Vaccine 36 (2018) A35–A42 Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Measles and Rubella Global Strategic Plan 2012–2020 midterm review report: Background and summary q Walter A. Orenstein a,⇑, Lisa Cairns b, Alan Hinman c, Benjamin Nkowane d, Jean-Marc Olivé e, Arthur L. Reingold f a Emory Vaccine Center, Emory University School of Medicine, Emory University, 1462 Clifton Road NE, Suite 446, Atlanta, GA 30322, USA 2650 Bowker Avenue, Victoria, Canada Center for Vaccine Equity, The Task Force for Global Health, 325 Swanton Way, Decatur, GA 30030, USA d 40 chemin des Pralies, 1279 Bossey, Switzerland e Wellenau 11, 6900 Lochau, Austria f 101 Haviland Hall, School of Public Health, University of California, Berkeley, CA 94720, USA b c a r t i c l e Keywords: Immunization Measles Rubella Evaluation Recommendations i n f o a b s t r a c t Measles, a vaccine-preventable illness, is one of the most infectious diseases known to man. In 2015, an estimated 134,200 measles deaths occurred globally. Rubella, also vaccine-preventable, is a concern because infection during pregnancy can result in congenital defects in the baby. More than 100,000 babies with congenital rubella syndrome were estimated to have been born globally in 2010. Eradication of both measles and rubella is considered to be feasible, beneficial, and more cost-effective than high-level control. All six World Health Organization (WHO) regions have measles elimination goals by 2020 and two have rubella elimination goals by that year. However, the World Health Assembly has not endorsed a global eradication goal for either disease. In 2012, the Measles and Rubella Initiative published a Global Measles and Rubella Strategic Plan, 2012–2020, referred to hereafter as the Plan, which aimed to achieve measles and rubella elimination in at least five WHO regions by end-2020 through the implementation of five core strategies, with progress evaluated against 2015 milestones. When, by end-2015, none of these milestones had been met, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) recommended a mid-term review of the Plan to evaluate progress toward goals, assess the quality of strategy implementation, and formulate lessons learned. A five-member team reviewed documents and conducted interviews with stakeholders as the basis for the review’s conclusions and recommendations. This team concluded that, although significant progress in measles elimination had been made, progress had slowed. It recommended that countries continue to work toward elimination goals with a focus on strengthening ongoing immunization systems. In addition, it concluded that the strategies articulated in the Plan were sound, however full implementation had been impeded by inadequate country ownership and global political will, reflected in inadequate resources. Detailed recommendations for each of the Plan’s five strategies as well as the areas of polio transition, governance and resource mobilization are outlined. Ó 2017 World Health Organization; licensee Elsevier Ltd. This is an open access article under the CC BY IGO license (http://creativecommons.org/licenses/by/3.0/igo/). 1. Background 1.1. General considerations q This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL. ⇑ Corresponding author. E-mail addresses: worenst@emory.edu (W.A. Orenstein), karenlisacairns@gmail. com (L. Cairns), ahinman@taskforce.org (A. Hinman), drnkowa@gmail.com (B. Nkowane), jmjolive@gmail.com (J.-M. Olivé), reingold@berkeley.edu (A.L. Reingold). In 2016, a midterm review of the Measles and Rubella Initiative’s (M&RI’s)1 Global Measles and Rubella Strategic Plan, 2012–2020 (‘the Plan’) was undertaken at the request of the World Health Organization’s (WHO’s) Strategic Advisory Group of Experts on Immunization (SAGE). The purpose of this article is to summarize 1 The M&RI is a consortium led by WHO, the United Nations Children’s Fund, the United States Centers for Disease Control and Prevention, the United Nations Foundation, and the American Red Cross. https://doi.org/10.1016/j.vaccine.2017.10.065 0264-410X/Ó 2017 World Health Organization; licensee Elsevier Ltd. This is an open access article under the CC BY IGO license (http://creativecommons.org/licenses/by/3.0/igo/). A36 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42 the major findings and recommendations of that review, the report of which is published in toto in (Vaccine, Volume 35, Supplement 3). As the audience for this article may encompass those with an interest in overall health delivery systems and not solely measles and rubella experts, basic information on measles and rubella and their control is included here. Measles, a viral illness, is one of the most highly infectious diseases known to man. Complications of measles include pneumonia, diarrhea and encephalitis. Case fatality ratios from measles vary from 0.1% in the developed world to 15% in the less developed world [1]. Population immunity of 92–95% is considered necessary to interrupt measles transmission [2]. Although a highly-effective measles vaccine has existed since 1963, in 2015, an estimated 134,200 measles deaths occurred globally [3]. This burden is unevenly distributed