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TENTH ANNUAL MEASLES INITIATIVE MEETING
HELD AT AMERICAN RED CROSS, WASHINGTON, D.C., 13-14 SEPTEMBER 2011
Tuesday Sessions
Athalia Christie introduced Ms Gail McGovern, President and CEO, American Red Cross.
Gail McGovern’s Opening Remarks
Ms McGovern remarked that the MI was a key player in the global public health arena. We have delivered unprecedented results in public health. Our work has prevented 4.3 million deaths. The lofty goal of eradication presents many challenges. We need to continue to strengthen RI and to target the poorest of the poor.
We will need significant transformation in the next few years. To be successful, we will need to innovate and collaborate, bringing new partners on board. What makes us so effective is the partnership among the five founding partners. We can leverage the complementary skills of the founding partners, using rapid funding mechanisms. Private sector contributions will be instrumental in making the world measles free. We are hoping for eradication by 2015. With lives at stake, we cannot afford to delay.
Ms McGovern introduced Bill Foege.
Keynote Address, Wm Foege
How many of you have ever had the relief of not having had smallpox or diphtheria? Our good fortune is due to the work of people who have done things in the past. People in the future will not know whom to thank. When I started in Africa 46 years ago, we saw measles death rates in Biafra of up to 50 percent. ME is no marginal event. There were 2 child vaccines given in the US when I was born 74 years ago. Now there are 18. The measles vaccine was a miracle in West Africa. It was like opening up hospital wards formerly devoted to measles treatment.
We all have mentors who leave their footprints on our hearts and minds. Maurice Hilleman was such a mentor. So was, and is, Sam Katz. When I think of the product of Maurice’s mind, and how that changes the world, we can raise the issue of measles eradication. Einstein said that we should widen the circle of our compassion.
You will hear some amazing stories, compared to 40 years ago. The delivery techniques have been demonstrated. The public is receptive. The resource needs are modest, compared, for example, to HIV. Do we have the social and political will?
The first lesson from the past is not to rely on lessons from the past. The arguments on eradicability have shifted from ‘can’ to ‘should.’ ‘Do no harm’ refers to errors of omission more than errors of commission.
We put polio on the hit list in 1988. The Carter Center promoted first guinea worm eradication, then polio. OCP is promoted by Merck, with ivermectin. We have a different pathway to eradication for each global initiative. There is always a spark plug, and always WHO buy-in. There is political agreement, and there is social will.
We originally thought like poor people, so we would work with what we had. We never dreamt that disease eradication would be of interest to the richest person in the world. We have consortia to assemble resources. We now have real time communication at the field. We set aside time every week at CDC on how to eliminate measles in the US. Finally, we got to the last barrier, the last problem, which would have been invisible had we not removed the other barriers. The PAHO program became so good that we cut down on measles importations.
‘The world will know by history only that this disease existed.’ Thomas Jefferson, writing to Edward Jenner.
The history will describe the leadership of Amcross and the alliance without turf boundaries. Measles will become the tugboat to carry the other programs along.
The history will describe a forensic program which will describe measles outbreaks as tragedies. It will marvel at the speed with which measles disappeared.
Megan Allday made admin announcements and received a round of applause for her hard work.
Anne Schuchat, CDC, chaired the first sessions.
This is one of my favorite meetings. It is extraordinary. It is one of the most efficient ways to have a session. In two hours, we’ll have a round the world tour, without jet lag, of what’s happening.
Peter Strebel, Global Overview
The joint MP declaration was on 31 January 2001.
Included:
There were est. 500,000 measles deaths globally in 2000.
Among our global goals for 2015:
Five of the six WHO regions have targeted measles for elimination. The Americas and Europe have rubella elimination goals.
Feasibility of measles eradication meeting, PAHO, Washington, July 2010. Target date of 2020 feasible if measurable progress.
SAGE meeting, 2010: measurable progress towards 2015 global targets and existing elimination goals is required before establishing a target date. SAGE findings endorsed by WHO’s EB in January 2011.
Measles coverage has risen from 72 to 85 percent since 2001, globally.
There was a global decline in cases through 2008, with no change since 2008. AFRO has seen incidence rises in the last two years.
There was a 76 percent decline in measles deaths by region, 2000 to 2010. India saw only a 26 percent decline in deaths.
Globally, measles accounted for 7 percent of <5 deaths in 1990, compared to 1 percent in 2008.
Challenges:
We have a network of 673 labs. We have outbreak and virus tracking. We can do diagnosis in the field.
Innovation
New vaccine delivery methods: needle free injection for use in Cambodia, aerosol vaccination for use in India; by late 2012, skin patch vaccination, still in early stages of development.
Synergies: GPEI, RI, Rubella, New vaccines (JE, Meningitis A)
The last decade has seen a 2/3 reduction in cases and a ¾ reduction in deaths, but with cases and deaths unchanged in the past three years.
