Vaccine xxx (2018) xxx–xxx

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Vaccine
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Conference report

Measles control in Australia – threats, opportunities and future needs

C. Raina MacIntyre a,h, Elizabeth Kpozehouen a,⇑, Mohana Kunasekaran a, Kathleen Harriman c,
Stephen Conaty d, Alexander Rosewell a, Julian Druce e,g, Nicolee Martin e, Anita E. Heywood a,b,
Heather F. Gidding a,b, James Wood a, Sonya Nicholl f
a
School of Public Health and Community Medicine, UNSW Medicine, The University of New South Wales, Sydney, NSW, Australia
b
National Centre for Immunisation Research and Surveillance, Westmead, NSW, Australia
c
California Department of Public Health, Richmond, CA, USA
d
Public Health Unit, South Western Sydney Local Health District, Australia
e
Victorian Infectious Diseases Reference Laboratory, Australia
f
Immunisation Unit, Health Protection NSW, Australia
g
VIDRL, Doherty Institute, Australia
h
Kirby Institute, Biosecurity Program, UNSW Medicine, The University of New South Wales, Sydney, NSW, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Control of measles was the focus of a national workshop held in 2015 in Sydney, Australia, bringing
Received 23 January 2018 together stakeholders in disease control and immunisation to discuss maintaining Australia’s measles
Received in revised form 7 June 2018 elimination status in the context of regional and global measles control.
Accepted 8 June 2018
The global epidemiology of measles was reviewed, including outbreaks in countries that have achieved
Available online xxxx
elimination, such as the Disneyland outbreak in the United States and large outbreaks in Sydney,
Australia. Transmission of measles between Australia and New Zealand occurs, but has not been a focus
Keywords:
of control measures. Risk groups, the genetic and seroepidemiology of measles as well as surveillance,
Measles vaccine
Infectious diseases
modelling and waning vaccine-induced immunity were reviewed. Gaps in policy, research and practice
Measles elimination for maintaining measles elimination status in Australia were identified and recommendations were
Immunisation developed.
Whole of life immunisation register Elimination of measles globally is challenging because of the infectiousness of measles and the need for
Measles 2-dose vaccine coverage rates in excess of 95% in all countries to achieve it. Until this occurs, interna-
tional travel will continue to permit measles importation from endemic countries to countries that have
achieved elimination. When measles cases are imported, failure to diagnose and isolate cases places the
health system at risk of measles outbreaks. Vaccine funding models can result in gaps in vaccine coverage
for adults and migrants. Australia introduced a whole-of-life immunisation register in 2016 and catch-up
vaccination for at-risk communities, which will improve measles control. Research on diagnosis,
immunology, case management and modelling of vaccination strategies are important to ensure contin-
ued control of measles.

1. Introduction elimination of endemic measles in Australia, ongoing outbreaks

In 2014, the World Health Organization (WHO) declared
measles eliminated in Australia, reflecting the success of the
National Immunisation Program and a 1998 measles control cam-
paign [1]. This campaign included moving the second dose of MMR
vaccine to 4 years of age, a catch-up campaign, the establishment
of a childhood immunisation register and financial incentives for
parents and doctors for vaccinating children [2]. Despite the
⇑ Corresponding author at: Level 3 Samuels Building, School of Public Health and
Community Medicine, University of New South Wales, Australia.
E-mail address: e.kpozehouen@unsw.edu.au (E. Kpozehouen).
continue to occur due to importation from endemic countries.
Measles has a reproductive number (R0) of 15–20 [3], therefore
population immunity of 92–95% is necessary to stop measles trans-
mission [4].
Measles remains a global problem, particularly in Asia, with tra-
vel being the major source of importation into Australia. Under-
standing the global epidemiology of measles is important for
measles control. Regionally, movement of people between Aus-
tralia and New Zealand, both of which are declared free of endemic
measles transmission by WHO, contributes to measles outbreaks in
both countries [5]. The largest migrant group into Australia is peo-
ple from New Zealand. Short term travel is also high volume

https://doi.org/10.1016/j.vaccine.2018.06.022
0264-410X/

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10.1016/j.vaccine.2018.06.022
2 C.R. MacIntyre et al. / Vaccine xxx (2018) xxx–xxx
between the countries [6]. Australia has special mutual migration
arrangements whereby citizens from either New Zealand or Aus-
tralia can visit, live and work in either country for indefinite period
of time [7].
