WHO EpiBrief: a report on the epidemiology of selected vaccine-preventable diseases in the European Region: No. 2/2018

No. 2/2018 A report on the epidemiology of selected vaccine-preventable diseases in the European Region France (2593; 6%). The highest crude incidence per million population for this period was in Serbia (283) followed by Ukraine (261). Fig.1 shows the number of cases reported by month from July 2017 through June 2018 by these and the other countries of the WHO European Region. Of the total, 17 088 (41%) cases were laboratory confirmed and 1516 (4%) were epidemiologically linked cases. The remaining 23 566 cases (56%) were classified as clinically compatible. For the first half of 2018, 38 (86%) of countries in the Region notifying measles cases submitted genomic sequence information for 2345 cases to the Measles Nucleotide Surveillance database (MeaNS)2 through WHO-accredited reference laboratories (as of 24 September 2018). The genotypes identified in the Region comprised D8 (n=1196), B3 (1144) and D4 (5). The dominant measles virus genotype D8 variant was the named strain Herborn.DEU/05.17/ (54% of all D8 variants); dominant B3 named strains were Dublin.IRL/8.16/ (37% of all B3 variants) and MVs/Saint Denis.FRA/36.17 (33%). Genotype D4, which was not reported in 2017, was reported by one country in the Region. Age distribution The age group was known in 42 134 cases (99.9%): 3165 (8%) were <1 year old, 7375 (18%) were 1–4 years old, 13 847 (33%) were 5–19 years old and 17 747 (42%) were ≥20 years old. (Fig. 2). Fig. 3 shows 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 January-June 2018. It also includes short reports on events of these diseases in France, Serbia and Ukraine. These short reports are based on additional information supplied by these countries. The surveillance data presented in this issue were reported by countries and are incorporated in the Centralized Information System for Infectious Diseases.1 Tabulated surveillance data by country for the first half of 2018 (as of 5 September 2018) are annexed to this issue. The analyses of these data are performed on cases with disease onset dates during the first half of 2018. Where these dates were unavailable, cases with the date of notification reported during this period were included. The numbers of cases in a specified time period may differ from reports produced by national or partner agencies if different dates are used. Percentages in this report were rounded to the nearest whole number. Measles in the WHO European Region January–June 2018 Incidence – notifications and laboratory data For the first half of 2018, 42 170 measles cases were reported by 44 of the 53 countries of the WHO European Region (Table 1 in annex). Of the total, 73% of cases (n=30 617) were reported by 3 countries: Ukraine (23 070; 55%), Serbia (4954; 12%) and Page 1 WHO EpiBrief No. 2/2018 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2018 N u m b er o f re p o rt e d m ea sl e s ca se s Other Italy Serbia Greece France Ukraine Fig. 1. Measles cases by month in the WHO European Region, 1 July 2017– 30 June 2018 (n=51 636) Page 2 the age distribution of reported measles cases in the top three countries reporting most cases: France, Serbia and Ukraine, by proportion and age-specific incidence. Vaccination status Vaccination status and age was known in 31 339 cases (74%). Of the 20 372 (65%) who were unvaccinated, 2919 cases (14%) were <1 year old, 5331 cases (26%) were 1–4 years old, 3657 cases (18%) were 5–9 years old, 3183 cases (16%) were 10–19 years old and 5282 cases (26%) were ≥20 years old. In addition, 10 961 cases (35%) were reportedly vaccinated with at least one measles-containing vaccine dose. Measles-related deaths There were 57 measles-related deaths in 8 countries among cases with disease onset in the first half of 2018: Romania (22 deaths), Serbia (14), Ukraine (8), Italy (4), France (3), Georgia (2), Greece (2), and Russian Federation (2). Most deaths (60%, n=34) occurred in children under 10 years of age: 24 cases were <1 year old and 10 cases were 1–9 years old. Of the remaining deaths 3 cases were 10–19 years old and 20 cases were ≥25 years old. All 57 deaths were laboratory-confirmed cases of measles. 