SAGE REPORT ON MEASLES AND RUBELLA, NOVEMBER 2012

Friday, 18th of January 2013

[source]Weekly Epidemiological Record (WER)[|source]

Full text report is at  http://www.who.int/wer/2013/wer8801.pdf

Measles and rubella Section

SAGE commended countries and Regions for the remarkable progress made in reducing measles mortality globally during the last 3 decades, contributing significantly to the 4th Millennium Development Goal. This progress would not have been possible without country commitment and the support of many partners. AMR has achieved elimination of both measles and rubella and the WPR is approaching interruption of endemic measles transmission. In addition, the number of countries using rubella vaccine in their routine childhood immunization programme has been steadily increasing. However, despite this progress, a careful assessment of the comprehensive reports presented indicates that based on current trends and programme performance, the 2015 global targets as well as Regional elimination targets in EUR (2015), EMR (2015) and AFR (2020) will not be achieved on time. SAGE urged countries and partners to raise the visibility of measles and rubella elimination activities and to ensure that they receive adequate priority and resources as a central component of the GVAP.

 In keeping with the GVAP target of measles and rubella elimination in at least 5 WHO Regions by 2020, SAGE urged SEAR to establish a measles elimination goal and AFR, EMR, SEAR and WPR to work towards establishing regional rubella elimination goals.

 SAGE endorsed the Global Measles and Rubella Strategic Plan for 2012–2020 and recommended full implementation of the key strategies in a manner that promotes country ownership, strengthens the immunization system, promotes equity and reinforces linkages with polio eradication and other programmes. SAGE noted that some key components of the strategic plan remain under-funded and urged countries and partners to work towards closing this funding gap.

 In 2011, >20 million children did not receive their first dose of measles vaccine on time and countries with low routine immunization coverage continue to experience the highest burden of measles. SAGE noted the innovative use of measles supplementary immunization activities to improve routine immunization service delivery and recommended that countries and partners should plan and implement specific strategies to strengthen routine immunization systems as part of measles and rubella control and elimination activities.

Despite increases in MCV1 coverage and the introduction of MCV2 as part of routine immunization programmes, large outbreaks have occurred in a number of countries in Europe, Africa and Asia over the past 24 months. SAGE noted the changing epidemiology of measles, with a shift in age distribution of cases towards older age groups, which is consistent with a programme that primarily targets young children. SAGE urged countries to conduct in-depth investigations of their outbreaks to determine the underlying reasons and the role of these older age groups in sustaining transmission, and to develop approaches to target these older age groups as appropriate. In considering age groups for measles vaccination, rubella susceptibility in older age groups also needs to be addressed.

 SAGE noted the gaps in the immunization coverage and surveillance data needed to guide the programme. Regions and countries are urged to strengthen reporting of district-level vaccination coverage, strengthen an integrated measles and rubella case-based, laboratory supported surveillance of fever and rash illness, and introduce surveillance of congenital rubella syndrome.

 Closer linkages between measles and rubella programme activities and the GPEI has well-recognized benefits. As GPEI elaborates its legacy planning as a component of its endgame strategic plan, SAGE recommended that countries and global immunization partners assess the potential synergies and take active steps, where appropriate, to adapt and apply the polio infrastructure and lessons learnt to support achievement of measles and rubella elimination targets and strengthening of routine immunization programmes.

 SAGE welcomed recent GAVI investments in measles and rubella control which provide significant additional resources for increasing routine coverage, measles-rubella and measles supplementary immunization activities, and timely outbreak response vaccination.

SAGE recommends that countries seize this unique opportunity and commit additional national resources to ensure that programme planning and implementation is of the highest quality. Each campaign should follow established “best practices” and be independently evaluated to ensure homogeneous vaccination coverage of >95%.

 SAGE endorsed the working group’s plan that includes: refining immunization strategies to address the changing epidemiology of measles and rubella; strategies to strengthen surveillance and monitoring, including the definition of an appropriate indicator of district-level coverage; and development of a prioritized list of research topics.

 SAGE reviewed and endorsed the draft framework for verification of measles and rubella elimination and encourages regions and countries, as they approach elimination, to adopt this approach. The framework should be evaluated and adjusted over time, based on country experience.

SAGE was concerned by the challenges and high costs resulting from the continuous importation of measles into countries which have achieved elimination, and suggested that the possibility that international travel regulations could potentially reduce the likelihood of measles importation be explored.

 SAGE welcomed the report from the measles aerosol project. This project, led by WHO, aims to achieve licensing of at least one method for respiratory delivery of a currently licensed measles vaccine. SAGE was presented with data from clinical studies, especially on a Phase II/III trial in India. The results from the pivotal non-inferiority immunogenicity trial showed that the per-protocol seropositivity in the aerosol arm was 85.4% (95% CI: 82.5%, 87.9%) as compared to 94.6% (95% CI: 92.7%, 96.1%) in the subcutaneous arm, with the difference in seropositivity being -9.2% (95% CI: -12.2%, -6.3%). This difference and the upper limit of the confidence interval were both greater than the non-inferiority margin of 5% defined in the study protocol. SAGE members concluded that the tested aerosol vaccine may not be suitable for primary vaccination of infants against measles.

 Nevertheless, SAGE recognized the potential benefits of a measles aerosol vaccine because it could be used by non-health-care workers in low-resource settings in the context of outbreaks, acute emergencies and outreach. It advised that the development of a combined measles rubella aerosol vaccine should be pursued, including demonstration studies of field acceptability and potential to contribute to increasing coverage in resource-limited settings, expansion of safety data, additional studies to adjust the dose delivered, and cost-effectiveness. SAGE also noted the potential usefulness of the aerosol route for administration of other vaccines.