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Published Date: 2019-02-28 04:56:16
Subject: PRO/EDR> Measles update (14): Pacific, Europe, North America
Archive Number: 20190228.6340512
MEASLES UPDATE (14): PACIFIC, EUROPE, NORTH AMERICA
***************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
Pacific
-----
[1] Philippines (Cavite)
[2] Philippines (Western Visayas)
[3] Philippines: 203 deaths
[4] Philippines: Department of Health Cordillera
[5] Japan (Osaka)

Europe
---
[6] Ukraine
[7] Belarus: Russian assistance
[8] Europe: surge in cases fueled by Ukrainian outbreak
[9] Turkey
[10] Switzerland

North America
---
[11] Canada (British Columbia, Vancouver)
[12] Canada: travel-associated, alert
[13] USA: CIDRAP news scan

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[1] Philippines (Cavite)
Date: Sat 23 Feb 2019
Source: Manila Buletin [abridged, edited]
https://news.mb.com.ph/2019/02/23/cavite-under-calamity-state-over-measles/


Governor Jesus Crispin C Remulla declared a state of calamity due to the measles outbreak that caused a number of deaths and cases in Cavite. Cavite, with 8 districts comprising 7 cities and 16 municipalities, is the country's most populous province. Afflicted by the measles virus are babies and children. Dr Nelson Soriano, Cavite's provincial epidemiologist, citing the update report, confirmed that at least 9 measles deaths and 424 cases have been recorded in the province's lowland and upland districts.

Remulla placed the province under calamity state after the Sangguniang Panlalawigan (SP or Provincial Board) under vice governor Ramon Jolo Revilla III approved on 18 Feb 2019 Resolution 1165 that took cognizance of the measles outbreak that the Department of Health (DoH) declared in Region IV-A or Calabarzon (Cavite, Laguna, Batangas, Rizal, and Quezon) area and elsewhere in the country early this month [Feb 2019].

The governor and the SP approved a P3-million [USD 58 000] fund allocation with the state of calamity declaration in the province. Remulla said the fund will be used for treatment and measles vaccination of the children.

Cavite provincial health officer Gilberto Ilog has already created a measles outbreak team that will monitor children with measles and the much-needed immunization. The Provincial Epidemiology and Surveillance Unit (PESU) reported that there were a total 424 recorded measles cases in the province from 1 Jan-22 Feb 2019, compared to the 16 cases in the same period in 2018. The PESU report showed that the 4 neighboring areas of Bacoor; Imus, the province's capital; General Trias; and Dasmarinas, the province's most populous; had the most number of cases with 104, 61, 55, and 52, respectively.

[byline: Anthony Giron]

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[Cavite is a province in the Philippines located on the southern shores of Manila Bay in the Calabarzon region on Luzon island. Situated 21 km south west of Metro Manila, it is one of the most industrialized and fastest growing provinces in the Philippines (Wikipedia). - Mod.LK]

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[2] Philippines (Western Visayas)
Date: Sun 24 Feb 2019
Source: Politiko Visayas [abridged, edited]
https://visayas.politics.com.ph/4-day-old-girl-among-latest-wv-measles-cases1/


A 4 day old girl is one of the most recent measles [cases] in Western Visayas, the Department of Health-Center for Health Development (DOH-CHD)-6 said. The DOH-CHD said that as of 22 Feb 2019, the number of suspected measles cases in the region [had reached] 688, with 33 cases confirmed, including that of the infant.

DOH-CHD 6 child health team leader Dr Mary Jane Juanico said the infant, from Bacolod City, is the youngest confirmed and documented measles case (https://protect2.fireeye.com/url?k=65e41b95-39c01adc-65e6e2a0-0cc47aa8d394-abbdbb8192a8f6fc&u=https://thedailyguardian.net/local-news/suspected-measles-cases-rise-to-688-youngest-victim-is-four-days-old/). She said the infant was possibly infected by her mother who was diagnosed with fever and rashes.

The infant is safe and has been discharged from the Corazon Montelibano Locsin Memorial Regional Hospital in Bacolod City, Juanico said. On the other hand, she said the oldest case is that of a 64-year-old male from Hinigaran.

