The US Centers for Disease Control and Prevention (CDC) issued a Watch Level-1 travel notice on June 10 for international citizens concerning the global measles outbreak. Measles, the most infectious of common diseases, is spread by air when an infected person coughs, sneezes, or speaks. Someone infected can infect nine out of 10 nonimmunized individuals with which they come in to contact.
According to data from the World Health Organization (WHO), global measles cases tripled in the first quarter of 2019 compared to the same period of 2018. More than 190,000 cases were reported by 170 countries through March 2019 compared to 62,800 cases from 163 countries during the same period in 2018. Actual numbers are likely much higher, largely because only 10 percent of cases are reported globally. The largest increases in measles cases during 2019 were reported in:
- Africa: 700%
- Europe: 300%
- Americas: 60%
- Asia and Western Pacific: 40%
This increase in global measles activity poses a particular threat to travelers, who can also serve as conduits for the spread of the disease across the globe. The risk of measles infection for travelers not only exists while visiting locations where measles activity is occurring but also while traveling. Data shows that at least 82 flights from or to the US during 2018 carried at least one person infected with measles - up from just 15 flights in 2017 and 10 in 2016.
Global Measles Outbreak - Importance of the Measles Vaccination
The best way to mitigate the risk of infection with measles is to ensure vaccinations are up to date. A two-dose vaccine is highly effective at protecting against infection. Before the vaccination was introduced in 1962, approximately 2.6 million people died from measles and measles-related complications each year. As of 2017, there were 110,000 measles-related deaths per year - a drastic reduction in disease-related deaths. Tackling the ongoing elevated measles activity is a critical global health priority as measles remains one of the leading causes of childhood mortality, accounting for 13 percent of deaths caused by vaccine-preventable diseases in children aged under five years in Africa.
Analysis of Elevated Measles Activity in Europe
Many experts believe that the continuing elevated measles activity observed since 2017 is due to a combination of low childhood vaccination rates and global transmission via high volumes of international travel. In relation to the former, the WHO European region (including Russia/CIS) continues to report significant outbreaks in Ukraine, Kazakhstan, Georgia, North Macedonia, Poland, Bulgaria, the Czech Republic, Switzerland, Austria, and Romania; France and Italy report ongoing and increasing measles activity. Malta, Norway, and Iceland reported the first cases of local transmission in several decades, with cases linked to travel; similarly, the UK has reported many travel-related cases, particularly in London. Even though the WHO European region achieved its highest vaccination coverage for measles at 90 percent in 2017, this is still lower than the recommended 92-95 percent needed to prevent wider community transmission.
European countries have experienced recent measles outbreaks mainly due to a decline or stagnation in overall national immunization coverage (in part due to vaccine-hesitancy), but also because of low vaccination coverage at the subnational level or in some local populations (particularly in marginalized groups), as well as immunity gaps in older populations who missed vaccination when younger. In Ukraine, where authorities reported 53,200 measles cases during 2018, the national vaccination coverage against measles was 95 percent until 2014; however, the nation’s health budget was frozen during 2015 when tensions and conflict broke out in the Crimean Peninsula, and by 2016, vaccination coverage had plunged to only 41 percent. The spread of measles from Ukraine to other parts of Europe then occurred, with a large outbreak reported in Romania soon after. In response to elevated measles activity seen across the region, all 53 EU member states have adopted the European Vaccine Action Plan (EVAP), which aims for at least 95 percent of individuals in every population to receive two doses of measles vaccine by 2020 to ensure community protection.
Measles Outbreak in Africa
Developing countries in Africa, particularly those suffering from internal conflict, have been worst affected by the measles epidemic during 2019 due to weak and struggling healthcare systems. The region has the lowest vaccine coverage for measles, estimated at 73 percent over the last decade for the first dose of the vaccine. Madagascar remains the country that has reported the most measles cases globally, with more than 46,000 cases reported during 2019 through April and more than 140,000 cases since the outbreak was first reported in September 2018. It is believed that the epidemic is slowing after 4 million children were vaccinated in mass-immunization campaigns in early 2019. Notably, large outbreaks are still ongoing in the Democratic Republic of Congo (DRC), Nigeria, Chad, Niger, and South Sudan. The disease has already caused over 1,000 and 1,500 measles-related deaths in Madagascar and the DRC, respectively. Children aged under 14 years are believed to account for most fatalities.
All travelers should take the necessary precautions to prevent measles infection as travel insurance is usually invalidated if immunization cannot be proven, leaving an unvaccinated afflicted traveler responsible for large hospital bills and other medical expenses.
