Global measles resurgence: Trends, challenges, and the road ahead

The global resurgence of measles represents a critical public health challenge, threatening decades of progress toward elimination. This review synthesizes recent research on measles epidemiology, prediction modeling, vaccination coverage, and elimination efforts. Despite effective vaccines being available for over half a century, declining immunization rates and persistent misinformation have created vulnerable populations worldwide. The COVID-19 pandemic has further disrupted routine immunization services, leading to missed vaccinations and accumulation of susceptible individuals. This analysis examines current trends, innovative prediction approaches, and the urgent need for renewed global commitment to measles elimination. 

Measles is one of the most contagious vaccine-preventable diseases, with the potential to cause severe complications and death, particularly among children under five years of age. Despite the availability of safe and effective vaccines since the 1960s, measles continues to pose significant global health challenges. The disease’s high transmissibility and the requirement for 95% vaccination coverage to achieve herd immunity make measles elimination particularly challenging in the face of declining vaccination rates and vaccine hesitancy. 

Disease burden and geographic distribution 

Recent global burden analyses reveal concerning trends in measles epidemiology. In 2021, measles caused approximately 4.1 million cases, 48,100 deaths, and 4.2 million disability-adjusted life years (DALYs) among children under five years globally. The burden remains disproportionately concentrated in low socio-demographic index (SDI) regions, with Western and Eastern Sub-Saharan Africa experiencing the highest case counts, each exceeding 1 million cases. 

The geographic distribution of the measles burden reflects underlying inequalities in healthcare access and vaccination coverage. Somalia reported the highest measles incidence rate at 8,965 cases per 100,000 population in 2021, followed by Vanuatu and Mali. These disparities highlight the persistent challenges in achieving equitable vaccine distribution and healthcare delivery in resource-limited settings. 

Impact of the COVID-19 pandemic 

The COVID-19 pandemic has significantly disrupted global measles control efforts. Between 2020 and 2022, approximately 1.2 million children in the European Region missed their measles vaccine, creating a susceptible cohort vulnerable to outbreaks. The pandemic’s impact on vaccination coverage was evident globally, with measles-containing vaccine first dose (MCV1) coverage declining with an estimated annual percentage change of -2.08% during 2019-2021. 

Paradoxically, while overall measles burden declined during the early pandemic period due to reduced international travel and public health measures that restricted transmission, certain regions experienced increases. East Asia notably showed upward trends in both mortality and DALY rates during 2019-2021, with estimated annual percentage changes of 155.55% and 146.94%, respectively. In Vietnam alone, more than 80,000 cases were reported 2025 by the end of May. 

Reference: Chen W, Du M, Deng J, et al. (2025). Global, regional, and national trends of measles burden and vaccination coverage among children under 5. Int J Infect Dis 156:107908. 

United States elimination status 

The United States has maintained a measles elimination status since 2000, demonstrating the feasibility of sustained elimination through high vaccination coverage and robust surveillance systems. During January 2022- June 2024, the US reported 338 measles cases, 17 rubella cases, and no congenital rubella syndrome cases. Most measles cases (90%) occurred in unvaccinated individuals or those with unknown vaccination status, emphasizing the continued importance of maintaining high vaccination coverage. 

However, concerning trends threaten this elimination status. MMR vaccination coverage among kindergartners decreased from 95.2% during 2019-2020 to 92.7% during 2023-2024. The consistent rise in non-medical exemptions across most US jurisdictions leaves increasing numbers of school-aged children vulnerable to vaccine-preventable diseases. 

Reference: Filardo TD, Mathis AD, Raines K, et al. (2025). Continued elimination of measles, rubella, and congenital rubella syndrome in the United States. Vaccine [In Press]. 

Global elimination challenges 

Despite regional successes, global measles elimination faces significant obstacles. While 96 countries have been verified to have eliminated endemic measles transmission, 13 verified countries have experienced the re-establishment of endemic transmission. This highlights the precarious nature of elimination achievements in the absence of coordinated global efforts. As it happened in the reintroduction frequently occurs from resource-rich to poor countries.   

