WHO EpiBrief: a report on the epidemiology of selected vaccine-preventable diseases in the European Region: No. 2/2020

No. 2/2020 A report on the epidemiology of selected vaccine-preventable diseases in the European Region Of the total cases in the Region for January–June 2020, 10 615 cases (88%) were reported by 6 countries: Uzbekistan (n=4056; 34%), Kazakhstan (3265; 27%), Russian Federation (1030; 9%), Romania (971; 8%), Kyrgyzstan (705; 6%) and Turkey (588; 5%). 5561 cases (46%) were laboratory confirmed and 1816 cases (15%) were epidemiologically linked. The remaining 4651 cases (39%) were classified as clinically compatible. For the first half of 2020, 19 (51%) of the 37 countries notifying measles cases submitted 246 genomic sequence information to the Measles Nucleotide Surveillance database (MeaNS)3 through WHO-accredited reference laboratories (as of 24 August 2020). The genotypes identified in the Region comprised D8 (n=128) and B3 (118). As in 2019, the dominant measles virus variant was D8 Gir Somnath.IND/42.16/ representing 33% of D8 variants. Other D8 variants included MVs/ Phatthalung.THA/22.19 (9%), MVs/Southern Finland.FIN/49.18/ (9%) and MVs/Dagon Seikkan.MMR/5.18 (4%). The named strain MVs/Kabul.AFG/20.2014/3 became the dominant B3 variant in the first half of 2020 (21% of all B3 variants) followed by Dublin.IRL/8.16/ (12.7%). No other genotypes were reported. Fig. 2 shows the number of sequences of measles virus in the WHO European Region reported to MeaNS. The measles and rubella surveillance data presented in this issue were reported by Member States of the WHO Regional Office for Europe and are incorporated in the Centralized information system for infectious diseases.1 The analyses of these data are performed on cases with disease onset dates during the first half of 2020. Where these dates were unavailable, cases with the date of notification reported during this period were included. If different dates are used the numbers of cases in a specified time period may differ from reports produced by national or partner agencies. Tabulated surveillance data by country for 2019 and January through June of 2020 (as of 29 July 2020) are annexed to this issue. They are also published in WHO EpiData no. 7/2020.2 Percentages in this report were rounded to the nearest whole number. Notifications and laboratory data For the first half of 2020, 12 028 measles cases were reported by 52 countries that submitted measles data (including zero reporting) (Table 1 in annex). This corresponds to a decline of 87% compared to cases reported during the first half of 2019 (n=92 798) (Fig. 1). Page 1 WHO EpiBrief No. 2/2020 Measles in the WHO European Region This issue of WHO EpiBrief provides an overview of selected epidemiological characteristics of measles and rubella in the WHO European Region based on monthly surveillance data for the first half of 2020. Fig. 1. Measles cases by month in the WHO European Region, 2018–June 2020 0 2 000 4 000 6 000 8 000 10 000 12 000 14 000 16 000 18 000 20 000 Ja n Fe b M ar A p r M ay Ju n Ju l A u g Se p O ct N o v D e c Ja n Fe b M ar A p r M ay Ju n Ju l A u g Se p O ct N o v D e c Ja n Fe b M ar A p r M ay Ju n 2018 (n=88693) 2019 (n=104443) 2020 (n=12028) N u m b er o f m ea sl es ca se s Laboratory-confirmed Epidemiologically linked Clinically compatible Page 2 Age distribution Of the total cases, the age group was known in 11 991 cases (99.7%): 4185 (35%) were <1 year old, 3132 (26%) were 1–4 years old, 2086 (17%) were 5–19 years old and 2588 (22%) were ≥20 years old (Fig. 3). The age distribution varied between countries. Fig. 4 shows the age distribution of measles cases in the 6 countries reporting the largest numbers of cases in the Region. Vaccination status Vaccination status was known for 10 280 cases (85%). Of the 8423 cases (82%) that were unvaccinated: 4031 (48%) were <1 year old, 2298 (27%) were 1–4 years old, WHO EPI-BRIEF No. 2/2020 WHO EpiBrief Fig. 2. The number of sequences of measles virus in the WHO European Region reported to MeaNS by genotype, 2018 through week 19, 2020 (as of 29 July 2020) 660 (8%) were 5–9 years old, 391 (5%) were 10–19 years old and 1043 (12%) were ≥20 years old. The remaining 1857 cases (18%) were reportedly vaccinated with at least one dose of measles-containing vaccine (MCV). Hospitalization Data on hospitalization status were available for 11 571 (96%) cases. Of these, 10 416 cases (90%) were hospitalized. Measles-related deaths In the first half of 2020, there were 10 reported measles-related deaths in 4 countries: Kazakhstan (5 deaths), Bulgaria (2), Turkey (2) and Kyrgyzstan (1). This corresponded to a death rate per 1000 measles cases of 0.83. 4 deaths occurred in infants, 4 deaths occurred in children between 1 and 7 years of age and 2 deaths were adults aged 29 and 45. All but one of the 10 deaths were laboratory-confirmed cases of measles; one case was epidemiologically-linked to a laboratory confirmed case. 8 fatal cases were unvaccinated. In the remaining 2 cases the vaccination status was unknown. Imported cases Importation status was known for 5928 (49%) measles cases. Of these, 345 (5.8%) cases were imported. Most imported cases (63%; n=307) were reported by Uzbekistan (n=241), Russian Federation (28), France (14), Italy (10), United Kingdom (7) and Germany (7). (Table 1 in annex). Fig. 3. Age distribution of measles cases in the WHO European Region, January–June 2020 (n=12 028)* N.B. Discarded cases are not included. *For 37 cases the age group was not reported. 35% 26% 9% 4% 4% 9% 13% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o fr ep o rt ed m ea sl es ca se s Age group (years) 0 20 40 60 80 100 120 140 160 180 200 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 2018 2019 2020 N u m b er o f se q u en ce s re p o rt ed to M ea N s Week and year of specimen collection B3 D8 D4 H1 Page 3 No.2/2020 WHO EpiBrief Fig. 4. Age distribution of measles cases in the six countries with the largest numbers of cases in the WHO European Region, January–June 2020 52% 30% 8% 2% 1% 6% 3% 0% 10% 20% 30% 40% 50% 60% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o f re p o rt e d m e a s le s c a s e s Age group (years) Kyrgyzstan (n=705) 9% 56% 12% 8% 3% 3% 9% 0% 10% 20% 30% 40% 50% 60% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o f re p o rt ed m ea sl es ca se s Age group (years) Turkey (n=588) 58% 17% 6% 3% 2% 4% 10% 0% 10% 20% 30% 40% 50% 60% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o f re p o rt e d m e a s le s c a s e s Age group (years) Uzbekistan (n=4056) 29% 29% 8% 3% 6% 13% 13% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o f re p o rt e d m e a s le s c a s e s Age group (years) Kazakhstan (n=3265) 15% 33% 11% 4% 3% 13% 22% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o f re p o rt e d m e a s le s c a s e s Age group (years) Russian Federation (n=1030) 20% 31% 17% 10% 5% 8% 9% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o f re p o rt ed m ea sl es c as es Age group (years) Romania (n=971) Notifications and laboratory data For the first half of 2020, 150 rubella cases were reported by 14 countries among 48 that submitted rubella data (including zero reporting) (Table 2 in annex). 