Preprint Not Peer Reviewed

The global resurgence of measles, estimating the risks of
international importations of measles among 181 countries
ed
and territories: A modelling study
iew
Oyelola A. Adegboye, MSc, PhD1,2,3 *†, Adeshina I. Adekunle, MSc, PhD 3,4†, Anton Pak
MSc, PhD 3,5, Md Abdul-Kuddus, MSc, PhD 3,6, Gillian Gorham MHA, PhD1, Damon P.
Eisen, MBBS, MD7, Emma S. McBryde, MBBS, PhD 3,7
v
1
Menzies School of Health Research, Charles Darwin University, Casuarina 0811, NT,
re
Australia.
2
Public Health & Tropical Medicine, College of Public Health, Medical and Veterinary
Sciences, James Cook University, Townsville 4811, QLD, Australia
3
Australian Institute of Tropical Health and Medicine, James Cook University, Townsville
4811, QLD, Australia
4
er
Defence Science and Technology Group, Department of Defence, Melbourne 3207
Australia.
5
Centre for the Business and Economics of Health, The University of Queensland, St Lucia
pe
4072, QLD, Australia
6
Department of Mathematics, University of Rajshahi, Rajshahi 6205, Bangladesh
7
College of Medicine and Dentistry. James Cook University, Townsville 4811, QLD,
Australia
ot
†
First authors
*Correspondence: Oyelola A. Adegboye, Menzies School of Health Research, Charles
Darwin University, Casuarina 0811, NT, Australia.
tn
Email: oyelola.adegboye@menzies.edu.au
rin
ep
Pr
This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4744239
Abstract
ed
Background: The resurgence of measles, a highly contagious infectious disease, has risen to
a global public health emergency of international concern.
Methods: A stochastic meta-population model, adapted from the Susceptible-Exposed-
iew
Infectious-Recovered compartment model, was employed to assess the risk of measles
importation. This model was adjusted for country-specific population and vaccination rates,
using air travel passenger data to quantify the risk of international measles importations.
Results: This study revealed a 150% increase in measles in 2019 from the previous year. There
was a noteworthy resurgence of measles outbreaks in high-middle and high socio-demographic
v
index (SDI) countries. A significant positive linear correlation was observed between the first
re
dose of measles-containing vaccine coverage and SDI (r=0.47, p < 0.0001). Overall, the United
States is estimated to have had 49,413 (95% UI: 46,057, 51,251) imported measles cases within
the first six months of 2022, with France at 10,782 (95% UI: 9,607, 11,268), Italy at 13,332
er
(95% UI: 12,619, 13,932), and Spain at 12,766 (95% UI: 12,075, 13,577).
Conclusion: As global borders reopen, sustaining high vaccination rates and vigilance remains
crucial, even in countries that have achieved measles elimination, to avert potential resurgence
pe
and outbreaks.
Keywords: Travel, Vaccine preventable diseases, Immunization, Vaccination, Health

Security
ot
tn
rin
ep
Pr
Introduction
ed
An important means of understanding the mass transmission of infectious disease is to identify
the risk of importation, especially in non-endemic countries. This informs planning of
prevention measures. Air travel and passenger volumes are key metrics to evaluate the risk of
iew
importing infection1, 2. They encompass the movement of passengers and crew through airports
and in flight 3. As we have seen in the case of the COVID-19 pandemic, many flight-associated
cases were not detected due to the low intensity of post-travel surveillance practised in most
v
countries3. In their study, Goel et al.4 estimated that as many as 2% of international air travel
re
passengers arriving at Toronto Pearson Airport Terminal tested positive for COVID-19 upon
arrival (two-thirds immediately and the rest within the 14-day window). There is a rising
er
concern about the spread of infectious diseases now that travel has resumed, especially due to
disruption of childhood immunization during the COVID-19 pandemic 5, 6.

pe
A vaccine-preventable disease of current interest is measles7. Measles, caused by a
paramyxovirus virus, is a highly infectious, febrile illness with fever, cough and, in severe
cases, pneumonia 8. Very small numbers of measles cases are seen in most developed countries
ot
due to high rates of immunization. However, the recent re-emergence of this highly contagious
infectious disease in many high-income countries has risen to alarming levels. The World
tn
Health Organization has warned that approximately 40 million children face a significant
vulnerability to the increasing measles risk 9. High-income countries like Australia 10 are at risk
rin
of measles outbreaks due to importation. Recent experience shows that this particularly affects
people who oppose measles vaccination and are therefore susceptible. Other studies have also
ep
raised the alarm about the looming effect of measles beyond the COVID-19 pandemic11, 12.
13
Measles may spread quickly from person to person via aerosolized respiratory particles .
14
Transmission depends on the duration of exposure, crowding, and climatic conditions . The
Pr
lifting of travel restrictions, coupled with a surge in travel activity among residents from
countries where measles is endemic and declining vaccination coverage heightens the risk of
ed
international measles transmission15.
The COVID-19 pandemic has contributed to the re-emergence of measles in many countries.
The global measles outbreak in 2019 was the largest since 2006 16. Measles cases jumped up
iew
to 900% in the African region, 120% in the European region, 50% in the Eastern Mediterranean
region and the Western Pacific region recorded a 230% increase 17. The measles resurgence
has raised concerns about whether measles should be declared a public health emergency of
v
international concern 18.
re
The global resurgence of measles has provided the opportunity for an epidemiological risk
assessment of the disease. In this study we used a stochastic meta-population model to quantify
er
the risk of international importations of measles into several regions based on air travel.
Materials and methods

pe
Country-specific transmission model
In this study, a discrete-time stochastic compartmental model was employed. The mathematical
ot
model is an adaption of the SEIR (Susceptible-Exposed-Infectious-Recovered) compartmental
model used for Ebola19 and COVID-191. The model adjusted for each country’s population and
tn
vaccination rate. Similar to prior studies by He and Earn,20 and Verguet et al.,21, the complete
ordinary differential equations (ODEs) describing country-specific model (i) stratified into S-
E-I-R compartments concerning measles is presented below:

rin
𝑑𝑑𝑆𝑆𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖

= (1 − 𝜏𝜏𝑖𝑖 )Πi − + 𝜇𝜇𝑚𝑚 𝐼𝐼𝑖𝑖 − 𝜇𝜇𝑖𝑖 𝑆𝑆𝑖𝑖
𝑑𝑑𝑑𝑑 𝑁𝑁𝑖𝑖
ep
𝑑𝑑𝐸𝐸𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖

= − (𝜎𝜎𝑖𝑖 + 𝜇𝜇𝑖𝑖 )𝐸𝐸𝑖𝑖
𝑑𝑑𝑑𝑑 𝑁𝑁𝑖𝑖
Pr
𝑑𝑑𝑑𝑑
𝑑𝑑𝑑𝑑
= 𝜎𝜎𝑖𝑖 𝐸𝐸𝑖𝑖 − (𝜇𝜇𝑚𝑚 + 𝛾𝛾𝑖𝑖 + 𝜇𝜇𝑖𝑖 )𝐼𝐼𝑖𝑖
𝑑𝑑𝑅𝑅𝑖𝑖
= 𝛾𝛾𝑖𝑖 𝐼𝐼𝑖𝑖 − 𝜇𝜇𝑖𝑖 𝑅𝑅𝑖𝑖 (1)
𝑑𝑑𝑑𝑑
ed
Where Π is the estimated country-specific (i) recruitment rate or loss rate, 𝛽𝛽 is the estimated
country-specific transmission rate, 𝜏𝜏 is the estimated country-specific vaccination rate, 𝜎𝜎 is the
iew
inverse of the measles incubation period, 𝛾𝛾 is the estimated measles recovery rate, 𝜇𝜇𝑚𝑚 is the
estimated measles mortality rate, while 𝜇𝜇 is the country-specific natural mortality rate.
Furthermore, adding the equations in (1), the country-specific population growth model is
v
shown below:
re
𝑑𝑑𝑁𝑁𝑖𝑖
= Πi − 𝜇𝜇𝑖𝑖 𝑁𝑁𝑖𝑖 (2)
𝑑𝑑𝑑𝑑
Meta-population model with disease importations er

The meta-population model incorporates disease importations between countries by modifying
equation (1) in order to estimate the number of imported measles cases between two countries.
pe
Suppose 𝑖𝑖 and 𝑗𝑗 are two countries, the dynamical model for the movement (𝑚𝑚) of people
𝑑𝑑𝑆𝑆𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖 𝑚𝑚𝑖𝑖𝑖𝑖 𝑆𝑆𝑖𝑖 𝑚𝑚𝑗𝑗𝑗𝑗 𝑆𝑆𝑗𝑗

between two countries 𝑖𝑖, 𝑗𝑗 is given as: = (1 − 𝜏𝜏𝑖𝑖 )Πi − + 𝜇𝜇𝑚𝑚 𝐼𝐼𝑖𝑖 − 𝜇𝜇𝑖𝑖 𝑆𝑆𝑖𝑖 − +
𝑑𝑑𝑑𝑑 𝑁𝑁𝑖𝑖 𝑁𝑁𝑖𝑖 𝑁𝑁𝑗𝑗
ot
𝑑𝑑𝐸𝐸𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖 𝑚𝑚𝑖𝑖𝑖𝑖 𝐸𝐸𝑖𝑖 𝑚𝑚𝑗𝑗𝑗𝑗 𝐸𝐸𝑗𝑗

= − (𝜎𝜎𝑖𝑖 + 𝜇𝜇𝑖𝑖 )𝐸𝐸𝑖𝑖 − +
𝑑𝑑𝑑𝑑 𝑁𝑁𝑖𝑖 𝑁𝑁𝑖𝑖 𝑁𝑁𝑗𝑗
𝑑𝑑𝑑𝑑
= 𝜎𝜎𝑖𝑖 𝐸𝐸𝑖𝑖 − (𝜇𝜇𝑚𝑚 + 𝛾𝛾𝑖𝑖 + 𝜇𝜇𝑖𝑖 )𝐼𝐼𝑖𝑖
tn
𝑑𝑑𝑑𝑑
𝑑𝑑𝑅𝑅𝑖𝑖 𝑚𝑚𝑖𝑖𝑖𝑖 𝑅𝑅𝑖𝑖 𝑚𝑚𝑗𝑗𝑗𝑗 𝑅𝑅𝑗𝑗

= 𝛾𝛾𝑖𝑖 𝐼𝐼𝑖𝑖 − 𝜇𝜇𝑖𝑖 𝑅𝑅𝑖𝑖 − + (3)
𝑑𝑑𝑑𝑑 𝑁𝑁𝑖𝑖 𝑁𝑁𝑗𝑗
rin
For each country, calculating the expected number of measles importations relied on the
stochastic compartmental above using the binomial distribution to estimate the number of
individuals experiencing an event at a given time step. In equation (3), only people who are
ep
uninfected or in the incubation stage can travel. Additionally, transmission was restricted to be
between unvaccinated populations. The scenarios analyses were conducted using the infectious
Pr
disease node of the Australia Nectar Research cloud (www.nectar.org.au).
Model parameterization and data sources
ed
Model parameters were estimated using available epidemiological data between 2000 and
2019. Where data were not available, estimates from the literature were used. Country-specific
population 22 and life expectancy data 23 were used to estimate country-specific (Π) recruitment
iew
rates. The country-specific measles transmission rates (𝛽𝛽𝑖𝑖 parameters) were also estimated
from the number of measles cases reported to the WHO measles and rubella surveillance data
24
system between 2000 and 2019 . The country-specific vaccination rates, 𝜏𝜏𝑖𝑖 , which is the
v
proportion of people vaccinated against measles with two doses of measles-containing vaccine
re
(MCV1 and MCV2) were estimated based on data from the WHO/UNICEF Joint Reporting
24
Form on Immunization for the study period . Additionally, it assumed that the incubation
1
er 1
period (𝜎𝜎) for measles was eight days 20, the measles recovery period (𝛾𝛾 ) was five days 20, and
25
the infection fatality rate (𝜇𝜇𝑚𝑚 ) was (0.002) . To determine the global risk of international
pe
importation of measles into several regions, air passenger data was used in simulating the early
risk of importation 26. The flight data was obtained from the Official Aviation Guide (OAG).
Countries with no migration/travel data were excluded, such as Cook Island, Estawani,
ot
Dominican, Monaco, Nauru, Palau, Saint Kitts and Nevis, San Marino and Tuvalu. After
tn
estimating key parameters using the nonlinear least square method implemented in R function
‘nls.lm’ with importation from 1 January 2022 for six months generating matrix of cumulative
number of importations based on 2000 chains was generated.

