Edward J. Hoekstra

Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study

BACKGROUND In 2002, the UN General Assembly Special Session on Children adopted a goal to reduce deaths owing to measles by half by the end of 2005, compared with 1999 estimates. We describe efforts and progress made towards this goal. METHODS We assessed trends in immunisation against measles on the basis of national implementation of the WHO/UNICEF comprehensive strategy for measles mortality reduction, and the provision of a second opportunity for measles immunisation. We used a natural history model to evaluate trends in mortality due to measles. RESULTS Between 1999 and 2005, according to our model mortality owing to measles was reduced by 60%, from an estimated 873,000 deaths (uncertainty bounds 634,000-1,140,000) in 1999 to 345,000 deaths (247,000-458,000) in 2005. The largest percentage reduction in estimated measles mortality during this period was in the western Pacific region (81%), followed by Africa (75%) and the eastern Mediterranean region (62%). Africa achieved the largest total reduction, contributing 72% of the global reduction in measles mortality. Nearly 7.5 million deaths from measles were prevented through immunisation between 1999 and 2005, with supplemental immunisation activities and improved routine immunisation accounting for 2.3 million of these prevented deaths. INTERPRETATION The achievement of the 2005 global measles mortality reduction goal is evidence of what can be accomplished for child survival in countries with high childhood mortality when safe, cost-effective, and affordable interventions are backed by country-level political commitment and an effective international partnership.

Distributing insecticide-treated bednets during measles vaccination: a low-cost means of achieving high and equitable coverage

OBJECTIVE To achieve high and equitable coverage of insecticide-treated bednets by integrating their distribution into a measles vaccination campaign. METHODS In December 2002 in the Lawra district in Ghana, a measles vaccination campaign lasting 1 week targeted all children aged 9 months-15 years. Families with one or more children less than five years old were targeted to receive a free insecticide-treated bednet. The Ghana Health Service, with support from the Ghana Red Cross and UNICEF, provided logistical support, volunteer workers and social mobilization during the campaign. Volunteers visited homes to inform caregivers about the campaign and encourage them to participate. We assessed pre-campaign coverage of bednets by interviewing caregivers leaving vaccination and distribution sites. Five months after distribution, a two-stage cluster survey using population-proportional sampling assessed bednet coverage, retention and use. Both the pre-campaign and post-campaign survey assessed household wealth using an asset inventory. FINDINGS At the campaign exit interview 636/776 (82.0%) caregivers reported that they had received a home visit by a Red Cross volunteer before the campaign and that 32/776 (4.1%) of the youngest children in each household who were less than 5 years of age slept under an insecticide-treated bednet. Five months after distribution caregivers reported that 204/219 (93.2%) of children aged 9 months to 5 years had been vaccinated during the campaign; 234/248 (94.4%) of households were observed to have an insecticide-treated bednet; and 170/249 (68.3%) were observed to have a net hung over a bed. Altogether 222/248 (89.5%) caregivers reported receiving at least one insecticide-treated bednet during the campaign, and 153/254 (60.2%) said that on the previous night their youngest child had slept under a bednet received during the campaign. For households in the poorest quintile, post-campaign coverage of insecticide-treated bednets was 10 times higher than pre-campaign coverage of households in the wealthiest quintile (46/51 (90.2%) versus 14/156 (9.0%)). The marginal operational cost was 0.32 US dollars per insecticide-treated bednet delivered. CONCLUSION These findings suggest that linking bednet distribution to measles vaccination campaigns may provide an important opportunity for achieving high and equitable coverage of bednets.

The Unfinished Measles Immunization Agenda

Despite achieving and sustaining global measles vaccination coverage of about 80% over the past decade, worldwide measles remains the fifth leading cause of mortality among children aged <5 years. In May 2002, the United Nations Special Session on Children endorsed the goal of reducing measles deaths by half by 2005. Countries and World Health Organization (WHO) regions that adopted aggressive measles control or elimination strategies have shown excellent results. In 2001, countries in the Americas reported an all time low of 537 confirmed measles cases. Substantial progress in measles control has also been achieved in the WHO Western Pacific Region, in seven southern African countries, and in selected countries in WHO European, Eastern Mediterranean, and Southeast Asian regions. The ongoing measles disease burden and availability of safe and effective measles mortality reduction strategies make a compelling case to complete the unfinished agenda of measles immunization.