across WHO regions, within regions, and even within countries. Due to its highly infectious nature, measles effectively seeks out unvaccinated individuals and is often considered to be the indicator disease or the ‘canary in the coal mine’, able to identify individuals and subpopulations who remain unreached by immunization programs. Measles vaccination coverage serves as an indicator of the quality of immunization programs [4], while the epidemiology of measles cases highlights specific geographic areas and populations in which immunization services require further strengthening. Although measles is often perceived as a childhood disease, the introduction of measles vaccine with partial disease control has allowed unimmunized individuals in many countries to remain unexposed to measles virus into adulthood and thus still be susceptible to infection, resulting in a much wider age distribution of measles cases than had historically been the case [1]. Rubella, another vaccine-preventable viral disease, is primarily a concern because infection during pregnancy can result in fetal death or severe congenital defects, including heart defects, cataracts, deafness, and cleft palate, in the baby. Rubella is one of the few known causes of autism [5]. In 2010, more than 100,000 babies with congenital rubella syndrome (CRS) were estimated to be born globally. As is the case with measles, the burden of disease is unevenly distributed across WHO regions [6]. The concept of measles eradication has been reviewed by the International Task Force for Disease Eradication (ITFDE), as well as by an independent group of experts and the SAGE, resulting in the affirmation of the feasibility and desirability of eventual eradication of measles. The ITFDE also reviewed progress towards rubella eradication, concluding that this was technically feasible and that the economic literature demonstrated that eradication of both measles and rubella was more cost-effective than indefinite high level control of either of these diseases [7–10]. All WHO regions now have measles elimination goals, while two have rubella elimination goals. The Global Vaccine Action Plan (GVAP), the implementation plan for the Decade of Vaccines, has targets to achieve measles elimination in four WHO regions and rubella elimination in two WHO regions by 2015, and to achieve measles and rubella elimination in five WHO regions by 2020 [11]. Nonetheless, at present no global measles or rubella eradication goal has been endorsed by the World Health Assembly. Measles-containing vaccines (MCV) are currently part of the schedule of childhood vaccinations in all countries. The most comprehensive approach to preventing both rubella and CRS includes use of rubella-containing vaccine (RCV) in childhood immunization schedules as well as targeting rubella-susceptible older age groups for vaccination [12]. A recent focus on CRS prevention has led to an acceleration of the introduction of RCV into childhood vaccination schedules globally. Measles and rubella vaccines are routinely administered subcutaneously as combined measles rubella vaccine (MR) or measles, mumps and rubella vaccine (MMR). The very high levels of population immunity needed to assure interruption of measles transmission require delivery of two doses of MCV [2]. At present, supplementary immunization activities (SIAs) (mass immunization campaigns) against measles targeting all persons in a given age group regardless of prior vaccination status are an integral part of national immunization program activities in many countries. Current WHO policy is that ‘‘Reaching all children with 2 doses of measles vaccine should be the standard for all national immunization programs. . .In addition to the first routine dose of MCV (MCV1), all countries should include a second routine dose of MCV (MCV2) in their national vaccination schedules regardless of the level of MCV1 coverage. . .Countries conducting regular campaigns to achieve high population immunity should consider cessation of campaigns only when >90–95% vaccination coverage has been achieved at the national level for both MCV1 and MCV2, as determined by accurate coverage data for a period of at least 3 consecutive years.” [13] In theory, target age groups for SIAs are selected based upon the age distribution of susceptibility to measles in the population, however, in practice the availability of resources is also taken into consideration. The frequency with which SIAs must be conducted to maintain herd immunity depends upon the population immunity existing in the targeted population [13]. Surveillance data are critical to guiding measles and rubella control and eradication efforts. Surveillance enables the establishment of burden of disease and mortality, and thus plays an important role in advocacy for and prioritization of activities targeting measles and rubella. Measles cases detected by surveillance identify un- or under-vaccinated populations, highlighting geographic areas or sub-populations in which vaccination programs overall – not only those targeting measles and rubella – require further support. Surveillance measures disease incidence, the best outcome indicator