90% of cases (n=135) were reported by Poland (49%; n=74), followed by Ukraine (16%; 24), Germany (9%; 13), Italy (8%; 12) and Turkey (8%; 12). Most cases (78%; n=117) were classified as clinically compatible and were mostly (81%) reported by Poland (n=74) and Ukraine (21). 1 case was classified as epidemiologically linked and 32 cases (21%) were laboratory confirmed. During the first half of 2020, one rubella virus sequence (genotype 2B) was entered in the Rubella Nucleotide Surveillance database (RubeNS)4 (as of 24 August 2020). Age distribution The age group was known in all 150 cases: 17 (11%) were <1 year old, 50 (33%) were 1–4 years old, 35 (23%) were 5–19 years old and 48 (32%) were ≥20 years old (Fig. 5). Of the 32 laboratory-confirmed cases, 1 was <1 year old, 12 were 1–4 years old, 2 were 5–14 years old, 1 was 15–19 years old, 4 were 20-29 years old and 12 were ≥40 years old (Fig.6). Eight laboratory-confirmed cases were in females aged 21-38. Vaccination status Vaccination status was known in all 150 cases. Of the 46 (31%) unvaccinated cases: 16 (35%) were <1 year old, 10 (22%) were 1–4 years old, 3 (7%) were 5–19 years old and 17 (37%) were ≥20 years old. The remaining 104 cases (69%) were reportedly vaccinated with at least one dose of rubella-containing vaccine. Page 4 WHO EpiBrief No. 2/2020 N.B. Discarded cases are not included. Fig. 5. Age distribution of rubella cases in the WHO European Region, January–June 2020 (n=150) Imported cases Importation status was known in 48 (32%) rubella cases. Of these, 2 cases (4%) were imported cases. Imported cases were reported by Hungary (n=1) and Norway (1). The number of reported measles cases in the Region for the first half of 2020 (n=12 028) was 87% less than that reported for the first half of 2019 (92 798). The number of countries reporting monthly zero measles cases increased from 15 in February 2020 to 44 in June 2020. Factors related to the ongoing COVID-19 pandemic are likely to have contributed to these observed trends. These include: • fewer visits to hospitals and medical practitioners during full or partial lockdown of countries, which may have led to milder cases of measles going undetected; • decreased measles virus transmission as a result of stay-at-home recommendations, closure of schools, banning of mass gatherings, closer of international borders, widespread physical distancing and improved hand hygiene and coughing/sneezing etiquette; and • interrupted or disrupted disease surveillance due to diversion of human and other resources to COVID-19- related matters. The number of reported rubella cases in the Region for the first half of 2020 (n=150) was also lower than that reported for the same period in 2019 (409) largely due to a decline in cases reported by Poland (from 188 cases to 74 cases) and Ukraine (from 94 cases to 24 cases). As in previous years, most reported rubella cases were Fig.6. Classification of reported rubella cases by age group in the WHO European Region, January–June 2020 (n=150) Rubella in the WHO European Region Comments Measles and rubella in the WHO European Region 11% 33% 16% 5% 