Larger and more prolonged outbreaks in Australia in recent
years have heightened the need to close the immunity gaps in
young adults, unimmunised children and selected migrant groups.
The uncertainty around long-term waning of vaccine-induced
measles immunity is also of potential concern [8].
Although there was a 79% decline in worldwide measles deaths
from 2000 to 2015, 134,200 deaths from measles were docu-
mented globally in 2015 [9]. Measles in endemic countries remains
a source of importation into countries which have achieved
elimination.
The United States (US) has seen recent large outbreaks of
measles, including 145 cases in Disneyland, California in 2014
[10], and a 2017 outbreak in the state of Minnesota in a Somali
community, with 71/79 cases being unvaccinated [11]. The num-
ber of reported measles cases in the European Region in 2015
was 30,762, almost twice the number of cases reported in 2014
[12]. Two-thirds of the 53 European region countries have elimi-
nated measles, but measles remains endemic in 14 countries
[13]. A measles outbreak in Romania began in February 2016 with
8803 cases, including 32 deaths, reported as of 18 August 2017
[14]. In addition, as of 17 August 2017, Italy had reported 4193
cases and 3 deaths since June 2016 [13].
Measles incidence decreased by 63% during 2013–2016 in the
WHO African Region. However, the region does not meet targets
for vaccination coverage and surveillance [15]. There has been a
gradual increase in coverage for both the first and second doses
of measles-containing vaccine (MCV), MCV1 and MCV2, in the
South-East Asia Region, but challenges in achieving measles elim-
ination in this region are exacerbated by under-immunisation and
unregistered birth cohorts in populous countries such as India and
Indonesia. In 2015, 3.23 million and 1.52 million children did not
receive MCV1 in India and Indonesia respectively [16]. Asia
remains the most important source of imported measles into
Australia.
Due to the number of large measles outbreaks that have
occurred in the Asia-Pacific region since 2012, and larger and
longer than usual measles outbreaks in recent years in Australia,
a workshop entitled ‘‘Current challenges in measles control” was
held in September 2015 at The University of New South Wales.
The aim of the workshop was to discuss current challenges in the
control of measles globally and issues around measles elimination
status in Australia. The workshop gathered various national and
international experts and stakeholders in policy, surveillance and
research. This report summarises the presentations, discussion
and recommendations from the workshop.
2. Global context and progress in measles control
Since measles is a target for elimination and eventually eradica-
tion, many challenges have been identified and have hindered pro-
gress toward these goals. Some of the contributing factors to
ongoing measles transmission are high population density, regions
with endemic measles, travel and under-vaccination. There has
been intense competition for human and financial resources
between global health initiatives in Africa and Asia, including polio
eradication and introduction of other newer vaccines, resulting in
delays in funding for measles supplementary immunization activ-
ities [17].
Countries in Africa and Asia face weaknesses in health care sys-
tems, which result in low vaccination coverage [15]. Humanitarian
crises resulting from armed conflicts and natural disasters further
adversely affect disease control and eradication efforts, and cause
Please cite this article in press as: MacIntyre CR et al. Measles control in Australia – threats, opportunities and future needs. Vaccine (2018), https://doi.org/
10.1016/j.vaccine.2018.06.022
population displacement, crowding, interruption of health ser-
vices, reduced access to health care facilities and increased risk
of outbreaks, including cross-border transmission [17].
Imported and import-related measles cases account for up to
100% of all cases in regions with interrupted endemic measles
transmission [18]. Between 2001 and 2013 as many as 95–100%
of measles cases reported in the US and Australia were travel
related [18–20], and between 2007 and 2011 secondary measles
transmission was documented in 19% of international flights carry-
ing infectious travellers [18,21]. Since 2005, no endemic transmis-
sion has been observed in Australia, and the South-East Asia Region
and Western Pacific Region were identified as main regions of ori-
gin for imported cases, most aged between 17 and 34 years [18]. In
October 2017, the WHO verification committee declared that New
Zealand has successfully eliminated endemic measles for the first
time, where no local case of measles has originated in New Zealand
between 2014 and 2017. Important locations for measles acquisi-
tion and subsequent importation into Australia are the Philippines,
Indonesia, Thailand, France and Romania.