rin
Data analysis and visualization
Relative changes in the incidence of measles cases from 2000 to 2019 were estimated as the
ep
difference between the number of cases in 2019 and 2000, divided by the number of cases in
2000. The incidence and relative changes of measles were visualized on a map. The distribution
Pr
of coverage of measles-containing vaccine (MCV) were also mapped.
The 2019 Social Demographic Index (SDI), an indicator that comprehensively reflects a
ed
country’s level of development and takes into account lag-distributed income per capita,
average years of schooling, and the fertility rate among females under the age of 25, was used
as raw values and grouped into five categories: low, low-middle, middle, high-middle and high
iew
SDI based on uppercut values of 0.455. 0.608, 0.670 and 0.805, respectively 27. Countries were
grouped into WHO regions: African, Americas, South-East Asian, European, Eastern
Mediterranean and Western Pacific. Spearman’s rank-order correlation was used to measure
v
the intensity and direction of the correlations between SDI index and MCV, SDI and measles.
re
All analyses and visualization were implemented in R program version 4.3.1.
Results
er
Global distribution of measles
pe
Between 2000 and 2017, the global incidence of measles cases declined (Figures 1, S1-S2). As
shown in Figures S1-S3, while low and lower-middle SDI countries accounted for the highest
burden of measles over the majority of the years 2000-2019 (Figure 2), there was a sudden
ot
resurgence of measles outbreaks in high-middle and high-SDI countries, suggesting a gap in
vaccination rates. Notably, several high-SDI countries, such as the Czech Republic, Japan,
tn
Lithuania, Slovakia, Luxembourg, France, New Zealand and the United States, have
experienced a significant increase in the incidence rates of measles between 2000 and 2019
rin
(Figure 1, 2, S1-S2). High-middle-SDI countries with substantial increases include Bulgaria,
Chile, Montenegro, Saudi Arabia, Serbia, Seychelles and Turkey. In contrast, high-SDI
ep
countries such as Austria, Japan and Australia exhibited relatively lower measles cases in 2019,
reporting 151, 742 and 286 measles cases, indicating relatively effective vaccination programs
Pr
and healthcare infrastructure. In comparison, high-SDI countries such as New Zealand
registered over 2000 cases and ranked second in measles incidence rates (per million) within
ed
the Western Pacific region.
Similarly, high-middle SDI countries with high measles burden in 2019 include Ukraine
iew
(57,282 cases), Kazakhstan (13,326 cases), and Russia (4491 cases). This underscores the need
for continuous surveillance and vaccination efforts even in high-income regions, as measles
resurgence remains a concern. Nations classified within the low-middle SDI stratum, such as
the Democratic Republic of Congo (DRC), South Sudan, Nigeria, and Somalia, bore a
v
disproportionately high burden of measles cases in 2019. For instance, DRC, in particular,
re
reported an alarming incidence of measles, with over 300,000 reported cases during that period.
A high measles prevalence was observed in some middle-SDI countries in Asia Pacific
er
countries like the Philippines, where over two-thirds of the total regional cases occurred in
2018. In 2019, a further increase of measles cases occurred in the Philippines exceeding
pe
40,000. A parallel situation unfolded in Thailand and Vietnam during the same period. Samoa
encountered a severe measles outbreak, marked by an astounding surge of 5000 cases in

ot
2019, a sharp contrast to the complete absence of measles cases in 2000.
(A)
tn
rin
ep
Pr
ed
v iew
re
(B)
er
pe
ot
tn
rin
Figure 1. The global distribution of measles cases. (A) Incidence of measles cases in 2019,
(B) Percentage increase/decrease in measles incidence cases between 2000 and 2019.
ep
Pr
ed
v iew
re
er
Figure 2. Relative dynamic of measles cases across SDI from 2000 to 2019.
pe
Global distribution of measles vaccination
Table 1 and Figure 3 present the measles-containing vaccine (MCV) coverage from 2000 to
2019 and the temporal changes observed. There is a positive global trend in measles
ot
vaccination coverage (MCV1 and MCV2) from 2000 to 2019. However, the extent of
tn
improvement varies significantly between regions and income groups (Figure 3).
The African and South Asian region experienced significant growth in first dose MCV
rin
coverage, with an impressive rise from 58% in 2000 to 75% in 2019 (Table 1). Unfortunately,
data for the second dose in low SDI regions was unavailable. Similarly, first-dose coverage
increased from 83% to 90% in the low-middle SDI regions, and the second-dose range
ep
increased from 67% to 82%. Some countries, such as Nigeria and India, have seen substantial
increases in coverage, particularly for the second dose (MCV2). This significant increase
Pr
10
highlights efforts to expand vaccination programs despite limited resources, healthcare
ed
infrastructure, and political, social, and economic factors.
Overall, high-middle and high SDI countries in the Americas and Europe had generally high
iew
coverage, and the majority maintained or improved their vaccination rates. Between 2000 and
2019, the coverage for the first dose of MCV remained over 94% in high SDI regions. Second-
dose coverage remained over 92%. High-middle SDI regions improved MCV coverage, with
v
the first-dose coverage rising from 94% to 97% and the second-dose coverage from 92% to
re
94%. However, a few countries in the Americas (including the US and Canada) and Europe
(e.g., North Macedonia, Poland, Romania, and Ukraine) experienced decreasing coverage over
time, which is a cause for concern. Middle SDI regions showed a concerning reduction of
er
second dose MCV coverage over the years from 94% to 91%.
pe
Table 1. Temporal Changes in Measles-Containing Vaccine Coverage (2000-2019) by SDI.

ot
First dose, Median (IQR) Second dose, Median (IQR)

SDI
2000 2019 % Change 2000 2019 % Change
NA (NA – NA (NA –
tn
Low SDI 58 (45 – 71) 75 (64 – 88) 27 (10 – 48) 63 (42 – 74)
NA) NA)
Low-middle SDI 83 (66 – 90) 90 (83 – 96) 14 (3 – 31) 67 (52 – 90) 82 (65 – 93) 17 (4 – 56)
Middle SDI 92 (82 – 96) 95 (83 – 97) 3 (-2 – 10) 94 (86 – 98) 91 (75 – 97) -1 (-14 – 4)
rin
High-middle SDI 94 (89 – 98) 97 (93 – 99) 1 (-2 – 9) 92 (75 – 98) 94 (88 – 98) 7 (0 – 15)
High SDI 94 (90 – 97) 95 (92 – 97) 2 (-2 – 7) 92 (87 – 98) 93 (87 – 94) 2 (-3 – 9)
ep
Pr
11
ed
v iew
re
er
pe
ot
tn
rin
ep
Pr
Figure 3. The coverage distribution of measles-containing vaccine-first dose in (A) 2000, (B)
2019. (C) Percentage change in coverage 2019 vs 2000
12
The association between Measles incidence, SDI and MCV
ed
When evaluating the relationship between the measles cases, SDI and MCV, we found a
significant positive linear correlation between the rate of coverage of the first dose of MCV1
and SDI (r=0.47, p < 0.0001) (Figure 3A). However, this relationship varied slightly among
iew
the SDI group. For example, a statistically moderate positive correlation was observed in the
Low-middle SDI group (r = 0.32, p = 0.046). No significant correlations between MCV1 and
SDI were found in the Middle SDI, High-middle SDI, and High SDI countries. There was only
v
a moderate correlation between MCV1 coverage and SDI values in low SDI countries (r=0.31,
re
p = 0.075). The number of measles cases had a non-significantly negative linear correlation
with the SDI (r=-0.12, p = 0.096) (Figure 3A). The relationship between measles and SDI
er
varied within SDI groups, but none were statistically significant. There was a low but
significant overall negative correlation between measles cases and MCV1 (r=-0.20, p=0.005);
pe
however, only low SDI showed a moderately negative significant correlation between measles
cases and MCV1 (r= -0.39, p=0.03) (Figure 3C).
Prediction of measles importation

ot
We estimated the importation of measles cases into 181 countries and territories within the first
tn
six months of 2022. The estimates for imported measles cases and their corresponding 95%
uncertainty intervals (UIs) based on 2000 simulations were presented in Table S1 and Figure
5. Understanding the distribution of imported measles cases across continents provides a global
rin
perspective on the risk of cross-border transmission. Overall, the United States (49,413, 95%
UI: 46057, 51251), United Kingdom 40,630 (38,795, 42,728), Germany 23,628 (22,298,
ep
24,893), United Arab Emirates 15,167 (95% CI: 14,076, 16,172) and Canada (13,853, 95% UI:
12,902, 14,393) were estimated to receive a substantial number of imported measles cases.
Pr
13
(A) (B) (C)
ed
i ew
e v
r r
ee
Figure 4. Relationship between (A) SDI and percentage vaccination coverage, (B) SDI and measles cases and (C) measles cases and vaccination
coverage in 2019.
t p
n o
in t
p r
r e
P 14
This high estimate reflects the country’s extensive international travel connections and the
ed
importance of robust vaccination programs. Other notable high SDI countries with high
measles importation include France (10,782, 95% UI: 9,607, 11,268), Italy (13,332, 95% UI:
12,619, 13,932) and Spain (12,766, 95% UI: 12,075, 13,577) in Europe and Australia in Asia
iew
pacific.
Similarly, the United Arab Emirates was projected to have the highest number of (15,167, 95%
UI: 14,076, 16,172) imported measles cases within the Asia continent, while India (11,964,
v
95% UI: 11,358, 12,557), Iran (7096, 95% UI: 6915, 7469), Saudi Arabia (5,685, 95% UI:
re
4,931, 6,286) and Iraq (5356, 95% UI: 5051, 5675) following closely. Within the African
region, Egypt was estimated to have the highest number of imported cases of measles (3,318,
er
95% UI: 2,901, 3,730), followed by South Africa (2,781, 95% UI: 2,379, 3,120), Ghana (2639,
95% UI: 2421, 2684) and Kenya (1,163, 95% CI: 972, 1,316).
pe
The dynamics of the international transmission of measles and the contributory role of different
SDI in the importation of measles vary by country (Figure 6 and Table S2). While low-middle
SDI African countries and the Americas served as frequent sources of imported cases globally,
ot
they were followed by high and high-middle SDI regions, particularly in Europe and the
Eastern Mediterranean. This new route may be attributed to these regions’ elevated
tn
international travel and trade connections with regions with high measles cases. For example,
15.5% and 36.5% of all imported cases in Algeria were from High and High-middle SDI
rin
Eastern Mediterranean countries. In Armenia, 15.1% and 11.9% of imported cases were from
High-middle SDI European and High SDI Eastern Mediterranean countries, respectively.
ep
Pr
15
ed
i ew
e v
r r
ee
t p
n o
in t
p r
r e
P
Figure 5. Estimated six months of imported measles cases in 2022.
16
(A) Low SDI
ed
v iew
re
(B) Low-middle SDI
er
pe
ot
tn
rin
ep
Pr
17
(C) Middle SDI
ed
v iew
re
(D) Middle high SDI
er
pe
ot
tn
(E) High SDI

