Elsevier

Vaccine

Volume 27, Issue 30, 19 June 2009, Pages 3927-3934
Vaccine

Review
Measles risk groups in Spain: Implications for the European measles-elimination target

https://doi.org/10.1016/j.vaccine.2009.04.024Get rights and content

Abstract

The European Region has set itself the goal of eliminating measles by 2010. Incidence has increased in recent years. This study sought to investigate outbreaks in Spain in the period 2005–2007, in order to identify measles-vulnerable groups and compare Spain to other European countries which have also had measles outbreaks.

The pattern observed for Spain proved different to that of other European countries, i.e., whereas young adults and infants aged under 15 months were affected in Spain, children aged under 9 years comprised the predominant group in other European countries.

Measles cases in Spain reflect low coverage when vaccination began, a pattern that could be repeated in neighbouring countries. Vaccination efforts should thus be targeted at vulnerable groups, namely: young adults; health professionals; travelling communities; and adopted infants and foreigners from countries with important pockets of susceptibles.

Introduction

In 1998, as one of its “Health for All in the 21st century” (HEALTH21) targets, the World Health Organization (WHO) envisaged the elimination of measles in the European Region by 2007 [1], and urged Member States to set up national indigenous measles-elimination plans [2]. In 2004, after reviewing the situation, the WHO Regional Office for Europe deferred the elimination deadline to 2010 [3].

Strategies for attaining the goal of eliminating endemic circulation of measles in the WHO European Region are based on: attaining and maintaining high vaccination coverages (≥95% with 2 doses of measles vaccine); and strengthening surveillance systems by rigorous epidemiological and laboratory investigation of all suspected cases, characterization of circulating virus and dissemination of information to health professionals and the public alike [3].

In 1998, the European Parliament adopted a European Commission proposal to set up a Surveillance Community Network for Vaccine-preventable Infectious Diseases (EUVAC.NET) [4]. To improve the diagnosis and characterization of the virus, the Global Measles/Rubella Laboratory Network (GM/RLN) was set up in 2002 [5].

In the late 1980s, many European countries introduced measles-containing vaccine (MCV). By the first half of the 1990s, they had introduced the second dose of vaccine and the combined measles, mumps and rubella (MMR) vaccine [6]. Since the year 2000, the age of administration of the second dose has been lowered [7].

A total of 53 member countries of the WHO European Region have routine vaccination programmes with 2 measles doses, achieving a mean first-dose coverage of 94% [3].

Since the proposal to eliminate measles in 1998, cases in the Europe remained constant at close on 38,000 annually until 2005, with this figure then rising to just under 57,000 in 2006 [8].

Spain introduced monovalent measles vaccine at age 15 months in 1978, which was subsequently replaced by MMR vaccine at the same age in 1981, and 12–15 months of age in 1996. Between 1988 and 1995, a second dose was introduced at age 11–13 years. A national seroepidemiological survey on vaccine-preventable diseases was conducted in 1996 and reported a susceptible level of 9.2% among children aged 6–9 years (born 1987–1990) [9]. As a result, the age of administration of the second dose was reduced to 3–6 years in 1999, with the aim of reducing the susceptible level to ≤5% across all age groups to ensure that the goal of measles elimination would be achieved [2]. Measles vaccination coverage in Spain has risen slowly, going from <85% in the pre-1987 era to ≥90% until 1993. Thereafter it continued climbing and has stood at ≥95% since 1999. Vaccination coverage figures for Autonomous Regions (ARs) have only been available since 2001, with all ARs registering ≥90% coverage for the first dose since then and for the second dose since 2003. The National Health System provides universal free health care, including vaccination, to all persons resident in Spain, regardless of their legal status.

Annual measles incidence in Spain underwent a marked decline after the introduction of vaccination and has stood at ≤1 per 100,000 inhabitants since 1999 (ARs data, available since 2001, report an incidence of ≤1 per 100,000 inhabitants in 2002, 2004 and 2005 for all ARs), with high coverages attained and sustained from that time onwards. These factors made it possible for the measles-elimination plan to be set up in 2001, in line with the strategies targeted at eradicating measles in the WHO European Region [10].

Since 1999, only familial outbreaks with very few transmission chains have been detected in Spain but in 2003 one large outbreak (182 cases), mainly affecting young adults, occurred in one Andalusian province [11]. Thereafter incidence decreased and in 2004 reached its lowest mark in the history of the disease (0.05 per 100,000 inhabitants). However, as a consequence of two other major outbreaks that affected two different Regions, Madrid and Barcelona (see Fig. 1); incidence rose once more, reaching 0.83 in 2006 and 0.59 in 2007.

This study sought to investigate the age-related case-distribution patterns of outbreaks reported in Spain and other European countries, and identify high-risk groups for measles.

Section snippets

Materials and methods

Vaccination history data (year of measles vaccine introduction and annual vaccination coverage) were obtained from the Ministry of Health registries in Spain and from official web pages hosted by individual countries, the EUVAC.NET [4], and the WHO [7].

Although just one confirmed case of measles would suffice for definition as a measles outbreak in an elimination context, only data on outbreaks involving more than one case were used for the purposes of this study [10].

Spanish measles outbreak

Results

A total of 10 outbreaks were identified in Spain and a further 32 in 17 European countries from 2005 to 2007. Reports of most of these outbreaks had been published in journals, the majority in Eurosurveillance and others on the EUVAC.NET web page.

Incidence, history of vaccination programme, MCV coverage and the years in which high first- and second-dose coverages (≥90%) were achieved are shown in Table 1 for these European countries. Countries with measles outbreaks were classified on the basis

Discussion

Different age-related susceptibility patterns were found in measles cases across Europe among countries with different vaccination histories and coverages in their respective vaccination programmes.

Countries that attained and maintained vaccination coverages ≥90% prior to or from the early 1990s, such as Spain, have the same age-related pattern, with young adults being mainly affected, i.e., unvaccinated persons, who were born before the introduction of the vaccine (currently over the age of

Acknowledgements

Our thanks to all those who helped in the task of collecting data on measles cases in Spain.

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