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Archive for the ‘Measles’ Category

The World Health Organization (WHO) Western Pacific Region: Will the measles epidemic grow out of control?


Measles outbreaks in the World Health Organization (WHO) Western Pacific Region are putting babies, children and young people at risk and threatening progress towards wiping out the disease.

The Region had historically low levels of measles cases and no major outbreaks in 2017. This landmark decline was achieved through steady efforts to vaccinate all children against measles, but last year, measles cases in the Region increased by 250%, and more than two-thirds of cases were in the Philippines. So far this year, the Philippines has reported 23 000 cases with 333 deaths — already more than all of last year. Tragically, most of the cases were among children under 5 years old.

Measles can cause debilitating complications, including encephalitis, severe diarrhoea and dehydration, pneumonia, ear infections and permanent vision loss.

“In recent months, we’ve seen how swiftly and easily measles can make a comeback in communities where not enough children have been immunized,” said WHO Regional Director for the Western Pacific Takeshi Kasai.

Nine countries and areas in the Region have been verified as having eliminated measles: Australia, Brunei Darussalam, Cambodia, Hong Kong SAR (China), Japan, Macao SAR (China), New Zealand, the Republic of Korea and Singapore. Elimination means there has been no prolonged local transmission of the virus for at least three years.

But even in countries where measles has been eliminated, as long as the virus is circulating elsewhere, people who are not immunized remain at risk of infection from an imported case. This, in turn can lead to an outbreak or re-establishment of transmission.

So far this year, Australia, Cambodia, China, Hong Kong SAR (China), Japan, the Lao People’s Democratic Republic, New Zealand, the Republic of Korea, Singapore and Viet Nam have all recorded measles cases.

“The resurgence of measles around the world has resulted in increased importation of the virus to several countries in our Region,” explained Dr Kasai. “What we want to stop is large-scale outbreaks resulting from those importations.”

Threat of outbreaks continues

Everybody should be vaccinated in all countries, whether or not they have achieved elimination, according to WHO guidelines. For a community to be protected, at least 95% of children must receive two doses of measles vaccine.

“Measles spreads like wildfire,” Dr Kasai explained. “It is the most contagious human disease, and it’s very good at seeking out and spreading among even small groups of people who are not immune.”

Since 2000, more than 21 million lives have been saved worldwide through measles immunization. In 2017 in the Western Pacific Region, 97% of children received a first dose of measles vaccine (compared to 85% in 2000), and 94% got the required second dose (compared to 2% in 2000).

Need to reach unvaccinated children

Although every country in the Region has committed to eliminating measles, some populations are still missed by immunization programmes. The lack of national strategies and efforts to increase access to vaccination are part of the problem, especially in hard-to-reach areas. Misconceptions about the effectiveness or safety of vaccines can also complicate efforts to vaccinate children.

WHO supports countries across the Region in efforts to vaccinate all children and strengthen their outbreak preparation and response. The Organization also encourages countries to address the reasons why children are not being vaccinated in some communities by combating misinformation and improving understanding of the importance and safety of vaccines.

In 2018, WHO published a Regional Strategy and Plan of Action for Measles and Rubella Elimination in the Western Pacific. The Plan assists countries in strengthening immunization programmes and developing national action plans for achieving the shared goal of measles elimination.

Europe: Measles and rubella monitoring report, March 2019


“…..Twenty-nine countries reported measles data for January 2019, with 881 cases reported by 19 countries and 10 countries reporting no cases. Germany did not report measles data for January 2019.
Overall, case numbers continued to increase compared with the previous two months. Romania, Italy, Poland and France had the highest case counts with 261, 165, 133 and 124 cases, respectively.
Notable increases were reported in Italy, Poland, France and Austria.

  • Italy reported 165 cases in January, compared with 76 in December and 58 in November.
  • Poland reported 133 cases in January, compared with 114 in December and 79 in November.
  • France reported 124 cases in January, compared with 54 in December and 61 in November.
  • Austria reported 25 cases in January, compared with one in December and four in November…..”

