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Monday, 11th of March 2013 Print


Biological Feasibility of Measles Eradication

  1. 1.   William J. Moss1 and
  2. 2.   Peter Strebel2 

+ Author Affiliations

  1. 1.    1Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
  2. 2.    2World Health Organization, Geneva, Switzerland
  3. Correspondence: William J. Moss, MD, MPH, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 (wmoss@jhsph.edu).


Recent progress in reducing global measles mortality has renewed interest in measles eradication. Three biological criteria are deemed important for disease eradication: (1) humans are the sole pathogen reservoir; (2) accurate diagnostic tests exist; and (3) an effective, practical intervention is available at reasonable cost. Interruption of transmission in large geographical areas for prolonged periods further supports the feasibility of eradication. Measles is thought by many experts to meet these criteria: no nonhuman reservoir is known to exist, accurate diagnostic tests are available, and attenuated measles vaccines are effective and immunogenic. Measles has been eliminated in large geographical areas, including the Americas. Measles eradication is biologically feasible. The challenges for measles eradication will be logistical, political, and financial.


Comparing Measles With Previous Eradication Programs: Enabling and Constraining Factors

  1. 1.   Robert Keegan1,
  2. 2.   Alya Dabbagh2,
  3. 3.   Peter M. Strebel2 and
  4. 4.   Stephen L. Cochi3 

+ Author Affiliations

  1. 1.    1Independent consultant, Atlanta, Georgia
  2. 2.    2Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
  3. 3.    3Global Immunization Division, Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, Georgia
  4. Correspondence: Peter M. Strebel, MBChB, MPH, IVB/EPI, World Health Organization, 20 Ave Appia, CH-1211 Geneva 27, Switzerland (strebelp@who.int).


Background. Five major disease eradication  initiatives were initiated during the second half of the 20th century. The enabling and constraining factors—political, social, economic, and other—for these previous and current eradication programs can inform decision making regarding a proposed measles eradication initiative.

Methods.We reviewed the literature on the  yaws, malaria, smallpox, guinea worm, and polio eradication programs and compared enabling and constraining factors for each of these programs with the same factors as they relate to a possible measles eradication initiative.

Results. A potential measles eradication  program would enjoy distinct advantages in comparison with earlier eradication programs, including strong political and societal support, economic analyses demonstrating a high level of cost-effectiveness, and a rigorous upfront process, compared with previous eradication initiatives, that has validated the feasibility of achieving measles eradication. However, increasing population density, urbanization, and wars/civil conflicts will pose serious challenges.

Conclusions. Measles eradication will be  very challenging but probably not as difficult to achieve as polio eradication. Measles eradication should be undertaken only if the commitments and resources will be adequate to meet the political, social, economic, and technical challenges.



Is There Enough Vaccine to Eradicate Measles? An Integrated Analysis of Measles-Containing Vaccine Supply and Demand

  1. 1.   Graegar Smith1,
  2. 2.   Joshua Michelson1,
  3. 3.   Rohit Singh1,
  4. 4.   Alya Dabbagh2,
  5. 5.   Edward Hoekstra3,
  6. 6.   Maya van den Ent3 and
  7. 7.   Apoorva Mallya4 

+ Author Affiliations

  1. 1.    1Oliver Wyman, Chicago, Illinois
  2. 2.    2Department of Immunization, Vaccines, and Biologicals, World Health Organization, Geneva, Switzerland
  3. 3.    3United Nations Children's Fund, New York
  4. 4.    4Global Health Delivery, Bill & Melinda Gates Foundation, Seattle, Washington
  5. Correspondence: Graegar Smith, MBA, Oliver Wyman, 155 N Wacker Drive, Ste 1500, Chicago, IL 60606 (graegar.smith@oliverwyman.com).


Responding to regional advancements in combating measles, the World Health Organization in May 2008 called for an assessment of the feasibility of measles eradication, including whether sufficient vaccine supply exists. Interviews with international health officials and vaccine-makers provided data for a detailed model of worldwide demand and supply for measles-containing vaccine (MCV). The study projected global MCV demand through 2025 with and without a global eradication goal. The study found that 5.2 billion MCV doses must be administered during 2010–2025 to maintain current measles programs, and 5.9 billion doses would likely be needed with a 2020 eradication goal; in the most intensive scenario, demand could increase to 7.5 billion doses. These volumes are within existing and planned MCV-manufacturing capacity, although there are risks. In some markets, capacity is concentrated: Supply-chain disruptions could reduce supply or increase prices. Mitigation strategies could include stockpiling, long-term contracts, and further coordination with manufacturers.




Risk Analysis for Measles Reintroduction After Global Certification of Eradication

  1. 1.   Raymond Sanders1,
  2. 2.   Alya Dabbagh2 and
  3. 3.   David Featherstone2 

+ Author Affiliations

  1. 1.    1Independent consultant, Worcester, United Kingdom
  2. 2.    2World Health Organization, Department of Immunization, Vaccines and Biologicals, Geneva, Switzerland
  3. Correspondence: Raymond Sanders, Ph.D, 72, Henwick Rd, Worcester, WR2 5NT, United Kingdom (ray@raysanders.co.uk).


Background.  Measles virus will continue to  exist after certification of global eradication as virus stocks and infectious materials held in laboratories, in persistently and chronically infected individuals, and possibly in undetected foci of transmission. A literature search was undertaken to identify and evaluate the main risks for reintroduction of measles transmission in the absence of universal measles immunization.

Methods.  A qualitative risk assessment was  conducted following a series of literature searches using the PubMed database.

Results. If the criteria for global  certification of eradication are stringent and require rigorous validation, then the risk of undetected measles transmission after certification is very low. Risk of unintentional reintroduction from any source, including persistent infections and laboratory materials is low to very low but depends on the extent of measles vaccine use. If immunization levels decrease, measles will become a credible agent for bioterrorism through intentional release.