of disease control and eradication programs. Well-done outbreak investigations are an important aspect of surveillance, allowing understanding of who is transmitting disease to whom, information which is critical to formulating effective vaccination strategy. Well-done outbreak investigations can also provide information to be used for economic analyses of the societal impact of measles or rubella. WHO provides guidance to countries on measles and rubella surveillance, and has developed indicators to monitor the quality of these activities [14,15]. Surveillance and outbreak investigations are underpinned by the diagnostic services of the Global Measles and Rubella Laboratory Network (GMRLN). This network of 723 labs provides confirmation of suspected measles and rubella cases by serologic testing to measure IgM antibody or significant rises in antibody and molecular methods to detect virus, as well as providing information on global genotype distribution and evidence of interruption of transmission of endemic genotypes. Historically, disease confirmation was based upon serological testing. However, new diagnostic methods based, for example, on dried blood spots or oral fluid have been developed and may be better adapted for use in certain settings than serology. Dried blood spots on filter paper offer the added advantage of not having to use a reverse cold chain for transporting clinical specimens to the laboratory. The same holds true for oral fluid (gingival crevicular fluid) which can be collected through non-invasive techniques. Both sample types can be used for either IgM antibody detection or molecular analysis [16]. National governments have the primary responsibility for management and governance of their national immunization programs. Interagency Coordinating Committees also play a central role in ensuring strong governance of immunization programs in countries that rely on external partner support. At national and regional levels, important roles are played by National Verification Committees (NVCs) and Regional Verification Commissions (RVCs) for elimination of measles and rubella. As yet, no global verification committee has been established. The M&RI and Gavi, the Vaccine W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42 Alliance (Gavi) have played critical roles in measles and rubella control and elimination efforts since 2000: The M&RI, formed in 2001 by the United Nations Foundation, WHO, United Nations Children’s Fund (UNICEF), United States Centers for Disease Control and Prevention (CDC) and the American Red Cross (ARC), has as its mission to lead and coordinate global efforts to achieve a world without measles and rubella [17]. Gavi, founded in 2001 by the Bill & Melinda Gates Foundation (BMGF), the World Bank, UNICEF and WHO, aims to save children’s lives and protect people’s health by increasing equitable use of vaccines in lower-income countries [18]. Measles and rubella elimination efforts are closely tied to global efforts to eradicate polio. The infrastructure built through these efforts not only supports polio eradication, but also measles, rubella, and other immunization activities. As polio eradication draws to a close, discussions are ongoing as to how polio assets can be transitioned to contribute to future health goals. 1.2. Current status of immunization program, disease surveillance, and program funding Globally, coverage with the first dose of MCV (MCV1) has largely stagnated since 2008 (Fig. 1). This figure hides heterogeneity in MCV1 coverage among and within WHO regions, as well as within large countries such as China and India. Between 2010 and 2015, the number of countries with MCV1 coverage 90% rose from 84 (44%) of 193 countries to 119 (61%) of 194 countries.2 By 2015, a second dose of MCV administered through ongoing immunization services (MCV2) was offered in 160 (82%) of 194 Member States, up from 97 (51%) in 2000. In many countries, the ongoing immunization system has been bolstered by SIAs. However, among 41 countries that conducted SIAs in 2015, only 21 (51%) reported coverage 95% based on doses delivered and only one (TimorLeste) achieved 95% based on a coverage survey. At times, SIAs have also been delayed due to funding gaps [19] (P. Strebel, personal communication). From 2012 to 2015, global coverage with the first dose of RCV rose from 42% to 46% (Fig. 2). Of 192 countries, 147 (74%) had RCV in their ongoing immunization services as of end 2015 [20]. Case-based surveillance for measles, i.e., surveillance systems that collect information about each individual case [21], exists in 189 (97%) of 194 countries. Actual cases reported by country from January through December 2016 are shown in Fig. 3. This surveillance is often integrated with the acute flaccid paralysis (AFP) surveillance conducted for poliovirus, and, in many countries, relies on resources from the Global Polio Eradication Initiative (GPEI). The quality of measles case-based surveillance is highly variable and the percentage of cases investigated varies a great deal among and within countries. Although 94% of WHO Member States report data monthly to regional WHO offices, at present, 88 (45%) of 