3% 11% 21% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥3 % o f re p o rt ed r u b el la c as es Age group (years) 0 10 20 30 40 50 <1 1-4 5-9 10-14 15-19 20-29 ≥3 N o .o f re p o rt ed r u b el la c as es Age group (years) Laboratory confirmed Epidemiologically linked Clinically compatable Page 5 No. 2/2020 WHO EpiBrief classified as clinically compatible. Considerable effort is required to increase the level of laboratory confirmation of suspected cases to confirm the occurrence or absence of rubella and exclude the possibility of over- reporting. Vaccination Attaining the optimal immunization coverage (≥95%) with two MCV doses at all subnational levels (provinces, regions and districts) whilst closing immunity gaps in all age groups is crucial. Despite the reduction in the number of reported measles cases, there are persisting immunity gaps in all age groups particularly in children <10 years old and in adults ≥20 years old. Some countries reported partial or full disruption of immunization services while movement restrictions were in place as part of the COVID-19 prevention and control measures during the first few months of the pandemic Any disruption of routine immunization services, even for short periods, will inevitably result in an accumulation of susceptible individuals, and an increased likelihood of outbreaks of vaccine- preventable diseases. Countries where disruptions occurred either at local or national level have been urged to make all possible efforts to equitably sustain high population immunity. This includes enumerating the cohorts of children who have missed their vaccine doses and putting in place an action plan for tailor-made catch-up immunization. WHO guidance on routine immunization services during the COVID-19 pandemic in the WHO European Region are available online.5 Surveillance All countries are urged to continue ensuring that their surveillance systems for measles and rubella are sensitive and specific enough to detect, confirm and classify all suspected cases.6 Countries should consider assessing the extent of the impact of the COVID-19 pandemic on surveillance for measles, rubella and other outbreak-prone vaccine-preventable diseases (VPDs) to ascertain if the observed decline in reported cases is likely due to changes in epidemiology (as an indirect result of non-pharmaceutical measures in COVID-19 response), or to decreased surveillance performance. The latter may lead to increased risk for outbreaks due to undetected circulation of measles, rubella or other VPDs, and efforts (including dedication of appropriate resources) should be made by countries to ensure high quality VPD surveillance. Elimination status As part of the annual verification process, the European Regional Verification Commission for Measles and Rubella Elimination (RVC) held a virtual session on 29 June 2020 to review annual status update reports for 2019 of 11 countries: Armenia, Azerbaijan, Denmark, Estonia, Finland, Latvia, Netherlands, Norway, Sweden, Tajikistan and Turkmenistan. The RVC verified that by the end of 2019, all 11 countries had maintained their measles elimination status; and 10 countries that had previously achieved rubella elimination maintained this status. The Commission also determined that for the first time, Denmark was verified as having eliminated rubella. Therefore, by the end of 2019 all 11 countries demonstrated the absence of endemic transmission of both diseases. Two