Marta Gacic-Dobo

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.

Global routine vaccination coverage, 2014.

The year 2014 marked the 40th anniversary of the World Health Organization’s (WHO) Expanded Program on Immunization, which was established to ensure equitable access to routine immunization services (1). Since 1974, global coverage with the four core vaccines (Bacille Calmette- Guérin vaccine [BCG; for protection against tuberculosis], diphtheria-tetanus-pertussis [DTP] vaccine, poliovirus vaccine, and measles vaccine) has increased from <5% to ≥85%, and additional vaccines have been added to the recommended schedule. Coverage with the 3rd dose of DTP vaccine (DTP3) by age 12 months is an indicator of immunization program performance because it reflects completion of the basic infant immunization schedule; coverage with other vaccines, including the 3rd dose of poliovirus vaccine (polio3); the 1st dose of measles-containing vaccine (MCV1) is also assessed. Estimated global DTP3 coverage has remained at 84%–86% since 2009, with estimated 2014 coverage at 86%. Estimated global coverage for the 2nd routine dose of measles-containing vaccine (MCV2) was 38% by age 24 months and 56% when older age groups were included, similar to levels reported in 2013 (36% and 55%, respectively). To reach and sustain high immunization coverage in all countries, adequate vaccine stock management and additional opportunities for immunization, such as through routine visits in the second year of life, are integral components to strengthening immunization programs and reducing morbidity and mortality from vaccine preventable diseases.

WHO and UNICEF estimates of national infant immunization coverage: methods and processes

WHO and the United Nations Childrens Fund (UNICEF) annually review data on immunization coverage to estimate national coverage with routine service delivery of the following vaccines: bacille Calmette-Guérin; diphtheria-tetanus-pertussis, first and third doses; either oral polio vaccine or inactivated polio vaccine, third dose of either; hepatitis B, third dose; Haemophilus influenzae type b, third dose; and a measles virus-containing vaccine, either for measles alone or in the form of a combination vaccine, one dose. The estimates are based on government reports submitted to WHO and UNICEF and are supplemented by survey results from the published and grey literature. Local experts, primarily national immunization system managers and WHO/UNICEF regional and national staff, are consulted for additional information on the performance of specific immunization systems. Estimates are derived through a country-by-country review of available data informed and constrained by a set of heuristics; no statistical or mathematical models are used. Draft estimates are made, sent to national authorities for review and comment and modified in light of their feedback. While the final estimates may not differ from reported data, they constitute an independent technical assessment by WHO and UNICEF of the performance of national immunization systems. These country-specific estimates, available from 1980 onward, are updated annually.

Rubella and congenital rubella syndrome: global update

Worldwide, it is estimated that there are more than 100.000 infants born with congenital rubella syndrome (CRS) each year. In 1998, standard case definitions for surveillance of CRS and rubella were developed by the World Health Organization (WHO). In 2001, 123 countries/territories reported a total of 836.356 rubella cases. In the future more countries are expected to report on rubella as a global measles/rubella laboratory network is further developed under the coordination of WHO. Operational research is being conducted to improve rubella surveillance. This includes projects on initiating CRS surveillance, comparative studies on diagnostic laboratory methods, and molecular epidemiology research to expand the global understanding of patterns of rubella virus circulation. In 1996 a WHO survey found that 78 od 214 reporting countries/territories (36%) were using rubella vaccine in their routine immunization services. By the en of 2002 a total of 124 of the 214 counties/territories (58%) were using rubella vaccine. Rubella vaccine use varies by stage of economic development: 100% for industrialized countries, 71% for countries with economies in transition, and 48% for developing countries. A safe effective rubella vaccine is available, and there are proven vaccination strategies for preventing rubella and CRS. A WHO position paper provides guidance on programmatic aspects of rubella vaccine introduction. The introduction of rubella vaccine is cost-effective and cost-beneficial but requires ongoing strengthening of routine immunization services and surveillance systems.

