Do we need a measles Do we need a measles vaccine stockpile for more vaccine stockpile for more effective measles outbreak effective measles outbreak

response?response?

Do we need a measles Do we need a measles vaccine stockpile for more vaccine stockpile for more effective measles outbreak effective measles outbreak

response?response? Global Measles and Rubella Management MeetingGlobal Measles and Rubella Management Meeting

  Salle B, WHO Headquarters, Geneva, Switzerland, 15 - 17 March 2011Salle B, WHO Headquarters, Geneva, Switzerland, 15 - 17 March 2011

Maya Van den Ent, PharmD, MPHMaya Van den Ent, PharmD, MPH

Robin Nandy, MBBS, MPHRobin Nandy, MBBS, MPH

Edward Hoekstra, MD. MScEdward Hoekstra, MD. MSc

Measles and Emergencies , Health Section, UNICEF HQMeasles and Emergencies , Health Section, UNICEF HQ

Measles EmergenciesMeasles Emergencies

Disasters

Measles Outbreaks

Funding Disasters through emergency funding

Funding Disasters through emergency funding

Measles vaccination campaign part of initial response

-SPHERE

-Core Commitments For Children

Measles Outbreak ResponseMeasles Outbreak Response

http://whqlibdoc.who.int/hq/2009/WHO_IVB_09.03_eng.pdf

WHO Measles Outbreak Response Guidelines (2009)

WHO Measles Outbreak Response Guidelines (2009)

Critical Aspects Of Measles Outbreak Response Immunisation

Critical Aspects Of Measles Outbreak Response Immunisation

Timing– As soon as possible after confirmation of the outbreak

Age range– Based on susceptibility profile, analysis of outbreak data, etc

Geographical area– Affected areas plus adjacent areas– Other high risk areas or population groups

Campaign coverage/quality

Proportion Cases Prevented By Intervention Coverage & Time: 6 – 59 m, Niamey, Niger

Proportion Cases Prevented By Intervention Coverage & Time: 6 – 59 m, Niamey, Niger

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30 40 50 60 70 80 90 100

Intervention Coverage(%)

Pro

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ases

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2 months 3 months

4 months +6 months

Proportion Cases Prevented By Intervention Coverage & Time: 6 – 15 y, Niamey, Niger

Proportion Cases Prevented By Intervention Coverage & Time: 6 – 15 y, Niamey, Niger

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30 40 50 60 70 80 90 100Intervention Coverage(%)

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4 months

Overview Of Recent Outbreaks & Response Efforts

Overview Of Recent Outbreaks & Response Efforts

Measles Outbreaks in AfricaMeasles Outbreaks in Africa

Small fraction of number of cases compared to pre-SIA era

28 countries experience outbreaks in June 2009 – Dec 2010

– Malawi, S. Africa, Zimbabwe, Zambia, Lesotho, Nigeria, DRC, Angola…

– > 200,000 reported cases– > 127,000 confirmed cases– > 1,400 measles deaths

Reported Measles Cases by Month andWHO Regions, 2006-2010

0

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Apr Jul Oct Jan2007

Apr Jul Oct Jan2008

Apr Jul Oct Jan2009

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AFR SEAR AMR EMR EUR WPR

Measles deaths, June 2009 – Dec 2010 (n = 1,463)Measles deaths, June 2009 – Dec 2010 (n = 1,463)

Type of Outbreak Response Immunization (ORI) by Number of Confirmed Cases

Type of Outbreak Response Immunization (ORI) by Number of Confirmed Cases

Timing Of Outbreak Response Immunization*Timing Of Outbreak Response Immunization*

Time period between

confirmation of outbreak and ORI

# of countries

Countries

0-3 months1Rwanda

3 – 6 months6Burundi, Cameroon, Chad, Ethiopia, Namibia, Senegal, Zambia

> 6 months5South Africa, Swaziland, Zimbabwe

Malawi, Lesotho (Nationwide)

Unknown12Benin, Botswana, DRC, Ghana, Liberia, Mali, Niger, Nigeria, Tanzania, Togo,Lesotho, Malawi (Initial local response)

*Outbreaks reported cases between June 2009 and Dec 2010

Estimated Number of Doses Used for Outbreak Response in 2010

Estimated Number of Doses Used for Outbreak Response in 2010

About 30 million doses

About $11 million for bundled vaccines

IssuesIssues

Lack of capacity and preparedness

Insufficient use of Government Emergency funds

Measles not always included in preparedness plans

Is a stockpile the solution?Learning from Meningitis

Is a stockpile the solution?Learning from Meningitis

Global Stockpile MeningitisGlobal Stockpile Meningitis

Global shortage of vaccines as compared to demand

– Mechanism to ensure access for most in need

Processing requests full time job during outbreak season

– WHO-HQ hosts ICG secretariat – ICG: IFRC, MSF, UNICEF and WHO

Time between outbreak and response : 4 - 8 weeks

Measles Stockpile?Measles Stockpile?

