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Progress, Challenges, and Lessons
Rubella goals
Progress, Challenges, and Lessons
Learned in Achieving Measles and
Rubella goals
Workshop 4: How to Optimize Workshop 4: How to Optimize Immunization Coverage?
GVIRF, 5 March 2014,
Dr Thomas Cherian , WHO/IVB
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100
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12
MC
V1
Co
ve
rag
e*
(%
)
No
. o
f re
po
rte
d c
ase
sM
illi
on
s
Number of cases MCV1 Coverage*
Measles global annual reported cases and MCV1 coverage*, 1980-2012
2
* MCV1 coverage: coverage with first dose of measles-containing vaccine as estimated by WHO and UNICEF
Campaigns
Measles and Rubella Targets
Global targets by 2015:
Measles mortality reduction of 95% vs. 2000
Measles reported incidence <5 cases per million
Measles vaccination coverage ≥ 90% national and ≥ 80% district
Regional targets:
Measles Elimination goals:
2000 AMRO
2012 WPRO
2015 EURO, EMRO
2020 AFRO, SEARO
Rubella Elimination goals:
2010 – AMRO, 2015 – EURO
Global Vaccine Action Plan (GVAP):
2020 Measles and rubella elimination in 5 WHO regions
3
0.1
1.0
10.0
100.0
1,000.0
Me
asl
es
inci
de
nce
pe
r m
illi
on
po
pu
lati
on
(lo
g
sca
le)
GOAL
GLOBAL
needed
AFR
EMR
EUR
SEAR
WPR
AMR
2015 Goal
Projected 10-
yr trend
Trend to
reach
goal
77% Reduction in Global Measles Incidence, 2000-2012
4
Measles control: the canary in the mine?
• Measles control highlights the importance of many of the goals and objectives of the GVAP
• Population immunity of >93-95% is needed to prevent large outbreaks, requiring homogeneous coverage >95% with 2 doses
• A variety of demand side and supply side factors responsible for immunity gaps and consequent outbreaks
• Data quality is important for monitoring coverage, detecting immunity gaps and taking corrective actions
• These can serve as the basis for operational research questions
Country Experiences
• Ecuador
• France
• UK
• Malawi
• Cambodia
0
50,000
100,000
150,000
200,000
250,000
300,000
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12
0
20
40
60
80
100
Measles cases Rubella cases M coverage MR coverage
MeaslesCatch-up campaigns
*MR in children aged 1 year as countries introduced measles-rubella containing vaccines
Measles Follow-up campaigns
Ro
utin
e in
fan
t vaccin
atio
n c
overa
ge (%
)C
on
firm
ed
cases Rubella speed-up
campaigns
The AmericasMeasles vaccination coverage among children <1 year of age* and reported
measles and rubella cases, 1970-2012
Source: Country reports to FCH-IM/PAHO.
Last endemic measles case
Last endemic rubella case
0
50,000
100,000
150,000
1996
1998
2000
2002
2004
2006
2008
2010
N0 C
ases
Rubella
Measles
Source: Country reports to FCH/IM.
* Includes rubella and measles cases reported to PAHO as of epidemiological week 47/2010.
**Countries that implemented “speed-up” campaigns (1st phase) in women only.
Adolescent and Adult Rubella Vaccination (“Speed-up”) Campaigns , The Americas*
English-speaking
Caribbean
Chile**
Brazil** (2001-02)
Costa Rica
Honduras
Ecuador
El Salvador
Colombia
Nicaragua
Paraguay
Venezuela
Argentina**
Bolivia
Dominican Rep
Peru
Bolivia (2)
Chile (2) Cuba
Guatemala Haiti
Venezuela (2)
Argentina (2)
Brazil (2) Haiti
Mexico
Canada, Cuba, Panama, United
States, UruguayThe commitment of the countries to conduct “speed-up”
campaigns ultimately prevented the reestablishment of endemic
measles virus transmission in the Region.
SIA < 15 Y
1994
SIA < 15 Y
2002
SIA < 15 Y
2011
SIA < 5 Y
1998
SIA < 5 Y
2008SIA 16-39 Y
2004
0
10
20
30
40
50
60
70
80
90
100
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
5,000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Measle
s v
accin
ation c
overa
ge (
%)
Num
ber
of
report
ed m
easle
s c
ases
measles cases measles vaccination coverage
measles vaccination coverage 2nd dose SIA < 15 Y
SIA < 5 Y SIA 16-39 Y
Data source:
measles cases - reported by national authorities to WHO annually
measles vaccination coverage - WHO/UNICEF immunization coverage estimates 1990-2010, as of August 2011;
SIA activities: WHO/EPI supplementary immunization activities database Date of slide: 19 September 2012
Reported measles cases and measles vaccination
coverage, 1990-2012, Ecuador
Distribution of confirmed measles cases by
province, Ecuador, 2011-2012* (N=329)
Source: Ministry of Health, Ecuador: Preliminary data by EW 36/2012
0
5
10
15
20
25
30
35
40
45
50
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25
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52 1 2 3 4 5 6 7 8 9
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N
Tungurahua Pichincha Guayas Cotopaxi ChimborazoPastaza Morona S Manabi Sto. Domingo
EPI WEEK
Sustained outbreak with low incidence
National vaccination campaign (6m – 14y)
Vaccinations at the department level
First case:
7/15/2011
EW/28 Last case
7/12/2012
EW/28
0
20
40
60
80
>1 year 1-4 years 5-14 years 15 and up
Nº
cases
Vaccine No Vaccine
Source: Immunization Program, Ministry of Health in Ecuador* Prelimininary data as of EW12/2012
% cases vaccinated
Total = 2%
Measles cases by age and vaccination
status, Ecuador, 2012
Measles cases by age and vaccination
status, Ecuador, 2012
Coverage range
<80%
80-94%
≥95%
Source: PAHO-WHO/UNICEF Joint Reporting Form, 2011
Recent measles outbreaks suggest that over-
estimation of routine and SIAs coverage may
have occurred?
