Measles in the WHO European Region, 2009–2018: Progress, Then a Resurgence

In 2010 all 53 countries in the World Health Organization's European Region — home to about 900 million people — renewed their commitment to eliminating measles, rubella and congenital rubella syndrome, a goal later made a priority of the European Vaccine Action Plan 2015–2020. This CDC and WHO report tracks progress from 2009 to 2018.

WHO's strategy for the region has four parts:

1. reach and keep at least 95% coverage with two doses of measles-containing vaccine (MCV) through routine immunization;
2. offer measles and rubella vaccination, including supplementary immunization activities (SIAs), to people still susceptible;
3. strengthen surveillance, investigating cases and confirming suspected cases and outbreaks in the laboratory;
4. improve the evidence on the benefits and risks of vaccination, and its use.

Vaccination

Every country in the region has given two MCV doses in its routine childhood schedule since 2002. From 2009 to 2017, regional coverage with the first dose (MCV1) stayed between 93% and 95%, while coverage with the second (MCV2) rose from 73% to 90%. In 2017, 30 countries (57%) reached at least 95% MCV1 coverage, but only 15 (28%) reached that level with both doses.

More than 16 million people were vaccinated in 21 SIAs in 13 countries. Nine of those campaigns (43%) reported coverage of at least 95%, and weighted average coverage was 88%; no follow-up coverage surveys were reported.

Surveillance

All countries report measles data to WHO each month, directly or through the European Centre for Disease Prevention and Control. By 2018, 47 countries reported individual cases and six reported only totals. Suspected cases are classified as laboratory-confirmed, epidemiologically linked, clinically compatible or discarded, and the WHO European Measles and Rubella Laboratory Network confirms and genotypes the virus.

Performance improved between 2009 and 2018:

Cases and deaths

Coverage with the first and second doses of measles-containing vaccine, and confirmed measles cases, WHO European Region, 2009–2018. CDC, MMWR.

• 2009: 8.8 cases per million (7,884 cases).
• 2010–2015: an average of 30.1 per million (an average of 28,021 cases a year).
• 2016: a low of 5.8 per million (5,273 cases).
• 2018: about fourteen times higher, at 89.5 per million (82,596 cases) — from 47 countries.

Eight countries reported 89% of the 2018 cases: Ukraine (53,218; 64% of the total), Serbia (5,076), Israel (2,919), France (2,913), Italy (2,517), Russia (2,256), Georgia (2,203) and Greece (2,193). Ukraine (1,209.2 per million) and Serbia (579.3) had the highest rates. Adults aged 20 and older made up 37% of 2018 cases — 68% in Italy, 67% in Serbia and 42% in Russia.

Of 179 measles deaths reported from 2009 to 2018, 114 came in 2017–2018, 93 of them in Romania (46), Ukraine (20), Serbia (15) and Italy (12).

The dominant virus genotype shifted over the decade: D4 in 2009–2012, D8 in 2013–2016 and B3 in 2017–2018.

Elimination — and the setback

The European Regional Verification Commission for Measles and Rubella Elimination, set up in 2011, reviews each country's evidence every year. By the end of 2017, 37 countries (70%) had gone at least 36 months without endemic measles transmission and were verified as having eliminated it.

Then reported cases tripled from 2017 to 2018, with eight countries reporting more than 2,000 cases each. Transmission that began in 2017 continued in France, Greece, Romania, Russia, Serbia and Ukraine, and imported cases sparked widespread spread in countries that had eliminated measles, including Albania, Belarus, the Czech Republic, Israel and Montenegro. Despite high national coverage, the report points to:

• lasting reservoirs of the virus in countries with limited resources and weak immunization systems;
• build-ups of unvaccinated young children in marginalized communities;
• young adults who had escaped both infection and vaccination during years when measles was rare.

Responses varied. Some countries' large outbreaks strained money and staff, delaying or weakening the response. Others never ran outbreak vaccination campaigns, for lack of political commitment, poor acceptance of mass immunization by officials and the public, no way to reach particular groups, or vaccine shortages. The 2018 midterm review of the Vaccine Action Plan added weak vaccine delivery and stock-outs in some middle-income countries, widespread antivaccine sentiment, large unvaccinated groups including ethnic and religious minorities and adults, and outbreaks in hospitals that spread to the community.

What comes next

WHO's European office set five priorities: reach and keep 95% coverage; understand barriers to vaccination in vulnerable groups and build demand; close immunity gaps with locally tailored approaches; keep surveillance strong enough for rapid detection and targeted response; and tighten infection control, especially during outbreaks. WHO's Strategic Advisory Group of Experts also recommends checking vaccination status at school entry.

Surveillance probably undercounts measles, because not every patient seeks care or is reported, and data quality varies by country.

Sources

• Zimmerman LA, Muscat M, Singh S, et al. "Progress Toward Measles Elimination — European Region, 2009–2018." MMWR 68(17). CDC. The report dates the SIAs to 2009–2017 in one place and 2009–2018 in another, so no period is given for them here; it also gives the number of countries that had interrupted transmission for at least 12 months as "43 (91%)," which do not agree with each other, so that figure is left out.