SUPPLEMENT ARTICLE
Progress toward Measles Elimination
in Germany
Wiebke Hellenbrand,1 Anette Siedler,1 Annedore Tischer,2 Christiane Meyer,1 Sabine Reiter,1 Gernot Rasch,1
Dieter Teichmann,1,a Sabine Santibanez,2 Doris Altmann,1 Hermann Claus,1 and Michael Kramer1
1
Center for Infectious Diseases Epidemiology and 2Department of Virology, Robert Koch Institute, Berlin, Germany
While the former East Germany (FEG) achieved a reduction of measles incidence to !1 case per 100,000
population before reunification in 1990, the former West Germany (FWG) experienced significant measles
morbidity. In 2001, according to statutory surveillance data, the incidence of measles was still higher in FWG
than in FEG (8.7 vs. 0.7 cases/100,000 population). This article describes the development of the vaccination
strategies in FEG and FWG, vaccination coverage, results of seroprevalence studies, measles surveillance in
Germany, the epidemiology of a recent outbreak, and the role of laboratory diagnosis for measles control in
Germany. Recent establishment of comprehensive nationwide surveillance and prevention programs to attain
higher vaccine coverage have led to a decrease in measles incidence. However, further improvement of ageappropriate vaccine coverage and closure of immunity gaps in school-age children are necessary to eliminate
measles in Germany.
Despite progress in recent years, measles morbidity remains significant in Germany, a country with an area
of 357,000 km2 and (in 2001) a population of 82 million
and a birth cohort of ∼770,000. Prior to the 1990 reunification of the former East Germany (German Democratic Republic; FEG) and West Germany (Federal Republic of Germany; FWG), approaches to measles
surveillance, vaccination strategies, and vaccine supplies
differed substantially in the two regions [1].
In FEG, a centralized health care system, with measles
as a reportable disease, successful vaccination strategies,
and a mandatory vaccination policy, brought the region
close to measles elimination prior to reunification
Presented in part: Investigation results for the measles outbreak in Nordfriesland
at the Conference of the German Society of Hygiene and Microbiology, Aachen,
Germany, 30 September–4 October 2001 (abstract P123).
a
Present affiliation: Department of Infectious Diseases and Tropical Medicine,
Dresden-Neustadt Hospital, Dreseden, Germany.
[2–5]. In contrast, FWG, with its decentralized health
care system, statutory surveillance of measles deaths
only, and a voluntary vaccination policy, experienced
significant measles morbidity [6]. In 2001, the Communicable Diseases Law Reform Act (CDLRA) [7] was
implemented, leading to increased emphasis on health
education and disease prevention and the institution of
statutory national surveillance of measles, vaccination
coverage at school entry, and vaccine-related adverse
events. The Act also provided a legal basis for the Standing Committee on Vaccination (STIKO), which was
founded in FWG in 1972 by the Federal Health Office
to develop evidence-based recommendations for vaccination in Germany. Multifaceted intervention programs have been implemented nationwide to improve
vaccination coverage in general and to hasten progress
towards measles elimination, which is targeted for 2007
in the World Health Organization (WHO) European
Region [8].
Reprints or correspondence: Dr. Wiebke Hellenbrand, Centre for Infectious
Diseases Epidemiology, Robert Koch Institute, Seestr., 13353 Berlin, Germany
([email protected]).
MEASLES VACCINATION
The Journal of Infectious Diseases 2003; 187(Suppl 1):S208–16
2003 by the Infectious Diseases Society of America. All rights reserved.
