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This meeting, hosted by the American Red Cross, brought together 120 participants from governments, partner agencies, and national societies over two days of plenary sessions. To view PowerPoints from the meeting, go tohttp://www.measlesrubellainitiative.org/mi/tools and click 'Presentations.'
My unofficial notes follow.
Good reading.
Bob Davis
ANNUAL MEETING, THE MEASLES AND RUBELLA INITIATIVE,
18-19 SEPTEMBER 2012, AMERICAN RED CROSS HQ, WASHINGTON , DC
This meeting brought together participants over two days of plenary sessions. Summary notes follow.
TUESDAY SESSIONS
DAVID MELTZER, the session chairman, introduced Gail McGovern, CEO of the American Red Cross, who greeted the recipients and saluted our efforts to assure that no child dies of measles or is born with congenital rubella syndrome. The Measles Initiative, renamed the Measles and Rubella Initiative, M&RI, supports routine immunization and SIAs. Our goals are bigger, and donations to the M&RI will go farther, especially with additional funding from the GAVI Alliance.
Our goal is to reduce measles mortality by 95 percent by 2015. Since 2001, we have assisted 80 countries to give 1 billion doses of measles vaccine, leading to a 74 percent reduction in measles mortality. We expect eventually to eradicate both measles and rubella. This will require full community participation. American Red Cross will continue to leverage the millions of volunteers working in the Red Cross/Red Crescent network. They go door to door on behalf of the Initiative. Without strong social mobilization, conquest of these diseases is impossible, as any unreached child provides a potential haven for the viruses.
We are collaborating with Sophie Blackall, the children’s illustrator who worked in DRC this year, witnessing at first hand the challenges of the vaccination campaigns. Her illustrations will be unveiled at a reception tonight and used by volunteers and mothers to get children vaccinated.
If we lose our grip, the virus will come back. I am confident that you will succeed in your mission to eradicate measles and rubella. Let me express my gratitude to the other founding partners, and to all partners, for their support in meeting these goals.
THOMAS FRIEDEN, CDC Director, spoke in a pre-recorded video on the Measles/Rubella Initiative. He stated that the M&RI has averted 10 million deaths to date after investments of $875 million. Where we fail to sustain high coverage, measles will come roaring back. Everything we do should complement and strengthen routine immunization.
VIDEO FROM THE FIVE FOUNDING PARTNERS
A video with clips from the five founding partners outlined the goals and challenges. Seth Berkley, CEO of the GAVI Alliance, confirmed $550 million funding over five years for measles/rubella.
LOUIS COOPER, Rubella and Congenital Rubella Syndrome: Lessons from the USA, 1964-2012
In his keynote address, Dr. Cooper reviewed the progress of rubella control over the last 14 months. Surveillance is often nonexistent, and the disease burden is underestimated.
The rubella project, New York, ’62-’98, was created to develop and test the vaccine. The ’64 rubella pandemic expanded the project to study and serve 1000 children with CRS (congenital rubella syndrome) and thus put faces and costs on this syndrome.
Rubella has no pathognomonic feature; it may be completely subclinical, so surveillance is difficult. No teeth, cataracts, and profound retardation are sometimes seen. We sometimes see low birthweight. We don’t have biennial peaks of rubella as with measles; outbreaks are less predictable. There are >20 possible clinical manifestations of CRS (congenital rubella syndrome). Hearing loss, cardiac signs, retardation, and eye signs including blindness are the commonest clinical manifestations.
Glaucoma is sometimes seen with CRS cataracts. Rubella heart disease is no longer life threatening.
Deafness from rubella is irreversible. Profound retardation is sometimes seen; less commonly, cerebral palsy and autism. In the New York CRS project (1962-1998), six percent of those with CRS had autism.
Deafness and blindness are sometimes seen in the same child. The ’64 pandemic was so great that it generated a federal act to cater to the educational needs of CRS victims.
We found adolescent behavioural problems in those who had CRS in early childhood. First trimester CRS leads to more profound consequences. Some adult victims live in group settings.
Reasserting the rationale of his presentation, Dr Cooper concluded with a discussion of the human and financial costs of CRS. For those in supported housing, costs were $175,000 per patient..
ANNE SCHUCHAT of CDC and the GAVI Board, our session chair, recounted stories of rubella from her experience. She promised that this was going to be a great session.
ROBERT KEZAALA, UNICEF, gave the WHO/UNICEF global overview of measles and rubella.
Global under-five deaths have declined from 12.1 million in 1990 to 7.6 m in 2010, with measles shrinking from 7 percent of all <5 mortality to about 1 percent. Liu et al, The Lancet, 9 June 2012. See also M. van den Ent et al., JID Suppl, July 2011. We expect close to zero measles mortality by 2015. Other interventions associated with measles vaccination: vitamin A, deworming, bednets, OPV, other interventions. The Measles Initiative spearheaded the shift from bednet social marketing strategy to mass distribution.
Since 2006, the mortality and incidence graphs have been almost flat. Although India lagged behind in measles incidence and mortality reductions it has since picked up the pace.
The Pareto-Juran principle: 20 percent of the work (the first 10 and the last 10) consumes 80 percent of your time and resources.
Since 2010, India has picked up.
Measles elimination deadlines by region: 2000 in PAHO (achieved and sustained), 2015 in EURO and EMRO, 2012 in WPRO, 2020 in AFRO. For SEARO, 95 percent mortality reduction by 2015.
Rubella elimination: PAHO has finished the job, EURO has set the elimination date for 2015, while the other regions (AFRO, SEARO, WPRO, EMRO) have not yet set elimination goals.
Challenges:
UNICEF Supply Division walks on water in supplying vaccines.
Summary: achievements, challenges, new strategic plans;
More harambee!
PETER STREBEL, WHO, Roadmap to Achieving Goals
In line with Decade of Vaccine goals:
The Global Vaccine Action Plan (GVAP) was developed and adopted by the World Health Assembly in 2012. The GVAP identifies measurable targets for each goal.
We expect measles elimination by 2015 in 4/6 WHO regions.
There is also a measles and rubella strategic plan, 2012-2020, co-signed by all five agency heads (WHO, UNICEF, CDC, UNF, American Red Cross).
By end 2020, achieve measles and rubella elimination in at least 5/6 WHO regions.
