Measles outbreaks in the 21st century
Outbreaks of the viral disease measles continue to occur in the 21st century. Although an effective measles vaccine exists, a controversy regarding the popular MMR formulation in the late 1990s has led to reduced vaccination coverage in some countries, which has disrupted efforts towards the eradication of measles.
Southern regions of the province of Quebec witnessed a measles outbreak affecting 94 persons in the Spring and Summer of 2007. The outbreak lasted 25 weeks, included more than one strain of the measles virus and had 12-17 generations of spread.
In 2008, Canada had more than 30 confirmed cases in Ontario in 2008, with more than half reported in Toronto.
 United States
Indigenous measles were declared to have been eliminated in North, Central, and South America; the last endemic case in the region was reported on November 12, 2002, with rural Canada still having minor endemic status. Outbreaks are still occurring, however, following importations of measles viruses from other world regions. In June 2006, an outbreak in Boston resulted after a resident became infected in India, and in October 2007, a Michigan girl who had been vaccinated contracted the disease overseas.
Between January 1 and April 25, 2008, a total of 64 confirmed measles cases were preliminarily reported in the United States to the Centers for Disease Control and Prevention, the most reported by this date since 2001, and the highest total number in six years. Of the 64 cases, 54 were associated with importation of measles from other countries into the United States, and 63 of the 64 patients were unvaccinated or had unknown or undocumented vaccination status. By July 9, 2008, a total of 127 cases were reported in 15 states, making it the largest US outbreak since 1997 (when 138 cases were reported). Most of the cases were acquired outside of the United States and afflicted individuals who had not been vaccinated.
On May 24, 2011 the Centers for Disease Control and Prevention reported that the United States has had 118 measles cases so far this year. The 118 cases were reported by 23 states and New York City between Jan 1 and May 20. Of the 118 cases, 105 (89%) were associated with cases abroad and 105 (89%) of the 118 patients had not been vaccinated.
There was an outbreak of measles in San Diego, California in early 2008. The outbreak is traced to an unvaccinated 7-year-old child who went on a family trip to Europe. The CDC refers to this as an "import-associated outbreak". The final diagnosis included 11 additional cases of measles in unvaccinated children in San Diego. All of the confirmed patients were not vaccinated because they were younger than 1, the minimum age for measles inoculation, or because their parents declined to have them vaccinated. The typical vaccine would be the MMR vaccine. The incident drew attention to the controversy over MMR vaccination. This was San Diego County's first measles outbreak since 1991.
There was an outbreak of measles in Pima County, Arizona in February 2008. There were 13 laboratory confirmed and 4 probable measles cases, though 22 cases were previously reported. The outbreak started with a visitor from Switzerland and resulted in a public health emergency declaration by Pima County. The last confirmed Pima County case occurred in 1994, and the last outbreak occurred in 1991.
Approximately 1000 cases of the disease were reported in Israel between August 2007 and May 2008 (in sharp contrast to just some dozen cases the year before). Many children in ultra-Orthodox Jewish communities were affected due to low vaccination coverage.
In 2008, Europe faced a measles epidemic, including large outbreaks in Austria, Italy, and Switzerland. In 2010, 30,367 cases were reported from across the 32 European countries reporting to euvac.net (72% of which were reported from Bulgaria, and 17% from France), and 21 measles-related deaths (17 in Bulgaria, 2 in France, and 1 in Romania). The World Health Organization reported over 26,000 measles cases in 36 European countries from January to October 2011, with 83% occurring in western Europe. There were nine deaths, of which six were French, and 7,288 hospitalizations.
In September 2008 an outbreak occurred among anthroposophists' children in the cities of The Hague and Utrecht. Some 90 infections of unvaccinated children were recorded by the Dutch National Institute for Public Health and the Environment (RIVM) by September 29. It was expected the outbreak would spread to the region of the Veluwe, locally known as a 'Bible Belt' with a large population of unvaccinated children on religious grounds.
 United Kingdom
After the MMR vaccine controversy began, the MMR vaccination compliance dropped sharply in the United Kingdom, from 92% in 1996 to 84% in 2002. In some parts of London, it was as low as 61% in 2003, far below the rate needed to avoid an epidemic of measles. By 2006 coverage for MMR in the UK at 24 months was 85%, lower than the about 94% coverage for other vaccines.
After vaccination rates dropped, the incidence of two of the three diseases increased greatly in the UK. In 1998 there were 56 confirmed cases of measles in the UK; in 2006 there were 449 in the first five months of the year, with the first death since 1992. Cases occurred in inadequately vaccinated children. The age group affected was too old to have received the routine MMR immunizations around the time the paper by Wakefield et al. was published, and too young to have contracted the natural disease as a child, and thus to achieve a herd immunity effect. With the decline in infection that followed the introduction of the MMR vaccine, these individuals had not been exposed to the disease, but still had no immunity, either natural or vaccine induced. Therefore, as immunization rates declined following the controversy and the disease re-emerged, they were susceptible to infection. Measles cases continued in 2006, at incidence rates 13 times greater than 1998 levels. Two children were severely and permanently injured by measles encephalitis despite undergoing kidney transplantation in London.
Disease outbreaks also caused casualties in nearby countries. 1,500 cases and three deaths were reported in the Irish outbreak of 2000, which occurred as a direct result of decreased vaccination rates following the MMR scare.
In 2008, for the first time in 14 years, measles was declared endemic in the UK, meaning that the disease was sustained within the population. This was caused by the preceding decade's low MMR vaccination rates, which created a population of susceptible children who could spread the disease. In May 2008, a British 17-year-old with an underlying immunodeficiency died of measles.
Beginning in April 2009 there was a large outbreak of measles in Bulgaria, with 23,791 cases, including 24 deaths, reported up to 28 July 2010. From Bulgaria, the strain was carried to Germany, Turkey, Greece, Macedonia, and other European countries.
Between January 2008 and April 2011, over 17,000 cases of measles were reported in France, including 2 deaths in 2010 and 6 deaths in 2011. From January to October 2011, there were 14,000 reported cases of measles in France, leading the country to launch an awareness campaign about MMR vaccination.
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