There are 20 MI partners, including the five founding partners.
Balcha Masresha, Measles Pre-Elimination in Africa
The pre-elimination strategy was developed in 2008, based on regional measles TAG recommendation. RI coverage has risen to about 81 percent (2010), with declines in cases until 2008.
MCV2 is introduced in Algeria, Lesotho, Swaziland, Seychelles and Mauritius; there are GAVI applications for Burundi, Ghana, Gambia, Eritrea, S. Tome, and Zambia. For 2012, Tanzania, Burkina Faso and Rwanda are eligible to apply. We have vaccinated about 40 million kids yearly, except during Nigeria SIAs, when the figure rose to 60 million.
Only Mozambique achieved 95 percent SIA coverage in all districts this year.
Surveillance: Non-measles febrile rash illness rates of 2 per 100,000, 24/42 in 2011, down from 30/40 in 2010.
We had 133,000 confirmed measles cases in 2010, with 82 percent of them from Malawi, RSA, Zambia and Zimbabwe.
We have had 20,060 cases in 2011 to date, mostly from Zambia, Tanzania, DRC, Nigeria, and Ethiopia. In 2011, DRC reported 106,000 cases.
DRC is rescheduled to 2012 for North Kivu, Bandundu, Bas-Congo, and Kinshasa. Delayed campaigns in DRC were disastrous.
Reasons for outbreaks:
27/42 countries met incidence target in 2011 to date. 15/42 are on track for surveillance indicators in 2011.
Challenges:
RC in Yamasssoukouro: commitment to ME 2020.
Satish Gupta, UNICEF/India, Measles Control in SEAR
He is presenting on behalf of WHO/SEARO, which was unable to attend.
SEARO RC, September 2010: adopted WHA goals of May 2010, with MCV1 coverage
> 90 percent nationally in all countries, incidence <5 per million, mortality reduction of 95 percent compared to 2000
2012 to be declared the year of intensification of RI in countries of SEAR
Nine countries are implementing elimination strategies; Timor Leste is doing mortality reduction; India, accelerated implementation of measles mortality reduction.
We have had a 42 percent reduction in measles mortality from 2000 to 2007.
Four countries have introduced MCV2.
There are 21 states with MCV2 and 14 states, all in the north, with SIAs.
Challenges: adequate resources, high quality surveillance system, including for AEFI, SIA funding, tech support for India, surveillance costs in five countries, support to Indonesia for ops costs and technical support
Enabling factors: agreement of technical experts (2009, 2011); political commitment present. In India, all costs for MCV2 and SIAs are borne by the national government; vaccine supply and security; excellent community acceptance; support from PEI infrastructure in five priority SEARO countries; lab support to measles surveillance
India and Nepal plan SIAs for 2012. India will do 9 months to 10 years in states to be identified. Nepal will use MR.
Summary:
Discussion
Peter Aaby, Guinea-Bissau
We have some critical issues. Increasing lack of maternal antibodies was not mentioned.
We are seeing more cases in those <9 months of age. We get good protection at 4.5 months. You can vaccinate much earlier. Reconsider the age of measles vaccination, now at 9 months.
Our current schedule is based on assumptions. In the study just concluded, we got impact on mortality. It is time for the vaccine community to face these facts: we are stimulating the immune system. If we eradicate measles, then stop vaccination, we will have killed more children than we have saved. Suspension of measles vaccination will risk doing harm. We should face the data.
Peter Strebel: Thanks to Peter Aaby. Some provocative points:
Declining maternal antibodies; yes, because of the success of the vaccination program. If transmission stops, you’ll see girls reaching child bearing age without exposure to measles. But the overall incidence of measles is reduced. The nonspecific effects are hotly debated. We struggle to replicate your results. More work is needed. We need to look carefully at moving the vaccination age down. What is the optimal age of primary vaccination? I challenge you on the statement that we have no data.
Frank Mahoney: No changes in the strategy in AFRO? With more cases in older age groups, are we revisiting the age range?
Balcha, replying to Mahoney: the situation in southern Africa is different from elsewhere. The age shift is more pronounced in southern Africa.
Sam Katz: a two dose program for measles is new. The single dose regime in the US yielded to two doses about 1990. Is the 2nd dose a booster dose, or is it to fill in the nonseroconverters?
Peter Strebel, replying to Sam Katz. We use the 2nd dose to do both. We do see a boost among the previous seroconverters. Moreover, 95 percent of the nonseroresponders to the first dose respond to the 2nd.
Dr Schuchat: We went to the 2 dose regime in the US because of kids who missed vaccine and kids who failed to seroconvert. To Balcha: you’re seeing resistance to vaccination in some countries. Is this isolated, or general?
Balcha: We’re talking about the Apostolic Church in Zimbabwe, especially the eastern and southern parts. They resist both RI and SIAs. There were huge efforts by the political leaders in Zimbabwe to mobilize the sect leaders to give the green light to vaccination. I doubt that this will be a continuing problem.
