Summary of the findings and recommendations of the

"Global technical consultation meeting to assess

the feasibility of measles eradication" SAGE

WHO, Geneva

November 2010

2

Outline

 Feasibility

 Challenges –  Regional –  Global

 Questions to SAGE

1. Biological feasibility

2. Programmatic feasibility

3. Vaccine market analysis

4. Impact on health systems

5. Economic analysis

7. Global context and political feasibility

Global Consultation

meeting (2010)

Recommend global

measles goal

6. Risk analysis for post-measles era

SAGE

Feasibility of Measles Eradication

WHA set global measles

goal?

1. Biological and Technical Feasibility

International Task Force on Disease Eradication Carter Center, June 4, 2009

"measles eradication is biologically feasible using tools that are currently available, as already demonstrated in the Americas, although implementation challenges remain in each of the remaining five regions" *

* WER , October 30, 2009

 Humans are the only host  Life-long immunity after natural infection  Only one serotype  Genetically stable  Rinderpest virus eradicated since 2001  Challenges:

–  Highly infectious (>93-95% population immunity needed) –  Population growth and density, migration and international travel –  HIV epidemic

 Measles vaccines are safe and effective   Vaccines provide long-term protection against all known

genotypes   Accurate diagnostic tests  Current vaccines have eliminated measles in the

Americas  Challenges:

–  Vaccine needs cold chain and sterile injection –  Not effective in early infancy –  2 doses needed

2. Programmatic Feasibility

Impact of Accelerated Activities

Number of reported measles cases by WHO Region, 2000-2009*

Number of estimated measles deaths, 2000-2008

Source: Cases from annual Joint Reporting Form Deaths from Wkly Epid Rec Dec 4, 2009 *2009 case data incomplete

67% decrease

78% decrease

High-low bars indicate uncertainty

Follow-up campaigns

Catch-up campaigns

Measles Elimination in the Americas, 1980-2009*

*Data until EW 52/2009. **Prior to 1995, reported cases. Source: Country reports to PAHO.

Routine infant vaccination coverage

(%)

Con

firm

ed c

ases

**

During the period 2000-2020, the measles elimination program in the Americas will have prevented 3.2 million cases of measles and 16,000 deaths, saving US$

208 million in treatment costs.

Interruption of endemic transmission

Measles Control Goals by WHO Region, November 2010

SE Asian mortality Reduction goal

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

3. Vaccine market analysis

Vaccine Market analysis – Oliver Wyman

  Interviews with industry and programme experts

  For eradication by 2020, total MCV demand would increase from ~3.5 to ~4.2 billion doses

  Manufacturing capacity would be sufficient

  Concentration of manufacturing capacity (low to moderate risk)

  Mitigate through stockpiles or long-term supply contracts

  Continually refine the demand forecast and rapidly communicate to suppliers

No.

of d

oses

in m

illio

ns

4. Impact of Measles Eradication Activities on Immunization

and Health Systems

Impact of Measles Eradication Activities on Immunization and Health Systems - LSHTM

  6 countries: –  Cameroon, Tajikistan, Brazil,

Vietnam, Bangladesh and Ethiopia

  Document reviews and interviews

  Both positive and negative impacts, but over all positive impact in ALL countries studied.

  Negative impact more pronounced in poorer countries with weak health systems and multiple SIAs

Health  System  

Key positive and negative effects of measles activities on the health system

  Positive effects: –  Better staff skills for service delivery and programme management. –  More lab equipment and improved surveillance –  Strengthened cold-chain and logistics system –  Better information on target populations –  More coordination with other sectors –  Add-on interventions

  Negative effects: –  Delay or interruption of health services during SIAs –  Incentives can have negative impacts on staff motivation

Adding health system value

Vitamin A

Polio Vaccination

De-worming Tablets

Bednets

>186 million >95 million >81 million >37 million

In 2008, 29 (88%) of 33 campaigns were integrated with at least one other intervention

5. Economic analysis

Economic Analysis of Measles Eradication - David Bishai and Ann Levin/Colleen Burgess

  Cost effectiveness analysis carried out by two groups

  Field evaluations in 6 countries: –  Brazil, Bangladesh, Columbia, Ethiopia, Tajikistan, Uganda –  Global analysis of costs

  Results –  Baseline: 90% mortality reduction –  Measles eradication by 2020 was highly cost-effective in all 6 countries and

globally (cost-saving in Brazil & Columbia) –  Eradication is highly CE when 2 doses of MCV are continued post

eradication, –  Intermediate targets 95% and 98% mortality reduction also highly CE

  Measles eradication ranks among top best buys in public health

20

Income Group by

Elimination Status #

Coun

trie

s Total Cost

(Millions, 2010 USD)

Incremental Cost

(Millions, 2010 USD)

Deaths Averted

DALYS Averted

ICER, $ per DALY

Averted (2010 USD)

