1. 1 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 Introduction and the Second Year of Life Contact Lessons and way forward Raoul KAMADJEU UNICEF ESARO Meeting of the WHO AFRO Measles and Rubella Technical Advisory Group 2-3 June 2015, Nairobi (Kenya)

2. 2 AFRO Measles TAG – Nairobi 2-3 June 2015 Outline 1.Background on MCV2 2.MCV2 introduction into EPI - Status update 3.MCV2 performance 4.Challenges o MCV2 introduction: findings of MCV2 PIEs 5.Improving MCV2 coverage and way forward 6.Conclusion and questions to the TAG

3. 3 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 - Background

4. 4 AFRO Measles TAG – Nairobi 2-3 June 2015 Measles and Rubella Elimination Goals by WHO Region

5. 5 AFRO Measles TAG – Nairobi 2-3 June 2015 a major strategic approach to maintain high quality population immunity* *Measles Elimination By 2020: A Strategy For The African Region - AFR/RC61/8 16 June 2011 (WHO AFRO) “…The introduction of a second dose of measles immunization in RI in eligible countries”

6. 6 AFRO Measles TAG – Nairobi 2-3 June 2015 AFRO Measles TAG position on MCV2* TAG suggested criteria for MCV2 introduction: ‒ Achievement of MCV1 coverage >80%, maintained for at least three consecutive years using WHO/UNICEF best estimates of vaccine coverage; and ‒ Attainment of one of the two primary measles surveillance performance indicators for at least two consecutive years.” *Report of the Second Meeting of the African Regional Measles Technical Advisory Group (TAG) – Recommendations (2008)

7. 7 AFRO Measles TAG – Nairobi 2-3 June 2015 WHO recommendation on MCV2 * All children should receive two doses of measles vaccine Minimum interval of one month between doses MCV1 at 9 or 12 months When MCV1 > 80% for 3 years then add MCV2 at: ‒ 15-18 months (if country has ongoing measles transmission) ‒ school entry (option if near elimination) Very high coverage (>90%) needed with both doses ‒ Mortality reduction: >90% national, >80% in every district ‒ Elimination: >95% in every district School entry screening for vaccination status *WHO Measles Vaccine Position Paper, WER Aug 2009 (http://www.who.int/wer/2009/wer8435.pdf)

8. 8 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 introduction into EPI AFRO Status update

9. 9 AFRO Measles TAG – Nairobi 2-3 June 2015 AFRO countries MCV2 status* Introduced to date (19 Countries) Planned introductions by end 2015 (5 Countries) No introduction planned by 2015 (27) Not applicable (Not AFRO) MCV2 as of May 2015: 19 countries (40%) MCV2 planned by end 2015: 5 (10%) By the end of 2015, 24 countries (51% of AFRO countries) would have introduced MCV2 into their RI schedule *As of May 205

10. 10 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 introduction – MCV1 pre-introduction All the countries introducing MCV2 have fulfilled the criteria of national MCV1 coverage ≥80% for 3 consecutive years and have sustained high MCV1 in the years preceding MCV2 introduction. Country201420132012201120102009200820072006 Botswana 94 Burkina Faso 8287899294 88 Burundi 9893 9291848892 Capo Verde 91 9697 969594 Eritrea 969899 97 95 Gambia 9695919296928889 Kenya 93 878688908077 Rwanda97 95 Ghana 889193 869585 Sao Tome 91 929192 Senegal 8483848179778480 Tanzania 9997939291889093 Zambia 8082839690879385 MCV2 year of introductionMCV1 coverage 3 years pre-introduction Data source: Official country reported coverage estimates – Access in May 2015

