We read with interest the communication from Dr. Gaddis who pointed out the extent of measles in Ukraine and areas beyond those we discussed in our article.
We focused on the European Union in part because many Americans tend to think of western Europe as medically sophisticated and having all-inclusive medical care systems. And despite the medical largess of western Europe, measles has again become endemic in several countries.
To respond to Dr. Gaddis’ specific concern, we now show a world map of measles (Figure 1). We agree wholeheartedly with his assertion that eastern Europe and parts of the old U.S.S.R. had larger outbreaks with the Ukraine among the biggest players (darker red color). For Ukraine, measles continues to circulate likely related to low immunization rates, expedited by the social and political upheavals in that area. Venezuela also fits this category of immunization interruption due to social and political problems.
Figure 1.
World map of measles activity as of the summer of 2019
From January 1 through July 31 2019, 182 countries reported 364,808 measles cases to WHO. the Democratic republic of Congo, Ukraine, and Madagascar had the largest 2019 outbreaks (Madagascar rate declining lately due to nationwide vaccination campaign.) Other countries with large outbreaks, in alphabetic order, are: Angola, Cameroon, Chad, Kazakhstan, Nigeria, Philippines, South Sudan, Sudan, and Thailand.
WHO source: https://www.undispatch.com/map-of-the-day-measles-outbreaks-around-the-world/
A number of medical-resource-limited countries (many African countries, southeast Asian countries, and India) not unexpectedly also had notable measles activity (Figure 1). Finally, New Zealand, and Brazil with reasonable-to-good medical resources joined the list with high measles activity.
So, ongoing measles is multifactorial:
Some countries have limited medical resources.
Other countries have disruptions in their social and medical networks, so immunizations are neglected.
Some affluent and socially stable countries have population subsets who refuse or delay vaccines and thus establish pockets of unimmunized persons where measles can flourish.
The real message of our story: There is likely no country to which one can travel that one can confidently label as truly without any risk of potential measles exposure. So, clinicians should be aware that there are few measles-safe zones and when seeing patients who plan international travel, ensure that measles vaccination is provided (including an accelerated vaccine for infants ≤12 months). This definitely extends to those healthcare workers who are internationally traveling for clinical or academic missions.