There is an alarming resurgence of measles. In the WHO European Region, a startling uptick has been observed, with now over 50,000 cases reported across 41 Member States during 2023. This is a staggering increase from the 941 cases recorded throughout 2022, marking a more than fiftyfold escalation.
Measles is a highly contagious virus. It can spread rapidly through breathing, coughing, or sneezing by an infected individual. The consequences of this disease can be severe, often leading to serious complications and, tragically, even fatalities.
In addition to the suffering caused by measles, containing outbreaks is costly and detracts from other health care services. Of course, an illness which can last two weeks or more also impacts families directly.
In a Region in which 33 countries are considered to have eliminated measles what are the reasons behind this surge in measles cases and what strategies are we exploring for curbing the spread of this virus. Joining us for discussion is Robb Butler, the Director of Communicable Diseases, Environment and Health at the World Health Organization Regional Office for Europe.
Find out more: https://www.who.int/health-topics/measles
There is an alarming resurgence of measles. In the WHO European Region, a startling uptick has been observed, with now over 50,000 cases reported across 41 Member States during 2023. This is a staggering increase from the 941 cases recorded throughout 2022, marking a more than fiftyfold escalation.
Measles is a highly contagious virus. It can spread rapidly through breathing, coughing, or sneezing by an infected individual. The consequences of this disease can be severe, often leading to serious complications and, tragically, even fatalities.
In addition to the suffering caused by measles, containing outbreaks is costly and detracts from other health care services. Of course, an illness which can last two weeks or more also impacts families directly.
In a Region in which 33 countries are considered to have eliminated measles what are the reasons behind this surge in measles cases and what strategies are we exploring for curbing the spread of this virus. Joining us for discussion is Robb Butler, the Director of Communicable Diseases, Environment and Health at the World Health Organization Regional Office for Europe.
Find out more: https://www.who.int/health-topics/measles
Transcript of Health In Europe Episode 41 – Outbreak Alert: Understanding the Measles Surge
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DAVID BARRETT: Hello! In this episode of the WHO Health and Europe podcast, we discuss the recent measles outbreak. I'm your host, David Barrett.
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We've launched this podcast to bring you the latest of WHO’s work in the European Region. Our region is broad and diverse, from the Mid-Atlantic and stretching as far as the Chinese border. We work with fascinating and driven individuals and groups. This podcast is about their stories and how they might impact our day-to-day life.
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DAVID: There is an alarming resurgence of measles in the WHO European Region. A startling uptick has been observed, with now over 50,000 cases reported across 41 member states during 2023. This is a staggering increase from the 941 cases recorded throughout 2022, marking more than a 50-fold escalation. Measles is a highly contagious virus. It can spread rapidly through breathing, coughing, or sneezing by an infected individual. The consequences of this disease can be severe, often leading to serious complications and tragically, even fatalities. In addition to the suffering caused by measles, containing outbreaks is costly and detracts from other health care services.
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Of course, an illness which can last two weeks or more also impacts families directly in a region in which 33 countries are considered to have eliminated measles. What are the reasons behind this surge in measles cases, and what strategies are we exploring for curbing the spread of this virus? Joining me is Robb Butler, the Director of Communicable Diseases, Environment and Health at the World Health Organization Regional Office for Europe.
Robb, for those people who may not have known somebody who has had measles or they haven't had measles themselves, can you please elaborate on the typical symptoms of measles and its complications, especially or particularly in vulnerable populations such as children?
ROBB BUTLER: Yeah, thanks very much, David. So indeed, it's it's highly contagious. And it's also a very dangerous disease. So typically, after coming in contact with the virus about 7 to 10 days after coming in contact with the
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virus, we would expect to see a rash, fever, cough, runny nose, a little bit of watery eyes, for example. And the fever can result in very high temperature indeed. Of course, the most vulnerable individuals are those less than five years of age and older than 20. Also pregnant women with children. We see extreme complications resulting from pneumonia and encephalitis. That's the brain swelling. And in about one of a thousand cases, very sadly, we'll see children die of this very preventable disease.
DAVID: Now, you say it's very preventable. Obviously, the vaccination has been around for quite a few decades, but we now have this surge of measles cases. Can you give us a little bit of an overview of the current measles outbreak in the WHO European Region, but really focusing on what has contributed to this significant rise, especially if we look in the past couple of years where there has sort of been at the low bottom of a curve of measles cases.
