6.3.5. Vaccine-preventable diseases (VPD)
Several of the serious vaccine-preventable diseases are
now almost eradicated from the EU. There have been no endemic cases of polio
since 1992, only a few cases of diphtheria are still being reported annually
from a couple of Member States, and reported tetanus rates are around one per
million or lower.
All diseases covered by the MMR vaccine (measles, mumps
and rubella), continue to show a good decline in the EU (apart from mumps in
recent years), even though vaccine coverage is not uniform, with Germany
reporting almost three quarters of all EU measles cases. The same downward
trend is seen for invasive infection with Haemophilus influenzae type b in the countries
that have introduced this vaccine. For pertussis, the picture is somewhat more
complex: overall EU incidence seems to be rising slightly, and there are
indications that the programmes have not achieved the intended effect of
preventing death in young infants, which is one of the main objectives of a
There are two invasive bacterial infections for which
vaccines are available for some of their strains but that are still not
routinely used in most Member States. These are invasive pneumococcal and
meningococcal infections. Rates for invasive pneumococcal infection seem to
remain stable across the EU at between five and six cases per 100 000 per
year, but this is a serious infectious disease causing several thousand deaths
each year, especially in the very young and the very old. Meningococcal
meningitis is one of the diseases for which surveillance figures are most
reliable: it is a serious and very characteristic disease receiving high public
attention. Annual rates remain relatively stable at between one and two cases
per 100 000 per year. Good vaccines are only available for one of the two
types commonly seen in Europe, but are being introduced in some Member States.
Important challenges in the coming years are to meet the
goal of eliminating measles and congenital rubella and maintaining the
polio-free situation. Most of the childhood diseases that are now preventable
by vaccination have been decreasing over the past few years as a result of
effective childhood vaccination programmes. Yet, despite all the efforts,
outbreaks still occur in population subgroups where vaccination uptake remains
New vaccines have recently been, or soon will be, licensed
(against varicella (chickenpox), human papilloma virus (HPV), and rotavirus).
This raises the question as to whether these vaccines should be included in vaccination
programmes, and if yes, how to monitor their impact and adverse effects.
Although Europe has maintained high vaccination coverage
and even increased it, there have been areas of decline in the uptake of
certain vaccines, with important consequences for the re-emergence and
outbreaks of certain diseases. Examples are diphtheria during the 1990s in the
Russian Federation and the former Soviet Republics and Baltic States
(particularly in Latvia). Also some Western European countries have had to cope
with a decrease from previously attained vaccine coverage levels. Political and
socioeconomic changes that followed the collapse of the former USSR, and
population density and deprivation in specific inner urban areas, were both
strongly correlated with lower vaccination uptake.
High vaccination coverage does not exhibit a direct
relationship with the wealth of a country, but with proper public health
policies. For example, there is a cluster of countries under the GNP threshold,
but with over 95% measles vaccine coverage; most of these are in the new EU
Member States (figure 6.5).
6.5. Measles (MCV1) vaccine coverage.
Infection due to Streptococcus pneumoniae (pneumococcus) mainly
affects the youngest and the oldest, and is the main cause of bacterial
respiratory tract infections in all age groups, but is also common as
asymptomatic carriage in the nasopharynx of young children. Invasive infections
carry a high death rate, and are a major cause of infection-related death in
young children. Unlike the older ‘polysaccharide’ vaccines, a new generation of
‘conjugated’ vaccines provide good protection against invasive disease even in
very young children. As these vaccines also protect against the carriage of the
bacteria, they have a potentially important role in preventing the spread of
antibiotic-resistant pneumococci in the child population.
The trends of invasive pneumococcal infections over the
last 10 years were stable in most countries, with the exception of Denmark
(declining) and the UK (increasing). In 2005, a total of 19 665 invasive pneumococcal infections (5.83 per 100 000 per year) were reported by 19
countries. Sweden (15.76 per 100 000) followed by Belgium (15.45 per 100
000) reported the highest incidence rates. Incidence rates were the highest in
the over-65 age group (15.3 per 100 000), followed by the under-4 age
group (14.1 per 100 000), while the incidence rate in the five to 24
year-olds remained low. After 25 years of age, the incidence rates increased
Conjugated pneumococcal vaccine was registered in the EU
in early 2001, and 12 European countries have now introduced it as a universal
vaccine in their childhood vaccination schemes, while several others recommend
it for children at-risk. As the vaccine does not cover all serotypes of
pneumococci, there is a need for enhanced surveillance both of the occurrence
of the disease and the distribution of serotypes.