0022-1899/2003/18710S-0032$15.00
History of measles vaccination. In FEG, single-dose
monovalent measles vaccination was introduced on a
S208 • JID 2003:187 (Suppl 1) • Hellenbrand et al.
voluntary basis in 1967, and in 1970 it became mandatory for
children ⭓8 months of age [1]. The Public Health Service
played a key role in administering and tracking vaccination,
which was free of charge [9]. High vaccine coverage quickly
led to a measles incidence of !10 per 100,000 population. However, due to the early age of vaccinees, a pool of susceptible
children accumulated, leading to an incidence of 172 per
100,000 population in 1980. Thus, the recommended age at
vaccination was increased to ⭓12 months, and revaccination
of all persons vaccinated at !1 year of age was attempted. In
1986, a second vaccine dose 6–12 months after the first was
routinely implemented. After the reunification of Germany in
1990, monovalent measles vaccine was replaced with trivalent
measles-mumps-rubella (MMR) vaccine, as recommended by
STIKO.
In FWG, measles vaccine was first licensed in 1967. Monovalent measles vaccine was recommended by STIKO in West
Germany from 1974, and bivalent measles-mumps vaccination
was recommended from 1976 onwards [10]. Immunization was
voluntary and recommended at ⭓12 months of age. MMR
vaccine was recommended from 1980 onwards, when the age
for vaccination was increased to ⭓14 months. In FWG, vaccines
were primarily administered by physicians in private practice
(85% of vaccinations [11]), and the cost was covered by statutory health insurance. This was extended to FEG after
reunification.
In 1991, a second dose of MMR was recommended for all
children ⭓5 years of age. In 1997, the first dose of MMR was
recommended to be given between 11 and 14 months of age,
and in 1998, the second dose was recommended to be given
as early as 4 weeks after the first and before the sixth birthday.
Last, in an effort to further improve age-appropriate immunization among preschool children, recommendations were
modified again in 2001. It is currently recommended that the
first dose of MMR be given between 11 and 14 months of age
and that the second dose be given between 15 and 23 months
of age [12]. In addition, postexposure vaccination is strongly
recommended for susceptible contacts of persons with measles
[12].
Vaccination coverage. From 1986 to 1988 (shortly before
reunification) in FEG, measles vaccination coverage was reported to be 98%–99% for at least one dose of measles vaccine
in 2-year-old children [13]. However, according to a representative, population-based survey, coverage at 24 months dropped
to 89% in 1989 and to 69% in 1992 [14]. In FWG, the coverage
at 24 months increased from 59% to 76% over the same period
[14]. In another representative, population-based survey, 77%
of 19- to 35-month-old children born in 1996 and 1997 had
received the first dose of MMR, with no differences detected
between FEG and FWG [15], and no marked improvement was
detected over the ascertained coverage in 1992. Vaccination
coverage at school entry was 86.1% for the first dose of MMR
in 1996–1997 [16]. By 1998–2001, coverage had increased to
90.3% (table 1) and coverage was higher in FEG, particularly
for the second vaccine dose.
In summary, available data reveal an important immunity
gap, particularly in children !3 years of age. Even at school
entry, vaccination coverage of 95%, which is recommended for
achieving measles elimination, had not been attained. In addition, uptake of the second dose of measles vaccine has been
poor, although it was better in FEG than FWG.
Seroprevalence studies.
A seroprevalence survey performed in 1990 in five regions of FEG revealed that 15.6% of
1-year-old children and only 1% of 2- and 3-year-old children
had no detectable measles antibodies [17]. Results of a seroprevalence study done in 1995 and 1996 in FEG and FWG
revealed that 78.5% of serum samples from 1-year old children,
32% from 2-year-old children, and 26% from 3-year-old children had no detectable measles antibodies [17, 18], in keeping
with the immunity gap described above. In 1998, data from
the National Health Survey revealed that ⭓95% of young adults
(20–25 years old) in FEG and FWG had measles antibodies
[17]. However, titers were significantly higher in FWG, reflecting the acquisition of natural immunity [17]. Infants born of
West German mothers also had significantly higher antibody
levels than infants born of East German mothers, reflecting the
longer persistence of maternal antibody after acquisition of
natural immunity (in FWG) than after immunization (in FEG)
[19].