UNICEF: Global cases of measles are surging to alarmingly high levels, led by 10 countries accounting for more than 74% of the total increase.


Countries with ten highest increases in cases between 2017 and 2018

Ukraine 30,338
Philippines 13,192
Brazil 10,262
Yemen 6,641
Venezuela 4,916
Serbia 4,355
Madagascar 4,307
Sudan 3,496
Thailand 2,758
France 2,269

Madagascar: “…Since the outbreak began in September, the country in East Africa has seen more than 68,000 cases of the highly infectious disease…The organization says 553 people have died and an additional 373 are suspected to have died because of the measles…..”

USA Today


Measles in the Philippines: from 1 January to 9 February this year, a total of 4,302 measles cases have been reported, with 70 deaths.

Philippines DOH

measles, outbreak, vaccines, immunization

The Department of Health (DOH) today points to vaccine hesitancy as one of the reasons for the recent measles outbreak in some regions of the country.
Validated data from different regions of the country by the Epidemiology Bureau of DoH revealed that from 1 January to 9 February this year, a total of 4,302 measles cases have been reported, with 70 deaths.
Ages of cases ranged from 1 month up to 75 years old with 1 to 4 years old (34%) followed by less than 9 months old (27%) as the most affected age-groups.  Sixty-six percent of them had no history of vaccination against measles.
Of the total deaths, ages ranged from one month to 31 years old. Notably, 79% of those who died had no history of vaccination.
Regions with high reported cases are NCR (1,296 cases and 18 deaths) CALABARZON (1,086 cases and 25 deaths), Central Luzon (481 cases with 3 deaths), Western Visayas (212 cases and 4 deaths) and Northern Mindanao (189 cases and 2 deaths).
Eastern Visayas, MIMAROPA, CALABARZON, Central Visayas and Bicol are regions that have shown increasing trend as to reported cases for this week.  
Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccination services.
The causes of measles outbreak involved a number of factors or elements. Loss of public confidence and trust in vaccines in the immunization program brought about by the Dengvaxia controversy has been documented as one of many factors that contributed to vaccine hesitancy in the country. This refers to mothers who became hesitant to have their children vaccinated with vaccines that were long proven to be effective.
 On October 2018, the World Health Organization conducted a study in selected areas in Metro Manila to identify reasons for not bringing their children for immunization. The top reasons are the following: fear due to Dengvaxia, and the lack of time among households.
Moreover, results of the vaccine confidence project in 2015 against 2018 by London School of Hygiene and Tropical Medicine on the respondents’ views that vaccines are important decreased from 93% to 32%; safe and effective from 82% down to 21% and vaccine confidence dropped from 93 to 32% respectively.
DOH has been conducting vaccination activities against measles such as Outbreak Immunization Responses (ORI) in several regions. This was followed by a nationwide Supplemental Immunization Activity (SIA) for 6 to 59 months old which was conducted in 2 phases – in April 2018 (NCR and Mindanao) and in September 2018 (other parts of Luzon and Visayas).  Despite the efforts of health workers, the SIA campaign had achieved a coverage of 69% during Phase 1 of implementation and 29% in Phase 2.
“I appeal to the public to rebuild your trust and confidence in vaccines that were long proven to be effective, and I am quite sure that all of us sometime in our lives have been recipients of these vaccines which had protected us from various diseases,” Health Secretary Francisco T. Duque III concluded.

US: Measles Cases in 2019


Measles Cases in 2019

From January 1 to February 7, 2019, 101** individual cases of measles have been confirmed in 10 states.

The states that have reported cases to CDC are California, Colorado, Connecticut, Georgia, Illinois, New Jersey, New York, Oregon, Texas, and Washington.

Trends in Measles Cases, 2010-2019

*Cases as of December 29, 2018. Case count is preliminary and subject to change.
**Cases as of February 7, 2019. Case count is preliminary and subject to change. Data are updated weekly.