rin
ep
Pr
18
ed
v iew
re
Figure 6. Percentage contribution of imported cases from each SDI.
er
The United States of America and Canada were estimated to have had 66.5% and 82.8% imported cases of
pe
measles from low-middle SDI American countries. By contrast, countries such as the UK, Estonia, Iceland,
Latvia, Lithuania, Norway, Moldova, Poland, Spain and Portugal all had a higher percentage (>60%) of
importation from high SDI European countries. For New Zealand and Australia, high/high-middle SDI
ot
European countries were estimated to account for the most sources of measles importation into both island
countries, 54.7% and 47.1%, respectively. High SDI Eastern Mediterranean countries were notable contributors
tn
to Australia, with 17.8% respectively. The following countries were estimated to have had more than 70% of
measles imported cases from low-middle SDI African countries: Benin, Cameroon, Chad, Equatorial Guinea,
rin
Gabon, Gambia, Ghana, Ivory Coast, Liberia, Rwanda, Sao Tome and Principe and Togo.
Discussion
ep
Main findings
This study analyzed global measle prevalence data, and extensive simulations were conducted to assess the
Pr
potential influx of imported measles cases across 181 countries and territories for the first half of 2022. We
generated estimates of measles importation and examined the contribution of SDI to the transmission of this
19
highly contagious disease. The United States, the United Kingdom, Germany, the United Arab Emirates, and
Canada were estimated to have received a substantial influx of imported measles cases, reflecting the influence
of extensive international travel connections.
ed
The dynamics of international measles transmission and the influence of different SDI regions on measles
importation exhibited diverse patterns. Low-middle SDI countries in Africa and the Americas stood out as
iew
primary sources of imported cases globally, followed notably by high and high-middle SDI regions, particularly
Europe and the Eastern Mediterranean. This shifting importation route can be attributed to these regions'
extensive international travel and trade connections with areas experiencing high measles prevalence. In contrast,
v
the United States of America and Canada experienced a considerable portion of imported measles cases, with
re
66.5% and 82.8% originating from low-middle SDI American countries. On the other hand, the United Kingdom,
Estonia, Iceland, Latvia, Lithuania, Norway, Moldova, Poland, Spain, and Portugal received more than 60% of
their imported cases from high SDI European countries. New Zealand and Australia had high/high-middle SDI
er
European countries as their primary sources of measles importation (54.7% and 47.1%, respectively) and lesser
pe
numbers from high SDI Eastern Mediterranean countries (17.8%).
Findings from this analysis indicate that estimating the risk of measles importation is achievable by monitoring
measles patterns in nations with substantial travel connections by applying meta-population models. Despite the
ot
vaccination efforts of several countries to mitigate the burden of measles through robust immunization
campaigns, our study has underscored the looming threat and inherent risks associated with measles importation.
tn
It emphasizes the critical need for concerted global efforts aimed at sustaining measles control and averting its
resurgence in susceptible populations.

rin
Prior to the introduction of the measles vaccine in 1963, an estimated 2.6 million deaths occurred annually due
to measles 8. However, between 2000 and 2018, measles vaccination prevented approximately 23.2 million deaths
ep
8 28, 29
, including through herd immunity . Moreover, measles vaccination programs have proven to be cost-
effective in both high-income and developing countries, offering significant value for money from both health
Pr
system and societal perspectives 30.
20
In 2019, we witnessed a concerning 142% surge in measles cases compared to the previous year, with the majority
of cases originating from Africa (71%), followed by Europe and Central Asia (11.9%) and East Asia and the
Pacific (10.4%). The global increase in measles underscores the ongoing importance of maintaining and
ed
strengthening vaccination efforts to protect vulnerable populations and prevent the resurgence of this highly
contagious and potentially deadly disease.
iew
Many developing countries face structural and economic weaknesses in their vaccination programs, often relying
31
on international funding . Additionally, these programs are facing the rise of vaccine hesitancy, significantly
reducing vaccine coverage in many developing and developed countries. This hesitancy has resulted in a manifold
v
increase in measles incidence and deaths around the world. While challenges such as vaccine supply chains and
re
access persist, especially in developing countries, examples of medical incidents related to vaccine programs or
inadequate communication about vaccine risks and benefits erode public confidence in national immunization
programs, including measles vaccinations. In Samoa, for example, community mistrust in the safety of measles
er
vaccination significantly increased after two vaccine-associated paediatric deaths32. This led to the immediate
pe
recall of all MMR vaccines and the suspension of the National Immunization Program between 2018 and 201932.
Even though investigations revealed that the deaths were due to medical negligence rather than the vaccine itself,
the lack of effective communication management regarding these incidents fuelled speculations from anti-
ot
vaccination groups, leading to the decline of public trust in vaccine safety. Despite the resumption of the
vaccination program, Samoa has struggled to achieve high coverage for measles vaccination due to persisting
tn
vaccine hesitancy.
In developed nations such as the US and Australia, the rise of anti-vaccination movements also poses a growing
rin
concern. In the US, vaccine exemptions doubled between 2006 and 2016. Immunization rates for five-year-olds
are reducing in Australia. Lowered vaccine confidence is a likely contributor to these trends 8.
ep
Furthermore, in low and low-middle SDI countries, where poverty is widespread and basic education is often
neither universally available nor accessible, a high prevalence of illiteracy is observed 33. This illiteracy can pose
Pr
a substantial challenge to immunization efforts, as these families may lack awareness of the importance of
21
immunization programs. For instance, Forshaw et al. (2017) demonstrated that a child with an educated mother
is more likely to have higher immunization coverage than a non-educated mother 34.
Impact of COVID-19 on measles resurgence
ed
The COVID-19 pandemic and the resultant disruptions in supplementary immunization activities have had a
profound impact. Approximately 61 million measles-containing vaccines were postponed or missed from 2020
iew
to 2022 7. When vaccine doses are postponed or missed, the overall population immunity decreases, leaving
vulnerable individuals more susceptible to measles infection. Those who do not receive the measles-containing
vaccine remain susceptible and can contribute to the transmission chain, potentially leading to localized or
v
widespread outbreaks. The delays and disruptions in childhood vaccination programs, including postponed
re
immunization campaigns resulted in declining vaccine coverage. These challenges underscore the importance of
maintaining and reinforcing immunization efforts, especially in the face of unforeseen disruptions like the
COVID-19 pandemic 35.

er
Limitations
pe
We acknowledge the following limitations of this study. These limitations stem from the data sources and their
availability, which shaped the estimates presented in this research. First, pre-COVID-19 air passenger data was
used in modelling measles transmission risk through international travel. In addition, the data did not capture the
ot
movement of people via land and sea and lacked data on cross-border movements at the national level. The
tn
inclusion of such information has the potential to enhance the precision and granularity of the estimated scenarios
regarding imported measles cases. Lastly, it is essential to recognize that the estimates presented in this study are
static and represent a particular point in time (over six months). The dynamic nature of measles and the evolving
rin
landscape of measles vaccination coverage and prevalence can influence the accuracy of these estimates. Changes
in vaccination campaigns, disease outbreaks, and other global health events may significantly affect the risk of
ep
measles transmission. Hence, our findings should be considered in light of these potential changes and serve as
a foundation for continuous monitoring and dynamic decision-making by health authorities.

Pr
The findings in this study have various policy implications. Measles remains a global threat to public health, with
recent outbreaks of acute respiratory viruses reinforcing the severity of the disease. Efforts to eradicate the disease
22
focus on vaccination. If the vaccine is not available and accessible, it leads to this disease's outbreaks. The study
highlights the significant impact of international travel connections in facilitating the importation of measles
cases. Countries such as the United States, the United Kingdom, Germany, the United Arab Emirates, and Canada
ed
emerge as key recipients. Importation dynamics of measles cases exhibit variability across different Socio-
Demographic Index (SDI) regions, with low-middle SDI countries in Africa and the Americas serving as primary
iew
sources of imported cases. Despite extensive vaccination campaigns, the study provides the first estimates of
measles importation due to air travel and emphasizes the persistent threat and inherent risks associated with
measles importation. This underscores the need for global collaboration to sustain measles control measures and
v
pre-empt a resurgence in susceptible populations. Moreover, the study highlights the urgency for enhanced
re
surveillance and robust border control measures to respond swiftly and contain imported measles cases from
countries experiencing outbreaks. Such proactive measures are crucial in averting the spread of the disease and
safeguarding vulnerable communities worldwide. er

pe
ot
tn
rin
ep
Pr
23
Conflict of interest: None declared.
Authors’ contributions
Conceptualization O.A.A.; data curation O.A.A. and M.A-K., formal analysis was by O.A.A. and A.I.A;
ed
original draft was written by O.A.A. and A.P.; review and editing were performed by O.A.A., A.I.A., A.P.,
M.A-K., G.G., N.N. and E.M.
iew
Declaration of interest
The authors declare no conflict of interest.
Funding
v
None
re
References
1
er
OA Adegboye, AI Adekunle, A Pak, et al. Change in outbreak epicentre and its impact on the
importation risks of covid-19 progression: A modelling study. Travel Medicine and Infectious Disease 2021;
40(101988.
2 R Zheng, Y Xu, W Wang, et al. Spatial transmission of covid-19 via public and private transportation in
pe
china. Travel medicine and infectious disease 2020; 34(101626.
3 DO Freedman. Air travel and sars-cov-2: Many remaining knowledge gaps. Journal of Travel Medicine
2022.
4 V Goel, D Bulir, E De Prophetis, et al. Covid-19 international border surveillance at toronto’s pearson
airport: A cohort study. BMJ open 2021; 11(7):e050714.
5 OA Ogundele, AA Omotoso, AT Fagbemi. Covid-19 outbreak: A potential threat to routine vaccination
ot
programme activities in nigeria. Human Vaccines & Immunotherapeutics 2021; 17(3):661-663.