3. Measles outbreaks in countries with elimination (Australian
and US case studies)
In countries with verified WHO elimination status, measles is
re-emerging as a serious public health threat and outbreaks are
occurring despite good public health infrastructure and health lit-
eracy. Post-elimination epidemiology illustrates that even in the
absence of endemic measles, transmission can still occur with
imported infections and pockets of susceptible individuals.
Among countries with elimination status, the US experienced a
large, multi-state measles outbreak in 2014–2015 with 145 US
cases linked to Disneyland, California. The outbreak likely started
from an international traveller, however the index case was not
identified [19]. In 2014, the US experienced 23 measles outbreaks
with one large outbreak of 383 cases occurring primarily among
unvaccinated Amish communities in Ohio [22], which was sparked
by two unvaccinated Amish men who were infected in the Philip-
pines while doing relief work [22]. The measles virus genotype in
the 2014 and 2015 US outbreaks was B3, identical to the virus type
that was circulating in the Philippines at that time, and which
caused large outbreaks there after Typhoon Haiyan hampered vac-
cination efforts. In 2017, an outbreak with 79 cases occurred, 71
unvaccinated, in a Somali community in Minnesota [23].
In the post-elimination era, most measles outbreaks in Australia
have been linked to imported cases with international travel
[1,24,25]. Global travel has increased exponentially, with 18.9 mil-
lion arrivals to Australia, including returning Australian residents,
non-Australian visitors, and permanent and long-term arrivals in
2016 [26].
In 2012, the largest measles outbreak in Australia since 1997
was sparked by a 25-year-old traveller returning from Thailand
[5]. Of 168 outbreak-related cases, 126 (75%) occurred in South-
Western Sydney where people of Pacific Island descent and New
Zealand origin were a major risk group and comprised 21% of the
cases [27]. Over 35% of the cases were infants less than one year
of age who were too young to be vaccinated, followed by almost
30% of the cases in adolescents 15–19 years of age [5]. Immunisa-
tion coverage in Western Sydney was high as recorded on the Aus-
tralian Immunisation Registry (AIR), but persons of Pacific Island
descent may be New Zealand citizens who are not registered on
the AIR and low coverage was reported in the 1990s among infants
who had most likely grown into adolescence by 2012 [27].
Although there is little research into vaccination practices
among Pacific Island communities in Australia, in New Zealand,
children from Pacific Island communities are at increased risk of
incomplete immunisation [25,28]. In a close-knit culture that
 C.R. MacIntyre et al. / Vaccine xxx (2018) xxx–xxx
practices communal living and has larger families, control mea-
sures such as quarantine may be a challenge to implement without
the support of the community [29].
In the 2012 Sydney outbreak, 20% of cases were infected in
health care facilities [5]. Nosocomial transmission is common in
measles outbreaks in the post-elimination era [2]. Such settings
are ideal for the transmission of measles due to closed spaces, pres-
ence of susceptible individuals, low awareness among health pro-
fessionals, poor triage and long waiting times [28]. Lack of
diagnostic experience among clinicians who may have never seen
a case of measles could allow the disease to go undetected [29,30].
A recent review found that up to 50% of transmission in developed
countries that hold measles elimination status, occurred in a health
care setting [31].
Prior to the 2012 outbreak, other smaller outbreaks of measles
were reported in Australia. In 2010, an outbreak of 9 cases was
linked to an 11-year-old refugee from a measles endemic country,
Malawi, who travelled on an international flight while infectious.
From early February until the end of March 2011, 26 cases were
confirmed, the first outbreak to be reported in the Western Sydney
Local Health District area since 2006. Additional sporadic out-
breaks have occurred in Australia since 2012; a university campus
in Queensland in 2015, and more recently outbreaks in Western
Sydney in 2016 and 2017.
The reasons for continuing measles outbreaks in countries with
verified elimination include an increased volume of travel to and
from endemic countries, and pockets of susceptible populations
due to low immunisation rates in certain vulnerable populations
such as immigrants and refugees possibly due to difficulty in
accessing care, primary vaccine failure, and waning immunity (sec-
ondary vaccine failure) in the absence of endemic disease. In one
study, 8.9% of 763 fully immunised children vaccinated a mean
of 7.4 years earlier, lacked protective levels of circulating
measles-specific neutralising antibodies suggesting that even 2
doses of the current vaccine may be insufficient at a population
level in countries that have achieved elimination status [30]. In
another study of notified cases of measles in Australia, under-
vaccination in both infants of vaccine refusers and adults was com-
mon, but some cases reported two doses of vaccine [31]. Studies
have also shown that vaccine-induced immunity might be less pro-
tective and may wane compared to immunity conferred by natural
measles infection [10,32–35].
