WHO Epidemiological Brief: a monthly publication on vaccine-preventable diseases and immunization data and analysis: No. 20, December 2011

Issue 15, April 2011 No. 20 (December 2011) Highlighting in the WHO European Region: • Monthly update on measles and rubella • Overview on imported and import-related measles cases in the European Region in 2010 • Case study: Measles importations, Slovenia, 2011 • Samples for laboratory investigation of mea‐ sles and rubella Update on measles in the European Region As of 1 December 2011, a total of 31 051 con‐ firmed measles cases have been reported by 42 Member States of 53 in the Region. Expected monthly measles surveillance reports for Octo‐ ber have been received from 42 Member States; 14 countries reported 456 confirmed measles cases and 28 provided a “zero” report (no mea‐ sles cases in October). Measles surveillance data were not submitted by 11 Member States. The 456 cases reported in October are within the range of monthly cases reported over the previ‐ ous two months (649 in August and 448 in Sep‐ tember). This represents a significant decrease compared to the monthly reported cases during March to May (6158, 6521 and 5625 respec‐ tively). Most of the countries affected with mea‐ sles outbreaks in 2011 are reporting a decreasing number of cases in the last few months (in Octo‐ ber France reported 70 cases, Italy 4 cases, Spain 60 and Switzerland 2). A measles outbreak continues in Romania, where the number of reported cases almost doubled during September and October (from 69 to 129). Measles is also on the rise in Ukraine, where 171 cases were reported between July and October, 59 (35%) of those cases being reported in the last month. Most of the cases are from the Lviv and Ivano‐Frankivsk regions in western Ukraine, where outbreaks among high‐ school students were reported. Rubella surveillance data were not received from 15 Member States in 2011 (four of which do not have rubella surveillance systems). In October, reports were received from 10 Member States and five of them provided a “zero” report. The highest number of cases was reported from Ro‐ mania (415) during the period January–July. The national surveillance system team and the WHO Regional Office for Europe are working together to update the database of Romanian surveillance data for the period August–October. A monthly publication on vaccine‐preventable diseases and immunization data and analysis No. 20 (December 2011) Page No. 1 of 9 Summary Measles and rubella, 2011 As of 1 December 2011, a total of 31 051 confirmed measles cases have been reported by 42 Member States of 53 in the Region. The 456 cases reported in October are within the range of monthly cases re‐ ported over the previous two months (649 in August and 448 in September). During the same period, January–October 2011, 623 confirmed rubella cases were reported from 18 of 53 Member States in the Region. Measles outbreaks, 2009–2011 Twenty nine countries in the World Health Organiza‐ tion (WHO) European Region experienced measles importations between 2009 and 2011, resulting in a total of 791 imported or import‐related measles cases. Several of these importations resulted in sub‐ sequent widespread outbreaks in multiple countries. Case Study: Slovenia; and Laboratory investigation article This issue of Epidemiological Brief also presents a case study on measles importation in Slovenia in 2011, and features an article showing the proportion of alternative samples versus conventional serum specimens collected by the WHO/Europe regional measles–rubella laboratory network in 2011. Overview on imported and import-related mea‐ sles cases in the European Region in 2010 As stated in the regional measles and rubella surveil‐ lance guidelines, the monitoring and evaluation of surveillance systems over time are necessary to identify areas that need strengthening and to pro‐ vide evidence demonstrating the relevance and qual‐ ity of the surveillance information. These objectives are particularly important in the context of eliminating measles and rubella. Therefore, WHO/ Europe has defined a set of surveillance perform‐ ance indicators that should be calculated for measles and rubella for every level of the system and regu‐ larly reported. One of the indicators to measure the performance of measles