6 K Abbas, V Mogasale. Disruptions to childhood immunisation due to the covid-19 pandemic. The
Lancet 2021; 398(10299):469-471.
tn
7 KA Gaythorpe, K Abbas, J Huber, et al. Impact of covid-19-related disruptions to measles,

meningococcal a, and yellow fever vaccination in 10 countries. Elife 2021; 10(e67023.
8 WHO. Measles, fact sheets. 2019.
9 World Health Organization [Press release]. Nearly 40 million children are dangerously susceptible to
growing measles threat. ed.^,eds.: World Health Organizatio, 2022.
rin
10 KM Williamson, T Merritt, DN Durrheim. Australia: An island in a sea of measles. The Medical Journal
of Australia 2020; 213(3):101-103. e1.
11 DN Durrheim, JK Andrus, S Tabassum, et al. A dangerous measles future looms beyond the covid-19
pandemic. Nature Medicine 2021; 27(3):360-361.
12 MS Rana, MM Alam, A Ikram, et al. Emergence of measles during the covid-19 pandemic threatens
ep
pakistan’s children and the wider region. Nature Medicine 2021; 27(7):1127-1128.
13 D Schenzle. An age-structured model of pre-and post-vaccination measles transmission. Mathematical
Medicine and Biology: A Journal of the IMA 1984; 1(2):169-191.
14 SN Gupta, R Vidya, N Gupta, MD Gupte. Factors precipitating outbreaks of measles in district kangra
Pr
of north india: A case-control study. International Journal of Applied and Basic Medical Research 2011;
1(1):24.
15 JD Clemens, BF Stanton, J Chakraborty, et al. Measles vaccination and childhood mortality in rural
bangladesh. American journal of epidemiology 1988; 128(6):1330-1339.
24
16 E Mahase. Measles cases at highest point since 2006 as outbreaks continue to spread. BMJ: British
Medical Journal (Online) 2019; 366(
17 WHO. Immunization, vaccines and biologicals; new measles surveillance data from who. 2019.
18 DN Durrheim, MG Baker, MR Capeding, et al. Accelerating measles elimination in the western pacific
region during the calm between the storms. The Lancet Regional Health–Western Pacific 2022; 23(
ed
19 Bosco Ho, Adeshina Adekunle, James Trauer, E McBryde. Global pandemic map. ed.^,eds., 2019.
20 D He, DJ Earn. The cohort effect in childhood disease dynamics. J R Soc Interface 2016; 13(120).
21 S Verguet, M Johri, SK Morris, et al. Controlling measles using supplemental immunization activities:
A mathematical model to inform optimal policy. Vaccine 2015; 33(10):1291-1296.
22 M Roser, H Ritchie, E Ortiz-Ospina, L Rodés-Guirao. World population growth. Our world in data
iew
2013.
23 M Roser, E Ortiz-Ospina, H Ritchie. Life expectancy. Our world in data 2013.
24 World Health Organization. Who immunization data portal - provisional measles and rubella data.
ed.^,eds., 2022.
25 E Hall, A Wodi, J Hamborsky, et al. Epidemiology and prevention of vaccine-preventable diseases: US
Department of Health and Human Services, Centers for Disease Control and …, 2021.
v
26 A Adekunle, M Meehan, D Rojas‐Alvarez, et al. Delaying the covid‐19 epidemic in australia:
Evaluating the effectiveness of international travel bans. Australian and New Zealand journal of public health
re
2020; 44(4):257-259.
27 Global Burden of Disease Collaborative Network. Global burden of disease study 2019 (gbd 2019)
socio-demographic index (sdi) 1950–2019. ed.^,eds. Vol 2022: Seattle, United States of America. Institute for
Health Metrics and Evaluation (IHME), 2020.
28 JD Porter, M Gastellu-Etchegorry, I Navarre, et al. Measles outbreaks in the mozambican refugee camps
er
in malawi: The continued need for an effective vaccine. International journal of epidemiology 1990;
19(4):1072-1077.
29 JA Bielicki, R Achermann, C Berger. Timing of measles immunization and effective population vaccine
coverage. Pediatrics 2012; 130(3):e600-e606.
pe
30 KM Thompson, CL Odahowski. Systematic review of health economic analyses of measles and rubella
immunization interventions. Risk Analysis 2016; 36(7):1297-1314.
31 M McQuestion, D Gnawali, C Kamara, et al. Creating sustainable financing and support for
immunization programs in fifteen developing countries. Health Affairs 2011; 30(6):1134-1140.
32 AT Craig, AE Heywood, H Worth. Measles epidemic in samoa and other pacific islands. The Lancet
Infectious Diseases 2020; 20(3):273-275.
ot
33 JP Chimombo. Issues in basic education in developing countries: An exploration of policy options for
improved delivery. Journal of international cooperation in education 2005; 8(1):129-152.
34 J Forshaw, SM Gerver, M Gill, et al. The global effect of maternal education on complete childhood
tn
vaccination: A systematic review and meta-analysis. BMC infectious diseases 2017; 17(1):801.
35 MG Dixon, M Ferrari, S Antoni, et al. Progress toward regional measles elimination—worldwide,
2000–2020. Morbidity and Mortality Weekly Report 2021; 70(45):1563.
rin
ep
Pr
25
SUPPLEMENTARY MATERIALS
The global resurgence of measles, estimating the risks of international

importations of measles among 181 countries and territories: A
modelling study
ed
Oyelola A. Adegboye, MSc, PhD1,2,3 *†, Adeshina I. Adekunle, MSc, PhD 3†, Anton Pak MSc, PhD 3,4, Md
Abdul-Kuddus, MSc, PhD 3, Gillian Gorham MSc, PhD1, Noni Winkler, MPH&TM5, Emma McBryde, MBBS,
iew
PhD 3
1
Menzies School of Health Research, Charles Darwin University, Casuarina 0811, NT, Australia.
2
Public Health & Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook
University, Townsville 4811, QLD, Australia
v
3
Australian Institute of Tropical Health and Medicine, James Cook University, Townsville 4811, QLD,
re
Australia
4
Centre for the Business and Economics of Health, The University of Queensland, St Lucia 4072, QLD,
Australia
5
National Centre for Immunisation Research and Surveillance, The Children’s Hospital at Westmead, NSW,
Australia er
†
First authors
*Correspondence: Oyelola A. Adegboye, Menzies School of Health Research, Charles Darwin University,
pe
Casuarina 0811, NT, Australia. Email: oyelola.adegboye@menzies.edu.au
ot
tn
rin
ep
Pr
26
Figure S1: Global temporal trends of measles incidence from 2000 to 2019
(A) Low SDI
ed
v iew
re
(B) Low-middle SDI er
pe
ot
tn
rin
ep
Pr
27
(C) Middle SDI
ed
v iew
re
(D) High-middle SDI
er
pe
ot
tn
rin
ep
Pr
28
(E) High SDI
ed
v iew
re
er
pe
ot
tn
rin
ep
Pr
29
ed
v iew
re
er
pe
Figure S2. Estimate rate of increase in measles cases, from 2000 to 2019
ot
tn
rin
ep
Pr
30
Figure S3. Observed and predicted measles cases, from 2000 to 2019
ed
i ew
e v
r r
ee
t p
n o
in t
p r
r e
P 31
ed
i ew
e v
r r
ee
t p
n o
in t
p r
r e
P 32
ed
i ew
e v
r r
ee
t p
n o
in t
p r
r e
P 33
ed
i ew
e v
r r
ee
t p
n o
in t
p r
r e
P 34
ed
i ew
e v
r r
ee
t p
n o
in t
p r
r e
P 35
ed
i ew
e v
r r
ee
t p
n o
in t
p r
r e
P 36
Table S1. Estimated imported measles cases and their 95% CI based on 2000 simulations
Country Mean SD Lower Upper

Afghanistan 171.87 33.98 150 187
ed
Albania 282.06 47.77 253 303
Algeria 452.57 326.50 270.75 504
Angola 177.07 73.06 128 218
Antigua and Barbuda 40.91 38.02 18 49
iew
Argentina 1895.71 419.70 1781 1998
Armenia 384.98 61.69 345 419
Australia 1633.20 235.47 1495 1758
Austria 2556.73 432.62 2331.75 2755
Azerbaijan 668.68 100.37 609 725.25
Bahamas 69.60 49.07 43 77
v
Bahrain 936.92 154.00 846.75 1026
Bangladesh 2148.37 199.62 2020.75 2280
re
Barbados 87.44 104.53 22 102.25
Belarus 210.52 66.43 168.75 246
Belgium 4125.91 695.05 3772.75 4433
Belize 15.75 12.92
er 8 20
Benin 283.01 80.48 228 306
Bhutan 0.01 0.25 0 0
Bolivia 66.11 23.49 55 72
pe
Bosnia and Herzegovina 212.08 62.31 174 241
Botswana 47.37 25.94 29 61
Brazil 1308.91 294.15 1192.75 1399
Brunei Darussalam 3.32 7.35 0 4
Bulgaria 968.60 129.84 888 1040.25
Burkina Faso 110.49 58.81 47 140
ot
Burundi 107.46 54.22 68.75 145

Cambodia 50.19 31.50 31 64
Cameroon 305.19 85.07 255.75 328
tn
Canada 13853.08 3268.32 12902.25 14393.75

Cape Verde 8.25 10.26 3 11
Central African Republic 15.63 14.45 6 22
Chad 70.00 30.54 47 81
rin
Chile 1101.75 251.04 1030 1162

China 3891.04 673.13 3519.75 4132.5
Colombia 1022.01 241.89 950 1083
Comoros 6.32 9.30 1 8
ep
Congo 47.57 30.93 27 61

Costa Rica 339.93 91.95 307 363
Croatia 452.21 104.88 389 503
Cuba 483.98 156.20 413 530
Cyprus 4234.30 278.76 4098 4384
Pr
Czech Republic 1324.49 236.74 1190.75 1454

Denmark 3659.37 571.81 3345 4009
Djibouti 69.44 38.02 48 84
37
Dominican Republic 65.42 48.54 38 79
DR Congo 71.78 39.77 48 86
Ecuador 207.73 61.38 181 227
Egypt 3318.66 681.00 2901 3730
El Salvador 87.72 28.71 75 96
ed
Equatorial Guinea 51.10 23.39 36 61
Eritrea 17.97 13.45 9 24
Estonia 551.77 131.54 476.75 632
Ethiopia 521.80 132.33 441 581
iew
Fiji 8.01 8.71 3 10
Finland 1038.10 239.06 883.75 1192.25
France 10782.94 2731.20 9607.25 11268.5
Gabon 249.40 59.63 217 262
Gambia 72.08 23.20 60 78
Georgia 949.45 115.77 874 1016
v
Germany 23628.11 3141.97 22298.25 24893.5
Ghana 2639.17 493.94 2421 2684
re
Greece 856.89 200.06 739 957
Grenada 32.34 45.73 2 47
Guatemala 186.14 52.43 165 201
Guinea 54.79 29.57
er 35 63
Guinea-Bissau 8.01 7.10 4 10
Guyana 97.60 99.95 37 116
Haiti 198.43 53.64 178 213.25
pe
Honduras 71.42 25.54 59 80
Hungary 1595.57 231.98 1468 1717.25
Iceland 392.63 86.57 340.75 442
India 11964.95 1043.15 11358.25 12557.5
Indonesia 864.67 194.47 735 982
Iran 7096.50 699.46 6915 7469
ot
Iraq 5356.50 436.97 5051.5 5675

Ireland 1225.70 253.95 1075 1362.25
Israel 1950.82 284.81 1785 2097
tn
Italy 13332.80 1683.45 12619.25 13932.75

Ivory Coast 620.34 168.78 511 657
Jamaica 104.77 80.42 59 117
Japan 812.96 185.37 700 910
rin
Jordan 1917.80 230.59 1822.75 2032.25

Kazakhstan 242.93 68.81 200 279
Kenya 1163.03 311.91 972 1316.25
Kiribati 0.00 0.09 0 0
ep
Kuwait 3642.77 494.10 3313 3994

Kyrgyzstan 38.73 26.16 22 51
Laos 3.36 7.56 0 4
Latvia 611.26 118.54 546 681
Lebanon 3470.28 536.12 3189 3757.25
Pr
Lesotho 7.35 6.62 3 9

