Global Measles and Rubella Strategic Plan 2011-2020 This strategic plan is a work in progress, and the final plan will be available before the end of the year.

Strategic Advisory Group of Experts (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

World Health Assembly, May 2011 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. year 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

What is New? The plan includes: rubella and CRS control/elimination activities to strengthen routine immunization and disease surveillance systems. outbreak preparedness and response research and development – reduction & eventual elimination of cases of rubella and CRS - renewed commitment from MI partners to allocate resources and provide technical assistance to strengthen routine immunization & surveillance Builds on > 10 years of experience implementing previous strategic plans. Incorporates the 2009 and 2010 guidance and recommendations from the WHO SAGE and the WHO Ad Hoc Global Measles Advisory Group. R&D is now one of the components of the strategy

A world without measles, rubella and congenital rubella syndrome Vision A world without measles, rubella and congenital rubella syndrome Reaching this vision will most likely happen beyond 2020

Goals By end 2015: Reduce global measles mortality by >95% compared to 2000 level Achieve regional measles and rubella/CRS elimination goals By end 2020: Achieve measles elimination in at least 5 WHO regions Achieve & sustain measles elimination in at least four WHO regions. – PAHO, EURO, EMRO & WPRO Achieve rubella and CRS elimination in at least 2 WHO regions – PAHO & EURO These are in line with the current regional measles & rubella targets

Measles and Rubella Elimination Goals by WHO Region, August 2011 World Health Organization Measles and Rubella Elimination Goals by WHO Region, August 2011 1 April, 2017 Americas, Europe, E. Mediterranean, W. Pacific, Africa have measles elimination goals Americas and Europe have rubella elimination goals 2015 2015 SEARO RC in Sept 2009 endorsed a resolution to mobilize support towards eliminate measles, 2010 RC meeting adopted the global 2015 measles targets (95% mortality reduction). Note: EURO changed target to 2015, EMRO is in process of changing target to 2015 2000 2010 2015 2012 2020 SEAR: 95% Measles Mortality Reduction by 2015 7

Milestones By end 2015 Achieve > 90% coverage with MCV1 (and RCV) nationally and > 80% in every district. Achieve > 90% coverage with M, MR or MMR during SIAs in every district. Reduce global measles incidence to < 5 per million Achieve rubella/CRS elimination in at least 2 WHO Regions Establish a rubella control/CRS prevention goal in at least 1 additional WHO region Establish a global measles eradication goal

Milestones By 2020 Sustain the achievement of the 2015 targets > 95% coverage with MCV1 & MCV2 (and RCV) in each district and nationally Achieve > 95% coverage with M, MR or MMR during SIAs in every district. Establish a global rubella and CRS eradication goal.

Strategies High vaccination coverage with two doses of measles and rubella vaccines Effective surveillance, monitoring and evaluation Outbreak preparedness and response Case management Research and development Emphasize text in blue. Under the research section, mention the following: Essential to provide the scientific underpinnings of the strategies and shaping evidence based policy 2011 CDC/WHO meeting: highlighted critical research areas needed to address risks and facilitate elimination. The WHO SAGE Working group on measles and rubella will help identify the highest priorities for research.

Guiding Principles Country ownership and sustainability Routine immunization and health systems strengthening Equity Linkages 1. Country ownership and sustainability Co-financing an indicator of political commitment and progress towards financial sustainability Capacity building towards technical sustainability 2. Routine immunization and health systems strengthening Using measles activities to strengthen routine immunization SIAs 1st and 2nd routine doses Develop global indicators to track improvement in routine Disease/lab surveillance strengthening 3. Equity ALL people have a right to needed vaccines. Outreach activities and SIAs ensure equity as they are specifically targeted towards reaching children missed by routine services. 4. Linkages Link measles and rubella more closely With polio through joint activities (e.g. SIAs, surveillance) With other child health interventions (Vit A, deworming tablets, bed nets, etc.)

Priorities Reach the 2015 measles mortality reduction goal Continue to improve routine coverage Key countries Countries with high measles disease burden Countries that have not introduced RCV into routine Low resource countries These are the MI priorities up to 2015, after which epidemiological-based evidence will be used to reprioritize activities to reach the 2020 goal Strategic plan covers All countries, however MI focuses on key countries.