and rubella surveillance is “Source of infec‐ tion identified”. This indicator is critical for countries with an incidence lower than 1 per 1 000 000 popu‐ lation, that are reaching elimination and have to document absence of endemic cases. It is calculated as the number of measles or rubella cases for which a source of infection is identified (e.g. imported, im‐ port‐related or endemic), divided by the total num‐ ber of cases reported × 100%. All surveillance levels/ countries should have >80% cases with source of infection identified. Countries should collect and analyse this information as part of routine case-based surveillance activities. This information is relevant for countries with higher incidence and ongoing outbreaks, if they want to confirm that outbreak is a result of importation. For complete and adequate analysis, epidemiological data and genotyping from the laboratory are manda‐ tory. Twenty-nine countries in the WHO European Region experienced measles importations between 2009 and 2011, resulting in a total of 791 imported or import‐related measles cases (Table 1). Several of these importations resulted in subsequent widespread outbreaks in multiple countries (1). As shown in Table 1, measles cases imported into European Region Member States in 2010 were either unvaccinated (81%) or had unknown vaccination status (10%). Eighty‐five percent of the imported cases were laboratory‐confirmed and most of the cases occurred in adults older than 15 years of age at the time of rash onset (57%). The WHO/Europe expects that, with increased num‐ ber of countries providing more complete case‐ based surveillance data with source of infection vari‐ able entered, surveillance for measles and rubella in the region will be dramatically improved towards elimination by 2015. Table 1: Epidemiologic characteristics of imported and import‐related measles cases in the European Region, by year (2009–2011) Category 2009 n (%) 2010 n (%) 2011 n (%) Gender Male 68 (52) 111 (50) 240 (55) Female 64 (48) 113 (50) 193 (44) Unknown ‐‐ ‐‐ 2 (<1) Age category (years) <1 9 (7) 25 (11) 24 (6) 01‐Apr 17 (13) 31 (14) 31 (8) 05‐Sep 10 (8) 12 (5) 30 (8) Oct‐14 23 (17) 30 (13) 43 (11) 15‐24 31 (23) 64 (29) 107 (27) 25+ 42 (32) 62 (28) 161 (41) No. of vaccines received 0 doses 98 (74) 178 (81) 303 (73) 1 dose 8 (6) 13 (6) 42 (10) 2+ doses 4 (3) 6 (3) 10 (2) Unknown 22 (17) 23 (10) 60 (14) Final classification Lab. Confirmed 106 (84) 187 (85) 394 (91) Epi‐linked 4 (3) 13 (6) 13 (3) Clinical 16 (13) 20 (9) 27 (6) Total 132 (100) 224 (100) 435 (100) Page No. 2 of 9No. 20 (December 2011) No. 20 (December 2011) Page No. 3 of 9 Case study: Measles importations, Slovenia, 2011 In 2011, following 10 years with no reported indige‐ nous cases of measles, Slovenia reported 22 cases of measles. Unlike other Member States that experi‐ enced large and prolonged secondary transmission and outbreaks following importation in 2011, the six imported cases in Slovenia resulted only in the total of 22 measles cases. The WHO measles and rubella elimination surveillance guidelines (2) stipulate that, in countries in pre‐elimination phase, measles out‐ breaks resulting from importations should have not more than 10 secondary cases per chain of transmis‐ sion (2). In summary, the importations into Slovenia in 2011 resulted in fewer measles cases when com‐ pared to other Member States, and the 22 reported cases had a diversity of genotypes (suggesting sepa‐ rate chains of transmission). These factors suggest that a case study of the measles surveillance and control system in Slovenia may provide an opportu‐ nity for other Member States of the Region to im‐ prove their programmes’ ability to limit the local spread of future importations. Several factors may have contributed to the success‐ ful containment of the Slovenian outbreaks. First, persistently high vaccination coverage in a strong immunization programme are likely major factors contributing to limited secondary transmission and the small outbreaks, due to the resulting high population immunity to measles. Vaccination coverage has improved remarkably over the past five years, with 2010 MCV1 coverage reported as 94.8%. Secondly, Slovenia has a sensitive high‐performing surveillance system with a strong laboratory support, which is able to detect and