Measles Control Program A Global and India ... - The INCLEN Trust

Measles Control Program
A Global and India Update
CHF – INCLEAN Advanced Vaccinology Course September 23, 2011
Edward Hoekstra, MD, MSc, UNICEF
Peter Strebel, MBChB, MPH, WHO

number of cases
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
immunization coverage (%)
Overview
5,000,000
4,500,000
4,000,000
3,500,000
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
Measles global annual reported cases
and MCV coverage, 1980 to 2010
Campaigns
100
90
80
70
60
50
40
30
20
10
0
• Progress
• Challenges
• Opportunities
Number of cases
WHO/UNICEF estimates
2 |

Burden of measles in 2000
• 40 million cases
• Complications:
– 8% pneumonia
– 1:1,000 encephalitis
– 1:10,000 blindness
• 500,000 deaths

Strategy for measles mortality reduction
1. Strong routine immunization > 90%
2. Provide second dose through routine
or campaign
3. Surveillance
4. Introduction of AD syringes

Number of reported cases
vaccination coverage (%)
Reported measles cases and measles
vaccination coverage, 1990 - 2006, Ghana
45,000
2001-2002
campaign
2006
campaign
100
40,000
90
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006*
80
70
60
50
40
30
20
10
0
measles cases
measles vaccination coverage

Global Goals
• Millennium development goal # 4 :
– Reduce child deaths among children by 2/3 by 2015 ( vs. 1990 )
– Measles immunization coverage indicator of access to care
• By 2005
– 50 % reduction in measles deaths ( achieved on time )
• By 2010
– 90 % reduction in measles deaths ( achieved in 5/6 WHO Regions )
• By 2015
– Vaccination coverage: 90 % national level and 80 % in every district
– Reported incidence: < 5 cases of measles per million
– Mortality reduction: 95 % ( vs 2000 )

Measles and Rubella Elimination Goals
by WHO Region, August 2011
Americas, Europe, E. Mediterranean, W. Pacific, Africa have measles elimination goals
Americas and Europe have rubella elimination goals
2015
2015
2000
2010
2015
2012
2020
SEAR: 95% Measles
Mortality Reduction
by 2015

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

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

Progress towards 2015 global
targets

Since 2000, global coverage of
the first dose of measles -
containing vaccine (MCV1) has
increased from 72 % to :
A 74 %
B 78 %
C 85 %
D 89 %

MCV coverage (%)
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Since 2001, 1 st dose coverage up by 12%
120
2015 Target
100
80
60
40
20
0
16 19 20
37 41 47 47 53 62 68 73 69 69 70 71 73 73 71 71 71 72 73 73 74 76 78 81 82 83 84 85
Global AFR AMR EMR
EUR SEAR WPR
12 |
Source: WHO/UNICEF coverage
estimates, 2011 revision. Date of slide:
29 July 2011

Number of MCV doses (in millions)
Scaling-up 2 nd Dose Strategies
Number of doses of measles vaccine administered, by delivery strategy, 2000 - 2010
500
450
400
350
300
Measles Initiative
250
200
1 billion vaccinated
as of July 2011
150
100
50
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
1st routine dose 2nd routine dose SIA
13 |
1 st routine dose: WHO/UNICEF coverage estimates, The World
Population Prospects New York, 2011. 2 nd routine dose: WHO/UNICEF
Joint reporting form, (not all countries report 2 nd dose). SIA dose;: WHO
SIA database, July 2011 (Provisional data)

Number of reported cases
Reported measles cases
down by two-thirds
900000
800000
Reported number of measles cases by WHO Region, 2000-
2010
700000
600000
500000
400000
300000
200000
100000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
AFR AMR EMR EUR SEAR WPR
14 |
Source: Cases from annual Joint Reporting Form
193 WHO Member States, Data as of August 2011

1000
250 500 750
0
Reported cases, thousands
0 400 800 1200 1600 2000
Estimated Global Measles Deaths
have decreased by three-quarters, 2000-2010
76%
2015 Target
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Estimated mortality
Reported cases
15 |
PROVISIONAL ESTIMATES
Source: 2010 WHO/IVB measles model, Sept 2011
Shading indicates uncertainty bounds

