Challenges in Measles Outbreak
Responses
MSF Perspectives
Florence Fermon - Myriam Henkens
10th 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
DRC: 2006
Niger: 2004
In endemic countries, outbreaks are
limited to young age classes.
Burkina Faso: 2009
Countries in
transition are
intermediate
Malawi: 2010
Outbreaks in countries following
“elimination” extend evenly age classes
Source: courtesy Matthew Ferrari
2. Failure to vaccinate rather than
vaccine failure
CV
80
180000
70
Cas de rougeole
160000
60
140000
120000
50
100000
40
80000
30
60000
20
40000
10
20000
0
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
Année
Source: VC(WHO 2002-2009 and MICS 2010), cases: Rapports épidémiologiques annuels, 4ème direction, RDC
Couverture vaccinale (%)
cas
200000
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
Measles outbreak responses in Africa 2004-2011
On going
Persons vaccinated – MSF
- DRC
- Burundi
- Chad
- Ethiopia
- Kenya
- Niger
- Nigeria
- Somalia
- Zambia
5000000
4500000
4000000
3500000
3000000
2500000
2000000
1500000
1000000
500000
0
2004
2005
2006
2007
2008
2009
2010
2011
Challenges
1.
2.
3.
4.
Outbreak detection and recognition
Outbreak response plan
Outbreak response implementation
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
Vaccination coverage before and after campaign (6-59 m), Ndjamena, Chad
Before
Campaign
After
Campaign
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)
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