A bottle of measles vaccination is seen on May 16, 2014. (Photo by Joe Raedle/Getty Images)

The United States has been shocked by a surge in measles cases with more than 100 incidents in January alone.

This, however, is much less worrisome than a current outbreak in Germany.

While authorities there had hoped to completely eliminate the disease this year, 254 new cases emerged in January, primarily in Berlin. If we consider that the German population is only one fourth of the United States', the German measles surge was about 10 times worse than the one in the United States in January, relative to the total population.

There is one significant difference, though: The outbreak has raised little attention in Germany. Whereas measles has been high on the news agenda for weeks in the United States, in Germany, it has neither caused a debate about the alleged risks of vaccines nor has the outbreak been featured on front pages.

The reason is simple: Germany has had even worse outbreaks over the past years.


Experts, however, say that the risks of ignoring the upsurge would be significant. "The outbreak in Berlin is a sobering setback. In general, Germany's immunization rate is too low," Anette Siedler, the director of Germany's renowned Robert Koch Institute, was quoted as saying by German media.

But according to the World Health Organization, Germany already has one of the world's highest immunization rates among 1-year-olds with 97 percent -- compared to the United States with 91 percent. So where do all the new cases come from?

German experts say that one third of all vaccinated German children either lack a sufficient immunization (which usually requires a second dose), or are vaccinated too late.

How could the recent outbreak spread so quickly?

In fact, most of those who caught the virus were adults -- whereas official statistics only take into account children. Similar patterns have been observed in California, where the majority of those who caught the virus were adults as well. Particularly those born between 1970 and 1990 might have missed vaccination doses, due to a lack of stringent recommendations by public health officials at that time. What is worrisome is that the course of the disease is particularly serious for adults, although children are usually more likely to get infected.

The reasons for the lack of vaccinations in Germany are similar to the ones that are often mentioned in the United States: In both countries, measles seemed to have been "eliminated," and subsequently people started to "relax" about immunization. Contrary to developing countries, where the terrifying repercussions of measles outbreaks are still too visible to ignore, many in the United States or Germany have never been confronted with the disease. This makes them more susceptible for the ongoing debates about the safety of vaccinations that have prevented some parents from becoming vaccinated or ensuring that their children receive the necessary doses.

What is different in Germany is that the cases have so far been limited to Berlin and Brandenburg, which is the state that surrounds Germany's capital.

Why the 1990s Yugoslav civil war might be to blame

Journalists survey the damage at the destroyed hospital building in Belgrade Thursday, May 20, 1999. The major Belgrade hospital in the Dedinje residential district was hit in the latest NATO round of NATO airstrikes, and killed at least three people and wounded dozens when a maternity ward, neurological unit and surgery unit were hit according to doctors. The alliance refused to acknowledge that it struck the hospital, but did say one of its laser-guided bombs dropped over the capital went astray, landing 1,500 feet (300 meters) from its intended target. (AP Photo/Vadim Ghirda) Original Filename: YUGOSLAVIA KOSOVO.jpg ORG XMIT: BEL121 Journalists survey the damage at the destroyed hospital building in Belgrade Thursday, May 20, 1999. (AP Photo/Vadim Ghirda)

Local authorities in Germany first noticed a surge in infections last October among asylum seekers from Serbia as well as Bosnia and Herzegovina. One potential reason for the increase in cases could be the fact that the Yugoslav civil war in the 1990s interrupted vaccination programs in the areas from where the refugees have now fled. Overall, nearly all of those who got infected said they had not been vaccinated.

Space to accommodate Germany's asylum seekers is rare and immigrants have complained that they are forced to live on little space -- a significant factor, considering that 90 percent of those without vaccination who come in contact with measles patients will catch the virus. Hence, the Robert Koch Institute has now recommended authorities to put a special emphasis on the vaccination of refugees who have fled Bosnia and Herzegovina.

Justin Lessler, an Assistant Epidemiology Professor at the Bloomberg School of Public Health, thinks that U.S. outbreaks could have similar origins. "There are several communities in the United States with close ties to countries with circulating measles and low vaccination rates, and these are certainly at risk. Since 2001, outbreaks in the US have been sparked by disease acquired in Romania, Kenya, Switzerland, and many more," Lessler told The Washington Post.

To generally blame immigrants for the surge in measles cases would be misleading, though. Contrary to Germany and the United States, many countries in Africa or Latin America claim to have already successfully eliminated the virus.

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With the latest measles outbreak spreading fast, you may be surprised by the state with the best child vaccination rate in the country. (Gillian Brockell/The Washington Post)

Map: 113 countries have higher measles immunization rates than the U.S. for 1-year-olds