4. Methods to maintain measles elimination in Australia –
Identified gaps and recommendations.
The global, regional and national epidemiology of measles, as
well as measles control guidelines and research gaps were
reviewed. Recommendations were drafted based on consideration
of epidemiology, research evidence, discussion and consensus.
The WHO Western Pacific region guidelines on verification of
measles elimination established in 2012 included three verification
criteria for measles elimination: documentation of interruption of
endemic measles virus transmission for a period of at least 36
months, presence of a well-performing and high-quality surveil-
lance system and supportive genotyping evidence [36]. These cri-
teria were assessed using indicators across five lines of evidence
including a description of measles epidemiology, quality of epi-
demiological and laboratory surveillance, population immunity,
vaccination program sustainability, and genotyping data [37].
Genotyping data are important in identifying importation and con-
firming lack of sustained endemic transmission. An Australian
National Verification Committee (NVC) for the Elimination of
Measles was convened in February 2013 to oversee the compila-
tion of data against the five lines of evidence for the period up until
Please cite this article in press as: MacIntyre CR et al. Measles control in Australia – threats, opportunities and future needs. Vaccine (2018), https://doi.org/
10.1016/j.vaccine.2018.06.022
3
the end of 2012, and the NVC’s report, along with reports from 13
other counties, was considered by the RVC during its third meeting
in October 2013[1].
To maintain Australia’s elimination status, it is critical to con-
tinue surveillance that is sensitive enough to detect all cases. In
addition, cases must be promptly isolated, and contacts must be
identified, their immune status assessed, post-exposure prophy-
laxis administered and quarantine implemented as needed. It is
also important to identify under-vaccinated populations vulnera-
ble to outbreaks after importation of measles cases.
The genetic characterisation of wild-type (WT) measles virus
provides a means to study the transmission pathways of the virus
and is an essential component of laboratory-based surveillance. It
aids the differentiation of wild-type virus strains from vaccine
strains, which is important in the elimination and post-
elimination phases. By comparing local sequences to global
sequences, determination of country of origin may be possible.
For molecular epidemiologic purposes, genotype designations are
considered the operational taxonomic unit, while related geno-
types are grouped by clades. The genotypes imported into Australia
since 2008 were mostly from countries in South Asia. Molecular
analysis of the 2012 Sydney outbreak identified a single lineage
of D8 genotype imported from Thailand [5]. However, identifying
additional gene targets could lead to further phylogenetic grouping
and establish more accurate transmission chains. In outbreak set-
tings, it is critical to rapidly differentiate vaccine strains from WT
strains to enable valuable resources to focus on contact tracing
and laboratory investigation of WT cases.
Mathematical modelling strategies have been used to inform
preparedness planning for outbreaks and interventions. Although
limitations exist, one of the most useful outputs of mathematical
models is the ability to estimate the effectiveness of potential
alternative vaccination schedules. Modelling can also track
changes in R0 to predict the risk of epidemics over time. The
Measles Control Campaign in Australia reduced the R0 of measles
from 0.9 to 0.57 and in the same study R was predicted to reach
the epidemic threshold in 2007 [43]. In another, R was predicted
to stay well below the epidemic threshold of 1 until 2012; from
2009 to 2011, R estimates based on national notification data
remained <1 [38,39].
4.1. Policy gaps for measles vaccination in Australia
Low vaccination coverage among risk groups including
migrants, refugees and health care workers is one of reasons for
the re-emergence of measles [40]. Other reasons include delayed
recognition of measles cases in health care facilities and low accep-
tance of mandatory vaccination policies by health care workers
[40–46].
Policies for quick diagnosis and triage of suspected measles
cases and immediate airborne precautions are critical to prevent
spread of measles in hospitals [42,47]. Large health care facilities
should maintain good triage protocols, up to date electronic occu-
pational health records and mandate vaccination of health care
workers against vaccine-preventable diseases such as measles
[41,48] as well require the use of respirators by health care work-
ers caring for patients with suspected measles, regardless of their
presumed immune status [44,49]. In Australia, national guidelines
recommend that all adults have evidence of measles immunity
such as year of birth before 1966, 2 doses of MMR vaccine or sero-
logical evidence of immunity [50], but measles vaccination is not
mandatory. Historically, screening of health care workers for
immunity has been found to be more cost-effective than universal
vaccination [51]. In 2002, New South Wales introduced policy for
screening and vaccination of health care workers against vaccine-
preventable diseases including measles [52].