GDP per Capita

Measles not eliminated by 2010

Low 42 $1,040 $137 1,045,000 32,398,000 $4 $503

Low-Mid 41 $10,529 ($296) 9,408,000 291,725,000 Cost /life saving $2,310

Upper-Mid 24 $1,759 $67 504,000 15,613,000 $4 $7,523

High 39 $53,823 $8,216 50,000 1,558,000 $5,273 $38,134

Measles eliminated by 2010*

Low-Mid** 16 $1,404 ($140) 66,000 2,037,000 Cost /life saving $2,310

Upper-Mid 19 $2,068 ($105) 81,000 2,526,000 Cost /life saving $7,523

High 12 $4,006 ($47) 2,000 58,000 Cost /life saving $38,134

TOTAL 193 $74,629 $7,832 11,156,000 345,915,000 N/A N/A

6. Risk analysis for post-eradication era

Risk analysis for post-eradication era - Ray Sanders

  Measles virus will continue to exist after eradication

  Re-introduction could occur from "natural" or "laboratory" sources

  Risk of accidental reintroduction from any source, including persistent infections and lab materials is low to very low,

  If immunization levels fall, measles will become a credible agent for bioterrorism

  Conclusion: post-eradication risks are low, and should not deter any attempt at measles eradication.

Stakeholders Analysis;

Comparing Measles with Previous Eradication Programs

7. Global Context and Political Feasibility

Stakeholders analysis – Coxswain Social Investments

 Assess stakeholders political will and financial capacity to support a measles eradication initiative through interviews and an E-survey – low response rate!

 Strong commitment among internal stakeholders and country commitment to regional elimination goals.

 At present, there is inadequate political will within donor and development agencies to support an eradication goal.

  'Time may not be ripe' for setting an eradication target now –  make progress with polio –  secure commitment to raise funds needed

Summary  of  findings  •  Measles  Partnership  perceived  to  be  strong  •  Donor  and  host-­‐government  support  considered  key  to  success  

•  No  consensus  on  =ming  •  Organiza=ons  with  internal  (knowledgeable)  employees  more  likely  to  support  eradica=on  

•  Many  mispercep=ons  stand  to  be  corrected  •  No  immediate  funding  streams  iden=fied  •  Polio  ini=a=ve  holds  valuable  experience  to  inform  decisions  and  strategies  

Comparing Measles with Previous Eradication Programs: Enabling and Constraining Factors – R. Keegan

  Literature review –  political, social, economic & technical factors –  compared with yaws, malaria, smallpox, guinea worm & polio

Key enabling factors Key challenges

Strong country support Increased insecurity

Information technology allows rapid communications

Infectiousness of measles

Laboratory technology is better Competition for funds

Affordable cost ($5-8 billion) Co-existence with polio

Comparing Measles with Previous Eradication Programs: Enabling and Constraining Factors – R. Keegan

Conclusions of study:

 Measles eradication will be very challenging, but probably not as difficult as polio or malaria eradication.

  Measles eradication should be undertaken only if the commitments and resources will be adequate to meet the political, social, economic, and technical challenges.

Challenges

  28 countries had measles outbreaks (June 2009 - October 2010) –  > 100,000 confirmed measles cases

reported –  > 1300 reported measles deaths –  18 of the 28 countries did their most

recent SIAs in the last 24 months.

  Data analysis and preliminary investigations revealed: –  gaps in routine immunization services –  suboptimal coverage during recent SIAs

(ANG, NAM, BOT) –  too long intervals between SIAs (SOA,

LES, ZAM)

Reported measles case burden. AFR (Jan –October 2010)

EMRO – war and conflict

31

EURO – vaccine antagonists (2009)

Source: Admin Coverage WHO UNICEF JRF, 2009 (WHO UNICEF Coverage Estimates used if Admin coverage not provided)

Both MCV1 and MCV2 ≥ 95% Either MCV1 or MCV2 > 95% Both MCV1 and MCV2 < 95%

Measles Coverage (DLHS-3)

0 10 20 30 40 50 60 70 80 90

100

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Catch-up Campaigns

India : 69.6%

Immunization Division, MOHFW, Govt. of India

2nd Dose of RI

Measles Cases, by Age and Region Viet Nam, Oct 2008 – Jan 2010

N = 7,490

AMRO: High costs for maintaining elimination

•  The Region is under constant threat of importations as long as endemic measles virus continues to circulate in other regions of the world.

•  Additional US $77 million required to continue follow-up SIAs in LAC during 2020-2040 if measles eradication is not achieved.1

•  Estimated costs associated with recent outbreaks US $8,600 - $20,300.

1Acharya A et al. Cost-effectiveness of measles elimination in Latin America and the Caribbean: a prospective analysis. Vaccine 2002; 20:3332-81.

Source: Preliminary information reported by the countries to PAHO.