Measles stockpile – Make funding available to respond to outbreaks– Questionable whether donors are willing to fund

Where should it be managed?– At global level?– In AFRO?– At national level?

What are criteria for allocation?

Does stockpile address the current problems?

Stockpile Managed at Global/Regional Level

(The Meningitis & YF Model)

Stockpile Managed at Global/Regional Level

(The Meningitis & YF Model)Requires:

Clear decision mechanism– Outbreak investigation standards– Risk analysis standards– Outbreak response standards

Interagency decision body

Emergency shipping mechanism

Monitoring and Evaluation

Pros and ConsStockpile Managed at Global / Regional Level

Pros and ConsStockpile Managed at Global / Regional Level

Pros

Enabling systematic outbreak response

Response time can be short, if mechanism well developed

Potential new source of funds

Cons

No country ownership

Time consuming at global level

Possible disincentive for other non contributing donors to support outbreak response

May detract countries from focusing on improving the quality of routine programmes

Stockpile Managed at National LevelStockpile Managed at National Level

Requires:

Full country buy-in to reserve % of RI stock for outbreak response preparedness

Pros

Country buy in

Part of program planning & preparedness

Faster response, as vaccines are already in country

Cons

Quality of outbreak response depending on country level understanding of ORI

Local politics may interfere in decision making

Difficult to monitor & follow up from global & regional level

Pros and Cons Stockpile Managed at National Level

Pros and Cons Stockpile Managed at National Level

QuestionsMeasles Stockpile?

QuestionsMeasles Stockpile?

Can we raise the funds?– $ 10 - 15 million annually– Revolving Fund?

What is the best mechanism?– Global / Regional vs National– Country/region specific?

Will the stockpile address the problems in Outbreak Response Immunization?

AcknowledgementsAcknowledgements

EPICENTRE– Rebecca Freedman-Grais

WHO– Peter Strebel– Alya Dabbagh– Balcha Masresha– William Perea– ICG secretariat

CDC– Robb Linkins

UNICEF– Robin Nandy– Rouslan Karimov

Extra slidesExtra slides

Simulated Measles Cases In Niamey, Niger (2003-2004)

Simulated Measles Cases In Niamey, Niger (2003-2004)

8.1%[ 4.9 ,8.9 ]averted with intervention on day 161

Reasons for outbreaksReasons for outbreaks

1. Still gaps in routine immunization coverage

2. Suboptimal coverage during recent SIAs (ZIM, NAM, ANG, BOT)

3. Too long (> 3 yrs) interval between SIAs (ZAM, LES, SEN)

4. Pockets of unvaccinated & resistant populations (ZIM)

5. Lower demand due to disappearing disease

6. Accumulation of susceptibles in older age groups

Type Of Outbreak Response Immunization*Type Of Outbreak Response Immunization*

Outbreak Response Immunization (ORI)Type

# of countries

Countries

No ORI7Angola, Burkina Faso, Cote d’Ivoire, Guinea Conakry, Mauritania, Sierra Leone

Selective ORI (6/9m – 59 m) in affected areas

6Benin, Botswana, Ghana, Mali, Mozambique (some DS) Nigeria, Zambia

Non Selective ORI (6/9m – 59 m) in affected areas

5Cameroon, Chad, Ethiopia, Senegal, Togo

Non selective wide age range ORI (6/9m – 14 y) in affected areas

4Burundi, DRC, Lesotho, Malawi

Nationwide ORI (6/9m – 59 m)

2Liberia, Swaziland

Nationwide wide age range ORI (6/9m – 14 y)

4South Africa, Zimbabwe, Lesotho, Malawi, following initial limited ORI

ORI with unknown age range

6Kenya, Mozambique (some DS), Namibia, Niger, Rwanda, Tanzania

*Outbreaks reported cases between June 2009 and Dec 2010

Measles reported cases, 2009-2010 (1 dot = 50 cases)Measles reported cases, 2009-2010 (1 dot = 50 cases)

Measles confirmed cases, 2009-2010 (1 dot = 50 cases)Measles confirmed cases, 2009-2010 (1 dot = 50 cases)