Negros Occidental still has the highest number of cases with 253, followed by Antique (161), Bacolod City (97), Iloilo Province (76), Aklan (40), Capiz (24), and Iloilo City (26). At least 3 deaths have been recorded. Juanico noted that 75 per cent of the suspected measles patients are unimmunized, even as the DOH-6 continues to intensify immunization efforts.

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[2 babies, a 1 year old boy and a 5 month old girl from Cebu Province and Lapu-Lapu City, are the latest fatalities of measles in Central Visayas. These raise the number of deaths of the measles virus this year [2019] in Central Visayas to 6 (https://cebudailynews.inquirer.net/219314/latest-measles-deaths-in-cv-two-babies-from-cebu). - Mod.LK

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[3] Philippines: 203 deaths
Date: Tue 26 Feb 2019
Source: Xinhua [abridged, edited]
http://www.xinhuanet.com/english/2019-02/26/c_137852498.htm


The death toll in the measles outbreak in the Philippines has reached 203 [out of 12 736 total cases], according to the latest data from the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) released on Tue [26 Feb 2019]. Between 1 Jan and 23 Feb 2019, 12 736 measles cases including 203 deaths were officially reported nationwide through the routine surveillance system from the Philippines Department of Health, OCHA said. OCHA said this is a significant increase compared to 2789 cases and 25 deaths reported in the same period in 2018.

With a median age of 2 years old, 57 per cent of measles cases are under 5 years old, it said. Data from 2018 showed that 10 per cent of cases were between 6 and 15 years of age, whereas 15 per cent were between 16 and 30 years of age. "The majority of measles cases are male at 53 per cent," OCHA said.

As of 23 Feb 2019, it said 63 per cent of cases were not vaccinated. "The overall risk remains high because of a large number of unprotected children and adults," OCHA said. "The occurrence of the epidemic in several densely populated urban areas promotes the rapid spread of the disease," OCHA added. OCHA said measles vaccination coverage (MCV1 and MCV2) at national level is low, and there are several pockets of under-immunized communities.

On 6 Feb 2019, the DOH declared a "measles outbreak" in Metro Manila. A day later, the Department of Health announced that the measles outbreak had spread to more areas in the Philippine main Luzon island, Western Visayas and Central Visayas in the central Philippines.

--
communicated by:
ProMED-mail rapporteur Kunihiko Iizuka

[Also see NDRRMC Update Sitrep No. 06 re Measles outbreak, 24 Feb 2019, 5:00 pm: https://reliefweb.int/report/philippines/ndrrmc-update-sitrep-no-06-re-measles-outbreak-24-february-2019-500-pm (report from Government of the Philippines published on 24 Feb 2019 - for cases by region). - Mod.LK]

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[4] Philippines: Department of Health Cordillera
Date: Tue 26 Feb 2019
Source: Sun Star [abridged, edited]
https://www.sunstar.com.ph/article/1794420/Baguio/Local-News/Cordillera-has-65-measles-cases?rss=1


The Department of Health Cordillera (DOH-CAR) recorded 65 confirmed cases of measles from 1 Jan-25 Feb 2019 of this year. Geeny Austria, nurse V of the Regional Epidemiology and Surveillance Unit (Resu), said aside from the 65 laboratory confirmed cases, 211 cases remain to be suspected measles cases. "The laboratory confirmed cases, which are spread out over the region; we are still awaiting the results in the province Kalinga and Abra. We are intently monitoring this because one case of measles can infect around 20 persons in a crowded area."

[byline: Jonathan Llanes]

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[5] Japan (Osaka)
Date: Tue 26 Feb 2019
Source: NHK News Web [Google translated, abridged, edited]
https://www3.nhk.or.jp/news/html/20190226/k10011828451000.html


The number of measles patients has increased, and in Osaka prefecture, the number of new patients reported in one week was 24 people; the number of measles patients across the country reached 222 people. It has already reached more than 70% of the number of patients in the last year.

According to the National Institute of Infectious Diseases, there are 48 measles patients reported from medical institutions nationwide in the week to 17 Feb 2019, of which 24 are in Osaka prefectures and half from the metropolitan. By prefecture: 77 people in Osaka prefecture, 49 people in Mie prefecture, 20 people in Aichi prefecture, 14 people in Tokyo, 9 people in Kyoto prefecture, etc.