4 C.R. MacIntyre et al. / Vaccine xxx (2018) xxx–xxx
School-based immunisation campaigns have proven to be effec-
tive in increasing rates of measles immunisation [53]. The Aus-
tralian Measles Control Campaign in 1998 increased
immunisation coverage from 84% to 94% [54]. Immunisation poli-
cies for school children in Australia differ from state to state;
NSW preschools cannot enrol a child unless parents provide infor-
mation about their child’s immunisation status including whether
parents are conscientious objectors to vaccination. A recent change
in policy excludes unvaccinated children from childcare in several
States without a medical exemption. There is a school immunisa-
tion schedule for high school students, including catch-up immuni-
sation for 2 doses of MMR vaccine for all students [55].
4.2. Research to inform measles control
In Australia, genotyping of measles virus is not routine. Geno-
typing differentiates wild-type and vaccine strains of measles
and can help track global transmission pathways. From 2008 to
2015, several different genotypes were imported and transmitted
into Australia from Asian and European countries, B3, D5 and D8
being the most common [56–58]. Investigation of cases of
unknown origin will assist in identifying sustained endogenous
transmission in Australia if it occurs.
Serosurveys conducted in Australia [59] and in other countries
that have eliminated measles [60] support a substantial decline
in anti-measles IgG antibody levels. This warrants further investi-
gation to determine the extent of waning of vaccine-induced
immunity and to what extent individuals with low or undetectable
levels of measles-specific IgG antibodies are protected against
infection if exposed to measles.
There is a gap in research on role of vitamin A in the manage-
ment of measles in developing countries and the effect of vitamin
A in reducing the rate of death in children with measles [61,62].
There is also a gap in research on the association between measles
and other diseases such as Kawasaki disease [63]. Two studies
show that Kawasaki disease could be an unusual response in a sus-
ceptible individual to various infectious agents [63,64].
The workshop recommended cost-effectiveness studies and
research in diagnosis, immunology, and modelling of measles out-
breaks. This includes integrating phylogenetic data with routine
surveillance data; the effect of viral load on infectiousness, disease
severity and response to treatment; and household and commu-
nity transmission studies.
The clinical significance of waning vaccine-induced measles
specific-IgG antibodies should be studied. Opportunistic studies
examining immune responses and symptoms in individuals with
various antibody levels and avidity following exposure to measles
are important to better understand population susceptibility.
Disease modelling could estimate of how quickly immunity
wanes over time and examine heterogeneity in terms of geo-
graphic and age-specific distribution of susceptibility; modelling
of cost-effectiveness of different vaccination schedules and catch-
up programs will also be useful.
4.3. Data gaps and opportunities in routine data collection for
maintenance of measles elimination in Australia.
The whole-of-life AIR has been established in 2016 in Aus-
tralia. It is recommended that information about migration status,
year of migration, refugee status, ethnicity and language spoken
at home be included. Including health care workers, child care
workers and high school teachers as occupational risk groups
would also be helpful. GPs should be able to check the measles
vaccination status of their patients on the AIR. The workshop rec-
ommended changes in routine collection of immunisation data.
For children, it was recommended to link AIR data with perinatal,
Please cite this article in press as: MacIntyre CR et al. Measles control in Australia – threats, opportunities and future needs. Vaccine (2018), https://doi.org/
10.1016/j.vaccine.2018.06.022
birth, death and marriage data, which can provide information
about ethnicity, language spoken at home, ancestry, country of
birth and parents’ country of birth. For adults, the AIR could inte-
grate information collected from various databases in primary
care and public health at the district and state levels on migrant
and refugee status and other risk factors to understand gaps in
immunisation coverage.
5. Recommendations
Consensus discussion among participants of the workshop
resulted in the following recommendation to reduce gaps in
measles control policy in Australia:
1. Increase visibility of measles elimination in Australia
Raise awareness of the role of immunisation providers in main-
taining elimination status and the importance of MMR vaccination.
Low acceptance of mandatory vaccination policies and vaccine rec-
ommendations by health care workers [40–46], are leading reasons
for under-vaccination particularly among adolescents and adults.
Improve awareness of measles among health care providers and
ensure systematic triage protocols and outbreak protocols in the
healthcare setting.