Addressing Key Risks

1. India: Highest Disease Burden Country Risk largest # of measles cases and deaths worldwide Determining the vaccination coverage needed to stop transmission in large, densely populated states No RCV except in private sector Tactics Intensified advocacy Conduct operational research to address key questions prior to setting an eradication target Enhance support to GoI (TA, M&E, etc) Introduce RCV into national EPI Continued advocacy with GoI to ensure measles mortality redcution remains high on the immunization agenda

2. Weak routine immunization and reporting systems Tactics Expansion of best practices for SIAs Support regular data validation activities Research on best approach for using SIAs to strengthen routine Research on innovative ways to improve coverage monitoring Focus on weakest countries Risk Resurgence in measles due to: weak health systems resulting in missed children low quality of administrative coverage data Insufficient resources leading to low quality/delayed measles SIAs Resurgence in measles due to: weak health systems & low (actual vs. reported) vaccination coverage Low quality of administrative coverage data leading to miscalculation of interval between SIAs and unexpected outbreaks.

3. Funding Gap Risk Tactics Competition with funding with PEI and other health initiatives Reduced political commitment The price of success! No RCV funding for 62 low-income countries (most GAVI-eligible) Tactics Enhance linkages with PEI, GAVI Increase # staff for advocacy/resource mobilization Communicate contribution of measles mortality reduction to reaching MDG4 + continued risk of resurgence Bring in new partners/donors The price of success – the perception that measles mortality reduction/elimination taken care of. It's an old problem and already solved! Enhance linkages with PEI leading to increased efficiency and cost savings.

4. Resistance to Immunization and Anti-Vaccination Lobbies Risk Measles and rubella are not perceived as serious problems Strong anti-vaccine groups Highly publicized and unfounded vaccine safety concerns Decreased coverage in western Europe leading to increased outbreaks and exportation to other regions Tactics Conduct operational research on communication strategies and develop communication tool kits Specific efforts to target the population at risk and health care professionals. Tracking of children to ensure they are immunized on time with 2 doses of M & R vaccines Measles not perceived as a serious problem, mostly in Western Europe. Research needed to better understand how anti-vaccine lobbies operate and how to intervene/counteract their messages. Conduct operational research on communication strategies and develop communication tool kits aimed at reaching vulnerable and high-risk populations as well as to address culture and belief systems. Look into role of civil society in addressing the anti-vaccination trends Specific efforts to target the population at risk and health care professionals, e.g. through advocacy and outreach via the annual European Immunization Week

5. Conflict and emergency settings Risk Conflicts and natural disasters causing displacement of populations Reduced access to health facilities Increased cross border transmission Tactics Immediate vaccination of all children affected by humanitarian emergencies Coordination of funding with humanitarian partners Use PEI lessons learned, e.g. Negotiating access Synchronization of cross boarder SIAs

Management and coordination Clearly defined roles and responsibilities countries, MI and immunization partners Clearly defined monitoring and evaluation indicators and process Regular coordination through: Weekly calls with regions and key countries Two annual meetings Reporting of annual progress Evidence-based planning and budgeting This will be further elaborated by Athalia and Andy on the governance and financing presentation. Effective management and coordination are ensured through having the following: 1. Clearly defined roles and responsibilities for countries, MI and immunization partners 2. Clearly defined monitoring and evaluation indicators and process- will address these in next slide 3. Regular and flexible coordination through: Weekly calls with regions and key countries- additional coordination calls are organized when needed (e.g. in outbreak situations) Two annual meetings 3. Streamlined reporting mechanism of annual progress, implementation challenges. Annual MI report, reports back to SAGE and the WHA 4. Evidence-based planning and budgeting

Monitoring and Evaluation Indicators Process indicators Impact indicators Guiding principles indicators The MI partners have established 3 sets of indicators – process, impact, and guiding principles. Process indicators: - No. countries with national MCV1 coverage >90% and % of districts in each country with coverage >80% - No. additional countries introducing a RCV into their routine EPI - Surveillance performance indicators (quality of surveillance and data reliability) Impact indicators: - Measles incidence. (Number of countries having an annual measles incidence of less than five cases per million.) - Estimated number of deaths attributable to measles Guiding principles indicators: - No. and proportion of countries contributing > 50% of the operational cost of SIAs funding. - No. and proportion of M, MR or MMR SIAs that include additional child health interventions. - No. countries including routine immunization and AEFI surveillance system strengthening training as part of SIA training activities.

Measles Deaths Averted, 2000-2010 Provisional Estimates. -- 15 Measles Deaths Averted, 2000-2010 Provisional Estimates* -- 15.8 Million Deaths Averted ! 2000-2010: 5.0 million deaths averted (32%) 2000-2010: 10.8 million deaths averted (68%) *Not official WHO estimates Modelled estimates using method of Wolfson et al, 2007

Anne Ray Charitable Trust