Measles in South America
The deteriorating economic situation in Venezuela has weakened healthcare systems (See CDC Watch level 3 travel health notice for health infrastructure breakdown in Venezuela), and it is believed that due to major political turmoil measles cases are likely underreported, but over 550 cases were reported through May. Clusters of unvaccinated refugees from Venezuela have also caused a spike in measles activity in neighboring countries, especially in Colombia where over 100 cases were identified. The Pan American Health Organization/WHO (PAHO/WHO) has advised all countries in the region to maintain an average vaccination coverage of 92-95 percent against measles needed to prevent wider transmission, and for authorities to focus vaccination efforts on vulnerable groups, especially refugees. In Brazil, travel-related cases have been reported with regularity during 2019, particularly in the popular tourist destinations of Rio de Janeiro and Sao Paulo.
Measles Cases in the United States
Measles was declared eliminated in the US in 2000 but has now re-emerged; Authorities reported the highest number of cases since 1992 (1,000 cases through April). Twenty-eight states reported at least one case of measles, with most cases reported in New York; however, the states of Washington, Califonia, and Pennsylvania have also reported outbreaks over sustained periods during 2019 that have so far cost health institutions USD 35 million to manage. Many cases in the US have been linked with travel to Southeast Asia and Israel where large outbreaks are ongoing; the CDC identified over 1,500 US citizens exposed to measles infection during intenational or domestic airline travel through April 2019. However, the large outbreaks in Brooklyn, N.Y.C. and Rocklands, New York, where more than 500 and 200 cases were reported, respectively, have been attributed to “unvaccinated clusters” in the local Orthodox Jewish communities. A recent online survey by the American Osteopathic Association (AOA) found that 45 percent of the 2,000 US adults questioned thought that vaccines were unsafe. Federal officials have been engaged in efforts to counter widespread “fake news” about the dangers of vaccines and to ensure individuals understand that vaccines are safe and effective.
In Asia, ongoing outbreaks are occurring in Vietnam, Japan, Malaysia, India, Myanmar, and the Philippines. During 2019, the largest outbreak in the region has occurred in the Philippines, where 26,000 cases were reported through March. Chronically low childhood vaccination rates due to vaccine hesitancy are widely accepted as the underlying reason for the outbreak. Vaccine-hesitancy has been high in the Philippines after the 2014 scandal involving the new vaccination for dengue fever, Dengvaxia, with a decrease in vaccine confidence from 93 percent to 32 percent noted from 2015 to 2018. Travelers returning from the Philippines have been responsible for many imported measles cases in the region, especially in Australia and New Zealand, as well as globally. In Hong Kong SAR and Macau, China, as well as in Singapore, measles cases related to travel through international airports have been regularly reported throughout 2019. Authorities have urged all travelers with plans to visit Southeast Asia to ensure vaccination before travel.
The Effect of Anti-vaccination Sentiment
Experts are particularly concerned about significant outbreaks in developed countries with high national vaccination rates, such as the US and France, but where anti-vaccination sentiments in local communities have taken root, particularly spread on social media. Anti-vaccination campaigns are founded on the perceived risks, fears, and speculation regarding an incorrect and disproven association between vaccines and autism – a conclusion that has since been thoroughly discredited by multiple international studies about vaccines and childhood development. The WHO has declared vaccination-hesitancy one of the top global health threats in 2019. Much of the measles activity in the US has been largely attributed to unvaccinated clusters. In some areas – New York being one – states are trying to pass legislation to limit religious vaccine-exemption for childhood routine immunization.
Measles activity has significantly increased in all regions of the globe. All travelers should take the necessary precautions to prevent measles infection as travel insurance is usually invalidated if immunization cannot be proven, leaving an unvaccinated afflicted traveler responsible for large hospital bills and other medical expenses. Furthermore, measles can cause serious life-threatening disease in young children, the elderly, or immunocompromised, and these individuals especially should ensure they have received full immunization before travel.
Recommendations for travelers:
- Before traveling, check with the relevant location profile on Worldcue Intel Central to see if an outbreak of measles is occurring in your intended destination.
- Talk to a doctor about travel immunizations at least four to six weeks before traveling, including booster vaccination prior to travel to areas with known ongoing outbreaks (particularly for adults who are not sure if they received two doses of vaccine as a child).
- If you have not been immunized, you will need two doses of the measles vaccine, separated by at least 28 days before traveling abroad.
- Infants traveling abroad between the ages of 6 and 11 months old should get an early dose of the vaccine.
- Use basic health precautions, including coughing or sneezing into your shoulder or a tissue, and washing your hands frequently with soap and water, or using hand sanitizer when soap and water are unavailable.
- Check with your travel medical provider regarding medical coverage in case of infection with measles.
- Upon return from a foreign country where there is known measles activity, watch for signs of rash and a fever within 21 days of visiting an affected area and call a doctor if these symptoms develop.
- Do not travel if you think you have measles.
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