Deaths from<unk>  per million persons in 2012 Disability-adjusted life year for<unk>  per 100,000 inhabitants in 2004<unk>  is extremely infectious and its continued circulation in a community depends on the generation of susceptible hosts by birth of children. In communities that generate insufficient new hosts the disease will die out. This concept was first recognized in<unk>  by Bartlett in 1957, who referred to the minimum number supporting<unk>  as the critical community size (CCS). Analysis of outbreaks in island communities suggested that the CCS for<unk>  is around 250,000. To achieve herd immunity, more than 95% of the community must be vaccinated due to the ease with which<unk>  is transmitted from person to person. In 2011, the WHO estimated that 158,000 deaths were caused by<unk> . This is down from 630,000 deaths in 1990. As of 2018,<unk>  remains a leading cause of vaccine-preventable deaths in the world. In developed countries the mortality rate is lower, for example in England and Wales from 2007 to 2017 death occurred between two and three cases out of 10,000. In children one to three cases out of every 1,000 die in the United States (0.1–0.2%). In populations with high levels of malnutrition and a lack of adequate healthcare, mortality can be as high as 10%. In cases with complications, the rate may rise to 20–30%. In 2012, the number of deaths due to<unk>  was 78% lower than in 2000 due to increased rates of immunization among UN member states. Reported cases WHO-Region 1980 1990 2000 2005 2014 African Region 1,240,993 481,204 520,102 316,224 71,574 Region of the Americas 257,790 218,579 1,755 66 19,898 Eastern Mediterranean Region 341,624 59,058 38,592 15,069 28,031 European Region 851,849 234,827 37,421 37,332 16,899 Southeast Asia Region 199,535 224,925 61,975 83,627 112,418 Western Pacific Region 1,319,640 155,490 176,493 128,016 213,366 Worldwide 4,211,431 1,374,083 836,338 580,287 462,186 Even in countries where vaccination has been introduced, rates may remain high.<unk>  is a leading cause of vaccine-preventable childhood mortality. Worldwide, the fatality rate has been significantly reduced by a vaccination campaign led by partners in the<unk>  Initiative: the American Red Cross, the United States CDC, the United Nations Foundation, UNICEF and the WHO. Globally,<unk>  fell 60% from an estimated 873,000 deaths in 1999 to 345,000 in 2005. Estimates for 2008 indicate deaths fell further to 164,000 globally, with 77% of the remaining<unk>  deaths in 2008 occurring within the Southeast Asian region. There were 142,300<unk>  related deaths globally in 2018, of which most cases were reported from African and eastern Mediterranean regions. These estimates were slightly higher than that of 2017, when 124,000 deaths were reported due to<unk>  infection globally. In 2000, the WHO established the Global<unk>  and Rubella Laboratory Network (GMRLN) to provide laboratory surveillance for<unk> , rubella, and congenital rubella syndrome. Data from 2016 to 2018 show that the most frequently detected<unk>  virus genotypes are decreasing, suggesting that increasing global population immunity has decreased the number of chains of transmission. Cases reported in the first three months of 2019, were 300% higher than in the first three months of 2018, with outbreaks in every region of the world, even in countries with high overall vaccination coverage where it spread among clusters of unvaccinated people. The numbers of reported cases as of mid-November is over 413,000 globally, with an additional 250,000 cases in DRC (as reported through their national system), similar to the increasing trends of infection reported in the earlier months of 2019, compared to 2018. In 2019, the total number of cases worldwide climbed to 869,770. The number of cases reported for 2020 is lower compare to 2019. It has been suggested that the COVID-19 pandemic has affected vaccination campaigns around the world, including in countries currently experiencing outbreaks, which could affect the number of cases in the future. Europe Incidence of and deaths due to<unk>  in England and Wales between 1940 and 2017 In England and Wales, though deaths from<unk>  were uncommon, they averaged about 500 per year in the 1940s. Deaths diminished with the improvement of medical care in the 1950s but the incidence of the disease did not retreat until vaccination was introduced in the late 1960s. Wider coverage was achieved in the 1980s with the<unk> , mumps and rubella, MMR vaccine. In 2013–14, there were almost 10,000 cases in 30 European countries. Most cases occurred in unvaccinated individuals and over 90% of cases