On August 20, the WHO Regional Office for Europe (EURO) reported a record high number of measles cases in Europe for the first six months of 2018. More than 41,000 children and adults have been infected with measles in 2018 (through July 6), a figure significantly higher than last year, which saw 23,927 cases of measles across Europe for the entirety of 2017. This also represents the highest number of cases in Europe since 2010. So far in 2018, 37 people have died in Europe due to measles.

Outbreak Observatory previously reported on a resurgence of measles in South America; a measles outbreak in the United Kingdom, where rates of measles are higher than they were in the 1990s; and abnormally high rates of measles in the United States. The latest figures from the European continent represent yet another troubling trend in the spread of this highly transmissible, vaccine-preventable infectious disease. This week, we explore which European nations have been hardest hit, and we examine the potential role of the European political climate in exacerbating the outbreak.

A preventable threat

Measles is a highly contagious respiratory virus. Along with the characteristic rash, symptoms include high fever, cough, runny nose, and red/watery eyes, and they typically present 7-14 days after infection. There can be serious complications, including hearing loss caused by ear infections, life-threatening pneumonia, and deafness and intellectual impairment caused by encephalitis. The Vaccine Knowledge Project (University of Oxford, UK) estimates that measles causes death in 1 out of every 1000 cases, a ratio that rises to 1 in 100 cases in the poorest regions of the world.

According to the US CDC, measles is spread through respiratory droplets coughed or sneezed into the air by infected individuals. Measles is so contagious that it is believed that a single person infected with measles will infect up to 90% of susceptible (ie, unvaccinated and no history of infection) persons they come into contact with. Fortunately, a vaccine for measles was developed in the 1960s, and modern vaccines are estimated to be 93% effective after one dose and 97% effective after two doses.

An estimated 3-4 million people contracted measles every year in the US before the vaccine was introduced in 1963. In the UK, between 400,000 and 600,000 cases were reported annually until the vaccine was introduced in 1968. Measles was declared eliminated in the US in 2000, and annual incidence dropped to as low as 37 reported cases in 2004. The UK achieved measles elimination in 2017.

Europe’s mixed progress report

Although Europe has witnessed a record number of cases in 2018, the picture varies dramatically by country. A report by WHO’s European Regional Verification Commission for Measles and Rubella Elimination (RVC), which met between June 13-15 in Paris, noted that 10 of 53 EURO Member States were considered endemic for measles in 2017. These 10 countries accounted for more than 93% of all measles cases reported in the region in 2017 (in alphabetical order): Belgium, Bosnia and Herzegovina, France, Georgia, Germany, Italy, Romania, Russian Federation, Serbia, and Ukraine. In 2018, seven countries have reported more than 1000 cases, with deaths reported in each: France, Georgia, Greece, Italy, Russian Federation, Serbia, and Ukraine.

Two countries deserve special note. First, Ukraine has been the hardest hit, with more than 23,000 people affected by measles, representing more than half of the 41,000 people affected in Europe for 2018. An analysis from the UN Dispatch argues that Ukraine faces numerous challenges to tackling the epidemic, including underfunded health systems; the ongoing conflict in Crimea and southern and eastern Ukraine, which limits access to routine health services; and high rates of vaccine hesitancy among Ukrainian parents. Second, Greece is experiencing one of the largest outbreaks in Europe, recording approximately 1,463 cases in 2018. Greece declared measles eliminated in 2017, but the disease was re-introduced following the arrival of migrants from Romania and across the Mediterranean, many of whom reside in camps along the southern coast.

The RVC report does note progress in some countries, with five Member States interrupting measles transmission within the past 24 months, including Austria, Kyrgyzstan, Poland, Switzerland, and Turkey. Cases in non-endemic countries, such as the 760 suspected cases in the UK in 2018, are linked to unvaccinated adults and children returning from travel abroad in endemic regions.

One challenge to controlling the spread of measles has been inadequate disease surveillance. For instance, the RVC observes that Ukraine’s surveillance performance “failed to meet requirements and/or were incorrectly calculated,” noting that only 24% of chains of transmission were genotyped (to determine the origin of the virus). The Commission calls for a greater commitment to nationwide comprehensive disease surveillance, including high-quality information and investigation by accredited laboratories.  

The politics of vaccination

Another major hurdle to controlling the spread of measles in Europe has been low immunization coverage. According to a recent MMWR report, coverage for the first dose of measles containing vaccination (MCV1) in Europe has “declined from 95% to 93% since 2012, with about half of EURO member states reporting lower coverage since 2013.” This percentage falls short of the 95% MCV1 target set by the WHO strategic framework for the elimination of measles in Europe. The European Centers for Disease Control (ECDC) notes that up to 80% of teenagers and young adults who contracted measles in 2017 had not been vaccinated (Note: the ECDC does not account for several countries in the EURO region, such as Russia and Ukraine).

This trend may be partially due to public complacency about the need for vaccination when the risk of contracting measles is less salient than it was a few decades ago. Another reason for declining immunization coverage may be higher levels of vaccine hesitancy among adults fearful of the effects of vaccines or mistrustful of government officials who advocate them. Skepticism of the MMR (measles, mumps, rubella) vaccine famously began in 1998 after the publication of Andrew Wakefield’s now discredited paper that the MMR vaccine causes autism.

Two decades later, the growth of the so-called “anti-vaccine” or “anti-vaxxer” movement in Europe has seemingly dovetailed with the rise of populist political parties, which are adept at using social media to spread their views about vaccine safety. As The Guardian (UK) recently noted, French politician and former presidential candidate Marine Le Pen has supported the right of French citizens to refuse vaccination in a country where 11 vaccines, including measles, are mandatory for children. In Italy, political activist Beppe Grillo and his Five Star Movement (akin to the Tea Party in the US) have espoused falsehoods about vaccines, including that they cause leukemia, autism, and allergies. Both France and Italy are currently facing large measles outbreaks.

In addition to ignoring the scientific evidence underpinning vaccine safety, many of Europe’s populist movements—which espouse nationalist agendas and advocate for separation from the European Union—fail to consider the inherently interconnected nature of disease outbreaks. The spread of measles in Europe has demonstrated how an outbreak in one nation threatens the health and wellbeing of citizens across the continent, regardless of their political or personal beliefs.

Conclusion

With Europe reporting record high rates of measles, European nations need to step up their response to the measles epidemic—in conjunction with the WHO, ECDC, and others—including heightened surveillance and enhanced immunization, education, and outreach efforts. While countries in southern and eastern Europe—including Greece, Italy, Ukraine, and Russia—are experiencing the brunt of the outbreak, abnormally high cases in non-endemic countries, such as the UK, demonstrate that all nations are potentially at risk. This risk rises significantly for individuals who have not been vaccinated. At a time when various political movements in Europe, the US, and elsewhere are espousing anti-science and anti-vaccine rhetoric, it will be doubly important for concerned government officials and members of the public to take action to protect public health.

Photo: Supporters of Italy's Five Star Movement (Movimento 5 Stelle) gather in 2012. Party leaders have called for relaxing mandatory vaccination policies. Italy is one of seven European countries facing over 1,000 measles cases in 2018. Photo courtesy of Flickr/Gabriele Fuso.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.