Strategic plan
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- GLOBAL MEASLES RUBELLA STRATEGIC PLAN 4
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- RUBELLA STRATEGIC PLAN 7 EXECUTIVE SUMMARY
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GLOBAL MEASLES
AND RUBELLA
STRATEGIC PLAN 2012- 2020 Photo credits: Most photographs in this document are © C. McNab/The Measles & Rubella Initiative with the exception of the following: Page 8 – #1 ©Daniel Cima/American Red Cross, #3 © UNICEF/NYHQ2010- 2353/Olivier Asselin; Page 12 – #1 ©UNICEF/NYHQ2004-0431 Christine Nesbitt; Page 16 - #1 ©WHO/ Thierry Parel; Page 18 – #2 CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D.; Page 22 - #1 © UNICEF/ NYHQ2007-0471/Christine Nesbitt; Page 24 – #2: ©Daniel Cima/American Red Cross, #3 WHO/ David Featherstone; Page 26 – #3 © UNICEF/NYHQ2005-0252/Giacomo Pirozzi; Page 28 – #1 WHO/ Rod Curtis, #3 © UNICEF/NYHQ2005-0252/Giacomo Pirozzi; Page 30 – #1 © UNICEF/NYHQ2006-0084 Shehzad Noorani; Page 31 – © UNICEF/NYHQ2006-1800/Josh Estey; Page 32 – © Gettyimages/Jamie Grill Photography; Page 33 – ©WHO/Christopher Black; Page 34 – #2 © GAVI_2011_Riccardo Gangale. WHO Library Cataloguing-in-Publication Data : Global measles and rubella strategic plan : 2012-2020. 1.Measles – prevention and control. 2.Rubella – prevention and control. 3. Congenital Rubella Syndrome – prevention and control. 4.Immunization programs – trends. 5.Epidemiologic surveillance. 6.Disease outbreaks. 7.Vaccinations – economics. 8.Strategic planning. 9.World Health Organization. ISBN 978 92 4 150339 6 (NLM classification: WC 500) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland.
CONTENTS Abbreviations and acronyms ...................................................................................................... 4 Foreword ..................................................................................................................................... 6 Executive summary .................................................................................................................... 8 Introduction ............................................................................................................................... 10 Vision, goals and milestones .................................................................................................... 13 Global context ........................................................................................................................... 14
Strategy to eliminate measles, rubella and CRS .................................................................... 20 1. Achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles- and rubella-containing vaccines ................................20 2. Monitor disease using effective surveillance and evaluate programmatic efforts to ensure progress ..........................................................................................................................21 3. Develop and maintain outbreak preparedness and respond rapidly to outbreaks and manage cases ..............................................................................................................................22 4. Communicate and engage to build public confidence and demand for immunization .....23 5. Perform the research and development needed to support cost-effective operations and improve vaccination and diagnostic tools..................................................................................24 Guiding principles to eliminate measles, rubella and CRS .................................................... 26 1. Country ownership and sustainability ....................................................................................26 2. Routine immunization and health systems strengthening ..................................................26 3. Equity ........................................................................................................................................27 4. Linkages ...................................................................................................................................27 Challenges to implementing the Strategic Plan ...................................................................... 30 1. Financial risks ..........................................................................................................................30 2. High population density and highly mobile populations ......................................................31 3. Weak immunization systems and inaccurate reporting of vaccination coverage ..............32 4. Managing perceptions and misperceptions ..........................................................................32 5. Conflict and emergency settings ...........................................................................................33 Roles and responsibilities ........................................................................................................ 34 1. National governments .............................................................................................................34 2. Global and regional partners .................................................................................................34 The Measles and Rubella Initiative ............................................................................................35 The GAVI Alliance .........................................................................................................................35 Tracking progress ..................................................................................................................... 36 Conclusion ................................................................................................................................. 37 References ................................................................................................................................ 38 Annex 1 ..................................................................................................................................... 42
