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
2012
2015
2000
2010
2010
2020
AFR – measles elimination by 2020
EUR – measles and rubella elimination by 2015
AMR – measles elimination by rubella 2010
SEAR – measles mortality reduction by 2010
EMR – measles elimination by 2015
WPR – measles elimination by 2012 rubella/CRS
prevention target for 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
WHA 2010 endorsed 3 global measles targets as milestones towards eradication

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) Lancet March 5 2011
Heymann et al.
Lancet March
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
, July 2010
193 WHO Member States.
Date of slide: 13 July 2010

10. 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 , 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 is
partially due to missing data for India
Achieved in (elimination) AMR
2.8 per 100,000* (elimination) EMR
0.6 per 100,000* (elimination) EUR
6.3 per 100,000* (elimination) WPR
* Elimination <0.1 per 100,000
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
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: 13 13

14. Number of Countries using rubella vaccine and estimated global rubella vaccination coverage, *
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
169
170
165
158
150
142
131
117
102
N of countries reporting
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 and WHO Regions,

18. Risk of Resurgence Method from Lancet 2007; 369: 191–200
Estimated number of measles deaths,
and projections – worldwide,
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

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 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 :

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 May in Atlanta
Aerosol
Vaccination
Point of care diagnostic test

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Out of date

25. 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

26. 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

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