52 fatal cases were unvaccinated, 2 cases had received one measles-containing vaccine dose, 1 case had received two measles-containing vaccine doses and in 2 cases the vaccination status was unknown. Hospitalization Data on hospitalization status was available for 70% (n=29 671) of all reported measles cases. Of these, WHO EPI-BRIEF No. 2/2018 WHO EpiBrief 24 027 were hospitalized, amounting to 81% of all cases with known hospitalization status. Of all the hospitalized cases, most were reported by Ukraine (n=16 507; 69%). Imported cases Importation status was known for 24% (n=11 171) of cases. Of these, 543 were reported as imported cases, amounting to 5.3% of cases with a known importation status. Of all the imported cases, most (392; 72%) were reported by United Kingdom (n=149), France (67), Turkey (54), Russian Federation (47), Italy (38) and Germany (37). Rubella in the WHO European Region January–June 2018 Incidence – notifications and laboratory data For the first half of 2018, 526 rubella cases were reported in 21 countries of the WHO European Region among 48 (91%) countries submitting rubella data (including zero reporting) (Table 2 in annex). Most cases were reported by Poland (n=283; 54%), followed by Ukraine (147; 28%) and Germany (31; 6%). Poland also had the highest crude incidence per million population (7.3). Of the total, 65 (16%) cases were laboratory confirmed, reported by 17 countries. Most (n=54; 83%) were reported by 6 countries: Turkey (10 cases), Ukraine (10), Italy (7), Kyrgyzstan (7), Germany (6) and Austria (5). Most cases reported by Poland and Ukraine were clinically compatible cases: 98% (87) and 88% (137), respectively. *Annualized crude incidence. **The age was not known in 36 cases. Fig. 2. Age distribution of measles cases by proportion (left) and incidence per million inhabitants* (right) in the WHO European Region, first half of 2018 (n=42 134)** 8% 18% 15% 9% 9% 17% 25% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥30 % o f re p o rt ed m ea sl es c as es Age group (years) 144 82 54 36 39 31 9 0 100 200 <1 1-4 5-9 10-14 15-19 20-29 ≥30 In c id e n c e o f re p o rt e d m e a s le s c a s e s p e r m ill io n i n h a b it a n ts Age group (years) Page 3 No. 2/2018 WHO EpiBrief During the first half of 2018, 1 rubella virus sequence was entered in the Rubella Nucleotide Surveillance database (RubeNS).3 The identified genotype was 2B. Fig. 3. Age distribution of measles cases by proportion (left) and incidence per million inhabitants* (right) in top three countries of the WHO European Region reporting cases, first half of 2018 (n=30 617)** Age distribution The age group was known in 482 cases: 37 cases (8%) were <1 year old, 140 cases (29%) were 1–4 years old, 6% 17% 19% 12% 11% 17% 18% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥30 % o f re p o rt e d m e a s le s c a s e s Age group (years) Ukraine (n=23 070) 8% 14% 4% 3% 5% 14% 53% 0% 10% 20% 30% 40% 50% 60% <1 1-4 5-9 10-14 15-19 20-29 ≥30 % o f re p o rt e d m e a s le s c a s e s Age group (years) Serbia (n=4951) 1368 1038 882 619 696 367 70 0 1000 2000 <1 1-4 5-9 10-14 15-19 20-29 ≥30 In c id e n c e o f re p o rt e d m e a s le s c a s e s p e r m ill io n i n h a b it a n ts Age group (years) Ukraine (n=23 070) 2261 949 203 139 217 308 230 0 1000 2000 3000 <1 1-4 5-9 10-14 15-19 20-29 ≥30 In c id e n c e o f re p o rt e d m e a s le s c a s e s p e r m ill io n i n h a b it a n ts Age group (years) Serbia (n=4951) 147 81 38 34 41 30 6 0 100 200 <1 1-4 5-9 10-14 15-19 20-29 ≥30 In c id e n c e o f re p o rt e d m e a s le s c a s e s p e r m ill io n i n h a b it a n ts Age group (years) France (n=2592) *Annualized crude incidence. **The age was not known in 1 case in France and 3 cases in Serbia. Page 4 WHO EpiBrief No. 2/2018 212 cases (44%) were 5–14 years old, 21 cases (4%) were 15–19 years old and 72 cases (15%) were ≥20 years old (Fig. 4). Vaccination status Vaccination status was known in 86% of cases (n=624). Of the 314 (50%) unvaccinated cases, 87 cases (28%) were <1 year old, 71 cases (23%) were 1–4 years old, 36 cases (11%) were 5–9 years old, 21 cases (7%) were 10– 14 years old and 99 cases (32%) were ≥15 years old. The remaining 310 cases (50%) were reportedly vaccinated with at least one rubella-containing vaccine dose. Imported cases Importation status was known in 23% (n=169) of rubella cases. Of these, 11 were reported as imported cases, amounting to 6.5% of cases with a known importation status. The imported cases were reported by Austria (n=3), United Kingdom (3), Czech Republic (1), Germany (1), Italy (1), Russian Federation (1) and Spain (1). Measles in France A measles outbreak started in November 2017 in the Nouvelle-Aquitaine region of France located in the southwest of the country. The first cases were reported among students attending the University of Bordeaux. The outbreak quickly spread into other regions of France and by 31 August 2018, a total of 2761 measles cases were reported (November 2017–August 2018). Three measles-related deaths were reported (as of 31 August 2018). The highest number of cases occurred in the Nouvelle- Aquitaine region (1065 cases) particularly in the district of Gironde (619 cases). The peak of the outbreak was in week 13 (26 March to 1 April 2018). The weekly distribution of measles cases is