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PANEL DISCUSSION, MEASLES AND RUBELLA, 2020 AND BEYOND

Monday, 16th of September 2013

Dear All,

Last week saw the global partners to the Measles and Rubella Initiative set out their views on measles eradication in an advocacy meeting held at the national headquarters of the American Red Cross. You will find below my notes from the panel discussion on this subject, with contributions by the GAVI Alliance and each of the five founding members of the Measles and Rubella Initiative.

Those interested in the presentations at the Washington meeting can consult them on the homepage of the M&RI at http://www.measlesrubellainitiative.org/resources/reports/presentations/

Good reading.

Bob Davis

 

Steve Cochi, CDC, introduced the panel discussion: Measles and Rubella, 2020 and Beyond.

Panel members: John Pearman, GAVI Alliance; Lisa Cairns, Centers for Disease Control and Prevention;   Peter Strebel, World Health Organization; Andy Gay, UN Foundation; Myrna Charles American Red Cross; Robert Kezaala, UNICEF.

Statements:

John Pearman, GAVI: you need to know your environment and adapt, looking at GPEI, GF, and GAVI. There are differences, but similarities as well.  MRI has a focus, especially compared to GAVI. Many of the partners are the same. GAVI will have 140 programs by end 2013. We are doing JE, Men A, HPV, IPV. Can countries cope with GAVI?  Country attitude: ‘Bring it on.’ Huge enthusiasm.  Historically, GAVI  provided $100 m in 2005-2006. We support MR SIAs to the tune of  $500 m. this is in addition to MCV2 and ORI support through 2015. What will happen strategically? MR is now firmly in our vaccine portfolio, along with JE and oral cholera vaccine and, likely, malaria and influenza for pregnant women. GAVI is entering its midterm review process, followed by a pledging conference in 2015.

Lisa Cairns, CDC:  [verbatim copy of CDC statement]

First, I would like to start by saying what a marvelous conference I feel this has been.  For years we have spoken of making this conference a true “advocacy” meeting, to recharge the batteries of the M&RI partners and to highlight all of the critical, non-technical work done to reach our goals.  From my perspective, this meeting, more than any other that I have attended, has succeeded in reaching these objectives.  We’ve had thought-provoking presentations on a range of topics, and been challenged by insightful questions from the audience, which has seemed particularly engaged.   We’ve had the new group sessions, which have provided opportunities for all meeting participants to contribute meaningfully to the discussion of important topics that are critical to measles and rubella elimination.  We’ve had a peak into all of the work done by the Communications team, prompting us to reflect on all of the communication avenues which have opened in the last decade, and how these can be exploited.   And through it all, we’ve been watched over by Sam Katz and Lou Cooper, as though by guardian angels.    I’d like to sincerely congratulate Myrna, who, despite concerns from the more traditional among us, stuck to her vision of what this conference could be, and has taken us to new heights.

I’ve been asked to make some comments this afternoon about the future of measles and rubella – to 2020 and beyond.

There is no question that meeting our 2020 goals poses distinct challenges, but this conference has highlighted ways in which these challenges can be approached.   We know that measles and rubella elimination is technically feasible, as has been demonstrated in the region of the Americas, and in selected countries in other parts of the world.  However, to turn this potential into reality I see two main challenges.  The first is creating social demand for vaccination, including addressing vaccine hesitancy and refusal.  The second is reaching consensus in the public health community that measles and rubella elimination and routine immunization strengthening can and should be synergistic, and ensuring that our actions support this synergy.

This meeting has enlarged on the dialogue around how best to generate social demand, and shown the real value of national Red Cross and Red Crescent societies, Lion’s Clubs, members of the Church of Latter Day Saints and other civil societies in reaching into communities in ways that technocrats do not even dream of.  We need to continue this work, expand it, and find ways of supporting it through such approaches as innovative fellowships, and linkages between and among local chapters. 

The European Regional Office of WHO has spent a great deal of time reflecting in a nuanced way on how to reach those who delay or refuse vaccination.  We have seen this become an increasing problem across the globe as disease incidence decreases and complacency sets in, and I suspect this problem will continue to increase.  It behooves all of us who work in program delivery of vaccines to look closely at the work that the European Regional Office has done to address this, and see whether we might tweak this work to apply in our own settings.

In this meeting, there has been a clear acknowledgement that measles and rubella elimination have “two legs” – the routine immunization program and, where necessary, supplementary immunization activities, or SIAs.   This is a perception that, I believe, a few years ago was much less widespread than it currently is – although we still have far to go in ensuring that the routine program capitalizes as much as possible on the existence of measles and rubella elimination goals to strengthen itself, and that measles and rubella elimination rest as much as possible on the routine immunization system.   Increasingly, we see programmatic translation of these concepts – we all heard the discussion this morning around how to use volunteers to move beyond SIAs to strengthening routine and Will Schluter, of the WHO Western Pacific Regional Office was recently describing to me how his measles and rubella colleague in the Office will be focusing on using RED to strengthen routine immunization programs, recognizing how this can contribute to measles elimination.