Liberia 105.07 29.21 88 114
Libya 405.19 361.68 187 462
38
Lithuania 642.64 124.14 565 720
Luxembourg 263.41 93.53 211 298
Macedonia 162.09 46.35 132 185
Madagascar 26.64 23.31 12 37
Malawi 40.54 21.90 27 49
ed
Malaysia 1665.32 232.96 1527.75 1781
Maldives 154.06 53.82 118 181
Mali 106.58 66.31 43 137
Malta 560.55 137.87 480 622.5
iew
Mauritania 36.88 47.61 10 43
Mauritius 85.43 44.66 56 105
Mexico 838.49 222.52 749 905
Micronesia 0.02 0.22 0 0
Moldova 195.22 47.77 166 220
Mongolia 5.22 8.55 1 8
v
Montenegro 56.88 74.98 27 58
Morocco 732.49 283.34 562 803.25
re
Mozambique 167.36 43.94 139 188
Myanmar 98.37 31.44 79 113
Namibia 146.00 38.64 125 162
Nepal 1401.61 128.41
er 1316 1484
Netherlands 5545.78 707.05 5199 5910.25
New Zealand 177.79 58.24 142 208
Nicaragua 69.36 25.42 58 78
pe
Niger 48.21 31.79 31 55
Nigeria 349.31 133.55 253 435
North Korea 0.06 0.42 0 0
Norway 2820.90 530.85 2522 3158
Oman 1963.33 235.49 1813 2107.25
Pakistan 2589.21 244.82 2445.75 2737
ot
Panama 464.32 134.44 412 498.25

Papua New Guinea 2.02 4.52 0 3
Paraguay 158.70 41.36 144 170
tn
Peru 695.31 167.88 640 741

Philippines 1674.29 222.95 1532 1802
Poland 4346.65 495.60 4107.5 4632
Portugal 2192.39 314.99 2035.5 2360
rin
Qatar 2241.53 349.45 2048 2423.25

Romania 1995.14 241.16 1861 2119
Russia 5613.81 824.33 5172.75 6013
Rwanda 421.85 93.15 376 438
ep
Saint Lucia 29.35 35.39 7 39

Saint Vincent and the
Grenadines 21.70 31.01 2 31
Samoa 0.05 0.56 0 0
Sao Tome and Principe 10.40 4.98 8 12
Pr
Saudi Arabia 5685.50 1356.83 4931 6286

Senegal 450.48 170.06 316 538
Serbia 560.67 110.19 494 614
39
Seychelles 112.42 43.00 85 132
Sierra Leone 98.68 39.02 72 118
Singapore 906.68 161.49 807 1000
Slovakia 572.34 85.75 526 610
Slovenia 195.51 70.72 155.75 223
ed
Solomon Islands 0.02 0.30 0 0
Somalia 13.37 15.69 5 16.25
South Africa 2781.75 673.67 2379.5 3120.5
South Korea 650.25 143.90 564 719
iew
South Sudan 25.52 21.36 14 33
Spain 12766.55 1703.66 12075 13577.75
Sri Lanka 995.73 137.88 904 1077
Sudan 794.51 162.60 699 868.25
Suriname 37.76 30.97 20 43
Sweden 4906.85 856.03 4441 5402
v
Switzerland 5047.52 855.35 4640 5340.25
Syria 400.59 54.25 370 432
re
Tajikistan 39.50 16.97 28 48
Tanzania 509.85 148.96 415 596
Thailand 2378.02 317.25 2184 2566.5
Timor-Leste 0.02 0.30
er 0 0
Togo 103.61 40.28 72 121
Tonga 0.03 0.41 0 0
Trinidad and Tobago 92.49 97.20 40 91
pe
Tunisia 412.45 119.00 310 481
Turkey 11541.33 1278.64 10918.5 12104.25
Turkmenistan 16.17 17.96 5 23
Uganda 364.88 123.60 286 433
Ukraine 1127.82 227.03 995 1249
United Arab Emirates 15167.98 2026.18 14076.75 16172.75
ot
United Kingdom 40630.78 4442.77 38795.5 42728.75

United States 49413.63 10875.10 46057.25 51251.75
Uruguay 342.60 84.98 313 367
tn
Uzbekistan 79.95 41.37 51 102

Vanuatu 0.24 0.94 0 0
Venezuela 152.43 58.67 123 172
Vietnam 308.22 87.29 254 352.25
rin
Yemen 2.85 1.69 2 4