HISTORY OF MEASLES SURVEILLANCE
All cases of measles were notifiable in FEG from 1962 onwards
[2, 10, 20]. By 1988, high vaccination coverage had led to a
measles incidence of !1 per 100,000 [3, 13, 21]. In keeping
Table 1.
Measles-mumps-rubella vaccination status at
school entry in the former West Germany (FWG) and the former East Germany (FEG), 1998–2001.
a
% vaccinated
Vaccine dose
FWG
FEG
Reunified
Germany
b
—
—
86.1
First, 1998–2001
c
83.8
94.2
90.3
Second, 1998–2001c
17.6
37.1
20.0
First, 1996–1997
a
The % vaccination among children who provided their immunization
documents was 85.5% in 1996–1997 and 89.1% in FWG, 90.2% in FEG,
and 89.3% in both together in 1998–2001.
b
Data from 183 of the 440 health departments in Germany [16].
c
Data from 15 of 16 FWG states and all 5 FEG states (Robert KochInstitut, unpublished data).
Progress toward Measles Elimination in Germany • JID 2003:187 (Suppl 1) • S209
with the recommendation to submit samples from all suspected
cases for laboratory investigation, a high proportion (80% in
1990) of reported cases was laboratory confirmed [17]. In addition, only a small proportion (10%) of suspected measles
cases was actually confirmed [17], as reported from other countries with low measles incidence [22, 23]. Over 50% of notified
cases in FEG were reported to have been vaccinated [20]. This
proportion decreased after reunification, fluctuating between
19.7% and 36.4% (mean, 26.0%) from 1993 to 2000. Among
preschool children, this proportion was even lower, averaging
only 11.1% during the same period [20] (Robert Koch Institute,
unpublished surveillance data).
In FWG, only measles-related deaths were notifiable from
1962 until the end of 2000. A rough estimate (based on mortality data) of measles incidence in FWG in the 1980s and mid1990s was 90 and 50 per 100,000 population, respectively [24].
From 1969 to 1990, measles mortality was consistently higher
in FWG than FEG (figure 1). Thereafter, data are only available
for reunited Germany. Hospitalization data for measles are
available from 1993 to 1999 (figure 2). Apart from the increase
in hospitalizations in 1996, which was due to a measles epidemic, a decreasing trend was observed in FWG, while in FEG
fewer than 0.5 hospitalizations per 100,000 population were
consistently observed after 1993.
CURRENT STATUS OF MEASLES
SURVEILLANCE
Sentinel surveillance for measles. A sentinel system for laboratory-supported measles surveillance, Arbeitsgemeinschaft
Masern, was established in October 1999 with 11200 primary
care physicians, mainly pediatricians (∼18% of all pediatricians)
[25–29]. Sentinel data provide more information on reported
cases than do the statutory surveillance data, including virus
isolation and genotyping performed in some cases at the National Reference Center for Measles, Mumps and Rubella (NRC
MMR) [26], and they also permit an estimate of measles incidence [28]. Sentinel data are thus a valuable complement to
statutory data [30].
Statutory national surveillance system (2001). In 2001,
all cases of clinically and laboratory confirmed measles became
notifiable by statute in Germany (CDLRA) according to a case
definition similar to that suggested by WHO (figure 3). The
following data are received at the national level for each casepatient: month and year of birth, sex, date of symptom onset,
date of diagnosis, confirmation status according to case definition, results of laboratory testing, and hospitalization, vital,
and vaccination status.
MEASLES DISEASE BURDEN IN 2001
Measles incidence. As determined on the basis of 6024 measles cases reported to the statutory surveillance system, the
incidence of measles was 0.7 per 100,000 population in FEG,
8.7 per 100,000 in FWG, and 7.3 per 100,000 in Germany for
the year 2001 (table 2). In both parts of Germany, incidence
is highest among 1- to 4-year-old children, but in FWG, morbidity is high among older children and adolescents as well
(table 2).