Global immunization: status, progress, challenges and future

Vaccines have made a major contribution to public health, including the eradication of one deadly disease, small pox, and the near eradication of another, poliomyelitis.Through the introduction of new vaccines, such as those against rotavirus and pneumococcal diseases, and with further improvements in coverage, vaccination can significantly contribute to the achievement of the health-related United Nations Millennium Development Goals.The Global Immunization Vision and Strategy (GIVS) was developed by WHO and UNICEF as a framework for strengthening national immunization programmes and protect as many people as possible against more diseases by expanding the reach of immunization, including new vaccines, to every eligible person.This paper briefly reviews global progress and challenges with respect to public vaccination programmes. The most striking recent achievement has been that of reduction of global measles mortality from an estimated 750,000 deaths in 2000 down to 197,000 in 2007. Global vaccination coverage trends continued to be positive. In 2007 most regions reached more than 80% of their target populations with three doses of DPT containing vaccines. However, the coverage remains well short of the 2010 goal on 90% coverage, particularly in the WHO region of Africa (estimated coverage 74%), and South-East Asia, (estimated coverage 69%). Elements that have contributed to the gain in immunization coverage include national multi-year planning, district-level planning and monitoring, re-establishment of outreach services and the establishment of national budget lines for immunization services strengthening. Remaining challenges include the need to: develop and implement strategies for reaching the difficult to reach; support evidence-based decisions to prioritize new vaccines for introduction; strengthening immunization systems to deliver new vaccines; expand vaccination to include older age groups; scale up vaccine preventable disease surveillance; improve quality of immunization coverage monitoring and use the data to improve programme performance; and explore financing options for reaching the GIVS goals, particularly in lower-middle income countries. Although introduction of new vaccines is important,this should not be at the expense of sustaining existing immunization activities. Instead the introduction of new vaccine introduction should be viewed as an opportunity to strengthen immunization systems, increase vaccine coverage and reduce inequities of access to immunization services.Vaccines have made a major contribution to public health, including the eradication of one deadly disease, small pox, and the near eradication of another, poliomyelitis.Through the introduction of new vaccines, such as those against rotavirus and pneumococcal diseases, and with further improvements in coverage, vaccination can significantly contribute to the achievement of the health-related United Nations Millennium Development Goals.The Global Immunization Vision and Strategy (GIVS) was developed by WHO and UNICEF as a framework for strengthening national immunization programmes and protect as many people as possible against more diseases by expanding the reach of immunization, including new vaccines, to every eligible person.This paper briefly reviews global progress and challenges with respect to public vaccination programmes.The most striking recent achievement has been that of reduction of global measles mortality from an estimated 750,000 deaths in 2000 down to 197,000 in 2007. Global vaccination coverage trends continued to be positive. In 2007 most regions reached more than 80% of their target populations with three doses of DPT containing vaccines. However, the coverage remains well short of the 2010 goal on 90% coverage, particularly in the WHO region of Africa (estimated coverage 74%), and South-East Asia, (estimated coverage 69%). Elements that have contributed to the gain in immunization coverage include national multi-year planning, district-level planning and monitoring, re-establishment of outreach services and the establishment of national budget lines for immunization services strengthening.Remaining challenges include the need to: develop and implement strategies for reaching the difficult to reach; support evidence-based decisions to prioritize new vaccines for introduction; strengthening immunization systems to deliver new vaccines; expand vaccination to include older age groups; scale up vaccine preventable disease surveillance; improve quality of immunization coverage monitoring and use the data to improve programme performance; and explore financing options for reaching the GIVS goals, particularly in lower-middle income countries.Although introduction of new vaccines is important,this should not be at the expense of sustaining existing immunization activities. Instead the introduction of new vaccine introduction should be viewed as an opportunity to strengthen immunization systems, increase vaccine coverage and reduce inequities of access to immunization services.

Progress toward regional measles elimination - worldwide, 2000-2014.

In 2000, the United Nations General Assembly adopted the Millennium Development Goals (MDG), with MDG4 being a two-thirds reduction in child mortality by 2015, and with measles vaccination coverage being one of the three indicators of progress toward this goal.* In 2010, the World Health Assembly established three milestones for measles control by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) for children aged 1 year to ≥90% nationally and ≥80% in every district; 2) reduce global annual measles incidence to fewer than five cases per million population; and 3) reduce global measles mortality by 95% from the 2000 estimate (1).† In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan§ with the objective to eliminate measles in four World Health Organization (WHO) regions by 2015. WHO member states in all six WHO regions have adopted measles elimination goals. This report updates the 2000–2013 report (2) and describes progress toward global control and regional measles elimination during 2000–2014. During this period, annual reported measles incidence declined 73% worldwide, from 146 to 40 cases per million population, and annual estimated measles deaths declined 79%, from 546,800 to 114,900. However, progress toward the 2015 milestones and elimination goals has slowed markedly since 2010. To resume progress toward milestones and goals for measles elimination, a review of current strategies and challenges to improving program performance is needed, and countries and their partners need to raise the visibility of measles elimination, address barriers to measles vaccination, and make substantial and sustained additional investments in strengthening health systems.

