A report on the epidemiology of selected vaccine-preventable diseases in the European Region 30% 20% 10%

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1 % of reported measles cases WHO EpiBrief A report on the epidemiology of selected vaccine-preventable diseases in the European Region No. /17 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. The surveillance data presented in this issue were reported by Member States and are incorporated in the centralized information system for infectious diseases (CISID). 1 Tabulated surveillance data by country for the first half of 17 (as of August 17) are annexed to this issue. The analyses of these data are performed on cases with disease onset dates during the first half of 17. 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 17 Incidence notifications and laboratory data For the first half of 17, 93 measles cases were reported in countries of the WHO European Region among 5 (9%) countries that submitted measles data (including zero reporting) (Table 1 in annex). Three countries, namely Monaco, San Marino and Turkmenistan, did not submit reports. Of the total cases, 95% (n=75) were reported by 1 countries: Italy (n=3; 39%), Romania (1; %), Ukraine (93; 1%), Germany (79; %), Tajikistan (55; %), France (35; %), Belgium (97; 3%), Bulgaria (11; %), Spain (11; %) and the Czech Republic (131; 1%). The highest incidence per million population for the first half of 17 was in Romania (9) followed by Tajikistan () and Italy (1). Of the total cases, 5315 (57%) were laboratory confirmed and (%) were epidemiologically linked. The remaining 111 cases (19%) were classified as clinically compatible. During the first half of 17, 975 measles virus sequences were reported to the Measles Nucleotide Surveillance database (MeaNS) by reference laboratories of the WHO European Region (as of August 17). The genotypes identified in the Region comprised D (n=5), B3 (57), H1 () and D9 (1). Overall, the predominant measles virus genotypes reported for the first half of 17 included several B3 lineages reported by 19 countries. The dominant strain in 1 countries was Dublin.IRL/.1 (5% of reported B3 sequences). Several measles virus genotype D lineages were also reported by 1 countries mostly Osaka.JPN/9.15, (5% of D sequences). Genotype H1, which is usually found in Asia, was reported by five countries in the Region. Age distribution Of those with known age group (n=93), 13 (11%) were under one year of age, (%) were 1 years of age, 1 (%) were 5 9 years of age, 31 (13%) were 1 19 years of age and 3973 (%) were years and older (Fig. 1). Fig. shows the age distribution of reported measles cases in the top six countries reporting cases: Italy, Romania, Ukraine, Germany, Tajikistan and France by proportion and agespecific incidence. The classification of cases by age group for the two countries that reported 59% of cases Fig. 1. Age distribution of measles cases by proportion in the WHO European Region, January June 17 (n=93) 3% % 1% % 11% % % N.B. Discarded cases are not included. 7% % 1% % *WHO EpiData no. /17 is available separately at data/assets/pdf_file/11/337/17 Epi_Data_EN_July1_June17.pdf?ua=1 No. /17 Page 1

2 % of reported measles cases Incidence of reported measles cases per 1, inhabitants % of reported measles cases Incidence of reported measles cases per 1, inhabitants % of reported measles cases Incidence of reported measles cases per 1, inhabitants % of reported measles cases Incidence of reported measles cases per 1, inhabitants WHO EpiBrief EPI-BRIEF Fig.. Age distribution of measles cases by proportion (left) and incidence per 1 inhabitants (right) in the four countries that reported 77% of cases with data on age in the WHO European Region, January June 17 (n=73) 5% % Italy Romania (n=3) ITALY (n=3) 3% 5.5 Italy (n=3) ITALY 3% % 1% % % 5% % 5% 5% % 5% % % Romania 37% 1% (n=1) 7% 5% 7% 7% 37% 5 9. Romania (n=1) 3% 15 % % 1% % % 5% % 3% % 1% % 5% % 3% % 1% % 7% 5% 7% 7% % Ukraine UKRAINE (n=93) % 9% 1% 7% 1% % 13% Germany GERMANY (n=79) 1% 11% 1% % 1% 19% Ukraine (n=93) Germany (n=79) Page No. /17