Experience in Global Measles Control, 1990–2001

Worldwide during the 1980s remarkable progress was made in controlling measles through increasing routine measles vaccination to nearly 80%. In 2000, an estimated 777,000 measles deaths occurred, of which 452,000 were in the African Region of the World Health Organization (WHO). In 2001, WHO and the United Nations Childrens Fund published a 5-year strategic plan to reduce measles mortality by half by 2005. Strategies include providing a second opportunity for measles immunization to all children through nationwide supplementary immunization activities, increasing routine vaccination coverage, and improving surveillance with laboratory confirmation of suspected measles cases. In 2000, over 100 million children received a dose of measles vaccine through supplementary immunization activities, a number projected to increase during 2002-2005. Current systems for monitoring measles vaccination coverage and disease burden must be improved to accurately assess progress toward measles control goals.

Measles Mortality Reduction Contributes Substantially to Reduction of All Cause Mortality Among Children Less Than Five Years of Age, 1990–2008

BACKGROUND The Millennium Development Goal 4 (MDG4) to reduce mortality in children aged <5 years by two-thirds from 1990 to 2015 has made substantial progress. We describe the contribution of measles mortality reduction efforts, including those spearheaded by the Measles Initiative (launched in 2001, the Measles Initiative is an international partnership committed to reducing measles deaths worldwide and is led by the American Red Cross, the Centers for Disease Control and Prevention, UNICEF, the United Nations Foundation, and the World Health Organization). METHODS We used published data to assess the effect of measles mortality reduction on overall and disease-specific global mortality rates among children aged <5 years by reviewing the results from studies with the best estimates on causes of deaths in children aged 0-59 months. RESULTS The estimated measles-related mortality among children aged <5 years worldwide decreased from 872,000 deaths in 1990 to 556,000 in 2001 (36% reduction) and to 118,000 in 2008 (86% reduction). All-cause mortality in this age group decreased from >12 million in 1990 to 10.6 million in 2001 (13% reduction) and to 8.8 million in 2008 (28% reduction). Measles accounted for about 7% of deaths in this age group in 1990 and 1% in 2008, equal to 23% of the global reduction in all-cause mortality in this age group from 1990 to 2008. CONCLUSIONS Aggressive efforts to prevent measles have led to this remarkable reduction in measles deaths. The current funding gap and insufficient political commitment for measles control jeopardizes these achievements and presents a substantial risk to achieving MDG4.

Global Measles Elimination Efforts: The Significance of Measles Elimination in the United States

Lessons learned from the successful end of endemic measles virus transmission (i.e., elimination) in the United States include the critical roles of strong political commitment, a regionwide initiative, adequate funding, and a broad coalition of partners. Implications of measles elimination in the United States for global measles control and regional elimination efforts include demonstration of the high vaccination coverage and, in turn, population immunity needed for elimination; the importance of accurate monitoring of vaccination coverage at local, state, and national levels; a vaccination strategy that includes at least 2 opportunities for measles immunization; and the essential role of integrated epidemiological and laboratory surveillance. The United States, with a population of 288 million, is, to our knowledge, the largest country to have ended endemic measles transmission. This experience provides evidence that sustained interruption of transmission can be achieved in large geographic areas, suggesting the feasibility of global eradication of measles.

One country, two worlds – The health disparity in China

Abstract As result of its spectacular economic growth, millions of Chinese have been lifted out of poverty, making China a model for impoverished countries. Although, for many, economic growth has led to prosperity, ever-growing disparities exist between those who have benefited from the economic advancement and those left behind. Massive gaps in development exist between: regions, urban and rural and social groups. This contribution is to develop a detailed understanding of the health disparity in China by examining the discrepancies in major health indicators. Current efforts to reduce the disparities, and its challenges, opportunities and global implications are also assessed.

Implementation of a Mass Measles Campaignin Central Afghanistan, December 2001to May 2002

In Afghanistan health services have been disrupted by 23 years of conflict and 1 of 4 children die before age 5 years. Measles accounts for an estimated 35,000 deaths annually. Surveillance data show a high proportion of measles cases (38%) among those >/=5 years old. In areas with complex emergencies, measles vaccination is recommended for those aged 6 months to 12-15 years. From December 2001 to May 2002, Afghan authorities and national and international organizations targeted 1,748,829 children aged 6 months to 12 years in five provinces in central Afghanistan for measles vaccinations. Two provinces reported coverage of >90% and two >80%. Coverage in Kabul city was 62%. A subsequent cluster survey in the city found 91% coverage (95% confidence interval [CI], 0.85-0.91) among children 6-59 months and 88% (95% CI, 0.87-0.95) among those 5-12 years old. Thus, this campaign achieved acceptable coverage despite considerable obstacles.