more sessions are planned before the end of 2020 for the RVC to review the annual status update reports for 2019 of the remaining countries.7 Elimination of both measles and rubella remains a priority goal for all countries of the WHO European Region. The cornerstones for eliminating these diseases remain high population immunity, closure of immunity gaps in the population and high-quality surveillance to monitor disease occurrence for public health action. Date of publication: 24 September 2020 Suggested citation: World Health Organization Regional Office for Europe. WHO EpiBrief, 2020, 2:1–8 Document number: WHO/EURO:2020-5630-45395-64959 © World Health Organization, 2020. All rights reserved. References 1. World Health Organization Regional Office for Europe. Centralized information system for infectious diseases (CISID). Copenhagen, WHO Regional Office for Europe. https://data.euro.who.int/cisid/ 2. World Health Organization Regional Office for Europe. WHO EpiData no. 7/2020. https://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/surveillance-and- data/who-epidata/epidata-72020 3. Measles Nucleotide Surveillance database (MeaNs) [online database]. London: Public Health England, and Geneva: World Health Organization. www.who-measles.org 4. Rubella Nucleotide Surveillance database (RubeNS). www.who-rubella.org [online database]. London: Public Health England, and Geneva: World Health Organization. www.who-rubella.org 5. World Health Organization Regional Office for Europe (2020). Guidance on routine immunization services during COVID-19 pandemic in the WHO European Region. 20 March 2020. www.euro.who.int/en/health-topics/disease-prevention/vaccines- and-immunization/publications/2020/guidance-on-routine-immunization-services-during-covid-19-pandemic-in-the-who- european-region,-20-march-2020 6. World Health Organization Regional Office for Europe (2012). Surveillance Guidelines for Measles, Rubella and Congenital Rubella Syndrome in the WHO European Region. Copenhagen. www.euro.who.int/__data/assets/pdf_file/0018/79020/e93035-2013.pdf?ua=1 7. World Health Organization Regional Office for Europe (2020). Measles and rubella elimination: verification process continues amid COVID-19 pandemic. www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/ news/news/2020/8/measles-and-rubella-elimination-verification-process-continues-amid-covid-19-pandemic (accessed 19 August 2020). WHO EpiBrief Page 6 No. 2/2020 WHO EpiBrief Page 7 No. 2/2020 Annex Table 1. Measles cases in the WHO European Region: classification, reporting and surveillance performance, January–June 2020 (as of 29 July 2020) L a b c o n fi rm e d E p i- L in k C li n ic a ll y c o m p a ti b le 3 C o m p le te n e ss 4 T im e li n e ss 4 M o n th & y e a r o f la st r e p o rt L a b o ra to ry in v e st ig a ti o n ra te 4 R a te o f d is c a rd e d c a se s 5 O ri g in o f in fe c ti o n 4 T im e li n e ss o f in v e st ig a ti o n 4 Albania 7 2 880 917 167.31 482 2 3 3 0 0 12 0 0 100% 100% Jun-20 100% 0.4 100% 100% Andorra 77 142 0.00 0 - 0 0 0 0 0 - - 100% 83% Jun-20 - 0.0 - - Armenia 2 957 731 2.37 7 0 0 0 0 0 18 - - 100% 100% Jun-20 100% 0.6 - 100% Austria 8 955 102 16.86 151 0 25 20 3 2 1 1 0 100% 100% Jun-20 91% 0.0 100% 8% Azerbaijan 10 047 718 25.98 261 0 2 2 0 0 7 0 0 100% 83% Jun-20 100% 0.1 100% 89% Belarus 7 9 452 411 20.21 191 0 0 0 0 0 96 - - 100% 100% Jun-20 100% 1.0 - 0% Belgium 11 539 328 41.68 481 0 45 14 6 25 - 0 0 