Challenges in Measles Outbreak Responses MSF Perspectives Florence Fermon - Myriam Henkens 10th Annual Measles Initiative Meeting 14/09/2011

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

Why the resurgence? 1.Build-up of susceptible children and adolescents 2.Failure to vaccinate rather than vaccine failure 3.Programmatic, political and financial challenges

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

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

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

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

MSF & measles outbreak responses Surveillance, treatment, vaccination (when authorized) 2009: Chad, Ethiopia, DRC, Pakistan, Bangladesh, Nigeria, Sudan, Burkina Faso –1.4 million vaccinated, treated 2010: Malawi, Chad, DRC, Ethiopia, Yemen, Zimbabwe, Mozambique, Burundi, South Africa, Somalia, Zambia –4.6 million vaccinated 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 treatments in DRC only

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

Challenges 1.Outbreak detection and recognition 2.Outbreak response plan 3.Outbreak response implementation 4.Outbreak prevention

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

Measles resurgence in Europe/USA

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)

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

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

Reaching the unreached Before Campaign After Campaign Card % (95% CI) 7.6 ( ) 5.5 ( ) 53.0 ( ) 40.2 ( ) Card/Recall % (95% CI) 33.0 ( ) 68.7 ( ) 80.6 ( ) 81.1 ( ) Vaccination coverage before and after campaign (6-59 m), Ndjamena, Chad

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

Missed opportunities CAR - Paoua and Congo Brazza - Betou (MSF ) –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

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)

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

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)

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