Edward J. Hoekstra, MD, MScEdward J. Hoekstra, MD, MSc Senior Health AdvisorSenior Health Advisor UNICEF HQ, New YorkUNICEF HQ, New York Peter StrebelPeter Strebel, MBChB, MPH, MBChB, MPH WHO HQ, GenevaWHO HQ, Geneva

Jeff Mcfarland, MDJeff Mcfarland, MD UNICEF HQ, New YorkUNICEF HQ, New York

Global Overview of MeaslesGlobal Overview of Measles

Partners for Measles Advocacy 7th Annual MeetingPartners for Measles Advocacy 7th Annual Meeting Washington D.C., 27 – 28 February 2007Washington D.C., 27 – 28 February 2007

2005 Mortality Reduction 2005 Mortality Reduction Goal Goal

Achieved !Achieved !!!

Measles Mortality Reduction Measles Mortality Reduction 47 UNICEF / WHO Priority Countries 47 UNICEF / WHO Priority Countries

19991999

No second opportunity 2005 ( 47 )No second opportunity 2005 ( 47 )

94 % of all measles deaths94 % of all measles deaths

Measles Mortality Reduction Measles Mortality Reduction 47 UNICEF / WHO Priority Countries 47 UNICEF / WHO Priority Countries

20052005

Nation - wide second opportunity 2005 ( 34 )Nation - wide second opportunity 2005 ( 34 )

Partial implementation of second opportunity 2005 ( 11 )Partial implementation of second opportunity 2005 ( 11 )

No second opportunity 2005 ( 2 )No second opportunity 2005 ( 2 )

11stst Dose Measles Coverage in 47 Measles Dose Measles Coverage in 47 Measles Priority Countries 1999 - 2005Priority Countries 1999 - 2005

50%

55%

60%

65%

70%

75%

1999 2000 2001 2002 2003 2004 2005

Coverage Measles1 st dose

Source: WHO / UNICEF coverage estimates, 1980 - 2005 as of August 2006

PercentPercent

54 %54 %

65 %65 %

77 %77 %

71 %71 % Global Coverage 1Global Coverage 1stst dose dose

Estimated Global Measles DeathsEstimated Global Measles Deaths1999 - 20051999 - 2005

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

1999 2000 2001 2002 2003 2004 2005

60%reduction

2005 Goal

Source: Lancet 2007, L Wolfson, P Strebel, M Gacic-Dobo, E Hoekstra, J McFarland, B HershHigh-low lines indicate uncertainty bounds

Percent reduction in estimated measles deaths Percent reduction in estimated measles deaths by WHO region between 1999 and 2005by WHO region between 1999 and 2005

-90

-80

-70

-60

-50

-40

-30

-20

-10

0

AFR SEAR WPR EMR GLOBAL

Region

% r

edu

ctio

n

60 %60 %81 %81 %75 %75 % 62 %62 %

2005 Mortality Reduction Goal Achieved !!2005 Mortality Reduction Goal Achieved !!

> 360 million vaccinated in SIAs

2.3 million additional deaths

prevented

Phone - in press conference

> 220 media reports

How was this possible ?How was this possible ?• Caring … Parents• Commitment … Countries and Governments• Cash …. Partnership

• Measles control benefited from other investments– Strengthening routine immunization systems ( GAVI )– Polio eradication infrastructure and field staff

Photo: Aung

Progress in 2006Progress in 2006

Measles Mortality Reduction Measles Mortality Reduction 47 UNICEF / WHO Priority Countries 47 UNICEF / WHO Priority Countries

20052005

Nation - wide second opportunity 2005 ( 34 )Nation - wide second opportunity 2005 ( 34 )

Partial implementation of second opportunity 2005 ( 11 )Partial implementation of second opportunity 2005 ( 11 )

No second opportunity 2005 ( 2 )No second opportunity 2005 ( 2 )

Measles Mortality Reduction Measles Mortality Reduction 47 UNICEF / WHO Priority Countries 47 UNICEF / WHO Priority Countries

20062006

Nation - wide second opportunity 2006 ( 42 )Nation - wide second opportunity 2006 ( 42 )

Partial implementation of second opportunity 2006 ( 3 )Partial implementation of second opportunity 2006 ( 3 )

No second opportunity 2006 ( 2 )No second opportunity 2006 ( 2 )

Measles Vaccines Shipped by UNICEFMeasles Vaccines Shipped by UNICEF1999 - 20061999 - 2006

96116

148 155 162 168

241

96

-101030507090

110130150170190210230250

1999 2000 2001 2002 2003 2004 2005 2006

Doses MillionsDoses Millions

A - D Syringes Shipped by UNICEFA - D Syringes Shipped by UNICEF1998 - 20061998 - 2006

Safe Injection PracticesSafe Injection Practices

78158

227

435490 479

673

832

53

0

100

200

300

400

500

600

700

800

900

1998 1999 2000 2001 2002 2003 2004 2005 2006

Number A-D Syringes in millionsNumber A-D Syringes in millions

0.5 ml Auto Disable Syringes0.5 ml Auto Disable Syringes

5162

134

70

105

47

3 7

26

0

20

40

60

80

100

120

140

1999 2000 2001 2002 2003 2004 2005 2006 2007

$ Millions$ Millions

Expenditures Measles Mortality ReductionExpenditures Measles Mortality Reduction

UNICEF HQ and WHO HQ , 1999 - 2007UNICEF HQ and WHO HQ , 1999 - 2007

m m && m m integrationintegration

Measles & Measles & MalariaMalaria

Foto: Mark Grabowsky

0

5

10

15

20

25

Gh

ana

Zam

bia

Mal

i

To

go

Eq

Gu

inea

Zam

bia

Mo

zam

biq

ue

Mad

agas

car

An

go

la

Ken

ya

Rw

and

a

Eth

iop

ia

Ind

on

esia

DR

C

Nig

eria

Ug

and

a

S.