100% 100% Jun-20 - - - - Bosnia and Herzegovina 3 301 000 424.42 1401 0 4 0 0 4 - 0 0 100% 67% Jun-20 - - - - Bulgaria 7 000 119 178.14 1247 0 245 227 7 11 - 2 2 100% 100% Jun-20 97% - 1% 100% Croatia 4 130 304 12.59 52 0 0 0 0 0 0 - - 100% 100% Jun-20 - 0.0 - - Cyprus 1 198 575 5.01 6 0 1 1 0 0 - 1 0 100% 83% Jun-20 100% - 100% 100% Czech Republic 10 689 209 53.98 577 0 4 4 0 0 - 1 0 100% 100% Jun-20 100% - 100% 0% Denmark 5 771 876 2.60 15 0 4 4 0 0 - 0 0 100% 100% Jun-20 100% - 100% 0% Estonia 1 325 648 20.37 27 0 0 0 0 0 31 - - 100% 100% Jun-20 100% 2.3 - 100% Finland 5 532 156 2.17 12 0 5 5 0 0 - 2 0 100% 100% Jun-20 100% - 100% 0% France 65 129 728 40.49 2637 2 230 158 31 41 - 14 0 100% 100% Jun-20 94% - 81% 0% Georgia 3 996 765 980.79 3920 2 14 12 0 2 24 0 0 100% 83% Jun-20 95% 0.6 93% 89% Germany 83 517 045 6.07 507 0 72 53 14 5 - 7 0 100% 100% Jun-20 91% - 85% 0% Greece 10 473 455 4.30 45 0 2 2 0 0 0 0 0 100% 100% Jun-20 100% 0.0 100% 0% Hungary 9 684 679 2.37 23 1 0 0 0 0 0 - - 100% 100% Jun-20 - 0.0 - - Iceland 339 031 26.55 9 0 0 0 0 0 - - - 100% 100% Jun-20 - - - - Ireland 4 882 495 14.95 73 0 18 2 0 16 - 2 0 100% 100% Jun-20 28% - 28% 11% Israel 8 519 377 120.67 1028 0 6 6 0 0 - 0 0 100% 100% Jun-20 100% - 0% 83% Italy 60 550 075 26.75 1620 1 101 81 12 8 19 10 0 100% 100% Jun-20 94% 0.0 82% 0% Kazakhstan 18 551 427 718.33 13326 21 3265 2003 1004 258 - 0 5 100% 33% Jun-20 - - - - Kyrgyzstan 7 6 415 850 358.95 2303 0 705 150 319 236 143 5 1 100% 100% Jun-20 35% 2.2 100% 97% Latvia 1 906 743 1.05 2 0 0 0 0 0 - - - 100% 100% Jun-20 - - - - Lithuania 2 759 627 301.49 832 0 1 1 0 0 - 1 0 100% 100% Jun-20 100% - 100% 100% Luxembourg 615 729 38.98 24 0 0 0 0 0 2 - - 100% 100% Jun-20 100% 0.3 - 100% Malta 440 372 72.67 32 0 2 2 0 0 - 0 0 100% 100% Jun-20 100% - 100% 0% Monaco 38 964 0.00 0 - 0 0 0 0 0 - - 100% 83% Jun-20 - 0.0 - - Montenegro 627 987 0.00 0 - - - - - - - - 0% 0% Dec-19 - - - - Netherlands 17 097 130 4.91 84 0 2 2 0 0 - 1 0 100% 100% Jun-20 100% - 50% 0% North Macedonia 2 083 459 904.27 1884 5 0 0 0 0 - - - 17% 17% Jan-20 - - - - Norway 5 378 857 3.16 17 0 4 4 0 0 - 2 0 100% 100% Jun-20 100% - 75% 100% Poland 37 887 768 36.08 1367 0 36 18 1 17 - 0 0 100% 100% Jun-20 - - - - Portugal 10 226 187 0.98 10 0 8 7 0 1 13 4 0 100% 100% Jun-20 81% 0.1 50% 100% Republic of Moldova 4 043 263 22.01 89 0 17 17 0 0 8 1 0 100% 100% Jun-20 100% 0.2 100% 96% Romania 19 364 557 89.65 1736 5 971 486 312 173 - 0 0 100% 100% Jun-20 76% - 100% 29% Russian Federation 145 872 256 28.58 4169 0 1030 1008 21 1 823 28 0 100% 100% Jun-20 100% 0.6 100% 37% San Marino 33 860 324.87 11 0 0 0 0 0 0 - - 100% 67% Jun-20 - 0.0 - - Serbia 8 772 235 2.39 21 0 0 0 0 0 - - - 100% 100% Jun-20 - - - - Slovakia 5 457 013 57.17 312 0 0 0 0 0 0 - - 100% 100% Jun-20 - 0.0 - - Slovenia 2 078 654 23.09 48 0 6 6 0 0 - 1 0 100% 100% Jun-20 100% - 100% 100% Spain 46 736 776 6.25 292 0 71 70 1 0 36 1 0 100% 100% Jun-20 100% 0.1 99% 47% Sweden 10 036 379 1.99 20 0 5 5 0 0 - 4 0 100% 100% Jun-20 100% - 100% 0% Switzerland 8 591 365 26.65 229 2 33 29 4 0 85 7 0 100% 100% Jun-20 100% 1.0 88% 30% Tajikistan 9 321 018 0.75 7 0 168 89 74 5 72 0 0 100% 83% Jun-20 97% 0.8 1% 100% Turkey 7 83 429 615 34.66 2892 3 588 588 0 0 1227 1 2 100% 100% Jun-20 100% 1.5 21% 98% Turkmenistan 7 5 942 089 0.00 0 - 0 0 0 0 46 - - 100% 100% Jun-20 100% 0.8 - 100% Ukraine 43 993 638 1303.19 57332 20 195 59 7 129 - 1 0 100% 100% Jun-20 32% - 97% 99% United Kingdom 