shown in Fig. 5. Of the total cases, 247 (9%) were <1 year old, 536 (19.5%) were 1–4 years old and 604 (22%) were 5–14 years old. Adults aged 20 years and older constituted 37% (n=1024) of the total reported cases (Fig. 6). Of the total cases, 1297 (47%) were laboratory confirmed, 573 (21%) were epidemiologically linked to *Annualized crude incidence. **The age was not known in 44 cases. Fig. 4. Age distribution of rubella cases in the WHO European Region, January-June 2018 (n=482) Fig. 5. Distribution of measles cases by week of onset of rash in France, 6 November 2017—31 August 2018 (n=2761)* 8% 29% 34% 10% 4% 6% 9% 0% 10% 20% 30% <1 1-4 5-9 10-14 15-19 20-29 ≥30 % o f re p o rt ed r u b el la c as es Age group (years) 0 20 40 60 80 100 120 140 160 180 200 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 2017 2018 N u m b er o f re p o rt ed m ea sl es c as es Week of onset of rash Data source: Santé publique France, mandatory reporting of measles cases. * provisional data as of 31 August 2018 Page 5 No. 2/2018 WHO EpiBrief laboratory-confirmed cases and 891 were classified as clinically compatible. Molecular characterization conducted on clinical specimens from 484 measles cases between November 2017 and end of July 2018 identified D8 genotype (424 cases) and B3 genotype (60 cases). Of the total cases, 624 (23%) were hospitalized. Pneumonia as a complication of measles was reported in 161 cases and 4 cases had acute encephalitis. Three of these cases with complications resulted in death – all 3 were laboratory-confirmed cases. Information on vaccination status was available for 2233 cases, all born after 1980 when the vaccination programme against measles started: 1666 were unvaccinated (75%), 310 had received one vaccine dose (14%) and 226 had received two doses (10%). For 31 cases the number of vaccine doses was unknown. Measles-related deaths in France The first measles-related death related to this outbreak was reported in February 2018 in an adult around 30 years old. This was followed by a second death in June in an adult around 25 years old. Both died as a result of respiratory complications. A third death occurred in July, in a teenager presenting with measles inclusion-body encephalitis. The latter two cases had a pre-existing high- risk condition (post-transplantation immunodeficiency). Outbreak response and control measures in France In response to the measles outbreak, a nationwide campaign of enhanced routine immunization activities was undertaken to identify unvaccinated or incompletely vaccinated people and vaccinate them with the combined measles, mumps and rubella vaccine according to the national recommendations. Locally, specific catch-up campaigns were also undertaken to target particular susceptible and affected population groups, such as university students, health professionals, nomadic minorities and inmates at a correctional facility. The outbreak control team established mobile vaccination teams to increase vaccination uptake among these groups. To increase awareness of the outbreak and the importance of vaccination against measles, the health authorities provided information to the public mostly in newspapers and social media. Information was also specially provided to health professionals and nomadic minorities. As of 1 January 2018, France has mandatory vaccination in place for a number of routine vaccines including the measles-mumps-rubella (MMR) vaccine for children born since that date. Other actions implemented by the Ministry of Health include the opening in 2017 of a national website (www.vaccination-info-service.fr), together with the national public health agency Santé publique France, targeting both the public and health professionals; and the provision of new recommendations to strengthen immunization of health professionals by 2019 (focused especially on vaccination against measles, pertussis and influenza). Measles in Serbia A measles outbreak started in 2017 in Serbia. A total of 5741 measles cases were reported across the country for the period October 2017 – 30 September 2018. Measles cases were reported in all 25 districts, but predominantly (84%) in five districts: Belgrade, Nisava, Raska, Pcinja and Jablanica. The highest number of cases occurred in the capital Belgrade (1742), the city of Nis (1235) and city of Leskovac (343). The peak of the outbreak was in March 2018. Of the total cases, 465 (8.1%) were <1 year old, 852 (14.8%) were 1–4 years old and 246 (4.3%) were 5–9 years old. Adults older than 20 years constituted 65.3% (n=3749) of the total reported cases. Most of the adults were 30–39 years old (n=1903) (Fig.7). Of the total cases, 2893 (50.4%) were laboratory confirmed, 1472 cases (25.6%) were epidemiologically linked to laboratory-confirmed cases and 1376 cases 