The United States is in the midst of its worst measles outbreak in a quarter of a century, sparking headline-grabbing fears that it will lose its ‘measles free’ status. The confirmation of more than 1,000 cases between January and June 2019 has prompted a major public debate about a vaccine-preventable disease that had faded from public memory for a generation.
Meanwhile, in Europe, a sobering report on the 30 Member States of the EU/European Economic Area has been released, putting US outbreaks in perspective. Between 1 January 2016 and 31 March 2019, the European Centre for Disease Control & Prevention (ECDC) recorded 44,074 cases of measles.
This 30-state region is smaller than the 53-state WHO European Region which includes Ukraine – a country where more than 50,000 measles cases have been reported in the first five months of 2019.
An outbreak of preventable disease in the US – and the threat to the Americas’ measles elimination effort – is a major public health concern. But the situation in Europe is considerably worse, even if it is not generating a proportionate level of concern.
Infants at risk: Too young to be vaccinated
The concern for health authorities in European countries is that there is still a large group of unvaccinated infants and adolescents who are at risk of catching – and spreading – the disease. The outbreaks show no signs of abating due to gaps in immunity and suboptimal vaccination coverage.
‘Measles continues to be an EU-wide health threat,’ said Andrea Ammon, ECDC Director.’ Due to failures in reaching the current global vaccination targets, 4.5 million children and teenagers in the EU/EEA below 20 years of age are unnecessarily at risk of measles.’
Two of the key groups are infants who are too young to be vaccinated and adolescents born in the years after 1999 when there was a dip in MMR vaccine uptake. The median age of cases has increased over the past decade – from 10 years of age in 2009 to 17 years in 2019. Adults aged 20 years and above represented 35% of reported cases in the 2016-2019 period.
The average notification rates were highest in infants, up to 44 times higher than other age groups. Almost half – 45% – of all measles deaths were reported in infants.
While most people choose to vaccinate their children against measles and to have other recommended vaccinations, some opt out. Experts say this is due to a range of factors, summarised by the ‘3 Cs’ shaping vaccine uptake: Confidence, Complacency and Convenience.
Confidence attracts most attention, which the US media in particularly pinning the blame of ‘anti-vaxxers’, but complacency – due to the absence of preventable diseases – remains a challenge. Many parents and younger health professionals have never seen a case of measles, thanks to vaccination.
Others would vaccinate their children but face practical challenges. For example, it has been shown that patents of ultraorthodox Jewish communities in London often missed immunisation appointments not because they had any objection to vaccination but because they have large families. Bringing six or seven children to a busy clinic by bus was an obstacle so health authorities found ways to make it easier for them to complete the vaccine schedule.
European countries first aimed to achieve measles-free status almost 20 years ago but have been hit with repeated waves of outbreaks. The number of countries achieving the WHO target of 95% vaccination coverage for two doses of measles-containing vaccine has dropped significantly. In 2017, only four countries achieved the target compared to 14 countries in 2007. A vaccination coverage of 95% is necessary in order to eliminate the disease.
‘According to the objectives set out by the World Health Organization, measles should have been eliminated in the European region already by 2000,’ said Vytenis Andriukaitis, EU Commissioner for Health and Food Safety. ‘However, Europe is still far from being a measles-free continent. These numbers are just unacceptable, especially given that an effective vaccine against the disease has existed since the 1960s.’
He noted that only four EU countries had reached the target of 95% coverage with two doses of MMR vaccine – the level required to achieve herd immunity.
‘Why is this important? It matters because we protect each other…. It is not just about personal choice: It is also a form of solidarity,’ said Andriukaitis.
The EU will host a Global Vaccination Summit in Brussels in September as part of its ongoing efforts to control outbreaks. ‘The Summit will give us an opportunity to hold a fulsome debate and give a strong message: vaccines save lives and we have to be series about it.’