Measles Outbreaks in 2019

Five outbreaks (defined as 3 or more cases) have been reported in 2019 in the following jurisdictions:

These outbreaks are linked to travelers who brought measles back from other countries such as Israel and Ukraine, where large measles outbreaks are occurring. Make sure you are vaccinated against measles before traveling internationally.

Spread of Measles

  • The majority of people who got measles were unvaccinated.
  • Measles is still common in many parts of the world including some countries in Europe, Asia, the Pacific, and Africa.
  • Travelers with measles continue to bring the disease into the U.S.
  • Measles can spread when it reaches a community in the U.S. where groups of people are unvaccinated.

Measles Outbreaks

In a given year, more measles cases can occur for any of the following reasons:

  • an increase in the number of travelers who get measles abroad and bring it into the U.S., and/or
  • further spread of measles in U.S. communities with pockets of unvaccinated people.

Reasons for an increase in cases some years:

  • 2018: The U.S. experienced 17 outbreaks in 2018, including three outbreaks in New York State, New York City, and New Jersey, respectively. Cases in those states occurred primarily among unvaccinated people in Orthodox Jewish communities. These outbreaks were associated with travelers who brought measles back from Israel, where a large outbreak is occurring. Eighty-two people brought measles to the U.S. from other countries in 2018. This is the greatest number of imported cases since measles was eliminated from the U.S. in 2000.
  • 2017: A 75-case outbreak was reported in Minnesota in a Somali-American community with poor vaccination coverage.
  • 2015: The United States experienced a large (147 cases), multi-state measles outbreak linked to an amusement park in California. The outbreak likely started from a traveler who became infected overseas with measles, then visited the amusement park while infectious; however, no source was identified. Analysis by CDC scientists showed that the measles virus type in this outbreak (B3) was identical to the virus type that caused the large measles outbreak in the Philippines in 2014.
  • 2014: The U.S. experienced 23 measles outbreaks in 2014, including one large outbreak of 383 cases, occurring primarily among unvaccinated Amish communities in Ohio. Many of the cases in the U.S. in 2014 were associated with cases brought in from the Philippines, which experienced a large measles outbreak.
  • 2013: The U.S. experienced 11 outbreaks in 2013, three of which had more than 20 cases, including an outbreak with 58 cases. For more information see Measles — United States, January 1-August 24, 2013.
  • 2011: In 2011, more than 30 countries in the WHO European Region reported an increase in measles, and France was experiencing a large outbreak. These led to a large number of importations (80) that year. Most of the cases that were brought to the U.S. in 2011 came from France. For more information see Measles — United States, January-May 20, 2011.
  • 2008: The increase in cases in 2008 was the result of spread in communities with groups of unvaccinated people. The U.S. experienced several outbreaks in 2008 including three large outbreaks. For more information see Update: Measles — United States, January–July 2008.

See also: The Surveillance Manual chapter on measles that describes case investigation, outbreak investigation, and outbreak control for additional information.

Measles Red Flag in the Philippines

Philippine DOH

he Department of Health (DOH) raised today the red flag for measles in other regions of Luzon, Central and Eastern Visayas aside from yesterday’s declaration in the National Capital Region.

As of 26 January 2019, validated data from CALABARZON was 575 cases with 9 deaths (CFR 2%) (2,538% an increase as compared to 21 cases of 2018), NCR was 441 with 5 deaths (CFR 1%) (1,125% increase as compared to 36 cases of 2018), Region 3 had 192 cases with 4 deaths (CFR 2%) (500% increase compared to 32 cases of 2018), Region 6 with 104 cases and 3 deaths (CFR 3%) (550% increase compared to 16 cases of 2018) and Region 7 with 71 cases with 1 death (CFR 1%) (3,450% increase compared to 2 cases of 2018).

“We are expanding the outbreak from Metro Manila to the other regions as cases have increased in the past weeks and to strengthen surveillance of new cases and alert mothers and caregivers to be more vigilant,” Health Secretary Francisco T. Duque III said.

