Is measles elimination possible in WHO European Region up to 2015? - Epidemiological Review

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_{Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland}

ABSTRACT

678'<2%-(&7,9( The assessment of epidemiological situation of measles in WHO European Region during

last decade in terms of progress in disease elimination.

0$7(5,$/$1'0(7+2'6. The surveillance data regarding measles control and vaccination coverage in entire

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many areas of WHO European Region during last decade. The incidence of measles was significantly higher than is required on that stage of measles elimination i.e. 1/1 000 000 excluding imported cases. Furthermore, WKHUHZHUHQRWLILHGIDWDOFDVHVUHODWHGWRPHDVOHVGXULQJFRQVLGHUHGSHULRG

&21&/86,2167KHLQVXIILFLHQWYDFFLQDWLRQFRYHUDJHLQPDQ\FRXQWULHVRIWKHUHJLRQFDXVHVWKHVXVWDLQDEOH

YLUXVWUDQVPLVVLRQLQSRSXODWLRQ7KDWVLWXDWLRQOLHVEHKLQGWKHKLJKSUREDELOLW\RIPHDVOHVRXWEUHDNVLQQHDUO\ future, that could delay the disease elimination in the set limit of time.

.H\ZRUGV: measles, epidemiological situation, WHO European Region

INTRODUCTION

0HDVOHVLVDQLQIHFWLRXVGLVHDVHFKDUDFWHUL]HGE\ WKHFULWHULDWKDWHQDEOHLWVHUDGLFDWLRQ$QLQWHUPHGLDWH stage to eradicate measles is its elimination, that was LQLWLDOO\SODQQHGE\\HDULQ:+2(XURSHDQ5H-gion. The disease elimination at a given area means the lack of endemic measles cases and virus transmission in case of its introduction to population. The set limit of WLPHZDVLQVXIILFLHQWWRPHHWWKHSURJUDP¶VREMHFWLYH The time period to finally complete the program in the UHJLRQZDVSURORQJHGXSWR7KHVWUDWHJ\IRFXVHV on the implementation of four components:

x to achieve and maintain high vaccination coverage among children and youth with two doses of measles vaccines (over 95%) according to routine vaccina-tion schedules,

x WR VHFXUH WKH SRVVLELOLW\ RI VHFRQG GRVH DJDLQVW measles through additional vaccination initiatives LQSRSXODWLRQVYXOQHUDEOHWRLQIHFWLRQ

x to intensify the system of measles surveillance using effective methods of epidemiological investigation ZLWKURXWLQHODERUDWRU\FRQILUPDWLRQ

x to improve the access to confirmed information concerning advantages and disadvantages of vac-cinations against measles for health professionals and whole society.

Some detailed assumptions of Measles Elimination Program in WHO European Region, as well as its later YHULILFDWLRQ DFFRPSOLVKHG LQ  ZHUH LQFOXGHG LQ SUHYLRXVSDSHUV

The aim of the study was the assessment of epi-demiological situation of measles in WHO European Region during last decade in terms of progress in disease HOLPLQDWLRQXSWR

MATERIAL AND METHODS

We have analyzed the data of measles epidemiologi-cal surveillance in WHO European Region and Poland, UHJLVWHUHGE\:+2DQG1DWLRQDO,QVWLWXWHRI+\JLHQHLQ :DUVDZLQ±7KHGDWDUHJDUGLQJPHD-sles control and vaccination coverage in entire region ZHUHFRPSDUHGWRWKHWDUJHWVWKDWVKRXOGEHDFKLHYHGDW the last stage of measles elimination program.