2. Create a different funding model for maintaining measles
elimination
Create a funding model that works outside the boundaries of
the Pharmaceutical Benefits Advisory Committee considering eco-
nomic and social gains and national and international responsibil-
ities toward maintaining elimination status and access to
vaccination [65]. The Australian Department of Health announced
free vaccination for refugees and other humanitarian entrants
through the National Immunisation Program (NIP), which meets
this gap. From 1 July 2017, MMR is provided free in most states
[66].
3. Whole-of-life immunisation register
The workshop recommended a whole-of-life immunisation reg-
ister that has the capacity to document measles immunisation for
all ages, including documentation of immunisation status at school
entry. An Australian Immunisation Register was launched in 2016
[67]. There is no national immunisation policy for entry to pre-
school, primary school, secondary school or university, and no
capacity to record and report immunisation history in education
facilities1. The workshop recommended compulsory recording of
immunisation status rather than compulsory vaccination. Up to a
third of the notified measles cases in travellers are children of
migrants who were born in Australia and were visiting friends and
relatives in their parents’ country of birth when they became
infected [31]. It was recommended that the whole-of-life immunisa-
tion register include information about child’s and parents’ country
of birth to flag people at risk of under-vaccination. Like health care
workers, school employees may be at increased risk of contracting
vaccine-preventable diseases [68]. The workshop recommended
addressing policy gaps for immunisation for school employees.
1
A new immunisation policy ‘‘No jab, no pay” was announced in 2015 where
conscientious objection is no longer an approved exception for eligibility for the Child
Care Rebate, Child Care Benefit, and Family Tax Benefit (Part A - Supplementary).
Under the new law parents who do not fully immunise their children up to 19 years of
age are no longer eligible for child care benefits and family assistance payments with
exceptions for children recorded with medical contraindications or natural immunity
for certain diseases and those on a recognised catch-up schedule
 C.R. MacIntyre et al. / Vaccine xxx (2018) xxx–xxx
4. Include history of measles immunisation in travel documents
Develop policies to reduce travel-related measles importation;
work with the travel industry and immigration department include
the measles vaccination status of travellers on yellow fever vacci-
nation cards; and apply international health regulations [69] to
encourage recording of measles immunisation.
5. Address policy gaps for disadvantaged populations
Focus on refugees and migrants who don’t have Medicare cards,
as well as health care workers, for whom there is an inadequate
delivery mechanism for funded vaccines [70]. Address challenges
for local health districts to monitor uptake of measles vaccine
among health care workers and address the gap in universal policy
for recording of health care worker immunisation status. Support
ongoing efforts in NSW to develop a database to record vaccination
of health care workers demonstrate feasibility. It was recom-
mended to apply this strategy nationwide.
6. Fund and conduct research in identified gap areas to inform
measles elimination in Australia
Research gaps were identified in the areas of diagnosis,
immunology, epidemiology, outbreak management, estimation of
vaccination coverage, and disease and economic modelling.
6. Conclusion
This workshop considered global perspectives, epidemiology,
research evidence, policy and challenges around measles control.
For countries that have eliminated measles, travel and importation
of measles remain the source of importation of measles. Pockets of
unimmunised people in Australia and other countries that have
eliminated measles, are a threat to maintaining elimination status.
Various strategies have been used to reduce transmission of
measles such as improving awareness of measles in the health care
setting, prompt identification of cases and contacts and vaccination
of susceptibles. Phylogenetic epidemiology and mathematical
modelling of measles has been used to inform efforts for measles
prevention and control. This workshop produced recommenda-
tions for gaps in policy, research and routine collection of data
for maintaining of measles elimination status. Key recommenda-
tions were having a whole-of-life immunisation register with
capacity to include information about child and parents’ country
of birth to flag people who are at risk of under-vaccination; to
introduce travel documentation of measles immunisation; address
the gap in universal policy for recording of immunisation status
among health care workers; cost-effectiveness studies of different
approaches to measles control, and to conduct research on gap
areas such as waning of vaccine-induced measles immunity. Due
to the high R0 of measles, over 95% immunity is required to erad-
icate this infection, making measles eradication a more difficult
task than smallpox, which had a much lower R0. Globally, measles
remains a challenge due to regions with endemic measles and low
vaccination coverage. As such, an integrated and comprehensive
strategy is required at country and global level to maintain elimi-
nation and achieve eradication.
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