9% 20% 12% 10% 13% 18% 19% 0% 5% 10% 15% 20% 25% <1 1-4 5-9 10-14 15-19 20-29 ≥30 % o f re p o rt ed m ea sl es c as es Age group (years) Fig. 6. Age distribution of reported measles cases in France, 1 November 2017—31 August 2018 (n=2760) *The age was not known in 1 case. Page 6 No. 2/2018 WHO EpiBrief to identify unvaccinated and incompletely vaccinated children aged between 12 months and 14 years and to vaccinate them according to the national childhood immunization schedule. To increase awareness of the outbreak and the importance of vaccination against measles the National Institute of Public Health in Serbia has also been regularly updating its website with situation reports and has undertaken activities for outbreak control since October 2017. Measles in Ukraine – an update1 The outbreak of measles has intensified in Ukraine (Fig.1). For the period 1 January to 31 August 2018, the country reported 29 465 measles cases and 13 measles- related deaths. All of Ukraine’s 24 regions were affected especially L’viv (n=5949), Zakarpattya (3018), Ivano- Frankivsk (2816), Odesa (2187), Kyiv City (1994), Ternopil (1634), Mykolaiv (1357) and Chernivtsi (1287). In Kyiv city, 1994 cases were reported. Of the total cases, 4633 cases (16%) were laboratory confirmed, 3986 cases (14%) were epidemiologically linked to laboratory-confirmed cases and 20 846 cases (70%) were classified as clinically compatible. The largest proportion of cases (n=12 065, 41%) were below 10 years of age: 1639 cases were <1 year old, 4912 were 1–4 years old and 5514 were 5–9 years old. Adults (18 years and older) accounted for 11 816 cases (40%). Of the 23 654 cases with a known vaccination status, the majority of cases were unvaccinated (n=13 411; 57%) while 4086 (17%) had received one measles-containing vaccine dose. Of the total, 21 482 cases (73%) were hospitalized. The 13 measles-related deaths included 9 children (5 in Odessa, 1 in Kyiv region, 1 in L’viv, 1 in Mykolaiv, 1 in Zakarpattya) and 4 adults (1 in Ivano-Frankivsk, 1 in Kirovohrad, 1 in Odessa and 1 in Ternopil). Outbreak control measures The first significant increase in the incidence of measles was noticed in May 2017. Since that time the Ministry of Health of Ukraine has been monitoring the measles outbreak response by holding regular conference calls with the regions of Ukraine. Eight meetings of the national Measles Task Force involving key stakeholders and partners, such as WHO and United Nations Children’s Fund (UNICEF) were conducted In the period (24%) were classified as clinically compatible. Molecular characterization of the circulating measles virus in Serbia between October 2017 and September 2018 identified B3 genotype. Vaccination status was known in 2454 cases: 1713 were unvaccinated (69.8%), 420 (17.1%) had received one dose and 321 (13.1%) had received two doses. Of the total cases, 33.2% (n=1905) were hospitalized. Pneumonia as a complication of measles was reported in 580 cases and 2 cases had acute encephalitis. Measles-related deaths in Serbia The first measles-related death in 20 years was reported in December 2017 and since then 14 additional deaths have been reported (as of 30 September 2018) as a result of complications from measles. The deaths were reported in all age groups: 1 infant, 3 children 2–4 years old and 11 adults (2 aged 20–29 years, 5 aged 30–39 years, 4 aged 40 –45 years). Pneumonia and respiratory insufficiency were reported in 12 of these cases. The diagnosis of measles in the fatal cases was confirmed with positive IgM test results in 9 cases. Three cases were reported unvaccinated and in one case the infant was not eligible for vaccination as it had not reached 12 months of age – the recommended age to receive the first dose of a measles-containing vaccine according to the Serbian childhood vaccination schedule. Vaccination status of the remaining 11 fatal cases was unknown. Outbreak response and control measures in Serbia In response to the outbreak, a nationwide campaign of enhanced routine immunization activities was undertaken Fig. 7. Age distribution of reported measles cases, Serbia, 1 October 2017—30 September 2018 (n=5729)* * For 12 cases the age was unknown and they are therefore not represented in the graph. 