--
communicated by:
ProMED-mail rapporteur Kunihiko Iizuka

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[6] Ukraine
Date: Sat 23 Feb 2019
Source: Outbreak News Today [abridged, edited]
https://protect2.fireeye.com/url?k=4553ac45-196b0b27-45515570-000babd9f75c-83e4e5f58b01ce2f&u=http://outbreaknewstoday.com/measles-outbreak-ukraine-21000-cases-2019/


The Center for Public Health of the Ministry of Health of Ukraine reports an additional 3264 cases in the past week. This includes 1545 adults and 1719 children. This brings the total measles cases to 21 355 through 15 Feb 2019, health officials state.

Lviv continues to report the most cases with 3446, followed by Rivne (1927), Vinnytsia (1901), Khmelnytsky (1542) and Kyiv (1791). The vaccination drive in Lviv began 18 Feb 2019 where 50 000 children are slated to get vaccinated. In total, nearly 3000 children have been vaccinated in the 1st 3 days of a campaign against measles. This is more than the average monthly rate of vaccination of children of Lviv region last year [2018].

[byline: Robert Herriman]

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[Eight people have died of measles in Ukraine since the start of the year [2019], already half as many as died in the whole of 2018, authorities said on Wed [20 Feb 2019]. The Health Ministry said in a statement that 2 deaths from the extremely contagious viral disease have been recorded since Sat [23 Feb 2019].

The World Health Organization's data show that Ukraine logged 53 000 confirmed measles cases last year [2018], accounting for more than half of all cases in Europe; https://globalnews.ca/news/4956322/measles-ukraine-deaths/. - Mod.LK]

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[7] Belarus: Russia assistance
Date: Tue 26 Feb 2019
Source: Precision vaccinations [abridged, edited]
https://protect2.fireeye.com/url?k=4ffb1d92-13c3baf0-4ff9e4a7-000babd9f75c-6e24ad28d098664a&u=https://www.precisionvaccinations.com/russia-donates-100000-measles-vaccines-belarus


The Healthcare Ministry of Belarus said they have received a shipment of 100 000 doses of measles vaccines provided by Russia, BelTA reported. This grant of measles vaccines is related to several measles outbreaks reported in Belarus recently. According to Belarus' deputy healthcare minister and chief sanitary inspector, Natalia Zhukova, communicable diseases remain a serious threat to public health, and vaccination is the most efficient way to stop the spread of infectious diseases, said this BelTA article.

Russia has earmarked financial support to help countries of Eastern Europe and Central Asia step up disease prevention and control activities. "The Russian measles vaccine makes it possible for us to control the epidemiological situation, despite the high measles incidence rates and the complex epidemiological situation near our country's borders," said Anna Popova, MD, head of Russia's Federal Service for Surveillance on Consumer Rights Protection and Human Well-Being and Chief State Sanitary, reported TASS.

Belarus is a landlocked country in Eastern Europe, with a population of over 9 million. Belarus' neighboring countries are experiencing significant measles outbreaks, such as Ukraine [see above].

[byline: Don Ward Hackett]

--
communicated by:
ProMED-mail rapporteur Kunihiko Iizuka

[The vaccines Russia has used in country over time are live measles vaccine and measles-mumps vaccines, mainly of Russian production, as well as foreign combination vaccines (measles, mumps, rubella; measles and rubella; and Priorix, GlaxoSmithKline. The live vaccine is attenuated measles vaccine of Leningrad-16 strain; https://academic.oup.com/jid/article/204/suppl_1/S366/2192642. - Mod.LK]

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[8] Europe: surge in cases fueled by Ukrainian outbreak
Date: 12 Feb 2019
Source: Science [abridged, edited]
https://www.sciencemag.org/news/2019/02/measles-cases-have-tripled-europe-fueled-ukrainian-outbreak


Measles cases more than tripled across Europe in 2018, and one country drove much of the surge: Ukraine. Nearly 83 000 cases of measles were reported in (WHO's European Region in 2018, compared with some 25 500 in 2017, WHO announced last week. Ukraine had more than 54 000 cases in 2018, its government says. Last year (2018), 16 Ukrainians died of the extremely contagious viral disease, which is easily prevented with a vaccine.