Five strategies are outlined in the measles and rubella strategic plan:
Four guiding principles:
Priorities:
Population immunity:
In 2011, there were 20.1 million infants not immunized, 1/3 in India, 1/3 in 10 other countries.
Root causes of low routine immunization coverage were presented as :
There are 141 countries giving a routine second dose.
MCV2 introduced in Bolivia, Botswana, Djibouti, India, Surinam last year; this year, Bangladesh, Burundi, Cambodia, Eritrea, Gambia, Ghana, S. Tome e Principe, and Zambia.
In 2013, Burkina Faso and Kenya will introduce.
WHO rubella vaccine position paper, July 2011: wide age range campaign for <15s, followed by RCV introduction in routine immunization
GAVI proposes roll-in between 2013 and 2018. In 2013, Cambodia, Cape Verde, Ghana, Indonesia, Kiribati, DPRK, Rwanda, Senegal, Vanuatu, Bangladesh are targeted.
GAVI Board set aside funds at its June 2012 session for outbreak response, to be managed by the Measles/Rubella Initiative.
Criteria: Lab confirmed, outbreak of national or international public health importance; field investigation/risk assessment; government commitment
Summary: We have the road maps, the proven strategies, the immediate priorities. Opportunities; renewed commitment within the M&RI; roll-out of rubella vaccine; new resources and partners
LISA CAIRNS, CDC, The Measles and Rubella Initiative: Preparing for the Next Decade
We need to operationalize our plans.
Joint declaration, 31 January 2001, signed by the five CEOs
Donations, $935 million from 2001 to 2012. Let me acknowledge, especially, contributions from the Anne Ray Charitable Trust.
Our operating procedures are:
We have teleconferences weekly and, for SEAR and EMR, monthly.
Annual meetings: Washington, GMMM, Lab Network
Monitoring and evaluation: progress towards 2015 elimination goals; introduction of MCV second dose and of rubella containing vaccine; country provision of costs; routine immunization and surveillance strengthening activities, including surveillance reviews
We saw, earlier this year, publication of the strategic plan for 2012-2020.
GAVI support for measles & rubella, > $750 million through 2018
GAVI support for outbreak response immunization, ORI, $55 m through M&RI
Lancet has published revised estimates of measles mortality reduction, Simons et al.
Measles & Rubella Initiative Charter under development: legal foundation, governance structure, roles and relationships of founding partners, executive team membership and decision making process
Strategic communication plan to position the M&RI in the coming decade: strengthening the brand, segmenting our audiences, consistent timely info, success and challenges, where we are going, what we need to get there (see presentation by Christine McNab, Wed PM).
Admin structure: Executive Team with reps from five founding partners, decision making through a consensus building process, with input from stakeholders; quarterly and ad hoc teleconferences.
Dedicated M&RI staff: Create three M&RI staff positions housed within the founding partners’ agencies: executive secretary, fund raiser, and a communications specialist. These people will sit in the founding agencies.
Opportunities for Partner and country Input: coordination calls open, as always; creation of M&RI Global Partners’ Group (MGPG), with a rotating chair from a nonfounding partner; meet in conjunction with annual meetings to insure country representation.
External evaluation of M&RI and its recent changes
Are we prepared for coming challenges? What can be done better? Evaluation team with expertise from public health management and global health, representing north/south
Discussion:
Davis: MR to get a handle on measles in 5- to 14-year olds; MSF as possible future partner for outbreak response
Ciro de Quadros: Congratulations to founding partners of MI. This is collective action at its best; congrats on inclusion of rubella. In the Americas, one key component we had was outbreak response. ‘We changed from outbreak response to outbreak prevention.’ This meant constant monitoring of coverage. Outbreak prevention was key to success in the Americas.
Peter Strebel: We do have outbreak preparedness as a main component of our strategy.
Anne Schuchat: There is a split between ORI resources and support to RI.
American Academy of Pediatrics: The 50 percent contribution for ops costs is key. How can we get countries up to 50 percent?
Robert Kezaala: This is a critical issue. This investment is usually predictable. Countries are encouraged to put this into their budgets. We have had some challenges along the way.
Sam Katz: Two things cross my mind. We tend to get compartmentalized. Polio eradication needs to be successful; if we can’t eradicate polio, we cannot move to measles eradication. How do we get 15,000 cases of measles in France? We need to keep measles vaccine on the front line in the US. We need to keep an eye on what is happening in the industrialized countries. Some doctors and nurses have never seen a case of measles and rubella. Communication is key.
WILLIAM MOSS, Johns Hopkins, Priorities in the Measles and Rubella Research Agenda
Key M&RI strategies: fifth of 5 is R & D.
Developing a research agenda needs
Measles landscape analysis for BMGF, December 2008
Effect of measles activities on health system
Improve monitoring by field friendly lab assays and immunisation registries
Improve surveillance on age specific seroprevalence of measles
Commission an MCV market supply study
Key questions:
CDC hosted expert group on research priorities, May 2011
This list was distilled from 137 proposed research questions.
The outcomes from the CDC hosted research meeting were published this year in Vaccine Volume 30, Issue 32, 6 July 2012, Pages 4709–4716.
Research questions from GMMM
Americas: identification of high risk groups, transmission in settings of high vaccine coverage, e.g. Quebec
Europe: Role of adolescents and adults, waning immunity communication strategies, economic analyses
Western Pacific Region: Transmission among infants, adolescents and adults, outbreak response
SAGE Working Group on Measles and Rubella
ToR: identify gaps in essential evidence and program barriers to achieving measles and rubella/CRS (congenital rubella syndrome) elimination targets; present SAGE with proposed areas for research
Approach: define the context for research priority setting; identify questions; define criteria for research priority setting; score listed research questions using criteria; address stakeholder values; refine questions and implementation process; period re-evaluation of research priorities
Summary:
Q and A
Okwo-Bele, WHO: Thanks your presentation. This is an incredible field. Some questions may be relevant to specific periods of the decade. Which priorities could become part of program management? Identification of high risk groups is relevant to all regions. Is there a protocol to identify high risk groups?
William Moss, Johns Hopkins: Critical questions develop and change over time.
Partner Presentations:
BEN FUTRANSKY, Activities of Lions Clubs
Our challenge, from BMGF, is to mobilize $15 million in support of M&RI and 2012 campaigns.
