Research Open Access
Like 0



Measles is still endemic in Italy and outbreaks are frequent. From 2016 to 2018, more than 7,000 measles cases were reported to the national integrated measles and rubella surveillance system, the largest outbreak since implementation of this system.


We aimed to describe the characteristics and spatiotemporal distribution of measles cases in Italy and explore determinants of incidence at municipality level.


We performed a retrospective observational study, mapping by municipalityall measles cases reported to the national surveillance system with symptom onset between 1 September 2016 and 31 July 2018. We also analysed measles–mumps-rubella (MMR) vaccination coverage (VC) data (2000–2017) for the first and second dose, collected from the Ministry of Health. We used regression analysis to explore factors associated with measles incidence at municipality level.


We analysed 7,854 cases, 3,927 (50%) female. Median age was 26 years; 475 cases (6%) were younger than 1 year. The outbreak occurred in two epidemic waves. The first started in central/northern regions (end of 2016), the second (mostly within 2018) was concentrated in southern regions. In 2016 and 2017, national VC was below 95% for both MMR doses. In 2017, only one region reported VC above 95% for the first dose. At municipality level, incidence was associated with higher urbanisation, less deprivation and fewer adults.


The spread of measles between September 2016 and July 2018 in Italy indicates the need to improve VC and to explore further how societal and other parameters might be linked to incidence.


Article metrics loading...

Loading full text...

Full text loading...