Other regions showed the number of cases reported at 70 cases with no deaths for MIMAROPA (3,400% increase compared to 2 cases of 2018), Region 1 with 64 cases with 2 deaths (CFR 3%) (220% increase compared to 20 cases of 2018), Region 10 with 60 cases with no deaths reported (4% decrease compared to 63 cases in 2018), Region 8 with 54 cases and 1 death (2% CFR) (5,300% increase compared to 1 case of 2018), Region 12 with 43 cases with no deaths (34% decrease compared to 66 cases of 2018).  These regions should likewise step-up their response against this highly communicable disease, as well as ensure that preventive measures play a vital role in preventing the spread of the disease; these must be emphasized to mothers and the general public as a whole.

Measles is a highly contagious respiratory disease caused by a virus. It is transferred from person-to-person by sneezing, coughing, and close personal contact. Its signs and symptoms include cough, runny nose, red eyes/conjunctivitis, fever, skin rashes lasting for more than 3 days.

The disease’s complications included diarrhea, middle ear infection, pneumonia (infection of the lungs), encephalitis (swelling of the brain), malnutrition, blindness which may lead to death.

“Supportive measures like building the nutritional status of the sick person and increasing oral rehydration are important measures to increase body resistance and replace lost body fluids caused by coughing, diarrhea, and perspiration,” Duque said, adding that immunization and vitamin A supplementation of nine-month old children and unvaccinated individuals are the best defenses against measles.
The DOH is advising mothers, the public to bring their children at the first sign of fever to the nearest health facility for prompt treatment and proper case management.

Measles in Europe: record number of both sick and immunized


Copenhagen, 7 February 2019

More children in the WHO European Region are being vaccinated against measles than ever before; but progress has been uneven between and within countries, leaving increasing clusters of susceptible individuals unprotected, and resulting in a record number of people affected by the virus in 2018. In light of measles data for the year 2018 released today, WHO urges European countries to target their interventions to those places and groups where immunization gaps persist.

Measles killed 72 children and adults in the European Region in 2018. According to monthly country reports for January to December 2018 (received as of 01 February 2019), 82 596 people in 47 of 53 countries contracted measles. In countries reporting hospitalization data, nearly 2/3 (61%) of measles cases were hospitalized. The total number of people infected with the virus in 2018 was the highest this decade: 3 times the total reported in 2017 and 15 times the record low number of people affected in 2016.

The surge in measles cases in 2018 followed a year in which the European Region achieved its highest ever estimated coverage for the second dose of measles vaccination (90% in 2017). More children in the Region received the full two-dose series on time, according to their countries’ immunization schedules, in 2017 than in any year since WHO started collecting data on the second dose in 2000. Coverage with the first dose of the vaccine also increased slightly to 95%, the highest level since 2013. However, progress in the Region, based on achievements at the national level, can mask gaps at subnational levels, which are often not recognized until outbreaks occur.

“The picture for 2018 makes it clear that the current pace of progress in raising immunization rates will be insufficient to stop measles circulation. While data indicate exceptionally high immunization coverage at regional level, they also reflect a record number affected and killed by the disease. This means that gaps at local level still offer an open door to the virus,” says Dr Zsuzsanna Jakab. “We cannot achieve healthier populations globally, as promised in WHO’s vision for the coming five years, if we do not work locally. We must do more and do it better to protect each and every person from diseases that can be easily avoided.”

Preventable tragedy

While immunization coverage has improved overall in the Region, many people remain susceptible.

  • Estimated coverage with the second dose of measles vaccine was below the 95% threshold to prevent circulation (that is, to achieve “herd immunity”) in 34 countries of the Region in 2017.
  • Subnational coverage rates point to disparities even within countries.
  • Suboptimal coverage for either dose sets the stage for transmission in the future.