Invasive meningococcal disease
Invasive meningococcal disease, caused by the bacterium Neisseria meningitides (meningococcus), is most
common in young children, with a secondary peak among teenagers. The death rate
from invasive disease remains high (around 8%) and survivors may suffer from
serious complications, including deafness, neurological problems and even
amputations. Most disease in Europe is caused by serogroups B and C. Since
1999, several countries have introduced vaccination programmes against
serogroup C disease, using a new conjugated vaccine, but to date there is no
vaccine against serogroup B disease.
Since 1999, countries such as Iceland and Ireland, that
experienced high incidence, show a sustained decrease possibly due to the
introduction of the meningococcal C vaccine in high-risk populations. In the
other countries, the reported incidence varied below 2/100 000 per year
with stable trends or even with a slight decrease in the past few years after
the introduction of the vaccine. In 2005, a total of 5 494 cases were reported by 26 countries. Ireland (with 4.94 per 100 000) and Malta (2.73 per
100 000) reported the highest incidence rates.
Invasive infection caused by
Haemophilus influenzae type b
Haemophilus influenzae type b (Hib) is a respiratory tract
bacterium, capable of causing meningitis and other severe systemic infections
in young children. Effective vaccines are available against invasive Hib
infection, and there has been a clearly declining trend in Europe over the last
10 years (most markedly in 1996–2001). Most countries had a stable incidence
rate over the past five years, but a slow increase was observed in the
Netherlands, Ireland and the UK. In 2005, 1 145 cases were reported by 25
countries. Estonia reported the highest incidence rate, with 1.48 per
100 000, followed by Sweden (1.31 per 100 000). Hib vaccination is
now included in all immunisation schedules in the EU countries except in
Poland, Romania and Bulgaria.
Pertussis is an acute bacterial infection of the
respiratory tract caused by the bacterium Bordetella pertussis. There is an effective
vaccine for this disease.
In the last 10 years, an overall higher incidence has been
observed in the Northern countries: Estonia, Finland, the Netherlands, Norway
and Sweden. A dramatic decrease was observed in Sweden at the beginning of this
period and in the UK and Ireland over the whole period. For the other
countries, the general incidence was lower. A slight decrease was observed
between 1995 and 2000, but after 2002, some countries have been showing
increasing trends. A very high proportion of cases have been reported among the
youngest age groups (0–14 years).
In 2005, a total of 13 207 cases were reported by 24
countries. The highest rate by far was reported in the Netherlands (40.17 per
100 000), with Norway reporting a rate of 19.10 per 100 000. By
contrast, the overall incidence rate in the EU was 4.10 per 100 000 per
year. Thus pertussis, although known to be preventable by vaccine, still
affects several European countries, and in some cases quite dramatically. Close
monitoring in all EU countries is needed to better assess the real burden and
risk of transmission of pertussis in order to refine control measures.
Diphtheria is an acute disease with inflammation of the
mucosal surfaces of the upper respiratory tract caused by a toxin from the
Diphtheria is transmitted from person to person through small droplets, and the
disease is preventable by vaccination. Since 1995, the Baltic countries, in
particular Latvia, have been most affected. The incidence in Latvia peaked in
1995 (15 per 100 000 per year) with a second peak in 2000 (11 per
100 000 per year). In Estonia and Lithuania the incidences in 1995 were
about one tenth of that of Latvia, and have gradually decreased over the
period. In the other EU countries, cases are only observed sporadically. In
2005, only Latvia reported cases (20) with an incidence of 0.87 per
Tetanus is induced by an exotoxin of the bacterium Clostridium tetani. The disease is
characterised by painful muscular contractions primarily of the facial muscles.
Generalised spasms can occur. The case fatality rate ranges from 10% to over
80% with the highest risk in infants and the elderly. Tetanus is mostly seen
after contaminated injuries, and the infection is not transmissible between
humans. There is an effective vaccine available.
