1. Updates in measles control in the African Region Measles Partnership Annual Meeting September 2008 Dr Balcha G Masresha WHO AFRO

2. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Outline of presentation Regional measles control goal and current status Routine immunisation Supplemental immunisation activities Measles case-based surveillance Programmatic challenges The pre-elimination goal for the African Region

3. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Estimated reduction in measles mortality (all ages) in the African Region, 2000-2006 91 % reduction

4. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Reported coverage vs WHO UNICEF estimates. AFR. 2001 - 2007

5. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles vaccination administrative coverage by category. AFR. 1981 - 2007

6. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa DPT1 – measles drop out rates. (WHO UNICEF estimates. 2006) 33 of 46 countries with drop-out rates >10% 11 countries with drop out rates 20% 3 countries with DTP1 90% with drop out rates 20%

7. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Stagnating coverage / high drop out rates… WHY? Infrastructure, financial and human resource limitations Limited geographic access and utilisation access for routine services Gaps in implementing the RED strategy: Outreach, community linkages, use of data for action, appropriate management of resources Logistics gaps including vaccine stock outs, aging cold chain and EPI vehicle fleet Inaccuracy of denominators… Improved quality of coverage reporting (e.g., administrative coverage data from CHWs / IPDs)

8. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa MP support for focused routine immunisation strengthening In 2008, 9 countries were supported financially A total of USD 1,050,000 Support focused to avert measles outbreaks, de-linked from the SIAs (i.e., these 9 countries were not scheduled for SIAs in 2008)

9. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa TAG 2008. Criteria for considering MCV2 MCV1 coverage >80%, for > 3 consecutive years (using WHO/UNICEF coverage estimates) and Attainment of one of the two primary measles surveillance performance indicators for at least two consecutive years. i.e., Non-measles febrile rash illness rate of > 2.0 cases per 100,000 population per year At least 1 suspected measles case investigated with blood specimens in > 80% of districts per year.

10. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Second Opportunity for measles vaccination (SIAs)

11. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Children reached in measles SIAs, 2001 – 2007, and target plans for 2008 - 2010. AFR

12. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles SIAs; results 97 SIAs in 43 countries reaching 329.9 million children from 2001 – end of 2007 12 rounds with admin coverage 90 – 94% 20 rounds with admin coverage < 90% By end of 2008, a further 63.4 million children will be targeted in 9 countries

13. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles SIAs: some examples of coverage gaps Gabon, Nov 2007 83% MCV 98% ITN Ghana, 2006 79% MCV Guinea Bissau, 2006; 85% MCV Nigeria, 2006; 83% MCV

14. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles Follow up SIAs Coverage by Region, Ethiopia. April - May 2008

15. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Intervention200620072008 Measles15 countries14 countries10 countries Vit A12138 Deworming7116 ITNs776 OPV525 Integrated delivery of interventions in measles SIAs. 2006 - 2008

16. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Integration in measles SIAs; AFR. 2007

17. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Integrated delivery of multiple interventions; is it always synergistic? Integration may be seen as being partner-led room for advocacy and local consensus building Weakness of central coordination Need for stronger involvement of all programs Delays in program level decisions/ resources/ logistics Stock-out of commodities disrupting acceptance of antigens; appropriate and detailed logistic planning Need for further operational research on the factors conducive to the synergy

18. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles case based surveillance

19. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa The Regional measles surveillance network 40 countries (749.4 million population) under case based surveillance with a network of National / Regional Referral measles laboratories Heavily dependent on the Polio infrastructure Staffing, vehicles, funding for activities …

20. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles surveillance performance & results. AFR. 2006 – July 2008 Indicator/ parameter200620072008 # suspected cases reported215802511125688 % investigated with blood specimens (target: >80%) 93%92%96% % districts reporting at least 1 suspected case (target: >80%) 54%71%68% % lab confirmed cases (target:<10%)30%22%25% # total confirmed measles cases7707786913410 Incidence of confirmed measles per 100,000 population 1.21.11.8 Annualised non measles febrile rash illness rate (target >2:100,000) -2.12.3

21. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles incidence. 2007 Regional incidence: > 10 cases per million for the last 3 years; Country incidence levels ranging from 0 – 60 cases per million

22. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Incidence per 100,000 population # of countries% of total regional population <0.11726% 0.1 – 0.4988% 0.5 – 0.99519% 1.0 – 1.99437% >/= 2.0410% Measles incidence. AFR. 2007

23. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Incidence of confirmed measles. Jan – June 2008. AFR

24. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Trends of measles case reports. Nigeria. 2005 - 2008 20052006 2007 Measles catch up campaign in Northern states Measles catch up campaign in Southern states 2008

25. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Measles case reports by final classification, Nigeria. 2007 vs 2008 Jan – Dec 2007 Jan – Mar 2008 Jan – Mar 2007

26. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Age & vaccination status of confirmed measles cases, Nigeria. Jan – Dec 2007 (n=2,297)

27. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa LGAs with reported measles outbreaks. Jan – July 2008, Nigeria

28. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Age & vaccination status of confirmed measles cases. Nigeria, Jan – Jul 2008 (n=8,887)

29. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Challenges for measles control in AFR Limitations in SIAs operational funding Currency exchange rates, Rising costs of fuel, Rising staff costs, … Limited local mobilization of $ resources for operational component of SIAs Complacency following significant reduction of measles case burden Gaps in SIAs coverage, surveillance performance… System-wide constraints preventing sustained increase of routine immunization coverage beyond 80% New Regional measles targets: pre-elimination

30. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Plans for Measles SIAs in 2009 18 countries = 39.7 million children Total cost of $49.7 million including surveillance support to 40 countries Focused support to close routine immunization program gaps and avert outbreaks in countries scheduled for SIAs in 2010 Expected MP portion of $37.8 million Local sources expected to raise $11.9 million MP role in advocacy!!!

31. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Pre-elimination regional goal to be achieved by end-2012Pre-elimination regional goal to be achieved by end-2012 Targets: >98% mortality reduction by 2012 as compared to estimates for 2000; Measles incidence <5 cases/10 6 population/year at national level in all countries; >90% routine MCV1 coverage at national level, and >80% in all districts; >95% SIAs coverage in all districts; AND…

32. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa … continued Measles surveillance performance: Non-measles febrile rash illness rate of >2.0 cases per 100,000 population per year; 1 suspected measles case investigated with blood specimens in at least 80% of districts per year; and Routine district reporting from 100% of districts. Pre-elimination regional goal to be achieved by end-2012 (contd)

33. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa Working towards the pre-elimination targets: anticipated challenges Overcoming the complacency and maintaining the political will to scale up measles control activities to pre-elimination levels esp. while polio eradication still poses a challenge Raising the required $ resources (at international and local levels) Maintaining the surveillance infrastructure Attaining the ambitious routine immunization goals of >90% MCV at national level and >80% in all districts

34. Bureau Régional de lOMS pour lAfrique /WHO Regional\Office for Africa The Measles Partnership