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 No 3

RESULTS

Epidemiological situation of measles in WHO (XURSHDQ5HJLRQKDVEHHQYDULRXVIRU\HDUV,QWKH LQLWLDOSHULRGWKHUHZHUHPHDVOHVRXWEUHDNVLQWKHHDVWHUQ countries of the region, such as: Turkey, Ukraine, Ka-]DNKVWDQ$]HUEDLMDQ7KHUHZDVDVLJQLILFDQWLQFUHDVH of measles incidence in France and Italy at that time. In WKHODVWIHZ\HDUVWKHRXWEUHDNVRFFXUUHGLQ%XOJDULDWKH highest measles incidence during the last decade was QRWLILHGLQ±5RPDQLDDDVZHOO DVLQ)UDQFHDQG8NUDLQHDJDLQ7KHKLJKHVWQXPEHURI measles cases in the region – over 30 000, was registered LQPRUHWKDQKDOIRIWKHPRFFXUUHGLQ)UDQFH,Q 3RODQGPHDVOHVLQFLGHQFHGHFUHDVHGLQ± WKHKLJKHVWLQFLGHQFHLQ±7KHUH ZHUHREVHUYHGWKHF\FOLFWUHQGVRIPHDVOHVRXWEUHDNVLQ many countries. At average 4 – 5 years after previous RXWEUHDNWKHUHZDVWKHQH[WRQHLQ8NUDLQH5RPDQLD )UDQFHDQG,WDO\WDE,7KHQXPEHURIPHDVOHVFDVHV LQWKHUHJLRQUHODWLYHO\GHFUHDVHGLQFRPSDUHG with the previous year, in 9 of the European Union countries there were no reported cases. Nevertheless, VRPHPHDVOHVRXWEUHDNVRFFXUUHGLQWKHRWKHUFRXQWULHV During the last decade measles epidemiological situa-tion in the WHO European Region significantly differed from incidence that was assumed to achieve in the last VWDJH RI WKH PHDVOHV HOLPLQDWLRQ SURJUDP  000, excluding imported cases). Moreover, there were VWLOOPHDVOHVUHODWHGGHDWKVLQ%XOJDULDLQ 5RPDQLDDQGLQ)UDQFHFXPXODWLYHO\IDWDOFDVHV in entire region.

Measles was notified mainly among the youngest FKLOGUHQ\RXWKDQG\RXQJDGXOWV,WZDVREVHUYHGWKDW

the higher measles incidence, the higher rate of cases LQDGXOWV7KHGLVWULEXWLRQRIPHDVOHVFDVHVE\DJHZDV LQPDQ\FRXQWULHVVLPLODUWR3RODQGWDE,,7KHPRVW of measles cases (90%) concerned unvaccinated indi-viduals or those with unknown immunization status, DSSUR[LPDWHO\ZHUHYDFFLQDWHGDJDLQVWPHDVOHVZLWK DVLQJOHGRVHDQGE\WZRGRVHVFKHGXOH0HDVOHV immunization coverage is too low in many countries (less, than required 95%), and the lack of immunity particularly concerns young adults. Maintenance of vaccination coverage on current level will preserve a present measles epidemiological situation in the region (fig.1) 7DEOH, 7KHQXPEHURIVXVSHFWHGDQGFRQILUPHGPHDVOHVFDVHVLQVHOHFWHGFRXQWULHVRI:+2(XURSHDQ5HJLRQLQ 1 Country            $OEDQLD - 4  6 93 33 1 10 11  1 Armenia - 4     3 1 100 19  Austria  99 16 9       19 $]HUEDLMDQ     393  5 16  90  Bulgaria - - - 6   3   155 1 France - -  - 44 55   5139   Georgia 199   1351 334 44 55   64 44 Spain -    349  305 43    Kazakhstan -    110   - - 30 54 Moldova 9334  4 6 34 10 - - - - 11 Germany -         1600 163 Poland 34  11 13  40 100 115 13  60 Romania 11 1     531  359  3565 Russian Federation 540   453    101 169  1950 Turkey     34 3 3  15 105  Ukraine  411 146  44534  41   1313  Great Britain -           Italy -     410 1619    660 1±7KHGDWDLQFOXGHVXVSHFWHGDQGFRQILUPHGFDVHVEXWWKHODERUDWRU\FRQILUPDWLRQUDWHKDVEHHQYDULRXVLQDQDO\]HGFRXQWULHVZLWK DYHUDJHYDOXHDERXW 7DEOH,, 7KHQXPEHURIPHDVOHVFDVHVLQ3RODQGDFFRUGLQJ WRDJHJURXSLQ Age group         0-4      39 6 1 5- 9 3 4 9 5  15 3  10- 14 3 1 9 - 13 13 1 1 15- 19 - - 5 4  11 1 4  1 -  6   -   - - 34 15  13 1 9 30- 34 - - 9  4 3 1 3 35 - 39 - - 6 - 1 6 - 6 40-44 - - 1 -  1 -  45 -49 1 - - - - 1 - 1 50-54 - - 1 - - - - 1 55-59 - 1 - - - 1 60 + - - - -Total 11 13  40 100 115 13 