rapidly respond to mea‐ sles importations and outbreaks. There is obligatory notification of every suspected case of measles within 3–6 hours to the Institute of Public Health, and the source of measles infection must be estab‐ lished for every case in order to define the chains of transmission and implement standard outbreak con‐ trol measures. Other key strategies that may have contributed to limiting local spread following the 2011 importations may include a school entry requirement for measles vaccination, adequate cold chain, and an outbreak response with prompt investigation of every case and cluster followed by immediate implementation of control measures. Figure 1: Confirmed measles by source of infection, Slovenia, 2011 (January–October) No. 20 (December 2011) Page No. 4 of 9 Samples for laboratory investigation of measles and rubella Suspect cases of measles and rubella are laboratory- confirmed based on the presence of IgM antibodies in the serum collected from the patient using ELISA‐ based assays. Alternatively, IgM antibodies can also be detected in oral fluid specimens. Another alterna‐ tive sample that has shown suitability for use in the WHO laboratory network for the detection of IgM antibodies as well as viral RNA are dried blood spots on filter paper. IgM detection can be carried out us‐ ing conventional serological assays, with only minor modification. Figure 2 shows the proportion of alternative samples versus conventional serum specimens collected by the measles–rubella laboratory network in 2011. In central and eastern European countries as well as the newly independent states, serum is the sample type collected most frequently (<99%). In western European countries, however, oral fluid is an impor‐ tant first alternative to serum. In Belgium and Nor‐ way, half of the specimens sent to the national mea‐ sles–rubella laboratory are oral fluid, in the Nether‐ lands about one third, whereas in Ireland and Finland it is around 10%. In the United Kingdom and France, 75% of specimens sent to the national laboratory for measles and rubella testing are oral fluid. The difference between both countries in this respect is that in the United Kingdom, the Health Protection Agency is the designated laboratory to perform laboratory confirmation, whereas in France, a large network of private laboratories are also performing measles and rubella testing, but on serum samples, not on oral fluid. In Germany, most of the samples tested by the national laboratory are nasopharyngeal swabs (34%). Spain and Switzerland collect nasal swabs in 24% of cases; Finland, Denmark and Belgium in about 10%. Not only nasal swabs but also urine samples are appropriate for virus detection and countries are urged to collect such type of specimens to facilitate virus detection. Dried blood spots are used in the WHO European Region but only in a few countries: Armenia, Georgia, Germany and the Netherlands. Figure 2: Number of samples by type and subregion, WHO European Region, 2011 (January–October) Monthly Summary Table 1. Classification of reported suspected measles cases, January—October 2011 (data as of 1 Dec 2011) Page No. 5 of 9  No. 20 (December 2011) La b co nf ir m ed Ep i- Li nk C li ni ca l2 C om p l et e- ne ss T im el in es s M on th o f la st re po rt La bo ra to ry in ve st ig at io n ra te de te ct io n ra te So ur ce o f in fe ct io n Albania 3 214 691 0.0 0 0 0 0 0 0 100% 60% Oct - 0.00 - Andorra 67 722 0.0 0 0 0 0 0 0 80% 40% Aug - 0.00 - Armenia 3 098 784 0.0 0 0 0 0 17 0 90% 100% Oct 100.0% 0.55 100.0% Austria 8 405 570 9.3 99 23 8 68 0 21 100% 60% Oct 29.7% NA 100.0% Azerbaijan 9 309 301 0.0 0 0 0 0 9 0 100% 80% Oct 100.0% 0.10 100.0% Belarus* 9 568 453 0.3 3 3 0 0 0 0 100% 60% Oct 100.0% 0.00 0.0% Belgium 10 741 129 47.1 538 349 60 129 0 32 100% 40% Oct 0.0% NA 28.4% Bosnia and Herzegovina* 3 755 478 1.3 5 0 0 5 0 0 20% 0% Oct 0.0% NA NA Bulgaria* 7 449 799 20.4 153 153 0 0 0 1 100% 50% Oct 0.7% NA 0.7% Croatia 4 397 338 1.1 7 5 2 0 0 2 60% 40% Jul 100.0% NA NA Cyprus 1 116 113 0.0 0 0 0 0 0 0 70% 70% Jul - 0.00 - Czech Republic 10 522 894 0.7 16 16 0 0 0 9 100% 70% Oct 100.0% 0.00 100.0% Denmark 5 570 660 14.2 83 76 7 0 0 4 100% 70% Oct 86.8% NA 98.8% Estonia 1 340 887 1.5 7 7 0 0 0 5 100% 100% Oct 100.0% NA 100.0% Finland 5 381 049 4.5 27 26 0 1 0 3 100% 