194 countries do not report case-based data to WHO headquarters. While case-based surveillance for rubella exists, the quality of this surveillance cannot be assessed at the global level as data have not been officially requested from regions. Not unexpectedly, given the fact that a global focus on rubella is relatively recent, surveillance for rubella remains weaker than that for measles. In addition to the resources provided by national governments, funding for measles and rubella control mobilized by the M&RI and Gavi has amounted to over USD 1.5 billion over the period 2001 to 2016. Estimates by the M&RI in October 2015 showed a projected budget shortfall of USD 431 million for the six-year period 2015–2020. Since that time, Gavi has pledged an additional USD 2 Between 2010 and 2015, the number of WHO Member States increased from 193 to 194. A37 220 million towards measles and rubella activities, bringing the total investment to nearly USD 1 billion for the period 2016–2020. 1.3. Global Measles and Rubella Strategic Plan, 2012–2020 In 2012, the M&RI published the Plan [17]. This document had, as a goal for end-2020, to achieve measles and rubella elimination in at least five WHO regions. Five core strategies to reach this goal were articulated, as follows: achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles- and rubella-containing vaccines; monitor disease using effective surveillance and evaluate programmatic efforts to ensure progress; develop and maintain outbreak preparedness, respond rapidly to outbreaks and manage cases; communicate and engage to build public confidence and demand for immunization; perform the research and development needed to support costeffective operations and improve vaccination and diagnostic tools. To measure progress toward the 2020 goal, specific milestones for 2015 were established. These milestones and an assessment of progress towards these are summarized in Table 1. Because the 2015 milestones were not being met, WHO’s SAGE recommended a midterm review (MTR) of the Plan. The objectives of the MTR were to: provide a candid review of progress towards, and key political, financial and technical reasons for not attaining, 2015 World Health Assembly targets and regional elimination goals; assess the quality of implementation of the Plan’s five key strategies and provide recommendations on how the strategies and principles should be refined to address weaknesses in immunization systems and to accelerate progress towards the global and regional goals; formulate a set of lessons learned, risks, and financial, political and programmatic priorities over the next five years (2016– 2020) for countries and partners in order to execute the work. 2. Methodology The MTR was conducted by a team of five individuals. The team undertook a comprehensive document review, and held interviews with and received presentations from stakeholders. These stakeholders included representatives of the ARC, BMGF, CDC, Gavi, Kid Risk, Inc., the Pennsylvania State University, United Nations Foundation (UNF), UNICEF, and WHO. Each team member (with the exception of the chairperson) was tasked with contacting specific Regional Offices of WHO to develop an in-depth understanding of the region’s experiences in pursuing measles elimination and rubella control through the use of a standardized questionnaire. Inferences were drawn based on discussions among team members following factual presentations from stakeholders and a review of the information received from WHO Regional Offices. The team’s conclusions and recommendations were presented to SAGE, the Measles and Rubella SAGE Working Group, and the M&RI. All recommendations for revisions from SAGE were accepted; other recommendations were discussed internally by the team and incorporated as considered appropriate. The MTR report examines each of the Plan’s five strategies, summarizing relevant background, progress and challenges to date, the deliberations of the MTR team, and recommendations for midterm corrections. In addition, in the context of measles and rubella elim- A38 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42 Fig. 1. Measles cases reported to the World Health Organization, by year, and first (MCV1) and second (MCV2) dose measles vaccine coverage, 1980–2015. Fig. 2. Coverage with first dose of rubella-containing vaccine, globally and by World Health Organization region, 1980–2015. ination, the report addresses the critical questions of building on the polio transition, governance, and resource mobilization. The overarching conclusions of the report as well as the major recommendations for each of the Plan’s five core strategies as well as polio transition, governance and resource mobilization are summarized below. The complete report is available at (Vaccine, Volume 35, Supplement 3) and through WHO at the website http://www.who.int/immunization/sage/meetings/2016/October/ 1_MTR_ Report_Final_Color_Sept_20_v2.pdf 3. Overarching conclusions The Plan set the ambitious goal of achieving measles and rubella elimination in at least five WHO regions by 2020 through the implementation of five core strategies. Significant gains toward measles elimination