1 First report of this outbreak was published in WHO EpiBrief, 2018, 1:1–16. www.euro.who.int/__data/assets/pdf_file/0009/370656/epibrief-1-2018-eng.pdf?ua=1 Page 7 No. 2/2018 WHO EpiBrief July 2017—August 2018, with the participation of the Minister of Health, deputy Minister of Health and the Ministry’s Public Health Center. In May 2018 supplementary immunization activities among 1–9 year-old children were further extended to all children under 17 years of age. In June 2018, the Measles Task Force extended the provision of free-of-charge measles-mumps-rubella (MMR) vaccination to adults in high-risk groups, including health care workers, military personnel, staff of educational institutions and adult students. WHO, UNICEF and other partners, namely the nongovernmental organizations Parents for Vaccination and Rotary International and national Rotary clubs continued actively supporting measles outbreak response activities. During the period November 2017—July 2018, integrated surveillance workshops on measles, rubella and congenital rubella syndrome were conducted in 23 oblasts of Ukraine by WHO in cooperation with the National Verification Committee for Measles and Rubella Elimination and the Public Health Center. WHO and partners plan to provide further support focused on strengthening country capacities and on microplanning of supplementary immunization activities, including forecasting of target group and vaccine needs. According to data reported by Ukraine for the first half of 2018, routine vaccination coverage with the first and second MMR doses for the full year 2018 is expected to reach over 90% for each dose. Comments Measles and rubella in the WHO European Region The number of reported measles cases for the first half of 2018 (n=42 170) was almost triple that reported for the first half of 2017 (14 674). This increase was mostly due to large numbers of cases reported from France, Greece, Italy, Serbia and Ukraine indicating large pools of persons susceptible to measles in these countries. Several countries in the Region have experienced a range of challenges in their efforts to eliminate measles and rubella in recent years, such as declines in overall routine immunization coverage, consistently low coverage among some marginalized groups and adults, and interruptions in vaccine supply. Rubella continues to be reported in fewer countries than measles. The number of reported cases in the Region (n=526) for the first half of 2018 was 26% higher than that reported for the same period in 2017 (n=418). This is attributed to the reported rubella cases in Ukraine, from 0 cases for 2017 to 147 cases for the first half of 2018. Only 3 of the 283 and 10 of the 147 reported cases in Poland and Ukraine, respectively, were laboratory-confirmed. Laboratory testing would be needed to confirm cases as rubella. Measles and Rubella Laboratory Network All 73 laboratories of the European Measles and Rubella Laboratory Network were accredited for 2018. In their annual reports to the Regional Verification Commission for Measles and Rubella Elimination (RVC), national verification committees (NVCs) continue to include laboratory data not only from WHO-accredited laboratories but also from other sources. The RVC therefore recommended in June 2018 that WHO- accredited national laboratories coordinate or facilitate access of these other laboratories to national measles and rubella external quality assessments to ensure their proficiency. During the first half of 2018, 84% of countries in the Region notifying measles cases submitted genomic sequence information to the Measles Nucleotide Surveillance database (MeaNS) (although only 78% of countries met the 80% target for viral detection). As in previous years, few countries submitted genomic sequence information on rubella cases to the Rubella Nucleotide Surveillance database (RubeNS). It is important to note that these genotype reports are not fully representative of the regional distribution of measles and rubella viruses. This is primarily because Member States differ in the rate of collecting specimens for viral sequencing but also due to differences in the reporting of sequence data to MeaNS/RubeNS. Elimination status Following review of submitted annual reports for 2017, the RVC verified in June 2018 that 37 of 53 countries interrupted endemic measles transmission for ≥36 months by the end of 2017, and are therefore considered to have eliminated measles.7 A further 6 countries provided evidence for the interruption of measles transmission for a period of <36 months. Ten countries remain endemic and face challenges in interrupting measles transmission. For rubella, 37 countries eliminated the disease and 5 interrupted transmission for a period of <36 months. Eleven were still considered endemic for rubella. 35 countries provided evidence for the elimination of both measles and rubella transmission while 8 countries are still endemic for both diseases. 1. World Health Organization. Centralized Information System for Infectious Diseases (CISID). Copenhagen. Regional Office for Europe. http://data.euro.who.int/CISID/ 2. Measles Nucleotide Surveillance database (MeaNS). www.who-measles.org 3. Rubella Nucleotide Surveillance database (RubeNS). www.who-rubella.org 4. Bernadou A, Astrugue C, Méchain M et al. Measles outbreak linked to insufficient vaccination coverage in Nouvelle- Aquitaine Region, France, October 2017 to July 2018. Euro Surveill. 