Lessons from Polio

Major  barriers  to  achieving  polio  thresholds  

Active conflict

Insufficient political buy-in

& insecurity

Insufficient political & societal buy-in

Insufficient vaccine effectiveness

Recurrent outbreaks due to weak routine immunization systems

Pop

ulat

ion

Imm

unity

Programme Performance

1. Where is the immunity threshold for stopping transmission highest?

2. Where is routine coverage lowest?

3. Where is the difference between these greatest?

Weak Immunisation Systems

  Coverage <80% in Sub-Saharan Africa and SE Asia

  23.7 million unvaccinated infants

  60% in large countries: –  India 7.4 m –  Nigeria 3.2 m –  China 1.1 m –  Pakistan 0.7 m –  Indonesia 0.7 m –  Ethiopia 0.6 m

Measles 1st dose coverage in 2009

80-89% (29 countries or 15%)

60-79% (35 countries or 18%)

>=90% (115 countries or 60%)

<60% (14 countries or 7%)

Source: WHO/UNICEF coverage estimates 1980-2009, July 2010

193 WHO Member States. Date of slide: 21 July 2010

* Excluding all activities in India, anticipated country contributions for follow-up SIAs, and intro. of MCV2

11 59

36 38 44

94

Figure 1: Measles Initiative Annual Donations 2001-2009 and Financial Resource Requirements, Projections,

Funding Gap 2010-2015*

2010-2015 funding gap $ 282 million US

Global Measles Update, May 17 2010 40 |

Risk of resurgence; scenario 2010 - 2013

Source: WHO/IVB measles deaths estimates, October 2009; Lancet 2007;369:191-200

  Method from Lancet 2007; 369: 191–200

  Projected worst case scenario: none of 47 priority countries carry out SIAs during 2010-2013

  Loss of contribution of measles to overall reduction in child mortality

Reported Number of Measles Cases and Estimated Coverage* with MCV1 in 7 southern African countries, 1990-2010†

* Vaccination coverage is a population weighted average for these 7 countries Source: WHO/UNICEF coverage estimates 1980-2009, Aug 2010. † Reported cases provisional as of Sept 2010; WHO/UNICEF Joint Reporting Form, 9 Sept 2010 WHO/ISTESA weekly outbreak update, 14Sept 2010

Catch-up campaigns

Follow-up campaigns

Measles resurgence in Southern Africa countries Confirmed measles cases and reported deaths, January 2009 – through October 2010

Namibia  Since  August  2009  Total  cases:  3,176  Total  deaths:  58  

South  Africa  Since  June    2009  Total  cases:  18,004  Total  deaths:  18  

Swaziland  Since  November    2009  Total  cases:  442  Total  deaths:  3  

Lesotho  Since  November  2009  Total  cases:  2,845  Total  deaths:  37  

Data source: Measles outbreak report, AFRO 7 Oct 27 2010

Botswana  Since  October  2009  Total  cases:  1,360  Total  deaths:  0  

Zambia  Since  May  2010  Total  cases:  10,0898  Total  deaths:  160  

Mozambique  Since  December  2009    Total  cases:  367  Total  deaths:  0    

Zimbabwe  Since  Sept  2009  Total  cases:  2,192  Total  deaths:  527  

Malawi  December  2009  Total  cases:  56,196  Total  deaths:  249  

B3

B2

≥10,000 cases

<1,000 cases 1,000-10,000 cases

Research Questions

•  What research gaps should be addressed to enable measles eradication?

•  epidemiological research •  operational research •  immunization strategies •  laboratory methods

•  Discussions held but more in-depth discussion needed to identify and prioritize research questions.

•  Meeting planned Q1 2011.

The Eradication Debate

Let's eradicate

This decade!!

No! Let's eradicate

Now!!

No! No! Let's Not

Eradicate!!

Key recommendations of ad hoc advisory group

  Measles can and should be eradicated.

  Measles eradication activities should be carried out in the context of strengthening routine immunization

  The WHA should consider establishing a target date for measles eradication once SEAR has established an elimination target.

  Global eradication by 2020 is feasible (given measurable progress towards 2015 targets)

  Measles eradication activities should be used to accelerate rubella control and the prevention of CRS.

'Eradication attacks inequities & provides the ultimate in social justice.'

Dr Bill Foege

Questions to SAGE - For Decision

  Can measles be eradicated?

  Should be measles be eradicated?

  What are the requirements for setting an eradication target? –  Elimination target for SEAR? –  Commitment of needed financial resources? –  Polio eradication? Milestones in polio eradication? –  Political commitment? –  Measurable progress towards the 2015 target?

  Is 2020 an appropriate target date?

  What are the appropriate strategies for eradication? –  Within the context of immunization and health systems?

  What are the recommended next steps for WHO?

Acknowledgements   Partners of the MI

  WHO Regional Advisors, Focal Points and study country WHO national staff

  Members of SAGE working group on measles

  Members of the QUIVER and Ad hoc QUIVER WG on measles

  BMGF

  WHO HQ team

  THANK YOU