"The current epidemic is the most massive in the entire postvaccine period," says Nataliya Vynnyk, a pediatric infectious disease specialist at Children's Clinical Hospital in Kyiv. With more than 15 000 cases and 7 deaths between 28 Dec 2018 and 1 Feb 2019, according to the country's Ministry of Health (MOH), the epidemic continues to worsen.

Ukraine's government is taking action. "It's egregious to have people have measles in the 21st century in a European country," says Ulana Suprun, a physician who has been Ukraine's acting minister of health since August 2016. She blames a decade of corruption, war, a lack of political commitment to vaccination, and antivaccine sentiment.

Elsewhere in Europe, vaccine skepticism has given the virus an opening. Cases in Greece doubled from 2017 to 2018; cases in France grew nearly 6-fold. Meanwhile, the United States logged 372 cases last year [2018]. An outbreak in Washington this year [2019] has resulted in 53 confirmed cases as of 11 Feb 2019, nearly all in unvaccinated children, pushing the US year-to-date tally above 100.

The Ukrainian outbreak caps a year in which measles cases surged around the globe. As of mid-January 2019, WHO had received reports of more than 229 000 measles cases in 2018. The global number is expected to rise by the time it is finalized in June 2019, but it's already a 32% increase from 2017.

"The root cause of the measles outbreaks is a failure to adequately vaccinate," says Katrina Kretsinger, the lead measles expert at WHO headquarters. "Many people in many countries remain susceptible, and large pockets of susceptible persons can lead to large outbreaks."

[byline: Meredith Wadman]

--
communicated by:
ProMED-mail rapporteur Kunihiko Iizuka

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[9] Turkey
Date: Sat 23 Feb 2019
Source: Xinhua [abridged, edited]
http://www.xinhuanet.com/english/2019-02/24/c_137845305.htm


Turkey's experts recently warned that epidemic diseases such as measles that have been off the grid for years might come back amid decreasing vaccination rates in the country in the past few years under the influence of anti-vaccine discourse. The anti-vaccination trend started with 183 people in 2011, reaching 980 in 2013 and 5091 in 2015. In 2017, a total of 23 600 families declined compulsory vaccine, professor Mehmet Ceylan, head of pediatric infectious diseases at Ankara's Hacettepe Medical Faculty, said.

The expert warned of an epidemic outbreak if vaccination rates falls under 95 per cent, or some 50 000 people in Turkey. Ceylan said that diseases such as diphtheria and tetanus, which have been off the grid in Turkey for years, might show up again.

WHO also voiced concern about the increasing anti-vaccination movement in Turkey. An increasing number of groups were "misleading" the public about the effects of vaccines, harming their trust in getting vaccinated, WHO said.

Turkish health ministry has set up a special website to inform the public about vaccines and to fight false facts. But the anti-vaccination movement is increasingly active on social media, with slogans such as "I have no obligation to vaccinate". A great majority is concerned with the content of the vaccines such as use of mercury or aluminum.

It's obligatory in Turkey that a baby be given a total of 16 different types of vaccination in the 1st 24 months. Parents have to sign an official document holding them responsible, if they reject vaccination. Professor Ata Nevzat Yalcin from Akdeniz University's Faculty of Medicine, Infection Diseases and Clinical Microbiology, warned against the latest trend of increasing measles in Turkey. "The worldwide increase in the disease in 2017 was also observed in our country," he said. There were 572 measles cases in 2014, 342 in 2015, 9 cases in 2016, 69 cases in 2017. In the 1st 9 months of 2018, the number of the cases exceeded 500, he added. Measles arises especially in the spring and winter months, and can cause recurrent epidemics every 2 to 3 years, Yalcin said.

According to the Health Ministry's figures, the measles vaccination rate was 97 per cent in 2015, 98 per cent in 2016, and 96 per cent in 2017. Turkey faced a measles outbreak, which was off the grid for many years, compounded by the arrival of millions of refugees after civil war erupted in neighboring Syria.

Some 7415 people were diagnosed with measles in Turkey in 2013, but the epidemic was prevented after an intense vaccination program. The number of people diagnosed with measles disease reached 510 in the 1st 9 months of 2018 in Turkey, a recent report of WHO said. According to WHO, the number of global measles cases doubled to 229 068 in 2018, and 82 596 of them were in Europe, mostly caused by stalled vaccination levels.