2018;23(30):pii=1800373. https:// doi.org/10.2807/1560-7917.ES.2018.23.30.1800373 5. Santé publique France. Epidemiological update on measles, 19 September 2018. http://invs.santepubliquefrance.fr/ Dossiers-thematiques/Maladies-infectieuses/Maladies-a-prevention-vaccinale/Rougeole/Points-d-actualites/Bulletin- epidemiologique-rougeole.-Donnees-de-surveillance-au-19-septembre-2018 6. Ministry of Health. France vaccination schedule. http://solidarites-sante.gouv.fr/IMG/pdf/ calendrier_vaccinations_2018.pdf 7. WHO Regional office for Europe. Seventh Meeting of the European Regional Verification Commission for Measles and Rubella Elimination. Report 2018. Copenhagen: WHO. www.euro.who.int/en/health-topics/communicable-diseases/ measles-and-rubella/publications/2018/7th-meeting-of-the-european-regional-verification-commission-for-measles-and -rubella-elimination-rvc.-report Page 8 No. 2/2018 Date of publication: 19 November 2018 Suggested citation: WHO EpiBrief, 2018, 2:1–10 Document number: WHO/EURO:2018-3363-43122-60364 © World Health Organization 2018 All rights reserved. References The resurgence of measles in the European Region reflects ongoing challenges in endemic countries to eliminate the disease. It also reflects the need for sustained efforts to protect gains in countries that are considered to have interrupted or eliminated measles. Elimination of both measles and rubella is a priority goal that all European countries have firmly committed to. To attain it, they need to ensure that immunization coverage of at least 95% is reached and maintained in all districts, and immunity gaps in the population are closed. Furthermore, high-quality surveillance is necessary to monitor disease occurrence and detect outbreaks so that appropriate and timely response measures can be taken. Accurate surveillance data is also needed to adequately ascertain the status of measles and rubella transmission as part of the elimination verification process. The goal will not be met unless all countries translate their political commitment into concrete programmatic actions that address identified challenges and guarantee adequate investment. Acknowledgements WHO gratefully acknowledges all those involved in collecting, compiling and submitting measles and rubella data. WHO EpiBrief Page 9 No. 2/2018 Annex Table 1. Measles cases: classification, reporting and surveillance performance January–June 2018 (as of 5 September 2018) 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 4 C o m p le te n e ss 5 T im e li n e ss 5 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 r a te 5 R a te o f d is c a rd e d c a se s 6 O ri g in o f in fe c ti o n 5 T im e li n e ss o f in v e st ig a ti o n 5 Albania 2 919 422 0.69 12 0 0 0 0 0 0 0 0 - 100% 17% Jun-18 - 0.00 - - Andorra 68 915 0 0 - 0 0 0 0 0 0 0 - 100% 100% Jun-18 - 0.00 - - Armenia 3 034 998 0.33 1 0 0 17 17 0 0 155 17 0 100% 67% Jun-18 100% 5.11 100% 99% Austria 8 613 647 9.64 94 0 2.73 62 55 6 1 16 15 0 100% 100% Jun-18 81% 0.19 100% 15% Azerbaijan 10 070 075 0 0 0 0 0 0 0 0 63 0 0 100% 100% Jun-18 100% 0.63 - 100% Belarus 9 429 102 0 1 0 8.33 157 157 0 0 222 0 0 100% 50% Jun-18 100% 2.35 0 0 Belgium 11 513 025 31.88 367 0 3.08 71 56 14 1 0 0 0 100% 100% Jun-18 - - - - Bosnia and Herzegovina 3 782 297 7.14 27 0 11.37 86 42 1 43 0 0 0 100% 33% Jun-18 - - - - Bulgaria 6 992 150 23.60 166 1 0 5 5 0 0 0 5 0 100% 100% Jun-18 100% 0.00 100% 100% Croatia 4 194 538 1.67 7 0 1.67 19 19 0 0 4 5 0 100% 83% Jun-18 100% 0.10 100% 0 Cyprus 1 198 198 0.83 4 0 3.76 14 14 0 0 0 5 0 100% 100% Jun-18 100% 0.00 100% 0 Czech Republic 10 563 111 13.73 149 0 7.05 149 146 1 2 0 0 0 100% 67% Jun-18 0% 0.00 0 0 Denmark 5 732 713 0.35 4 0 0.26 3 3 0 0 0 0 0 100% 100% Jun-18 100% 0.00 100% 0 Estonia 1 302 401 0 1 0 2.69 10 10 0 0 41 3 0 100% 100% Jun-18 100% 3.15 100% 100% Finland 5 556 439 0.72 10 0 0.18 4 4 0 0 0 2 0 100% 100% Jun-18 100% 0.00 50.0% 0 France 65 205 671 7.50 519 1 19.37 2593 1143 559 891 0 67 3 100% 100% Jun-18 79% 0.00 83.0% 0.0% Georgia 3 973 681 23.66 96 0 141.93 1128 869 65 194 321 0 2 100% 83% Jun-18 86% 8.08 99.6% 96% Germany 80 560 850 10.80 936 1 2.30 408 337 52 19 0 37 0 100% 100% Jun-18 93% 0.00 81.6% 0 Greece 10 871 762 97.87 1067 2 98.51 2145 1211 490 444 67 3 2 100% 100% Jun-18 74% 0.62 7.9% 0 Hungary 9 754 429 3.18 36 0 0.36 13 13 0 0 14 6 0 100% 100% Jun-18 100% 0.14 92.3% 93% Iceland 336 938 2.97 3 0 0 0 0 0 0 0 0 - 100% 100% Jun-18 - 0.00 - - Ireland 4 790 845 5.22 25 0 5.64 55 48 2 5 0 1 0 100% 100% Jun-18 98% 0.00 81.8% 85% Israel 8 455 489 1.77 16 0 8.75 151 116 32 3 0 3 0 100% 50% Jun-18 100% 0.00 2.0% 83% Italy 59 788 104 89.62 5404 4 16.71 2036 1535 