Updates in measles control in the African Region Measles Partnership Annual Meeting September 2008...

Updates in measles Updates in measles control in the African control in the African

RegionRegion

Measles Partnership Annual MeetingSeptember 2008

Dr Balcha G MasreshaDr Balcha G MasreshaWHO AFROWHO AFRO

Bureau Régional de l’OMS pour l’Afrique /WHO Regional\Office for Africa

Outline of presentation

Regional measles control goal and current

status

Routine immunisation

Supplemental immunisation activities

Measles case-based surveillance

Programmatic challenges

The “pre-elimination” goal for the African Region


0

100000

200000

300000

400000

500000

600000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Regional goal for 2009

Estimated reduction in measles mortality Estimated reduction in measles mortality (all ages) in the African Region, 2000-(all ages) in the African Region, 2000-

20062006

91 % 91 % reductionreduction


Reported coverage vs WHO UNICEF Reported coverage vs WHO UNICEF estimates. AFR. 2001 - 2007estimates. AFR. 2001 - 2007

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20

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50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006 2007

% a

dm

inis

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ive

cov

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e

reported coverage DPT3 reported coverage MCV

WHO UNIECF estimates DPT3 WHO UNICEF estimates MCV


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5

10

15

20

25

30

35

40

45

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81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07

nu

mb

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of

co

un

trie

s r

ep

ort

ing

<50% 50% - 79% >/=80%

Measles vaccination administrative Measles vaccination administrative coverage by category. AFR. 1981 - 2007coverage by category. AFR. 1981 - 2007


DPT1 – measles drop out rates.DPT1 – measles drop out rates.(WHO UNICEF estimates. 2006)(WHO UNICEF estimates. 2006)

• 33 of 46 countries with

drop-out rates >10%

• 11 countries with drop out

rates ≥ 20%

• 3 countries with DTP1 ≥

90% with drop out rates

≥ 20%


Stagnating coverage / high drop out Stagnating coverage / high drop out rates… WHY?rates… WHY?

• Infrastructure, financial and human resource limitations

• Limited geographic access and utilisation access for routine services

• Gaps in implementing the RED strategy:

• Outreach, community linkages, use of data for action, appropriate management of resources

• Logistics gaps including vaccine stock outs, aging cold chain and EPI vehicle fleet

• Inaccuracy of denominators…

• Improved quality of coverage reporting (e.g., administrative coverage data from CHWs / IPDs)


MP support for focused routine immunisation strengthening

• In 2008, 9 countries were supported financially

• A total of USD 1,050,000

• Support focused to avert measles outbreaks, de-linked from the SIAs (i.e., these 9 countries were not scheduled for SIAs in 2008)


TAG 2008. TAG 2008. Criteria for considering MCV2Criteria for considering MCV2

MCV1 coverage >80%, for > 3 consecutive years (using

WHO/UNICEF coverage estimates)

and Attainment of one of the two primary measles surveillance

performance indicators for at least two consecutive years. i.e.,

Non-measles febrile rash illness rate of > 2.0 cases per

100,000 population per year At least 1 suspected measles case investigated with blood

specimens in > 80% of districts per year.


Second Opportunity for Second Opportunity for measles vaccination (SIAs)measles vaccination (SIAs)


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60

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80

90

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

year

nu

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f ch

ild

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in

millions

catch-up SIAs follow-up SIAs Follow up SIAs projections

Children reached in measles SIAs, 2001 – 2007, Children reached in measles SIAs, 2001 – 2007, and target plans for 2008 - 2010. AFRand target plans for 2008 - 2010. AFR


Measles SIAs; resultsMeasles SIAs; results

97 SIAs in 43 countries reaching 329.9 million

children from 2001 – end of 2007

12 rounds with admin coverage 90 – 94%

20 rounds with admin coverage < 90%

By end of 2008, a further 63.4 million children will

be targeted in 9 countries


Intervention 2006 2007 2008

Measles 15 countries 14 countries 10 countries

Vit A 12 13 8

Deworming 7 11 6

ITNs 7 7 6

OPV 5 2 5

Integrated delivery of Integrated delivery of interventions in measles SIAs. interventions in measles SIAs.

2006 - 20082006 - 2008


Integration in measles SIAs; AFR. 2007Integration in measles SIAs; AFR. 2007Country Measles Vitamin A Deworming ITNs OPV

Burkina Faso x x xComoros x xCongo x x xDR Congo x xEthiopia x xGabon x x x xGambia x xLesotho x x xLiberia x x x xMadagascar x x x xMali x x x x xMauritania x xNiger x xSaotome & Principe xSouth africa x xTogo x x xZambia x x x x


Integrated delivery of multiple interventions; is it always

synergistic?