As determined on the basis of 867 measles cases reported to
the sentinel system, the incidence of measles was 0.5 per 100,000
population in FEG, 14.9 per 100,000 in FWG, and 13.8 per
Figure 1. Measles mortality in Germany, 1962–2000. Mortality data for the former West Germany (FWG) are available only until 1990; thereafter,
mortality data are available only for both parts of Germany together. FEG, former East Germany. Sources: Federal Office of Statistics, Wiesbaden and
[2].
S210 • JID 2003:187 (Suppl 1) • Hellenbrand et al.
Figure 2. Measles hospitalizations in the former East Germany (FEG) and the former West Germany (FWG), 1993–1999. *, Epidemic year. Source:
Federal Office of Statistics, Wiesbaden.
100,000 in Germany for the year 2001 (table 2). The incidence
for specific age groups among children was similar for the
sentinel and statutory surveillance systems, although the estimates based on sentinel data are higher among children !5
years of age and lower in those between 10 and 19 years of age
(table 2). The age distribution from both systems reveals that
a significant proportion of disease occurs in school-age
children.
Laboratory confirmation. In FEG, 71% of the cases reported were laboratory confirmed compared with 34% in FWG
(statutory surveillance data, table 2). According to data from
the sentinel system, laboratory diagnosis was performed by
physicians in 43% of suspected measles cases, of which 58%
were confirmed [30].
Vaccination status of measles cases. Information on vaccination status of cases reported to the statutory surveillance
system was unreliable in 2001 due to problems with the surveillance software. In the sentinel system, only 7% of all reported and 8.4% of the laboratory-confirmed cases were among
children who were vaccinated. Of the children with laboratoryconfirmed cases, 2 had been vaccinated twice (unpublished
data, Robert Koch Institute).
Measles-related hospitalizations. Among the 80% of cases
with available information on hospitalization, a higher proportion was hospitalized in FEG (35%) than in FWG (11%)
(table 2). Information on the duration of hospitalization is
missing in most cases. In the sentinel system, no hospitalizations were reported from FEG, and 2.2% of cases reportedly
were hospitalized in FWG.
Measles-related complications and deaths. Statutory reporting does not include information on complications other
than death. One death, that of an 8-month-old unvaccinated
male infant with laboratory-confirmed measles (IgM positive)
and streptococcal sepsis, was reported to the statutory surveillance system. Sentinel data showed that the incidence of
complications was highest among older children (27% among
those 15–19 years old), followed by adults (24%) and children
!5 years of age (21%). In 5- to 14-year-old children, the complication rate was 16%.
Regional variation in measles incidence and outbreaks.
In FEG, no measles cases were reported from 83 (74%) of the
112 counties, and in a further 12 counties (11%), the incidence
was !1 per 100,000. Thus 17 counties (15%) had an incidence
of ⭓1 per 100,000 (figure 4). Only one county had an incidence
of 110 per 100,000, at 28.5 per 100,000 population, and it was
related to the only reported outbreak in FEG, which originated
in a neighboring FWG county. In FWG, only 60 (18%) of the
328 counties reported no cases of measles, a further 45 counties
(14%) had an incidence of !1 per 100,000 population, leaving
223 counties (68%) with an incidence of ⭓1 per 100,000. Fiftyseven counties (17%) had an incidence of 110 per 100,000
(figure 4).
A measles outbreak that occurred in the state of SchleswigHolstein in northern Germany from January to April 2001 was
investigated by the local health authorities with assistance from
the Robert Koch Institute (RKI) [31]. A total of 141 of 167
cases either reported or identified through active-case finding
could be interviewed, of which 133 fulfilled the clinical case
definition. Of these, 21 (16%) were also laboratory confirmed.