3 cases Number of reported measles cases Number of reported measles cases WHO EpiBrief (Italy and Romania) is presented in Fig 3. Vaccination status Vaccination status was known in 7 cases (%), of which 51 cases (3%) were unvaccinated and 99 cases (17%) were reportedly vaccinated with at least one measles-containing vaccine dose. Of the 51 unvaccinated cases: cases (1%) were <1 year old, 19 cases (3%) were 1 years old, 79 cases (1%) were 5 9 years old, 751 cases (11%) were 1 19 years old and 79 cases (%) were years old. Measles-related deaths During this period 13 measles-related deaths were reported in six countries: six in Romania, two in Italy and one each in Bulgaria, Germany, Portugal, Spain and Switzerland. With the exception of two fatal cases, none had received a measles vaccine. The fatal cases in Romania and Bulgaria were infants and young children (<3 years old), those in Italy were older children and 9 years old, and those in Germany, Portugal, Spain and Switzerland were 37, 17, 7 and 5 years old, respectively. Hospitalization Data on hospitalization status was available for 7% (n=39) of all reported measles cases. Of these, 3 were hospitalized, amounting to 7% of all cases with known hospitalization status. Of all the hospitalized cases, most were reported in Romania (n=15; 5%) and Tajikistan (9; 1%). Imported cases Importation status was known for 7% (n=731) of cases. Of these, 19 were reported as imported cases, amounting to.7% of cases with a known importation 1, Italy (n=3) status. Of all the imported cases, most (1%; n=13) were reported by Germany (), Italy (31), United Kingdom (n=5), France (3) and Spain (17). Rubella in the WHO European Region January-June 17 Incidence notifications and laboratory data For the first half of 17, 3 rubella cases were reported in 1 countries of the WHO European Region among 5 (5%) countries submitting rubella data (including zero reporting) (Table in annex). Most cases were reported by Poland (n=53; 5%), followed by Italy (; %), Germany (; 11%) and Austria (; 7%). For the first half of 17, Poland also had the highest incidence per million population (.) however, no cases were laboratory confirmed. Of the total, 71 (1%) cases were laboratory confirmed, most of which were reported by Italy (n=), Austria (3) and Germany (1). No rubella virus sequences were reported to the Rubella Nucleotide Surveillance database (RubeNS). 3 Age distribution The age group was known in all cases: 3 cases (1%) were <1 years old, 1 cases (5%) were 1 9 years old, cases (%) were 1 19 years old and 11 cases (%) were years old (Fig. ). The classification of cases by age group for the four countries that reported 95% of cases in the Region is presented in Fig 5. Vaccination status Vaccination status was known in 33 of cases (%). Of the 17 (51%) unvaccinated cases, 3 cases (1%) Fig. 3. Classification of measles cases by age group in Italy and Romania that together reported 59% of cases with data on age in the WHO European Region, January June 17 (n=55) 1, Romania (n=1) 1, 1, Clinically compatible Epidemiologically linked Laboratory confirmed No. /17 Page 3

4 cases Number of reported rubella cases Number of reported rubella cases Number of reported rubella cases Number of reported rubella cases % of reported rubella cases WHO EpiBrief Fig.. Age distribution of rubella cases in the WHO European Region, January June 17 (n=3) 3% % 1% % 1% % 7% N.B. Discarded cases are not included. were <1 year old, 3 cases (1%) were 1 years old, cases (15%) were 5 9 years old, 1 cases (%) were 1 1 years old and cases (3%) were 15 years old. The remaining 1 cases (9%) were reportedly vaccinated with at least one rubella-containing 9% % 9% 17% vaccine dose. Of these, 1 cases were reported by Poland. Imported cases Importation status was known in % (n=95) of rubella cases. Of these, 3 cases were reported as imported, amounting to 3.% of cases with a known importation status. The imported cases were reported from Austria (n=1), Czech Republic (1) and the United Kingdom (1). Comments Measles and rubella in the WHO European Region With 935, the total number of measles cases reported in the European Region for the first half of 17 exceeded the number reported for the entire year of 1 (n=519). This is predominantly due to continued measles transmission in Italy and Romania, but also significant increases in reported cases in a number of countries including Belgium, Bulgaria, Czech Republic, France, Germany, Spain, Tajikistan and Ukraine. Fig. 5. Classification of rubella cases by age group in the four countries that reported 95% of cases with data on age in the WHO European Region, January June 17 (n=37) Poland (n=53) Germany (n=) Italy (n=) Austria (n=) Clinically compatible Epidemiologically linked Laboratory confirmed Page No. /17