11. 11 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 introduction – status update 10 out of the 19 countries (52%) have introduced MVC2 with GAVI support. A PIE was conducted in 5 countries with MCV2 introduction date > 2012 MCV2 is in most cases provided at 18 months of age. Few exceptions to this rules are Senegal and Seychelles. Three countries are providing MR as MCV2 while 4 countries are providing MMR Countries Year of introductionVaccine for MCV2 visitAge of administration Support for introductionPIE (Year) 1 Algeria2000M (MMR from 2015) 6 years (18 months from 2015) with MMR1 at 11 monthsSELF 2 Lesotho2000M18 monthsSELF 3 Seychelles2000MMR6 yrs (MCV1 at 15 months)SELF 4 South Africa2000M/MMR12-15-18 monthsSELF 5 Swaziland2002M18 monthsSELF 6 Mauritius2003M 18 monthsSELF 7 Capo Verde2009MMR18 monthsSELF 8 Eritrea2012M18 months+GAVI2015 9 Gambia2012M18 months+GAVI 10 Ghana2012M18 months+GAVI2013 11 Botswana2013M18 months+GAVI 12 Burundi2013M18 months+GAVI2014 13 Kenya2013M18 monthsSELF2015 14 Sao Tome2013MR18 months+GAVI 15 Zambia2013M 18 months+GAVI2014 16 Burkina Faso2014M18 months+GAVI 17 Rwanda2014M12 months+GAVI 18 Senegal2014MR15 months+GAVI 19 Tanzania2014MR 18 months+GAVI

12. 12 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 performance

13. 13 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 performance *Data source: Official country reported coverage estimates – Access in May 2015 ** Not yet officially reported by the country MCV2 > 80% MCV2 60 - 80% MCV2 < 60% No data CountryYear of MCV2 introductionMCV2 2014 1 Algeria2000100 2 Lesotho200054 3 Seychelles200098 4 South Africa200081 5 Swaziland200289 6 Mauritius200385 7 Capo Verde200979 8 Eritrea201269** 9 Gambia201273 10 Ghana201267 11 Botswana201385 12 Burundi201360 13 Kenya201325** 14 Sao Tome201371 15 Burkina Faso2014 16 Rwanda201477 17 Senegal201413 18 Tanzania201444 19 Zambia201433 MCV2 coverage < 80%: 12 including 5 with MCV2<60%

14. 14 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 performance in early introduction* *Data source: Official country reported coverage estimates – Access in May 2015 80% MCV2 coverage at Year 1, Year 2 and Year 3 post introduction

15. 15 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV1 - MCV2 dropout rate 2014* *Data source: WHO/UNICEF reported National Immunization Coverage 2014 Drop out rate (%) 20%

16. 16 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 coverage trend in “early introducers” (2004 to 2013) ZAF LSO MUS DZA SWZ SYC Some countries were able to achieve and maintain high coverage early in MCV2 introduction

17. 17 AFRO Measles TAG – Nairobi 2-3 June 2015 Challenges to MCV2 introduction and uptake Key summary findings of PIEs

18. 18 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 Post Introduction Evaluations Purpose to evaluate the impact of introduction on country’s immunization program To rapidly identify problems needing correction PIE to be conducted 6 – 12 months following the introduction (WHO Recommendation) Assessment conducted at all levels of the health system by a team of experts (national and internationals) using adapted tools

19. 19 AFRO Measles TAG – Nairobi 2-3 June 2015 PIE – programmatic areas assessed Planning and process Advocacy, comm, soc mob Training and Knowledge of HCW Service delivery, recording, reporting Monitoring and supervis. Cold chain, vaccine mgt and logistic Sustain. and finance Injection safety and waste disposal Monitoring of AEFI

20. 20 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 PIEs implementation status YearDonePlanned 2013 Ghana (MCV2, PCV, RV) (August, 19 months after introduction) 2014 Burundi (MCV2, RV) (June, 17 months after introduction) Zambia (MCV, PCV, RV – combined with EPI and in-depth surveillance review) (July, 12 months after introduction) 2015 Eritrea (MCV2, RV) (Feb, 31 months after introduction) Kenya (MCV2, RV) (May, 22 months after introduction) Senegal Gambia Tanzania

21. 21 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 PIEs Key findings Programmatic areas Key findings Service delivery, integration, reducing missed opportunities Strategies to reach children > 9 months not planned Strategies for vaccination in second year of life not established Opportunities to link MCV2 with other child health activities >1 year not fully explored Strategies for defaulters tracing not in place Lack of clarity when zero-dose children come in for MCV2. Knowledge of HCW sub-optimal (training for MCV2 not given sufficient attention since it is “an old vaccine”)

22. 22 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 PIEs Key findings Programmatic areas Key findings Demand creation Provision of immunization service > 1 year new to care takers Sub-optimal knowledge of EPI clients on MCV2 and immunization activities > 1 year Demand creation activities limited Opportunities to increase demand creation exist but are not fully harnessed (health education during EPI sessions/antenatal visits, health visits, mass media, etc..)