  1. World Health Organization (WHO). Measles. Geneva: WHO. [Accessed: 14 Apr 2019]. Available from: http://www.who.int/mediacentre/factsheets/fs286/en/
  2. Pan American Health Organization (PAHO)/World Health Organization (WHO). Measles elimination in the Americas. Washington: PAHO, Geneva: WHO. [Accessed: 8 Feb 2018]. Available from: http://www.paho.org/hq/index.php?option=com_content&view=article&id=12526%3Ameasles-elimination-in-the-americas&catid=6648%3Afact-sheets&Itemid=40721&lang=en
  3. Paniz-Mondolfi AE, Tami A, Grillet ME, Márquez M, Hernández-Villena J, Escalona-Rodríguez MA, et al. Resurgence of Vaccine-Preventable Diseases in Venezuela as a Regional Public Health Threat in the Americas. Emerg Infect Dis. 2019;25(4):625-32.  https://doi.org/10.3201/eid2504.181305  PMID: 30698523 
  4. World Health Organization (WHO). Measles and rubella surveillance data. Geneva: WHO. [Accessed: 8 Feb 2018]. Available from: http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/
  5. World Health Organization Regional Office for Europe (WHO/Europe). Seventh meeting of the European Regional Verification Commission for Measles and Rubella Elimination (RVC). Copenhagen: WHO/Europe. [Accessed: 16 Oct 2018]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0008/378926/7th-RVC-Meeting-Report-FINAL.pdf
  6. Filia A, Tavilla A, Bella A, Magurano F, Ansaldi F, Chironna M, et al. Measles in Italy, July 2009 to September 2010. Euro Surveill. 2011;16(29):19925. PMID: 21801692 
  7. Filia A, Bella A, Rota M, Tavilla A, Magurano F, Baggieri M, et al. Analysis of national measles surveillance data in Italy from October 2010 to December 2011 and priorities for reaching the 2015 measles elimination goal. Euro Surveill. 2013;18(20):20480. PMID: 23725868 
  8. Accordo tra il Ministro della salute, le regioni e le province autonome di Trento e Bolzano sul documento recante: «Piano nazionale per l’eliminazione del morbillo e della rosolia congenita». [Agreement between the Minister of Health, the regions and autonomous provinces of Trento and Bolzano on the document: “National plan for the elimination of measles and congenital rubella”].Rome: Ministero della Salute; 2003. Available from: http://www.trovanorme.salute.gov.it/norme/dettaglioAtto?id=9081&completo=true
  9. Vaccinazioni dell’età pediatrica e dell’adolescente. Coperture vaccinali. [Vaccinations at paediatric and adolescent age. Vaccination coverage]. Rome: Ministero della Salute. [Accessed: 13 Feb 2018]. Italian. Available from: http://www.salute.gov.it/portale/documentazione/p6_2_8_3_1.jsp?id=20
  10. Ciofi degli Atti M, Filia A, Revello MG, Buffolano W, Salmaso S. Rubella control in Italy. Euro Surveill. 2004;9(4):19-21.  https://doi.org/10.2807/esm.09.04.00462-en  PMID: 15192262 
  11. Reparto Epidemiologia delle Malattie Infettive ISS-CNESPS. Sorveglianza Integrata del Morbillo e della Rosolia. [Integrated surveillance of measles and rubella]. [Accessed: 13 mar 2018]. Italian. Available from: https://old.iss.it/site/RMI/morbillo/Default.aspx?ReturnUrl=%2fsite%2frmi%2fmorbillo%2f
  12. European Commission. Commission Implementing Decision of 8 August 2012 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council. Official Journal of the European Union. Luxembourg: Publications Office of the European Union; 2012:L262. Available from: http://data.europa.eu/eli/dec_impl/2012/506/oj/eng
  13. Grandolfo ME, Medda E, Novello F, Ridolfi B. Seroepidemiological evaluation of 1989-91 mass vaccination campaigns against measles, in Italy. Epidemiol Infect. 1998;121(3):645-52.  https://doi.org/10.1017/S095026889800154X  PMID: 10030715 
  14. EpiCentro. Morbillo. Aspetti epidemiologici. [Measles. Epidemiological aspects]. Rome: Istituto Superiore di Sanità. [Accessed: 16 Feb 2018]. Italian. Available from: http://www.epicentro.iss.it/problemi/morbillo/epidItalia.asp
  15. EpiCentro. Morbillo e rosolia News. Aggiornamento mensile gennaio 2016. [Measles and rubella news: monthly report January 2016]. Rome: Istituto Superiore di Sanita; 2016. Italian. Available from: http://www.epicentro.iss.it/morbillo/bollettino/RM_News_2015_23.pdf
  16. EpiCentro. Morbillo e rosolia News. Aggiornamento mensile luglio 2016. [Measles and rubella news: monthly report July 2016]. Rome: Istituto Superiore di Sanita; 2016 Italian. Available from: http://www.epicentro.iss.it/morbillo/bollettino/RM_News_2016_29.pdf
  17. EpiCentro. Morbillo e rosolia News: il bollettino della sorveglianza integrata morbillo-rosolia. [Measles and rubella news: the bulletin on measles-rubella integrated surveillance]. Rome: Istituto Superiore di Sanita. [Accessed: 4 Jul 2018]. Italian. Available from: https://www.epicentro.iss.it/morbillo/bollettino
  18. Istituto nazionale di statistica (ISTAT). Archivio dei confini delle unità amministrative a fini statistici [Archive of administrative unit boundaries for statistical purposes]. Rome: ISTAT. [Accessed: 3 Oct 2018]. Italian. Available from: https://www.istat.it/it/archivio/124086
  19. World Health Organization Regional Office for Europe (WHO/Europe). Surveillance guidelines for measles, rubella and congenital rubella syndrome in the WHO European Region, update December 2012. Copenhagen: WHO/Europe; 2012. Available from: http://www.euro.who.int/en/health-topics/communicable-diseases/measles-and-rubella/publications/2012/surveillance-guidelines-for-measles,-rubella-and-congenital-rubella-syndrome-in-the-who-european-region,-update-december-2012
  20. D’Ancona F, Gianfredi V, Riccardo F, Iannazzo S. Immunisation Registries at regional level in Italy and the roadmap for a future Italian National Registry. Ann Ig. 2018;30(2):77-85. PMID: 29465145 