70% Oct 3.7% NA 48.1% France 63 103 600 232.6 14951 4840 1873 8238 0 275 100% 30% Oct 95.6% NA 80.5% Georgia* 4 330 693 14.5 63 9 25 29 0 0 100% 80% Oct 23.7% NA NA Germany 82 140 752 17.8 1480 820 559 101 0 15 70% 40% Jul 0.0% NA 94.2% Greece 11 392 891 3.1 40 35 1 4 0 5 100% 60% Oct 100.0% NA 100.0% Hungary 9 964 621 0.0 2 2 0 0 0 2 100% 70% Oct 100.0% 0.00 100.0% Iceland 324 050 0.0 0 0 0 0 0 0 100% 60% Oct - 0.00 - Ireland 4 527 814 58.5 276 122 63 91 0 11 100% 60% Oct 100.9% NA 54.3% Israel* 7 545 524 5.3 40 9 0 31 0 0 100% 100% Oct 22.5% NA NA Italy 60 686 264 74.6 4553 1506 1714 1333 0 24 100% 20% Oct 44.1% NA 33.0% Kazakhstan* 16 240 343 1.8 30 24 0 6 0 0 30% 10% Mar 80.0% NA NA Kyrgyzstan 5 405 749 40.9 221 221 0 0 366 0 80% 10% Aug 100.0% NA NA Latvia 2 242 757 0.0 1 1 0 0 0 1 100% 20% Oct 100.0% 0.00 100.0% Lithuania 3 311 227 1.2 7 7 0 0 0 3 100% 60% Oct 100.0% NA 100.0% Luxembourg 514 108 7.8 6 1 0 5 0 2 100% 60% Oct 100.0% NA 66.7% Malta 418 134 7.2 4 4 0 0 0 1 100% 70% Oct 100.0% NA 75.0% Monaco 37 785 - - - - - - - - - No Report - NA NA Montenegro* 632 157 7.9 5 5 0 0 0 0 50% 40% Jun 100.0% NA NA Netherlands 16 647 522 1.9 46 29 16 1 0 14 100% 20% Oct 100.0% NA 95.7% Norway 4 917 917 5.9 38 37 0 1 0 9 100% 40% Oct 97.4% NA 97.4% Poland 38 307 380 1.0 40 29 3 8 0 1 100% 40% Oct 100.0% NA 100.0% Portugal 10 679 646 0.0 1 1 0 0 0 1 100% 40% Oct 100.0% 0.00 100.0% Republic of Moldova 3 555 765 0.0 0 0 0 0 0 0 30% 10% Mar - 0.00 - Romania 21 445 408 126.1 2709 1081 1603 25 0 4 100% 0% Oct 100.0% NA 100.0% Russian Federation 142 822 544 1.5 223 219 3 1 39 7 100% 100% Oct 100.0% NA NA San Marino 29 332 - - - - - - - - - No Report - NA NA Serbia* 9 842 939 36.4 358 75 13 270 0 0 100% 50% Oct 21.7% NA NA Slovakia 5 470 405 0.0 2 2 0 0 0 2 100% 90% Oct 100.0% 0.00 100.0% Slovenia 2 035 215 7.4 22 22 0 0 0 7 100% 90% Oct 100.0% NA 95.5% Spain 46 366 600 39.4 1876 1450 224 202 0 47 100% 70% Oct 100.0% NA 2.5% Sweden 9 427 367 0.6 22 22 0 0 0 16 100% 70% Oct 100.0% 0.00 100.0% Switzerland 7 694 595 78.4 651 400 93 158 105 48 90% 70% Oct 75.4% NA NA Tajikistan* 6 982 372 0.0 0 0 0 0 0 0 100% 10% Oct - 0.00 - The former Yugoslav Republic of Macedonia* 2 063 819 353.2 729 51 241 437 0 0 100% 80% Oct 10.5% NA NA Turkey 73 689 680 1.3 105 105 0 0 0 11 90% 70% Oct 100.0% NA NA Turkmenistan 5 099 686 0.0 0 0 0 0 0 0 90% 20% Sep - 0.00 - Ukraine* 45 242 024 3.8 173 64 0 109 0 0 90% 90% Oct 37.0% NA NA United Kingdom 62 439 828 14.0 971 971 0 0 0 99 100% 60% Oct 100.0% NA NA Uzbekistan* 27 802 722 16.8 468 199 0 269 0 0 100% 10% Oct 42.5% NA NA Total/Averages 899 321 103 33.8 31051 13021 6508 11522 536 682 97.3% 56.6% 88.6% 0.06 39.6% Data source : Monthly aggregate and case-based data reported by Member States to WHO/Europe and/or EUVAC.NET. 1 Source: "World Population Prospects: The 2008 Revision", New York, United Nations and updates provided by Member States. D is ca rd ed Surveillance Indicators 3 Imported or import related measles cases included in total measles. * Member States reporting aggregate measles data in years 2010 and 2011. Indicators not meeting target and countries not reporting monthly measles data are highligted in red; NA=Not Applicable; "-" = data not available or can not be calculated due to insufficient denominator. Country 2 Cases with missing classification are classified as "Clinical". Total Population1 Total confirmed measles Im po rt at io n3 Reporting Incidence Rate per 1 million population (Jan-Oct) Classification Monthly Summary Table 2. Classification of reported suspected rubella cases, January—October 2011 (data as of 1 Dec. 2011) Page No. 6 of 9  No. 20 (December 2011) La b co nf ir m ed Ep i- Li nk C lin ic al 2 D is ca rd ed C om pl et e- ne ss T im el in es s M on th o f la st re po rt La bo ra to ry in ve st ig at io n ra te D et ec ti on r at e So ur ce o f in fe ct io n Ad eq ua cy o f In ve st ig at io n Albania 3 215 988 0.0 0 0 0 0 0 0 100% 70% Oct - 0.00 - - Andorra 86 165 0.0 0 0 0 0 0 0 80% 30% Aug - 0.00 - - Armenia 3 100 236 0.0 0 0 0 0 7 0 100% 100% Mar - 0.23 - - Austria 8 413 429 0.2 3 0 0 3 0 1 100% 20% Jul 50.0% 0.00 75.0% - Azerbaijan 9 306 023 0.0 0 0 0 0 8 0 100% 80% Oct 100.0% 0.09 100.0% 0.0% Belarus 9 559 441 0.7 7 7 0 0 0 0 90% 50% Oct 0.0% 0.00 0.0% 0.0% Belgium 10 754 056 - - - - - - - - - No Report - - - - Bosnia and Herzegovina 3 755 478 6.1 23 6 4 13 0 0 20% 0% Oct 0.0% - - 0.0% Bulgaria 7 446 135 4.8 36 0 0 36 0 0 100% 20% Jun 5.6% - 5.6% - Croatia 4 395 560 0.0 0 0 0 0 0 0 40% 20% Jul - 0.00 - - Cyprus 1 116 564 0.0 0 0 0 0 0 0 70% 50% Jul - 0.00 - - Czech Republic 10 534 293 2.4 27 12 10 5 0 2 100% 30% Jul 93.1% - 93.1% - Denmark 5 572 594 - - - - - - - - - No Report - - - - Estonia 1 340 537 0.0 0 0 0 0 0 0 100% 80% Oct - 0.00 - - Finland 5 384 770 0.7 8 7 1 0 0 4 100% 40% Jul 25.0% 0.00 33.3% - France 63 125 896 - - - - - - - - - No Report - - - - Georgia 4 329 026 11.1 48 2 0 46 0 0 100% 80% Oct 0.0% - - 0.0% Germany 82 162 512 - - - - - - - - - No Report - - - - Greece 11 390 031 0.0 0 0 0 0 0 0 50% 20% Jul - 0.00 - - Hungary 9 966 116 0.0 2 2 0 0 0 2 100% 30% Jul 50.0% 0.00 50.0% - Iceland 324 366 0.0 0 0 0 0 0 0 70% 40% Jul - 0.00 - - Ireland 4 525 802 1.5 7 1 1 5 0 0 100% 30% Jun 28.6% - 14.3% - Israel 7 562 194 0.0 0 0 0 0 0 0 100% 60% Oct - 0.00 - - Italy 60 788 696 - - - - - - - - - No Report - - - - Kazakhstan 16 206 750 - - - - - - - - - No Report - - - - Kyrgyzstan 5 392 580 - - - - - - - - - No Report - - - - Latvia 2 243 142 1.3 3 2 1 0 0 0 100% 10% Jun 100.0% - 100.0% - Lithuania 3 307 481 0.0 0 0 0 0 0 0 60% 30% Jul - 0.00 - - Luxembourg 515 941 0.0 0 0 0 0 0 0 70% 30% Jul - 0.00 - - Malta 417 855 0.0 0 0 0 0 0 0 70% 50% Jul - 0.00 - - Monaco 35 427 - - - - - - - - - No Report - - - - Montenegro 632 261 0.0 0 0 0 0 0 0 40% 30% Apr - 0.00 - - Netherlands 16 664 746 0.0 1 0 1 0 0 1 100% 0% Jun 50.0% 0.00 50.0% - Norway 4 924 848 0.2 2 1 1 0 0 1 100% 20% Jul 66.7% 0.00 66.7% - Poland 38 298 948 - - - - - - - - - No Report - - - - Portugal 10 689 663 0.0 0 0 0 0 2 0 60% 20% Jul 0.0% 0.02 0.0% 0.0% Republic of Moldova 3 544 864 0.0 0 0 0 0 0 0 30% 10% Mar - 0.00 - - Romania 21 436 496 19.4 415 140 228 47 0 0 100% 0% Jul 100.0% - 100.0% - Russian Federation 142 835 552 - - - - - - - - - No Report - - - - San Marino 31 735 - - - - - - - - - No Report - - - - Serbia 9 853 969 - - - - - - - - - No Report - - - - Slovakia 5 471 502 0.0 0 0 0 0 0 0 100% 50% Oct - 0.00 - - Slovenia 2 035 012 0.0 0 0 0 0 0 0 30% 0% Jun - 0.00 - - Spain 46 454 896 0.2 7 5 0 2 0 0 100% 30% Jul 100.0% 0.00 100.0% - Sweden 9 440 747 0.2 4 3 1 0 0 2 100% 40% Jul 66.7% 0.00 66.7% - Switzerland 7 701 690 0.0 0 0 0 0 22 0 70% 20% Jul 90.9% 0.29 9.1% 0.0% Tajikistan 6 976 958 0.0 0 0 0 0 0 0 100% 10% Oct - 0.00 - - The former Yugoslav Republic of Macedonia 2 063 893 1.9 4 0 0 4 0 0 100% 70% Oct 0.0% - - 0.0% Turkey 73 639 600 - - - - - - - - - No Report - - - - Turkmenistan 5 105 301 - - - - - - - - - No Report - - - - Ukraine 45 190 180 - - - - - - - - - No Report - - - - United Kingdom 62 417 432 0.1 6 6 0 0 0 0 100% 30% Jul 100.0% 0.00 100.0% - Uzbekistan 27 760 268 0.7 20 0 0 20 0 0 10% 0% Mar 0.0% 0.00 0.0% 0.0% Total/Averages 899 445 645 0.7 623 194 248 181 39 13 56.6% 23.0% 50.0% 0.00 19.3% 0.0% Data source : Monthly aggregate and case-based data reported by Member States to WHO/Europe and/or TESSy/ECDC 1 Source: "World Population Prospects: The 2008 Revision", New York, United Nations and updates provided by Member States. Country 2 Cases with missing classification are classified as "Clinical". Surveillance Indicator (Please see page 4 for detail) 3 Imported or import related rubella cases included in total rubella. Indicators not meeting target and countries not reporting monthly rubella data are highligted in red. "-" indicates data not available/applicable or can not be calculated due to insufficient denominator. Total Population1 Classification Total confirmed Rubella Im po rt at io n3Annualized Incidence Rate per 1 million population Reporting Monthly Summary Table 3: Confirmed measles cases for last 12 months, November 2010—October 2011 (data as of 1 Dec. 2011) Page No. 7 of 9 No. 20 (December 2011) Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Albania 3 214 691 0.0 0 0 0 0 0 0 0 0 0 0 0 0 0 Oct Andorra 67 722 0.0 0 0 0 0 0 0 0 0 0 0 0 - - Aug Armenia 3 098 784 0.0 0 0 0 0 0 0 0 0 0 0 0 0 0 Oct Austria 8 405 570 12.1 102 1 2 7 5 5 9 18 33 16 4 2 0 Oct Azerbaijan 9 309 301 0.0 0 0 0 0 0 0 0 0 0 0 0 0 0 Oct Belarus 9 568 453 0.3 3 0 0 0 0 0 0 3 0 0 0 0 0 Oct Belgium 10 741 129 50.1 538 0 0 6 23 142 98 122 86 39 10 10 2 Oct Bosnia and Herzegovina 3 755 