ROBB: So, this is a major concern to us. It's a large increase compared to the just 942 cases we saw in the whole of 2022. Why is this happening? Because, uh, because individuals have not vaccinated, uh, their children, uh, according to their national schedules. And this is due to a number of different factors, because, of course, it's been exacerbated or worsened by the pandemic, which saw people struggling to get access to immunization services in some countries and some children missing their routine vaccinations. There's an accumulation of 1.2 million children who missed routine vaccinations throughout the pandemic.
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that said, we had gaps before the pandemic. I mean, if we if you think about this, we have around 92 to 97% of first and second dose of measles, typically at a national level in many member states. But where we see an accumulation of the 5 or 10% of the population that is not vaccinated, that represents a risk, because of course, year after year that susceptible population to measles grows annually. And that's problematic. And that's why we see explosive outbreaks occurring in the region at the moment. And also in certain member states more severely. There's a lack of information sometimes, which is the cause of this, where parents don't appreciate why they should vaccinate children. In some cases, it's a lack of trust and lack of confidence, not only in the vaccines but in the authorities that provide the vaccines, resulting in a lack of vaccination
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or parents choosing not to vaccinate their nearest and dearest. And also we see often challenges in terms of access. And here I mean, I can personally recall the first time I came across this was in 2010, where we had a large measles outbreak in Bulgaria, and Slovan Grad were among a Roma and Sinti population, where 25,000 cases resulted in 24 deaths of children in a single community, and this was not due to a lack of knowledge. This was not due to a lack of trust, but this was due to a lack of accessing the services because they weren't tailored to the needs of that local population, and because that population were marginalized and not served in a in a way that they expected to be served. So we see this reason, the reasons for children being under vaccinated as being multiple and very different in different contexts.
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DAVID: So that then brings us on to if there are these different reasons, such as either the accessibility, vaccine hesitancy, lack of trust, etc., what public health measures can be taken to control and prevent the spread of measles, to get that information out there to ensure people understand how severe this virus actually is?
ROBB: Well, first and foremost, measles is a great proxy or tracer indicator for universal health coverage because it's such a contagious disease where we see children not vaccinated points to a shortcoming in the health system. We're not reaching each and every last child. So that's our first red flag. It kind of identifies that population, which is being underserved. And I choose to use the word purposefully underserved. Not hard to reach because in this case, they are being underserved by health authorities and by us as the public health providers in their in their respective communities.
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So the first thing that I would say is we need to zoom in on where the gaps are, and those are very clear. Add immunization registries in some cases, those are even registries. And E records in countries can very quickly identify those subpopulations that are under vaccinated and those that are being most affected, particularly at a time of outbreaks. We can then identify the reasons for those gaps. And here, the vaccine preventable diseases and immunization team at EURO, here at WHO Regional Office for Europe, have a very strong track record in terms of applying behavioral and social science methods to identifying why individuals have either chosen not to or are not accessing immunization services, and then to help countries, of course, communicate to the populations once they've been identified. And that again needs tailoring. It's not a one size fits all.
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It's not a spray and pray approach to the way in which we communicate with these populations. The messages have to be tailored and they have to be contextually specific to that environment and to that population. So those are some of the ways in which we help countries. Of course, we prior to any outbreak, making sure that we consistently surveil what is happening in each of the countries, making sure that we track the data we look at, we can often predict where we will expect to see an outbreak in the future by dips in vaccine coverage. So by watching the data, we can be fairly accurate in terms of foreseeing problems before they've arrived and conducting catch up, mop up vaccination campaigns, as we call them, to catch up those children that have not been and catch up, those adults often who have not been vaccinated previously.
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DAVID: You noted a little earlier that one of the reasons why we have under vaccination currently was because of the Covid 19 pandemic. One of the questions I have with regards to that is that the Covid 19 pandemic globally, put very clearly, put a spotlight on vaccinations, the importance of vaccinations. Now, that went in two very separate directions. Certainly on one side you had even you had the anti-vax population who said, no, this is bad. And they were putting out all of their information about why this was a bad thing. But all of a sudden, people understood much more about the importance of vaccinations, how vaccinations are developed, how they are distributed, all of the safety factors and such that go within that. So with knowing that
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we had two years of the pandemic, do you think the pandemic has helped or hindered the vaccination drive for other diseases, such as measles?