The European Vaccine Action Plan 2015–2020 (EVAP) lays out a strategy endorsed by all 53 Member States to eliminate both measles and rubella. Most importantly, at least 95% of every population needs to be immune, through two doses of vaccination or prior exposure to the virus, to ensure community protection for everyone – including babies too young to be vaccinated and others who cannot be immunized due to existing diseases and medical conditions.

“In adopting EVAP, all countries in the European Region agreed that elimination of measles and rubella is possible, and is also a cost-effective way to protect people of all ages from avoidable suffering and death,” says Dr Nedret Emiroglu, Director of the Division of Health Emergencies and Communicable Diseases, WHO Regional Office for Europe.

Forty-three European countries interrupted transmission of endemic measles for at least 12 months as of the end of 2017. Some of them, also managed to limit the spread of the virus following importation to very few cases in 2017 and 2018, showing that elimination of the disease is well within reach for the whole Region. “Progress in achieving high national coverage is commendable. However, it cannot make us blind to the people and places that are still being missed. It is here that we must now concentrate increased efforts. We should never become complacent about our successes but continue to strive to reach the final mile. Together we can make this happen,” concludes Dr Emiroglu.

Closing the door on measles

Many factors contribute to suboptimal immunization coverage and the spread of measles. To prevent outbreaks and eliminate measles, countries need to sustain high national and subnational immunization coverage with two doses of measles-containing vaccine, as well as identify and address all pockets of underimmunization among their populations.

The Regional Office continues to work with countries in the Region to enhance their immunization and disease surveillance systems. This includes building capacities and providing guidance to:

  • ensure that all population groups have equitable access to vaccination services and that these are convenient;
  • identify who has been missed in the past and reach them with the vaccines they need;
  • ensure that health workers are vaccinated to prevent transmission in health facilities, and that they have sufficient technical knowledge about vaccines and the immune system to feel confident in recommending vaccination to their patients;
  • strengthen trust in vaccines and health authorities;
  • secure access to a timely and affordable supply of vaccines;
  • improve outbreak detection and response;
  • listen and respond to people’s concerns, and respond to any health event that could be potentially related to vaccine safety.

Most of the countries struggling with suboptimal immunization coverage against measles in the Region are middle-income countries. The Regional Office is working with these countries to implement a coordinated strategy to address targeted programme areas.

WHO: All about measles


Key facts

  • Even though a safe and cost-effective vaccine is available, in 2017, there were 110 000 measles deaths globally, mostly among children under the age of five.
  • Measles vaccination resulted in a 80% drop in measles deaths between 2000 and 2017 worldwide.
  • In 2017, about 85% of the world’s children received one dose of measles vaccine by their first birthday through routine health services – up from 72% in 2000.
  • During 2000-2017, measles vaccination prevented an estimated 21.1 million deaths making measles vaccine one of the best buys in public health.

Measles is a highly contagious, serious disease caused by a virus. Before the introduction of measles vaccine in 1963 and widespread vaccination, major epidemics occurred approximately every 2–3 years and measles caused an estimated 2.6 million deaths each year.

Approximately  110 000 people died from measles in 2017 – mostly children under the age of 5 years, despite the availability of a safe and effective vaccine.

Measles is caused by a virus in the paramyxovirus family and it is normally passed through direct contact and through the air. The virus infects the respiratory tract, then spreads throughout the body. Measles is a human disease and is not known to occur in animals.

Accelerated immunization activities have had a major impact on reducing measles deaths. During 2000– 2017, measles vaccination prevented an estimated  21.1 million deaths. Global measles deaths have decreased by  80% from an estimated  545 000 in 2000* to  110 000 in 2017.

Signs and symptoms

The first sign of measles is usually a high fever, which begins about 10 to 12 days after exposure to the virus, and lasts 4 to 7 days. A runny nose, a cough, red and watery eyes, and small white spots inside the cheeks can develop in the initial stage. After several days, a rash erupts, usually on the face and upper neck. Over about 3 days, the rash spreads, eventually reaching the hands and feet. The rash lasts for 5 to 6 days, and then fades. On average, the rash occurs 14 days after exposure to the virus (within a range of 7 to 18 days).