We gave $575,000 to support social mobilization and advocacy activities, including $300,000 BMGF grant
Measles and MR campaigns: Nepal, Cameroon, Uganda, Zambia, Kenya; routine immunization in Madagascar, Ethiopia and Mali; support to PAHO for vaccination in Haiti
Lions do advocacy pre-campaign, kick-off campaigns, volunteering at vaccination posts
We support RI through world immunization week in Ethiopia, involvement in MCH week in Madagascar, and vaccine awareness events in Mali.
We have, to date, received $8.3 m in donations to support SIAs.
We use our internal communications channels to get the message out to the world.
FRED RILEY, LDS Immunization Initiative
LDS joined the Measles Initiative in 2003; from 2003 through 2012, church has contributed $16.6 m. LDS partnered with GAVI from 2011. In 2012, immunization made a major humanitarian initiative within the church.
We now call ourselves ‘immunization.’ We partnered with the GAVI Alliance, contributing >$1 m to GAVI.
We have fielded 63,600 volunteers in 35 countries.
Objectives:
We have worked on SIAs and on new vaccine roll-in.
We are doing a best practices paper on social mobilization.
This year, we have shortened missions from US volunteers, and look forward to local self-sufficiency by LDS congregations overseas.
Future considerations:
We have seen so much overlap and replication of efforts. We want to meet with those involved in social mobilization.
Discussion:
Steve Cochi, CDC: On the Lions Club efforts, you mentioned that one of your priorities is blindness prevention. Taking into account that measles and rubella are main causes of blindness, how has that interacted with your global priority for blindness?
Ben Futransky, Lions: We were challenged by Helen Keller to put blindness first. Blindness prevention is and has been among our priorities. This has made the introduction of MI easier.
Dr Louis Cooper: We sent round our rubella teams in Lions Club vans. The International Pediatric Association is the most recent partner in the M&RI. We want to get our paediatrician members on board. We don’t need overlap and duplication.
Alan Brooks, GAVI: Congratulations to both speakers. We welcome LDS on board. One thing that struck me was the expansiveness of what you were discussing.
Afternoon Sessions, Tuesday, 18 September
HELEN EVANS, GAVI Alliance, GAVI Support to Measles and Rubella
We have a threshold of $1520 GNI per capita, updated annually.
In development:
Country by country approach: introducing more flexibility
Access to acceptable vaccine prices for lower middle income countries
Future decisions: malaria, IPV, cholera, dengue, others
Focus is on strengthening the capacity of integrated health systems to deliver immunization outcomes.
NUVI funding includes 80 centers per target, as a one time only grant to support pre-introduction activities. For campaigns involving new vaccine introduction delivery, 65 cents per target is granted to support pre-introduction activities.
GAVI’s commitments for rubella and measles: $176 m from 2004 through 2008 to support campaigns
Routine second dose, 11 countries supported, 3 fresh applications
MR vaccine, 9 current applicants
GAVI support:
Long term strategy to prevent deaths in six countries with high routine immunization
Bridging: help avoid further measles resurgence before and during the MR vaccine roll out
Outbreak prevention
$55 m for support to measles outbreak response activities
Six countries for preventive SIAs: Afghanistan, Chad, DRC, Ethiopia, Nigeria and Pakistan
This support is in addition to GAVI support for MCV2 and other platforms for health systems strengthening.
GAVI support is predicated on countries’ ability to cover vaccine and ops costs after the initial campaign. Campaign support does not require cofinancing.
GAVI Partners’ forum is planned for 5 to 7 December in Dar es Salaam.
ANDREA GAY, UN Foundation, Funding Update
M&RI annual expenditure, $75 m in 2012. We have had two spikes, one after the tsunami and one from GAVI.
Total expenditure, $935 m from 2001 to 2012
We expect $250 m by 2015, with increasing expenditure each successive year.
Our funding gap, 2013 to 2015, $96 m – to be recalculated before end 2012 to include recently approved GAVI support.
WPRO elimination goal is a major goal for 2012, with major support.
The regional goals are of large importance in M&RI decision making.
Measles eradication investment case: research, costing options will be available in early 2013
GAVI, responding to questions from floor:
We don’t have an approach to fragile countries. We have a paper going to the Board in December on this subject. We looked at DPT3 coverage as a benchmark for GAVI support. We look also at income levels and government stability.
The six countries targeted for measles support are also eligible for cash grants.
Alan Brooks: We want to do the needful to lengthen the interval between successive SIAs. We have guidelines for support to these six countries. For rubella support, GAVI provides vaccines and ops support to the tune of 80 percent. The government must commit to recurrent costs for routine RCV post-campaign. This includes a letter from the finance minister with financial commitments.
WANG XIAOJUN, WHO/WPRO, Working towards Measles Elimination
We had a 69 percent measles case reduction in Jan-June 2012. About half of WPR measles cases came from China in first six months of 2012.
Most countries have at least 1 case per million. Cambodia, Outer Mongolia are at <1 per million.
China saw a 92 percent decline in measles from 2008 through 2011. In Japan, the decline was 96 percent.
Australia has a few imports. Malaysia has ongoing transmission.
Addressing programme challenges
Securing political commitment and resources
Interrupting endemic measles transmission
Closing immunity gaps and preventing outbreaks
Closing surveillance gaps
Ensuring adequate outbreak preparedness and response
The final stage is always the most difficult.
Measles elimination in Western Pacific Region
2003 Regional Committee resolution : Measles eradication and hep B control as two new pillars to strengthen EPI
Goal intended to create momentum for improving RI, especially for the most marginalized populations
Measles virus is always able to seek out any unimmunized child.
Summary
Progress being made in Western Pacific
Interrupting transmission is priority in 2012 and 2013
Intensified efforts needed to identify and close critical gaps in every country and area.
Sustaining achievements made can be more challenging
Effectively synergizing measles elimination and accelerated rubella control activities
Measles elimination provides a great opportunity to promote equity in immunization and health.
LI QUANLE, MoH, China, Progress towards Measles Elimination, China 2012
Each of last three years had a record low incidence rate, down to <1/100,000.
Most cases in coastal and NW provinces.
We have 331 prefectural labs and 31 provincial labs. There is one reference lab.
Challenges:
Challenges:
Outbreak along border with Myanmar; all 23 cases in people from Myanmar.