The epidemic curve is shown in figure 5. Only 17% of casepatients were ⭐5 years of age, while 25% were 6–10 years old,
46% were 11–20 years old, and 11% were 120 years old. Most
(95/133) of the case-patients attended school or public day care
institutions. Five (4%) case-patients were hospitalized. Most
patients (93%) had never been vaccinated, and 8 of the 9 persons with a history of vaccination were unable to provide proof
of their vaccination status. The outbreak came to an end after
a 2-week Easter holiday and an information campaign conducted upon return to school to encourage vaccination of susceptible children. This outbreak was not detected by the sentinel
Progress toward Measles Elimination in Germany • JID 2003:187 (Suppl 1) • S211
Figure 3.
German measles case definition. CF, complement fixation; NT, neutralization test; PCR, polymerase chain reaction.
system [28]. Additional outbreaks occurred in other areas of
Germany, such as Northrhine Westphalia and Bavaria, in 2001
but were not formally investigated by RKI. The largest outbreak
in Bavaria occurred from November 2001 to April 2002, with
1166 measles cases in an area known for its large anthroposophical population who object to vaccination against childhood diseases [32].
ROLE OF THE LABORATORY
Laboratory confirmation of suspected cases is increasingly important as the incidence of measles decreases in a country.
WHO recommends that in countries attempting to eliminate
measles, all isolated cases and at least 1 case from each chain
of transmission should be laboratory confirmed [33]. This is
the approach taken in FEG, where 71% of cases reported to
the statutory surveillance system were laboratory confirmed
(table 2), compared with only 34% of cases reported from
FWG.
In Germany, testing for measles is done mainly in private
laboratories by detection of virus-specific antibodies. The NRC
MMR plays a key role in performing seroprevalence surveys
[17] and is also involved in confirming the clinical diagnosis
of measles for physicians participating in the measles sentinel
system, performing 85% of all testing. Besides serologic methods, detection of viral RNA by nested polymerase chain reaction
and virus isolation are used. Genotyping was performed according to WHO recommendations [34, 35] in selected cases.
In the high-incidence region of southern Germany, genotypes
C2 and D6 were detected in 2000 as in previous years [36].
However, in 2001, preliminary analysis showed only a new
variant, genotype D7, in this region. This D7 genotype was also
found in the outbreak in Nordfriesland described above and
during a measles outbreak in a military base in southern Germany (RKI, unpublished data). In FEG, where measles incidence is very low, genotypes B3, D4, D6, G2, and D7 were
detected. This suggests that at least some of these cases may
S212 • JID 2003:187 (Suppl 1) • Hellenbrand et al.
have been imported. The D6 genotype also circulated in other
European countries, and the other types were found in the subSahara region (B3), in Asia and Africa (D4), and in Indonesia
(G2) [37].
RECENT INITIATIVES
In 1999, the National Ten-Item Program to Increase the Acceptance of Vaccination and to Increase Vaccination Coverage
in Germany [38] and the more specific National Intervention
Program: Measles, Mumps and Rubella, with an emphasis on
the elimination of measles [39], were launched. These programs
aim to improve surveillance and vaccination in a complex federalized system through a harmonization of efforts among institutions and responsible individuals at the federal and state
level, in particular all levels of the Public Health Service, physicians in private practice, statutory health insurance, medical
and paramedical organizations, and occupational health
services.
The nationwide establishment of measles surveillance, which
has been instrumental in documenting and thereby increasing
awareness of the burden of disease due to measles in Germany,
and the adoption of STIKO recommendations for vaccination
by all states were key achievements for the acceleration of measles elimination. The role of the Public Health Service in administration of vaccination upon identification of missing vaccinations in school children has been strengthened through
funding agreements with statutory health insurance in some
states.
Surveys in Germany have shown that advice of the physician
is paramount in influencing the decision for vaccination, yet
patient-physician contacts were not routinely used to check
vaccine coverage [40–42]. Improved remuneration, at least in
some jurisdictions, and extension of the license to vaccinate to
all medical specialties are recent incentives that should encourage use of the patient-physician contact to identify and
administer outstanding vaccines. A court ruling from 1999 that
Table 2.
