP per capita (IMF data):
5. List of countries by infant mortality rate (CIA World Factbook
6. List of countries by life expectancy (CIA World Factbook data):
7. Access to clean water. Guardian online Datablog (WHO data):
Competing interests: No competing interests
Cottrell & Roberts summary of the recent epidemiology of measles
infection in Western Europe shows that the number of confirmed cases have
recently been increasing. The authors correctly point out that cases
should be managed and notified on the basis of clinical suspicion rather
than laboratory diagnostic confirmation. Whilst practical, this approach
impacts not only on the care of the patient, but also on the infection
control practices of hospitals. Indeed, any suspected case requiring
admission necessitates respiratory isolation, and instigates staff and
patient contact tracing until the diagnosis is excluded.
As the number of confirmed measles cases increase, in turn this will
result in this diagnosis being considered as a possible differential by
paediatricians and physicians with greater frequency. Thus it becomes
imperative that the presence of an active measles infection can be
effectively and rapidly ruled out in order to avoid precious hospital
resources being unnecessarily diverted, especially in times of increased
need for isolation rooms, such as during an influenza season. Current
testing for acute cases of measles uses buccal swabs, that in turn are
tested for the presence of measles IgM antibodies and viral RNA, both
tests being carried out in reference laboratories. This adds a significant
delay to the results. As such, on site testing facilities with high
negative predictive values may soon be necessary, in order to ensure that
merely the thought of measles is not enough to grind much of hospitals'
infection control practice to a standstill.
Competing interests: No competing interests