There has also been allusion in this meeting to the need to ensure that measles and rubella elimination have a place at the table as the polio legacy is discussed.  In fact, I think there is a need to move beyond that, and ensure that the many lessons that have been learned painfully and over many years by the polio eradication program are translated to other immunization settings.  The polio program has a wealth of experience in reaching nomads, using technology, and enhancing accountability – to name just a few areas – that is directly relevant to all those of us who work in immunizations.  Beyond polio, it is clear from this conference and interactions across the globe that there are many immunization “best practices” that deserve further dissemination and replication. We need to find fora to ensure that this is done.

In closing, I would say that, when I think of immunizations, I always think of all the difficulty that life holds which parents long to protect their children from.  In most cases, there is not much that parents can do; but we can do something about vaccine-preventable diseases.  Let’s make sure that all parents have the opportunity to protect their children from measles and congenital rubella syndrome.

Peter Strebel, WHO: three points:

1)      With SEAR coming on board this Friday, we have six regions committed to measles elimination, and two to rubella elimination. We have two great vaccines.

2)      GAVI support for MR introduction. We protect 15 birth cohorts with our under-15 MR campaigns. This is a huge building block in the wall of eradication. Most of the 56 countries not yet giving rubella are GAVI eligible. Between now and 2020, each MR campaign has to be a brick in that wall of immunity.

3)      Next year is the 40^th anniversary of the establishment of EPI. We need to reinforce the synergies. Unlike GPEI, which uses OPV, we need to give measles vaccine parenterally. MRE is an engine for building the program.

The big question is when. Do the six regional resolutions constitute a global commitment? No, not without a WHA resolution. Our D-G says measles can be eradicated. WHO must play a leading role in getting there. We need a WHA resolution, with target date.

The Strategic Advisory Group of Experts, SAGE, wants to see progress towards existing target dates before recommending global eradication. Finally, we need to see what the partners are saying and mobilizing.

Andy Gay, UN Foundation

You’ve heard from three organizations for which immunization is a core activity. UNF was created in 1998 without immunization  as a core activity. Now, immunization accounts for about 70 percent of our giving since our establishment.

UNF is committed to measles eradication through 2022. That’s important. Our Board members have presence in all continents. Koffi Annan has already called for measles eradication. The Board is supportive of what the partners decide. This meeting has shown the power of communications and social mob as a type of communication. This takes us to the country level all the time. This is our biggest challenge. How do we get countries to do the kind of social mob that Amcross and LDS and Lions are doing? This needs expansion. That’s a major challenge. So are government commitments. This meeting has been fabulous to show what can be done. How can we do this on a large scale? You can do microplanning for a campaign; that info can be used for postcampaign RI.

WHO has MLM training. Those are really good. When we do field evaluations, people said they knew, for example, how to do vaccine forecasting. But we need retraining because of staff turnover. We need to build on management structures for routine. I’ll use 2020 as a goal. As we get closer, we can adjust those goals.

Dr. Myrna Charles, American Red Cross: Amcross is one of the five founding partners of the MI (now MRI). Our original goal was to support national RC societies. We also are a leading fund raiser and in advocacy. We are wholeheartedly in support of the MRI.

My personal views, off the cuff: this is an advocacy meeting, but also a technical meeting. Let me use the analogy of Habitat for Humanity. We have technical people of the best, including Sam Katz and Lou Cooper. We also have excellent nontechnical people.

Habitat for Humanity combines the best technical expertise with the work of enthusiastic volunteers to build homes.  We have people in countries endemic for measles. Creating demand is essential to MRI. How can we use nontechnical experts to build demand and support? How can we get to 2020? We need to create demand using, for example, house to house.

There were so many great ideas put out here. I think the GPEI is a model from which we should learn. MRI will be compared to GPEI. We have to build demand for immunizations, all immunizations, for the healthy child. I hope that the advocacy meeting will be a forum for nontechnical expertise, especially those from measles endemic countries.

Dr. Robert Kezaala, UNICEF:

UNICEF’s engagement in the Measles and Rubella Initiative is premised on the Organisation’s committing to child survival: A Promise Renewed (APR). We have the knowledge and technologies to reach the world’s most marginalized children with life-saving interventions. Now is a time to deliver on our long-standing commitment to end preventable child deaths. APR encompasses three principles 

1)      Evidence based country programming

2)      Transparency and mutual accountability

3)      Global communication and social mobilization

 

UNICEF is committed to work within the M&RI partnership to support countries in providing 2 doses of measles vaccination in each country’s option, whether through SIAs or routine EPI.  We see a spectrum from demand creation (Social Mobilization) to impact evaluation (Surveillance). In the middle ground of immunization logistics, cold chain, supervision, planning and training, UNICEF EPI personnel will fully apply themselves to the utmost of their ability. On communication, we have committed to host the M&RI communications person in New York.

 

Regarding vaccine supply, UNICEF plays a key role in vaccine procurement, for self-procuring countries and those supported by GAVI. UNICEF will continue to provide the safest, affordable vaccines. The year 2013 saw challenges in balancing M/MR vaccine demand and supply. UNICEF-Supply Division will host a demand forecast meeting in 1^st week of November to forge smooth links between M/MR vaccine supply and program requirements for 2014.

 

The fourth element is under the Organisation’s Core Commitment to Children in emergencies – where Measles vaccination is specifically spelt out. UNICEF reiterates commitment to the M&RI goals and the points raised by my fellow panelists. The M&RI has demonstrated that there are many achievements beyond the stretch of each individual partner.