--
communicated by:
ProMED-mail rapporteur Kunihiko Iizuka

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[10] Switzerland
Date: Mon 25 Feb 2019
Source: Swissinfo.ch [abridged, edited]
https://www.swissinfo.ch/eng/infectious-disease_why-some-swiss-people-still-get-measles/44774826


Measles, a potentially deadly virus, is still breaking out in Switzerland, despite the availability of vaccinations.

At the beginning of February 2019, 60 children who had not been vaccinated were sent home after measles erupted in the Steiner School in the town of Biel. Families with an anthroposophical lifestyle, as advocated by Rudolf Steiner, are often restrictive with vaccinations because of the purported benefits of getting a disease naturally. Many others fear the side effects of vaccines more than the underlying diseases that they protect against. Daniel Koch, head of the infectious diseases department at the Swiss Federal Health Officeexternal link (BAG) assures the public that bad reactions are rare and that the effects of measles are much worse.

In 2018 there were 48 measles cases in Switzerland, but in an epidemic year, figures can rise to well over 1000 sufferers (1112 in 2009). To eradicate it, WHO advocates a vaccination coverage of 95% of the population. Swiss coverage is below this at 94%.

There are large differences between Swiss cantons, with more urban cantons reaching a near 100% level, while rural areas score much lower, with the lowest vaccination rate in the tiny canton of Appenzell Inner Rhodes at 82%.

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[11] Canada (British Columbia, Vancouver)
Date: Sun 24 Feb 2019
Source: Global News [abridged, edited]
https://globalnews.ca/news/4992680/vancouver-measles-outbreak-delta-hospital-update/


The mother of a patient with one of the 2 new measles cases reported in Metro Vancouver says her child may have exposed people to the contagious disease as far away as Delta and that doctors there missed the diagnosis. Her concerns come as Vancouver Coastal Health (VCH) struggles to contain a growing measles outbreak that now stands at 10 cases, including one whose source of exposure has yet to be confirmed.

That case relates to the mother, who contacted Global News, saying she took her child to Delta Hospital on 20 Feb 2019 after showing symptoms of measles, including a rash, despite receiving a measles vaccination. During this visit to Delta Hospital, the mother said doctors never considered measles a possibility. Instead, they said the symptoms were likely a reaction to medication from an earlier misdiagnosis of strep throat and sent the 2 home.

"I disagreed with that," the mother said. "I said: 'Can you please check for measles because of the way the rash was presenting?' It just didn't seem reasonable that it could be anything else." Eventually, the mother and her child went to St. Paul's Hospital in Vancouver, where the child was immediately put into isolation and tested after doctors saw the rash. A positive measles result was delivered the next day.

Both of the patients with new measles cases reported by VCH live in the Fraser Health Authority region. Fraser Health Authority told Global News it has conducted its own investigations into both cases and determined there is no wider risk to the public, deciding a warning did not need to be issued.

Langley Schools shared a letter sent to parents by Fraser Health Authority, which said one of the patients whose case is linked to the outbreak in Vancouver lives in its coverage area, but the authority repeated its stance that there was "no evidence of measles transmission into the wider Vancouver or Fraser Health community."

[byline: Sean Boynton]

--
communicated by:
ProMED-mail rapporteur Kunihiko Iizuka

[According to City News, 24 Feb 2019, (https://www.citynews1130.com/2019/02/24/twelve-measles-cases/), "Vancouver Coastal Health has confirmed 2 new cases of measles in Vancouver, bringing the total to 13 this year (2019). [Ten cases are stated as being confirmed in the report above].

"Both people who were infected caught the disease abroad, and the cases aren't linked to the outbreak at French-language schools in Vancouver. One infected person lives in the Vancouver Coastal Health region, and the other passed through Richmond and YVR [Vancouver airport] on the way to Edmonton and Northwest Territories." - Mod.LK]

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[12] Canada: alert
Date: Sun 24 Feb 2019
Source: CBC News [abridged, edited]
https://www.cbc.ca/news/canada/edmonton/confirmed-case-of-measles-prompts-alert-for-edmonton-airport-leduc-locations-1.5031785


An individual with lab-confirmed measles stopped in Edmonton while en route from Vancouver to Inuvik on 12 Feb 2019, stated a news release by Alberta Health Service. Acknowledging that "measles is only one plane ride away," Alberta has issued a health alert for a handful of locations in and around Edmonton International Airport after diagnosis was confirmed on an individual who spent 19 hours in the area on a layover.