Most measles-related deaths are caused by complications associated with the disease. Serious complications are more common in children under the age of 5, or adults over the age of 30. The most serious complications include blindness, encephalitis (an infection that causes brain swelling), severe diarrhoea and related dehydration, ear infections, or severe respiratory infections such as pneumonia. Severe measles is more likely among poorly nourished young children, especially those with insufficient vitamin A, or whose immune systems have been weakened by HIV/AIDS or other diseases.

Who is at risk?

Unvaccinated young children are at highest risk of measles and its complications, including death. Unvaccinated pregnant women are also at risk. Any non-immune person (who has not been vaccinated or was vaccinated but did not develop immunity) can become infected.

Measles is still common in many developing countries – particularly in parts of Africa and Asia. The overwhelming majority (more than 95%) of measles deaths occur in countries with low per capita incomes and weak health infrastructures.

Measles outbreaks can be particularly deadly in countries experiencing or recovering from a natural disaster or conflict. Damage to health infrastructure and health services interrupts routine immunization, and overcrowding in residential camps greatly increases the risk of infection.


Measles is one of the world’s most contagious diseases. It is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretions.

The virus remains active and contagious in the air or on infected surfaces for up to 2 hours. It can be transmitted by an infected person from 4 days prior to the onset of the rash to 4 days after the rash erupts.

Measles outbreaks can result in epidemics that cause many deaths, especially among young, malnourished children. In countries where measles has been largely eliminated, cases imported from other countries remain an important source of infection.


No specific antiviral treatment exists for measles virus.

Severe complications from measles can be avoided through supportive care that ensures good nutrition, adequate fluid intake and treatment of dehydration with WHO-recommended oral rehydration solution. This solution replaces fluids and other essential elements that are lost through diarrhoea or vomiting. Antibiotics should be prescribed to treat eye and ear infections, and pneumonia.

All children diagnosed with measles should receive two doses of vitamin A supplements, given 24 hours apart. This treatment restores low vitamin A levels during measles that occur even in well-nourished children and can help prevent eye damage and blindness. Vitamin A supplements have been shown to reduce the number of deaths from measles by 50%.


Routine measles vaccination for children, combined with mass immunization campaigns in countries with high case and death rates, are key public health strategies to reduce global measles deaths. The measles vaccine has been in use for over 50 years. It is safe, effective and inexpensive. It costs approximately one US dollar to immunize a child against measles.

The measles vaccine is often incorporated with rubella and/or mumps vaccines. It is equally safe and effective in the single or combined form. Adding rubella to measles vaccine increases the cost only slightly, and allows for shared delivery and administration costs.

In 2017, about 85% of the world’s children received 1 dose of measles vaccine by their first birthday through routine health services – up from 72% in 2000. Two doses of the vaccine are recommended to ensure immunity and prevent outbreaks, as about 15% of vaccinated children fail to develop immunity from the first dose. In 2017, 67% of children received the second dose of the measles vaccine.

Of the estimated 20.8 million infants not vaccinated with at least one dose of measles vaccine through routine immunization in 2017, about 8.1 million were in 3 countries: India, Nigeria and Pakistan

WHO response

In 2010, the World Health Assembly established 3 milestones towards the future eradication of measles to be achieved by 2015:

increase routine coverage with the first dose of measles-containing vaccine (MCV1) by more than 90% nationally and more than 80% in every district;

reduce and maintain annual measles incidence to less than 5 cases per million;

reduce estimated measles mortality by more than 95% from the 2000 estimate; and

In 2012, the Health Assembly endorsed the Global Vaccine Action Plan, with the objective of eliminating measles in four WHO regions by 2015 and in five regions by 2020.