have been made. From 2012–2014, more than 4 million measles-related deaths are estimated to have been averted through measles vaccination. By end 2015, RVCs in the American, European and Western Pacific Regions had verified elimination of measles in 61 Member States and elimination of rubella in 55 Member States. Although all six WHO regions now have measles elimination goals by 2020 and two have rubella elimination goals by this date, recent years have seen a slowing of progress. No region except the Americas has yet achieved its 2015 milestones. All countries should continue to work toward elimination goals with a particular focus on strengthening routine immunization systems. The basic strategies articulated in the Plan are sound, however these require full implementation. The main impediments to full implementation have been inadequate country ownership and global political will, reflected in inadequate resources. Although all six regions have measles elimination goals with the ultimate vision of a world free of measles, it is premature to set a timeframe for eradication at this point. Instead, the annual review of progress toward the GVAP goals should be used to assess progress toward measles elimination. A determination should be made, not later than 2020, whether a formal global goal for measles eradication should be set with timeframes for achievement. In the meantime, all regions should work toward achieving the regional elimination goals. Strengthening of immunization systems is critical to achieving regional elimination goals. Working to achieve measles and W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42 A39 Fig. 3. Incidence of reported measles cases, World Health Organization, January – December 2016 (12 months), with case-counts of reported outbreak areas indicated (2015 outbreak data included for Dem Rep Congo and Somalia). rubella elimination can help strengthen health systems in general and immunization systems in particular. Two examples of this are the role of measles elimination in increasing immunization coverage in the United States, and the impact of school entry vaccination record checks in Shandong Province, China. [22,23] The latter were implemented to check for measles vaccination as part of a study to evaluate the feasibility of measles elimination, but resulted in increased coverage for all recommended vaccines. The ways in which measles and rubella elimination strengthens programs should continue to be carefully documented. Disease incidence, in the presence of an effective surveillance system, is the most important indicator of progress. The presence or absence of measles is one of the best indicators of overall immunization program performance. A costed implementation plan in response to these recommendations should be developed by the M&RI not later than twelve months after the release of this report. 4. Recommendations Strategy 1. Monitor disease using effective surveillance and evaluate programmatic efforts to ensure progress. A top priority for achieving the goals of the Measles and Rubella Strategic Plan is to enhance integrated case-based, laboratorysupported surveillance for measles and rubella. All countries must implement case-based surveillance for measles and rubella, and report case information to the WHO Regional Office on a weekly basis. A working group on surveillance and outbreak investigation and response should be developed at global level. Protocols should be updated or, when necessary, developed, to guide surveillance and outbreak investigation and response. Countries need to dedicate resources for surveillance and partners need to supplement resources as needed, including resources for staffing, laboratory support, training, and other operational costs. CRS surveillance, either sentinel or national level, should be implemented, especially in countries using MR. As the GPEI winds down, at a minimum the current level of measles and rubella surveillance should be maintained. Wherever possible, the polio transition should be capitalized on to further strengthen measles and rubella surveillance, as well as surveillance for other vaccine preventable diseases (VPDs). Both in outbreak investigations as well as in routine surveillance, all cases should be classified to determine the proportion of cases attributable to program failure – that is, cases in persons who should have been vaccinated according to the national schedule, but were not. Strategy 2. Achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles- and rubella-containing vaccines. Measles and rubella control and elimination activities at national level should be located within the overall immunization program. A40 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42 Table 1 Status of Global Measles and Rubella Strategic Plan: 2012–2020 2015 milestones. Legend: Black: Little or no progress. Gray: Moderate progress but inadequate to meet 2015 milestone. 