67 530 172 13.06 882 1 84 84 0 0 - 7 0 100% 100% Jun-20 100% - 100% 0% Uzbekistan 32 981 716 53.06 1750 0 4056 339 0 3717 1 241 0 100% 83% Jun-20 10% 0.0 56% 90% Region 930 166 592 112.28 104443 65 12028 5561 1816 4651 2664 345 10 97% 92% 59% 0.5 68% 72% Total measles cases 2 Data source: Monthly aggregated and case-based data reported by Member States to WHO/Europe directly or via ECDC/TESSy. Member States submitting aggregate data: Belgium, Bosnia and Herzegovina, Kazakhstan, North Macedonia, Poland (since Feb 2019) and Serbia. 1 Population source : United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2019 Revision. 2 All confirmed measles cases regardless of origin. 3 Unless specified as laboratory confirmed or epi-linked, cases are classified as clinically compatible. 4 Target (>=80%) not achieving are highlighted in red. 5 Rate of discarded cases not achieving the target (>=2 discarded cases per 100 000) are highlighted in red. Rate of discarded cases is not calculated for the countries submitting only confirmed measles cases. 6 Surveillance indicators can not be calculated for Member States submitting aggregate data. 7 Country classifies discard cases as “discarded, not measles, not rubella”. Report Surveillance Indicators 6 Country Total Population in 2019 1 2019 (as of 29 July 2020) 2020 Incidence Rate (per 1 million population) Total measles cases 2 Total measles deaths Classification D is c a rd e d m e a sl e s Im p o rt e d c a se s M e a sl e s d e a th s Table 2. Rubella cases in the WHO European Region: classification, reporting and surveillance performance, January–June 2020 (as of 29 July 2020) WHO EpiBrief Page 8 No. 2/2020 L a b c o n fi rm e d E p i- L in k C li n ic a ll y c o m p a ti b le 3 C o m p le te n e ss 4 T im e li n e ss 4 M o n th & y e a r o f la st re p o rt L a b o ra to ry in v e st ig a ti o n ra te 4 R a te o f d is c a rd e d c a se s 5 O ri g in o f in fe c ti o n 4 T im e li n e ss o f in v e st ig a ti o n 4 Albania 7 2 880 917 0.00 0 0 0 0 0 12 - 100% 100% Jun-20 100% 0.4 - 100% Andorra 77 142 0.00 0 0 0 0 0 0 - 100% 83% Jun-20 - 0.0 - - Armenia 2 957 731 0.00 0 0 0 0 0 0 - 100% 100% Jun-20 - 0.0 - - Austria 8 955 102 0.00 0 1 0 1 0 - 0 100% 83% Jun-20 - - 0% 0% Azerbaijan 10 047 718 0.20 2 2 2 0 0 1 0 100% 83% Jun-20 67% 0.0 0% 100% Belarus 7 9 452 411 0.00 0 1 1 0 0 96 0 100% 100% Jun-20 100% 1.0 0% 0% Belgium 8 11 539 328 - - - - - - - - - - - - - - - Bosnia and Herzegovina 3 301 000 0.91 3 0 0 0 0 - - 100% 67% Jun-20 - - - - Bulgaria 7 000 119 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Croatia 4 130 304 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Cyprus 1 198 575 0.00 0 1 1 0 0 - 0 100% 83% Jun-20 100% - 0% 0% Czech Republic 10 689 209 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Denmark 8 5 771 876 - - - - - - - - - - - - - - - Estonia 1 325 648 0.00 0 0 0 0 0 3 - 100% 100% Jun-20 100% 0.2 - 100% Finland 5 532 156 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - France 8 65 129 728 - - - - - - - - - - - - - - - Georgia 3 996 765 2.25 9 0 0 0 0 8 - 100% 83% Jun-20 75% 0.2 - 88% Germany 83 517 045 0.68 57 13 4 0 9 - 0 100% 100% Jun-20 31% - 54% 0% Greece 10 473 455 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Hungary 9 684 679 0.00 0 0 0 0 0 0 - 100% 100% Jun-20 - 0.0 - - Iceland 339 031 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Ireland 4 882 495 0.20 1 2 1 0 1 - 1 100% 100% Jun-20 50% - 50% 100% Israel 