Katrina Kretsinger, CDC: For Balcha or Peter. Wide age range campaign. Future implications for AFRO. The RC did not discuss rubella. More recent thinking has eclipsed that question. To convince the managers of the need for rubella, we need some data, which now come primarily from our measles labs.
Strebel: Nepal and Laos are introducing rubella vaccination with SIA going up to 15 or even 19 with combined vaccines. Adding rubella knocks down CRS and measles.
Dr Schuchat: Let me applaud SEAR for devoting 2012 to RI. How can we make that commitment real? At the global level, it looked like the cases went up in 2012, but with fewer deaths. Why the divergence in the 2010 data?
Strebel: The cases went up because of the outbreak in southern Africa. All the 7 countries in southern Africa had large numbers of cases in older children and young adults. In 2011, the DRC outbreak will have an impact. Ditto with Horn of Africa.
Sergei Deshevoi, WHO/EURO Region, Measles and Rubella
Timebound goal for ME by 2015
53 member states, 890 m population, very heterogeneous
Original measles/rubella target, 2010; now, 2015
We have seen huge declines in measles and rubella.
We have 3 countries with measles coverage < 80 percent: Austria, Ukraine and Azerbaijan.
They do measles/rubella catch-up campaigns. Ukraine had a media crisis after death in one vaccinee. Georgia campaign outcome was influenced by the Ukrainian campaign.
In the last 10 years, we have seen measles outbreaks in Romania, Ukraine, Bulgaria, and France. Only 35/53 countries do case based measles surveillance.
Outbreaks start in young adults and children in the age for RI, with spread to infants. Some nosocomial transmission. Exportation to other regions, including measles free PAHO.
European Immunization Week: advocacy, information
Vaccine Communications Activities:
Elimination verification process, starting in November 2011, first meeting of MRRVC
Total needs include cash support to 13 member states
Ops research needs:
David Sniadack, Update on Measles Elimination in WPR
RC has reaffirmed the 2012 measles elimination goal. We are down to <20,000 cases for 2011.
China had the highest incidence in 2008. They have seen a 78 percent decline in cases since their SIA.
Most districts had >95 percent coverage.
China did huge campaign in 2010, vaccinating 102 million.
In 2011 to date, 15.8 cases per million.
Japan, cases <5 per million
Australian lab results show imports from 5/6 WHO regions.
Rubella incidence is <10/million in many countries, but underreported. Countries have been using RCV for many years.
Late introducers of RCV: Laos, Cambodia, Viet Nam; some countries waiting for GAVI Board decision.
Measles Elimination Budget, $5.7 million for 2011-2012. Largest items, SIAs and ORI, 1.8 million each. Funding gap, $2.4 million
Nadia Teleb, EMRO, Measles Control and Elimination in the EMR
We have 23 countries, mostly low income.
ME target date revised to 2015
Regional strategy:
Five countries have not yet introduced MCV2. Fifteen countries give rubella vaccine. High coverage for MCV1 and MCV2, except in poor countries like Sudan, Yemen, Somalia and Afghanistan.
Problem countries: Morocco, Sudan, Somalia, Yemen, Afghanistan, Pakistan
Of the 23 countries, 19 are doing case based surveillance. Southern Sudan, Djibouti and Somalia do sentinel site surveillance. Genotyping data available except from Palestine, Lebanon, UAE, and South Sudan.
Surveillance indicators have improved between 2005 and 2010, but with only 42 percent of countries achieving the reporting rate of >2/100,000 population at the national level.
Rubella testing is done in all countries except Djibouti and Somalia.
Clustering of rubella cases in Afghanistan, Sudan, Yemen, and Tunisia.
Good ME progress from 2000 to 2008. With eight countries close to the elimination goal. Bahrain, Jordan, Palestine, Tunisia, Egypt, Syria, Oman all have low incidence. Many cases in Pakistan, Afghanistan, and Sudan.
Measles case based surveillance in 20 countries, with regional guidelines for validation of elimination developed. National validation committees in five countries; others are in the process.
Challenges:
Opportunities:
Summary: Remarkable progress in mortality reduction, but more efforts needed with the current political turmoil; bridging funding gaps to support LIC countries is challenging
Discussion:
Casey Boudreau, CDC – Are immunization weeks increasing support for EPI?
Deshevoi: We are seeing the decline in public perception and support for measles and immunization in general. We need immunization weeks.
Teleb: We are new to immunization weeks, but our initial experience is encouraging.
Sniadack: This was our first year with regional immunization weeks. Most countries participated. There was no single theme for WPR. We have measles elimination and hep B control as twin goals. Our main focus was on RI.
Robert Kezaala, WHO HQ: When we went into measles control, following the PAHO model of catch-up and keep-up. PAHO reached 95 percent. Many other regions did not. After 10 years, we may need to go up to 15 to eliminate susceptibles in older age groups.