2015 Milestone Reduce annual measles incidence to less than five cases per million and maintain that level Achieve at least 90% coverage with measles-containing vaccine (or measles-rubella-containing vaccine as appropriate) naonally, and exceed 80% vaccinaon coverage in every district or equivalent administrave unit Achieve at least 95% coverage with measles, measles-rubella or measles-mumps-rubella vaccine during supplementary immunizaon acvies (SIAs) in every district 2015 Data Global incidence of 39.3 per million Establish a rubella/congenal rubella syndrome eliminaon goal in at least three addional World Health Organizaon regions (i.e., in addion to the Region of the Americas and the European Region that had established goals before 2012) Establish a target date for the global eradicaon of measles One addional region, the Western Pacific Region, has established a rubella eliminaon goal but no date is associated with it Evaluaon 119 (61%) countries have coverage with first dose of measles-containing vaccine exceeding 90% at naonal level Of 34 countries conducng SIAs between 2012 and 2014 and conducng coverage evaluaons of the SIA, 16 (47%) reached 95% naonal coverage No target date for global measles eradicaon established Two doses of MCV or measles-rubella–containing vaccine (MRCV) delivered through ongoing services is the standard for all national immunization programs. Preventive SIAs should be conducted on a regular basis, if routine two dose coverage is insufficient to achieve and maintain high population immunity. Efforts to enhance measles and rubella prevention should take into account the importance of strengthening the overall immunization delivery system. A standardized method to categorize countries based on their level of disease control and likelihood of achieving and sustaining achievement of measles and rubella elimination goals should be developed. Immunization strategies and surveillance strategies should be tailored to the country categorization. All countries should institute a school entry check for immunization, including vaccination against measles and rubella as well as against other VPDs. Vaccination should be provided to children who have not received vaccine. The ways in which this provides an opportunity for children who have missed not only measles and rubella but other vaccines to be brought up to date with their immunizations has been described in both the United States and China [22,23]. Every opportunity should be taken to vaccinate people not adequately vaccinated, particularly those under 15 years of age. Strategy 3. Develop and maintain outbreak preparedness, respond rapidly to outbreaks and manage cases. Emphasis should be placed on prevention of outbreaks through monitoring of risk status and increased attention to vaccination of underserved communities and in high risk settings. All measles outbreaks should be promptly investigated and used to develop a susceptibility profile of the population to better inform measles control and elimination strategies, including outbreak prevention and response immunization. Based on existing experience, training materials should be developed for use at global, regional and country levels to perform outbreak investigations as well as to understand the underlying reasons that outbreaks are occurring and disseminate results of these investigations to all levels of the system. There must be adequate financial, human and laboratory resources to conduct adequate outbreak investigations. Countries eligible for funding from Gavi (Gavi-eligible countries) should consider using Health System and Immunization Strengthening funds for this. Financial resources should be urgently mobilized to support outbreak investigation and control in non–Gavi-eligible countries. Countries should develop national measles outbreak pre- W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42 paredness and response plans. Funding requirements for the implementation of these Plans should be included in measles and rubella program financial resource requirements (FRR). When outbreaks are detected, in addition to investigation, countries should take steps to mitigate the outbreak through vaccination. The magnitude of the response should be based on the characteristics of the outbreak, the stage of measles control, and the category to which countries belong (see Strategy 2, bullet 4 above).3 Strategy 4. Communicate and engage to build public confidence and demand for immunization. Increased resources are needed for communication to raise the visibility of VPDs, with a focus on measles and rubella. Creating and promoting demand for immunization requires long term investment and should be an integral part of routine immunization strategy. Communication plans may target many different audiences (e.g., politicians, public health leaders and workers, healthcare providers, caregivers, etc.). Plans targeting each of these audiences should be developed and audience-specific messages developed and tested. Data on measles incidence, including complications and deaths, as well as information on the costs associated with outbreaks, should be the focus of educating various audiences about the importance of preventing the illness. Data should be supplemented by stories of actual cases to illustrate the statistical data. Collection of information on cases of CRS can also be a powerful advocacy tool. In advocating for improved prevention