5 WHO EpiBrief The total for 17 is expected to become much higher still, due to delayed reporting of cases and continued outbreaks. Countries with large outbreaks often face challenges in timely collection of subnational surveillance data and thus, the submission of consolidated national data to international agencies is delayed. In addition, outbreaks in Italy and Romania are continuing. Updates on the number of cases in Italy and Romania are available online on their respective health authorities website.,5 The number of reported rubella cases in the Region for the first half of 17 was 5% lower than that reported for the same period in 1 (n=913). This is primarily due to a 7% decline in reported rubella cases in Poland, from 7 cases for the first half of 1 to 53 cases for the same period in 17. All of the reported cases in Poland in 17 were classified as clinically compatible. On the other hand, un- and/or under-vaccinated cases among children 1 9 years of age (3%) reflect sub-optimal routine immunization coverage rates in recent years. All eligible children in this age group should have received at least one vaccine dose according to national immunization programme schedules. Immunization coverage of at least 95% with two doses of a measles-containing vaccine needs to be reached and maintained at national level and in all districts through the routine immunization programme. Every country needs to actively identify reasons for the presence of un- and/or under-vaccinated individuals in the community and devise tailored strategies to address the identified challenges in their immunization programmes. Attaining and maintaining high population immunity is crucial to stop ongoing measles and rubella transmission and prevent outbreaks in the Region. At a regional level, the proportion of measles cases was highest in adults years and older (%) demonstrating immunity gaps in this population group in some countries. More efforts are needed to identify susceptible individuals and systematically address their vaccination needs. References 1. World Health Organization. Centralized Information system for infectious diseases (CISID). Copenhagen. Regional Office for Europe. Measles Nucleotide Surveillance database (MeaNS) Rubella Nucleotide Surveillance database (RubeNS). Ministry of Health. National Institute of Health. Morbillo in Italia. Weekly bulletin. morbillo/infografica17.asp 5. National Institute of Public Health, Romania. Rujeola, weekly updates. (in Romanian). informari-saptamanale/rujeola-1 Date of publication: September 17 Suggested citation: WHO EpiBrief, 17, :1 World Health Organization, 17 No. /17 Page 5

6 Lab confirmed Epi-Link Clinically compatible Discarded Measles Imported cases Completeness Timeliness Month & year of last report Laboratory investigation rate Rate of discarded cases Origin of infection Timeliness of investigation Annex Table 1. Measles cases: classification, reporting and surveillance performance, January June 17 (as of 1 August 17) 1 (as of 1 August 17) 17 Classification Reporting Surveillance Indicators Country Total Population in 17 1 Incidence Rate (per 1 million population) Total measles cases 3 Annualized Incidence Rate (per 1 million population) Total measles cases 3 Albania % 3% Jun Andorra % 5% May Armenia % 3% May-17 1% 1. 1% 97% Austria % 1% Jun-17 9%.5 93% 5% Azerbaijan % 1% Jun-17 9%.5 % 57% Belarus % 1% Jun-17 1% % 1% Belgium % 7% Jun-17 %. Bosnia and Herzegovina % 7% Jun-17 %. Bulgaria % 3% Jun-17 97%. 3% 1% Croatia % 3% Jun-17 1%. 75% Cyprus % 1% Jun-17 1%. 1% Czech Republic % 1% Jun-17 1%.1 99% % Denmark % 1% Jun-17 1%. 1% Estonia % 1% Jun-17 1% 3.3 % 1% Finland % 1% Jun-17 1%. 1% France % 1% Jun-17 91%. 9% % Georgia % 3% Jun-17 5%. 1% 1% Germany % 1% Jun-17 9%. 7% Greece % 1% Jun-17 1%. 75% Hungary % 5% Jun-17 1%.17 3% 97% Iceland % 3% Jun-17 1%. 5% 1% Ireland % 1% Jun-17 7%. 57% 57% Israel % 33% May-17 %. Italy % 3% Jun-17 %. % Kazakhstan % 7% Jun-17 %. Kyrgyzstan % 3% Jun-17 99% % Latvia % 1% Jun Lithuania % 3% Jun-17 1%. 1% Luxembourg % 1% Jun-17 1%. 7% 1% Malta % 1% Jun Monaco No Report Montenegro % 7% Jun-17 1%.1 1% 1% Netherlands % 1% Jun-17 1%.1 1% Norway % 1% Jun Poland % 1% Jun-17 5%. 15% 1% Portugal % 3% Jun-17 7% 1.7 1% 7% Republic of Moldova 5.. 1% 7% Jun Romania % 1% Jun-17 1%. 3% 1% Russian Federation % 7% Jun-17 1%.7 11% 7% San Marino No Report Serbia % 3% Jun-17 %. Slovakia % 1% Jun-17 7%.7 1% 7% Slovenia % 1% Jun-17 1%. 1% 1% Spain % 3% Jun-17 9%.1 % 7% Sweden % 1% Jun-17 1%.9 1% Switzerland % 1% Jun-17 9%. 51% 1% Tajikistan % 3% May-17 1% 1.3 7% 1% The former Yugoslav Republic of Macedonia % 7% Jun Turkey % % Jun-17 93%. Turkmenistan No Report Ukraine % 1% Jun-17 %. United Kingdom % 1% Jun-17 1%. % 1% Uzbekistan % 33% Jun-17 1%. 1% Total/Averages % 79.%.%.5.5% 33.% Data source: Monthly aggregated and case-based data reported by Member States to WHO/Europe or via ECDC/TESSy. 1 Source: " World Population Prospects: The 15 Revision", New York, United Nations. Incidence not meeting the target (<1) and countries not reporting monthly measles data are highlighted in red. The imported measles cases are excluded from the numerator while calculating the incidence rate. 3 All confirmed measles cases regardless of origin. Unless specified as laboratory confirmed or epi-linked, cases are classified as clinically compatible. Member States submitting aggregate data: Bosnia and Herzegovina, Kazakhstan, Republic of Moldova, San Marino, Serbia, the former Yugoslav Republic of Macedonia, Turkmenistan, Ukraine. Page No. /17

