Global Measles Rubella Update

Katrina Kretsinger, MD, MA WHO/IVB/EPI

Strategic Advisory Group of Experts on Immunization Meeting October 8, 2019

Geneva, Switzerland

Measles and Rubella TargetsGlobal: World Health Assembly, 2010

Milestones by 2015:

1. MCV1 coverage ≥ 90% national & ≥ 80% in every district

2. Measles reported incidence <5 cases/million

3. Measles mortality reduction of 95% vs. 2000

Regional elimination: GVAP, 2012By 2020:Elimination of measles & rubella in 5 WHO Regions

2018 report:

Milestones:

1. 118 (61%) Member States achieved ≥ 90% coverage; 57 (29%) MS achieved ≥ 80% in every district

2. Reported incidence 50 cases / million

3. 2017: 80% reduction estimated mortality vs 2000

Regional elimination:

• No Regions measles-eliminated

• One Region (PAHO) rubella-eliminated

Global Measles Vaccine Coverage FlatMeasles containing vaccine 1st dose (MCV1) coverage by WHO region, 1980-2018

Source: WHO/UNICEF coverage estimates 2018 revision, July 2019.Immunization Vaccines and Biologicals, (IVB), World Health Organization (WHO).194 WHO Member States. Date of slide: 08 July 2019.

86%

Steady Increases in Measles Second Dose Number of countries having introduced 2nd dose of measles containing vaccines (MCV2) and global MCV2 coverage, 2000-2018

Source: WHO/UNICEF coverage estimates 2018 revision, July 2019, and WHO database, as at 01 July 2019.Immunization Vaccines and Biologicals, (IVB), World Health Organization (WHO).194 WHO Member States. Date of slide: 08 July 2019.

2018 introductions: Bolivia, Dominican Republic, Honduras, Solomon Islands

69%

Dramatic Increases in Rubella Vaccine Coverage Number of countries having introduced rubella containing vaccines and global infant coverage of 1st dose of rubella containing vaccines (RCV1)*, 1989-2018

Source: WHO/UNICEF coverage estimates 2018 revision, July 2019, and WHO database as at 01 July 2019.Immunization Vaccines and Biologicals, (IVB), World Health Organization (WHO).194 WHO Member States. Date of slide: 08 July 2019.

*coverage estimates for the 1st dose of rubella containing vaccines are based on WHO and UNICEF estimates of coverage of measles containing vaccines.

2018 introductions: Angola, Côte d'Ivoire, Eritrea, Mozambique, Mauritania, Togo

69%

Countries with rubella vaccine in the national immunization programme, and planned introductions in 2019

21 countries still to introduce

80% Reduction in Estimated Global Measles Deaths, 2000-2017

21.1 million deaths prevented from 2000-2017 by measles vaccination

545,174

109,638

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2017 Estimated Deaths by Region

AFR AMR EMR EUR SEAR WPR

Italy bans unvaccinated children from schools

Anti-vaxx 'mobs'

Lawmakers to propose bill to

allow teens to get vaccinated without parental consent

States seek to force parents

to vaccinate children

New York measles outbreak

prompts state of emergency

Anti-vaxxers' must not be given credence

Philippines measles outbreak fed by

distrust of vaccinesAnti-vaxxers distract from a more serious th

reat

TEDROS ADHANOM GHEBREYESUS

Many parents aren’t afraid of so

cial media trolls but sim

ply can’t access or afford vaccine

‘Dramatic resurgence’ of measles seen in Europe, WHO reports

Global measles cases three times higher than last year

UK loses measles elimination

status after vaccine use drops

Retour en force de la rougeole en Europe,

l'OMS appelle à intensifier la vaccination

El sarampión resurge con fuerza

en Europa, según la OMS

US may soon lose measles

elimination status, CDC says

Increases in Reported Measles CasesMeasles global annual reported cases and MCV1 and MCV2* coverage, 1980-2018

2018 reported measles cases = 353,236

Data source: JRF annual data

2019 reported measles cases (through Sept 7, 2019) = 401,024

Same time in 2018, 154,588 cases

Data source: Monthly surveillance data

2017 reported measles cases = 173,330

Data source: JRF annual data

2018 estimated total measles cases = 9.8 million (95% CI: 6.4 M – 40.5M)Data source: WER, submitted for publication

2016: 18 reported cases / million

125 countries w incidence < 5 / million33 countries w incidence ≥ 10 / million

2018: 50 reported cases / million

96 countries w incidence < 5 / million75 countries w incidence ≥ 10 / million

Increase in Measles Incidence, 2016-2018

Source: IVB/WHO

Increases in all Regions 2017-2018 Reported number of measles cases by Region, 2000-2018

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Measles case distribution by month and WHO Region (2015-2019)

Notes: Based on data received 2019-08 - Data Source: IVB Database - This is surveillance data, hence for the last month(s), the data may be incomplete.

