Situation at a glance
Since 2022, Indonesia has recorded an increase in suspected and confirmed measles cases compared to previous years. Between 1 January and 3 April 2023, a total of 2161 suspected measles cases (848 laboratory-confirmed and 1313 clinically compatible [suspected]) have been reported across 18 of 38 provinces in Indonesia, primarily from the provinces of West Java (796 cases), Central Papua (770 cases), and Banten (197 cases).
Measles is endemic in Indonesia and is reported every year. However, in 2022 and 2023, there has been a significant increase in the number of confirmed cases, as compared to those reported annually since 2018: there were 920 reported cases in 2018, 639 in 2019, 310 in 2020, and 132 in 2021.
The current outbreak is characterized by suboptimal population immunity, including children without measles vaccination. Supplemental immunization activity (SIA) was conducted in 2022, targeting children <15 years old in high-risk provinces (Aceh, North Sumatera, Riau, Riau Islands, and West Sumatera), 9 – 59 months old in provinces in Java-Bali, and 9 months to 12 years old in the remaining provinces, with efforts to strengthen routine immunization and catch-up activities ongoing to address the population immunity gaps.
Description of the situation
Between 1 January and 3 April 2023, a total of 2161 measles cases (848 laboratory-confirmed and 1313 clinically compatible [suspected]) have been reported across 18 of 38 provinces in Indonesia, primarily from the provinces of West Java (796 cases), Central Papua (770 cases), and Banten (197 cases).
In 2022, a total of 4845 laboratory-confirmed measles cases and six deaths (CFR 0.1%) were reported across 32 of the 38 provinces. The provinces mainly affected were Aceh (978 cases), West Sumatra (859 cases), Riau (500 cases), and East Java (459 cases). Annual trend analysis shows the number of cases reported annually in 2022 and currently in 2023 is higher than usual: there were 920 cases in 2018, 639 cases in 2019, 310 cases in 2020, and 132 cases in 2021 (Figure 1).
Figure 1: Number of measles cases reported by month of onset of symptoms and confirmation category. Indonesia. January 2019 – March 2023.
Source: Indonesia Ministry of Health
In 2022, among the 4845 confirmed measles cases with available age information, 93% (4502) were between 1 and 14 years old. However, a few cases have also been observed in the older age group, with at least 41 cases reported among people over 40. Among the confirmed cases, 67% had not received any dose of measles-containing vaccine (MCV), 6% had received one dose, 7% had received both doses, and vaccination history was unknown for 21 % (991) of confirmed cases (Figure 3).
In 2023, among the 2076 confirmed cases with available age information, 95% (1978) were between 1 and 14 years of age. Among the confirmed cases, 75% had not received any dose of MCV, while 11% had received one dose, 10% had received both doses, and vaccination history was unknown for 3%. Among these 2076 cases, 100% (212) of those younger than 9 months old, 87% (47) 9-12 months, and 66% (1303) of those aged 1-14 years had not received any dose of MCV (Figure 2).
Figure 2: Percentage of vaccination coverage among confirmed measles cases by age group, 1 January to 3 April 2023. Indonesia. (n=2138)
Source: Indonesia Ministry of Health
The current outbreak is mainly characterized by suboptimal population immunity, as evidenced by the increased gap in immunity (Figure 2). According to the WHO/UNICEF Joint Reporting Form (JRF), the vaccination coverage in Indonesia in 2020 was 87% for measles-containing-vaccine first-dose (MCV1) and only 65% for measles-containing-vaccine second dose (MCV2). In 2021, national coverage of MCV1 was 87%, and MCV2 was 59%, with variation in administrative vaccination coverage at the sub-national level; these data indicate a very high number of children are susceptible to measles infection.
Epidemiology of measles
Measles is a human disease caused by a virus in the paramyxovirus family. The virus infects the respiratory tract, then spreads throughout the body. It can lead to major epidemics with significant morbidity and mortality, especially among vulnerable people. Among young and malnourished children, pregnant women, and immunocompromised individuals, including those with HIV, cancer or treated with immunosuppressives, measles can cause serious complications, including severe diarrhea, blindness, encephalitis, pneumonia, and death.
Transmission is primarily person-to-person by airborne respiratory droplets that disperse rapidly when an infected person coughs or sneezes. Transmission can also occur through direct contact with infected secretions. Transmission from asymptomatic exposed immune persons has not been demonstrated. The virus remains contagious in the air or on contaminated surfaces for up to two hours. A patient is infectious from four days before the start of the rash to four days after its appearance. There is no specific antiviral treatment for measles, but most people recover within 2-3 weeks.
An effective and safe vaccine is available for prevention and control. The MCV1 is given at the age of nine months, while the MCV2 is given at the age of 15 months. A 95% population coverage of MCV1 and MCV2 is required to stop measles circulation.
In areas with low vaccination coverage, epidemics typically occur every two to three years and usually last between two and three months. However, their duration varies according to population size, crowding, and the population’s immunity status.
Several measles outbreaks have been reported in Indonesia between 2011 to 2023. One of the biggest outbreaks occurred in East Java province in 2016 where 3765 cases were reported, associated with low vaccination coverage levels.
Measles is preventable by vaccination, which provides lifelong immunity in most recipients. In countries with low vaccination coverage, epidemics may occur every two to three years. However, their duration varies according to population size, crowding, and the population's immunity status.
The measles vaccine has been in use for nearly 60 years. It is safe, effective, and inexpensive. Vaccination is recommended for all susceptible children and adults for whom the vaccine is not contraindicated. National immunization programs must ensure the safe provision of immunization services that can reach all children with two doses of the measles vaccine. Routine measles vaccination for children and mass immunization campaigns in countries with high case and death rates are key public health strategies to reduce global measles deaths.
WHO recommends maintaining sustained homogeneous coverage of at least 95% with the first and second doses of the MCV vaccine and strengthening integrated epidemiological surveillance of measles and rubella to achieve timely detection of all suspected cases in public, private, and social security healthcare facilities. WHO continues to strengthen the global laboratory network to ensure timely diagnosis of measles and track the international spread of the measles viruses to allow a more coordinated country approach in targeting vaccination activities and reducing deaths from this vaccine-preventable disease.
It is critical to quickly recognize and treat measles complications to reduce the disease’s severity and mortality. Severe complications from measles can be reduced through supportive care that ensures good nutrition, adequate fluid intake, and treatment of dehydration with WHO-recommended oral rehydration solution. This solution replaces fluids and other essential elements lost through diarrhoea or vomiting. Antibiotics should be prescribed to treat eye and ear infections and pneumonia.
While there is no specific antiviral treatment for measles, prompt vitamin A in therapeutic doses is recommended to reduce complications and mortality among children infected with measles. Two doses of vitamin A oral supplements should be given 24 hours apart, irrespective of the timing of previous doses of vitamin A: 50 000 IU should be given to infants aged < 6 months, 100 000 IU to infants aged 6-11 months, and 200 000 IU to children aged 12-59 months. This treatment restores low vitamin A levels in acute measles cases that occur even in well-nourished children and can help prevent eye damage and blindness. Vitamin A supplements have also been shown to reduce the number of measles deaths.
WHO does not recommend any restrictions on travel or trade to or from Indonesia based on the information presented in this report.
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2023-04-28 17:56:08Z
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