Schuchat: We’ll have later sessions on strategy in light of epidemiology.
Frank Mahoney: We see outbreaks the year after <5 campaigns. Let’s look at the strategy in light of the epidemiology. Should we rethink our strategies?
Strebel: We have to look at surveillance to determine whether this is a failure of strategy or a failure of implementation. We get good <15 campaigns, but with less good <5 campaigns.
Teleb: We are not talking about failure of strategy in Sudan, but failure properly to implement the strategy. In the states with low coverage, we saw cases. In Morocco, we had failure properly to implement the strategy which led to outbreaks. Neither the catch-up nor the follow-up campaign was successful. Morocco has to vaccinate up to 30 years; otherwise, continuing transmission.
Sniadack: Viet Nam had an outbreak in 2008 among young adults. Slowly, there was an accumulation of cases in <7s. The situation was reversed in terms of age of cases. This went on for 18 months until they did a 2010 campaign for kids <6. They have never targeted adults; no fresh cases among adults. How high an age do we need to reach? Do we have to target up to 30? The Vietnamese experience is interesting.
Deshevoi: Our failure to achieve elimination is due to many factors. We have managerial issues. Tajikistan failed to do 2nd dose, which explains 1500 cases after an excellent campaign targeting <27s.
Jos Vandelaer: In a few years’ time, we’ll have to decide whether to move for ME. The criteria include: do we have to do something extra to meet the 2015 criteria? Or does the continuation of present and planned activities suffice?
Strebel: That’s a critical question. Looking globally, we’ve seen a levelling off of incidence. We need game changes. We’ve gotten to a level where we are not going to reach targets. We need 95 percent coverage in campaigns. We have to develop tactics borrowed from GPEI. The research agenda is critical.
Anne Schuchat: In the US we have this off and on concern about measles. We look at France. What’s happening there is not too different from what’s happening in the US. We need to step things up.
AFTERNOON SESSIONS
Jon Andrus, PAHO, chaired the afternoon sessions.
Steve Cochi, CDC, Global Measles and Rubella Strategic Plan
There is some segmentation of the 10 year horizon to 2020. The basis for the 2020 goal is the SAGE meeting of November 2010, with measurable progress towards 2015 global targets and the WHA resolution of May 2011, with endorsement of 2015 milestones towards eradication. Targets aligned with the MDG 4 goal on U5MR reduction.
The new plan includes
Vision: a world without measles, rubella, and CRS
By end 2015:
By end 2020, achieve ME in 5/6 regions
PAHO and EURO have rubella elimination goals. WPRO has rubella and CRS targets for 2015.
Milestones by end 2015:
Milestones for 2020:
Strategies:
Guiding principles:
Priorities:
Addressing key risks:
Ease of measles spread by air routes
1: India: highest disease burden country
Risk Tactics
Largest number of cases Intensified advocacy
and deaths worldwide
Determining the coverage Conduct OR to address key questions before setting goal
needed to stop transmission
in large, densely
populated states
2: Weak RI and reporting systems
Risk Tactics
Resurgent in measles due to
weak health systems resulting Expansion of best practices for SIAs
in missed kids
Low quality of admin data Support regular data validation activities
Insufficient resources leading Research on best approach for using SIAs to
to low quality/delayed SIAs strengthen routine
Research on innovative ways to improve
coverage monitoring
Focus on weakest countries
3: Funding Gap
Risk Tactics
Competition with funding Enhance linkages with PEI, GAVI
for PEI Increase number of staff for advocacy/resource mob
Reduced political commitment Communicate contribution of measles mortality
to reaching MDG 4, continued risk of resurgence
The price of success
No RCV funding for 62 low GAVI
income countries
4 Resistance to immunization and antivaccination lobbies
Risk Tactics
Measles and rubella perceived Conduct OR on communication strategies and develop communication tool kits
as not serious
Strong anti-vaccine groups
Highly publicized and unfounded Specific efforts to target the population at risk and
publicity health care professionals
Concerns on vaccine safety
5 Conflict and emergency settings
Risk Tactics
Conflicts and diseases with Immediate vaccination of all kids affected by emergencies
displacement of populations
We appear to have averted, provisionally, 15.8 million deaths (modelled estimates using methods of Wolfson et al., 2007)
Andrea Gay, Measles Initiative Management and Financing
MI management and Finance Mechanisms
Steps in the MI process: annual country plans, review, consolidate, prioritize; fundraising; disbursement; implementation; m and e; reporting; annual country plans
Management strengths:
DAY TWO
Ed Hoekstra chaired the first sessions, starting with rubella.
Susan Reef and Peter Strebel, Updated WHO Rubella Vaccine Position Paper and Implications for Regions and Countries
Susan presented.
There are estimated to be 112,000 CRS cases yearly, with SEAR and AFR predominating in cases.
There are 131 countries giving rubella worldwide, up from 83 in 1996. In AFRO, 3/46.
