Measles is a highly infectious and potentially severe disease that can be prevented by a safe and effective vaccine. When given in two doses, at least 98% of vaccine recipients develop protective immunity against the disease. The countries in the European Region of the World Health Organization, including the EU and EEA/EFTA countries, have committed to eliminate measles by 2015. Elimination of measles requires sustained vaccination coverage above 95% with two doses of a measles containing vaccine.
Measles is re-emerging in Europe. More than 30 000 measles cases were reported by EU and EEA/EFTA countries in 2010, a fivefold increase compared to the annual average for the preceding five years. Eighty-five percent of the reported were unvaccinated. The dramatic increase was primarily due to a large outbreak in Bulgaria during 2009-2010 with more than 24 000 reported cases and 24 deaths. However, many other countries including France, Germany, Italy, Ireland, Romania and Spain also reported a considerable increase in the number of cases during 2010. The outbreaks in the EU are principally the result of transmission between Member States. The majority (71%) of the imported cases in 2010 were imported from another European country.
The high incidence continues in 2011, with significant outbreaks ongoing in France, Spain and Belgium. As of 12 May 2011, more than 10 000 cases and four fatalities have been reported from 18 of the 31 EU and EEA/EFTA countries. Among the cases are several unvaccinated health care personnel.
Source: Institut de Veille Sanitaire. Epidémie de rougeole en France. Actualisation* des données de déclaration obligatoire au 19 avril 2011
There is increasing indigenous transmission of measles across France with more than 14 500 reported cases since the beginning of January 2008, including five deaths.
The third and to date largest wave of the epidemic started in October 2010. Since then, there has been more than 9 000 notified cases. Over 3 000 cases were reported in March 2011 alone (Figure 1). Two deaths and 13 neurological complications (12 encephalitis cases and one case with myelitis/ Guillain-Barré syndrome) were reported in 2011.
Figure 1: Number of notified measles by date of onset of rash, France, January 2008-March 2011
The highest incidence in 2010 was observed in infants (< one year of age) who are not eligible for vaccination. The number of cases in the 0 to 12 months age group tripled in 2010 compared to 2009. The highest incidence is reported from South-East France but practically all of the regions of France have been affected (Figure 2).
Figure 2: Distribution of measles cases and incidence, by département, France, October 2010 -March 2011
Source: Centro de Coordinación de Alertas y Emergencias Sanitarias, Ministerio de Sanidad Política Social e Igualdad
Spain has to date reported 786 cases (685 laboratory confirmed) in 2011. Outbreaks are ongoing in 9 of the 17 autonomous communities and one of the two autonomous cities, affecting most areas of the country. Major cities, such as, Madrid, Barcelona and Seville are also reporting outbreaks. Cluster sizes vary from 2 to more than 200 cases and two genotypes, B3 and D4, are circulating concurrently.
The following groups can be distinguished among the infected:
- Children below 15 months of age who have not yet received their first dose of MMR vaccine,
- Adults 25 to 40 years old born after the introduction of the childhood measles vaccination programme,
- Unvaccinated people of all ages living in low economic resource areas,
- Individuals coming from low income countries with low vaccination coverage,
- Unvaccinated health care workers.
Control measures include contact tracing, extra dose of measles containing vaccine to infants from 6 months of age, post-exposure vaccination within 72 hours, vaccination of health professionals and information campaigns to the public and in schools. Belgium
Since the beginning of 2011, there have been several measles outbreaks in Belgium with at least 231 cases (122 laboratory confirmed), compared to 40 cases in 2009 and 33 cases in 2008 respectively (Figure 3).
The first outbreak started in Flanders in anthroposophic schools later spreading to other schools and a Roma community. The majority of cases (87%) were unvaccinated. The main reported reasons for non-vaccination were anthroposophical beliefs (55%), pediatricians advising against vaccination (26%), and delayed vaccination because of concurrent illness or travel (13%).
Outbreaks are now reported from other provinces as well. As of 11 May 2011, all provinces, except Antwerp, have reported cases. The circulating strain is measles virus genotype D4. Information about complications is available for 136 patients. Twenty-six of these (19%) required hospitalisation. Complications include seven cases of pneumonia (one followed by septic shock) and one case of encephalitis. Twenty cases were linked either to travelling to or contact with cases from another MS (the majority from France).
Mandatory reporting of measles was only introduced in 2009 and the true measles incidence is assumed to be higher than currently reported.
Figure 3 : Number of reported measles cases by symptom onset, Belgium, January 2007-April 2011
Summary of measles situation in EU and EEA/EFTA countries:
As of 11 May 2011, more than 10 000 cases have been detected by ECDC in the EU and EEA/EFTA countries through epidemic intelligence activities compiling data from different sources, such as, WHO, EUVAC.Net, reports of public health institutes of Member States, ProMed articles and the media (Figure 4). Besides France, Spain and Belgium several other EU and EEA/EFTA countries report higher number of cases compared to the same period last year mainly among unvaccinated individuals: Switzerland (337), Denmark (54), Sweden (13), Romania (254) Norway (18) and Finland (9).
Figure 4: Number of reported measles cases during January – 11 May 2011
The increasing incidence and geographical spread of measles in EU and EEA/EFTA Member States means that the risk of exposure to measles has increased for visitors to and within Europe. The US Centers for Disease Prevention and Control advise travellers intending to visit Europe to vaccinate infants from six months of age, and the WHO Office for the European Region is encouraging health authorities and travel health professionals to advocate for immunisation before travel to, from or within Europe, and to provide measles vaccination for travellers who lack evidence of immunity against measles.
ECDC is closely monitoring reports about measles outbreaks in the EU and EEA/EFTA Member States and neighbouring countries in Europe, and continues to work in close collaboration with the Member States and the World Health Organisation towards the elimination goal in 2015.
ECDC’s risk assessment guidelines for infectious diseases transmitted on aircraft (RAGIDA)