Background:
The introduction of measles vaccination into routine childhood vaccination programmes has led to a shift of disease burden and incidence among young adults. This was confirmed by the recent rise in measles cases and outbreaks throughout Europe. To prevent outbreaks and eliminate measles, one of the key objectives of the WHO Europe measles elimination framework is achieving overall vaccination coverage of ≥95% in the population on a district level.
In the absence of national registers, data on vaccination coverage in Germany is recorded at the age of school entry, through insurance refund claim data and population studies. Vaccination status (VS) of young adults is largely unknown.

Methods:
We assessed measles vaccination coverage in young adults aged 20-34 years on a district level of the German Federal State of Rhineland-Palatinate. The knowledge and attitude towards immunization of unvaccinated to vaccinated young adults were compared using Likert questions. We used proportional allocation for stratified random sampling across 36 counties. We mailed a self-administered questionnaire with pre-paid return envelopes along with an offer to complete online. Prior to calculating coverage we tested for non-responder bias using logistic regression.

Results:
465 (28%) of 1,637 persons contacted responded (mail: 23%, online: 5%). More women responded than men (odds ratio (OR)=2.1; 95% confidence intervall (CI)=1.7-2.6) but age did not vary between responders and non-responders. Vaccination coverage was 90% (95%CI=87%-93%) for one and 56% (95%CI=51%-61%) for two doses. We found a statistically significant association between receiving two doses and age group. The 20-24 years age group had a 2.3 higher incidence rate ratio (95%CI=1.7-3.2) than the reference group of 30-34 year old to have received two doses of measles vaccination. The group of 25-29 year old had a 1.5 higher incidence rate (95%CI=1.0-2.1) than the reference group to have received two doses of measles vaccination.

Conclusions:
Coverage has failed to reach the WHO Europe elimination goal of 95% measles vaccination in the general population. Targeted approaches including enlistment of occupational health services and checking vaccination status during general practitioner (GP) visits are needed to increase vaccination uptake in this age group in order to achieve measles elimination.