ABBREVIATIONS AND ACRONYMS AEFI
adverse event following immunization ARC
CDC
Centers for Disease Control and Prevention (USA) CIDA
Canadian International Development Agency cMYP
comprehensive multiyear plans for immunization CRS
congenital rubella syndrome DFID
Department for International Development, United Kingdom DHS
Demographic and Health Survey DTP
diphtheria-tetanus-pertussis [vaccine] ELISA enzyme-linked immunosorbent assay EPI
GIVS
Global Immunization Vision and Strategy GPEI
Global Polio Eradication Initiative HPV
human papillomavirus [vaccine] IgM
immunoglobulin M IPV
inactivated poliovirus vaccine LabNet Global Measles and Rubella Laboratory Network LLIN
M
measles [vaccine] MCV
measles-containing vaccine MCV1
first dose of MCV MCV2
second dose of MCV MDG
Millennium Development Goal MR Initiative Measles and Rubella Initiative MICS
MMR
measles-mumps-rubella [vaccine] MR
measles-rubella [vaccine] RCV
rubella-containing vaccine SAGE Strategic Advisory Group of Experts on immunization SIA
UNF
United Nations Foundation UNICEF United Nations Children’s Fund USA
USAID United States Agency for International Development WHO
GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 4 GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 5 1 FOREWORD Implementation of this Global Measles and Rubella Strategic Plan can protect and improve the lives of children and their mothers throughout the world, rapidly and sustainably. Overwhelming evidence demonstrates the benefit of providing universal access to measles- and rubella-containing vaccines. Globally, an estimated 535 000 children died of measles in 2000. By 2010, the global push to improve vaccine coverage resulted in a 74% reduction in deaths. These efforts, supported by the Measles and Rubella Initiative, contributed 23% of the overall decline in under-five deaths between 1990 and 2008 and are driving progress towards meeting Millennium Development Goal 4 (MDG4). However, as we have seen in several countries in the African, South-East Asian, European, Eastern Mediterranean and Western Pacific Regions, measles returns when we let down our guard. Rubella also remains a threat to pregnant women and their fetuses in particular, with more than 100 000 children born each year with congenital rubella syndrome (CRS), which includes heart defects, blindness and deafness. We can completely prevent these illnesses, deaths and disabilities, and the global imperative to invest in vaccination has never been stronger. Measles- and rubella-containing vaccines are among the most cost-effective public health tools available. All 194 World Health Organization (WHO) Member States remain committed to reduce measles deaths by 95% by 2015, and four of six WHO regions have set rubella control or elimination targets. As 2015 approaches, increased access to measles, rubella and other vaccines will immediately produce improved child-mortality outcomes. This Strategic Plan provides the blueprint. It builds on years of experience in implementing immunization programmes and incorporates lessons from accelerated measles control and polio eradication initiatives. The Plan stresses the importance of strong routine immunization systems supplemented by campaigns, laboratory-backed surveillance, outbreak preparedness and case management, as well as research and development. It also reminds us that public health is about people, above all, and that our work to build public trust and demand for vaccination is as important as the work to build and maintain measles and rubella vaccine supply and cold chains. In this Decade of Vaccines, let us use the Strategic Plan to expand global equitable access to these measles and rubella vaccines that have saved millions of lives over several decades. With strong partnerships, resources and political will, we can, and must work together to achieve and maintain the elimination of measles, rubella and CRS globally.
Director-General World Health Organization Thomas R. Frieden Director U.S. Centers for Disease Control and Prevention Anthony Lake Executive Director United Nations Children’s Fund Gail J. McGovern President and Chief Executive Officer American Red Cross Timothy E. Wirth President United Nations Foundation GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 6 GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 7 EXECUTIVE SUMMARY This Strategic Plan 2012–2020 explains how countries, working together with the MR Initiative and its partners, will achieve a world without measles, rubella and congenital rubella syndrome (CRS). The Plan builds on the experience and successes of a decade of accelerated measles control efforts that resulted in a 74% reduction in measles deaths globally between 2000 and 2010 (1). It integrates the newest 2011 World Health Organization (WHO) policy on rubella vaccination which recommends combining measles and rubella control strategies and planning efforts, given the shared surveillance and widespread use of combined measles-rubella vaccine formulations, i.e. measles-rubella (MR) and measles-mumps-rubella (MMR). The Plan presents clear strategies that country immunization managers, working with domestic and international partners, can use as a blueprint to achieve the 2015 and 2020 measles and rubella control and elimination goals. The strategy focuses on the implementation of five core components. 1. Achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles- and rubella-containing vaccines. 2. Monitor disease using effective surveillance, and evaluate programmatic efforts to ensure progress. 3. Develop and maintain outbreak preparedness, respond rapidly to outbreaks and manage cases.