Measles elimination in WHO European Region ₄₅₃

No 3

DISCUSSION

The current measles epidemiological situation in WHO European Region does not give an optimistic view at the diseases elimination in the immediate years. 7KHRFFXUUHQFHRIPHDVOHVRXWEUHDNVSURYLGHVDQHYL-dence of insufficient immunization coverage against measles among children, youth and young adults. That VLWXDWLRQHQDEOHVYLUXVWUDQVPLVVLRQLQSRSXODWLRQ+LJK FRQWDJLRXVPHDVOHVYLUXVOHDGVWRRXWEUHDNVHYHU\IHZ \HDUV7KH\ JLYH WKH SRVVLELOLW\ WR GHYHORS  QDWXUDO LPPXQLW\DJDLQVWPHDVOHVEXWZLWKWKHULVNRIGLVHDVH complications, that may occur especially in youngest LQIDQWVDQGDGXOWVEHFDXVHDGLVHDVHLVUHFRJQL]HGDV untypical for these groups of population (5). The current epidemiological situation of measles in WHO European 5HJLRQVHHPVWREHGLVWDQWIURPWKHVWDJHRILWVHUDGL-FDWLRQKRZHYHUWKHIDFWVKRXOGQRWEHLQWHUSUHWHGDVD failure of vaccinations. For example, measles incidence LQ3RODQGKDGEHHQRQWKHDYHUDJHOHYHO± EHIRUHZKHQWKHYDFFLQDWLRQZDVLQFOXGHGWRLP-munization schedule. The highest rate of incidence dur-ing the last decade was only 0,3/100 000. Unfortunately, the advantageous of epidemiological situation affected GHFUHDVHGSXEOLFDFFHSWDQFHRIPHDVOHVYDFFLQDWLRQV EHFDXVHLWVHHPHGQRWWREHDVHULRXVSUREOHPIRUFRP-munity. The high vaccination coverage against measles, ZKLOHKXPDQERG\LVWKHRQO\UHVHUYRLUIRUWKHDJHQW can develop herd immunity (6).

In that case, not only vaccinated people are pro-WHFWHGEXWDOVRWKRVHZKRDYRLGHGYDFFLQDWLRQ7KHIDFW FDQEHUHFRJQL]HGDVDQFRQILUPDWLRQRIYDFFLQDWLRQV¶ useless for some individuals. The situation may lead to decreased acceptance of vaccinations, as well as, lower YDFFLQDWLRQVFRYHUDJH$VDUHVXOWWKHQXPEHURI adverse effects following immunization also decreases,

ZKDWLVFRPIRUWDEOHIRUDQWLYDFFLQDWLRQPRYHPHQW DFWLYLVWV6XEVHTXHQWO\WKHSRSXODWLRQRIXQYDFFLQDWHG and unimmunized people has significantly increased. &RQVHTXHQWO\WKHPHDVOHVRXWEUHDNVPD\RFFXUDJDLQ The increased measles incidence develop the real risk WREHLQIHFWHGIRUXQLPPXQL]HGSHRSOH$ZDUHQHVVRI SRWHQWLDOWKUHDWPRELOL]HFRPPXQLW\WREHLQWHUHVWHGLQ YDFFLQDWLRQV

7KHYDULDEOHDFFHSWDQFHRIYDFFLQDWLRQVZDVRE-served when triple vaccination against measles, mumps DQGUXEHOOD005ZDVLQWURGXFHGLQRUGHUWRDFKLHYH PHDVOHVDQGUXEHOODHUDGLFDWLRQZLWKWKH:+2UHFRP-PHQGDWLRQ7KLVHIIHFWLVSDUWLFXODUO\XQIDYRUDEOHLQ the last stage of the program of measles elimination. Nevertheless, it is recognized more often recently.