The absence of a global eradication target has been identified as a critical barrier to progress. The periodic 5-yearly cycles of global measles resurgence (2014, 2019-20, and 2024-25) can be directly attributed to this lack of global leadership and commitment. Each wave claims predominantly young, unvaccinated, or malnourished children, representing a morally intolerable burden of preventable deaths and disability. 

Reference: Durrheim DN, Andrus JK, Tabassum S, et al. (2025). Measles and rubella eradication: Commitment to a global target is now a matter of urgency. Lancet Infect Dis [Online]. 

Machine learning applications 

Recent advances in machine learning have shown promise for predicting measles outbreaks and informing public health preparedness. A comprehensive study utilizing eXtreme Gradient Boosting (XGBoost) algorithms demonstrated the ability to predict 72% of US counties that experienced measles cases in 2019, accounting for 94% of all measles cases. 

The model incorporated 17 predictor variables, including county population, vaccination coverage rates, sociodemographic factors, and air travel-related exposure scores. County population emerged as the most important predictor, followed by race/ethnicity variables and air travel-related measles exposure scores. The model’s performance could be adjusted through threshold modifications to balance sensitivity and specificity based on public health priorities and resource availability. 

Model limitations and future directions 

While promising, current prediction models face several limitations. The lack of county-level vaccination coverage data for many regions reduces model specificity, as state-level proxies may not capture local pockets of susceptibility. Additionally, the models were trained on limited years of data (2014, 2018, 2019), potentially limiting their applicability under different epidemiologic conditions. 

Future model improvements require more geographically granular and real-time data collection, particularly for vaccination coverage and air travel patterns. The integration of social media sentiment analysis, economic indicators, and conflict data could further enhance prediction accuracy and enable more targeted interventions. 

Reference: Kujawski SA, Ru B, Afanador NL, et al. (2024). A machine learning model to predict measles outbreaks in the United States. Vaccine 42:126289. 

Vaccine hesitancy 

Vaccine hesitancy has emerged as a significant threat to measles elimination efforts. The proliferation of misinformation about vaccine safety has undermined public confidence in immunization programs, contributing to declining coverage rates in many high-income countries. England exemplifies this challenge, with MMR vaccination coverage declining for five consecutive years, reaching only 83.9% for both doses by 2023/2024. 

Combating vaccine hesitancy requires multifaceted approaches, including community engagement, culturally tailored education, and leveraging trusted community leaders. Faith-based institutions and community health workers play crucial roles in building vaccine confidence, particularly in communities with historical mistrust of healthcare systems. 

Reference: Mpabalwani E, Ippolito G, Asogun D, et al. (2025). Global resurgence of measles: Turning the tide through a bold agenda for prevention and control. Int J Infect Dis 155:107901. 

Personal opinion:  

A recent surge of measles cases in Texas is a stark warning that decades of global progress against this preventable disease are at real risk of unraveling. While each of the above articles highlights different facets of the measles crisis—ranging from global resurgence, modeling innovations, and elimination challenges to the role of misinformation—the recent measles outbreak in Texas crystallizes the urgency of the moment and exposes the consequences of complacency. 

Despite sophisticated machine learning models that can predict outbreak risk and pinpoint vulnerable counties, the Texas experience shows that predictive analytics are only as effective as the public health action that follows. The state’s overall MMR coverage appeared adequate on paper, but local pockets of underimmunization—often masked by state-level averages—created fertile ground for rapid transmission. Nearly 60% of outbreak-related cases in Texas occurred in children under 5 and adults over 19, underscoring the risk to both the youngest and the most vulnerable. 

The analysis of vaccination coverage during that outbreak is especially alarming: even as the crisis unfolded, coverage estimates in exposed populations ranged from as low as 40% to just under 90%, well below the 93% threshold needed for herd immunity. This gap enabled the virus to spread not only within Texas but into neighboring states, illustrating how local failures can quickly become regional and even national threats. The deaths of unvaccinated individuals during this outbreak are a reminder that measles is not a benign childhood illness, but a deadly and highly contagious virus. 

By Health Literacy Asia