478 1.3 5 0 0 0 0 0 0 0 0 0 0 4 1 Oct Bulgaria 7 449 799 36.6 273 52 65 76 27 27 6 18 1 0 0 1 0 Oct Croatia 4 397 338 1.6 7 0 0 2 0 0 0 0 3 2 - - - Jul Cyprus 1 116 113 0.0 0 0 0 0 0 0 0 0 0 0 - - - Jul Czech Republic 10 522 894 1.5 16 0 0 0 0 4 5 4 1 1 1 0 0 Oct Denmark 5 570 660 15.4 86 1 0 7 13 23 19 19 2 2 0 0 0 Oct Estonia 1 340 887 5.2 7 0 0 0 0 4 1 1 1 0 0 0 0 Oct Finland 5 381 049 5.0 27 0 0 1 1 1 4 12 2 0 5 1 0 Oct France 63 103 600 260.7 16449 501 997 1545 2462 3722 3313 2271 925 410 147 86 70 Oct Georgia 4 330 693 15.9 69 2 4 0 1 4 3 11 6 7 18 6 7 Oct Germany 82 140 752 19.4 1593 68 45 69 95 195 428 434 167 92 - - - Jul Greece 11 392 891 3.6 41 1 0 0 2 6 17 10 2 3 0 0 0 Oct Hungary 9 964 621 0.2 2 0 0 0 0 1 1 0 0 0 0 0 0 Oct Iceland 324 050 0.0 0 0 0 0 0 0 0 0 0 0 0 0 0 Oct Ireland 4 527 814 63.8 289 8 4 1 5 11 17 12 30 42 72 60 27 Oct Israel 7 545 524 5.3 40 0 0 0 0 4 0 3 2 0 0 21 10 Oct Italy 60 686 264 78.4 4759 97 109 329 334 568 897 1232 733 307 116 33 4 Oct Kazakhstan 16 240 343 1.8 30 0 0 2 13 15 - - - - - - - Mar Kyrgyzstan 5 405 749 0.0 0 0 0 0 0 0 0 0 0 0 0 0 0 Aug Latvia 2 242 757 0.9 2 0 0 0 0 1 0 0 0 1 0 0 0 Oct Lithuania 3 311 227 2.1 7 0 0 0 0 0 1 2 4 0 0 0 0 Oct Luxembourg 514 108 11.7 6 0 0 0 0 1 0 2 2 0 1 0 0 Oct Malta 418 134 9.6 4 0 0 0 1 0 1 0 0 0 2 0 0 Oct Monaco 37 785 - - - - - - - - - - - - - - No Report Montenegro 632 157 7.9 5 0 0 0 0 3 1 0 1 - - - - Jun Netherlands 16 647 522 2.9 49 0 3 2 1 10 16 11 5 0 1 0 0 Oct Norway 4 917 917 7.7 38 0 0 4 12 7 2 3 5 1 2 1 1 Oct Poland 38 307 380 1.0 40 0 0 2 2 2 8 6 6 6 4 4 0 Oct Portugal 10 679 646 0.1 1 0 0 0 0 1 0 0 0 0 0 0 0 Oct Republic of Moldova 3 555 765 0.0 0 0 0 0 0 0 - - - - - - - Mar Romania 21 445 408 132.0 2831 42 80 131 192 402 396 514 455 379 44 69 127 Oct Russian Federation 142 822 544 1.6 227 4 0 24 23 18 25 20 46 23 7 8 29 Oct San Marino 29 332 - - - - - - - - - - - - - - No Report Serbia 9 842 939 36.5 359 1 0 45 56 120 63 37 25 6 4 2 0 Oct Slovakia 5 470 405 0.4 2 0 0 0 0 1 0 1 0 0 0 0 0 Oct Slovenia 2 035 215 10.8 22 0 0 0 0 0 2 1 7 12 0 0 0 Oct Spain 46 366 600 43.0 1993 64 53 98 159 251 448 362 174 157 93 74 60 Oct Sweden 9 427 367 2.3 22 0 0 4 1 1 8 4 1 2 1 0 0 Oct Switzerland 7 694 595 88.8 683 8 24 58 48 109 210 127 58 28 10 1 2 Oct Tajikistan 6 982 372 0.0 0 0 0 0 0 0 0 0 0 0 0 0 0 Oct The former Yugoslav Republic of Macedonia 2 063 819 404.1 834 54 51 88 95 204 236 74 24 6 2 0 0 Oct Turkey 73 689 680 1.4 106 0 1 6 31 40 12 5 5 6 0 0 0 Oct Turkmenistan 5 099 686 0.0 0 0 0 0 0 0 0 0 0 0 0 0 - Sep Ukraine 45 242 024 4.0 183 10 0 0 1 0 1 10 0 44 45 13 59 Oct United Kingdom 62 439 828 15.9 994 17 6 31 33 143 171 186 133 105 60 52 57 Oct Uzbekistan 27 802 722 16.8 468 0 0 44 58 112 102 90 48 14 0 0 0 Oct Total/Averages 899 321 103 36.93 33212 931 1444 2582 3694 6158 6521 5625 2993 1711 649 448 456 1 Source: "World Population Prospects: The 2008 Revision", New York, United Nations and updates provided by Member States. Month of last report 2011Total Cases Nov10- Oct11 2010 Country Total Population1 Incidence Rate per 1 million population Nov10-Oct11 Monthly Summary Table 4. Measles and rubella laboratory test results, January—October 2011 (data as of 1 Dec 2011) Page No. 8 of 9 No. 20 (December 2011) Tested for measles Positive for measles (%) Measles Equivocal Negative for measles Tested for rubella Positive for rubella (%) Rubella Equivocal Negative for rubella % Complete- ness % Timeli- ness Month of last report Albania 25 0 (0.0) 0 25 5 1 (20.0) 0 4 100.0% 90.0% Oct Andorra No Lab Armenia 35 0 (0.0) 0 35 35 0 (0.0) 4 31 100.0% 100.0% Oct Austria 1133 62 (5.0) 0 1071 4787 3 (0.0) 0 4784 100.0% 100.0% Oct Azerbaijan 13 0 (0.0) 0 13 13 0 (0.0) 0 13 80.0% 40.0% Sep Belarus 417 56 (13.0) 11 330 321 23 (7.0) 3 295 100.0% 100.0% Oct Belgium 663 311 (47.0) 14 329 56 6 (11.0) 3 40 100.0% 100.0% Oct Bosnia and Herzegovina No Report Bulgaria 76 35 (46.0) 0 41 52 2 (4.0) 0 50 100.0% 80.0% Oct Croatia 11 8 (73.0) 0 3 9 0 (0.0) 0 9 100.0% 100.0% Oct Cyprus 0 0 0 0 0 0 0 0 100.0% 100.0% Oct Czech Republic 38 17 (45.0) 8 13 59 8 (14.0) 3 48 100.0% 90.0% Oct Denmark 1174 188 (16.0) 28 958 511 19 (4.0) 77 415 90.0% 40.0% Sep Estonia 148 7 (5.0) 2 139 520 4 (1.0) 0 516 100.0% 100.0% Oct Finland 1493 130 (9.0) 0 1362 514 10 (2.0) 0 504 100.0% 80.0% Oct France 2936 1963 (67.0) 