By 2017, the global push to improve vaccine coverage resulted in an  80% reduction in deaths. During 2000– 2017, with support from the Measles & Rubella Initiative and Gavi, the Vaccine Alliance, measles vaccination prevented an estimated  21.1 million deaths; most of the deaths averted were in the African region and in countries supported by the Gavi Alliance.

But without sustained attention, hard fought gains can easily be lost. Where children are unvaccinated, outbreaks occur. Because of low coverage nationally or in pockets, multiple regions were hit with large measles outbreaks in 2017, causing many deaths. Based on current trends of measles vaccination coverage and incidence, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) concluded that measles elimination is greatly under threat, and the disease has resurged in a number of countries that had achieved, or were close to achieving, elimination.

WHO continues to strengthen the global laboratory network to ensure timely diagnosis of measles and track international spread of the measles viruses to allow more coordinated country approach in targeting vaccination activities and reduce measles deaths from this vaccine-preventable disease.

The Measles & Rubella Initiative

Launched in 2001, the Measles & Rubella Initiative (M&R Initiative) is a global partnership led by the American Red Cross, United Nations Foundation, Centers for Disease Control and Prevention (CDC), UNICEF and WHO. The Initiative is committed to ensuring that no child dies from measles or is born with congenital rubella syndrome. We help countries to plan, fund and measure efforts to stop measles and rubella for good.


Madagascar: Nearly 20,000 measles cases recorded since October


Measles – Madagascar

Disease outbreak news
17 January 2019

WHO is supporting the Ministry of Public Health of Madagascar to respond to an unusually large measles outbreak. Madagascar last experienced measles outbreaks in 2003 and 2004, with reported number of cases at 62 233 and 35 558, respectively. Since then, the number of reported cases had sharply declined until the current outbreak. From 4 October 2018 to 7 January 2019, 19 539 measles cases and 39 “facility-based” deaths (case fatality ratio: 0.2%) have been reported by the Ministry of Public Health (MoH) of Madagascar. Cases were reported from 66 of 114 total districts in all 22 regions of Madagascar. Among the 19 539 measles cases, 375 have been laboratory confirmed (all are IgM+) and 19 164 were confirmed by epidemiological link. Cases confirmed by epidemiological link are those who presented clinical symptoms based on the case definition and had been in contact with another laboratory confirmed or epidemiologically linked case. The outbreak has spread to densely populated urban cities including Toamasina, Mahajanga, Antsirabe, Toliara and the capital city Antananarivo. Most cases were reported from Analamanga (61%) and Boeny (20%) regions. The highest attack rates were observed in Antananarivo-Renivohitra district (714 per 100 000 inhabitants), and Ambato-Boina district (668 per 100 000 inhabitants), in Analamanga and Mahajanga regions, respectively. These rates are considerably higher compared to the national attack rate of 108 per 100 000 inhabitants.

In the current epidemic, children aged 1 to 14 years account for 64% of the total number of cases. The age distribution in this group is as follows: under five years at 35%, 5-9 years at 22% and 10-14 years at 19%. Both sexes are equally affected with a male to female ratio of 1.04. The national immunization programme recommends routine measles immunization for children aged nine months. According to WHO and the United Nations International Children’s Emergency Fund (UNICEF), the estimated measles immunization coverage in Madagascar was 58% in 2017. More than half of the cases (51%) reported during the current outbreak have not been vaccinated or have unknown immunization status. Madagascar has the highest proportion of malnutrition among children under five (47%) in the African region which can increase children’s risk of serious complications and death from measles infection.

The circulating genotype for the current measles outbreak in Madagascar is B3, usually found in Africa and Europe. No measles cases with travel history to Madagascar, however, have been reported in neighboring countries and initial investigations in Madagascar have not shown any link with cases from countries with measles outbreak in the Africa region or Europe.

The measles outbreak has occurred concurrently with the resurgence of plague in the country—which reoccurs seasonally—straining the public health response.