107 394 129 38 4 100% 100% Jun-18 82% 0.22 89.0% 0 Kazakhstan 18 256 484 0.11 2 0 0.03 1 1 0 0 0 0 0 83% 83% May-18 - - - - Kyrgyzstan 6 213 441 0.48 5 0 24.62 310 274 16 20 303 4 0 100% 50% Jun-18 97% 4.88 99.0% 74% Latvia 1 935 780 2.07 5 0 3.10 15 15 0 0 0 3 0 100% 100% Jun-18 100% 0.00 20.0% 100% Lithuania 2 817 402 0.00 2 0 0 1 1 0 0 0 1 0 100% 83% Jun-18 100% 0.00 100% 0 Luxembourg 591 126 1.69 4 0 0 1 1 0 0 0 1 0 100% 100% Jun-18 100% 0.00 100% 100% Malta 421 387 0 0 - 0 0 0 0 0 0 0 - 100% 100% Jun-18 - 0.00 - - Monaco 38 166 0 0 - 0 0 0 0 0 0 0 - 83% 67% Jun-18 - 0.00 - - Montenegro 626 240 0 0 0 23.95 32 3 0 29 1 2 0 83% 50% May-18 15% 0.16 6.3% 9% Netherlands 17 084 531 0.59 16 0 0.35 15 14 1 0 0 3 0 100% 100% Jun-18 0% 0.00 86.7% 0 Norway 5 387 342 0 1 0 0.28 7 7 0 0 0 4 0 100% 100% Jun-18 100% 0.00 71.4% 100% Poland 38 522 728 1.38 63 0 0.65 62 45 5 12 0 12 0 100% 100% Jun-18 86% 0.00 100.0% 100% Portugal 10 229 432 3.13 34 1 6.11 129 121 0 8 319 4 0 100% 83% Jun-18 97% 3.12 92.2% 78% Republic of Moldova 4 044 534 0 0 - 4.57 37 36 1 0 0 0 0 100% 83% Jun-18 - - - - Romania 19 105 089 382.41 7330 22 16.51 635 553 64 18 0 4 22 100% 100% Jun-18 97% 0.00 100% 100% Russian Federation 143 261 490 6.09 898 0 5.24 1549 1486 52 11 1570 47 2 100% 100% Jun-18 99% 1.10 100% 50% San Marino 32 241 0 0 - 0.00 0 0 0 0 0 0 - 100% 67% Jun-18 - 0.00 - - Serbia 8 742 764 80.29 702 1 283.32 4954 2577 0 2377 0 0 14 100% 100% Jun-18 - - - - Slovakia 5 434 237 1.47 11 0 10.12 116 80 36 0 5 6 0 100% 100% Jun-18 4% 0.09 94.8% 98% Slovenia 2 073 018 2.89 8 0 1.45 8 8 0 0 0 2 0 100% 100% Jun-18 88% 0.00 37.5% 100% Spain 46 116 884 2.84 149 0 1.84 182 175 7 0 68 12 0 100% 100% Jun-18 100% 0.15 8.8% 96% Sweden 9 987 062 3.50 46 0 0.65 25 25 0 0 0 12 0 100% 100% Jun-18 100% 0.00 100% 0 Switzerland 8 523 590 11.50 105 1 0.65 27 24 3 0 69 16 0 100% 100% Jun-18 100% 0.81 92.6% 29% Tajikistan 9 046 723 71.74 649 0 0 0 0 0 0 45 0 0 100% 83% Jun-18 100% 0.50 - 87% The former Yugoslav Republic of Macedonia 2 085 315 9.59 20 0 3.60 15 13 1 1 0 0 0 100% 50% Jun-18 - - - - Turkey 81 086 257 0.81 69 0 1.89 361 360 1 0 2321 54 0 100% 50% Jun-18 100% 2.86 15.8% 97% Turkmenistan 5 565 070 0 0 - 0 0 0 0 0 36 0 0 100% 0% Jun-18 100% 0.65 - 100% Ukraine 44 170 002 108.26 4782 5 261.15 23070 3977 0 19093 0 0 8 100% 67% Jun-18 - - - - United Kingdom 65 912 569 2.32 282 0 10.14 1486 1486 0 0 0 149 0 100% 83% Jun-18 100% 0.00 97.6% 0 Uzbekistan 31 064 765 0 0 0 0.10 6 6 0 0 33 0 0 100% 83% Jun-18 100% 0.11 100% 100% Total/Averages 917 084 469 25.83 24128 39 22.70 42170 17088 1516 23566 5802 543 57 99.1% 83.6% 89.8% 0.70 24.1% 41.1% Total measles death 2017 (as of 05 September 2018) M e a sl e s D e a th Country Data source: Monthly aggregated and case-based data reported by Member States to WHO/Europe or via ECDC/TESSy. Member States submitting aggregate data: Belgium, Bosnia and Herzegovina, Kazakhstan, Republic of Moldova, Serbia, the former Yugoslav Republic of Macedonia and Ukraine. 1 Data source: " World Population Prospects: The 2015 Revision", New York, United Nations. 2 Incidence rates not meeting the target (<1 per million population) are highlighted in red. Imported measles cases are excluded from the numerator while calculating the incidence rate. 3 All confirmed measles cases regardless of origin. 4 Unless specified as laboratory confirmed or epi-linked, cases are classified as clinically compatible. 5 Laboratory investigation rates not achieving target of ≥80% are highlighted in red. 6 Discard rates not achieving the target (≥2 discarded cases per 100 000) are highlighted in red. 7 Surveillance indicators could not be calculated for Member States submitting aggregate data. ReportingClassification D is c a rd e d M e a sl e s Total Population in 2018 1 Incidence Rate (per 1 million population)2 Total measles cases 3 2018 Annualized Incidence Rate (per 1 million population)2 Surveillance Indicators 7 Total measles cases 3 Im p o rt e d c a se s Page 10 No. 2/2018 WHO EpiBrief 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 4 C o m p le te n e ss 5 T im e li n e ss 5 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 r a te 5 R a te o f d is c a rd e d c a se s 6 O ri g in o f in fe c ti o n 5 T im e li n e ss o f in v e st ig a ti o n 5 Albania 2 919 422 0 0 0 0 0 0 0 0 0 100% 17% Jun-18 - 0 - - Andorra 68 915 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Armenia 3 034 998 0 0 0 0 0 0 0 2 0 100% 67% Jun-18 100% 0.07 - 100% Austria 8 613 647 4.53 42 0.29 5 5 0 0 0 0 100% 100% Jun-18 100% 0 100% 0 Azerbaijan 10 070 075 0 0 0 0 0 0 0 35 0 100% 100% Jun-18 100% 0.35 - 100% Belarus 9 429 102 0.11 1 0 1 1 0 0 222 1 100% 50% Jun-18 0% 2.35 100% 0 Belgium 8 11 513 025 - - - - - - - - - - - See footnote - - - - Bosnia and Herzegovina 3 782 297 