Characteristics of reported measles cases by region, Germany, 2001.
FWG ⫹ FEG
FEG
FWG
Statutory data
Sentinel data
Statutory data
Sentinel data
Statutory data
Sentinel data
(n p 5924; IR p 8.7) (n p 864; IR p 14.9)a (n p 100; IR p 0.7) (n p 3; IR p 0.5)a (n p 6024; IR p 7.3) (n p 867; IR p 13.8)a
Variable
Age group data are no. of cases (%), no.
of cases per 100,000 population
b
!1 year
102 (2%); 15.1
43 (5%); NA
4 (4%); 4.1
—
106 (2%); 13.7
43 (5%); 34.1
1–4 years
1653 (28%); 57.2
356 (41%); NA
38 (38%); 13.3
1 (33%); NA
1691 (28%); 53.2
357 (41%); 71.9
5–9 years
1576 (27%); 41.0
298 (34%); NA
14 (14%); 3.5
1 (33%); NA
1590 (27%); 37.4
299 (34%); 44.2
10–14 years
1018 (17%); 25.8
124 (14%); NA
10 (10%); 1.3
1 (33%); NA
1028 (17%); 21.9
125 (14%); 15.7
15–19 years
785 (13%); 21.6
30 (3%); NA
5 (5%); 0.5
—
790 (13%); 17.0
30 (3%); 12.8
⭓20 years
767 (13%); 1.4
13 (1%); NA
29 (29%); 0.3
—
796 (13%); 1.2
13 (1%); 1.4
8 years
5 years
6 years
6 years
8 years
5 years
Median age
Vaccination statusc
Unvaccinated
NA
773 (92.9%)
1 dose
NA
55 (6.6%)
NA
⭓2 doses
NA
4 (0.5%)
NA
35 (35%)
0
3
Hospitalizedd within 30 days of rash onset
502 (11%)
19 (2%)
NA
0
NA
773 (92.6%)
3
NA
58 (6.9%)
0
NA
537 (11%)
4 (0.5%)
19 (2%)
Final classification of cases
Clinically confirmed
2967
353
16
2983
356
Laboratory confirmed
2004
251
71
—
2075
251
260
13
—
966e
260
Epidemiologically linked
NOTE.
a
953e
Unless otherwise stated, data are no. (%) of reported cases. FEG, former East Germany; FWG, former West Germany; IR, incidence rate per 100,000 population; NA, not applicable.
Estimated according to no. of participating physicians in relation to all doctors in the region.
b
Twenty-three cases reported to the statutory system did not have information on age.
c
Vaccination history available for 835 (96%) sentinel cases. Vaccination history for cases reported to the statutory system is unreliable.
d
Information on hospitalization available for 4758 (80%) and 83 (83%) of cases reported to the statutory system from FWG and FEG, respectively. Information on hospitalization was generally available
for all sentinel cases. Duration of hospitalization was not available in most cases.
e
Epidemiologically linked to laboratory-confirmed case.
Figure 4. Measles incidence in the 16 German states in 2001. Upper boundary of intervals (not shown) is 0.0 to !0.1, 0.1 to !1.0, 1.0 to !10,
10.0 to !50, and 50 to !600. Source: statutory surveillance data, Robert Koch Institute.
clearly defined requirements for patient information prior to
vaccination and recognized the STIKO recommendations as
state of the art reduced physicians’ concerns regarding liability.
In addition, improvement of the medical curriculum with respect to immunization is planned.