Zambia 118.76 46.84 89 138.25
Zimbabwe 107.43 50.33 74 134
ep
Pr
40
Table S2. Percentage contribution of imported measles cases from each SDI
High-
High-
d
High High- High- High- middle
High High SDI: High High-middle middle Low Low Low SDI:
SDI: middle middle middle SDI:
Country SDI: Eastern SDI:
Western SDI: SDI:
SDI: Eastern
SDI: South-
SDI: SDI: SDI: Eastern
e
Americas Mediterranean Europe Mediterranean Western Africa Americas Mediterranean
Pacific Africa Americas Europe East
Pacific
Asia
w
Afghanistan 0 2.6 2.2 0 0 0 5.4 4.8 0 0 0.2 0 0
Albania 0 3 4.3 0 0 0 0.3 90.2 0 0 0.1 0 0
Algeria
Angola
Antigua and Barbuda
Argentina
0
0
0.7
0.1
15.5
1.5
0
0.4
2.5
4.6
7.1
1.9
0
0
0
0
0
0
0
0
0
0
26.7
0
36.5
0.6
0.1
0.3
5.7
3.4
1.7
2.1
0
0
v
0
0
i e 0
0
0
0
5.6
2.4
0
0
0
0
0
0
0
0
0
0
e
Armenia 0 11.1 4.9 0 0 0 1.9 15.1 0 0 0.1 0 0
r
Australia 0.1 17.8 30.3 0.1 0 0 6.1 16.8 0 0 0.3 0 0
Austria 0 2.8 29.9 0 0 0 3.3 32.8 0 0 0.3 0 0
r
Azerbaijan 0 22.7 4.6 0 0 0 4 5.6 0 0 0 0 0
Bahamas 2.9 0.7 9.2 0 0 3.6 0 5.5 0 0 0 0 0
e
Bahrain 0 8.9 3.2 0 0 0 29.9 4.6 0 0 0.2 0 0
Bangladesh 0 65.2 1 0 0 0 25.7 2.1 0 0 0.1 0 0
Barbados
Belarus
Belgium
Belize
0.6
0
0
3.1
1
3.4
1.7
0
18.8
22.9
39.1
5
0
0
0
0
0
0
0
0
pe 38.2
0
0
6.9
0.1
2.7
1.7
0.7
2.8
24.4
37.8
1.6
0
0
0
0
0
0
0
0
0
0
3
0
0
0
0
0
0
0
0
0
Benin
Bhutan
Bolivia
0
0
0.2
0.3
0
0.4
0.5
4
2.6
o
0
24
0
t
0
0
0
0
0
0.2
0.2
0
0.1
0.8
8
0.5
0
0
0
0
0
0
11.7
0
0
0
0
0
0
0
0
n
Bosnia and Herzegovina 0 25.2 5.4 0 0 0 6.2 51.8 0 0 0.3 0 0
Botswana 0 1.8 6.1 0 0 0.1 1.3 2.9 0 0 5.6 0 0
t
Brazil 0.2 1.9 17.1 0 0 0.2 1.5 5.7 0 0 0.2 0 0
Brunei Darussalam 0.2 9.2 6.2 2.4 0 0 23.1 13.6 0 1.3 0 0 0
in
Bulgaria 0 3.3 22.1 0 0 0 1.6 69.3 0 0 0 0 0
Burkina Faso 0 0.6 1.3 0 0 0 0.4 1.5 0 0 49.2 0 0
Burundi
Cambodia
Cameroon
Canada
0
0.3
0
0.1
p r 0.4
16.7
1.6
0.6
0.4
33.2
1.1
4.5
0
0.4
0
0
0
0
0
0
0
0
0
0.3
2.5
5.9
0.3
0.8
1.4
16.7
4.5
2.5
0
0
0
0
0
0.1
0
0
90.9
0.8
7.4
0.2
0
0
0
0
0
0
0
0
Cape Verde
Chad
r e
Central African Republic
0.2
0
0
0
4.9
1
22.9
2.8
2.4
0
0
0
0
0
0
0
0
0
0
7.5
1.1
9.8
6.7
1.1
0
0
0
0
0
0
7.5
58.5
19.2
0
0
0
0
0
0
Chile
P 0.1 0.1 1.8 0 0 0.1 0.2 1.2 0 0 0 0 0
41
China 0.1 7.8 10.6 0.1 0 0 7.6 11.5 0 0 2.1 0 0
Colombia 0.2 0.2 1.8 0 0 0.3 0.3 1.5 0 0 0 0 0
Comoros 0 22.5 1 0 0 0 16 8 0 0 50.5 0 0
Congo
Costa Rica
Croatia
Cuba
0
0.7
0
0.9
1.6
0.1
13.2
0.1
1.9
4
30.7
10.3
0
0
0
0
0
0
0
0
0
0.5
0
1.3
0.4
0.1
3.2
0.2
7.1
1
43.3
7.9
0
0
0
0
ed 0
0
0
0
40.3
0
0.2
0
0
0
0
0
0
0
0
0
w
Cyprus 0 1.4 5.1 0 0 0 2.6 85.8 0 0 0 0 0
Czech Republic 0 2.2 57.5 0 0 0 2.4 29.6 0 0 0.1 0 0
Denmark
Djibouti
Dominican Republic
DR Congo
0
0
9
0
2.2
59.9
1.1
0.9
56.9
2.7
51.7
4.3
0
0
0
0
0
0
0
0
0
0
4.6
0
1.6
14.2
1
1.2
22.5
2.9
21.6
9.3
0
0
v
0
0
i e 0
0
0
0
0.3
10.3
0.1
26.9
0
0
0
0
0
0
0
0
e
Ecuador 0.5 0.3 2.6 0 0 0.3 0.2 1.4 0 0 0.1 0 0
r
Egypt 0 17.9 2.6 0 0 0 38.2 9.1 0 0 0.5 0 0
El Salvador 0.8 0.7 1.4 0 0 0.6 0.1 0.6 0 0 0.1 0 0
r
Equatorial Guinea 0 0 7 0 0 0.2 0.2 5.6 0 0 1.8 0 0
Eritrea 0.1 62.3 12.2 0 0 0 6 7.3 0 0 5.5 0 0
e
Estonia 0 0.8 83.3 0 0 0 0.8 13.2 0 0 0 0 0
Ethiopia 0 20.9 3.4 0 0 0 6.7 2.4 0 0 11.8 0 0
e
Fiji 0.8 1.8 22.3 1.6 0 0.2 1.9 5.1 0 0 0 0 0
Finland 0 4.6 56 0 0 0 1.5 22.4 0 0 0.4 0 0
France
Gabon
Gambia
Georgia
0
0
0
0
2.8
0
2.2
11.5
36.7
0.7
2
11
0
0
0
0
0
0
t
0
0 p 0
0
0
0
3.3
0.4
0.3
3.6
20
1.3
0.3
21.3
0
0
0
0
0
0
0
0
1
3.5
1.7
0.1
0
0
0
0
0
0
0
0
Germany
Ghana
Greece
0
0
0
1.3
1
16.9
30.8
0.5
30.8
n o 0
0
0
0
0
0
0
0
0
2.2
0.4
10
42.1
0.6
16.8
0
0
0
0
0
0
0.3
2.5
0.4
0
0
0
0
0
0
t
Grenada 0.3 0 3.7 0 0 80.3 0 1.1 0 0 0 0 0
Guatemala 0.4 0 1.4 0 0 0.4 0.5 0.5 0 0 0 0 0
in
Guinea 0 4.6 2.1 0 0 0 0.5 2.7 0 0 13.7 0 0
Guinea-Bissau 0 0.9 1 0 0 0 0 2.3 0 0 27.6 0 0
Guyana
Haiti
Honduras
Hungary
0.2
0.4
0.8
0
p r 0
0.1
0.1
1.5
0.6
0.6
2.8
49.3
0
0
0
0
0
0
0
0
40.9
0.3
0.6
0
0
0.5
0.2
1.3
0
0.1
0.9
39.8
0
0
0
0
0
0
0
0
0.1
0.4
0
0.1
0
0
0
0
0
0
0
0
Iceland
India
Indonesia
r e 0.2
0
0
0.3
50.3
25.6
91.7
3.8
13.8
0
0
0.3
0
0
0
0
0
0
0.3
25.1
31.7
6.4
2.5
7.7
0
0
0
0
0
0.1
0
0.5
0
0
0
0
0
0
0
Iran
Iraq
P 0
0
5.3
12.2
0.4
0.3
0
0
0
0
0
0
2.3
17.5
1.8
1.1
0
0
0
0
0
0
0
0
0
0
42
Ireland 0.1 5.5 39 0 0 0 2.1 30.7 0 0 0.1 0 0
Israel 0.1 0.3 20.2 0 0 0 4.4 64.3 0 0 0.5 0 0
Italy 0 2.7 30.1 0 0 0 2.4 45.9 0 0 0.2 0 0
Ivory Coast
Jamaica
Japan
Jordan
0
2.9
0.6
0
0.6
0.4
8.5
18.2
0.5
7.4
33.5
1.3
0
0
0.2
0
0
0
0
0
0
9.1
0.1
0
0.5
0.2
6.6
4.9
1.3
2.6
25.1
5.1
0
0
0
0
ed 0
0
0
0
8.9
0
1.1
0.2
0
0
0
0
0
0
0
0
w
Kazakhstan 0 2.8 24 0 0 0 4.7 23.4 0 0 0 0 0
Kenya 0 17.2 3.9 0 0 0 5.4 2.1 0 0 24.4 0 0
Kiribati
Kuwait
Kyrgyzstan
Laos
66.7
0
0
0.7
0
50.4
10.8
18.2
0
0.9
19.9
28.3
33.3
0
0
1.1
0
0
0
0
0
0
0
0
0
26.7
8.5
4.3
0
1.8
38.7
28.4
0
0
v
0
0
i e 0
0
0
0.2
0
0.1
0
0
0
0
0
0
0
0
0
0
e
Latvia 0 0.5 83.2 0 0 0 0.4 12.7 0 0 0.1 0 0
r
Lebanon 0 17.3 0.9 0 0 0 18.4 6.7 0 0 0.4 0 0
Lesotho 0 2.5 1.8 0 0 0 0.8 1.8 0 0 9.6 0 0
r
Liberia 0 1.1 0.9 0 0 0 0.1 0.3 0 0 4.3 0 0
Libya 0 1.3 0 0 0 0 49.4 0.1 0 0 14.8 0 0
e
Lithuania 0 0.3 72.8 0 0 0 0.6 24.4 0 0 0 0 0
Luxembourg 0 1.5 51.5 0 0 0 2.8 27.8 0 0 0.7 0 0
e
Macedonia 0 31.2 8.5 0 0 0 1 51.7 0 0 0.1 0 0
Madagascar 0 0.5 5.4 0 0.2 0 2.8 23.8 0 0 22.3 0 0
Malawi
Malaysia
Maldives
Mali
0
0
0
0
4.4
14
24.3
1.1
8.8
5.4
23
2.6
0
0.1
0
0
0
0
t
0
0 p 0
0
0
0
1
12.7
7.6
1.3
3.4
3.4
15
4.9
0
0
0
0
0
0
0
0
15.1
0.1
0.2
46.6
0
0
0
0
0
0
0
0
Malta
Mauritania
Mauritius
0
0
0
0.7
13.1
4.1
50.4
3.1
37.1
n o 0
0
0
0
0
0.1
0
0.1
0
1.2
4.9
4.7
42.2
4.5
13
0
0
0
0
0
0
0
20
4.7
0
0
0
0
0
0
t
Mexico 2.9 0.7 13.7 0 0 0.6 0.5 4.5 0 0 0.1 0 0
Micronesia 46.3 0 0 2.4 0 0 0 0 0 0 0 0 0
in
Moldova 0 0.9 63.5 0 0 0 1.6 31.8 0 0 0 0 0
Mongolia 0.5 14.7 48.5 0.2 0 0 8 21.5 0 0 1.2 0 0
Montenegro
Morocco
Mozambique
Myanmar
0
0
0
0
p r 1.2
19.1
43.5
75.9
8.7
23.2
2.5
3.2
0
0
0
0.3
0
0
0
0
0
0
0
0
2.6
10
0.6
9.7
84
12.6
5.4
4
0
0
0
0
0
0
0
0
0.1
5.5
3.5
0.1
0
0
0
0
0
0
0
0
Namibia
Nepal
Netherlands
r e0
0
0
49
92.6
1.6
5.7
1.2
53
0
0
0
0
0
0
0
0
0
0.2
4.1
2.8
1.6
0.9
31
0
0
0
0
0
0
1.8
0
0.4
0
0
0
0
0
0
New Zealand
Nicaragua
P 0.4
0.7
14.8
0
43.7
2.6
0.5
0
0
0
0
0.4
5.4
0.8
11
0.8
0
0
0
0
0.4
0
0
0
0
0
43
Niger 0 0.7 0.6 0 0 0 4.5 4.1 0 0 7.5 0 0
Nigeria 0.1 12.7 24.5 0 0 0 6.7 9 0 0 40.1 0 0
North Korea 0.8 1.6 88.8 0 0 0 0 5.6 0 0 0 0 0
Norway
Oman
Pakistan
Panama
0
0
0
0.1
1.5
65
35.9
0.2
68.4
1.6
3.7
2
0
0
0
0
0
0
0
0
0
0
0
1.2
1.2
8.9
30
0.6
20
2.6
5.7
2.6
0
0
0
0
ed 0
0
0
0
0.3
0.2
0.1
0
0
0
0
0
0
0
0
0
w
Papua New Guinea 0.2 3 23.2 3.7 0 0 0 14.7 0 0.2 0 0 0
Paraguay 0.1 0.1 0.2 0 0 0 0.1 0.5 0 0 0.1 0 0
Peru
Philippines
Poland
Portugal
0.1
0.1
0
0
0.1
65.2
2.8
1.1
2.4
6.4
64.4
69.3
0
0.1
0
0
0
0
0
0
0.1
0.1
0
0
0.4
10.9
0.6
1.2
1.4
5.8
28.8
16.8
0
0
v
0
0
i e 0
0
0
0
0
0.1
0
0.1
0
0
0
0
0
0
0
0
e
Qatar 0 0 3.5 0 0 0 35.3 11 0 0 0.4 0 0
r
Romania 0 3.9 23.9 0 0 0 3 63.5 0 0 0 0 0
Russia 0 1.9 16.5 0 0 0 4.9 57.8 0 0 0 0 0
r
Rwanda 0 2.5 0.8 0 0 0 0.6 0.6 0 0 1.1 0 0
Saint Lucia 1.2 0 8.4 0 0 52.8 0 2.1 0 0 0 0 0
e
0.2 0.7 0.5 0 0 83.1 0 0 0 0 0 0 0
Grenadines
e
Samoa 18.9 0 8.9 66.7 0 0 0 0 0 1.1 0 0 0
Sao Tome and Principe 0 0 0.1 0 0 0 0 0.4 0 0 1 0 0
Saudi Arabia
Senegal
Serbia
Seychelles
0
0
0
0
4.2
0.5
6.9
45.2
1.1
0.8
10.6
17.7
0
0
0
0
0
0
t
0
0 p 0
0
0
0
41.3
0.4
1.5
4
2.6
1.4
60.9
10.5
0
0
0
0
0
0
0
0
0.3
40
0.1
4.8
0
0
0
0
0
0
0
0
Sierra Leone
Singapore
Slovakia
0
0.1
0
0.1
17.8
0
4.3
18.8
46.1
n o 0
0
0
0
0
0
0
0
0
0
8.8
0.1
2.3
31.7
53.6
0
0
0
0
0.1
0
24.1
0.3
0
0
0
0
0
0
0
t
Slovenia 0 2.5 21.7 0 0 0 4 65 0 0 0.1 0 0
Solomon Islands 7.5 2.5 0 80 0 0 0 0 0 2.5 0 0 0
in
Somalia 0.2 45.4 23.4 0 0 0 6.6 5.3 0 0 11.3 0 0
South Africa 0 5.4 9.9 0 0 0 2.2 3.5 0 0 2.4 0 0
r
South Korea 0.3 17.6 12 0.1 0 0 6.3 24.8 0 0 1.1 0 0
South Sudan 0 2 4 0 0 0 7 4.6 0 0 38.6 0 0
Spain
Sri Lanka
Sudan
e
0
0
0
p 1.6
68
37
62.8
6.1
0.9
0
0
0
0
0
0
0
0
0
1.6
11.7
18.8
13.6
4.1
2.9
0
0
0
0
0
0
0.4
0.2
1.7
0
0
0
0
0
0
Suriname
Sweden
Switzerland
Syria
P r 0.1
0
0
0
0.7
0.9
3.2
20.4
4
53.6
33
0.2
0
0
0
0
0
0
0
0
21
0
0
0
0.1
1.3
3.4
2.9
1.3
30
45.1
0
0
0
0
0
0
0
0
0
0.1
0.4
0.6
0
0
0
0
0
0
0
0
0
44
Tajikistan 0 2.5 6.8 0 0 0 7.2 7 0 0 0 0 0
Tanzania 0 13 5.6 0 0 0 18.4 2.2 0 0 27 0 0
Thailand 0 29.5 22.3 0.1 0 0 13.2 7.7 0 0 0.2 0 0
Timor-Leste
Togo
Tonga
Trinidad and Tobago
2.7
0
46.2
0.5
0
0.5
0
0.7
2.7
1.6
1.9
6
75.7
0
44.2
0
0
0
0
0
0
0
0
0.1
0
0.2
0
1.1
0
3.5
1.9
2.1
0
0
0
0
ed 0
0
0
0
0
18.2
0
0
0
0
0
0
0
0
0
0
w
Tunisia 0 40.9 2.5 0 0 0 19.5 9.2 0 0 12.1 0 0
Turkey 0 8.7 3.9 0 0 0 7.1 20.6 0 0 0.2 0 0
Turkmenistan
Uganda
Ukraine
United Arab Emirates
0
0
0
0
8.7
6.4
5.3
4.4
18.5
3.3
34.9
4.7
0
0
0
0
0
0
0
0
0.1
0
0
0
19.3
10.9
6.7
27.2
36.2
1.7
35.2
4.5
0
0
v
0
0
i e 0
0
0
0
0
30
0.1
0.6
0
0
0
0
0
0
0
0
e
United Kingdom 0 2.6 67.3 0 0 0.1 1.6 14.5 0 0 0.6 0 0
r
United States 0.1 1 13.7 0 0 0.5 1.5 4.8 0 0 0.2 0 0
Uruguay 0.1 0.2 1.3 0 0 0.1 0.3 1.2 0 0 0.1 0 0
r
Uzbekistan 0 10.7 34 0 0 0 6.2 21.9 0 0 0.1 0 0
Vanuatu 0.2 0.4 88.5 10.2 0 0 0 0 0 0 0 0 0
e
Venezuela 0.2 0.9 1.1 0 0 5 2.3 3.4 0 0 0 0 0
Vietnam 0.4 15.2 42.4 0.3 0 0 4.4 13.3 0 0.1 0.1 0 0
e
Yemen 0 0 0 0 0 0 0 0 0 0 0 0 0
Zambia 0 0.8 8.5 0 0 0 0.7 2.6 0 0 17.4 0 0
Zimbabwe
Table S2…contd
0 1.8 6.5 0 0
t p 0 1.3 2.2 0 0 17.7 0 0
Low
SDI:
Low
SDI:
Low-
middle
Low-
middle
n o
Low-middle
SDI: Eastern
Low-
middle
Low-
middle
SDI:
Low-
middle Middle
Middle
SDI:
Middle SDI:
Eastern
Middle
Middle
SDI:
Middle
SDI:
t
Country South-
Western SDI:
SDI:
Mediterranea SDI: South-
SDI: SDI:
America Mediterranea
SDI: South-
Western
East America Western Africa Europe East
Pacific Africa n Europe East s n Pacific
in
Asia s Pacific Asia
Asia
Afghanistan 0 0 0.5 0 0 0 0 0 0 0 84.3 0 0 0
Albania
Algeria
Angola
0
0
0
p r
0
0
0
0.5
4.8
46
0.8
0.1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
41
0
0
0
0.8
29.3
0.5
0
0
0
0
0
0
0
0
0
re
Antigua and Barbuda 0 0 0.8 51 0 0 0 0 0 12 0 0 0 0
Argentina 0 0 0.4 94.6 0 0 0 0 0 0.1 0.2 0 0 0
P
Armenia 0 0 0.4 0.2 0 0 0 0 0 0 66.2 0 0 0
45
Australia 0 0 8.1 0.4 0 0 0 0 0.3 0 19.6 0 0 0.1
Austria 0 0 3.8 13.1 0 0 0 0 0.4 0.1 13.5 0 0 0
d
Azerbaijan 0 0 0.8 0 0 0 0 0 0 0 62.2 0 0 0
Bahamas 0 0 3.3 60 0 0 0 0 0 14.7 0.1 0 0 0
Bahrain
Bangladesh
Barbados
0
0
0
0
0
0
3.7
0.9
3
0.1
0
12.1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
23.4
w e 49.4
4.9
0.1
0
0
0
0
0
0
0
0
0
e
Belarus 0 0 2.3 1.9 0 0 0 0 0 0 42.4 0 0 0
Belgium
Belize
Benin
0
0
0
0
0
0
1.9
4.1
85.3
11.6
71.2
0
0
0
0
0
0
0
0
0
0
0
0
0
0.2
0
0.4
v i
0.1
7.4
0
2.9
0
0.7
0
0
0
0
0
0
0
0
0
Bhutan
Bolivia
44
0
0
0
0
0.8
0
93.9
0
0
0
0
8
0
0
0
r e
0
0
0
0.4
0
1
0
0
12
0
0
0
r
Bosnia and Herzegovina 0 0 0.4 1.5 0 0 0 0 0 0 9.2 0 0 0
Botswana 0 0 40.3 0 0 0 0 0 41.6 0 0.3 0 0 0
Brazil
Brunei Darussalam
Bulgaria
0
0
0
0
0
0
8.8
24.6
1.2
61.2
0
0.7
0
0
0
ee 0
0
0
0
0
0
0
0
0
0.3
0
0.1
0.3
0
0
2.5
15.8
1.6
0
0
0
0
0.1
0
0
3.4
0
Burkina Faso
Burundi
Cambodia
0
0
0
0
0
0
44.4
4.1
17.1
0
0
0.9
0
0
0
t p 0
0
0
0
0
0.1
0
0
0
0.2
0
0.1
0
0
0
2.3
0.3
7.2
0
0
0
0
0
0.2
0
0
0.3
Cameroon
Canada
Cape Verde
0
0
0
0
0
0
83.5
2.6
58.8
0
82.8
0
n o 0
0
0
0
0
0
0
0
0
0
0
0
0.4
0
0
0
1.9
0
1
3.7
0.8
0
0
0
0
0
0
0
0
0
Central African Republic
Chad
Chile
0
0
0
0
0
0
in t
18.6
73.3
0.1
0
0
96.1
0
0
0
0
0
0
0
0
0
0
0
0
0.6
0
0
0
0
0.2
0.3
1.9
0.1
0
0
0
0
0
0
0
0
0
China
Colombia
Comoros
0
0
0
p r 0
0
0
36.8
0.5
0.1
0.7
94.8
0
0
0
0
0
0
0
0
0
0
0
0
0
0.8
0
0
0.1
0.3
0
21.6
0.2
1.9
0
0
0
0
0
0
0.1
0
0
Congo
Costa Rica
Croatia
r e 0
0
0
0
0
0
40
0.2
3.7
0
92.7
1.7
0
0
0
0
0
0
0
0
0
0
0
0
4.7
0
0.2
0
0.6
0
4
0
3.8
0
0
0
0
0
0
0
0
0
Cuba
P 0 0 2.4 73.4 0 0 0 0 0.2 2.4 1 0 0 0
46
Cyprus 0 0 2.5 0.1 0 0 0 0 0 0 2.6 0 0 0
Czech Republic 0 0 1.6 2.9 0 0 0 0 0.1 0 3.3 0 0 0
d
Denmark 0 0 1.8 0.9 0 0 0 0 0.1 0 13.6 0 0 0
Djibouti 0 0 3.8 0.2 0 0 0 0 0.1 0 5.9 0 0 0
Dominican Republic
DR Congo
Ecuador
0
0
0
0
0
0
2.3
52
0.6
0
0
93.1
0
0
0
0
0
0
0
0
0
0
0
0
0
2.3
0
8.1
0
0.3
w e 0.4
3.2
0.6
0
0
0
0
0
0
0
0
0
e
Egypt 0 0 9.1 0.1 0 0 0 0 0.1 0 22.3 0 0 0
El Salvador
Equatorial Guinea
Eritrea
0
0
0
0
0
0
0
81.2
5.5
95.1
1.1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
v i
0.5
0
0.1
0.1
2.8
1
0
0
0
0
0
0
0
0
0
Estonia
Ethiopia
0
0
0
0
0.7
50.2
0.6
0.1
0
0
0
0
0
0
0
0
r e
0.1
2.2
0
0
0.5
2.2
0
0
0
0
0
0
r
Fiji 0 0 4.4 0 0 0 0 0 0.5 0.3 60.9 0 0 0
Finland 0 0 2.8 8.1 0 0 0 0 0.3 0 3.8 0 0 0
France
Gabon
Gambia
0
0
0
0
0
0
4
93.3
92.3
20.3
0
0
0
0
0
ee 0
0
0
0
0
0
0
0
0
0.2
0.1
0.5
0
0
0
11.7
0.5
0.6
0
0
0
0
0
0
0
0
0
Georgia
Germany
Ghana
0
0
0
0
0
0
0.7
2.7
94.6
0
12.7
0
0
0
0
t p 0
0
0
0
0
0
0
0
0
0
0.8
0.1
0
0.2
0
51.8
6.9
0.3
0
0
0
0
0
0
0
0
0
Greece
Grenada
Guatemala
0
0
0
0
0
0
7.2
2.1
0.2
2
6.9
95.9
n o 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5.5
0.6
15.7
0.1
0
0.1
0
0
0
0
0
0
0
0
Guinea
Guinea-Bissau
Guyana
0
0
0
0
0
0
in t
66.5
66.1
0
0
0
41.8
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0
0.1
0
0
16.3
9.8
2.1
0
0
0
0
0
0
0
0
0
0
Haiti
Honduras
Hungary
0
0
0
p r 0
0
0
0.3
0.4
1.2
96.6
93.2
2.6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0.8
0.8
0
0
0.2
4
0
0
0
0
0
0
0
0
0
Iceland
India
Indonesia
r e
0
0
0
0
0
0
0.3
9.1
8.2
0.4
0.2
1.3
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0
0.2
0
0
0
0.3
8.6
11
0
0
0
0
0
0
0
0
0.1
Iran
P 0 0 0.4 0 0 0 0 0 0 0 89.7 0 0 0
47
Iraq 0 0 0.2 0 0 0 0 0 0 0 68.8 0 0 0
Ireland 0 0 18.9 1.7 0 0 0 0 0.1 0 1.6 0 0 0
d
Israel 0 0 8.4 1.3 0 0 0 0 0.1 0 0.2 0 0 0
Italy 0 0 5.6 7.9 0 0 0 0 0.1 0.1 4.9 0.1 0 0
Ivory Coast
Jamaica
Japan
0
0
0
0
0
0
85.5
1.9
10.1
0
57.2
3.4
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0
0.2
0
18.2
0.1
w e 2.7
0
9.9
0
0
0
0
0
0
0
0
0.4
e
Jordan 0 0 1.8 0.1 0 0 0 0 0 0 68.5 0 0 0
Kazakhstan
Kenya
Kiribati
0
0
0
0
0
0
2.5
41.2
0
1.2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.5
0
v i
0
0
0
41.4
5.2
0
0
0
0
0
0
0
0
0
0
Kuwait
Kyrgyzstan
0
0
0
0
0.7
2.1
0
2.1
0
0
0
0
0
0
0
0
r e
0
0
0
0
19.4
17.8
0
0
0
0
0
0
r
Laos 0 0 10.1 0 0 0 0.2 0 1.5 0 5.3 0 1 0.6
Latvia 0 0 0.9 1.7 0 0 0 0 0.1 0 0.4 0 0 0
Lebanon
Lesotho
Liberia
0
0
0
0
0
0
9.1
54.5
93.2
0.1
0
0
0
0
0
ee 0
0
0
0
0
0
0
0
0
0
29
0
0
0
0
47.2
0
0.2
0
0
0
0
0
0
0
0
0
Libya
Lithuania
Luxembourg
0
0
0
0
0
0
0.8
0.5
3.9
0
0.2
3.5
0
0
0
t p 0
0
0
0
0
0
0
0
0
0
0
0.2
0
0
0
33.7
1.1
8
0
0
0
0
0
0
0
0
0
Macedonia
Madagascar
Malawi
0
0
0
0
0
0
0.8
26.4
57.7
0.4
3.8
0.3
n o 0
0
0
0
0
0
0
0
0
0
0
0
0
2.5
9.1
0
0
0
6.3
12.3
0.3
0
0
0
0
0
0
0
0
0
Malaysia
Maldives
Mali
0
0
0
0
0
0
in t
17
6.2
37
0.1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0.2
0.3
0
0
0
47
23.4
6
0
0
0
0
0
0
0.1
0
0
Malta
Mauritania
Mauritius
0
0
0
p r 0
0
0
0.8
12.5
24.3
0.3
0.3
1.8
0
0
0
0
0
0
0
0
0
0
0
0
0
0.1
2.4
0
0
0.1
4.4
41.4
7.6
0
0
0
0
0
0
0
0
0
Mexico
Micronesia
Moldova
r e
0
0
0
0
0
0
2.6
0
1.9
73.1
0
0.1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.6
0
0
0.7
0
0.3
0
0
0
0
0
0
0
51.2
0
Mongolia
P 0 0 0 0 0 0 0 0 0.4 0 4.8 0 0 0.1
48
Montenegro 0 0 2.4 0 0 0 0 0 0 0 1 0 0 0
Morocco 0 0 17.7 0.3 0 0 0 0 0.1 0 11.5 0 0 0
d
Mozambique 0 0 41.4 0 0 0 0 0 2.7 0 0.4 0 0 0
Myanmar 0 0 4.7 0.2 0 0 0 0 0.3 0 1.3 0 0.1 0
Namibia
Nepal
Netherlands
0
0
0
0
0
0
41.4
0.2
4.5
0
0
1.4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0.2
0
0
0
w e 0.2
0.9
5.1
0
0
0
0
0
0
0
0
0
e
New Zealand 0 0 8.9 1 0 0 0 0 0.4 0.1 13.2 0 0 0.1
Nicaragua
Niger
Nigeria
0
0
0
0
0
0
0.5
67
0
93.3
0.2
0.3
0
0
0
0
0
0
0
0
0
0
0
0
0
0.2
2.6
v i
0.7
0
0
0.1
15.1
3.8
0
0
0
0
0
0
0
0
0
North Korea
Norway
0
0
0
0
0
2.4
0
1.3
0
0
0
0
0
0
0
0
r e
0
0.2
0
0
0
4.6
0
0
1.6
0
1.6
0
r
Oman 0 0 3.8 0 0 0 0 0 0 0 17.9 0 0 0
Pakistan 0 0 2.2 0 0 0 0 0 0 0 22.4 0 0 0
Panama
Papua New Guinea
Paraguay
0
0
0
0
0
0
0.8
47.6
0
90.9
0
98.7
0
0
0
ee 0
0
0
0
0
0
0
0
0
0
0
0
1.4
0
0.2
0.2
4.2
0.1
0
0
0
0
0
0
0
3.1
0
Peru
Philippines
Poland
0
0
0
0
0
0
0.3
6.1
1.2
94.3
2.5
1.2
0
0
0
t p 0
0
0
0
0
0
0
0
0
0
0.2
0
0.2
0.1
0
0.8
2.3
0.9
0
0
0
0
0
0
0
0
0
Portugal
Qatar
Romania
0
0
0
0
0
0
1.8
4.8
1.9
7.5
0.1
0.9
n o 0
0
0
0
0
0
0
0
0
0
0
0
0.5
1.2
0.1
0
0
0
1.6
43.8
2.7
0
0
0
0
0
0
0
0
0
Russia
Rwanda
Saint Lucia
0
0
0
0
0
0
in t
1.2
94
2.3
10.2
0
25.2
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0.2
0
0
0
7.8
7.2
0.2
0.2
0
0
0
0
0
0
0
0
0
Grenadines
Samoa
0
0
p r 0
0
0
0
9.1
0
0
0
0
0
0
0
0
0
0
0
6.4
0
0
0
0
0
0
0
0
4.4
re
Sao Tome and Principe 0 0 97 0 0 0 0 0 1.5 0 0 0 0 0
Saudi Arabia 0 0 22.1 0 0 0 0 0 0 0 28.2 0 0 0
Senegal 0 0 54.9 0 0 0 0 0 0.3 0 1.6 0 0 0
Serbia
P 0 0 2.7 1 0 0 0 0 0.1 0 16.2 0 0 0
49
Seychelles 0 0 8.3 0 0 0 0 0 0.2 0 9.4 0 0 0
Sierra Leone 0 0 66.2 0 0 0 0 0 0.1 0 2.9 0 0 0
d
Singapore 0 0 11.9 0.6 0 0 0 0 0.2 0 9.5 0 0 0.3
Slovakia 0 0 0 0 0 0 0 0 0 0 0.1 0 0 0
Slovenia
Solomon Islands
Somalia
0
0
0
0
0
0
1.4
0
5.3
1.7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
w e 3.4
0
2.5
0.1
0
0
0
0
0
0
7.5
0
e
South Africa 0 0 51.5 0.1 0 0 0 0 21.4 0 3.5 0 0 0
South Korea
South Sudan
Spain
0
0
0
0
0
0
18.4
42.7
2.1
1.5
0
15.6
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0.2
0.1
v i
0
0
0
16.7
0.9
2.1
0
0
0
0
0
0
0.8
0
0
Sri Lanka
Sudan
0
0
0
0
3.8
34.2
0.1
0
0
0
0
0
0
0
0
0
r e
0
0.1
0
0
6
4.5
0
0
0
0
0
0
r
Suriname 0 0 0.8 62.4 0 0 0 0 0 9.4 0 0 0 0
Sweden 0 0 1.3 0.7 0 0 0 0 0.1 0 11.5 0 0 0
Switzerland
Syria
Tajikistan
0
0
0
0
0
0
3.5
0.6
0
6.3
0
0
0
0
0
ee 0
0
0
0
0
0
0
0
0
0.3
0
0
0
0
0
4.6
75.9
76.5
0
0
0
0
0
0
0
0
0
Tanzania
Thailand
Timor-Leste
0
0
0
0
0
0
27.8
4.1
0
0
0.5
0
0
0
0
t p 0
0
0
0
0
0
0
0
0
0.8
0.1
0
0
0
0
5.3
22.2
0
0
0
0
0
0
10.8
0
0
8.1
Togo
Tonga
Trinidad and Tobago
0
0
0
0
0
0
75
0
3
0
0
45.3
n o 0
0
0
0
0
0
0
0
0
0
0
0
0.3
0
0
0
0
41.2
0.6
0
0.2
0
0
0
0
0
0
0
5.8
0
Tunisia
Turkey
Turkmenistan
0
0
0
0
0
0
in t
8.6
2.9
9.9
0.6
0.2
0.7
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0
0
0
0
0
6.4
56.4
6.4
0
0
0.1
0
0
0
0
0
0
Uganda
Ukraine
United Arab Emirates
0
0
0
p r 0
0
0
38.7
4.4
18.4
0.1
4.9
0.1
0
0
0
0
0
0
0
0
0
0
0
0
0.6
0.2
0
0
0
0
8.3
8.2
40
0
0
0
0
0
0
0
0
0
United Kingdom
United States
Uruguay
r e 0
0
0
0
0
0
10.1
7.7
0.1
0.9
66.5
96.5
0
0
0
0
0
0
0
0
0
0
0
0
0.1
0
0
0.1
2
0.2
2.2
2.1
0
0
0
0
0
0
0
0
0
0
Uzbekistan
P 0 0 4.1 0 0 0 0 0 0 0 22.8 0 0 0
50
Vanuatu 0 0 0 0 0 0 0 0 0 0 0 0 0.4 0.2
Venezuela 0 0 4.3 76.6 0 0 0 0 0 0.6 5.5 0 0 0
d
Vietnam 0 0 13.3 0.3 0 0 0 0 0 0 9.9 0 0.1 0.1
Yemen 0 0 0 0 0 0 0 0 0 0 100 0 0 0
Zambia
Zimbabwe
0
0
0
0
58.5
45
0
0.4
0
0
0
0
0
0
0
0
10.9
19.9
0
0
w e 0.5
5.2
0
0
0
0
0
0
v i e
r e
er
pe
o t
t n
r in
e p
P r 51
ed
v iew
re
er
pe
ot
tn
rin
ep
Pr
52

