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

Measles and Rubella Control Goals by WHO regions, 2011 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 WHA 2010 endorsed 3 global measles targets as milestones towards eradication

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

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

The debate continues … Lancet (November 20, 2010) Lancet March 5 2011 Heymann et al. Lancet March 5 2011 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) 82% globally Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 193 WHO Member States. Date of slide: 13 July 2010

Immunization coverage with measles containing vaccines in infants, 2009 80-89% (29 countries or 15%) 50-79% (45 countries or 23%) >=90% (115 countries or 60%) <50% (4 countries or 2%) 2015 target 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 2015 target Decline in SEAR in 2009 is partially due to missing data for India Achieved in 2002 2000 1995 (elimination) AMR 2.8 per 100,000* 2010 1997 (elimination) EMR 0.6 per 100,000* 2010 2002 (elimination) EUR 6.3 per 100,000* 2012 2005 (elimination) WPR * Elimination <0.1 per 100,000 Source: WHO/IVB database. Data for 2009. Date of Slide 08 December 2010

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

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 13 13

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

Number of reported rubella cases by WHO regions, 2000-2009 169 170 165 158 150 142 131 117 102 N of countries reporting Source: WHO/IVB database. Date of Slide 11 March 2011

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

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 and WHO Regions, 2006-2010

Risk of Resurgence Method from Lancet 2007; 369: 191–200 Estimated number of measles deaths, 2000-2008 and projections – worldwide, 2009-2013 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 Source: Wkly Epid Rec, Dec 4, 2009

Priorities

#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)

#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

#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"

#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

#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

Summary Remarkable progress Progress in India and China 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

Critical Issues Common vision and goal Resource mobilization 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

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