Studies have shown that parents feel inadequately informed
about issues related to vaccination, that many do not perceive
vaccination as being an important disease-prevention measure
for their children, and that fear of adverse effects is common
[42, 43]. Efforts are underway to improve awareness of the
importance and safety of vaccination among the general population through increased involvement of people in paramedical and other health care or people-oriented professions, such
as midwives and day care and school staff, as well as through
Vaccine Information Days organized by state and local public
health services. More consolidated campaigns are planned in
S214 • JID 2003:187 (Suppl 1) • Hellenbrand et al.
conjunction with the Federal Center for Health Education. In
addition, agenda-setting in the media, including the Internet,
is being implemented by RKI and other medical and paramedical organizations.
DISCUSSION
The difficulties in attaining high vaccine coverage in a country
with a decentralized health care and public health system, such
as in FWG, are illustrated by this overview. In contrast, FEG
had a centralized health care system with mandatory vaccination and thus attained much higher vaccination coverage,
thereby obtaining a level of measles control approaching elimination. More than a decade after reunification, the impact of
achieving high age-appropriate vaccination coverage in FEG in
the 1980s is still evident, with a ∼15–fold lower incidence of
Figure 5. Epidemic curve, measles outbreak in the county of Nordfriesland, Germany, January–April, 2001 (n p 133 cases).
measles, fewer measles-related hospitalizations, and only very
few small outbreaks. Despite lower antibody levels, there is no
evidence of waning vaccine-induced immunity among persons
vaccinated in FEG in the 1980s: The incidence of measles
among persons 15- to 19-years-old in FEG (0.5 per 100,000
population) was 140-fold lower than the incidence among their
counterparts in FWG.
Despite a decrease in vaccine coverage immediately following
reunification, vaccine coverage at school entry remains higher
in FEG than FWG, presumably reflecting the wider acceptance
in FEG of vaccination as a preventive measure. Although vaccine coverage at school entry has improved in FWG, ageappropriate vaccination remains far below the target. The investigation of the outbreak in the county of Nordfriesland and
the overall age distribution of measles cases show that insufficient vaccine coverage of school-age children is an important
risk factor for the occurrence of outbreaks that may require
supplementary immunization activities. Further efforts are
needed to routinely document vaccine coverage at an earlier
age and to perform more comprehensive analyses of vaccine
coverage at the regional level.
Further improvement in vaccine coverage is expected from
the recent harmonization of vaccination recommendations at
the state level, establishment of uniform collection of vaccine
coverage data, and involvement of local health departments in
vaccination of school children. The latest change in vaccination
schedule, recommending earlier administration of the second
dose of MMR, is expected to improve age-appropriate as well
as overall vaccine coverage. Obligatory reporting of adverse
vaccine effects will provide a sound database for the assessment
of vaccine safety.
Although the overall incidence of 7.3 (13.8 according to
sentinel data) measles cases per 100,000 population in 2001 is
likely an underestimate, the incidence of measles in Germany
has decreased significantly from the estimate of ∼50 per 100,000
per year made for FWG only a few years ago. This is also
reflected in the continued decrease in hospitalizations due to
measles in FWG from 1997 onwards. However, the remaining
large regional differences permit the continued occurrence of
significant outbreaks.
In conclusion, important prerequisites for attaining measles
elimination in Germany are now in place. However, Germany
remains a country with poor control of measles activity [44],
as, according to sentinel data, the proportion of cases confirmed
by laboratory remains higher than 50% and age-appropriate
coverage with the first dose of measles vaccine remains well
below 90%, resulting in an unstable incidence. Nonetheless, the
increased awareness of this problem brought about by the establishment of comprehensive surveillance and the ongoing
development and implementation of the national control and
prevention programs in Germany should greatly accelerate the
achievement of elimination to ensure meeting the time frame
put forward by the WHO Regional Office for Europe.
Acknowledgments
We thank our colleagues Eva Kristiansen-Trenel and Volker
Bach for their help in obtaining literature, Christian Kluger,
Andreas Reich, and Gérard Krause for preparing the epidemiologic curve of the outbreak in Nordfriesland (i.e., figure 5),
and Guido Wessels for help in preparing figure 4.
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