Transcript Scaling-up for Measles Eradication Implications for WHO

Global Measles and Rubella:
Highlights, Priorities and Critical
Issues
Global Measles and Rubella Management Meeting
15-17 March, WHO/HQ Geneva
Peter Strebel and Edward Hoekstra
Tenth Anniversary of the Measles Initiative
 Joint Declaration, 31 January 2001
 Work together in partnership to further
reduce measles mortality according to
each partner organization's strengths
 To advocate for human and financial
resources
 Support strategies outlined in the
WHO/UNICEF Strategic Plan, including
use of rubella vaccine
 Support the GAVI goal of saving lives
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Measles and Rubella Control Goals by WHO regions, 2011
2015
2015
2015
2012
2015
2000
2010
2010
2020
AFR – measles elimination by 2020
EUR – measles and rubella elimination by 2015
AMR – measles elimination by 2000 rubella 2010
SEAR – measles mortality reduction by 2010
EMR – measles elimination by 2015
WPR – measles elimination by 2012 rubella/CRS
prevention target for 2015
Highlights
WHA, May 2010
 Report A63/18: "Global Eradication of Measles"
– Summary of global progress
– Requirements for eradication
– Feasibility of elimination in each region
 2015 Global Targets as milestones towards eradication
– Vaccination coverage of 90% national level and 80% in every district
– Reported incidence of <5 cases of measles per million
– Mortality reduction of 95% vs 2000
 Targets aligned with the 2015 Millennium Development
Goal of reducing child mortality by 2/3
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Feasibility of Measles Eradication
 July 2010 – Global Consultation
– Measles can and should be
eradicated
– In the context of strengthening
immunization and primary health
care systems
– Opportunity to accelerate rubella
control and the prevention of
congenital rubella syndrome
– Target date of 2020 feasible if
measurable progress
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SAGE, November 2010
 Measles can and should be eradicated
 Measurable progress towards 2015 global targets and
existing regional elimination goals is required before
establishing a target date
 Requested frequent updates on progress
 Executive Board (Jan 2011) endorsed SAGE approach
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The debate continues …
 Lancet (November 20, 2010)
– Heymann et al.
 Lancet March 5 2011
–
–
–
–
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Christie and Gay
Durrheim and Bashour
Andrus and de Quadros
The authors reply…
Measles containing vaccine coverage by WHO region,
1980-2009 (WHO/UNICEF coverage estimates)
MCV coverage (%)
100
80
73
68
60
69 69 70 71
73 73 71 71
70 71
72 73 74
80
76 78
81 82 82
62
53
47 46
40
37
20
16
41
19 20
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
0
Global
EUR
AFR
SEAR
AMR
WPR
Source: WHO/UNICEF coverage estimates
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1980-2009, July 2010
193 WHO Member States.
Date of slide: 13 July 2010
EMR
82% globally
Immunization coverage with measles containing vaccines in
infants, 2009
<50% (4 countries or 2%)
2015
target
50-79% (45 countries or 23%)
80-89% (29 countries or 15%)
>=90% (115 countries or 60%)
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Source: WHO/UNICEF coverage estimates 1980-2009, July 2010
193 WHO Member States. Date of slide: 21 July 2010
Reported measles incidence by WHO regions,
2000-2009
120
incidence per 1 000 000
900
700
2015
target
600
500
80
60
40
20
0
2007
400
2008
2009
AFR
AMR
EMR
SEAR*
WPR
GLOBAL
EUR
300
200
Decline in SEAR in 2009 is
partially due to missing data for India
AFR
AMR
EMR
EUR
SEAR*
2009
2008
2007
2006
2005
2004
2003
2002
0
2001
100
2000
incidence per 1 000 000
800
100
WPR
Source: WHO/IVB database. Data for 2009.
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Date of Slide 08 December 2010
Estimated Global Measles Deaths, 2000-2009
74%
0
79%
2000
2001
2002
2003
2004
New model
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2005
2006
2007
2008
Lancet
*Provisional estimates. Shading indicates
uncertainty bounds
2009
2015 target =
95%
Mortality Reduction Rate
U5 all cause mortality vs U5 Measles
mortality
Measles accounts for ~23% of overall
decrease in child mortality
1990: 12.1 mil
2008: 8.8 mil
Lopez et al (2006) Global Burden of Disease and Risk Factors;
Black et al 2010 Global, regional, and national causes of child
mortality in 2008: a systematic review, Lancet 2010;375:1967 - 87
Number of Countries using rubella vaccine and estimated global rubella
vaccination coverage, 1980-2009*
130 countries (67%) using RCV
100%
160
140
70%
countrries with rubella vaccine
2009
2007
2008
2006
2005
2003
2004
2002
2001
2000
1998
1999
0
1997
0%
1996
20
1994
1995
10%
1993
40
1992
20%
1990
1991
60
1989
30%
1988
80
1987
40%
1985
1986
100
1984
50%
1983
120
1981
1982
60%
1980
vaccination coverage
80%
estimated coverage
*excludes China in 2009
N° countries using vaccine
180
90%
Most using MMR vaccine
2 dose schedule
95% MCV1 coverage
in countries using vaccine
vs. 76% in non-using countries
Thousands
Number of reported rubella cases by WHO
regions, 2000-2009
900
800
700
WPR
SEAR
EUR
EMR
AMR
AFR
600
500
400
300
200
100
0
2000
N of countries reporting
102
2001
117
2002
117
Source: WHO/IVB database.
