International Journal of Infectious Diseases 83 (2019) 95–97

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International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Perspective

Is the global measles resurgence a “public health emergency of

international concern”?
David N. Durrheima,* , Natasha S. Crowcroftb , Lucille H. Blumbergc
a
School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2287, Australia
b
Public Health Ontario and University of Toronto Laboratory Medicine and Pathobiology and Dalla Lana School of Public Health, Toronto, ON, Canada
c
National Institute for Communicable Diseases, Johannesburg, South Africa

A R T I C L E I N F O

Article history:
Received 16 April 2019

Corresponding Editor: Eskild Petersen,

Aarhus, Denmark

The 2005 revision of the International Health Regulations (IHR) other States for which a coordinated international response is
came into force on 15 June 2007 and is legally binding on 196 essential” (World Health Organization, 2014). This is the only
countries, including all the Member States of World Health PHEIC that remains in effect, five years after it was first declared.
Organization (WHO). In the IHR, a public health emergency of How does the global measles situation measure up against the
international concern (PHEIC) is defined as: “an extraordinary four PHEIC criteria considering the poliovirus precedent?
event that may constitute a public health risk to other countries Firstly, is the public health impact of this event potentially serious?
through international spread of disease and may require an There was considerable fanfare following the release of the 2016
international coordinated response.” (World Health Organization, estimated global measles deaths. In a joint press statement, the
2005). The IHR requires that countries notify the WHO of any United States CDC, GAVI, UNICEF and WHO, lauded the 84% decline
public health event that meets any two of the following four in measles deaths from 550,000 in 2000 to 89,780 in 2016, the first
criteria: Is the public health impact of this event potentially time that there had been less than 100,000 measles deaths
serious?; Is this event unusual or unexpected?; Is there the recorded globally in a particular year (World Health Organization,
potential for international spread?; or Is there the potential for 2017). Tragically the 2017 figures are far less rosy, with 109,638
travel and trade restrictions? deaths reported due to measles (Dabbagh et al., 2018); almost
The purpose of declaring a PHEIC is to focus attention on those 20,000 additional deaths over 2016, an increase of 22%! This
acute public health risks that have the potential to cross borders upsurge in deaths is unrelenting. It suggests that current strategies
and threaten people worldwide, and “require coordinated mobi- are either ineffective or ineffectually implemented. This is an
lisation of extraordinary resources by the international communi- enormous public health impact and undoubtedly serious.
ty” for prevention and response. The decision to declare a PHEIC Secondly, is this event unusual or unexpected?
rests with the WHO Director-General. A global expert consultation in 2010 concluded that measles
To date four PHEICs have been declared; the: 2009 H1N1 eradication was technically and programmatically feasible with
influenza pandemic declaration; 2014 polio declaration; 2014 existing tools and should be pursued (World Health Organization,
Ebola declaration with the outbreak in West Africa; and 2016 Zika 2011). At the World Health Assembly in 2012, 198 countries
virus declaration. The polio PHEIC declaration stands apart as committed to achieving interruption of measles virus circulation in
poliovirus is certainly not a novel or emerging pathogen, but it sets four World Health Organization (WHO) Regions by 2015 and in five
an interesting and laudable precedent. The PHEIC issued on 5 May Regions by 2020 (Global Vaccine Action Plan, 2012). There was
2014 references the resurgence of polio after its near-eradication, encouraging progress with the Americas verified as having
deeming this an “extraordinary event and a public health risk to interrupted endemic measles transmission in 2016, and elimina-
tion verified in 37 (of 53) European, 7 (of 27) Western Pacific, and 4
(of 11) South East Asian countries by the end of 2018.
* Corresponding author.
However, four Regions (the Americas, Europe, South East Asia
E-mail address: [email protected] (D.N. Durrheim). and Eastern Mediterranean) experienced massive measles

https://doi.org/10.1016/j.ijid.2019.04.016
1201-9712/© 2019 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
96 D.N. Durrheim et al. / International Journal of Infectious Diseases 83 (2019) 95–97

