Measles in the Era of Elimination: Confronting a Global Resurgence

Measles remains one of the most contagious infectious diseases and a leading cause of vaccine-preventable mortality, despite the availability of safe, effective, and inexpensive vaccines for over five decades. While global immunization efforts have substantially reduced measles incidence and mortality, recent years have seen a resurgence of outbreaks, highlighting the fragility of progress towards measles elimination.

This thesis investigates measles transmission dynamics and control strategies in the elimination era, using the Netherlands, which is a country with generally high vaccination coverage but persistent immunity gaps, to situates findings within the global context of measles elimination. A multidisciplinary approach was employed, combining outbreak investigations, epidemiological analyses, immunological assessments, health economic evaluation, and systematic reviews and meta-analyses.

Using data from the 2013–2014 measles outbreak in the Netherlands, which predominantly affected undervaccinated orthodox Protestant communities, this thesis demonstrates how local outbreaks in clustered susceptible populations can lead to substantial international spread. Genotyping confirmed links between cases in the Netherlands and importations to Canada, the United States, and Belgium, including transmission to the United Kingdom associated with international air travel. These findings highlight the critical role of molecular epidemiology in tracing transmission pathways and underscore the importance of cross-border coordination and targeted vaccination strategies.

Transmission dynamics in specific high-risk settings were further described, including healthcare facilities. An outbreak among healthcare workers revealed cases of measles in previously vaccinated individuals, indicating secondary vaccine failure. Although clinical disease was mild and no onward transmission occurred, these findings raise important considerations regarding waning immunity and the potential need to reassess vaccination strategies for high-risk occupational groups.

This thesis included an analysis of the economic impact of the 2013–2014 measles outbreak in the Netherlands, which was estimated to cost approximately $4.7 million. This underscores the substantial financial burden of outbreaks and reinforces the cost-effectiveness of preventive vaccination strategies.


The thesis also evaluates outbreak response strategies, including early measles vaccination. Analysis of a targeted intervention offering early measles–mumps–rubella (MMR) vaccination to infants aged 6–14 months in low-coverage areas demonstrated moderate uptake and highlighted significant sociodemographic determinants of vaccine acceptance.

Evidence from systematic reviews and meta-analyses indicates that early administration of the first measles-containing vaccine (MCV1) is immunogenic, effective, and safe, although some evidence suggests reduced antibody titres following subsequent doses, with uncertain clinical significance. These findings support the use of early vaccination in high-risk settings while emphasizing the need for further research into long-term immune responses.

In the context of a global resurgence of measles driven by declining vaccination coverage, health system disruptions, and increasing misinformation, this work provides actionable insights to strengthen immunization programmes and inform policy. Sustained progress towards measles elimination will require high and equitable vaccination coverage, strong surveillance, and coordinated global efforts to prevent re-establishment of endemic measles transmission and reduce preventable measles morbidity and mortality worldwide.