Date of Slide 11 March 2011
2003
131
2004
142
2005
150
2006
158
2007
2008
2009
165
170
169
Progress in the Field
 China targets elimination
–
–
–
–
Catch-up campaign, Oct. 2010
103 million children vaccinated
High quality
State-of-the-art communications
 India starts implementing 2nd
dose
– Phase 1 catch-up campaign
– 25 million children in 13 states
– Good vaccine handling,
injection safety
– Demand low in urban areas
– Weak national level
coordination
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Setbacks in Africa
 28 countries experience
outbreaks in 2010
Reported Measles Cases by Month and
WHO Regions, 2006-2010
AFR
SEAR
AMR
EMR
EUR
– Malawi, S. Africa, Zimbabwe,
Zambia, Lesotho, Nigeria, DRC,
Angola…
– CERF funding used in 4
countries
WPR
35000
30000
25000
20000
 >127,000 confirmed cases and
over 1,400 measles deaths
15000
10000
 Reasons:
5000
0
Jan
2006
Apr
Jul
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Oct
Jan
2007
Apr
Jul
Oct
Jan
2008
Apr
Jul
Oct
Jan
2009
Apr
Jul
Oct
Jan
2010
Apr
Jul
Oct
– Gaps in immunization coverage,
– Delayed follow-up SIAs
– Funding shortfalls
Risk of Resurgence
Estimated number of measles deaths, 2000-2008
and projections – worldwide, 2009-2013
 Method from Lancet 2007; 369:
191–200
800,000
 3 Scenarios (India excluded):
700,000
– SIAs continue
– SIAs stop
– Half SIAs continue
600,000
500,000
400,000
300,000
 Loss of contribution of measles to
overall reduction in child mortality
200,000
100,000
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
estimates SIAs continue Sias stop Half SIAs continue
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Source: Wkly Epid Rec, Dec 4, 2009
Priorities
#1 Gaps Population Immunity
 Increase 1st dose vaccination
coverage
Measles IgM positive results per province:
South Africa, January 2009 -3 March 2011
(N=18,404 lab-confirmed cases)
 High quality SIAs
Mass vaccination campaign (week 15-18)
800
 Introduce routine 2nd dose
700
600
– GAVI window reopened
– Establish visit in 2nd year
Number
500
400
300
 Timely, focussed outbreak
response
200
100
0
1
5
9 13 17 21 25 29 33 37 41 45 49 53 4
8 12 16 20 24 28 32 36 40 44 48 52
2009
2010
2011
Epidemiological week (Date collected)
ECP
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FSP
GAP
KZP
LPP
MPP
NCP
NWP
WCP
#2 Surveillance and Monitoring
 Improve quality of surveillance
– Completeness
– Timeliness
 Investigate and track outbreaks
 New model for estimating
deaths
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Wkly Epid Rec 2010 85:489-496
#3 Financial Sustainability
 Increase country commitment
Measles Initiative Donations, 2001-2010
180
160
– MI advocacy visits
– Support Sabin Vaccine Institute
and Taskforce for Global Health
$ US Million
140
120
100
 Increase partner support
80
60
40
20
0
2001
2002
2003
Donations
* Excluding all country contributions
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2004
2005
2006
2007
2008
2009
Rollover from 2009
2010
– Coordinated advocacy and
resource mobilization
– Revise "good faith contract"
#4 Innovation and Research
Aerosol
Vaccination
 Develop and introduce new
tools
– Specimen collection
– Aerosol vaccination
– Point of care diagnostic tests
 Implementation research
Point of care diagnostic test
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– Meeting on 24-25 May in
Atlanta
#5. New Measles Strategic Plan
 New Strategic Plan, 2011-2020
–
–
–
–
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Aligned with DOV
Goals
Strategies
Guiding principles
• Immunization system
strengthening
• Synergies, rubella, polio etc.
Summary
 Remarkable progress
– ¾ reduction in measles deaths and reported incidence rate
– Elimination of measles and rubella in the Americas
 Progress in India and China
 New tools for diagnosis and vaccination
 Challenges:
– Levelling off coverage, incidence, deaths
– Declining resources
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Critical Issues
 Common vision and goal
– Measles Initiative Joint Declaration - does it need revising?
– Position of rubella?
 Resource mobilization
– Measles the invisible gorilla!
– Advocacy and resource mobilization plan?
 Contribution to systems strengthening
– Indicators to document contribution
 Outbreak tracking and response
– Role for a vaccine stock-pile
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Acknowledgements
 Country & regional immunization and surveillance staff
 Measles Initiative partners:
IFFIm
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