Now that the football World Cup is in full swing in Germany, the safety of visitors to the country might be expected to be among the highest of national priorities. Nevertheless, with eight national teams from the Americas competing in the tournament plus their accompanying supporters, the Pan American Health Organization (PAHO) has taken the extraordinary step of issuing a health advisory notice to travellers to the World Cup.
Visitors to Germany are warned by PAHO to be certain that they are immunised against measles because of the outbreak that has been going on in North Rhine-Westphalia since February this year. This state has had around 1400 cases of measles, the largest outbreak in Germany since notification became mandatory in 2001. Three cities in the state—Cologne, Dortmund, and Gelsenkirchen—will host World Cup games, and six teams from the Americas will play in these cities. PAHO also wants health-care workers in the Americas to be aware of the possibility of measles importation. A recent measles outbreak in Venezuela—the first in 4 years—began with the importation of a case from Spain.
An effective vaccine against measles has been available for more than 40 years. Globally, the number of reported measles cases has fallen from over 4 million in 1980 to around 500 000 in 2004. These are considerable underestimates of the actual number of people affected by measles, which is probably around 30 million per year. In 2003 the World Health Assembly resolved to half measles deaths by the end of 2005 compared with 1999 levels. The vehicle set up to achieve this goal is the Measles Initiative, a collaboration between several organisations including WHO and UNICEF, which has focused its efforts on the 47 low-income countries that account for 98% of global measles deaths. Progress has been impressive, with measles deaths falling from 871 000 in 1999 to 454 000 in 2004, a reduction of 48%, with 500 million children worldwide receiving measles vaccine between these dates.
The greatest burden of measles is in sub-Saharan Africa (216 000 deaths in 2004) and south Asia (202 000). Yet the disease continues to splutter on in parts of the world that are wealthy enough to not require international aid to support prevention efforts. In 1994 the PAHO nations agreed to eliminate measles virus from their region by 2000. They did not quite achieve this target, but indigenous measles transmission was interrupted in November 2002. The 108 measles cases reported in the Americas in 2004 were all related to importation. By contrast, the WHO European region—with a population almost exactly the same as that of the PAHO region—reported 29 503 measles cases in 2004, and measles deaths are estimated at 4850 in 2003. Europe is a great exporter of measles: 37% of measles cases imported into the USA during 1993—2001 and 21% of all Canadian cases during 1999—2001 were linked to Europe, and 50% of cases imported into European Union (EU) countries are from other EU countries. But despite being the home of a nasty little epidemic, it was not until 2002 that WHO Europe implemented a plan for measles elimination by 2010. The plan was revised in 2005 to include the goal of rubella elimination by 2010.
Although all 52 European region member states have adopted a routine two-dose childhood measles vaccination schedule, current outbreaks have been reported in Denmark, Greece, Spain, Sweden, and Ukraine, in addition to Germany. Italy has a particularly poor recent record, with more than 9000 cases in 2002 and almost 11 000 in 2003, although the number fell to around 600 in 2004. The official rate of measles vaccination among German children at school entry is 93%, but the accuracy of this figure has been questioned because only children presenting their vaccination cards are counted and immunisation is often given too late. In addition, because only 66% of children receive the second dose of vaccine many are left without effective immunity to measles. Although German law requires health authorities to provide information on vaccination, 50% of parents questioned in a survey said they were insufficiently informed on the topic.
During the current outbreak in North Rhine-Westphalia, public-health officials have been urged to offer vaccination to all school students without measles immunity, but action has been hesitant. Germany is one of the European nations that has undertaken to eliminate measles from the continent by 2010. Unless German authorities and those elsewhere in Europe start to take measles seriously now, that target will not be met and Europe will continue to be the unnecessary exporter of a preventable infection.