  21. Eurostat RAMON - Reference And Management Of Nomenclatures. Degree of Urbanisation (DEGURBA) - Local Administrative Units. Brussels: European Commission. [Accessed: 4 Apr 2018]. Available from: http://ec.europa.eu/eurostat/ramon/miscellaneous/index.cfm?TargetUrl=DSP_DEGURBA
  22. Caranci N, De Felici P, Giuliano G, Mancini F, Rosano A. Utilizzo degli indici di deprivazione per orientare le politiche pubbliche di contrasto alla povertà. [Use of deprivation index to inform public policies against poverty]. ISFOL; 2016. Italian. Available from: http://isfoloa.isfol.it/xmlui/handle/123456789/1328
  23. Minichilli F, Santoro M, Bianchi F, Caranci N, De Santis M, Pasetto R. [Evaluation of the use of the socioeconomic deprivation index at area level in ecological studies on environment and health]. Epidemiol Prev. 2017;41(3-4):187-96. PMID: 28929715 
  24. Istituto nazionale di statistica (ISTAT). Principali statistiche geografiche sui comuni. [Geographical information about the municipalities]. Rome: ISTAT. [Accessed: 20 Jul 2018]. Italian. Available from: https://www.istat.it/it/archivio/156224
  25. ggplot2: An implementation of the Grammar of Graphics in R. tidyverse; 2018. Available from: https://github.com/tidyverse/ggplot2
  26. Istituto nazionale di statistica (ISTAT). Statistiche demografiche [Demographical statistics]. Rome: ISTAT. [Accessed: 15 Jan 2018]. Available from: http://demo.istat.it/pop2017/index.html
  27. van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate Imputation by Chained Equations in R. J Statistical Software; 2012. Available from: https://www.jstatsoft.org/article/view/v045i03
  28. Fitzpatrick G, Ward M, Ennis O, Johnson H, Cotter S, Carr MJ, et al. Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011. Euro Surveill. 2012;17(49):20330.  https://doi.org/10.2807/ese.17.49.20330-en  PMID: 23231894 
  29. Yang W, Wen L, Li S-L, Chen K, Zhang W-Y, Shaman J. Geospatial characteristics of measles transmission in China during 2005-2014. PLOS Comput Biol. 2017;13(4):e1005474.  https://doi.org/10.1371/journal.pcbi.1005474  PMID: 28376097 
  30. Salmaso S, Gabutti G, Rota MC, Giordano C, Penna C, Mandolini D, et al. Pattern of susceptibility to measles in Italy. Bull World Health Organ. 2000;78(8):950-5. PMID: 10994277 
  31. R Core Team. R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing; 2019. Available from: https://www.R-project.org
  32. RStudio Team. RStudio: Integrated Development Environment for R. Boston: RStudio Inc.; 2019. Available from: http://www.rstudio.com/
  33. Ciofi Degli Atti ML, Salmaso S, Bella A, Arigliani R, Gangemi M, Chiamenti G, et al. Pediatric sentinel surveillance of vaccine-preventable diseases in Italy. Pediatr Infect Dis J. 2002;21(8):763-8.  https://doi.org/10.1097/00006454-200208000-00013  PMID: 12192166 
  34. Ciofi degli Atti ML, Rota MC, Mandolini D, Bella A, Gabutti G, Crovari P, et al. Assessment of varicella underreporting in Italy. Epidemiol Infect. 2002;128(3):479-84.  https://doi.org/10.1017/S0950268802006878  PMID: 12113493 
  35. Filia A, Bella A, Del Manso M, Baggieri M, Magurano F, Rota MC. Ongoing outbreak with well over 4,000 measles cases in Italy from January to end August 2017 - what is making elimination so difficult? Euro Surveill. 2017;22(37):30614.  https://doi.org/10.2807/1560-7917.ES.2017.22.37.30614  PMID: 28933342 
  36. Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis. 2004;189(s1) Suppl 1;S4-16.  https://doi.org/10.1086/377712  PMID: 15106083 
  37. Parent du Châtelet I, Antona D, Freymuth F, Muscat M, Halftermeyer-Zhou F, Maine C, et al. Spotlight on measles 2010: update on the ongoing measles outbreak in France, 2008-2010. Euro Surveill. 2010;15(36):19656. PMID: 20843472 
  38. Rivadeneira MF, Bassanesi SL, Fuchs SC. Role of health determinants in a measles outbreak in Ecuador: a case-control study with aggregated data. BMC Public Health. 2018;18(1):269.  https://doi.org/10.1186/s12889-018-5163-9  PMID: 29458349 
  39. Chong KC, Zhang C, Jia KM, Zee BCY, Luo T, Wang L, et al. Targeting adults for supplementary immunization activities of measles control in central China: A Mathematical Modelling Study. Sci Rep. 2018;8(1):16124.  https://doi.org/10.1038/s41598-018-34461-0  PMID: 30382120 
  40. Keenan A, Ghebrehewet S, Vivancos R, Seddon D, MacPherson P, Hungerford D. Measles outbreaks in the UK, is it when and where, rather than if? A database cohort study of childhood population susceptibility in Liverpool, UK. BMJ Open. 2017;7(3):e014106.  https://doi.org/10.1136/bmjopen-2016-014106  PMID: 28363926 
  41. Hoes J, Boef AGC, Knol MJ, de Melker HE, Mollema L, van der Klis FRM, et al. Socioeconomic status is associated with antibody levels against vaccine preventable diseases in the Netherlands. Front Public Health. 2018;6:209.  https://doi.org/10.3389/fpubh.2018.00209  PMID: 30140666 
  42. Fielding JE, Bolam B, Danchin MH. Immunisation coverage and socioeconomic status - questioning inequity in the ‘No Jab, No Pay’ policy. Aust N Z J Public Health. 2017;41(5):455-7.  https://doi.org/10.1111/1753-6405.12676  PMID: 28664595 
  43. Giambi C, Fabiani M, D’Ancona F, Ferrara L, Fiacchini D, Gallo T, et al. Parental vaccine hesitancy in Italy - Results from a national survey. Vaccine. 2018;36(6):779-87.  https://doi.org/10.1016/j.vaccine.2017.12.074  PMID: 29325822 
  44. Burioni R, Odone A, Signorelli C. Lessons from Italy’s policy shift on immunization. Nature. 2018;555(7694):30.  https://doi.org/10.1038/d41586-018-02267-9  PMID: 29493608 

Data & Media loading...

Supplementary data

Comment has been disabled for this content
Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error