New policy to enhance EPI services, MoH, July 2012
Strengthen leadership and optimize coordination at all levels
Improve access to vaccines and info about vaccination
Assure adequate subsidy for immunizing doctors and establish an immunization working fund for operations expenses
Strengthen EPI performance through evaluation and incentives
Recommendations:
Q and A:
Lora Shimp, JSI: Pls elaborate what you’re doing based on people centered approach as distinguished from disease centered approach. One issue seen in Bulgaria is that we need to see peoples’ values.
Get away from epidemiological perspective, and look at disease from parents’ values perspective.
Xiaojun Wang, responding: we need to integrate this programme into communities’ values.
Peter Strebel, WHO: No dichotomy. We see a continuum between epidemiology and individuals.
Maya van den Ent, UNICEF: Nigeria is working on this approach. Social scientists accompany epidemiologists on polio case investigations.
Fred Riley, LDS: Historically, social mobilization is regarded as a short term, finite intervention. It needs to be regarded as an infinite process, helping to mobilize people around immunization taken as a whole.
Response to David Sniadack:
In China, Shinxiang SIAs were poorly conducted, with medical officers unmotivated. We asked for better surveillance to detect, especially, importations of polio. All efforts were aimed at polio importations from Pakistan. Since the end of the polio campaign, we have seen sporadic measles cases, without the clustering seen in previous years.
The WPRO Regional Director visited Malaysia this June and saw the Minister to propose change in measles vaccination schedule.
DR PRADEEP HALDAR, Progress on SIAs and MCV2 introduction in India
Measles vaccination was introduced in 1985, with line listing of measles outbreak case introduced in 2005 in selected states.
In 2010, GoI introduced 2nd dose of measles. There were 14 states with measles SIAs, 21 states with MCV2.
The SIAs covered <10 year olds.
All immunizations were from static posts, with no house to house immunization.
Average campaign duration: 12 working days over three weeks; first week was in schools, 2nd and 3rd weeks for non school going children
Target population: 135 m children under 10 years of age, 265 districts in 14 states.
Phase 1, 45 districts
Phase 2, 152 districts
Phase 3, 167 districts
In general, SIA coverage was from 80 to 90 percent, based on coverage surveys. Of 197 districts, most were >90 percent. Admin coverage was 89 percent.
IPC, interpersonal communication, was the most effective form of social mobilization.
All state governments have ordered second dose under routine immunization in campaign districts after six months.
Key partners: WHO and UNICEF
Areas of support:
Summary of MCV2
Under routine immunization, introduced in 21 states/union territories in 2010
Measles SIA done in 197 districts in two phases
167 districts remaining in five states
Case based surveillance
Measles second dose will be universalized in the entire country by 2014.
Measles surveillance is slowly expanding, with line listings.
We have seen huge reductions in outbreaks and measles cases in Phase 1 and 2 districts, with > 90 percent reductions in outbreaks and cases postcampaign.
ARUN THAPA, examples of best practices in SEAR
We looked at Bangladesh, Myanmar and Nepal.
Four countries have introduced rubella vaccine.
Best practices:
Bangladesh:
Best practices, Nepal:
Best practices, Myanmar:
Rebecca Fields and Satish Gupta, using MR SIAs to strengthen routine immunization
SATISH GUPTA, Indian routine immunization and Measles SIA synergies assessment
Assessment: repeatedly measure routine immunization process indicators in 20 selected facilities before, during and after Phase 1 of the SIA
We started in Jharkhand state, using surveyors from UNICEF, MCHIP, NPSP and CDC., checking the same 20 facilities in January, March and November 2011.
Of the 20 indicators, the eight underperformers from baseline all improved. However, the 11 high baseline performers did not greatly improve.
There were five indicators which were and remained unsatisfactory.
Recommendations:
Some RI indicators may be easier to impact by SIAs
Other indicators may be too constrained
Synergy focal points are needed throughout the SIA process.
REBECCA FIELDS, JSI, Using Measles SIAs to Strengthen Routine Immunization
The LSHTM study on impact of measles elimination on health systems showed impact in countries with very good and very weak systems. In countries with intermediate performance, there may be an adverse impact.
WHO: you need special attention to assure that MI activities strengthen RI and surveillance.
We looked at Lao PDR and Bihar State in 2011. We also reviewed best practices work from Ethiopia.
Processes outlined in country guidance module:
1 communicate and advocate for RI strengthening
2. assign clear responsibilities before/during/after SIAs
3. identify challenges to routine immunization that SIAs can help address
4. prioritize certain activities base don feasibility, potential contribution, resources needed
5. plan and budget for routine immunization strengthening activities
6. monitor and evaluate to build accountability for this component of SIA
Use at least one indicator describing a program area which a country selects for using SIAs to strengthen RI.
What’s needed to implement the above?
Why use SIAs to strengthen routine immunization?
Because routine immunization is essential to achieving high levels of pop immunity. Adding this component incurs marginal costs but can lead to specific, last improvements in routine immunization, thereby helping to achieve elimination targets.
WEDNESDAY SESSIONS
BALCHA MASRESHA, Priorities to Reach the 2020 Measles Elimination Goal
We are working with pre-elimination targets, and have done so since 2008.
Most 2010 cases were from Malawi; most 2011 cases were from DRC. We had spikes of incidence in 2009, 2010 and 2011. Cases declared approached 200,000 in 2010 and 2011.
Only 16/46 countries had 90 percent coverage in 2009, 2010 and 2011. There were 8 countries with coverage <60 percent last year.
By end 2015, 40 countries are expected to be giving MCV2. Burundi and Zambia will be introducing MCV2 this year. Rwanda and Burkina Faso are applying for next year.
SIAs reached 17 m in 10 countries in 2012 to date. We will reach an additional 22.3 million by end 2012 in five more countries; three of these cover a wide age group.
Admin coverage for SIAs was under 95 percent except in Mali, Nigeria, Angola, CAR, Eritrea and Gabon. BF, Chad, Namibia, Benin, Mozambique and STP had the highest SIA coverage.
Most countries failed to reach 50 percent, i.e. $0.32 per child.
Ghana has exceeded 80 percent RI coverage since 2005, with low incidence in all years.
Kenya has stalled at 80 percent, with declining routine coverage and thousands of cases in 2011/2012.
Nigeria has rising coverage, but cases remain high.