7 Lab confirmed Epi-Link Clinically compatible Discarded Rubella Imported cases Completeness Timeliness Month of last report Laboratory investigation rate Rate of discarded cases Origin of infection Timeliness of investigation WHO EpiBrief Table. Rubella cases: classification, reporting and surveillance performance, January June 17 (as of 1 August 17) 1 (as of 1 August 17) 17 Classification Reporting Surveillance Indicators Country Total Population in 17 1 Incidence Rate (per 1 million population) Total rubella cases 3 Annualized Incidence Rate (per 1 million population) Total rubella cases 3 Albania % 3% Jun Andorra % 5% May Armenia % 3% May-17 1%. 1% 1% Austria % 1% Jun-17 1%. 1% % Azerbaijan % 1% Jun-17 97%. % 59% Belarus % 1% Jun-17 % 1.53 % % Belgium See footnote Bosnia and Herzegovina % 5% Jun Bulgaria % 1% Jun Croatia % 5% Jun Cyprus % 1% Jun Czech Republic % 1% Jun-17 1%. 5% % Denmark See footnote Estonia % 1% Jun-17 95% 1.1 % 1% Finland % 1% Jun France See footnote Georgia % 3% Jun-17 1%.91 1% 97% Germany % 1% Jun-17 %. 3% % Greece % 1% Jun Hungary % 33% Jun Iceland % 3% Jun Ireland % 1% Jun-17 %. % % Israel % 33% May Italy % 3% Jun-17 %. 7% % Kazakhstan % 7% Jun Kyrgyzstan % 3% Jun-17 1%. 1% % Latvia % 1% Jun Lithuania % 3% Jun Luxembourg % 1% Jun Malta % 1% Jun Monaco No Report Montenegro 5.. 7% 33% Apr Netherlands % 1% Jun Norway % 1% Jun Poland % 1% Jun-17 %. % % Portugal % 7% Jun-17 7%. 1% 1% Republic of Moldova 5.. 1% 7% Jun Romania % 5% Jun-17 75%. 1% 1% Russian Federation % 7% Jun-17 1%. 1% % San Marino No Report Serbia No Report Slovakia % 1% Jun-17 5%. 5% 5% Slovenia % 1% Jun Spain % 1% Jun-17 1%. 1% 1% Sweden % 1% Jun Switzerland % 1% Jun-17 %.13 % 7% Tajikistan % 7% May-17 1%. 1% 1% The former Yugoslav Republic of Macedonia % 7% Jun Turkey No Report Turkmenistan No Report Ukraine No Report United Kingdom % 1% Jun-17 1%. 1% 1% Uzbekistan % 33% Jun-17 1%. 1% % Total/Averages % 9.5% 3.1%.3 7.5% 1.9% Data source: Monthly aggregated and case-based data reported by Member States to WHO/Europe or via ECDC/TESSy. 1 Source: World Population Prospects: The 15 Revision", New York, United Nations. Incidence not meeting the target (<1) and countries not reporting monthly rubella data are highlighted in red. The imported rubella cases are excluded from the numerator while calculating the incidence rate. 3 All confirmed rubella cases regardless of origin. Unless specified as laboratory confirmed or epi-linked, cases are classified as clinically compatible. 5 Belgium, Denmark, and France do not have comprehensive rubella surveillance systems. Member States submitting aggregate data: Bosnia and Herzegovina, Kazakhstan, Republic of Moldova, San Marino, Serbia, the former Yugoslav Republic of Macedonia, Turkmenistan, Ukraine. No. /17 Page 7

8 Number of sequences reported Number of sequences reported Fig 1. Distribution of named strains of D measles genotype in the WHO European Region by week of sample collection, January June 17 (data as of August 17) 35 D - Not named D - MVs/Osaka.JPN/9.15/ D - MVs/Victoria.AUS/.11/ D - MVs/Frankfurt Main.DEU/17.11/ D - MVs/Cambridge.GBR/5.1/ D - MVi/Hulu Langat.MYS/.11/ Week of sample collection Fig. Distribution of named strains of B3 measles genotype in the WHO European Region by week of sample collection, January June 17 (data as of August 17) 35 B3 - Not named B3 - MVs/Kabul.AFG/.1/3 B3 - MVs/Niger.NGA/.13/ B3 - MVs/Dublin.IRL/.1/ B3 - MVs/Kansas.USA/1./ B3 - MVi/Harare.ZWE/3.9/ Week of sample collection Page No. /17