A spike in measles cases across Europe led by France – caused by the difficulty of innoculating migrant, religious and complacent communities – has triggered moves to co-ordinate vaccination across the continent.
According to data released yesterday (27 April) by the World Health Organisation (WHO), France is leading a European upsurge in measles cases, having recorded almost as many in the first three months of the year – 4,937 – as for the whole of last year, when 5,090 cases were recorded there.
The UN agency said significant outbreaks were also taking place in Spain, the former Yugoslav Republic of Macedonia, Serbia and Turkey.
The figures were released at a round table on measles convened in Brussels by the United Nations and featuring delegates from Belgium, France, Germany and Switzerland.
The upsurge was blamed on the difficulty of vaccinating certain communities. These include children whose parents are unaware that measles still exists.
"Clearly the vaccination is the victim of its own success, people have come to think of it as a historic virus. This is negligent and presumptuous," said Didier Houssin, a director-general in the French Ministry of Health.
Other groups at heightened risk include Roma and other migrant communities – who do not access national health services as frequently as others – and religious groups such as children at Anthroposophic or 'Steiner' schools.
Such schools sometimes encourage the belief that it is better to succumb to diseases such as measles in order to strengthen the body's natural immunity. A rise in the measles virus in Germany in 2008 – which emerged in Anthroposophic schools – spilled over into Austria, Italy and Norway.
European concerted action
John Ryan, a head of unit in the European Commission's health and consumer protection department, said that the Hungarian EU Presidency had tabled a proposal on vaccination for adoption at the council of EU health ministers in June.
He said that the proposals included measures for closer cooperation between EU member states on vaccination, including better coordination of vaccination records.
Ryan said there were many opportunities for enhanced cooperation and coordination at EU level. Examples included developing guidance for reaching out to under-served populations, such as the Roma, and on how to adapt children from one vaccination schedule to another; strengthening EU surveillance for vaccine-preventable diseases; and providing multilingual information on vaccination for healthcare professionals and the public.
The round table heard that the upsurge in infections in France was causing deaths at the rate of one to two for each 1,000 infections. The most vulnerable groups include teenagers and university-aged adults, for whom the disease can be virulent and dangerous.
Rebecca Martin, the WHO's European programme manager for immunisation, said in relation to Roma and migrant communities: "This is a very sensitive issue and needs to be handled carefully. We at the WHO are trying to find a way of dealing with migrant health, working with the member states, but it needs time and effort to understand the communities and to explain the issues to them."
The round table was formally opened by Princess Mathilde of Belgium, a special representative of WHO Europe working on vaccine-preventable diseases. She said: "During the past year, we have witnessed something quite disturbing in the European region. Falling immunisation coverage rates have led to outbreaks of diseases that were previously rare or eradicated in Europe."
"In Western Europe – closer to home – we have seen numerous outbreaks of measles. Indeed, thousands of measles cases have been reported since the beginning of this year," the princess added, saying: "In an age where vaccines can give protection against such diseases, it is alarming to see outbreaks continue to occur. The cost is high – both in health terms and because of the financial burden placed on a country's health system."
"Public trust in immunisation is decreasing," according to Steven Allen, UNICEF regional director for Central and Eastern Europe and the Commonwealth of Independent States. "In an era of global migration and mobility, diseases do not remain behind borders. We need to be transparent and share information no matter how difficult or embarrassing that might be," he said.
The problems with immunisation for measles in Europe include: the difficulty of assessing the vaccination of migrants and socially disadvantaged groups; that healthcare professionals have difficulty keeping up with children who migrate across different member states, especially in relation to the records kept and the languages of these records; and that there is a lack of guidance of how to deal with vaccination records across different member states, according to John Ryan, a head of unit in the health and consumer protection department at the European Commission.
He told the round table: "The Hungarian [EU] Presidency has tabled a proposal for adoption at the Health Council of Ministers in June for cooperation between member states on vaccination, including cross-border cooperation on vaccination records."
Ryan said that while fully respecting the competence of member states in the delivery of health care, the Commission believes that there are many opportunities in the area of childhood immunisation for enhanced cooperation and coordination at EU level, working with the WHO.
He explained: "Examples include: developing commonly agreed guidance and methodologies for reaching out to under-served populations, such as the Roma; strengthening monitoring and assessing vaccination coverage and surveillance for vaccine-preventable diseases; providing support for communication strategies and multilingual information on vaccination in the EU for healthcare professionals and the public, and developing commonly agreed guidance for healthcare professionals on how to adapt children from one vaccination schedule to another."
"There is scope for examining with the member states, the European Centre for Disease Prevention and Control and the WHO how to better record vaccination of children so as to make schedules easier to follow," Ryan concluded.
The World Health Organisation's (WHO) European programme manager for immunisation, Rebecca Martin, told EURACTIV that the main reason for the upsurge in measles is that "children are not getting immunised".
She went on: "The reasons for low coverage are many but the results are the same, many of the migrant populations do not have access to services so the coverage tends to be lower among migrant populations. But it is not restricted to these groups."
She explained that a large rise in measles virus in Germany in 2008 –which emerged in Anthroposophic schools and groups who were not philosophically supportive of immunisation – had spilled over into Norway, Austria and Italy.
"We need to educate people that measles is still around and that it is a disease that can lead to death, she said, adding: "This [the lack of vaccination within Roma and migrant communities] is a very sensitive issue and needs to be handled carefully. We at the WHO are trying to find a way of dealing with migrant health, working with the member states, but it needs time and effort to understand the communities and to explain the issues to them."
In relation to Anthroposophic schools, Martin said: "The Netherlands has invaluable experience dealing with leaders from religious groups opposed to vaccination. In order to explain to them the current situation with these diseases, they have been making inroads into the communities."
Analysis of the French figures shows a larger distribution of cases in the south of France, according to Didier Houssin, a director-general in the French Ministry of Work, Employment and Health. He said: "It is not just migrants and Roma who are out of reach but also young adults who may be in the university and schools, they are in some ways more difficult to reach out to because they are so unaware of the risks, but it is they – because of their age profile – who are at the greatest risk."
Measles, also known as rubeola, is an infection of the respiratory system caused by a virus. Symptoms include fever, cough, runny nose, red eyes and a distinctive rash. The EU had a goal of eliminating measles from its borders by 2010. But a study published in 2009 revealed that measles remained a serious public health concern in Europe.
Published by international medical journal The Lancet and co-funded by the European Commission, it claimed that "measles persists in Europe despite the incorporation of the measles vaccine into routine childhood vaccination programmes more than twenty years ago".
The report expressed concern that in certain areas, vaccination levels had fallen below expectations, stating: "High measles incidence in some European countries revealed suboptimum vaccination coverage." For example, outbreaks of measles remained high among religious objectors in the Dutch Bible Belt and the highly mobile and unvaccinated Sinti and Roma communities in Romania.
The latest outbreak will confirm these fears. There are already some programmes in Europe for assisting migrant communities with vaccination. In Bulgaria, for example, a country with a sizeable Roma population, the authorities have launched a project empowering 105 "health mediators" to operate as Roma representatives, trained to explain the need for vaccination among the community.
The round table in Brussels was held in conjunction with European Immunisation Week.
- June: EU health ministers expected to agree coordinated action on measles vaccination at Health Council of Ministers.
- World Health Organisation (Europe):Immunisation information
EU Actors positions
- EUVAC.NET:A surveillance community network for vaccine preventable infectious diseases (Homepage)
- EUVAC.NET:Measles surveillance first quarterly report 2010
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