DRC had >130,000 cases in 2011, with delayed SIA implementation. Huge Kinshasa outbreak in 2005 just before the planned SIA. This year, we are registering 1500 cases per week, with cases in 80 health zones.
We get 2.9 cases of rash & fever/100,000 in reporting countries. Incidence of confirmed cases, 1.6 per 100,000 in 2011.
In 56 percent of countries do we have <5 cases per million by end 2011.
Main challenges:
Priorities for the region:
Opportunities:
Effort to realign HSS support, with focus on CAR, Chad, DRC, Ethiopia, Guinea-Bissau, Guinea, Nigeria, Niger, Uganda, Zambia
GAVI support to SIAs in Ethiopia, Nigeria and DRC in 2013, MR SIAs, and outbreak response
We are honored to have the support of the International Pediatric Association.
Discussion
Why better cofinancing in 2012? Balcha: Because of ministers’ discussions on this topic at WHO regional committee meeting. Also, we have had nontraditional partners coming to the table.
Baguma: You mentioned population movements, specifically Kenya. We are getting many visitors in Uganda from DRC. What strategies have you put in place to address this issue?
Balcha: The measles eradication plans being prepared by countries are expected to address this issue. Refugees are vaccinated on entry.
DINA PFEIFER, Outbreaks in Europe
We have 53 member states in 12 time zones, with four official languages.
MCV2 was rolled in between 1968 and 2004 by different countries.
Much progress towards 2010 regional elimination goal; over ½ of member states did not achieve measles elimination by 2010. The target was moved from 2010 to 2015.
We missed a window of opportunity to pick up on the pockets of susceptible. We had outbreaks in Turkey, Kazakhstan, Ukraine, Germany, UK, western Europe, with interruption of transmission in 2007 to 2009; then outbreaks in Italy, Germany, Switzerland. The last 7 years have had cases in Bulgaria, France, again in Ukraine. There are 10 countries contributing to 90 percent of all cases. Most cases, 52.2 percent, are aged 10 or older.
Whys and wherefores:
Controversies:
Understanding the diseases/prevention:
Mortality rate is not much different from in the 1960s.
Medical care is not substantially changing the outcomes of measles disease.
Changes of medical education methodology mid-1980s and today’s curricula; you don’t see measles cases, you don’t learn the disease.
Immunization gaps in immunizing small children; novel strategies in unimmunized adults
Subpopulations, including health care workers, migratory populations
Surveillance: Case based reporting, case investigation and lab confirmation, monitoring by sub national strata, reporting quality and timeliness
On rubella, we don’t have good case based data. Case based reporting is critical for elimination. We have had outbreaks of rubella in Russia and Rumania.
European Immunization Week is one way to address communication issues. We have had online chats with health professionals.
Draft framework for measles/rubella elimination finalized in 2011; regional verification commission established in January 2012.
ROBERT KEZAALA, UNICEF, Measles Vaccination in Emergency Settings
UNICEF booklet, Core commitments for Children in Emergencies, should always be used as a reference point whenever advocacy for rmesles immunization is required in any emergency setting.
UNICEF core commitments include vaccination of all <5s and vitamin A supplementation.
Recent measles vaccination supply in emergencies, 2011: Libya, DRC, Burkina Faso, Kenya, Guinea, South Sudan, Tunisia, Mauritania, Ethiopia, Ivory Coast, Pakistan
Mali’s problem is partly spillover from Libya, partly their civil conflict. They have missed three rounds of OPV SIAs in conflict zones. Interagency response for health & other sectors; 278,000 kids targeted for measles shots. No security problems for vaccinators, and no cases of severe AEFI (adverse events following immunization). Coverage of 91 percent among <15s.
Among outcomes: Health centers were revitalized, way paved for more humanitarian interventions in the future. Staff trained to assist in upcoming polio and tetanus campaigns
Horn of Africa: Severe drought in the Horn; Somali conflict precipitated a crisis. There were 16,000 cases in Somalia, 78 percent <5. South and central Somalia was inaccessible for Child Health Days.
UNICEF secured $406 m for Horn of African appeal, with 5 million doses of MCV stocked in Nairobi.
In Kenya, nursing students were recruited to vaccinate the children. Ethiopia did 105 districts. UNICEF mobilized 248 personnel from ESAR countries to respond to the emergency.
Conclusion
Global documentation is suboptimal and hard to capture.
Small scale activities take place over time.
Resource mobilization for vaccination is easier, especially with high level visits to highlight the urgency and plight of children.
Grey areas between outbreak response immunization and preventive SIAs.
Discussion:
How do you get people to see the benefits of vaccination?
Dina Pfeifer: We have to target whole populations and medical professionals across the whole European region. The poster and the leaflet will not make the day. In Ukraine, we have a dire situation. The vaccine campaign did not take off because of an unrelated death.
Some countries are doing operational research. We have strategies being taken to the regional level. This covers m/r, hep A, pertussis, and influenza.
Robert Kezaala: We are still in the honeymoon period in Africa. People come in large numbers because they remember measles. IDPs and refugees are an easy population to vaccinate. Coverage is high in the camps. Going towards elimination, this might be tough. Polio has shown that as the disease declines, so does the interest of public powers. To reach the last child is not seen as a priority.
David Sniadack: The common theme is the importance of measles virus importations. Look at the communications efforts during the last European Cup, including vaccination of soccer players. Individuals have the responsibility to prevent deaths in other countries.
Dina Pfeifer: It is the resident population which counts. From the communications side, we don’t stress the importations. ‘Someone else is guilty’ if we discuss importations. Assigning blame is not useful.
Louis Cooper: When we met in Rome and looked at the issue of measles across countries, I sensed no feeling of outrage. In the western hemisphere, we’d have had a lot of media attention and public outrage.
Dina Pfeifer: We have had measles cases among medical professionals. This has helped us. Medical opinion is highly independent. There was a stunning vaccine opponent in my children’s secondary school.
KATRI KONTIO, PAHO, Verification of Measles and rubella elimination in the Americas, challenges in Ecuador and Haiti
She speaks on behalf of Carlos Castillo-Solorzano.
How to maintain regional measles/rubella elimination?
We have gone 12 years without endemic measles transmission, and three years without rubella endemic virus transmission.
We have had many measles importations, with 174 in 2011.
The lab has a role to play in the context of low incidence, with two blood samples.