The efficient realization of MMR vaccinations that allows to achieve required immunization coverage is regarded as crucial condition to eliminate measles. Performing the program of measles surveillance is the more essential, the closer to the state of measles elimination, although most countries of WHO European Region have not reached the goal yet. Currently, the DFKLHYHPHQWRIPHDVOHVHOLPLQDWLRQE\UHTXLUHVDQ increase of vaccination coverage in children and youth, using triple MMR vaccines, as well as maintaining the high level of immunization according to routine vac-cination schedules. When it is needed, some additional YDFFLQDWLRQFDPSDLJQVVKRXOGEHLPSOHPHQWHGLQRUGHU WRUHGXFHVRPHPHDVOHVFDVHVDPRQJDGXOWVVXVFHSWLEOH WRWKHYLUXVLQIHFWLRQ7KHREVHUYHGGHFOLQLQJWUHQGRI PHDVOHVYDFFLQDWLRQVPXVWEHUHYHUVHG)XUWKHUPRUH LWLVLPSRUWDQWWRUHEXLOGVRFLHW\¶VUHOLDQFHWRWKHYDF-FLQDWLRQVV\VWHPDQGKROGLWRQWKHVXLWDEOHOHYHO 5HJUHWWDEO\PRVWRI:+2(XURSHDQ5HJLRQFRXQWULHV do not efficiently required vaccinations as United States GR,WEHFRPHVGXW\IRUKHDOWKSURIHVVLRQDOVWRUHDVVXUH parents to make a good decision concerning

vaccina-)LJ 7KHQXPEHURIPHDVOHVFDVHVLQ:+2(XURSHDQ5HJLRQRQWKHEDFNJURXQGRIYDFFLQDWLRQFRYHUDJHVWYDFFLQH dose - MVC1₎

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454 No 3

tions (11). That is the reason to raise their qualifications regularly in the field of making conversations with par-HQWVHVSHFLDOO\WKRVHZKRGRXEWWKHHIIHFWLYHQHVVDQG safety of vaccinations. For more efficient monitoring of progress in measles elimination, there is the improved VXUYHLOODQFHQHHGHGWKDWVKRXOGEHUHVWULFWHGWRORZHU PHDVOHVLQFLGHQFH,WVKRXOGEHDOVRHPSKDVL]HGWRLQWUR-GXFHWKHLQGLVSHQVDEOHURXWLQHODERUDWRU\FRQILUPDWLRQ RIPHDVOHVFDVHV

SUMMARY

In conclusion, according to our analysis there are PDQ\ DFWLRQV WR EH XQGHUWDNHQ LQ RUGHU WR DFKLHYH PHDVOHVHOLPLQDWLRQLQ:+2(XURSHDQ5HJLRQE\ \HDU7KHSXUSRVHLVSRVVLEOHWRDFKLHYHVXJJHVWLQJDQ American Region, where transmission of indigenous PHDVOHVYLUXVZDVLQWHUUXSWHGLQ\HDU+RZHYHU too low immunization coverage in many countries of the region creates some conditions to remain virus transmis-VLRQLQSRSXODWLRQ,WWKUHDWVWKHPHDVOHVRXWEUHDNVLQWKH LPPHGLDWHIXWXUHZKDWPD\SURKLELWWKHDFKLHYHPHQW of measles elimination on time.

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Epidemiology and Preventive Medicine, Jagiellonian Uni-versity Medical College,

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