Conclusions. Posteradication risks are low  and should not deter any attempt at measles eradication. More information on measles transmission dynamics and the role of atypical infections is required to determine requirements for global certification of eradication. Posteradication risks would be minimized through development and implementation of an international risk management strategy, including requirements for a posteradication vaccine stockpile.





How Can Measles Eradication Strengthen Health Care Systems?

  1. 1.   Ulla K. Griffiths1,
  2. 2.   Sandra Mounier-Jack1,
  3. 3.   Valeria Oliveira-Cruz1,
  4. 4.   Dina Balabanova1,
  5. 5.   Piya Hanvoravongchai2 and
  6. 6.   Pierre Ongolo3 

+ Author Affiliations

  1. 1.    1Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
  2. 2.    2Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Bangkok, Thailand
  3. 3.    3Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Cameroon
  4. Correspondence: U. K. Griffiths, MSc, Dept of Global Health and Development, London School of Hygiene and Tropical Medicine, 5–17 Tavistock Place, London WC1H 9SH, UK (ulla.griffiths@Ishtm.ac.uk).


Elimination and eradication initiatives are generally delivered through a vertical approach, which can potentially hamper health systems. We propose 3 approaches by which a measles eradication initiative can ensure that health systems are left strengthened when the eradication goal has been accomplished. First, focus should be placed on strengthening routine vaccination, which could generate positive trickle-up effects on other primary health care services. Second, increased integration with multifunctional health services should be emphasized. Third, efforts should be made to change traditional donor behavior that prioritizes vaccination campaigns and uses uncoordinated staff incentives.



Impact of Measles Elimination Activities on Immunization Services and Health Systems: Findings From Six Countries

  1. 1.   P. Hanvoravongchai1,
  2. 2.   S. Mounier-Jack2,
  3. 3.   V. Oliveira Cruz2,
  4. 4.   D. Balabanova2,
  5. 5.   R. Biellik3,
  6. 6.   Y. Kitaw4,
  7. 7.   T. Koehlmoos5,
  8. 8.   S. Loureiro6,
  9. 9.   M. Molla7,

10. H. Nguyen8,

11. P. Ongolo-Zogo9,

12. U. Sadykova10,

13. H. Sarma5,

14. M. Teixeira6,

15. J. Uddin5,

16. A. Dabbagh11 and

17. U. K. Griffiths2 

+ Author Affiliations

  1. 1.    1Department of Global Health and Development, LSHTM, Faculty of Tropical Medicine, Bangkok, Thailand
  2. 2.    2Department of Global Health and Development, LSHTM, 5-17 Tavistock Place, London, United Kingdom
  3. 3.    3Independent consultant, Geneva, Switzerland
  4. 4.    4Independent consultant, Addis Ababa, Ethiopia
  5. 5.    5Health Systems and Infectious Diseases Division, International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
  6. 6.    6Instituto de Saude Coletiva, Federal University of Bahia, Salvador, Brazil
  7. 7.    7Department of Health Management, Environmental Health and Behavioural Sciences, School Of Public Health, Addis Ababa University, Ethiopia
  8. 8.    8Department of Epidemiology, Hanoi School of Public Health, Vietnam
  9. 9.    9Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Avenue Henri Dunant, Cameroon

10.  10Dushanbe, Tajikistan

11.  11WHO, Geneva, Switzerland

  1. Correspondence: Piya Hanvoravongchai, MD, MSc, ScD, LSHTM, 9th Floor, Anekprasong Building, Faculty of Tropical Medicine, 420/6 Rajvithi Road, Bangkok 10400, Thailand (piya.hanvoravongchai@lshtm.ac.uk).


Background. One of the key concerns in  determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam.

Methods.  Primary data were collected from  key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches.

Results. This study found that the impact of  AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia.

Conclusions. We conclude that while weaker  health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.




Impact of Measles Eradication Activities on Routine Immunization Services and Health Systems in Bangladesh

  1. 1.   Tracey Pérez Koehlmoos,
  2. 2.   Jasim Uddin and
  3. 3.   Haribondu Sarma 

+ Author Affiliations

  1. 1.    Health Systems & Infectious Diseases Division, ICDDR,B, Dhaka, Bangladesh
  2. Correspondence: Tracey Pérez Koehlmoos, PhD, MHA, Health & Family Planning Systems Program, Health Systems & Infectious Diseases Division, ICDDR,B, 68 Shahed Tajuddin Ahmed, Sarani, Mohakhali, Dhaka-1212 Bangladesh (traceylynnk@hotmail.com).


Background. Seroprevalence studies suggest  that vaccination coverage of 90%–95% is needed to eliminate measles. In Bangladesh, routine measles vaccination coverage rates have recently reached 80%–85%. The Government of Bangladesh implemented catch-up vaccination through supplementary immunization activities (SIAs). The aim of the present study was to understand the impact of SIAs on immunization services and the health system.

Methods. The study was conducted at 4 sites,  all of which had relatively low routine vaccination coverage rates. A document review was performed, followed by interviews of key personnel selected by purposive and snowball sampling. A staff profiling survey was also undertaken.

Results.  Despite overall high levels of  immunization, the expanded program on immunization for measles has not reached the coverage levels targeted by the Government of Bangladesh. The first SIAs vaccinated 35 million children, and the second targeted an additional 20 million. According to data and respondents, implementation of the SIAs was successful with sufficient funds being available, although timely disbursement of funds was inadequate in some areas. Staff were well motivated, and additional training helped boost a positive approach to vaccination.

Conclusions. The SIAs had a positive impact  on health and immunization systems and have created a framework on which other health care interventions for bacterial and viral diseases could be based.