Preprint Not Peer Reviewed

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Preprint Not Peer Reviewed

Uploaded by

Copyright:

Available Formats

The global resurgence of measles, estimating the risks of

international importations of measles among 181 countries

Keywords: Travel, Vaccine preventable diseases, Immunization, Vaccination, Health

the risk of importation, especially in non-endemic countries. This informs planning of

disruption of childhood immunization during the COVID-19 pandemic 5, 6.

Materials and methods

model is an adaption of the SEIR (Susceptible-Exposed-Infectious-Recovered) compartmental

E-I-R compartments concerning measles is presented below:

𝑑𝑑𝑆𝑆𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖

𝑑𝑑𝐸𝐸𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖

country-specific transmission rate, 𝜏𝜏 is the estimated country-specific vaccination rate, 𝜎𝜎 is the

Meta-population model with disease importations er

𝑑𝑑𝑆𝑆𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖 𝑚𝑚𝑖𝑖𝑖𝑖 𝑆𝑆𝑖𝑖 𝑚𝑚𝑗𝑗𝑗𝑗 𝑆𝑆𝑗𝑗

𝑑𝑑𝐸𝐸𝑖𝑖 𝛽𝛽𝑖𝑖 𝑆𝑆𝑖𝑖 𝐼𝐼𝑖𝑖 𝑚𝑚𝑖𝑖𝑖𝑖 𝐸𝐸𝑖𝑖 𝑚𝑚𝑗𝑗𝑗𝑗 𝐸𝐸𝑗𝑗

𝑑𝑑𝑅𝑅𝑖𝑖 𝑚𝑚𝑖𝑖𝑖𝑖 𝑅𝑅𝑖𝑖 𝑚𝑚𝑗𝑗𝑗𝑗 𝑅𝑅𝑗𝑗

disease node of the Australia Nectar Research cloud (www.nectar.org.au).

number of importations based on 2000 chains was generated.

Data analysis and visualization

of coverage of measles-containing vaccine (MCV) were also mapped.

resurgence of measles outbreaks in high-middle and high-SDI countries, suggesting a gap in

(Figure 1, 2, S1-S2). High-middle-SDI countries with substantial increases include Bulgaria,

and healthcare infrastructure. In comparison, high-SDI countries such as New Zealand

encountered a severe measles outbreak, marked by an astounding surge of 5000 cases in

2019, a sharp contrast to the complete absence of measles cases in 2000.

Table 1. Temporal Changes in Measles-Containing Vaccine Coverage (2000-2019) by SDI.

First dose, Median (IQR) Second dose, Median (IQR)

cases and MCV1 (r= -0.39, p=0.03) (Figure 3C).

Prediction of measles importation

(E) High SDI

of extensive international travel connections.

resurgence in susceptible populations.

system and societal perspectives 30.

contagious and potentially deadly disease.

Impact of COVID-19 on measles resurgence

COVID-19 pandemic 35.

a foundation for continuous monitoring and dynamic decision-making by health authorities.

safeguarding vulnerable communities worldwide. er

M.A-K., G.G., N.N. and E.M.

The authors declare no conflict of interest.

programme activities in nigeria. Human Vaccines & Immunotherapeutics 2021; 17(3):661-663.

7 KA Gaythorpe, K Abbas, J Huber, et al. Impact of covid-19-related disruptions to measles,

The global resurgence of measles, estimating the risks of international

Country Mean SD Lower Upper

Burundi 107.46 54.22 68.75 145

Canada 13853.08 3268.32 12902.25 14393.75

Chile 1101.75 251.04 1030 1162

Congo 47.57 30.93 27 61

Czech Republic 1324.49 236.74 1190.75 1454

Iraq 5356.50 436.97 5051.5 5675

Italy 13332.80 1683.45 12619.25 13932.75

Jordan 1917.80 230.59 1822.75 2032.25

Kuwait 3642.77 494.10 3313 3994

Lesotho 7.35 6.62 3 9

Panama 464.32 134.44 412 498.25

Peru 695.31 167.88 640 741

Qatar 2241.53 349.45 2048 2423.25

Saint Lucia 29.35 35.39 7 39

Saudi Arabia 5685.50 1356.83 4931 6286

United Kingdom 40630.78 4442.77 38795.5 42728.75

Uzbekistan 79.95 41.37 51 102

Yemen 2.85 1.69 2 4

P 0.1 0.1 1.8 0 0 0.1 0.2 1.2 0 0 0 0 0

t p 0 1.3 2.2 0 0 17.7 0 0