outbreaks in 2017. The Americas was the only Region to have elimination settings (Gastañaduy et al., 2018). However, this level
achieved measles elimination and was celebrating that accom- of response is justified by the need to sustain elimination for the
plishment in 2016, the same year that measles deaths reached a good of everyone, but relies on countries co-operating with each
nadir. However, the region lost that status in 2017 with re- other and having the political support to make it happen. The
established transmission in Venezuela and Brazil as well as situation in the Americas and Europe dramatically illustrates the
measles outbreaks in many other countries throughout 2018. The result of a few countries dropping the ball – everyone suffers the
Americas have led the world in being the first Region to achieve colossal direct and opportunistic health costs, not to mention
smallpox, polio and measles elimination. This failure to sustain personal suffering, because other countries have gifted them
measles elimination stands in stark contrast to the previous measles outbreaks. The IHR is the best, and perhaps only, tool for
achievements, underlining the current crisis. In the European dealing with this situation effectively, and the question arises, Why
Region both Germany and Russia re-established measles trans- has measles not already been declared a PHEIC? What is
mission for more than 12 months after previously interrupting constraining global public health leaders and why does measles
transmission for 24 months, and Europe experienced record command so little support from global donors, the United Nations
numbers of measles cases with 72 deaths in 2018 (EURO, 2019). and national governments when compared with other public
The UNICEF announcement that global measles cases had health crises?
increased by 48.1% between 2017 and 2018, with 98 countries The public health urgency of the current global measles
reporting measles cases in 2018 compared to 2017 is profoundly situation has been recognised by technical experts involved in
alarming (UNICEF, 2019). Thus it is hard to argue that this event is all aspects of measles elimination. The stagnation of measles first
not extraordinarily unusual and unexpected. dose coverage at approximately 85% for the past eight years is
Thirdly, is there the potential for international spread? There is dismally less than the 95% homogeneous coverage of each birth
probably no better recent illustration of the ability of measles virus cohort recommended by SAGE. Globally, 20.8 million infants did
to rapidly spread globally than the 2014 outbreak in the not receive measles vaccine through routine immunization
Philippines. This outbreak saw the B3 measles genotype seeded services in 2017. The inadequacy of measles surveillance in many
into the vast majority of countries contributing to the Measles countries has further severely hampered progress towards
Nucleotide Surveillance (MeaNS) database. The 2019 Philippines elimination goals (SAGE, 2018). What we observe is the predictable
B3 and Thailand D8 measles outbreaks are providing a startling result of the system we have created; interludes of relative
déjà vu experience with all countries that have been verified to tranquillity followed by massive measles outbreaks, often affecting
have eliminated measles in the Western Pacific Region currently older age groups than were historically impacted, which consume
being inundated with importations. Similarly, the outbreak in huge amounts of public health resources and undermine confi-
Venezuela that started in 2017 spread to surrounding countries, dence in immunization.
with the worst impact in Brazil where PAHO reported 10,334 In a recent call to action, the six chairpersons of Regional
confirmed cases and 12 deaths in a little over a year, including Verification Commissions for Measles and Rubella elimination
amongst vulnerable Indigenous communities (PAHO, 2019). Out- discussed the compelling epidemiological, economic and ethical
breaks have flared constantly since then, affecting 12 countries of arguments for setting a global measles eradication goal and
the Americas in 2018. strongly advocated that it was urgent that exceptional coordinated
Measles is uniquely transmissible. This is graphically illustrated efforts were made to ensure a world where no child dies of measles
by comparing measles’ basis reproduction number (R0), or the (Durrheim et al., 2019).
number of secondary cases on average resulting from the So is a PHEIC declaration justified in response to the global
introduction of an infectious case into a fully susceptible measles resurgence? Three of four diagnostic criteria appear
population, with those of the specific infectious diseases previ- satisfied and the current deteriorating situation is placing many
ously declared as PHEICs. Although population density, birth rates young lives at grave risk. A PHEIC declaration could: reenergize the
and opportunities for transmission result in some variation global community to urgently strengthen health systems to ensure
between countries, the R0 for measles is generally considered to that every child born is reached with two potent doses of measles-
be about 16 (Guerra et al., 2017). In comparison, polio has an R0 of containing vaccine; rapidly stimulate communication innovation
6.0, H1N1 2009 of 1.3, Ebola of 1.5, and Zika virus of 2.1 (van den to effectively engage migrants and travellers on the risks of
Driessche, 2017). Measles’ phenomenal transmissibility coupled measles as well as the benefits and safety of immunisation; refocus
with the unbridled volume and speed of international travel, and weary donors on the incredible return that increased investment in
the inadequately immunised status of many international travel- measles immunisation and accelerated elimination achievement
lers, guarantees not only a potential but a reality of vast would deliver; and release emergency funding from the Pandemic
international measles spread as currently being experienced. Emergency Financing Facility of the World Bank Group (Gostin and
Fourthly, is there the potential for travel and trade restrictions? It Katz, 2016).
is hard to imagine that any government would impose travel or Should “extraordinary resources” be mobilised by the interna-
trade restrictions on the basis of current measles epidemiology, tional community to respond to this public health risk that has the
although there is clear recognition by some verified countries that potential to cross borders and threaten people worldwide? If we
international workers, business and recreational travellers, and follow the advice that Plato put in the mouth of Socrates, “we must
economic migrants are a major source of virus importation (WPRO, go wherever the wind of the argument carries us.” (Plato, 1974)
2018; EURO, 2018). There have even been suggestions recently by Thus the answer must be “yes” – measles is a de facto PHEIC – it
some countries that international travellers should provide proof should be declared!.
of measles vaccination or proof of immunity as an entry or visa
requirement. Conflict of interest
A key characteristic of a PHEIC is the requirement for
extraordinary resources. The cost of firefighting measles is No conflict of interest to declare.
extremely high when compared with the cost of prevention
(Sundaram et al., 2019; Ramsay et al., 2019). Indeed by Funding source
conventional economic metrics, it is not cost-effective to respond
to measles outbreaks in the way that is recommended in None.
 D.N. Durrheim et al. / International Journal of Infectious Diseases 83 (2019) 95–97 97

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