8 519 377 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Italy 60 550 075 0.40 24 12 3 0 9 4 0 100% 100% Jun-20 81% 0.0 17% 0% Kazakhstan 18 551 427 0.27 5 0 0 0 0 - - 100% 33% Jun-20 - - - - Kyrgyzstan 7 6 415 850 0.62 4 0 0 0 0 143 - 100% 100% Jun-20 22% 2.2 - 94% Latvia 1 906 743 1.05 2 0 0 0 0 - - 100% 100% Jun-20 - - - - Lithuania 2 759 627 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Luxembourg 615 729 0.00 0 0 0 0 0 1 - 100% 100% Jun-20 100% 0.2 - 100% Malta 440 372 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Monaco 38 964 0.00 0 0 0 0 0 0 - 100% 83% Jun-20 - 0.0 - - Montenegro 627 987 0.00 0 - - - - - - 0% 0% Dec-19 - - - - Netherlands 17 097 130 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - North Macedonia 2 083 459 0.00 0 0 0 0 0 - - 17% 17% Jan-20 - - - - Norway 5 378 857 0.00 0 1 1 0 0 - 1 100% 100% Jun-20 100% - 100% 100% Poland 37 887 768 7.71 292 74 0 0 74 - 0 100% 100% Jun-20 - - - - Portugal 10 226 187 0.20 2 1 0 0 1 3 0 100% 100% Jun-20 50% 0.0 100% 100% Republic of Moldova 4 043 263 0.00 0 0 0 0 0 1 - 100% 100% Jun-20 100% 0.0 - 100% Romania 19 364 557 0.21 4 3 1 0 2 - 0 83% 83% May-20 33% - 100% 33% Russian Federation 145 872 256 0.23 34 3 3 0 0 0 0 100% 100% Jun-20 100% 0.0 100% 100% San Marino 33 860 0.00 0 0 0 0 0 0 - 100% 50% Jun-20 - 0.0 - - Serbia 8 772 235 - - - - - - - - - - No report - - - - Slovakia 5 457 013 0.00 0 0 0 0 0 0 - 100% 100% Jun-20 - 0.0 - - Slovenia 2 078 654 0.00 0 0 0 0 0 - - 100% 100% Jun-20 - - - - Spain 46 736 776 0.09 4 0 0 0 0 4 - 100% 100% Jun-20 75% 0.0 - 50% Sweden 10 036 379 0.00 0 0 0 0 0 0 - 100% 83% Jun-20 - 0.0 - - Switzerland 8 591 365 0.12 1 0 0 0 0 6 - 100% 100% Jun-20 100% 0.1 - 0% Tajikistan 9 321 018 0.00 0 0 0 0 0 6 - 100% 83% Jun-20 100% 0.1 - 100% Turkey 7 83 429 615 0.58 48 12 12 0 0 1239 0 100% 100% Jun-20 100% 1.5 67% 98% Turkmenistan 7 5 942 089 0.00 0 0 0 0 0 46 - 100% 100% Jun-20 100% 0.8 - 100% Ukraine 43 993 638 3.23 142 24 3 0 21 - 0 100% 100% Jun-20 13% - 92% 100% United Kingdom 67 530 172 0.04 3 0 0 0 0 - - 100% 100% Jun-20 - - - - Uzbekistan 32 981 716 0.00 0 0 0 0 0 0 - 100% 83% Jun-20 - 0.0 - - Region 930 166 592 0.68 637 150 32 1 117 1573 2 89% 83% 91% 0.3 63% 89% Country Total Population in 2019 1 2019 (as of 29 July 2020) 2020 Incidence Rate (per 1 million population) Total rubella cases 2 Total rubella cases 2 Classification Data source: Monthly aggregated and case-based data reported by Member States to WHO/Europe directly or via ECDC/TESSy. Member States submitting aggregate data: Bosnia and Herzegovina, Kazakhstan, North Macedonia and Poland. 1 Population source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2019 Revision. 2 All confirmed rubella cases regardless of origin. 3 Unless specified as laboratory confirmed or epi-linked, cases are classified as clinically compatible. 4 Target (>=80%) not achieving are highlighted in red. 5 Rate of discarded cases not achieving the target (>=2 discarded cases per 100 000) are highlighted in red. Rate of discarded cases is not calculated for the countries submitting only confirmed rubella cases. 6 Surveillance indicators can not be calculated for Member States submitting aggregate data. 7 Country classifies discard cases as “discarded, not measles, not rubella”. 8 Country does not have a comprehensive rubella surveillance system. D is c a rd e d ru b e ll a Im p o rt e d c a se s Report Surveillance Indicators 6 WHO/EURO:2020-5630-45395-64959