13 958 0 0 0 0 90.0% 60.0% Oct Georgia 36 6 (17.0) 0 30 38 4 (11.0) 4 30 90.0% 50.0% Sep Germany 1034 655 (63.0) 5 374 71 5 (7.0) 3 63 100.0% 100.0% Oct Greece 119 25 (21.0) 0 94 213 47 (22.0) 0 166 90.0% 40.0% Sep Hungary 67 0 (0.0) 0 67 329 7 (2.0) 1 321 100.0% 100.0% Oct Iceland 39 0 (0.0) 0 39 72 0 (0.0) 0 72 90.0% 60.0% Sep Ireland 461 145 (31.0) 21 295 1438 3 (0.0) 17 1418 100.0% 80.0% Oct Israel 108 29 (27.0) 0 79 601 69 (11.0) 0 532 100.0% 90.0% Oct Italy No Report Kazakhstan 110 82 (75.0) 3 25 59 1 (2.0) 2 55 100.0% 80.0% Oct Kyrgyzstan 860 244 (28.0) 8 606 771 7 (1.0) 17 745 90.0% 70.0% Oct Latvia 337 2 (1.0) 1 334 342 3 (1.0) 4 335 100.0% 80.0% Oct Lithuania 14 6 (43.0) 1 7 13 0 (0.0) 1 12 100.0% 100.0% Oct Luxembourg 116 11 (9.0) 0 105 42 2 (5.0) 1 39 100.0% 100.0% Oct Malta 8 5 (63.0) 0 3 1114 6 (1.0) 0 1108 100.0% 100.0% Oct Monaco No Lab Montenegro No Lab Netherlands 123 49 (40.0) 0 74 121 3 (2.0) 0 118 90.0% 60.0% Sep Norway 238 85 (36.0) 2 151 38 1 (3.0) 1 36 100.0% 100.0% Oct Poland 62 30 (48.0) 2 30 45 6 (13.0) 1 38 100.0% 100.0% Oct Portugal 13 3 (23.0) 0 8 0 0 0 0 100.0% 100.0% Oct Republic of Moldova 13 0 (0.0) 0 13 13 0 (0.0) 0 13 90.0% 80.0% Sep Romania 2047 1468 (72.0) 37 542 704 157 (22.0) 27 520 100.0% 100.0% Oct Russian Federation 3652 438 (12.0) 8 3206 3338 270 (8.0) 10 3058 100.0% 90.0% Oct San Marino No Lab Serbia 221 118 (53.0) 3 100 317 1 (0.0) 0 316 100.0% 50.0% Oct Slovakia 10 2 (20.0) 0 8 13 6 (46.0) 0 7 100.0% 90.0% Oct Slovenia 139 41 (29.0) 6 92 16 0 (0.0) 0 16 100.0% 100.0% Oct Spain 3348 1718 (51.0) 60 500 27 7 (26.0) 0 12 80.0% 70.0% Aug Sweden No Report Switzerland 489 439 (90.0) 20 30 11 11 (100.0) 0 0 100.0% 100.0% Oct Tajikistan 20 1 (5.0) 0 19 20 0 (0.0) 0 20 80.0% 20.0% Sep The former Yugoslav Republic of Macedonia 173 52 (30.0) 18 103 111 0 (0.0) 2 109 90.0% 30.0% Sep Turkey 6204 145 (2.0) 87 5972 5567 226 (4.0) 290 5051 100.0% 80.0% Oct Turkmenistan 37 0 (0.0) 2 35 35 0 (0.0) 0 35 90.0% 60.0% Sep Ukraine 590 86 (15.0) 3 501 1069 610 (57.0) 12 447 100.0% 100.0% Oct United Kingdom 3886 1017 (26.0) 0 2869 813 7 (1.0) 0 806 100.0% 60.0% Oct Uzbekistan 236 172 (73.0) 13 51 70 1 (1.0) 3 66 100.0% 60.0% Oct Total / Average 32972 9851 (30%) 376 21639 24313 1536 (6%) 486 22273 96.5% 80.0% Data source : Aggregated monthly lab data provided by laboratories of the regional measles and rubella lab network. Country Specimen* (Serum, Oral Fluid, Swab, Urine and other) *Specimen based data are not population based, and should not be interpreted as indicators for epidemiological surveillance. Laboratories may have received more than 1 clinical sample or may have conducted more than 1 test for a given case reported in Table 1. Reporting Contact us: Vaccine‐preventable Diseases and Immunization Programme WHO Regional Office for Europe Tel.: +45 39 17 13 31   Email: vaccine@euro.who.int   Web site: http://www.euro.who.int P ol io C om pa tib le Pe nd in g D is ca rd ed W ild P ol io ca se s VD PV /V A PP N on p ol io A FP r at e3 A de qu at e St oo l co lle ct io n Su rv . I nd ex 5 P ol io C om pa tib le Pe nd in g D is ca rd ed W ild P ol io ca se s VD PV /V A PP N on p ol io A FP r at e3 A de qu at e St oo l co lle ct io n Su rv . I nd ex 5 % C om pl et en es s % T im el in es s W ee k of la st re po rt Albania 13 13 0 0 0 13 0 0 1.79 100.0 1.00 4 4 0 0 1 3 0 0 0.46 100.0 0.5 85.0 36.0 46 Andorra 0 0 0 0 0 0 0 0 0.00 0.0 0.00 0 0 0 0 0 0 0 0 0.00 0.0 0.0 75.0 14.0 36 Armenia 13 13 1 0 0 13 0 0 2.08 61.5 0.62 18 18 1 0 6 12 0 0 2.08 88.9 0.9 97.0 74.0 47 Austria 3 3 0 0 0 3 0 0 0.24 0.0 0.00 1 1 0 0 0 1 0 0 0.09 0.0 0.1 95.0 36.0 46 Azerbaijan 29 29 0 0 0 29 0 0 1.51 100.0 1.00 32 32 0 0 11 21 0 0 1.16 96.9 1.0 87.0 85.0 46 Belarus 41 41 2 0 0 41 0 0 2.85 92.7 0.98 40 40 2 0 15 25 0 0 1.87 77.5 0.9 47.0 48.0 46 Belgium 3 3 0 0 0 3 0 0 0.17 0.0 0.06 1 1 0 0 0 1 0 0 0.06 0.0 0.0 81.0 40.0 46 Bosnia and Herzegovina 6 6 0 0 0 6 0 0 1.06 66.7 0.83 8 8 1 0 7 1 0 0 0.20 50.0 0.1 81.0 53.0 44 Bulgaria 13 13 2 0 0 13 0 0 1.26 92.3 0.92 12 12 0 0 10 2 0 0 0.21 91.7 0.2 41.0 40.0 46 Croatia 0 0 0 0 0 0 0 0 0.00 0.0 0.00 0 0 0 0 0 0 0 0 0.00 0.0 0.0 97.0 23.0 47 Cyprus 7 7 0 0 0 7 0 0 3.57 85.7 0.86 2 2 0 0 2 0 0 0 0.00 100.0 0.0 91.0 93.0 46 Czech Republic 2 2 0 0 0 2 0 0 0.14 100.0 0.14 5 5 0 0 0 5 0 0 0.36 100.0 0.4 75.0 70.0 45 Estonia 