Arizona import in 2008, with 800,000 USD spent containing 7 cases in health care facilities. With 34 cases in India in 2005, an outbreak of 34 cost 267,000 to suppress.
Protecting society is very expensive, even when there is only one case in the outbreak.
There were 329 cases of measles in Ecuador, with late notification of the first cases.
Age specific attack rates in the Ecuador outbreak were as high as 28 per 100,000 in younger age groups.
Did we overestimate routine vaccination coverage in Ecuador national figures masked heterogeneity of coverage in the provinces.
We saw 94 and 92 percent in MMR1 and MMR2 respectively.
Most of those affected were indigenous, often mobile. The zones affected were rural. They were street vendors working in overcrowded conditions, with little access to culturally sensitive health services.
There were overcrowded inpatient wards.
To provide evidence of not having measles virus circulation, collected specimens should be collected within the last three months after detection of the last case.
They did retrospective analysis of serum samples taken from suspected dengue cases.
Challenges:
Communications between epidemiology and lab teams
Haiti had its last measles cases in 2001, last rubella case in 2006.
Surveillance was of spotty quality.
Immunization coverage shows general figures above 90 percent. The cMYP for 2011 to 2015 calls for strengthening of RI.
Needed:
Rapid assessments of surveillance systems
Active case searches
Involve private sector in disease surveillance
On the programme side, 95 percent coverage needed. High quality follow-up vaccination campaigns.
SUSAN REEF, CDC, Monitoring the Impact of Rubella
The goal of rubella vaccination is to prevent congenital rubella infection
Surveillance is to document the impact and, as needed, modify your strategy.
Field and lab surveillance should be integrated with measles in a single surveillance system. You need molecular epidemiology and monitoring vaccination coverage.
Up to half of mothers who give birth to infants with CRS (congenital rubella syndrome) present without rash illness, or subclinical, not identified as rubella cases.
England and Wales started with girls, went over to MMR vaccine from 1988. Vaccination of girls produced modest declines in CRS. In the US, we gave rubella from 1969, with cases seen in adolescents and young adults because of poor choice of age range for vaccination. In 1977, targeting of adolescents, adults, colleges, teachers, and military. By 2004, expert panel concluded that rubella virus is no longer endemic.
Molecular epidemiology determines the endemic strain in each country so as to identify the origin of the virus, especially the imports. We had two cases in 2012 this year, both imports from Africa.
There are four common rubella virus genotypes, based on lab work from 2000 to 2012.
Our lab samples are scanty, less than 10 percent of what we have in the measles lab database.
Summary:
Q and A:
Dr. Cooper:
Rubella can lead to encephalitis.
Many congenital cataracts are attributable to CRS.
Sue Reef: Agreed. We can look at cataract prevalence as an indicator of program success.
[Words of farewell to Athalia Christie, Steve Sosler, David Featherstone, and Ed Hoekstra, from Andy Gay and Peter Strebel]
Maya van den Ent, Reaching Missed Children: Lessons learned from Polio
During routine and SIAs, we missed the same kids. See Hellinger et al., BWHO, 2012
Where do we miss the kids?
Polio sanctuaries, such as Chad, DRC, and Angola
2.7 m children are polio zero dose. IMB report, June 2012
Vaccination status of nonpolio AFP cases is a good clue; very high figure in Angola
Risk profiling in Nigeria: rural 52 percent, illiterate; farmers, with some nomads
We’re rapid expanding our use of risk profiling and special investigations better to understand exactly who is most at risk.
Social and operations reasons, see www.polioinfo.org
Overt refusals are not the main reason for missing children in any country. ‘Child absent’ is the main reason.
Can we increase demand from parents so that they make sure their children are immunized?
Can we innovate to bring the vaccines to where the children are, e.g., markets?
We need data driven approach to communications and social mobilization. We use independent monitoring data and special surveys, e.g., LQAS and convenience surveys.
Rapid social research using focus group discussions and other qualitative techniques for revising communication and operational strategies
In Pakistan, parental awareness of SIAs is low.
Overt refusals in Pakistan are limited to small pockets. Refusals are converted in a majority of cases.
Take home messages:
Integrated communication action:
What measles can learn from polio:
Q and A:
Lora Shimp: It has taken GPEI a long time to learn these lessons: we have so much campaign data, with independent monitoring data showing 5 to 6 percent refusals. You can have about a 30 percent attrition rate with your volunteers. Literacy is an issue. There is increasing illiteracy among marginalized populations (Bulgaria). Importance of reaching 9- to 24-month-olds.
Satish Gupta: we do baby tracking of newborns in some of our larger states. This means postneonatal follow-up to make sure that kids get their shots on time.
One participant: In China, there was much house to house mobilization to reach remote populations in 2010.
One participant: Most of the polio interventions were built around campaigns. We need continuous communications; drum beating all the time.
Balcha: In Ethiopia, we insisted on KAP assessment of HW’s understanding. Many HWs did not understand the value of measles SIAs.
JIM GOODSON ET AL., Competence and Sustainable Global Lab Surveillance for Measles and Rubella
We have 181 countries with lab support to case based surveillance; 12 still lacking.
Multiple layers in the WHO lab network, similar to GPEI.
Three global reference labs: Atlanta, London, Japan. Six regional reference labs, one in each region.
Strengths of the Lab Net Structure
Major activities:
Training and capacity building:
Workshops
Multifunctional
Continual process:
Measles virus: nomenclature update, 2 March 2012, published in WER
Rubella virus nomenclature update to be published in late 2012 or early 2013
R & D: Oral fluid samples, trials in Zimbabwe, Malawi, Kenya, Benin, Ivory Coast
One criterion for elimination is the absence of an endemic genotype for one year
As with polio, measles lab can generate dendograms.
WHO website now publishes measles genotypes; B3 predominates in Africa.
Challenges:
Financial support
Expansion of case based surveillance
Staff turnover
Need to maintain and expand sequence databases
Better use of data by lining epi and lab data in Africa
Expansion in India
Summary:
KIMBERLY THOMPSON, Measles and Rubella Investment Cases: Stakeholder Analysis and Update
Measles & Rubella Strategic Plan, 2012-2020
‘With strong partnership, resource and political will, we can, and must work together to achieve and maintain the elimination of measles, rubella and CRS globally.’