PAHO and EURO have elimination goals; WPRO has an accelerated control and prevention goal for 2015.
The 2011 position paper – see www.who.int/wer
We need to document the impact of rubella vaccination.
SAGE recommends that countries use the two dose measles vaccine strategy to use MR or MMR. Only one dose of RCV is needed to achieve rubella and CRS elimination. All subsequent SIAs should be MR or MMR.
Paradoxical effect: increase in susceptibility among child bearing age women, CBAW, with higher CRS when coverage is low.
If coverage is high enough, rubella will be reduced or interrupted.
SAGE recommends that countries should achieve and maintain coverage of 80 percent or greater, delivered through RI and/or regular SIAs.
CRS reduction alone can be done through vaccination of adolescent and adult females only. Impact is limited by coverage achieved and age groups targeted.
2011 – GAVI worked with sub teams to develop Vaccine Introduction Strategy for HPV, JE, typhoid and rubella vaccines. November, GAVI Board to review recommendations. strategies.
Summary
Risk of CRS is greater than the risk of the paradoxical effect.
Political and financial commitment to achieve and maintain coverage at >80 percent.
Jon Andrus and Carlos Castillo-Solórzano, PAHO, Achieving and Sustaining Measles and Rubella Elimination
Jon presented.
Last endemic case of measles, 2002. Deaths averted over two decades, 16,000 in the region.
Beginning in 2001, over a 15 year period the rubella/CRS initiative will have saved an estimated 3 billion USD by preventing more than 112,000 CRS cases in Latin America and the Caribbean.
In 2011, 1.066 cases of measles per million. This is mostly from Quebec. Measles is rare in Latin America, where FU campaigns are of high quality.
We have had 7 cases of rubella this year in the Americas.
We propose to submit work of rubella and measles commissions to PAHO Directing Council in September 2012.
World Youth Day brought together about 1 million youth in one place in Madrid.
Alerts are not mandatory for mass gathering events, but are recommended.
Journal of Infectious Diseases, Rubella and CRS Elimination in the Americas, September 29 2011
We request that WHA consider a global measles eradication goal. ME activities should be used to accelerate the control of rubella and the prevention of CRS, while cementing the achievements of PE and introduction of new vaccines.
James Goodson et al., Rubella Epidemiology in Africa
Most of this appeared in JID earlier this year, Goodson et al.
From modelling, we estimated 42,000 annual cases of CRS in AFRO. Rubella epidemiology in the region was not well described. AJPH published study from Ghana, 2000, Joy Lawn et al.
Only Cape Verde, Mauritius and Seychelles have introduced rubella vaccination.
We looked for surveillance at lab data from measles labs, analyzing age, sex and residence in countries with >30 lab confirmed rubella cases from 2002 through 2009.
There were 22 published reports of rubella seroprevalence, ranging from 1 to 29 percent, with susceptibility among CBAW ranging from 6 to 16 percent.
There were 25,000 rubella cases, lab confirmed, in 2002 to 2009. Most cases were rural. There were 1329 positives in >15 year olds.
The cases we observed were the tip of the iceberg.
Summary:
Susceptibility among adults ranges from 1 to 29 percent.
Rubella virus is circulating widely in Africa, with five percent of reported rubella cases occurring in CBAW. This suggests that rubella during pregnancy remains largely undetected.
Discussion
Lisa Cairns, CDC: For PAHO, you mention the quality of SIAs in PAHO. How do you assure high quality? What is your policy on measles importations?
Jon: The FU campaigns need political commitment. The ministers need to be on board, for example, through the meetings of the Directing Council. Also, advocacy and communication are needed, so that the public demands these services. We’ve used regional immunization week for this purpose. Where FU campaigns fail is through poor timing. I cite Argentina’s four year interval of a few years ago. They had a huge outbreak.
Case investigation is costly, especially in North America.
Robert Steinglass: How good are we in judging whether there is long term political commitment? What is the safety net if we misjudge sustainability of government commitment?
Goodson, replying: The 80 percent criterion is the threshold for the rubella commitment.
The measles outbreaks in Africa, eye popping though they are, are less common and smaller than in the past.
Reef: It’s hard to determine political will. One thing in favor of rubella is that it’s MR or MMR combined. As people buy into ME, it’s a safety net for rubella. There is a synergy.
A well done catch-up campaign protects those vaccinated. Good FU protects fresh susceptibles.
Jon Andrus: We need vaccine laws to sustain commitments. We brought together >200 parliamentarians in Addis Ababa to push for vaccination through legislation.
David Sniadack: Inclusion of RCV in GAVI: the main barrier is commitment to procure routine vaccines. It’s great that GAVI is supporting large scale campaigns to introduce RCV. Is GAVI going to support routine rubella vaccine?
Ed to Sue: You mentioned that 60 countries do not give rubella vaccine. Sue: How many are GAVI eligible? Of the 62 countries, 50 are GAVI eligible. Responding to Sniadack, we need to speak with members of the GAVI Board.
