International Measles Outbreaks

Measles

Measles cases greatly decreased after the introduction of the measles vaccine in the 1960s.
Measles cases greatly decreased after the introduction of the measles vaccine in the 1960s. Photo courtesy of the National Center for Immunization and Respiratory Diseases

Rates of measles are usually fairly low in the United States.

Before the routine measles vaccination though, rates of measles cases were high. There used to be about 500,000 cases of measles and high rates of complications from those cases, including about 500 measles deaths each year in the United States.

After the last big measles outbreak in 1989 and the introduction of the MMR booster dose in 1994, cases of measles have dropped.

In 2000, it was even declared that the endemic spread of measles in the United States had ended, and continued cases have all been imported from outside the U.S.

Measles Outbreaks

Unfortunately, imported measles cases can still trigger small measles outbreaks in people who are at risk for measles, include those who are unvaccinated or under-vaccinated. This includes:

  • infants who are too young to get their first dose of MMR
  • toddlers and preschoolers who are too young to get their booster dose of MMR
  • children who have a problem with their immune system, and so either can't get the MMR vaccine, or had the MMR vaccines but they don't work effectively because they are immunocompromised, such as children who are receiving chemotherapy for cancer

Most cases of measles are in children and adults who have simply not been vaccinated by choice though.

In 2014, there were over 600 cases of measles in the United States, including 58 in California alone, a large measles outbreak in New York City, and another in Ohio (377 cases).

International Measles Outbreaks 2016

In addition to many developing countries where measles is still endemic, measles outbreaks have been reported internationally in:

  • European Union - There are currently outbreaks in Romania, Italy and the United Kingdom, although measles cases are down from previous highs in Europe, with just under 4,000 cases in 2015 and 62% of them in Germany, where an unvaccinated child died. There were also six cases of measles encephalitis in 2015.
  • West Africa - children in many countries hit by the Ebola outbreak were not vaccinated against measles during that time and are now in the middle of a big measles outbreak, with many cases and deaths in Liberia, Chad, and Cameroon, etc.
  • Philippines - at least 2,231 cases and 2 deaths in 2015, which follows a big year in 2014 - 58,010 suspected cases and 110 measles deaths, with many cases in Metropolitan Manila, Calabarzon, and Central Luzon, which led to outbreaks in Australia, Canada, Japan, New Zealand, the United Kingdom.
  • Kyrgyzstan - at least 18,000 cases in 2015 with at least two deaths in children.
  • Ethiopia - at least 9,732 cases in 2015 and at least one death in an unvaccinated child.
  • Bosnia and Herzegovina - more than 3,800 since January 2014.
  • Australia - 42 cases in 2016 (334 cases in 2014 - the most in 16 years).
  • Vietnam - 332 cases in 2015, which follows a big year in 2014 - at least 2 deaths in children (media reports of deaths and cases are much higher though) among at least 18,597 suspected cases
  • Solomon Islands - at least 4,300 cases and 7 deaths in an ongoing outbreak.
  • Canada - at least 6 cases in 2016. There were at least 19 cases in Ontario and 159 cases in Quebec (linked to the Disneyland Outbreak) in 2015 (total of 196 cases), which follows a big year for measles in Canada in 2014 - at least 418 cases, including 31 cases in Alberta (new outbreak in Edmonton), 19 in Ontario, 8 in Manitoba, 16 in Saskatchewan, and most cases beginning in a Christian school in British Columbia, which then spread to the general community.
  • Singapore - at least 72 cases as of early April.
  • Micronesia - an ongoing outbreak in at least 4 states of the Federated States of Micronesia - Yap, Chuuk, Kosrae, and Pohnpei.
  • Japan - only 5 cases so far in 2016 (462 cases in 2014 including at least one case of measles encephalitis and almost all unvaccinated or partially vaccinated)
  • New Zealand - 12 cases in 2016 (at least 281 cases in 2014)
  • Brazil - 689 cases in 2014
  • Netherlands - at least 2,499 cases in the Dutch "Bible belt" with at least one case of measles encephalitis and one death, a 17-year-old girl. Almost all of the measles cases in this outbreak are unvaccinated and the majority are children. An outbreak in Canada, with 42 cases, was linked to this outbreak in the Netherlands. A new outbreak in The Hague region has already gotten at least 15 people sick.
  • Ukraine - 2,309 cases
  • Russia - several large ongoing outbreaks in 2014 with rates of measles running 10 times higher than they were last year.
  • Turkey - 7,132 cases (up from 700 last year)
  • Georgia - more than 5,369 cases and 2 deaths
  • Indonesia - 6,300 confirmed cases
  • Syria - at least 7,000 cases
  • Pakistan - at least 290 children have died as over 30,000 people have gotten measles so far this year and their are daily reports of more children dying
  • Southern Africa, including measles outbreaks in Lesotho, Malawi, Namibia, Mozambique, South Africa, Zambia, and Zimbabwe. In South Africa, the National Institute for Communicable Diseases had issued an outbreak alert after an increase in measles cases in five South African provinces.
  • Eastern Africa, including measles outbreaks in Ethiopia and Kenya

High numbers of measles cases in Europe which began in 2010 continued in 2011, with more than 30,000 cases in each of those years. Overall, with more than 30,000 cases of measles in Europe in 2011, there were 8 deaths, 27 cases of measles encephalitis, and 1,482 cases of pneumonia. Most cases were in unvaccinated (82%) or incompletely vaccinated (13%) people.