% Reduction
Reduction in Estimated Measles Deaths by
WHO Region 2000 to 2010
0
-10
-20
AMR EUR AFR WPR EMR SEAR* India GLOBAL
26%
-30
-40
-50
87% 85% 79% 78%
85%
76%
-60
-70
-80
-90
-100
95% 2015 reduction goal
16 |
* SEAR excluding India
Source: 2010 measles burden model,
WHO/IVB, September 2011

Major causes of mortality among children

Deaths Averted
Measles Deaths Averted, 2000-2010
2,000
1,800
1,600
1,400
1,200
5.0 million deaths
averted (32%)
1,000
800
600
400
10.8 million deaths
averted (68%)
200
-
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Total deaths averted with SIA and improved RI
Total deaths averted by sustaining year 2000 RI coverage
18 |
*Provisional estimates
Based on method of Wolfson et al, Lancet 2007

Challenges

# 1: India
• 134 million children need
vaccination
• High quality
– Coverage >90%
– Immunization safety including
needle disposal
20 |

Estimated Measles Mortality, India
60000
50000
40000
30000
20000
10000
0
Arunachal Pradesh
Manipur
J & K
Tripura
Source: Measles Strategic Planning model
60,000- 100,000 estimated
deaths
Meghalaya
Nagaland
Punjab
Uttarakhand
Haryana
Karnataka
Chattisgarh
Maharashtra
Gujarat
Orissa
Andhra Pradesh
West Bengal
Assam
Jharkhand
Madhya Pradesh
Rajasthan
Bihar
Uttar Pradesh
>80% deaths

MCV1: Coverage of Measles containing vaccine
per DLHS-3; CES-06 for Nagaland
2 nd Dose of Measles vaccine:
State specific delivery strategies
SIA: MCV1 < 80%
RI: MCV1 > 80%

2 nd Dose of
Measles in RI
• 17 states (MCV1 > 80 %)
introduced measles 2 nd
dose in their routine
immunization program
• 45 districts, who
completed measles
campaign in phase -1 are
in process of introducing
2 nd dose in their RI
program

MCV2 introduction through Supplementary
Immunization Activity (SIA) in Phases
Phase 1
• Initiated in November 2010;
• 45 districts from 13 states
o 9 district from Chhattisgarh
o 5 districts from each of the 6
states (Bihar, Jharkhand,
Rajasthan, Madhya Pradesh,
Gujarat & Haryana)
o 1 district from each of the 6
North-East states
• Approximately 14 million target
children 9 months – 10 yrs

Measles SIA plan, India
Phase 1, 45 districts covered
Phase 2 A (144 districts)
Phase 2 B (81 districts)
Phase 3 (91 districts)
Total target- 135 million children
Districts- 361

No. of cases (in thousands)
MCV1 coverage (%)
# 2: Resurgence in Africa
• 4-fold increase since 2008
600,000
500,000
400,000
100
90
80
70
60
• Large outbreaks in Burkina
Faso (2009), S. Africa (2010),
and DRC (2011)
300,000
200,000
100,000
Number of cases
WHO/UNICEF estimates
Administrative coverage
50
40
30
20
• Outbreaks in drought affected
Horn of Africa
– High case-fatality
10
0
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010‡
Year
26 |
Weekly Epidemiological Record
(2011) 86:129-136

# 3: Weak Immunization Systems
Measles 1 st dose coverage among infants, 2010
• 1 st dose:
– 67 Countries have
MCV1 coverage

$ US Million
# 4: Financing is late and unpredictable
180
Measles Initiative Annual Donations, 2001-2011*
160
140
120
100
80
60
40
20
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
*Excluding country contributions
Donations
28 |

Summary
• Measles strategy works
• Achievements
– 1 st dose coverage up to 85%
– 1 billion doses delivered in campaigns
– 2 / 3 reduction in cases
– 3 / 4 reduction in deaths
• Challenges
– Cases and deaths unchanged in past 3 years
29 |

Anne Ray Charitable Trust