International Notes The Feasibility of Measles Elimination in Europe

Major progress toward the elimination of measles has been achieved in the United States and several other countries in recent years because of extensive vaccination of targeted populations (1). These successful experiences suggest the technical feasibility of worldwide eradication of measles (2). Yet in many other areas--including much of Western Europe--measles incidence rates are 10-10,000 times higher than in the United States. The following report describes the current impact of measles in Europe and the current status of efforts to eliminate the disease from that region.

The feasibility of measles elimination in Europe was discussed at an informal consultation held at the World Health Organization (WHO), Regional Office for Europe, in Copenhagen, on January 17-18, 1983. The past and present impact of measles in the Region was considered.

Although there is widespread belief among the public and some health professionals that measles is a mild illness, it caused thousands of deaths each year in the Region before measles vaccine was available. Even though the incidence of measles has been reduced substantially by the use of vaccine, measles continues to cause hundreds of deaths each year in the Region, as well as hundreds of thousands of cases of acute illness with accompanying school absenteeism and loss of work. In addition, acute nervous-system complications, pneumonia, and otitis continue to occur and may lead to permanent disability. Cases of subacute sclerosing panencephalitis (SSPE), a late complication of measles, also continue to occur in Europe.

Experience with measles vaccine in Europe has indicated that it is highly effective; when given during the second year of life, seroconversion rates above 90% are usual. Its effectiveness in preventing disease in the face of exposure is comparable. Indications to date are that vaccine-induced immunity is durable and probably life-long. Measles cases among vaccinated individuals result from unsuccessful or faulty vaccination rather than from loss of immunity. In some countries, a second dose of vaccine is given to reduce even further the proportion of vaccine failures. Reactions to the vaccine are few and generally involve transient fever or rash in 5%-15% of recipients. More serious complications are extremely rare. Contraindications to vaccination in routine situations are few: compromised immune status (whether due to disease or medication), acute febrile illness (more serious than upper respiratory infection), and pregnancy. Although experience is limited, no evidence of risk to the fetus has been demonstrated when vaccine is administered to a pregnant woman. Problems observed earlier with vaccine failures resulting from fragility of the vaccine can be overcome by proper attention to vaccine handling (the "cold chain") and by use of newer, more stable vaccines (i.e., those meeting WHO criteria). As immunization levels rise, the proportion of cases that occur in vaccinated individuals can be expected to rise. These cases do not reflect waning immunity but are confined to the small proportion of children who did not seroconvert on initial vaccination.

Although there has been general agreement about the desirability of measles vaccination, there has been variable implementation of programs throughout the Region. Vaccine coverage rates ranging from less than 10% to 90% have been reported from different countries. In general, the impact on measles incidence has paralleled vaccine coverage. Great success in reducing measles incidence has been reported from several countries, and studies have demonstrated the highly favorable cost/benefit ratio resulting from measles vaccination. In many countries, even further benefits have been realized by the use of combined measles-rubella (MR) or measles-mumps-rubella (MMR) vaccines.

Initial success in reducing the occurrence of measles has led several countries to consider elimination of indigenous disease, i.e., cases of measles that cannot be traced directly (within a few generations of transmission) to a foreign source. This definition falls short of total eradication and acknowledges that periodic importations will certainly occur. At least three countries in in the Region are known to have established elimination goals--Czechoslovakia, Finland, and Sweden. In Czechoslovakia (3), measles incidence has been reduced to a level of only 25 cases during 1982 (almost all of them imported). Sweden and Finland have only recently begun their programs (using combined MMR vaccine).

Experience to date indicates that elimination of measles is technically feasible and that successful strategies will include at least three elements: achievement and maintenance of high immunization levels (certainly in excess of 90%), effective surveillance, and aggressive response to cases.

Implementing the first element will clearly involve substantial efforts to educate the general public about the dangers of measles and desirability of prevention. The mass media may be useful in this regard. Physicians and other health-care providers also need to be reminded of the severity of the disease and the effectiveness of immunization. Endorsement from professional associations (particularly those of pediatricians) can help achieve this, as can educational devices such as journal articles and sets of slides. Review of immunization status at the time of entry to day nurseries, kindergartens, schools, and similar institutions is a useful means of assuring high coverage.

Surveillance of disease is a critical element, and surveillance programs need to be strengthened to minimize the present (variable) degree of underreporting. Measles should be a notifiable disease in all countries. Periodic serologic surveys are valuable to monitor immunity levels in the population. Ongoing review of programs is essential.

Once suspected cases are detected, prompt investigation and outbreak control measures, including identification and vaccination of susceptibles, are needed. Experience in the German Democratic Republic indicates that outbreaks are smaller and shorter when aggressive outbreak control measures are applied than when they are not.

Since measles is a highly contagious disease and since there is a great movement of people within the Region, a coordinated regional approach to elimination is essential. WHO can aid both the development and the implementation of detailed elimination strategies to meet the different situations in different countries. Regional meetings to develop coordinated strategies and monitor progress would be most helpful. The time required to achieve elimination will differ from country to country, depending on the present state of measles immunization and control. In some countries, it should be achieved in a few years, and in most countries, it should be achievable by 1990. Reported by WHO Weekly Epidemiological Record 1983:58;229-30; Div of Immunization, Center for Prevention Svcs, CDC.

References

1. Assaad F. Measles: summary of worldwide impact. International Symposium on Measles Immunization. Reviews Inf Dis 1983;5:452-9.

2. Foege WH. The global elimination of measles. Public Health Reports 1982;97:402-5.

3. World Health Organization Weekly Epidemiological Record 1983;58:85-6.

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