Ed: RI for rubella is not in the investment plan? Sue: Yes.
EMRO: Our worry is that countries will not be able to sustain postcampaign vaccination. Will there be a waning of GAVI support, as with injection safety, which lasted only for three years?
Raza, Pakistan: Introduction of rubella needs costing. We have pneumo and rotavirus. Where is rubella in the priority list?
Peter Aaby: We’ll be studying rubella in the coming years. If I understand correctly, rubella campaigns should be measles/rubella campaigns, probably in the rainy season with low transmission. We have few data on seasonality in West Africa. Measles vaccination has more impact in the dry than in the rainy season.
Goodson: Would like to learn more about the dry versus rainy season, as mentioned. The AFRO guidelines call for SIAs during the low season of transmission.
Hoekstra: Rainy season implementation is not so feasible during the rainy season.
Robert Kezaala: My comment is on political commitment. Everyone remembers the post-election violence in Kenya. The East African Community proposes to remove elections from national control. What about a PAHO style revolving fund for measles vaccines? Could the MI push towards a subregional revolving vaccine? Maybe start with measles or meningitis. Small regional blocks are more likely to work than regional ones. Can we learn something from PAHO?
Andrus: The Revolving Fund works. We could start with epidemic prone diseases. Returning to Dr Raza’s question, what info would Pakistan need to assist in priority setting? In the Americas, we have an initiative for this. For us, rubella is low hanging fruit. For every dollar put into rubella vaccination, you save USD13 in medical costs.
Sam Katz: For 10 years, we’ve had the MI. No question, because measles kills kids. With rubella, you have the tragedy of CRS. Susan, you said there were 112,000 kids with CRS yearly. I’m sure that figure is much higher. Are you underestimating deafness and hardness of hearing?
Susan: We base the 112,000 on serological studies, with mathematical models applied to the serodata. The figure is probably an underestimate, but the best we have.
Balcha: Let me take you back to the steps in introduction. The first step is the need to establish the disease burden. We recognize the limitations of the data. It is hard to sell the problem to the national EPI managers. Let’s get better data on BoD.
Susan: Let’s use measles as a platform for rubella.
Frank Mahoney: Jon, how important were BoD studies in PAHO? Jon: Diarrhea outbreaks in Nicaragua led to rotavirus introduction in that country. In the early ‘80s, polio BoD studies led to OPV priority setting.
Mahoney: CRS is hard to study. Jon: We had estimates of 37,000 cases in the region. We found that introduction of rubella as part of MR/MMR was easy.
Susan: When the Caribbean controlled measles, rubella became important.
Mahoney: Are school entry laws important in the Americas? Jon: the most important legislation is that providing a line item for vaccines for infants. Among our countries, 2/3 have vaccine laws. We at PAHO have produced model laws.
Mahoney: Is a single dose of MR sufficient? Why not two doses of MR?
Susan: We recommend two doses for measles. Programmatically, people get 2 doses of rubella. That’s fine. It’s easier to give MR than M.
Steve Cochi: Several studies have shown that the costing of events when the measles case is unrecognized and treating in ER. We have seen $300,000 to $800,000 costs for small clusters of measles cases. This explains Levin’s cost-effectiveness analysis. The countries of the Americas have a vested interested in reducing measles in the rest of the world.
Maya van den Ent, Ed Hoekstra, David Brown, Halima Dao, Satish Gupta, Routine Immunization: The Missed Child Perspective
Maya presented. MCV1 coverage rose to 78 percent in 47 priority countries by 2010. Global coverage was 85 percent by the same year. Few countries remain under 70 percent, mostly in central Africa.
Universal Declaration of Human Rights and Convention on the Rights of the Child call for ‘the right to life, survival and development.’
If we look at U5MR by wealth quintiles, e.g., from Indonesia, the U5MR is 22/1000, compared to 77/1000 in the poorest quintile.
The level of under-nutrition in children belonging to the poorest quintile has remained stagnant for a decade (1993-2006) (Progress for Children: Achieving the MDGs with Equity, September 2010).
In 2010, 19.1 million kinds did not get MCV1 in infancy.
In descending order, by absolute numbers : India, Nigeria, DRC, Uganda, Pakistan, Indonesia, Ethiopia, Afghanistan, RSA, and USA
In India, urban coverage, FIC, is 63 percent, against 50 percent in the country. Richest quintile is 73 percent; poorest quintile, 36 percent. In India, UP, Bihar, MP, Rajasthan and Gujarat account for 2/3 of all unvaccinated children in India. Within states, there are large variations.
In DRC, there are large gaps between urban/rural and from province to province.
Links between SIAs and RI:
Measles campaigns reach the poorest, Kenya, 2002: Vijayaraghavan M et al., Health Policy 2007, 83: 27-36
Conclusions:
Tracey Goodman, WHO, Introduction of MCV2
MCV2 at 15-18 months if country has ongoing measles transmission, at school entry if near elimination.