Percent of municipalities in different
levels of MMR1 vaccination coverage
Latin America, 2010
Measles Vaccination Strategy in France
• 1983 – measles vaccine introduced
• 1986 – MMR at 12m
• 1996 – MMR2 at 3-6 y
• 2005 elimination strategy:
– MMR1 at 12m and MMR2 at 1-2 y
– Catch-up 1d for 1980-91 birth cohorts
– Catch-up 2d for all cohorts since 1991
– Vaccination for health care workers recommended
• 2008 birth cohort by 2 years of age:
– MMR1 = 89%
– MMR2 = 61%
• 1994-1997 birth cohort:
– MMR1 coverage 96% by 11 years
– MMR2 coverage 85% by 15 years
Measles Outbreak in France, 2008-2011N=22,178 cases in 3 epidemic waves incidence: 2.7, 5.2, 25.6 per 100,000
Distribution of MMR 1 coverage and measles
cases, France
MMR1 Coverage at 24 months, 2003-2008 Measles cases and incidence, 2010
Reasons for the French outbreak
• Historically and currently low coverage
– MCV1 and MCV2 <90%
– Some parents choose not to vaccinate
– Not lack of access for financial or socio-cultural reasons
• Catch-up vaccination not fully implemented
– Bad reputation from Hepatitis B school-based catch-up
– Controversy around H1N1 influenza programme
– Health care workers resistant to vaccination
Annual measles notifications & vaccine coverage
England and Wales 1950-2000
MMR vaccine
Measles vaccine
MR campaign
Source: Public Health England
Beginning of the
"Wakefield effect"
MMR coverage at two and five years of age, England 1997/8-2011/12
Annual confirmed cases of measles England and Wales 1996 to 2012
0
500
1000
1500
2000
2500
1996 1998 2000 2002 2004 2006 2008 2010 2012
Localised outbreaks in low
coverage populations
Measles re-established
Distribution of confirmed measles cases in England by year of birth, Q1 2013
05
10152025303540
SIA < 15 Y
1998
SIA < 15 Y
2010
SIA < 5 Y
2002
SIA < 5 Y
2005
SIA < 5 Y
2008
0
10
20
30
40
50
60
70
80
90
100
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
199
1
199
2
199
3
199
4
199
5
199
6
199
7
199
8
199
9
200
0
200
1
200
2
200
3
200
4
200
5
200
6
200
7
200
8
200
9
201
0
201
1
201
2
201
3*
Measle
s v
accin
ation c
overa
ge (
%)
Num
ber
of re
port
ed m
easle
s c
ases
measles cases measles vaccination coverage SIA < 15 Y SIA < 5 Y
99.8% admin
89% admin
120% admin
115% admin
Reported measles cases and measles
vaccination coverage, 1996-2013*, Malawi
21
*2013 data through 10.09.2013
107% admin
Data source:
measles cases - reported by national authorities to WHO annually; monthly reports used for 2013
measles vaccination coverage - WHO/UNICEF immunization coverage estimates 1990-2012, as of July 2013;
SIA activities: WHO/EPI supplementary immunization activities database
1) SIA administrative coverage can be misleading
2) Routine coverage 70%-90% and medium quality
SIAs are insufficient to eliminate measles
Confirmed measles cases by age,
Malawi, 2010 (N=131,725)
Confirmed measles cases by age,
Malawi, 2010 (N=131,725)
0%
5%
10%
15%
20%
25%
30%
35%
9–11 m 12–59 m 5–14 y 15–19 y >20 y
Pro
po
rtio
n o
f ca
ses
pe
r a
ge
gro
up
Adapted from Minetti, Emerg Infect Dis 2013; 19(2):202-9
Reaching Every Community through Measles
Elimination in Cambodia
I. Defining unreached/High Risk Communities (HRC)
– EPI review 2010
II. Mapping HRC & assessing true coverage/risk
through card checking
– Measles SIAs - 2011
III. Targeting HRC for routine EPI improvements
– Linked to introduction of MCV2 - 2012
1. Defining High Risk Communities – 2010
• Unimmunized infants concentrated
in specific high risk communities *
– Remote, mobile, ethnic & urban poor
– Poorly identified by admin coverage
– Community status needs assessment
by immunization card checks
• HRC represent a risk for measles
elimination & all other
immunization goals
* EPI Review 2010
2. Mapping HRC during Measles SIA - 2011
• HRC identified in Health Centre SIA micro plans
– Based on socio economic status (not coverage)
– Include estimate of community health service access
• During SIA - card check of infants 0 – 23 mths in HRC
– 32,500 infants in 2,200 villages checked
– Classified as: up-to-date, not up –to-date, no immunization
• Comprehensive list of 1,600 high risk communities
across Cambodia
3. Using MCV2 to improve HRC coverage
Impact - No measles cases* since late 2011
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100
J F M A M J J A SON D J F M A M J J A S OND J F MA M J J A S ON D J F M A M J J A S ON D J F M A M J J A S O ND J F M AM J J A S O N D J
2007 2008 2009 2010 2011 2012 2013Year
Nu
mb
er
of
me
as
les
ca
se
s
HR
SIA
SIA
SIA
*Lab confirmed measles cases
2012 National discard rate = 6.9/100,000 population
Summary
• Prevention of measles outbreaks demands
homogeneous very high coverage
• Measles outbreaks highlight gaps in coverage
• Pursuit of measles elimination drives service
delivery towards universal access