0.26 1 0.26 2 0 0 2 0 0 83% 17% May-18 - - - - Bulgaria 6 992 150 0 0 0.07 1 0 0 1 0 0 100% 100% Jun-18 0% 0 0% 100% Croatia 4 194 538 0 0 0 0 0 0 0 0 0 100% 67% Jun-18 - 0 - - Cyprus 1 198 198 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Czech Republic 10 563 111 0.09 2 0.05 1 1 0 0 0 0 100% 17% Jun-18 100% 0 100% 0 Denmark 8 5 732 713 - - - - - - - - - - - See footnote - - - - Estonia 1 302 401 0 0 0 0 0 0 0 7 0 100% 100% Jun-18 100% 0.54 - 100% Finland 5 556 439 0.18 1 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - France 8 65 205 671 - - - - - - - - - - - See footnote - - - - Georgia 3 973 681 1.26 5 0 0 0 0 0 52 0 100% 33% Jun-18 67% 1.31 - 100% Germany 80 560 850 0.91 74 0.19 31 6 0 25 0 0 100% 100% Jun-18 19% 0 58% 0 Greece 10 871 762 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Hungary 9 754 429 0 0 0 0 0 0 0 5 0 100% 50% Jun-18 100% 0.05 - 100% Iceland 336 938 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Ireland 4 790 845 0 0 0.31 3 0 0 3 0 0 100% 100% Jun-18 0% 0 33% 33% Israel 8 455 489 0 0 0.06 1 0 0 1 0 0 100% 50% Jun-18 100% 0 0% 100% Italy 59 788 104 1.12 68 0.11 14 7 2 5 7 1 100% 100% Jun-18 89% 0.01 64% 0 Kazakhstan 18 256 484 0.00 0 0 0 0 0 0 0 0 83% 83% May-18 - - - - Kyrgyzstan 6 213 441 0.64 4 0.56 7 7 0 0 0 0 100% 50% Jun-18 100% 0 100% 71% Latvia 1 935 780 0 0 0.52 3 3 0 0 0 1 100% 83% Jun-18 100% 0 100% 33% Lithuania 2 817 402 0 0 0.18 1 1 0 0 0 0 100% 83% Jun-18 100% 0 100% 0 Luxembourg 591 126 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Malta 421 387 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Monaco 38 166 - - - - - - - - - - - No Report - - - - Montenegro 626 240 0 0 0 0 0 0 0 0 0 83% 50% May-18 - 0 - - Netherlands 17 084 531 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Norway 5 387 342 0 0 0 0 0 0 0 0 0 100% 83% Jun-18 - 0 - - Poland 38 522 728 12.36 476 3.67 283 3 1 279 0 0 100% 100% Jun-18 - - - - Portugal 10 229 432 0.39 4 0.10 3 1 0 2 6 1 100% 83% Jun-18 67% 0.06 100% 78% Republic of Moldova 4 044 534 0 0 0 0 0 0 0 0 0 100% 83% Jun-18 - - - - Romania 19 105 089 0.47 9 0.10 4 2 0 2 0 0 100% 67% Jun-18 75% 0 100% 100% Russian Federation 143 261 490 0.04 7 0.01 3 3 0 0 0 1 100% 100% Jun-18 100% 0 100% 100% San Marino 32 241 0 0 0 0 0 0 0 0 0 100% 67% Jun-18 - 0 - - Serbia 8 742 764 - - - - - - - - - - - No Report - - - - Slovakia 5 434 237 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Slovenia 2 073 018 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Spain 46 116 884 0 1 0.03 3 2 0 1 1 0 100% 100% Jun-18 75% 0 33% 75% Sweden 9 987 062 0 0 0 0 0 0 0 0 0 100% 100% Jun-18 - 0 - - Switzerland 8 523 590 0.12 1 0.12 2 2 0 0 15 0 100% 100% Jun-18 94% 0.18 50% 6% Tajikistan 9 046 723 0.11 1 0 0 0 0 0 15 0 83% 83% Jun-18 100% 0.17 - 100% The former Yugoslav Republic of Macedonia 2 085 315 0 0 0 0 0 0 0 0 0 100% 33% Jun-18 - - - - Turkey 81 086 257 0.02 2 0.06 10 10 0 0 2321 0 100% 50% Jun-18 0% 2.86 20% 0.4% Turkmenistan 5 565 070 0 0 0 0 0 0 0 41 0 100% 0% Jun-18 100% 0.74 - 100% Ukraine 44 170 002 - - 1.66 147 10 0 137 0 0 100% 50% Jun-18 - - - - United Kingdom 65 912 569 0 3 0 1 1 0 0 0 1 100% 67% Jun-18 100% 0 100% 0 Uzbekistan 31 064 765 0.03 1 0 0 0 0 0 5 0 100% 83% Jun-18 100% 0.02 - 100% Total/Averages 917 084 469 0.75 703 0.28 526 65 3 458 2734 6 91.2% 71.1% 84.2% 0.38 11.6% 7.0% Total rubella cases 3 Im p o rt e d c a se s Classification D is c a rd e d R u b e ll a Data source: Monthly aggregated and case-based data reported by Member States to WHO/Europe or via ECDC/TESSy. Member States submitting aggregate data: Bosnia and Herzegovina, Kazakhstan, Poland, Republic of Moldova, the former Yugoslav Republic of Macedonia and Ukraine. 1 Data source: World Population Prospects: The 2015 Revision", New York, United Nations. 2 Incidence rates not meeting the target (<1 per million population) are highlighted in red. Imported rubella cases are excluded from the numerator while calculating the incidence rate. 3 All confirmed rubella cases regardless of origin. 4 Unless specified as laboratory confirmed or epi-linked, cases are classified as clinically compatible. 5 Target (>=80%) not achieving are highlighted in red. 6 Discard rates not achieving the target (>=2 discarded cases per 100 000) are highlighted in red. 7 Surveillance indicators could not be calculated for Member States submitting aggregate data. 8 Belgium, Denmark, and France do not have comprehensive rubella surveillance systems. Incidence Rate (per 1 million population)2 2017 (as of 05 September 2018) 2018 Surveillance Indicators 7 Annualized Incidence Rate (per 1 million population) 2 Reporting Total Population in 2018 1Country Total rubella cases 3 Table 2. Rubella cases: classification, reporting and surveillance performance January–June 2018 (as of 5 September 2018)