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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MC

V1

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(%

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No

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f re

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rte

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ase

sM

illi

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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

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1.0

10.0

100.0

1,000.0

Me

asl

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inci

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pe

r m

illi

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po

pu

lati

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(lo

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sca

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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

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50,000

100,000

150,000

200,000

250,000

300,000

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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

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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

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1,000

1,500

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4,500

5,000

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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

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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

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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

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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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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