Volume 17, Number 8–August 2011
Research
Spread of Measles Virus D4-Hamburg, Europe, 2008–2011
Author affiliations: Robert Koch Institute, Berlin, Germany (A. Mankertz, S. Santibanez); National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria (Z. Mihneva); Department of Health and Environment, München, Germany (H. Gold); Institute of Hygiene and the Environment, Hamburg, Germany (S. Baumgarte); Governmental Institute of Public Health of Lower Saxony, Hannover, Germany (A. Baillot); Health Office City of Mannheim, Mannheim, Germany (R. Helble); Public Health Office, Essen, Germany (H. Roggendorf); Institute for Public Health, Skopje, Republic of Macedonia (G. Bosevska); Institute of Virology, Belgrade, Serbia (J. Nedeljkovic); National Institute of Public Health, Warsaw, Poland (A. Makowka); Scientific Institute of Public Health, Brussels, Belgium (V. Hutse); Medical University of Vienna, Vienna, Austria (H. Holzmann, S.W. Aberle); University of Geneva Hospitals, Geneva, Switzerland (S. Cordey); Cantacuzino National Institute of Research and Development for Microbiology and Immunology, Bucharest, Romania (G. Necula); Hellenic Pasteur Institute, Athens, Greece (A. Mentis); Refik Saydam National Public Health Agency, Ankara, Turkey (G. Korukluoğlu); Virus Reference Laboratory, Dublin, Ireland (M. Carr); Health Protection Agency, London, UK (K.E. Brown); Laboratoire National de Santé/CRP-Santé, Luxembourg (J.M. Hübschen, C.P. Muller); and World Health Organization Regional Office for Europe, Copenhagen, Denmark (M.N. Mulders)
Suggested citation for this article
Abstract
A new strain of measles virus, D4-Hamburg, was imported from London to Hamburg in December 2008 and subsequently spread to Bulgaria, where an outbreak of >24,300 cases was observed. We analyzed spread of the virus to demonstrate the importance of addressing hard-to-reach communities within the World Health Organization European Region regarding access to medical care and vaccination campaigns. The D4-Hamburg strain appeared during 2009–2011 in Poland, Ireland, Northern Ireland, Austria, Greece, Romania, Turkey, Macedonia, Serbia, Switzerland, and Belgium and was repeatedly reimported to Germany. The strain was present in Europe for >27 months and led to >25,000 cases in 12 countries. Spread of the virus was prevalently but not exclusively associated with travel by persons in the Roma ethnic group; because this travel extends beyond the borders of any European country, measures to prevent the spread of measles should be implemented by the region as a whole.
The 53 member states of the World Health Organization (WHO) European Region (EUR) have set a goal to eliminate measles and rubella virus transmission by 2015 in Europe (1). Elimination targets include 95% vaccination coverage with 2 doses of measles virus–containing vaccine (MVCV), an incidence of <1 measles case per million population, 80% of outbreaks associated with <10 cases, and transmission of indigenous or imported measles virus for no longer than 12 months in a defined region (2). Thus, monitoring transmission chains of measles virus is an indispensable tool to assess elimination progress, although the specific boundaries of the region have not yet been defined for the WHO EUR.
To comply with the goal of eliminating measles virus, Germany implemented a national intervention program against measles, mumps, and rubella (MMR) in 1999 (3). Since then, measles incidence in Germany has declined. Molecular surveillance showed that endemic genotypes C2 (MVi/Kempten.DEU/23.00) and D6 (MVi/Berlin.DEU/47.00) (4) were replaced rapidly by genotype D7 (MVi/Mainz.DEU/06.00), which circulated until the beginning of 2003 (5). Imported measles virus of genotypes B3, D4, D5, D6, D8, D9, and H1 appeared in Germany from 2005 onward. In 2009 and 2010, most cases were linked to measles virus of genotype D4, of which several distinct subvariants were detected.
Elimination targets have not yet been met in Germany. Vaccination coverage in Germany, routinely assessed in children 5–6 years of age during an examination before school entry, is still below the required 95% for the second dose of MVCV. Recent outbreaks showed an immunization gap in adolescents and young adults (6). Consequently, outbreaks still occur in Germany every year, although recently they have been more limited in number of cases, length of time, and extent of national transmission (7,8). A total of 915 measles cases were reported in 2008, 571 in 2009, and 780 in 2010; incidence was 7–10 cases/1 million population (www3.rki.de/SurvStat/QueryFormaspx).
The reasons for Germany's malperformance are complex. Measles virus vaccination is not mandatory, and some groups within the German population do not comply with official vaccination recommendations (9) because of philosophical or religious beliefs or fear of adverse effects (10). As in other countries in Europe, strategies to address hard-to-reach populations and improve access to medical care, preventive measures, and vaccination campaigns have not yet been developed. In this article, we describe exportation of a measles D4 variant from Germany and its subsequent circulation in Europe.
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Suggested Citation for this Article
Mankertz A, Mihneva Z, Gold H, Baumgarte S, Baillot A, Helble R, et al. Spread of measles virus D4-Hamburg, Europe, 2008–2011. Emerg Infect Dis [serial on the Internet]. 2011 Aug [date cited]. http://www.cdc.gov/EID/content/17/8/101994.htm
DOI: 10.3201/eid1708.101994
Comments to the Authors
Please use the form below to submit correspondence to the authors or contact them at the following address:
Annette Mankertz, National Reference Centre for Measles, Mumps, Rubella, Germany, Regional Reference Laboratory WHO EUR, Viral Infections, Robert-Koch Institut, Nordufer 20, D-13353 Berlin, Germany; email: mankertza@rki.de
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