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ROBB: That's a good question, and I think it manifests itself differently in different contexts. I would say, by and large, it's helped us educate on the power and the value of vaccines and to express that vaccines have worked, particularly where we have data showing that Covid 19 vaccination saved lives. And ultimately it did in this and every region of the world. So but on the other hand, we've had an emergence of skepticism around Covid 19 vaccines that has not been beneficial to any of our vaccination programs. So of course, this has impacted vaccination programs in different ways where that's emerged. I think it's important to note that in some countries where we have vaccine hesitancy, it affects all vaccines. But then there are outliers to this. The country that we sat in the moment, Denmark would be a good example of this, where we had had a crisis in 2016 around HPV, human papillomavirus
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vaccination against cervical cancer, where we saw an 80% - eight zero - drop in coverage due to an association that was made with a syndrome and illness that would relate to tiredness and lethargy in in young women. And an association was made incorrectly with the vaccine, with the vaccine, with the HPV vaccine and the demand for that vaccine just fell off a cliff 87% to 16% in a period of 6 to 9 months. At the same time, that drop in demand for that vaccine did not affect their childhood vaccination program. So, we didn't see a dip in diphtheria, tetanus, pertussis. We didn't see a dip in measles or polio vaccination across the country. So, it it's sometimes it's it increases the coverage of childhood vaccines
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in other cases, it doesn't affect it at all. What the Danes did particularly well, as did Ireland, was then recover from that crisis incredibly quickly, rebuilding trust, making sure they communicated the science. And ultimately, of course, the HPV vaccine speaks for itself. The impact on cervical cancer and genital warts across this region has been just remarkable.
DAVID: The data that we've received, of course, measles has been also along with mumps and rubella, has been impacted by an incorrect association, as you put it. And that was back in the late 1990s. But this then brings us into that whole, especially in today's era of social media, which is really a double edged sword, because you can have organizations such as the World Health Organization putting out information which hopefully is trusted, and it's up to date and it's got all of the facts,
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but you also have all of the misinformation and disinformation which is also coming out. So how does the World Health Organization address these two twin challenges of both misinformation and vaccine hesitancy?
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ROBB: I mean, I think the World Health Organization has come a long way in the last 5 or 10 years in this respect. I mean, we have an entire unit dedicated to Infodemic, as we call them now at headquarters, and a bulk of that work undertaken at the regional office as well in terms of tackling myths and disinformation. Vaccine hesitancy, however, cannot be a singled down to an information or a lack of information. I think that's the important point here. I in the old days, I used to refer to these three c’s of confidence, complacency and convenience. You know, we have complacency issues. People are not aware. They don't… they're not familiar with the risks that is posed by measles. Those that we've discussed earlier in this conversation and the dangers of vaccine preventable diseases today. Then you've got the confidence issue, which is more related to a lack of trust, lack of confidence, not only in the vaccines, but also in the people that provide those vaccines and the health authorities that provide them. And then this massive ‘C’ of
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convenience, which is: are we delivering the services as people expect to receive them? So, I think there is a bulk of work that needs to take place on tackling mis disinformation, infodemic, and making sure that people have high health literacy so that they can navigate, a very complex environment. The emergence of a behavioural and cultural insights unit at WHO/Europe is incredibly helpful for this endeavor. It allows us to marry the social data with the medical data, if you like, the biosocial versus the biomedical, marrying those two data sets and using social data for public health and well-being purposes.
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DAVID: How does this current measles outbreak in Europe, considering factors like travel and migration, impact the global situation, especially as we approach spring and summer when people typically go on vacation?
ROBB: Well, I think the first risk is that we export measles from the European region, which is, if you think about it, just remarkable with a simple, safe solution being two doses of vaccine that could be in every child's arm. The fact that we export measles to other regions and let's face the Americas have eliminated as a region both measles and rubella. So, we put their elimination status as a region under risk every time somebody travels with measles from Europe. So, there's a there is a global risk. I mean, measles is much the same as polio, as I always say, it can fly in first class tomorrow from anywhere in the world and that import those importations can result in outbreaks.
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And that's what we've seen in our region. Importations at across the region, importations between regions and of course, it's most alarming when it, when it threatens, all of the good work that has been done by regions that have got across that goal line already. So, there's a major issue there. I mean, everybody should be checking vaccination status because as I said before, it is an incredibly dangerous disease and one that can really affect communities, families and, and, and your most loved ones in the most severe way.