Progress Toward Control of Rubella and Prevention of Congenital Rubella Syndrome—Worldwide, 2009

Rubella, usually a mild rash illness in children and adults, can cause serious consequences when a pregnant woman is infected, particularly in early pregnancy. These serious consequences include miscarriage, fetal death or an infant born with birth defects (i.e., congenital rubella syndrome (CRS)). The primary purpose for rubella vaccination is the prevention of congenital rubella infection including CRS. Since 1969, several rubella virus vaccines have been licensed for use; however, until the 1990s, use of rubella-containing vaccine (RCV) was limited primarily to developed countries. In 1996, it was estimated that 110,000 infants with CRS were born annually in developing countries. In 2000, the first World Health Organization rubella vaccine position paper was published to guide introduction of RCV in national childhood immunization schedules. From 1996 to 2009, the number of countries that introduced RCV into their national routine childhood immunization programs increased by 57% from 83 countries in 1996 to 130 countries in 2009. In addition, three of the six WHO regions established rubella control and CRS prevention goals: Region of the Americas and Europe rubella elimination by 2010 and 2015, respectively, and Western Pacific Region-accelerated rubella control and CRS prevention by 2015. Also, during this time period, the number of rubella cases reported decreased from 670,894 in 2000 to 121,344 in 2009. Rubella control and prevention of CRS can be accelerated by integrating with current global measles mortality reduction and regional elimination activities.

Global Progress Toward Rubella and Congenital Rubella Syndrome Control and Elimination - 2000-2014.

Rubella virus usually causes a mild fever and rash in children and adults. However, infection during pregnancy, especially during the first trimester, can result in miscarriage, fetal death, stillbirth, or a constellation of congenital malformations known as congenital rubella syndrome (CRS). In 2011, the World Health Organization (WHO) updated guidance on the preferred strategy for introduction of rubella-containing vaccine (RCV) into national routine immunization schedules, including an initial vaccination campaign usually targeting children aged 9 months-15 years . The Global Vaccine Action Plan endorsed by the World Health Assembly in 2012 and the Global Measles and Rubella Strategic Plan (2012-2020) published by Measles and Rubella Initiative partners in 2012 both include goals to eliminate rubella and CRS in at least two WHO regions by 2015, and at least five WHO regions by 2020 (2,3). This report updates a previous report and summarizes global progress toward rubella and CRS control and elimination during 2000-2014. As of December 2014, RCV had been introduced in 140 (72%) countries, an increase from 99 (51%) countries in 2000 (for this report, WHO member states are referred to as countries). Reported rubella cases declined 95%, from 670,894 cases in 102 countries in 2000 to 33,068 cases in 162 countries in 2014, although reporting is inconsistent. To achieve the 2020 Global Vaccine Action Plan rubella and CRS elimination goals, RCV introduction needs to continue as country criteria indicating readiness are met, and rubella and CRS surveillance need to be strengthened to ensure that progress toward elimination can be measured.

Global use of rubella vaccines, 1980-2009.

In most developing countries, rubella vaccine has not been included in the Expanded Programme on Immunization because of lack of information on the burden of disease caused by rubella virus, increased cost associated with adding rubella vaccine, and the concern that if high vaccine coverage cannot be achieved and maintained, the risk of congenital rubella syndrome (CRS) may increase. Data for 2009 reported by countries to the World Health Organization (WHO) and United Nations Childrens Fund through the annual Joint Reporting Form were used to indicate patterns in the worldwide use of rubella vaccines, describe the number of reported rubella and CRS cases by WHO Region, and explore factors associated with decisions by countries to introduce rubella vaccine in their national childhood immunization programs. The number of WHO Member States using rubella-containing vaccine (RCV) in their national childhood immunization schedule increased from 83 (43%) in 1996 to 130 (67%) in 2009. Although scheduled ages for rubella vaccination vary across countries and regions, most countries have a 2-dose schedule using a combined measles-mumps-rubella vaccine. Among 130 countries using RCV in 2009, median coverage with the first dose of measles-containing vaccine (MCV1) was 95% (interquartile range [IQR], 90%-98%), compared with a median MCV1 coverage of 76% (IQR, 64%-88%) in countries not using RCV. The median per capita gross national income among 130 countries using RCV was US

A mid-term assessment of progress towards the immunization coverage goal of the Global Immunization Vision and Strategy (GIVS)

6300 (IQR,