Very high coverage, over 90 percent, is needed with both doses.
School entry screening for vaccination status.
There are 139 countries with two dose schedules.
MCV2 is given at school entry in the Americas and Asia, as well as some Gulf states and parts of Southeast Asia.
MCV2 coverage is spotty, but Asia and the Gulf states achieve > 90 percent.
Bangladesh, Burundi, Cambodia, Eritrea, Gambia, Ghana, Myanmar, S. Tome, and Zambia were all approved in July 2011 for MCV2.
GAVI support is for five years’ vaccine and injection materials, with no copayment.
Possible future MCV2 applicants: Burkina Faso, Kenya, Malawi, Nicaragua, Nepal, Rwanda and Tanzania. Botswana, Guatemala and Honduras are GAVI ineligible.
Evaluate choice between 5 dose and 10 dose vial; the latter has higher wastage. The 5 dose vial does not have overall increased burden on cold chain. There is a psychological impact on the health workers when they switch to five dose vials.
Measles strategic planning tool, on Technet21 index
Opportunity to link intervention or add boosters, such as vitamin A, DTP, etc.
Bigger impact when MCV2 reaches zero dose kids
Chance to catch up missed/delayed doses of primary series (typically lost to EPI system when unvaccinated child is >12months – policy implications).
Recording/M & E
Requires revision of cards, forms, wall monitoring charts, database systems
Calculating target population
Definition of FIC shifting
Recording MCV1 and MCV2 in campaigns
Include MCV2 in EPI surveys, MICS and DHS
Challenges of producing global WHO/UNICEF estimates of MCV2 coverage
Looking forward
Short term opportunity with GAVI window
Ed Hoekstra: The UNICEF Supply Division will see if there is a demand for 5-, 10-, and 20-dose vials.
Hoekstra: Country experiences with MCV2?
Raja: We are underperforming with MCV2 coverage in provinces of Pakistan with 2010 introduction.
Gupta: We are giving three vaccines in the second year of life in 17 states. The MCV2 coverage was 50 to 60 percent, even in high performing southern states.
Discussion
Peter Aaby: We should use this chance to test these policies. From the presentations, it’s an option to give at 12 months. Why so late? We need RCTs to show vitamin A effect when given with vaccines. Sex differential in mortality between girls and boys. We should differentiate between boys and girls, since their response is not the same.
Let’s take a look at the high titer measles vaccines. Those trials were repeated. We found excess mortality with high titer vaccines.
Maya van den Ent: What we’ve seen in surveys is that in most settings, there are nonsignificant differences in coverage between boys and girls. I cannot address the immunological questions.
Steinglass: Thanks to Tracey for underlining the operational issues of MCV2 roll-in. Is there any GAVI condition for countries to assume funding for MCV1 as a precondition for MCV2? Is there a GAVI requirement for measles vaccine purchase before getting GAVI funding of RCV?
Tracey Goodman: There are no such requirements as suggested by Steinglass. We’ve had so many problems with this that we didn’t want the fuss and bother, especially given the sums involved.
Maya van den Ent: Steinglass raises the valid question of sustainability. We need more advocacy for sustainable financing.
One participant: Criteria for MCV2 included both national and subnational coverage. Is this still the case? Any information on the impact of MCV2 on incidence, especially from developing countries? What about the need for SIAs?
Tracey: The criterion is based on 3 years’ 80 percent coverage, based on WHO/UNICEF estimates. On the impact, we haven’t started to monitor. We haven’t adjusted our tools. That will be part of the work ahead.
On Aaby’s comment, we do appreciate alternative views. Why do we do what we do? Your research has been reviewed by our internal committees. The 9 month age is based on the epidemiology and maternal antibody issues. We are looking at the immunization schedule, especially with a view to the new vaccines, and whether we should fine tune it. That’s a trade-off between operational issues, including simplicity, and timeliness of vaccination. Moreover, we note that kids are often not vaccinated on time. One month delay on DPT containing vaccines.
Lora Shimp: With pneumo, you have a sudden influx of demand. Do you vaccinate yearlings? There is a lack of clarity whether to do postinfantile vaccinations. We did not plan for postvaccination shots, which led to vaccine stockouts. We need clarity on the policy for giving pneumo in the second year of life.
Alan Hinman: Rights based planning: in November 2002, the GAVI Board said that ‘the global burden of measles deaths is unacceptable. Children have the human right not to die from measles.’
Robert Kezaala chaired the post-lunch sessions.
Balcha Masresha, Outbreaks in Southern Africa in 2010
Within southern Africa, I will focus on 7 countries.
Pre-outbreak coverage was usually 50 to 79 percent.