Global Vaccine Action Plan (GVAP)
Developing the investment case:
Key questions:
Focus on characterization of risks, costs and benefits:
What path do we expect based on the current situation, noting that we are currently not on track to meet existing goals?
What is required to get on track to meet existing goals?
What is required to meet the GVAP goals?
Is eradication better than control?
What is the impact of the speed of eradication effort?
Cost modelling
Insights from prior studies
Insights for prior studies:
Key gaps:
Disease modelling
Recent studies suggest missed global measles goal, with 74 percent reduction (Simons 2012). Regional assessments suggest not on track to achieve al 2015 measles and rubella goals. Lessons learning from GPEI: Slowly approaching the unknown threshold required to stop transmission is not ideal; Use models with coverage and serological studies to manage population immunity such that we expect no cases.
Existing models for global analyses focus on measles, need dynamic model that helps countries model their population immunity
Preliminary insights:
Routine immunizationis sufficient to stop transmission: outbreak reveals problems with population immunity AFTER it is too late; places with lowest quality RI needs greater coordination to manage population immunity, but poor RI is partly the consequence/reflection of poor coordination.
Prevention: Requires ongoing management of population immunity, which we cannot easily observed; often undervalued, no credit for avoiding bad outcomes
Perceptions matter
Elimination goals
Easier to achieve if immunization starts big and fast
But implementation often easier to start slow with phase in and pursue gradual creep toward threshold and better to make slow progress
Outbreaks are expensive
Elimination of rubella is a good option, given measles goal
We are all in this together.
MR viruses spread quickly and create outbreaks
Stakeholder commitments an expectation v important
Ultimately achieving the vision will require all countries to shift into prevention mode
Do we need to finish polio first, or can we finds way to help the countries with the biggest challenges to go farther much faster?
Road ahead
We invite your input on this PowerPoint.
We will soon request your input on
Q and A
Dr Cooper: Will rubella treatment costs rise with improvements in medical care in Asia and Africa?
K. Thompson: We factor in costs of medical care costs. We are figuring out how to factor in costs for rubella treatment.
AFTERNOON SESSIONS, WEDNESDAY, 19 SEPTEMBER
Communications and Public Engagement: David Meltzer chaired these sessions.
CHRISTINE MCNAB, Rollout of New Communication Plan
Scope and role of communications:
Advocacy, public information, social mobilization, programme communication/community engagement
I will speak mostly about advocacy and public information.
Core: 1 dedicated consultant, Christine McNab
Five founding partner communications officers, 10 percent
Plans to hire a full time specialist on collaboration/amplification through partners, Lions, GAVI, American Academy of Pediatrics, BMGF
Plus massive international network of UNICEF, WHO, IFRC and other partners IF we use it.
New strategic plan, launched in Geneva on 24 April 2012 with new Lancet morality figures; also available on I-pad.
New logo, with and without strapline
Measles & Rubella Initiative
New branding guidelines: promote consistent visibility for M&RI and partners
News releases:
Advocacy achievements: missions to Sierra Leone, Kenya, Niger
Advocacy priority: WPR measles elimination advocacy and communications
Challenges: traditional media interest in global health is sliding.
Positioning a ‘single issue’ program
Ongoing perception of low threat of measles
Low understanding of rubella and CRS (congenital rubella syndrome)
Solutions and opportunities:
Reach audiences through social media and other e channels
Emphasis on progress/results for GVAP, child survival, MDG4, equity
Use North American, Europe outbreaks to show threats
Document, promote story of CRS (congenital rubella syndrome)
New communications strategy
Positioning the M&R Initiative
Position the Initiative to Strategic Plan
2. Monitor disease and evaluate efforts
3. outbreak and case management – profile outbreak prevention; promote case management
4. communication and engagement: advocate for larger investment; finalize best practice social mobilization guide for m and r and routine immunization; consider innovation stream for technology and community engagement; resistance to MMR vaccination; need to tackle in a more coordinated manner
5. R & D: publish annual R & D for M & R report
CALENDAR OF COMING EVENTS
Dec: 2012: Measles mortality figures
Jan 2013: SAGE findings on regional progress
April 2013: World Immunization Week
Cost benefits/eradication (when ready)
Outbreaks: Ethiopia, DRC, India, Pakistan
2012-2013, SIAs, MR introductions
Sept 2013: SEAR Regional Committee Meeting
Sept 2013: UN MDG meeting
Summary:
Invest in communications at all levels
Communications is changing. we need to be there
M & R I has something to say. Let’s think big.
You have a role.
CHRISTINE MCNAB, Mass Measles Campaign, Myanmar
Targeted, 6.4 million children 9 to 59 months
Launch with health minister
Social mobilization through NGOs, FBOs, CSOs
Grass roots level movement with IPC training
Mass media
Campaign logo
Banners at every fixed post
Invitation cards
Ensure invitations are sent to every single household in country by household visits 3-4 days before the campaign
Committee meetings chaired by health minister
9 international monitors
Monitoring visits organized by WHO and UNICEF
Flip charts used nationwide, resulting in standardized training at all levels
Post organization
High turnout of community for vaccination
Well organized, orderly flow of children and caretakers
Cold chain and injection safety
Adequate logistics
Well maintained cold chain
Some intramuscular injections reported
Correct use of safety boxes
Some challenges with temperature, despite good use of icepacks. VVMs showed no cold chain problems.
AEFI (adverse events following immunization) Management: All health workers trained
Excellent partnership between midwives, NGOs, INGOs and village leaders
Info sources: invitation cards were most often cited.
Around 5402 houses visited; 6000 kids checked randomly. Coverage, 97 percent.
Info sources:
Miking 2141
Cards 4027
Gaps still persist in high age group and some outbreak may occur in near future.
Community trust in PEI is very high.
Q and A
Robert Davis: the use of invitation cards requires more documentation, from Myanmar and elsewhere.
Peter Strebel: When you vaccinate zero dose kids, do you record it on the child’s vaccination card?
Christine McNab: Not sure. They had master lists of those vaccinated, but many kids came without cards.
David Meltzer: WHO described this initiative as a stunning success. Why don’t we brag a little? When we have outbreaks, why don’t we scare a little? Proper planning and execution are essential to the 97 percent coverage achieved.
