108 Bull World Health Organ 2009;87:108–115 | doi:10.2471/BLT.07.050187

Objective To determine morbidity and costs related to a large measles outbreak in Germany and to identify ways to improve the country’s national measles elimination strategy. Methods We investigated a large outbreak of measles in the federal state of North Rhine-Westphalia (NRW) that occurred in 2006 after 2 years of low measles incidence (< 1 case per 100 000). WHO’s clinical case definition was used, and surveillance data from 2006 and 2001 were compared. All cases notified in Duisburg, the most severely affected city, were contacted and interviewed or sent a questionnaire. Health-care provider costs were calculated using information on complications, hospitalization and physician consultations. Findings In NRW, 1749 cases were notified over a 48-week period. Compared with 2001, the distribution of cases shifted to older age groups (especially the 10–14 year group). Most cases (n = 614) occurred in Duisburg. Of these, 81 % were interviewed; 15 % were hospitalized and two died. Of the 464 for whom information was available, 80 % were reported as unvaccinated. Common reasons for non-vaccination were parents either forgetting (36%) or rejecting (28%) vaccination. The average cost per measles case was estimated at €373. Conclusion An accumulation of non-immune individuals led to this outbreak. The shift in age distribution has implications for the effectiveness of measles control and the elimination strategy in place. Immediate nationwide school-based catch-up vaccination campaigns targeting older age groups are needed to close critical immunity gaps. Otherwise, the elimination of measles in German