A letter in The Lancet: The measles crisis in Europe—the need for a joined-up approach.
Measles elimination in Europe is in crisis. More than 80 000 confirmed cases were reported in 2018 in the 53 countries in the WHO European Region, the highest figure for 20 years. 14 countries in the region reported more than 500 confirmed cases, including four countries that were previously deemed to have eliminated measles (Greece, Albania, Israel, and the UK), meaning interrupted transmission for 3 years. New strategies are urgently needed to put measles elimination in Europe back on track.
In theory, controlling measles should be straightforward. Two doses of the measles, mumps, and rubella (MMR) vaccine provide highly efficacious protection that is long lasting. Yet, in practice, achieving elimination has proven challenging. One of the most contagious diseases, measles can strike susceptible pockets even if vaccination coverage on a national level is high.
Although asserting elimination status for individual nations might serve as a motivational tool, countries can experience large outbreaks even after several years of interrupted transmission. Countries such as Greece, Germany, and Kyrgyzstan reported consistently high MMR uptake over the past decade but are still experiencing outbreaks. Moreover, outbreaks do not occur in isolation: they traverse country borders, sometimes lasting years, and affecting different countries at different times.
In light of these issues, there is a need to link efforts across the continent. The Pan American Health Organization4 interrupted measles transmission in the early 2000s through combined strategies, including high routine immunisation, catch-up campaigns during periods of low transmission, and follow-up campaigns ensuring high levels of immunity at the age of school entry, all applied uniformly across the Americas.
Applying a similar joined-up approach in Europe would serve the dual purpose of increasing immunity in the general population while reducing the chance of imported cases reaching susceptible pockets.
Epidemiological investigation would also benefit from combined efforts. Linking genetic and case data to better understand chains of transmission has proven successful for other diseases and might reveal the interconnectivity of measles across Europe. Subnational seroprevalence studies could be used to better identify pockets of susceptibles. Improved vaccine supply, advocacy, and communication to population groups found to be most at risk could help increase immunity to the levels required.
Such efforts would come at a fraction of the cost of responding to outbreaks. The Americas have shown that elimination of measles is feasible through a combination of political willpower, targeted interventions, and concerted effort. If Europe can sustain a similar approach, it might still follow suit.