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DAVID: Robb, thank you very much for that. I have one last question for you. It's very clear for individuals and their family members, as you were saying, check your vaccination history, make sure people are vaccinated.
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What would you recommend to, health authorities knowing that our region covers 53 countries and within those countries there are regions within there, etc.. But what would you recommend to health authorities, to decision makers?
ROBB: In the area of health and such at this time, to help curve this outbreak back down again, use the data, look at the data, use the data, analyze the data. Identify where the pockets of vulnerability are to prevent any future outbreak. If you have an outbreak at the moment, the only answer to that is vaccination. And the only the only answer to vaccination is either getting people to come to vaccination, to vaccination services and vaccine, vaccinate themselves and their children. Or it is to go to the people in the community and vaccinate them. So, but I think my answer is, you know,
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the data, the surveillance data and the information, the intelligence that we have in each and every country is very a unique, resource for tailoring the response to the needs of the most vulnerable, because this is a disease and this is a virus that affects those most vulnerable and those most marginalized and, unprotected. Our approach to tackling measles.
DAVID: Is it the correct approach or do we need to shift?
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ROBB: Every generation generates new parents and we go to the same parents with the same issues. It's either trust or it's a lack of knowledge, or it's a lack of access to services, or it's some other reason why they're not vaccinating their children.
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For me, I think we have to institutionalize and reach the parents of tomorrow. So institutionalize education and the science behind vaccines to some degree, but also to build a more resilient demand future demand for for vaccination. For me that means school-based learning. I think we have to get in with a younger population to get them to understand the true value and the impact of vaccination, because it is unquestionable. And I'm not just talking here about eradication of a single disease such as smallpox. If you look at the total health gain of vaccination over the past 40, 50 years alone, it is remarkable what you would find in terms of lives saved. It's hundreds of millions globally. So, what I would where I think we should shift instead of saying, okay, we've faced the same problem for
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200 years since Jenner, since Edward Jenner first vaccinated a child against smallpox, we've faced vaccine hesitancy and vaccine skepticism. But we've never tried to institutionalize that, that that vaccination education, if I can put it that way. And also to make the parents and the adults of tomorrow maybe a little bit more critical of what they read and, and, and careful to act upon.
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A more informed choice and to understand not just the science, but understand what is that a strong source of science and a strong source of health advice, and what is not a strong source of health advice? I think that needs that needs an education element. And for me, that starts with the younger not, not the older.
DAVID: With that kind of a new approach of education at a young age and such, those people who currently might be skeptical of vaccines will say, no, no, no, you're just trying to indoctrinate us. And we have questions about vaccines and how they're produced and such. What would you say to those people?
ROBB: Making an informed choice is about asking questions. We are very, very happy if people are having a dialogue, a meaningful dialogue around vaccination and are asking questions, that means that we're we're on a good track.
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We welcome that, of course. What I where I see as a gap here is within the ability of frontline health care workers to answer those questions. And here we need to give time in the practice and in their work environments to make sure that those health workers have the opportunity to respond. And if they can't respond, that's okay because they can find the answer, they can ask that the individual, the parents come back and continue the conversation. But I heard somebody once say that the worst-case scenario is where you end the conversation. You don't keep that conversation open, but you say, I don't know, you know, go and find it somewhere else, because invariably they will find it somewhere else and you don't know who they're going to find that information from. So, it's important that GPs, health care workers have those skills and that ability to engage in that conversation because ultimately, that's where the decisions will be made on the information that they receive. And we know that the health care worker remains the most trusted source of that
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information. That goes for immunization and much, much more.
DAVID: Robb, thank you very much for this. Greatly appreciated.
ROBB: Thanks very much, David.
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DAVID: That was Robb Butler, the Director of Communicable Diseases, Environment and Health for the WHO European Region. If you would like to find out more about what the World Health Organization is doing in its efforts against measles and this recent outbreak, do visit our website at www.who.int. And remember - knowledge about your vaccination status or taking that step to vaccinate yourself or a family member is just a conversation away with your family doctor or local health authority.
And that wraps up this edition of Health in Europe. From all of us here at the World Health Organization - wishing you and your loved ones most excellent health. Goodbye for now.