Measles was officially eliminated in 2000, but cases imported from elsewhere threaten to reestablish the virus. More cases have been registered in 2011 than in any year since 1996, leading to fears of outbreaks among unvaccinated children. Less than 50% 50 to 79% 80 to 89% 90% and over Unknown United States Vaccine coverage Estimated coverage for the first dose of a measles-containg vaccine is provided by the World Health Organization and the United Nations��� Children���s Fund. Causes of death in children under five, 1990 Causes of death in children under five, 2008 Measles (7%) Pneumonia (21%) Diarrhoea (20%) Measles (1%) Malaria (8%) Pneumonia (18%) Diarrhoea (15%) Other (58%) Other (47%) Malaria (5%) 1980 1990 1985 1995 2005 2000 2009 0 1 2 3 4 5 Reported measles cases (millions) 870,000 one.altone.alt8,000 Reported cases dropped by 95% VACCINES New promise, old doubts nature.com/vaccines THE CASE OF MEASLES Great advances in the development and distribution of vaccines mean that some diseases can be eradicated. Measles is an important case study: efforts to stem the disease have been successful, but uneven political commitment, lack of funds and public fear threaten to undermine the progress. PAST: PRESENT: A killer crushed Trouble spots In 1980, before vaccination was widespread, there were around 4 million cases of measles and an esti- mated 2.6 million deaths from the disease worldwide1. Childhood mortality targets set by the United Nations, along with accelerated control programmes, have cut the proportion of childhood deaths caused by measles from 7% in 1990 to 1% in 2008 (ref. 2). Ideally, 95% of children need to receive two doses of a measles- containing vaccine to interrupt disease transmission. By 2009, almost 60% of countries had achieved 90% coverage with at least one dose ��� but some are still far below this, and some are slipping backwards. 4 3 4 | N A T U R E | V O L 4 7 3 | 2 6 M A Y 2 0 1 1 �� 2011 Macmillan Publishers Limited. All rights reserved

India Europe India is struggling to reduce deaths from measles3, mainly because of a lack of money and political will to provide two doses of vaccine to all children. There are some indications that this is changing. India (69%) Southern Africa (21%) Rest of the world (10%) Measles deaths in under-fives by region, 2008 More than 30,000 measles cases were reported in 2010, five times more than the annual average for the past five years4. Many have been traced back to a major Bulgarian outbreak in 2009���10. Unfounded fears over the measles, mumps and rubella (MMR) vaccine have contributed to the resurgence. Outbreaks have been seen in 28 countries in the past two years5, mainly because of a lack of funding and political commitment to follow-up vaccination campaigns, and problems with vaccine delivery. There has also been resistance among some religious groups in Zimbabwe, Botswana, Malawi and South Africa. Africa 2000 01 02 03 04 05 06 07 08 09 10 0 100 200 300 400 500 600 Measles cases (thousands) Measles cases Estimated vaccine coverage (%) Estimated vaccine coverage 0 20 40 60 80 100 Estimated FUTURE: Funding, fears and uncertainty Because measles deaths have fallen, vaccination efforts now compete for funding with other diseases, so investment has dropped. Some countries are struggling to introduce the recommended second dose of measles- containing vaccine, let alone new vaccines ��� for invasive pneumococcal disease and rotavirus, for example ��� that could save many more lives. 0 40 80 120 160 Donations Projected funding 2001 03 05 07 09 11 13 15 Funding ($US millions) Estimated deaths Worst-case scenario Status quo 0 Estimated deaths (thousands) 200 400 600 800 2000 02 04 06 08 10 12 Assuming no catch-up immunizations in troubled countries, public-health officials predict a worst-case scenario in which the death��toll could exceed 500,000 by 2013 (ref. 1). In a ���status-quo��� scenario, modest increases in first-dose vaccine coverage are complemented by catch-up immunizations at about 2008 levels ��� but this still falls short of global eradication. 1. Strebel, P. M. et al. J. Infect. Dis. doi:10.1093/infds/jir111 (2011). 2. van den Ent, M. V. X., Brown, D. W., Hoekstra, E. J., Christie, A. & Cochi, S. L. J. Infect. Dis. doi:10.1093/infds.jir081 (2011). 3. Black, R. E. et al. Lancet 375, 1969���1987 (2010). 4. European Centre for Disease Prevention and Control. Epidemiological Update on Measles in EU/EEA (2011) available at: go.nature.com/yndhco 5. Centers for Disease Control and Prevention. MMWR Morb. Mortal. Wkly Rep. 60, 374���378 (2011). 2 6 M A Y 2 0 1 1 | V O L 4 7 3 | N A T U R E | 4 3 5 FEATURE NEWS �� 2011 Macmillan Publishers Limited. All rights reserved