Global Measles and Rubella: Highlights, Priorities and Critical Issues

1. 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

2. 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

3. 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 WPR – measles elimination by 2012 rubella/CRS prevention target for 2015 EMR – measles elimination by 2015

4. Highlights

5. 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

6. 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

7. 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

8. The debate continues … • Lancet (November 20, 2010) • Heymann et al. • Lancet March 5 2011 • Christie and Gay • Durrheim and Bashour • Andrus and de Quadros • The authors reply…

9. Measles containing vaccine coverage by WHO region, 1980-2009 (WHO/UNICEF coverage estimates) 82% globally Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 193 WHO Member States. Date of slide: 13 July 2010

10. Immunization coverage with measles containing vaccines in infants, 2009 <50% (4 countries or 2%) 50-79% (45 countries or 23%) 80-89% (29 countries or 15%) >=90% (115 countries or 60%) 2015 target Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 193 WHO Member States. Date of slide: 21 July 2010

11. Reported measles incidence by WHO regions, 2000-2009 2015 target Decline in SEAR in 2009 is partially due to missing data for India Source: WHO/IVB database. Data for 2009. Date of Slide 08 December 2010

12. Estimated Global Measles Deaths, 2000-2009 74% 79% 2015 target = 95% *Provisional estimates. Shading indicates uncertainty bounds

13. Mortality Reduction Rate U5 all cause mortality vs U5 Measles mortality Measles accounts for ~23% of overall decrease in child mortality 2008: 8.8 mil 1990: 12.1 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

14. Number of Countries using rubella vaccine and estimated global rubella vaccination coverage, 1980-2009* 130 countries (67%) using RCV Most using MMR vaccine 2 dose schedule 95% MCV1 coverage in countries using vaccine vs. 76% in non-using countries *excludes China in 2009

15. Number of reported rubella cases by WHO regions, 2000-2009 Source: WHO/IVB database. Date of Slide 11 March 2011

16. 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

17. Setbacks in Africa • 28 countries experience outbreaks in 2010 • Malawi, S. Africa, Zimbabwe, Zambia, Lesotho, Nigeria, DRC, Angola… • CERF funding used in 4 countries • >127,000 confirmed cases and over 1,400 measles deaths • Reasons: • Gaps in immunization coverage, • Delayed follow-up SIAs • Funding shortfalls Reported Measles Cases by Month andWHO Regions, 2006-2010

18. Risk of Resurgence • Method from Lancet 2007; 369: 191–200 • 3 Scenarios (India excluded): • SIAs continue • SIAs stop • Half SIAs continue • Loss of contribution of measles to overall reduction in child mortality Estimated number of measles deaths, 2000-2008 and projections – worldwide, 2009-2013 Source: Wkly Epid Rec, Dec 4, 2009

19. Priorities

20. #1 Gaps Population Immunity • Increase 1st dose vaccination coverage • High quality SIAs • Introduce routine 2nd dose • GAVI window reopened • Establish visit in 2nd year • Timely, focussed outbreak response Measles IgM positive results per province: South Africa, January 2009 -3 March 2011 (N=18,404 lab-confirmed cases)

21. #2 Surveillance and Monitoring • Improve quality of surveillance • Completeness • Timeliness • Investigate and track outbreaks • New model for estimating deaths Wkly Epid Rec 2010 85:489-496

22. #3 Financial Sustainability • Increase country commitment • MI advocacy visits • Support Sabin Vaccine Institute and Taskforce for Global Health • Increase partner support • Coordinated advocacy and resource mobilization • Revise "good faith contract"

23. #4 Innovation and Research • Develop and introduce new tools • Specimen collection • Aerosol vaccination • Point of care diagnostic tests • Implementation research • Meeting on 24-25 May in Atlanta Aerosol Vaccination Point of care diagnostic test

24. #5. New Measles Strategic Plan • New Strategic Plan, 2011-2020 • Aligned with DOV • Goals • Strategies • Guiding principles • Immunization system strengthening • Synergies, rubella, polio etc. Out of date

25. 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

26. 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

27. Acknowledgements • Country & regional immunization and surveillance staff • Measles Initiative partners: IFFIm