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2019 monthly measles cases: Surge in cases reported from Madagascar and Ukraine

Measles Incidence Rate per Million(August 2018 – July 2019)

Top 10**

Country Cases RateMadagascar 151032 6066.87

Ukraine 81964 1844.43

India**** 76588 57.84

Philippines 46689 451.89

Nigeria 27195 146.22

Brazil 11573 55.73

Kazakhstan 10015 556.77

DR Congo 9378 119.11

Thailand 7544 109.55

Pakistan 6510 33.7

Other countries with high incidence rates***

Country Cases RateGeorgia 4812 1225.86

The Republic of North Macedonia 1897 911.49

Kyrgyzstan 2898 486.59

Israel 3914 477.79Bosnia and

Herzegovina 1377 391.55

Lithuania 793 272.67

Notes: Based on data received 2019-09 and covering the period between 2018-08 and 2019-07 - Incidence: Number of cases / population* * 1,000,000 - * World population prospects, 2019 revision - ** Countries with the highest number of cases for the period - *** Countries with the highest incidence rates (excluding those already listed in the table above) ****WHO classifies all suspected measles cases reported from India as measles clinically compatible if a specimen was not collected as per the algorithm for classification of suspected measles in the WHO VPD Surveillance Standards. Thus numbers might be different between what WHO reports and what India reports.

Measles cases from countries with known discrepancies between case-based and aggregate surveillance, as reported by country

Country Year Cases in Case-based

Cases in Aggregate Data Source for aggregate #s

DR Congo 2018 5624 65,098 SITUATION EPIDEMIOLOGIQUE DE LA ROUGEOLE EN RDC, Week of 27/08/20192019 7094 161,397

Somalia 2018 131 9,135 Somali EPI/POL Weekly Update Week 342019 28 2,870

Selected Measles Outbreaks: Reported Cases over Past 24 Months (August 2017- July 2019)

Philippines:many years of

low coverage in a federal system exacerbated by

Dengvaxiaconcerns

Ukraine: it’s complicated

China: Historic and unprecedented

successes

Israel: Multiple

importations

Yemen: conflict setting

Thailand: Unaddressed immunity gaps

DR Congo*: endemic

transmission w low

population immunity Madagascar:

Classic island epidemiology

USA: high measles

coverage, pockets of low

coverage. Multiple

importations Venezuela: collapse of health system

Brazil: cross-border importations into

underserved region

India: Improved surveillance

Vaccine Pressure Affecting Genotype Diversity

Distribution of measles genotypes (August 2018 – July 2019)

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Age Range and Vaccination Status of Measles Cases, Global, 2013-2018 (N=912,860)

0 doses 1 dose 2 or more doses Unknown vaccination status

59,180

322,017

151,337

66,92480,838

160,008

63,401

10/10/2019 | Source of data: WHO measles case-based surveillance data, 2013-2018 16

Patel et al. Submitted for publication

Wide Age Distribution of Measles Cases: Most Un- or Under-vaccinated

Age Distribution % of total infants <1 year 18%

children 1-<5 years 35%

children 5-<10 years 17%

adolescents and adults >=10 years

30%

Unknown 0.5%

Zero MCV doses: 69% of cases w known vaccination status

9,161

17

• Lack of confidence in vaccination may be growing among key subgroups

• Access and practical factors still most predominant barrier

• Under-vaccination requires a valid diagnosis

• Multi-component and tailored strategies are most effective

Barriers Related to Access or Attitudes?

Measles exportations: a glimpse into an expanding problem

Source: MeaNS database, queried 9/30/2019 18

Source country Separate reports of recent travel from source country

Number of countries with reports from source country

Ukraine 75 22Thailand 53 20Venezuela 52 3Romania 51 15Philippines 49 13India 39 12Italy 38 15France 31 10Indonesia 30 9Pakistan 24 8Russian Federation 22 10

Methods • Measles Nucleotide Surveillance (MeaNS)

of the Global Measles Rubella Laboratory Network (GMRLN) queried

• N450 sequences reported 01/01/2017 –09/30/2019

Results• 18,733 sequences reported

• 2% of approx 930,000 measles cases reported over same time period

• 780 (4%) sequences with “recent travel history”

Limitations of data • Non-representative due to reporting bias

• Limited to reported measles cases with genotype sequence reported AND epidemiologic travel information collected

• Patient report of travel history may not accurately reflect source of infection

Measles anywhere is measles everywhere!

