Challenges in Measles Outbreak Responses MSF Perspectives

1. Challenges in Measles Outbreak ResponsesMSF Perspectives Florence Fermon - Myriam Henkens 10th Annual Measles Initiative Meeting 14/09/2011

2. Measles resurgence in Africa Resurgence comes after a period of intensified efforts Since 2000, routine measles vaccination coverage has increased from an estimated 52% to 85% In 2009, 30 African countries experienced measles outbreaks >60,000 reported cases and >1000 reported deaths (WHO) In 2010, 28 countries experienced measles outbreaks 223,000 reported cases and 1200 deaths (WHO) Real numbers of measles cases and deaths are considerably larger than the numbers reported WHA resolution (RC61) calls for measles elimination in AFRO by 2020

3. Why the resurgence? Build-up of susceptible children and adolescents Failure to vaccinate rather than vaccine failure Programmatic, political and financial challenges

4. 1. Susceptibility build up • Two sources of immunity • Natural immunity due to infection • Vaccine derived immunity • As vaccination increases • Less circulating virus • Age distribution of cases changes - a natural consequence of the success of vaccination programs • Children (on average) are older when they become infected

5. Different age distributions DRC: 2006 Niger: 2004 In endemic countries, outbreaks are limited to young age classes. Burkina Faso: 2009 Countries in transition are intermediate Malawi: 2010 Outbreaks in countries following “elimination” extend evenly age classes Source: courtesy Matthew Ferrari

6. 2. Failure to vaccinate rather than vaccine failure Source: VC(WHO 2002-2009 and MICS 2010), cases: Rapports épidémiologiques annuels, 4ème direction, RDC

7. Programmatic, political and financial challenges • Measles victims of MI success and outbreak responses low on politicians and donors agenda • Delays/reluctance in implementing outbreak responses, despite international recommendations • Lack of efficient coordination • Lack of rapid funding • Delays in implementing campaigns - SIAs – despite strong international support (vaccines and operating costs) DRC 2010 => outbreak 2011

8. MSF & measles outbreak responses Surveillance, treatment, vaccination (when authorized) • 2009: Chad, Ethiopia, DRC, Pakistan, Bangladesh, Nigeria, Sudan, Burkina Faso • 1.4 million vaccinated, 202 000 treated • 2010: Malawi, Chad, DRC, Ethiopia, Yemen, Zimbabwe, Mozambique, Burundi, South Africa, Somalia, Zambia • 4.6 million vaccinated 190 000 treated • 2011: DRC Bangladesh Burundi, Chad, Ethiopia, Kenya, Niger, Somalia, Zambia • already 3 million vaccinated in DRC only, more than 4 million total in August • More than 50 000 treatments in DRC only

9. Measles outbreak responses in Africa 2004-2011Persons vaccinated – MSF • On going • DRC • Burundi • Chad • Ethiopia • Kenya • Niger • Nigeria • Somalia • Zambia

10. Challenges • Outbreak detection and recognition • Outbreak response plan • Outbreak response implementation • Outbreak prevention

11. 1. Outbreak detection & recognition • Inaccurate (inflated) vaccination coverage data  biased risk assessment • Weak surveillance system  late detection of increase in case number • Outbreaks = “failure to vaccinate”  late official recognition of outbreak (MOH and main actors) • But outbreaks do and will occur in many countries

12. Measles resurgence in Europe/USA

13. 2. Outbreak response plan • Lack of knowledge of the WHO recommendations • Lack of knowledge of the usefulness of vaccination in outbreak • No standard tools nor technical recommendations for reactive campaigns • Lack of organized technical support (measles >< polio or meningitis)

14. 3. Outbreak response implementation • Coordination between the different partners • Competition with other priorities (polio campaigns) • Free treatment, increased access to treatment • Timely vaccines availability • Timely funding

15. 4. Outbreak prevention • Maintain the number of susceptibles as low as possible • EPI • Flexibility in age range • Immunization included in comprehensive package of care • Special approach to reach children never vaccinated (“reach the un reached”) • Reduce missed opportunities (surveys, health care contacts, etc) • More accurate data in performance, coverage, etc

16. Reaching the unreached Vaccination coverage before and after campaign (6-59 m), Ndjamena, Chad

17. Lessons learned, N’djamena, Chad • Chronically low vaccine coverage • Failure to reach older children through routine services • Measles-susceptibles built up and to precipitate the 2010 epidemic • 18% received their first dose in 2010 • previously vaccinated children were easier to reach during the outbreak than unvaccinated children

18. Missed opportunities • CAR - Paoua and Congo Brazza - Betou (MSF - 2010) • limited access to care areas • children were not offered vaccination (in or outpatients) • 0 to 11 m: 65 to 94% were not immunized according to recommendations • 12 to 59 m: 86% to 98% were not immunized and could not be according to the EPI schedules

19. 4. Outbreak prevention (2) • SIA / vaccination campaign • Implement TAG recommendations and adjust age group to local epidemiology • Fixed duration of campaigns >< coverage reached • Adapt SIA intervals to needs • Accurate data collection • Independent coverage surveys • Implementation according to plan (DRC 2010)

20. What could be done? • Outbreak response included as a component of the Measles Initiative • Outbreak response included into national control programs • Renewed political and financial commitment • Strategies to ensure countries implement SIAs according to plan • Improved coordination in country – Meningitis and Polio could be used as example • Limitations / constraints of implementing recommended strategies should be acknowledged

21. What could be done? (2) • Creative strategies • to reduce the missed opportunities, • to reach the unreached • Consider multi Ag campaign (polio, MenA conj, etc) • Develop a risk assessment tool (susceptible population, social determinants, operational strategy) • Develop supporting tools/documents (WHO 2009 recommendations in French, practical accompanying document) • Financial mechanism for rapid response • New vaccines (easy to administer, no cold chain, etc)

22. Acknowledgments • MSF teams – field and HQ • Epicentre (Rebecca Grais, Andrea Minetti) • Matthew Ferrari Thank You For Your Attention