Public health response

The Ministry of Public Health of Madagascar is coordinating the response activities, with the support of WHO and other partners. Public Health response measures include:

  • Enhancement of active surveillance (active case finding, community-based surveillance, distribution of specimen collection kits) in all affected districts.
  • Use of the Global Measles Programmatic Risk Assessment Tool to target priority districts for vaccination.
  • Completion of targeted vaccination campaigns:
    • Campaign conducted from 22 October to 9 November 2018 in four districts of Antanavarivo city. The campaign targeted at least 95% of children aged between nine and 59 months. Preliminary results show coverage of 84% of the targeted population.
    • Campaign planned from 14 to 18 January targeting 2 083 734 children aged between nine months and nine years in 25 districts across 13 regions. The campaign is being funded by Measles Rubella Initiative (MRI), the Government of Madagascar, WHO, UNICEF, Catholic Relief Services (CRS), Commission de l’Océan Indien (COI), the United States Agency for International Development (USAID), the Embassy of France in Madagascar and the World Bank and the total cost is US$ 2 355 989.
  • Reinforcement of routine immunization (one dose of measles-containing vaccine (MCV) as per the national immunization programme) for children aged between nine and 11 months.
  • Continued management of severe measles cases in referral hospitals, provided to patients free of charge. Vitamin A is being administered to patients under care in all referral and district health centres.
  • Continued community mobilization with the support of UNICEF and USAID, aiming to increase understanding of the disease as well as uptake of the vaccines from campaigns and routine vaccination.
  • Reactivation by USAID of the 910 hotline, formerly used during the 2017 plague epidemic, for information sharing on measles.

WHO risk assessment

Measles is an acute, highly contagious viral disease that has potential to lead to major epidemics. Low coverage with measles vaccine combined with a low incidence of measles in recent years in Madagascar has contributed to a significant proportion of the population which is susceptible to measles. According to WHO and UNICEF estimates, the measles immunization coverage in Madagascar was 58% in 2017. The malnutrition rate is also a contributor as malnutrition increases children’s vulnerability of serious complications and death from measles infection.

WHO estimates the overall risk for Madagascar from this measles outbreak to be very high. Currently, several concomitant factors are likely to hinder or delay public health intervention and might jeopardize the response: post-election conflict, geographical isolation and remoteness of cases, insecurity, hurricane season and multiple outbreaks. Targeted immunization campaigns and strengthening of routine immunization activities are paramount in the effective control of the outbreak. Administration of Vitamin A, specifically in a context of high rates of malnutrition, can reduce illness and deaths from measles infection.

The risk at the regional level is low although the spread of measles to neighboring Indian Ocean islands and other African countries and Europe cannot be excluded. Strengthening of surveillance in neighboring countries is recommended. The overall global risk is considered to be low.

WHO advice

WHO urges all Member States to:

  • Vaccinate to maintain coverage of 95% with two doses of MCV.
  • Vaccinate at-risk populations (without proof of vaccination or immunity against measles and rubella), such as health workers, people working in tourism and transportation (hotel and catering, airports, taxi drivers, etc.), and international travelers.
  • Maintain a reserve of MCV and syringes for control of imported cases in each country in the region.
  • Strengthen epidemiological surveillance of fever or rash cases for timely detection of all suspected cases of measles in public and private healthcare facilities and ensure that samples are received by laboratories within five days of being taken.
  • Provide a rapid response to imported measles cases through the activation of rapid response teams to prevent the establishment or reestablishment of endemic transmission.
  • Administer vitamin A supplementation to all children diagnosed with measles to reduce the complications and mortality (50,000 IU for a child <6 months=”” of=”” age,=”” 100,000=”” iu=”” for=”” children=”” 6-12=”” months=”” of=”” age=”” or=”” 200,000=”” iu=”” for=”” children=”” 12-59=”” months);=”” two=”” doses,=”” immediately=”” upon=”” diagnosis=”” and=”” on=”” the=”” following=””>

WHO does not recommend any restriction on travel and or trade to Madagascar based on the information available on the current outbreak.

For more information on Measles, please see the link below:


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