Why Now? Cause(s) of Measles Up-swing

Ø Root Cause: Gaps in population immunity due to insufficient vaccine coverage

ü Weak and fragile health systems in many countries

ü Civil unrest, famine, active conflict, socio-economic/political crisis

ü Changing attitudes, access, and service quality

ü Susceptibility distributed across wide age groups

ü Outbreaks affecting sub-groups: adolescents / adults, migrants, indigenous, religious groups

ü Variable political commitment to vaccination

Ø Global spread

ü Increasing interconnectedness through international travel

ü Measles virus highly infectious; incubation period 7-21 days; infectious up to 4 days prior to rash

ü Outbreaks in countries with high international travel create pressure on high-performing countries

Ø Director General and World Health Emergencies (WHE) engaged• Vaccine Summit (Sept 2019, Brussels, co-hosted with EU)• Stronger communications and outreach, e.g., Member States,

media, key messages, traveler guidance Ø Improved outbreak response

Ø Coordination with Regions and partnersØ Grading and response to measles outbreaks (e.g., grade 2

measles emergencies: EUR, Madagascar, DR Congo, Lebanon) Ø Measles Outbreaks Incident Management Support Team (IMST)

Ø WHO’s Strategic Technical Advisory Group for Infectious Hazards (STAG-IH) to review measles situation

WHO Response to Global Measles Outbreaks

Rubella Case Distribution by Month and WHO Region (2015-2019)

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Notes: Based on data received 2019-09 - Data Source: IVB Database - This datais surveillance , hence for the last month(s), the data may be incomplete.

Progress and Setbacks in Measles Rubella EliminationRegional Scorecard on Verification of Elimination, October 2019

WHO Region(No. Member States)

Regional Verification

Commissions Established

Elimination Achieved Re-established

No. of MS (areas) % of MS

Americas (n=35) Yes Measles: 33Rubella: 35

94%100%

VenezuelaBrazil

Europe (n=53) Yes Measles: 35Rubella: 39

66%74%

Albania, Czech Republic, Greece, United Kingdom

Western Pacific (n=27) Yes Measles: 7 (2)Rubella: 4 (1)

26%15%

Mongolia

Eastern Mediterranean (21) Yes Measles: 3Rubella: 3

14%14%

South-East Asia (n=11) Yes Measles: 5 45%

Africa (n=47) Yes - -

TOTAL (n=194) Measles: 83 (43%)Rubella: 81 (42%)

EUR: 1 (2%) additional countries interrupted measles transmission fr >12 m but <36 m.3 (6%) additional countries interrupted rubella transmission for >12 m but <36 m.

WPR: 2 reporting entities verified for measles elimination; 1 reporting entity verified for rubella elimination SEAR: 6 member states verified as having achieved control of rubella

SummarySubstantial progress in measles and rubella control since 2000

• Global number of cases and estimated deaths significantly reduced• 83 countries verified as measles eliminated; 21 million deaths averted• 81 countries verified as rubella eliminated• More countries with rubella vaccine and measles second dose introduced

Concerns• Resurgence of measles in all regions• Increasing vulnerability of countries with strong programs and high coverage

Recent trends highlight • Measles – gains are fragile

• Very infectious and will find pockets of susceptibility • Regional measles elimination can be achieved but difficult to sustain

• Rubella – gains appear to be very robust

Need for concerted global, regional and national commitment to achieve and sustain goals

10/10/2019 | Title of the presentation 25

AcknowledgementsMick Mulders

Yoann Nedelac

Kate O’Brien

Walter Orenstein

Minal Patel

Robert Perry

Susan Reef

Will Schluter

Stephanie Shendale

Claudia Steulet

Nikki Turner

Susan Wang

Narendra Arora

Ma Chao

Shalini Desai

Laure Dumolard

David Durrheim

Marta Gacic-Dobo

Deepa Gamage

Tracey Gooodman

Joachim Hombach

Ann Lindstrand

Lisa Menning

Bill Moss

Thank you!