"Because we have so much measles virus circulating in the world, we're going to see more outbreaks of measles from travellers," Dr Gloria Keays, Edmonton's medical health officer, said a news conference. "At any time, measles is only one plane ride away." An individual with lab-confirmed measles stopped in the Edmonton area on 12 Feb 2019 while en route from Vancouver to Inuvik, Alberta Health Services said in a news release.

--
communicated by:
ProMED-mail rapporteur Kunihiko Iizuka

[This case apparently involves an individual who travelled from an international destination to Inuvik by airplane. -Mod.LK]

******
[13] US: CIDRAP news scan
Date: Mon 25 Feb 2019
Source: CIDRAP [abridged, edited]
http://www.cidrap.umn.edu/news-perspective/2019/02/news-scan-Feb 2019-25-2019


Since its report last week, the US Centers for Disease Control and Prevention (CDC) today [25 Feb 2019] reported 32 more measles cases for 2019, raising the total to 159 in 10 states. Also, one more outbreak was reported, which involves 4 cases in the Champaign-Urbana area of Illinois, lifting the number of outbreaks to 6. CDC defines an outbreak as 3 or more cases.

On 24 Jan 2019, the University of Illinois' McKinley Health Center said it was working with the Champaign-Urbana Public Health District (CUPHD) regarding a recent measles case. In a 17 Feb 2019 update, CUPHD reported the 3rd and 4th cases of measles. The 3rd case-patient was in isolation for the entire infectious period, and the 4th case was pending genotyping from the CDC. The CUPHD noted that all 4 of the measles patients were no longer infectious.

The biggest outbreak is centered near Vancouver, Washington, in and around Clark County, which reported 4 new cases, raising its total to 65 since early January 2019. Among the other ongoing outbreaks, New York's Rockland County reported 3 more cases, raising its total to 138 since September 2018, and an outbreak under way since October 2018 in the Orthodox Jewish community in Brooklyn, New York has 17 more cases. Also, New York's Monroe County has 7 cases, 4 of them lab-confirmed and 3 that meet the clinical profile.

--
communicated by:
ProMED-mail rapporteur Mary Marshall

See Also

Measles update (13) 20190224.6333936
Measles update (12): Americas, Asia 20190220.6326123
Measles update (11) 20190217.6322038
Measles update (10) 20190214.6316885
Measles update (09): Americas, Asia, Indian Ocean, Europe, worldwide, vaccine 20190208.6305944
Measles update (08): worldwide, Americas, Asia, Pacific, Indian Ocean 20190205.6295288
Measles update (07): Americas, Africa, Europe 20190131.6288456 
Measles update (06): Americas, Europe 20190125.6278243
Measles update (03): Europe, Americas, Asia, Africa, vaccine 20190112.6254875
Measles update (02): Pacific, Europe, Americas, Middle East, comment 20190108.6248575
Measles update (01): Americas, Africa, Southeast Asia 20190102.6240858
2018
---
Measles update (81): Europe, Americas, Africa 20181231.6236997
Measles update (80): Europe, Pacific, Asia, Americas, Middle East 20181228.6226574
Measles update (79): Middle East, Americas, Europe, Pacific 20181223.6221389
Measles update (78): Europe, Americas, Africa 20181220.6216069
Measles update (77): Americas, Europe, Pacific 20181213.6207900
Measles update (76): Southeast Asia, Europe, Americas 20181209.6200560
Measles update (75): S America, SE Asia, vaccine 20181206.6183455
Measles update (74): WHO, PAHO, South America, USA, Southeast Asia 20181202.6176861
Measles update (73): WHO, Europe, Pacific, Middle East, USA, South America 20181201.6174755
Measles update (72): Middle East, Africa, Southeast Asia 20181128.6168366
Measles update (71): Europe, Americas, Southeast Asia, Pacific 20181125.6163324
Measles update (70): Europe, Pacific, Americas 20181115.6146626
Measles update (60): Europe, Middle East, Africa 20181004.6069532
Measles update (50): Americas, Europe 20180812.5961680
Measles update (40): Middle East, Europe, Americas 20180704.5888315
Measles update (30): Americas, Asia, Africa, Europe 20180510.5791951
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