France was the hardest hit, with over 15,000 cases of measles and at least 6 deaths last year, 651 cases of severe pneumonia and 16 cases of encephalitis.

In 2013, Europe reported a milder measles season, with just 10,271 cases of measles, with most of the cases being found in Germany, Italy, Romania, the Netherlands and the United Kingdom. As in previous years, almost all cases were not vaccinated or were only partially vaccinated. These cases have been complicated by 8 cases of acute measles encephalitis and there have been 3 deaths.

The European Centre for Disease Prevention and Control also reports that like most countries in the developing world, measles had once again endemic in many parts of Europe "due to a decrease in the uptake of immunisation."

SSPE in Europe

A new development is the report in Germany of three cases of subacute sclerosing panencephalitis (SSPE), a rare, late complication of measles. On average, subacute sclerosing panencephalitis occurs about seven years after having a natural measles infection. The CDC reports that it causes a "progressive deterioration of behavior and intellect, followed by ataxia (awkwardness), myoclonic seizures, and eventually death."

Among the cases include:

  • a six-year-old girl who had developed measles when she was seven-months-old and too young to get an MMR vaccine. Although she was only just diagnosed in October, she is already unable to walk and talk and has to be fed via a gastric tube.
  • a 13-year-old girl who died in October. It is thought that she developed measles as an infant after being exposed to an unvaccinated 11-year-old boy at her doctor's office.
  • a 19-year-old boy who developed measles when he was just 6-months-old from an unvaccinated child, SSPE when he was 10, and just died from complications of SSPE in February 2014.

Although there is no cure for SSPE, it is important to keep in mind that like measles, it can be prevented with the MMR vaccine.

A report on the "Epidemiology of Subacute Sclerosing Panencephalitis (SSPE) in Germany from 2003 to 2009: A Risk Estimation" that was published in PLoS ONE identified 31 children with SSPE and they found that "the risk of developing SSPE after acute measles infection below 5 years of age to be in the range of 1 in 1700 to 1 in 3300 cases of measles infection."

Progress Toward Measles Elimination

Talk about eliminating measles began shortly after we began immunizations to prevent measles.

Unfortunately, over the years, most countries have fallen short in their goals of controlling and eliminating measles.

One of the first goals was to reduce measles morbidity by 90% and measles mortality by 95% by 1995. The World Health Assembly was short of that goal, reaching only 78% and 88% respectively.

One of the next goals was to vaccinate 90% of children against measles by 2000. That goal wasn't met either, although progress was certainly made.

The latest goals, to be met by 2015, likely won't be met either:

  • increase routine coverage with the first dose of measles-containing vaccine (MCV1) for children aged 1 year to ≥90% nationally and ≥80% in every district
  • reduce global annual measles incidence to <5 cases per million
  • reduce global measles mortality by 95% from the 2000 estimate

In 2000, there were 544,200 measles death around the world. In 2013, while progress had been made in reducing the number of deaths, 145,700 still died of this vaccine-preventable disease.

When will we eliminate measles?

Measles Outbreaks - What You Need To Know

Other things to know about measles and measles outbreaks include:

  • From 2 to 5% of people do not respond to their first dose of measles vaccine, which is why a booster dose is recommended.
     
  • More than 99% of people develop immunity to measles after two doses of a measles vaccine, like MMR.
     
  • A booster dose of MMR was first recommended in 1990 (for four year olds), so many adults born before 1986 may not have had two doses of MMR.
     
  • Measles is fatal in about 0.2% of cases.
     
  • The measles virus is spread by respiratory droplets and can stay in an area for up to two hours after a person with measles symptoms has left.
     
  • People with measles are contagious from four days before to four days after they develop the measles rash.
     
  • Call your pediatrician if you think your child has measles (don't just show up at their office or in the ER), especially if he develops a high fever and/or rash during a local measles outbreak or after a trip out of the country.

Most importantly, parents should understand that a measles vaccine (MMR) is the best way to protect your child from measles, and is especially important if there is a measles outbreak in your area or if you are traveling to an area with high rates of measles.

Sources:

CDC. Measles: Unprotected Story: 106 Degrees: A True Story. November 4, 2010. Accessed February 2011.

CDC. Outbreak of Measles --- San Diego, California, January--February 2008. MMWR. February 29, 2008 / 57(08);203-206

CDC. Update: Measles --- United States, January--July 2008. MMWR. August 22, 2008 / 57(33);893-896

European Centre for Disease Prevention and Control. Measles Surveillance Data. September 2013 - August 2014.

Manual for the Surveillance of Vaccine-Preventable Diseases (4th Edition, 2008)

The Pink Book: Epidemiology and Prevention of Vaccine Preventable Diseases. Updated 11th Edition, (May 2009)

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