Impact of Supplementary Immunization Activities in Measles-Endemic Areas: A Case Study From Guangxi, China

Because of limited resources, each year during the period from 1999 through 2007, only about one-quarter of the 111 counties in Guangxi province were selected by means of risk assessment to participate in Supplementary Immunization Activities (SIAs), targeting children aged 8 months to 14 years during 1999-2003 and 8 months to 10 years during 2004-2007. Approximately 2 million doses of measles vaccines were administrated each year during SIAs. Estimated from the National Notifiable Diseases Surveillance System, with a reliable internal consistency over years, the average annual incidences of measles before SIAs (1993-1998), during the first phase (1999-2003), and during the second phase (2004-2007) were 16.05, 9.10, and 2.46 cases per 100,000, respectively. The overall provincewide annual incidence decreased by 84.67%, from 12.12 cases per 100,000 in 2000 to 2.10 cases per 100,000 in 2007. The percentage of counties with annual incidence ≥10 cases per 100,000 decreased from 55% in 1993 to <1% in 2007. Compared with the pre-SIA period, the greatest decrease in annual incidence was 83.93% for the 10-14.9-year-old group and the smallest decrease was 46.16% for children <1 year old. The multiple-year SIAs targeting children in selected high-risk counties were effective in controlling measles in mountainous, impoverished, and multiethnic measles-endemic areas.

Reducing measles mortality, reducing child mortality

Global eff orts to expand the use of the measles vaccine over the past 5 years has resulted in the greatest measurable reduction in under-5 mortality from measles, with annual deaths reduced by 48%, to 454 000 (range 329 000–596 000) in 2004 from 871 000 (633 000–1 139 000) in 1999. This reduction also makes a small but quantifi able contribution towards Millennium Development Goal 4 (MDG-4): the reduction of under-5 mortality by two-thirds by 2015. To achieve MDG-4, the international community and governments will have to reach more children with existing and new life-saving interventions. In the fi rst 5 years of eff orts to reach the goal of MDG-4, measurable results in reducing under-5 child mortality have been achieved mostly by expanding existing capabilities. The history of the expanded use of measles vaccine to reduce under-5 mortality provides lessons on how to eff ectively expand the reach and increase the eff ect of currently available interventions. Key factors have been: a clear and achievable goal; a proven technology and strategy; regular and comprehensive coordination and cooperation among the main actors; and documentation and dissemination of results to ensure quality of measles immunisation campaigns and sustained fi nancing. The renewed resolve and eff ort to realise the full potential of the measles vaccine predates the MDGs. The Pan American Health Organization showed what could be achieved on an international scale when in 1994 it resolved to eliminate indigenous measles from the Americas by 2000 through the expanded use of measles vaccine. Since November, 2002, there has not been endemic measles in the Americas. In 2000, the American Red Cross, Centers for Disease Control and Prevention (USA), UNICEF, the UN Foundation, WHO, the Canadian International Development Agency, and others discussed how the success in eliminating measles in the Americas might be duplicated in the rest of the world. The initial fi nancial and theoretical obstacles were formidable— measles most severely aff ects children in the poorest communities of countries with the least fi nancial and human resources, and widespread skepticism commonly dictates that poverty-stricken countries would be unable to duplicate what had worked in the Americas. To overcome these obstacles and harness much needed support, it was necessary to articulate an ambitious yet achievable goal, successfully coordinate key players, show proof of concept by successful imple mentation in selected countries, and document and disseminate successes to ensure quality and suffi cient funding. At the beginning of 2001, in consultation with partners, WHO and UNICEF, released their report. Their strategic plan, which was derived from the Pan American Health Organization strategy, put forward two primary goals: reduce annual measles mortality by half by 2005 from the 1999 baseline, and achieve and maintain measles elimination in countries and regions with an elimination goal (panel). 45 countries (34 in Africa) accounting for 94% of the global measles deaths in 1999, were targeted. In February, 2001, the Measles Initiative for Africa was established with American Red Cross, Centers for Disease Control and Prevention (USA), UN Foundation, UNICEF, and WHO as key founding members. To reduce deaths from measles, the Initiative was dedicated to funding and facilitating national measles campaigns across wide age-ranges (so-called catch-up campaigns) in the 34 target countries in Africa. In May, 2002, the UN General Assembly Special Session on Children adopted the measles mortality reduction goal and in May, 2003, the World Health Assembly endorsed Resolution WHO56·20 calling for all member states to achieve the goal. To ensure successful implementation of the campaigns, the Initiative began weekly conference calls open to all partners and governments. These calls promoted timely and open exchange of information and enhanced cooperation and coordination of multiagency eff orts. Other new mechanisms to ensure successful Published Online September 18, 2006 DOI:10.1016/S01406736(06)69335-5