of measles and rubella, it will be important to collect stories of how a focus on those diseases not only improved their control but also helped to enhance overall immunization and health systems (see Resource Mobilization Section below). Strategy 5. Perform the research and development needed to support cost- effective operations and improve vaccination and diagnostic tools Programmatically-oriented operations research, in addition to technologically-oriented research, should be used to determine how to best interrupt measles transmission. Such operations research should include achieving optimal uptake of vaccination in populations, which populations should be targeted for special immunization efforts, how to optimize surveillance systems, and the economic impact of disease. Sustained commitment to adequately funding measles and rubella research is required. An advocacy plan to secure funding for research should be developed. A working group focusing in a sustained fashion on advocating for, promoting, and prioritizing measles and rubella research, similar to the Polio Research Committee, is critical. The natural home for this working group is WHO. Building on the polio transition Given the imminent reduction in polio eradication resources, which can have an adverse impact on both measles and rubella control/elimination efforts, a focus on transition of polio resources is urgent and needs to be a top priority. 3 This categorization refers to that described under the fourth bullet, Strategy 2. A41 All stakeholders involved in control and elimination of measles and rubella as well as those involved in immunization system strengthening should engage in polio transition planning (at all levels) to leverage the opportunity and avoid the risks of the end of the GPEI. Strengthening immunization systems and the control and elimination of measles and rubella should be designated as high priorities for polio transition planning and implementation. Governance It is imperative that there be close collaboration and coordination between Gavi and the M&RI, as a central element in building the overall immunization system and in order to ensure that measles and rubella control and elimination efforts are coordinated and efficient. Efforts to control and eliminate measles and rubella should be integrated with the general immunization system and should be used to build and enhance the overall immunization system. Resource mobilization A multi-year FRR document for measles and rubella in the context of the overall immunization system should be developed. The FRR should include demand-driven, country-driven projections on need, and reflect funding from Gavi, the M&RI, other partners and domestic financing. This document should be complemented by yearly work plans with detailed national partners’ financial contributions. The recent welcome additional support from Gavi for measles and rubella activities provides a major step forward for achieving measles and rubella goals. However, it is not, in itself, sufficient to provide adequate assistance globally, as many countries are not Gavi-eligible or are graduating from Gavi-eligibility and key global strategies such as surveillance and research are under-resourced. Consequently, there is a need for additional funding. Efforts should be made to identify examples of when a focus on measles and rubella elimination has led to building of the overall immunization system (e.g., where a focus on measles and rubella led to a school entry check for those vaccines as well as other vaccines recommended for children, leading to improved coverage for all recommended vaccines). 5. Conclusion Despite the tremendous progress made towards both measles and rubella elimination since 2001 and the significant gains made during the period 2012–2015, neither measles nor rubella elimination are on track to achieve the ambitious goals laid out in the Plan, nor those in the Global Vaccine Action Plan. The basic strategies articulated in the Plan are sound, but full implementation of them has been limited by lack of country and global political will and country ownership, reflected in insufficient resources. In principle, the 2020 goals can still be reached, but doing so would require a substantial escalation of political will and resources as well as heavy reliance on SIAs. The report recommends focusing on improving ongoing immunization systems – although this may delay reaching measles and rubella elimination goals – in order to ensure that gains in measles and rubella control can be sustained. Re-orienting the measles and rubella elimination program to increase emphasis on surveillance so that programmatic and strategic decisions can be guided by data is critical. A42 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42 Acknowledgments We would like to acknowledge the invaluable assistance provided by the following WHO staff who served as the Secretariat to the review: Peter Strebel, Kaushik Banerjee, Mick Mulders, Minal Patel and Marta Gacic Dobo at WHO headquarters, and Deborah Bettels, Nadia Teleb Badr, Desiree Pastor, Pamela Bravo Alcantara, Balcha G. 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