Challenges in Measles Outbreak Responses

MSF Perspectives

Florence Fermon - Myriam Henkens10th Annual Measles Initiative Meeting

14/09/2011

Measles resurgence in Africa

• Resurgence comes after a period of intensified efforts – Since 2000, routine measles vaccination coverage has

increased from an estimated 52% to 85%

• In 2009, 30 African countries experienced measles outbreaks – >60,000 reported cases and >1000 reported deaths (WHO)

• In 2010, 28 countries experienced measles outbreaks – 223,000 reported cases and 1200 deaths (WHO)

• Real numbers of measles cases and deaths are considerably larger than the numbers reported

• WHA resolution (RC61) calls for measles elimination in AFRO by 2020

Why the resurgence?

1. Build-up of susceptible children and adolescents

2. Failure to vaccinate rather than vaccine failure

3. Programmatic, political and financial challenges

1. Susceptibility build up

• Two sources of immunity• Natural immunity due to infection

• Vaccine derived immunity

• As vaccination increases • Less circulating virus

• Age distribution of cases changes - a natural consequence of the success of vaccination programs

– Children (on average) are older when they become infected

Different age distributions

Malawi: 2010

Burkina Faso: 2009

Niger: 2004DRC: 2006In endemic countries, outbreaks are limited to young age classes.

Outbreaks in countries following “elimination” extend evenly age classes

Countries in transition are intermediate

Source: courtesy Matthew Ferrari

2. Failure to vaccinate rather than vaccine failure

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20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

2002 2003 2004 2005 2006 2007 2008 2009 2010

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Source: VC(WHO 2002-2009 and MICS 2010), cases: Rapports épidémiologiques annuels, 4ème direction, RDC

Programmatic, political and financial challenges

• Measles victims of MI success and outbreak responses low on politicians and donors agenda

• Delays/reluctance in implementing outbreak responses, despite international recommendations

• Lack of efficient coordination• Lack of rapid funding

• Delays in implementing campaigns - SIAs – despite strong international support (vaccines and operating costs)DRC 2010 => outbreak 2011

MSF & measles outbreak responses

Surveillance, treatment, vaccination (when authorized)• 2009: Chad, Ethiopia, DRC, Pakistan, Bangladesh,

Nigeria, Sudan, Burkina Faso– 1.4 million vaccinated, 202 000 treated

• 2010: Malawi, Chad, DRC, Ethiopia, Yemen, Zimbabwe, Mozambique, Burundi, South Africa, Somalia, Zambia– 4.6 million vaccinated 190 000 treated

• 2011: DRC Bangladesh Burundi, Chad, Ethiopia, Kenya, Niger, Somalia, Zambia– already 3 million vaccinated in DRC only, more than 4 million

total in August – More than 50 000 treatments in DRC only

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

5000000

2004 2005 2006 2007 2008 2009 2010 2011

Measles outbreak responses in Africa 2004-2011Persons vaccinated – MSF On going

- DRC- Burundi- Chad- Ethiopia- Kenya- Niger- Nigeria- Somalia- Zambia

Challenges

1. Outbreak detection and recognition

2. Outbreak response plan

3. Outbreak response implementation

4. Outbreak prevention

1. Outbreak detection & recognition

• Inaccurate (inflated) vaccination coverage data biased risk assessment

• Weak surveillance system late detection of increase in case number

• Outbreaks = “failure to vaccinate” late official recognition of outbreak (MOH and main actors)

• But outbreaks do and will occur in many countries

Measles resurgence in Europe/USA

2. Outbreak response plan

• Lack of knowledge of the WHO recommendations

• Lack of knowledge of the usefulness of vaccination in outbreak

• No standard tools nor technical recommendations for reactive campaigns

• Lack of organized technical support (measles >< polio or meningitis)

3. Outbreak response implementation

• Coordination between the different partners

• Competition with other priorities (polio campaigns)

• Free treatment, increased access to treatment

• Timely vaccines availability

• Timely funding

4. Outbreak prevention

• Maintain the number of susceptibles as low as possible

• EPI– Flexibility in age range– Immunization included in comprehensive package of

care – Special approach to reach children never vaccinated

(“reach the un reached”)– Reduce missed opportunities (surveys, health care

contacts, etc)– More accurate data in performance, coverage, etc

Reaching the unreached

BeforeCampaign

AfterCampaign

2005 2010 2005 2010

Card %(95% CI)

7.6 (6.3-8.9)

5.5 (4.1-5.6)

53.0 (50.6-55.4)

40.2 (36.9-43.5)

Card/Recall %(95% CI)

33.0 (30.9-35.1)

68.7 (66.7-70.7)

80.6 (78.6-82.6)

81.1 (79.8-82.4)

Vaccination coverage before and after campaign (6-59 m), Ndjamena, Chad

Lessons learned, N’djamena, Chad

• Chronically low vaccine coverage – Failure to reach older children through routine

services – Measles-susceptibles built up and to

precipitate the 2010 epidemic• 18% received their first dose in 2010

– previously vaccinated children were easier to reach during the outbreak than unvaccinated children

Missed opportunities

• CAR - Paoua and Congo Brazza - Betou (MSF - 2010)– limited access to care areas– children were not offered vaccination (in or

outpatients)– 0 to 11 m: 65 to 94% were not immunized

according to recommendations – 12 to 59 m: 86% to 98% were not immunized

and could not be according to the EPI schedules

4. Outbreak prevention (2)

• SIA / vaccination campaign– Implement TAG recommendations and adjust

age group to local epidemiology– Fixed duration of campaigns >< coverage

reached– Adapt SIA intervals to needs – Accurate data collection – Independent coverage surveys– Implementation according to plan (DRC 2010)

What could be done?

• Outbreak response included as a component of the Measles Initiative

• Outbreak response included into national control programs

• Renewed political and financial commitment • Strategies to ensure countries implement SIAs according

to plan

• Improved coordination in country – Meningitis and Polio could be used as example

• Limitations / constraints of implementing recommended strategies should be acknowledged

What could be done? (2)• Creative strategies

– to reduce the missed opportunities, – to reach the unreached

• Consider multi Ag campaign (polio, MenA conj, etc)

• Develop a risk assessment tool (susceptible population, social determinants, operational strategy)

• Develop supporting tools/documents (WHO 2009 recommendations in French, practical accompanying document)

• Financial mechanism for rapid response

• New vaccines (easy to administer, no cold chain, etc)

Acknowledgments

• MSF teams – field and HQ• Epicentre (Rebecca Grais, Andrea Minetti)• Matthew Ferrari

Thank You For Your Attention