Leo

ne

Gh

ana

Ind

on

esia

Mad

agas

car

Zam

bia

LIN

s d

eliv

ered

per

cam

pai

gn

(m

illi

on

s)

0

5

10

15

20

25

LIN

s d

eliv

ered

cu

mu

lati

ve (

mil

lio

ns)

Per Campaign Cumulative

LLINs delivered during integrated campaigns, 2002-2007

Rapid ITN scale - up

In 2006, most LLINs are being delivered during integrated

measles campaigns.

2006Pre-2006 2007

Source: Global Fund

Measles Control GoalsMeasles Control Goalsby WHO Regionby WHO Region

20002000

20102010

20102010 20122012

Africa and SE Asia have mortality reduction goals

Americas, Europe, E. Mediterranean, W. Pacific have elimination goalsAmericas, Europe, E. Mediterranean, W. Pacific have elimination goals

GIVS Goal: 90% reduction in deaths by 2010 (vs. 2000)

StrategiesStrategies

Mortality Mortality

Reduction Reduction

Elimination Elimination

1st dose coverage > 90% > 95%

2nd Opportunity All children All children

Surveillance Aggregate or

case - based

Case - based

Case Management Vitamin A Supportive Rx

Vitamin A Supportive Rx

0.001

0.01

0.1

1

10

100

1000

inci

den

ce p

er 1

00

k

AFR AMR EMR EUR SEAR WPR

Reported Measles Incidence by WHO region, Reported Measles Incidence by WHO region, 1980 - 20051980 - 2005

Source: Joint Reporting Form, WHO/IVB database, August 2006

Elimination

Americas: Measles Eliminated since 2002• Importations cause limited outbreaks • No persistent genotype

0

50

100

150

200

250

1 14 27 40 1 14 27 40 1 14 27 40 1 14 27 40 1 14 27 40 1 14 27 40

Co

nfi

rmed

cas

es

2001 2002 2003

D6

tran

smis

sio

n

end

s

D9

tran

smis

sio

n

end

s

GenotypeD4D5D6D8D9B3H1Unknown / other

2004

Sources: PAHO, Country reports, Global Measles Laboratory

2005 2006

What will it take to achieve the goal ?

0

200,000

400,000

600,000

800,000

1,000,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Estim

ated M

easle

s Mor

tality

Status Quo Improve Routine + Followup Improve Routine + Followup + Remaining Catchup

90%

Source: WHO/IVR projections, February 2007

What will it take to achieve the goal ?

0

200,000

400,000

600,000

800,000

1,000,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Estim

ated M

easle

s Mor

tality

Status Quo Improve Routine + Followup Improve Routine + Followup + Remaining Catchup

Source: WHO/IVR projections, February 2007

90%

What will it take to achieve the goal ?

0

200,000

400,000

600,000

800,000

1,000,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Estim

ated M

easle

s Mor

tality

Status Quo Improve Routine + Followup Improve Routine + Followup + Remaining Catchup

Source: WHO/IVR projections, February 2007

90%

What will it take to achieve the goal ?

0

200,000

400,000

600,000

800,000

1,000,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Estim

ated M

easle

s Mor

tality

Status Quo Improve Routine + Followup Improve Routine + Followup + Remaining Catchup

Source: WHO/IVR projections, February 2007

90%

Planned measles campaignsPlanned measles campaignsJanuary – December 2007January – December 2007

WHO/IVB SIA database, as of 31 January 2007

Measles activities onlyMeasles activities only

MRMR

MMRMMR

Other interventions:Vitamin A – 19De-worming – 10Bed nets – 9OPV - 4

ChallengesChallenges

• Complete catch-up • Sustain the gains

• Stronger routine • Quality follow – up• Low incidence declining support • Government financing of follow - up SIAs

• Integrate with other child health programmes

… … going down hill is also going forward ..going down hill is also going forward ..

Source: Orenstein WA. Pediatr Infect Dis J 2006; 25: 1093-1101

FundingFunding

MeaslesGood spots, bad spots

“ … But the fight against diseaseis like any battle. It is unwise to let your guard drop when you are on top … "

…The Economist, 20 Jan 2007

Funding for Measles Mortality ReductionFunding for Measles Mortality Reduction2007 - 2010 ( in million USD )2007 - 2010 ( in million USD )

80

147

252

ARC/CDC/UNF

GAVI/IFFIm

Shortfall

Estimated Total Funds needed = 479 million USD ( Measles Investment Case II )Excludes country contributions

SummarySummary

• Most ambitious measles goals ever– Less than 4 years to go

• Comprehensive strategy required • Inverse relationship: funding downdown, measles upup

– Some 2.3 m lives are saved; But don't fail now

… … We are going to ASIAWe are going to ASIA ……

Myanmar January 2007Myanmar January 2007

… … Next stepNext step

So … Where in the world is Peter Strebel ??So … Where in the world is Peter Strebel ??

ThanksThanks