23. 23 AFRO Measles TAG – Nairobi 2-3 June 2015 MCV2 PIEs Key findings Programmatic areas Key findings Monitoring of doses/coverage /dropout Unstable population figures Target population for MCV2 new to the program and not widely understood Recording of MCV doses still a challenge Monitoring of MCV2 not fully established ‒Poor recording of MCV2 doses ‒Monitoring of MCV2 at all levels not established ‒High MCV1-MCV2 dropout rates observed (reflecting low MCV2 coverage) but not monitored ‒Impact of MCV2 introduction on vaccine utilization/wastage is not systematically monitored

24. 24 AFRO Measles TAG – Nairobi 2-3 June 2015 Improving MCV2 coverage Way forward

25. 25 AFRO Measles TAG – Nairobi 2-3 June 2015 Modeling MCV2 impact – Theoretical model Changes in susceptible population by level of MCV2 coverage in a theoretical population with a birth cohort of 500,000, assuming MCV1 coverage 80% at 9 months maintained over time. At coverage 70%, 80% and 90% it will take 9, 13 and 22 years respectively for the population of susceptible to accumulate above the birth cohort No MCV2 MCV1 = 80% Assumed constant over years MCV2 = 50% MCV2 = 40% MCV2 = 70% MCV2 = 80% MCV2 = 60% MCV2 = 90% Birth cohort MCV SIAs Susceptible accumulated above birth cohort – Recommended time for measles SIA

26. 26 AFRO Measles TAG – Nairobi 2-3 June 2015 Way forward to improve MCV2 performance 1.Institution of a pre-MCV2 introduction readiness assessment/planning tool developed by WHO/UNICEF? 2.WHO-AFRO to institute reporting on dropout between MCV1 and MCV2 as key performance indicator (to be reported in feedback bulletin and included in monitoring charts ) for countries with MCV2 3.WHO and UNICEF to conduct additional operational research on strategies/best practices to improve MCV2 coverage around: service delivery, demand creation and integration with 2 nd year of life activities

27. 27 AFRO Measles TAG – Nairobi 2-3 June 2015 Way forward to improve MCV2 performance 4.Sharing lessons learned and best practice from other countries to inform MCV2 introduction and performance 5.Changing EPI target age from the historic 9 months (0- 11 months) to under 2 or under 5 years 6.Monitoring the implementation of PIEs recommendations

28. 28 AFRO Measles TAG – Nairobi 2-3 June 2015 Conclusion and questions to the TAG

29. 29 AFRO Measles TAG – Nairobi 2-3 June 2015 Conclusion 19 countries in WHO/AFRO Region (40%) have introduced MCV2 into their RI schedule, with more countries planning to introduce MCV2 in the near future Concerns remain over low performance of MCV2 and appropriate actions should be taken to improve MCV2 performance Not all countries have exploited MCV2 introduction to make policy and practice changes to increase MCV1 and MCV2 coverage

30. 30 AFRO Measles TAG – Nairobi 2-3 June 2015 Questions to the TAG on MCV2 1.Is it time the TAG revisit its MCV2 introduction criteria that were set in 2008 (coverage criteria, surveillance criteria)? 2.Should WHO institutes a pre-introduction assessment (6, 8 months prior to MCV2 introduction?) 3.Should AFRO countries institute universal school entry MCV checks and referral when there is not evidence of 2 doses of MCV?

31. 31 AFRO Measles TAG – Nairobi 2-3 June 2015 Thank you