0 0 0 0 0 0 0 0 0.00 0.0 0.00 0 0 0 0 0 0 0 0 0.00 0.0 0.0 85.0 87.0 47 Georgia 7 7 0 0 0 7 0 0 0.97 100.0 0.97 10 10 1 0 1 8 0 1 1.21 100.0 1.0 91.0 93.0 46 Germany 11 10 0 0 0 11 0 0 0.10 10.0 0.03 Greece 20 20 1 0 0 20 0 0 1.21 40.0 0.60 25 25 2 0 25 0 0 0 0.00 76.0 0.0 54.0 51.0 45 Hungary 13 13 0 0 0 13 0 0 0.89 38.5 0.54 7 7 0 0 1 6 0 0 0.44 28.6 0.1 93.0 61.0 46 Ireland 2 2 0 0 0 2 0 0 0.21 50.0 0.11 6 6 0 0 0 6 0 0 0.67 16.7 0.3 93.0 23.0 45 Israel 11 11 0 0 0 11 0 0 0.54 0.0 0.15 16 15 0 0 1 15 0 0 0.79 6.7 0.2 75.0 74.0 46 Italy 53 53 0 0 0 53 0 0 0.62 58.5 0.39 50 50 1 0 10 40 0 0 0.51 56.0 0.3 10.0 8.0 44 Kazakhstan* 113 112 4 0 0 112 1 0 2.85 99.1 0.99 49 49 0 0 26 23 0 0 0.62 98.0 0.6 16.0 14.0 25 Kyrgyzstan 68 64 0 0 0 68 0 0 4.24 96.9 1.00 62 59 0 0 11 51 0 0 3.41 100.0 1.0 25.0 25.0 46 Latvia 5 5 0 0 0 5 0 0 1.60 100.0 1.00 0 0 0 0 0 0 0 0 0.00 0.0 0.0 89.0 78.0 46 Lithuania 10 10 0 0 0 10 0 0 2.02 100.0 1.00 10 10 0 0 0 10 0 0 2.21 100.0 1.0 93.0 80.0 46 Malta 0 0 0 0 0 0 0 0 0.00 0.0 0.00 0 0 0 0 0 0 0 0 0.00 0.0 0.0 91.0 14.0 45 Montenegro 1 1 0 0 0 1 0 0 0.82 100.0 0.82 2 2 0 0 1 1 0 0 0.90 0.0 0.9 81.0 82.0 46 Norway 9 9 0 0 0 9 0 0 0.98 55.6 0.77 8 8 0 0 5 3 0 0 0.35 12.5 0.2 77.0 23.0 42 Poland 47 47 0 0 0 46 0 1 0.81 72.3 0.67 32 32 2 0 8 24 0 0 0.46 71.9 0.4 95.0 76.0 46 Portugal 8 8 0 0 0 8 0 0 0.50 50.0 0.31 8 7 1 0 1 7 0 0 0.47 42.9 0.3 56.0 4.0 45 Republic of Moldova 15 15 3 0 0 15 0 0 2.52 73.3 0.87 7 7 0 0 1 6 0 0 1.10 100.0 1.0 89.0 91.0 47 Romania 16 16 1 0 0 16 0 0 0.49 100.0 0.49 19 19 0 0 4 15 0 0 0.50 100.0 0.5 89.0 85.0 47 Russian Federation* 397 390 68 0 0 378 14 5 1.76 94.9 0.95 338 336 29 0 96 242 0 0 1.20 92.6 1.1 75.0 76.0 45 Serbia 20 20 0 0 0 20 0 0 1.15 90.0 0.95 8 8 1 0 4 4 0 0 0.25 75.0 0.3 85.0 85.0 46 Slovakia 1 1 0 0 0 1 0 0 0.12 0.0 0.00 2 2 0 0 0 2 0 0 0.26 100.0 0.3 77.0 63.0 46 Slovenia 0 0 0 0 0 0 0 0 0.00 0.0 0.00 0 0 0 0 0 0 0 0 0.00 0.0 0.0 93.0 74.0 46 Spain 31 31 2 0 0 31 0 0 0.45 45.2 0.33 23 23 0 0 5 18 0 0 0.28 26.1 0.2 93.0 63.0 45 Switzerland 9 9 0 0 0 9 0 0 0.77 33.3 0.43 5 3 0 0 0 5 0 0 0.47 66.7 0.3 81.0 38.0 45 Tajikistan* 712 585 0 58 0 193 460 1 7.58 86.7 0.88 55 52 0 0 9 46 0 0 1.95 96.2 1.9 75.0 76.0 46 The former Yugoslav Republic of Macedonia 7 7 0 0 0 7 0 0 1.93 100.0 1.00 3 3 1 0 0 3 0 0 0.91 100.0 0.9 89.0 87.0 46 Turkey 221 215 6 0 0 240 0 2 1.14 74.0 0.79 172 172 3 0 46 125 0 1 0.71 82.0 0.6 83.0 85.0 46 Turkmenistan* 50 50 0 0 0 46 3 1 3.12 100.0 1.00 29 29 0 0 5 24 0 0 1.77 100.0 1.8 54.0 55.0 46 Ukraine 130 125 22 0 0 129 0 1 2.00 96.0 0.98 112 112 24 0 28 83 0 0 1.38 98.2 1.0 85.0 87.0 46 Uzbekistan 146 132 4 0 0 146 0 0 1.81 97.7 0.98 174 171 4 0 34 140 0 0 1.89 96.5 1.0 66.0 63.0 45 Average/Total 2263 2098 116 58 0 1737 478 11 1.66 86.00 0.89 1355 1340 73 0 374 978 0 2 0.76 87.00 0.7 75.0 56.0 3 Non-polio AFP cases per 100 000 children under the age of 15 years (annualized for current year). Number of non-polio (discarded) AFP cases X 100000 / total population under 15 years. A FP c as es u nd er 15 y ea rs o f a ge H ot A FP C as es 2 Classificaion Rates 5 Surveillance Index = non-polio AFP rate up to 1.0 x (% AFP cases with atleast 1 adequate specimens within 14 days of onset). 4 two stool samples collected with 14 days and 48 hours apart. Countries A FP C as es 1 1 AFP case of all ages (Denmark, Finland, France, Iceland, Luxembourg, Monaco, Netherlands, San Marino, Sweden and United Kingdom do not report AFP cases. High quality surveillance (e.g. enterovirus and/or environmental) to detect poliovirus exists in Member States with no AFP surveillance. 2 Hot cases = AFP case reported with a priority code (e.g. less than three doses of polio vaccine/Clinically polio/Recent travel to endemic country/high risk group). *Countries infected in 2010. Nonpolio AFP Rate and Surveillance Index targets for these member states have been revised to 2.0 and 1.6 respectively. Table 5: Classification of AFP cases, surveillance performance and weekly reporting to WHO EURO by country, 2010-2011, WHO European Region A FP C as es 1 H ot A FP C as es 2 Classificaion 2010 (1-53 weeks) A FP c as es u nd er 15 y ea r of a ge Rates Reporting 2011 (1-48 weeks) Page No. 9 of 9 No. 20 (December 2011) © World Health Organization 2011 All rights reserved. Document number: WHO/EURO:2011-7605-47372-69579