An overall decreasing trend has been seen over the last 10
years, with a slight increase between 2001 and 2003. The incidence rates were
always below 0.2 per 100 000 per year in the EU15 states, except for Italy and Portugal in 1995. In the new Member States, tetanus incidence rates were below 0.35 per
100 000 per year, except for Slovenia where incidence was at 0.45 per
100 000 per year in 2000 (nine cases) and for Malta with 0.5 per
100 000 per year in 2002 (two cases). In 2005, altogether 137 cases were
reported by 21 countries. Italy reported almost 50% of all cases and the
highest incidence rates were in Malta (0.25 per 100 000), followed by Italy (0.11 per 100 000).
Measles is an acute illness causes by morbillivirus. The
disease is preventable by a vaccine that provides life-long immunity. The
elimination of measles by 2010 (interruption of indigenous measles
transmission) is part of the strategic plan for measles and congenital rubella
infection in the European Region of the WHO.
Due to the two-dose vaccination policy, the incidence of
measles in Europe has decreased dramatically over the last 10 years from almost
35 per 100 000 per year before 1997 to less than 10 per 100 000 per
year after 1998 (Figure 6.6).
Figure 6.6. Measles trend in Europe between 1995 - 2004.
This drop is mainly due to a sharp decrease in the number
of cases in France and in Italy, but the incidence has decreased greatly in
most countries over the 10-year period. A recrudescence of measles was observed
in the Netherlands (1999–2000), Spain (2003), Poland (1998) and Lithuania (2002). Since 2000 a significant number of cases have still been observed in France, Germany and Italy. The incidence in these countries has fluctuated between five and 42 per
100 000 per year. In the other countries, incidence has fluctuated between
one and 10 per 100 000 per year since 2000.
In 2005, a total of 1 291 cases were reported by 25
countries, with more than 50% of cases (776) from Germany. The overall
incidence in the EU was 0.28 per 100 000 per year and the highest rates
per 100 000 were reported by Ireland (2.26) and Germany (0.94).
Elimination has not yet been achieved, and few countries were able to maintain
an incidence rate below one per 1 000 000 per year during the past
Mumps is caused by the mumps virus. Mumps is preventable
by a vaccine.
Between 1996 and 2005, there was a generally decreasing
incidence until 2002, but since then the number of cases has again been
steadily increasing. Various countries experienced peaks in incidence over this
10-year period, notably Poland in 1998 and 2004, Estonia in 1998, France in
1995–96, Italy in 1995–96 and 1999–2000, Latvia in 2000–01, Lithuania in 1999,
Malta in 2000, Portugal in 1996–97 and Spain in 1996 and 2000.
In 2005, a total of 52 918 cases were reported by 23
countries. The UK, followed by Iceland, reported the highest incidence rates
(77.24 and 28.95 per 100 000, respectively). In those countries, mumps
mainly affected young adults. The overall incidence in the reporting countries
was 17.65 per 100 000 per year.
Rubella is a mild febrile illness affecting both adults
and children. The most serious consequence of rubella results from infection
during the first trimester of pregnancy, when rubella infection can cause
miscarriage, foetal death or severe birth defects. The overall trend of rubella
in the last 10 years is declining, with two peaks seen in 1997 and 2001.
However, recrudescence was observed particularly in Poland in 1997 and 2001, in Latvia in 1996 and 2002, in Lithuania in 1995 and 1999–2000, Czech
Republic in 1998 and 2002, Italy in 1996–97 and 2001–02, Iceland in
1996 and Spain in 1996.
In 2005, a total of 1 498 cases were reported by 22
countries. The overall incidence was 0.51 per 100 000 per year, with
Lithuania (3.44 per 100 000) and the Netherlands (2.23 per 100 000)
reporting the highest rates. The age and sex distribution varied across
countries, and may reflect a variation in the vaccine coverage by sex (some
vaccination programmes started in women first) together with a variation in
notification (more attention is given to rubella in girls and women).
Polio is caused by poliovirus. Childhood immunisation has
been an effective preventive measure. In Europe, the last case of flaccid
paralysis caused by wild polio was reported by Turkey in November 1998, and in
June 2002 the WHO European Region was declared polio free. However, poliovirus
imported from endemic countries remains a threat, as demonstrated in 1992–93
when imported polio caused an outbreak of 71 cases with two deaths in an
unvaccinated community in the Netherlands. Polio eradication has implications
in terms of the vaccination policies of Member States as many are changing from
the live vaccine to inactivated vaccines in order to avoid vaccine associated