ROBERT DAVIS, American Red Cross, House to House Mobilization for Successful Measles SIAs: Sitrep after Five Years in Africa
Since 2001, the partners have adopted house to house vaccination for polio campaigns. This may be one of the reasons why we now have only three polio endemic countries remaining in the world.
Over the last five years, the American Red Cross has supported house to house social mobilization in 10 African countries: Benin, Burundi, C.A.R., Kenya, Mali, Mozambique, Namibia, Senegal, Tanzania, and Uganda. The use of preregistration of eligible children, defaulter follow-up, and such add-ons as megaphones has been associated with higher coverage than in non-intervention areas. Differences in campaign coverage ranged from 6 to 12 percent higher than in those without house to house intervention.
Traditional mass media approaches may miss the least readily accessible populations, even in urban areas. Herd immunity is more easily achievable when we systematically reach populations who lack, e.g., radio and TV.
American Red Cross & partners need to consult on how best to apply lessons learned from SIAs to routine immunization. A network of volunteers already exists to sensitize the community. Possible modalities include birth registration and follow-up; periodic village canvasses; linkages to health facilities for defaulter follow-up.
If house to house mobilization goes global with measles, as with polio, then more resources and partners will be needed. You can’t go global on a shoestring, and you can’t do it with 1 or 2 partners, as at present. TIf H2H mobilization goes global with measles, as with polio, then more resources and partners will be needed. You can’t go global on a shoestring, and you can’t do it with 1 or 2 partners, as at present.
The decision whether to go global with house to house should predate any WHA resolution. We do not need the long gap before implementation which we saw with introduction of the polio house to house policy, 13 years after the WHA resolution of 1988.
BERTHA MLAY, Tanzania Red Cross, the Experience on Social Mobilization for the Integrated Measles Campaign of 2011
We have 16,000 volunteers countrywide.
[graph with coverage and measles cases by year from 2002]
We covered Mara, Arusha, Tabora and Dar es Salaam, with support from American Red Cross and UNICEF. TRCS is a member of the ICC.
We chose regions based on poor access, low coverage, high risk areas, reported measles cases.
Strategies:
Challenges: late arrival/shortage of vaccines at the posts
Delays in funds flows
Change of vaccination posts at the last minute
Lessons learned:
Alignment of TRCS plan with govt plan was key for ownership and avoidance of duplication.
Megaphones helped to reach the unreached.
Strong partnerships and good coordination contributed to success.
Use of multiple interventions boost their morale and commitment.
Social mobilization as a behaviour change activity needs time and through planning.
Use of volunteers from the same community minimizes costs.
Use of volunteer registration list at immunization post facilitated identification and follow-up of no show children.
Enhancement of working relationship with other measles partners is important.
TRCS to focus on social mobilization for RI and not only campaign.
Tanzania will introduce pneumococcal and rotavirus vaccines from Jan 2013.
BAGUMA BILDAD, Uganda Red Cross, URCS Mass Measles Social mobilization Campaign
Major aim: To increase the number of children vaccinated, regardless of vaccination status and disease history
URCS covered only Kampala and 13 other districts out of 112.
Joint planning with MoH and district health offices
There were 1.23 million children registered, permitting basic information on defaulters.
URCS assisted and supported campaign activities at sites in over 5700 vaccination posts.
URCS deployed 17 vehicles for logistics.
Challenges:
Some households did not cooperate because of misinformation by some local leaders who were not paid.
In Kampala, there were delays and posts closed.
Not enough days in Kampala.
Non-payment of vaccinators in Kampala; campaign was affected negatively.
Poor microplanning in Kampala
Withholding of tally sheets by vaccinators due to no payment
Lessons learned:
Social mobilization should be started a month earlier than the campaign.
Involvement of both parents
Use of the media and house to house helped to reach the unreached
Close collaboration with all partners involved in the SIA
Partners need to plan support to the districts
Kampala city alone needs a minimum of 1000 volunteers for any future campaign if all households are to be reached with campaign messages.
Q and A:
Using house to house between campaigns: how would that work? Would it be ongoing? Stand alone?
Bertha Mlay, Tanzania Red Cross: Social mobilization during campaigns starts 2 weeks before the campaign. Other partners use radio and TV. We did for five days before the campaign and during the campaign. We left some written materials, we think they will continue reading. This will help them with routine immunization postcampaign. Social mobilization is a continuous process; there is a need to work on routine immunization.
Baguma Bildad, Uganda Red Cross: My view is that you can increase RI if you have community volunteers who go to the mothers even if there is no campaign. This can be done with, e.g. Monthly visits.
Christine McNab: Who covered the other districts? How do you join up with the other partners?
Bertha: All partners work on the social mobilization. There was a focus on areas with measles cases and hard to reach areas.
David Meltzer: Coordination is key; importance of mobilizing communities; the Red Cross emblem raises awareness itself; it opens doors by itself. Training them and having them speak to their neighbors. We need both cold chain and human chains to succeed.
Dr. Cooper spoke on behalf of the International Pediatric Association and the American Pediatric Association. We have our website talking about M& R I. GAVI has given us a small grant to reinforce the capacity of national societies to support M&RI.
STEVE COCHI, Concluding Thoughts
Yes, we can do it, together. We are celebrating our 12th year of existence. The first 10 years of our partnership has been 9.6 m deaths prevented, with 74 percent reduction in deaths from 2000 to 2010. When we look at the decline in child mortality, measles is between ¼ and 1/5 of the overall decline in U5MR. I want to thank you and the health workers and volunteers in the field.
We heard that the initiative is moving into adolescence. We are maturing as an initiative. The teenager believes that anything is possible. I have seen in this room a problem solving, forward looking spirit. We are now the measles and rubella partnership. We are formalizing this game change. Thanks to Louis Cooper for sharing his 50 years of experience on rubella. Stanley Plotkin and Sam Katz, two pioneers in vaccine development, are in the room with us today.
We have renewed our commitments to each other. We welcome reports from LDS and Lions on their expanding commitments. We welcome recent GAVI Board decisions to focus on six key countries. We had Rebecca Fields and Satish Gupta on using SIAs to strengthen RI. We have the global Action Plan.
Let us not forget equity. Measles is the canary in the coal mine. Measles and rubella vaccines are a best buy. I wish you all safe travels. Return next year to share our experiences. Remember that 100,000 newborns are born with CRS (congenital rubella syndrome) each year.