• Integration may be seen as being “partner-led”

• room for advocacy and local consensus building

• Weakness of central coordination

• Need for stronger involvement of all programs

• Delays in program level decisions/ resources/ logistics

• Stock-out of “commodities” disrupting acceptance of antigens;

• appropriate and detailed logistic planning

• Need for further operational research on the factors conducive

to the synergy


Measles case based surveillance


The Regional measles surveillance networkThe Regional measles surveillance network

• 40 countries (749.4 million population) under case

based surveillance• with a network of National / Regional Referral measles

laboratories

• Heavily dependent on the Polio infrastructure• Staffing, vehicles, funding for activities …


Measles surveillance performance & Measles surveillance performance & results. AFR. 2006 – July 2008results. AFR. 2006 – July 2008

Indicator/ parameter 2006 2007 2008

# suspected cases reported 21580 25111 25688

% investigated with blood specimens (target: >80%)

93% 92% 96%

% districts reporting at least 1 suspected case (target: >80%)

54% 71% 68%

% lab confirmed cases (target:<10%) 30% 22% 25%

# total confirmed measles cases 7707 7869 13410

Incidence of confirmed measles per 100,000 population

1.2 1.1 1.8

Annualised non measles febrile rash illness rate (target >2:100,000)

- 2.1 2.3


Measles incidence. 2007Measles incidence. 2007

Regional incidence:

> 10 cases per million

for the last 3 years;

Country incidence levels

ranging from 0 – 60

cases per million


Incidence per 100,000 population

# of countries % of total regional

population

<0.1 17 26%

0.1 – 0.49 8 8%

0.5 – 0.99 5 19%

1.0 – 1.99 4 37%

>/= 2.0 4 10%

Measles incidence. AFR. 2007Measles incidence. AFR. 2007


Incidence of confirmed measles.

Jan – June 2008. AFR


Trends of measles case reports. Nigeria. 2005 Trends of measles case reports. Nigeria. 2005 - 2008- 2008

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5

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janv-05

Apr July Oct janv-06

Apr July Oct janv-07

Apr July Oct janv-08M

easl

es c

ase

rep

ort

s in

tho

usa

nd

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Northern States Southern States

2005 2006 2007

Measles catch up campaign

in Northern states

Measles catch up campaign

in Southern states

2008


Measles case reports by final classification, Measles case reports by final classification, Nigeria. 2007 vs 2008Nigeria. 2007 vs 2008

Jan – Dec 2007

Jan – Mar 2008

Jan – Mar 2007


Age & vaccination status of confirmed measles cases, Age & vaccination status of confirmed measles cases, Nigeria. Jan – Dec 2007 (n=2,297)Nigeria. Jan – Dec 2007 (n=2,297)


LGAs with reported measles outbreaks.LGAs with reported measles outbreaks.Jan – July 2008, NigeriaJan – July 2008, Nigeria


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Missing < 9months

9 - 11months

1 - 2years

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5 - 14years

15 yearsand over

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rme

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1 or more doses

unvaccinated

missing/ unknown

Age & vaccination status of confirmed measles cases. Age & vaccination status of confirmed measles cases. Nigeria, Jan – Jul 2008 (n=8,887)Nigeria, Jan – Jul 2008 (n=8,887)


Challenges for measles control in AFR

• Limitations in SIAs operational funding • Currency exchange rates, Rising costs of fuel, Rising staff costs, …

• Limited local mobilization of $ resources for operational

component of SIAs

• Complacency following significant reduction of measles case

burden• Gaps in SIAs coverage, surveillance performance…

• System-wide constraints preventing sustained increase of

routine immunization coverage beyond 80%

• New Regional measles targets: “pre-elimination”


Plans for Measles SIAs in 2009

• 18 countries = 39.7 million children

• Total cost of $49.7 million • including

• surveillance support to 40 countries

• Focused support to close routine immunization program gaps and avert outbreaks in countries scheduled for SIAs in 2010

• Expected MP portion of $37.8 million

• Local sources expected to raise $11.9 million• MP role in advocacy!!!


““Pre-elimination regional goalPre-elimination regional goal” to be ” to be achieved by end-2012achieved by end-2012

Targets: >98% mortality reduction by 2012 as compared to

estimates for 2000;

Measles incidence <5 cases/106 population/year at

national level in all countries;

>90% routine MCV1 coverage at national level, and

>80% in all districts;

>95% SIAs coverage in all districts;

AND…


… continued

Measles surveillance performance: Non-measles febrile rash illness rate of >2.0 cases

per 100,000 population per year;

≥1 suspected measles case investigated with

blood specimens in at least 80% of districts per

year; and

Routine district reporting from 100% of districts.

““Pre-elimination regional goal” to be Pre-elimination regional goal” to be achieved by end-2012 (cont’d)achieved by end-2012 (cont’d)


Working towards the pre-elimination targets:

anticipated challenges• Overcoming the complacency and maintaining the

political will to scale up measles control activities to “pre-elimination” levels esp. while polio eradication still poses a challenge

• Raising the required $ resources (at international and local levels)

• Maintaining the surveillance infrastructure

• Attaining the ambitious routine immunization goals of >90% MCV at national level and >80% in all districts


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Updates in measles control in the African Region Measles Partnership Annual Meeting September 2008...

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