occurred in Germany, Italy, Netherlands, Romania, and United Kingdom. Between October 2014 and March 2015, a<unk>  outbreak in the German capital of Berlin resulted in at least 782 cases. In 2017, numbers continued to increase in Europe to 21,315 cases, with 35 deaths. In preliminary figures for 2018, reported cases in the region increased 3-fold to 82,596 in 47 countries, with 72 deaths; Ukraine had the most cases (53,218), with the highest incidence rates being in Ukraine (1209 cases per million), Serbia (579), Georgia (564) and Albania (500). The previous year (2017) saw an estimated<unk>  vaccine coverage of 95% for the first dose and 90% for the second dose in the region, the latter figure being the highest-ever estimated second-dose coverage. In 2019, the United Kingdom, Albania, the Czech Republic, and Greece lost their<unk> -free status due to ongoing and prolonged spread of the disease in these countries. In the first 6 months of 2019, 90,000 cases occurred in Europe. Americas As a result of widespread vaccination, the disease was declared eliminated from the Americas in 2016. However, there were cases again in 2017, 2018, 2019, and 2020 in this region. United States<unk>  cases in the US from 1938 to 2019 In the United States,<unk>  affected approximately 3,000 people per million in the 1960s before the vaccine was available. With consistent widespread childhood vaccination, this figure fell to 13 cases per million by the 1980s, and to about 1 case per million by 2000. In 1991, an outbreak of<unk>  in Philadelphia was centered at the Faith Tabernacle Congregation, a faith healing church that actively discouraged parishioners from vaccinating their children. Over 1400 people were infected with<unk>  and nine children died. Before immunization in the United States, between three and four million cases occurred each year. The United States was declared free of circulating<unk>  in 2000, with 911 cases from 2001 to 2011. In 2014 the CDC said endemic<unk> , rubella, and congenital rubella syndrome had not returned to the United States. Occasional<unk>  outbreaks persist, however, because of cases imported from abroad, of which more than half are the result of unvaccinated U.S. residents who are infected abroad and infect others upon return to the United States. The CDC continues to recommend<unk>  vaccination throughout the population to prevent outbreaks like these. In 2014, an outbreak was initiated in Ohio when two unvaccinated Amish men harboring asymptomatic<unk>  returned to the United States from missionary work in the Philippines. Their return to a community with low vaccination rates led to an outbreak that rose to include a total of 383 cases across nine counties. Of the 383 cases, 340 (89%) occurred in unvaccinated individuals. From 4 January, to 2 April 2015, there were 159 cases of<unk>  reported to the CDC. Of those 159 cases, 111 (70%) were determined to have come from an earlier exposure in late December 2014. This outbreak was believed to have originated from the Disneyland theme park in California. The Disneyland outbreak was held responsible for the infection of 147 people in seven U.S. states as well as Mexico and Canada, the majority of which were either unvaccinated or had unknown vaccination status. Of the cases 48% were unvaccinated and 38% were unsure of their vaccination status. The initial exposure to the virus was never identified. In 2015, a U.S. woman in Washington state died of pneumonia, as a result of<unk> . She was the first fatality in the U.S. from<unk>  since 2003. The woman had been vaccinated for<unk>  and was taking immunosuppressive drugs for another condition. The drugs suppressed the woman's immunity to<unk> , and the woman became infected with<unk> ; she did not develop a rash, but contracted pneumonia, which caused her death. In June 2017, the Maine Health and Environmental Testing Laboratory confirmed a case of<unk>  in Franklin County. This instance marks the first case of<unk>  in 20 years for the state of Maine. In 2018 one case occurred in Portland, Oregon, with 500 people exposed; 40 of them lacked immunity to the virus and were being monitored by county health officials as of 2 July 2018. There were 273 cases of<unk>  reported throughout the United States in 2018, including an outbreak in Brooklyn with more than 200 reported cases from October 2018 to February 2019. The outbreak was tied with population density of the Orthodox Jewish community, with the initial exposure from an unvaccinated child that caught<unk>  while visiting Israel. A resurgence of<unk>  occurred during
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