Countries reviewed: Botswana, Lesotho, Malawi, Namibia, RSA, Swaziland, Zambia, Zimbabwe
We had a 10fold increase in cases in 2010. These 7 countries accounted for 77 percent of all AFRO cases in 2010.
N = 133,412
Malawi had a huge, short outbreak; other countries had protracted outbreaks. Outbreaks appear to have spread from South Africa to Namibia, then other countries; Zambia was the last.
Many cases were aged 5 and above. Most cases were unvaccinated.
Malawi has targeted 5- to 14-year-olds because of the wide age distribution. Among infants, 73 percent of cases were aged 6 to 11 months. In countries with high HIV seroprevalence, vaccination should be considered from six months.
Apostolic religious groups are about 1/3 of the population. They have the lowest usage rate of health services, both for EPI and MCH.
Focus group research done in two provinces.
In Manicaland, some districts set up outreach points especially for the Apostolics, with early morning and late evening service delivery.
There was IEC through radio and TV spots, with SMS messages.
Prime Minister met with the leaders, traditional chiefs, etc.
Parliamentary committee met.
They got 97 percent coverage, in the sampled population, after these interventions.
Contributing factors:
Six to 14 years in Lusaka, six to 59 months in all other provinces of Zambia
6 months to 14 years in all countries except Zambia
Experiences with measles outbreak management in southern Africa:
Lessons learned and way forward:
Immunity gaps: timely conduct of FU SIAs, adequate vaccination in all districts, engaging religious refusals
Johann van den Heever, Measles Outbreak and Response 2009-2011, South Africa
Vaccination introduced in 1975, modifiable in 1980.
Measles vaccination at 9 and 18 months
Control to elimination: 1995
Follow-ups in 2000, 2004, 1007, 2010. Next one due in 2013.
Case based surveillance since 1998
We had an outbreak from 8/2003 through 4/2005.
Official figures on coverage, 94 percent in 2010; WHO/UNICEF, 65 percent, WHO/UNICEF figures never >65 percent.
First clusters of cases in Gauteng, Tshwane and Johannesburg; spread to KZN, Mpumalanga and the rest of the country
High incidence in infants, especially <9 months of age
Outbreak peaked in early 2010,with total cases 18,434, all IgM positive.
Gauteng province most affected, though all provinces had cases.
Outbreak response immunization
Initially limited to schools, followed by district wide school campaign in Tshwane,
Aug-Sept 2009
Gauteng: province wide campaign targeted all from 9 months to 22 years in schools
National SIA April 2010, targeting children aged six months to 15 years.
Outbreak response immunization
Most cases aged six months to 15 years, including many <9 months.
Coverage was highest in under-fives. Only 14 districts achieved 95 percent.
The Gauteng campaign underperformed, with 88 percent coverage.
There were 81 cases from Jan through August 2011.
Many cases in infants.
National responses:
Local response:
Other priorities:
Research questions:
Increase MCV1 and MCV2 coverage, using RED
Minimize dropout to under 10 percent
Additional dose to kids entering hospital
Keep SIAs.
Keep surveillance optimal.
Consider add’l dose as part of school immunization.
Preparedness plans prepared.
Myriam Henkens, Challenges in Measles Outbreak responses: MSF Perspectives
In 2009, we saw outbreaks in 30 African countries, with >1000 reported deaths.
Underreporting of cases and deaths.
As vaccination increases, there is less circulating virus, with changes in age distribution of cases.
Where coverage is low, cases are in younger age groups. In Malawi, cases were in older age groups.
Problem is not vaccine failure, but failure to vaccinate.
Challenges:
MI is victim of its success.
Delays/reluctance to do outbreak responses
Lack of efficient coordination
Lack of rapid funding
Delays in implementing campaigns despite strong international support. In DRC, this meant delays in 2010 and led to the outbreak in 2011.
MSF has done surveillance, treatment, and vaccination
2009: Chad, Ethiopia, DRC, Pakistan, Bangladesh, Nigeria, Sudan, Burkina Faso, with 1.4 million vaccinations
2010: Malawi, Chad, DRC, Ethiopia, Yemen, Zimbabwe, Mozambique, Burundi, RSA, Somalia, Zambia
4.5 million vaccinated
2011: already 3 million vaccinated in DRC alone
We often find inflated vaccination coverage, with biased risk assessment.
There is a weak surveillance system
Outbreaks = ‘failure to vaccinate.’ Late official recognition of outbreak
Outbreak response plan:
Lack of knowledge of the WHO 2009 recs
Lack of knowledge of the usefulness of vaccination in outbreaks
No standard tools for reactive campaigns
Lack of organized technical support, in contrast to polio and meningitis
Outbreak response implemented
Issues:
Outbreak prevention: Maintain the number of susceptibles as low as possible
EPI:
We have reviewed missed opportunities in Congo and C.A.R.
Fixed duration of campaigns does not always permit us to reach desired coverage
Independent coverage surveys
Implementation according to plan (DRC 2010)
What can be done?