4. Communicate and engage to build public confidence and demand for immunization. 5. Perform the research and development needed to support cost-effective operations and improve vaccination and diagnostic tools. The Plan provides the global context and an assessment of the current state of the world with respect to national, regional and global management of measles and rubella. It outlines guiding principles that provide a foundation for all measles and rubella control efforts, including country ownership, strengthening routine immunization and health systems, ensuring linkages with other health interventions and providing equity in immunization by reaching every child. Given the progress made to date, the plan includes a list of priority countries that require additional support to meet regional and global goals. It also examines key challenges to measles and rubella control and elimination, including: financial risks; high population density and highly mobile populations; weak immunization systems and inaccurate reporting of vaccination coverage; managing perceptions and misperceptions; and conflict and emergency settings. The Plan offers solutions to these challenges, discusses the roles and responsibilities of stakeholders, and provides indicators to monitor and evaluate national, regional and global progress towards the vision and goals. Countries bear the largest responsibility for measles and rubella control and elimination, and they must support sustainable national planning, funding and advocacy to protect their citizens from devastating preventable diseases. 2 GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 8 The MR Initiative and its five spearheading partners — the American Red Cross, United States Centers for Disease Control and Prevention, United Nations Children’s Fund, United Nations Foundation and World Health Organization — endorse this Strategic Plan and will work with countries and international donors on its implementation. As countries work towards attaining national, regional and global measles, rubella and CRS control and elimination goals, they can rely on technical and financial support from the MR Initiative and its partners, including the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization). To support this Plan, the MR Initiative developed and maintains a Financial Resource Requirements document that it reviews and updates regularly. The MR Initiative recommends that all stakeholders use this Plan and the referenced technical guidance to secure the commitments and actions required for a world free of measles, rubella and CRS.
GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 9 INTRODUCTION Measles is one of the most infectious human diseases and can cause serious illness, life- long complications and death. Prior to the availability of measles vaccine, measles infected over 90% of children before they reached 15 years of age. These infections were estimated to cause more than two million deaths and between 15 000 and 60 000 cases of blindness annually worldwide (2). By contrast to measles, rubella infections cause a relatively mild disease for children. However, rubella infection in women during early pregnancy can severely affect the fetus, resulting in miscarriage, fetal death, or the combination of disabling conditions collectively called congenital rubella syndrome (CRS), which includes heart disease, blindness and deafness. The highly effective, safe and relatively inexpensive measles- and rubella-containing vaccines protect individuals from infection, and their widespread use can completely stop the spread of the viruses in populations that achieve and maintain high levels of immunity. Countries began using measles vaccines in the 1960s, and immediately identified their use as highly cost-effective. The use of rubella vaccine began in 1969, and a combined formulation (MR or MMR) in the 1970s. Given the similar clinical presentations of measles and rubella, and the combined vaccine products, national and global health leaders have increasingly focused on simultaneous management of both diseases. In the year 2000, the World Health Organization (WHO) estimated that 535 000 children died of measles, the majority in developing countries, and this burden accounted for 5% of all under- five mortality (3). In some developing countries, case-fatality rates for measles among young children may still reach 5–6% (4). In industrialized countries, approximately 10–30% of measles cases require hospitalization, and one in a thousand of these cases among children results in death from measles complications. Improving measles vaccination coverage and reducing measles-related deaths is a global imperative, particularly as it relates to the United Nation’s Millennium Development Goal 4 (MDG4), which aims to reduce the overall number of deaths among children by two-thirds between 1990 and 2015 (5). The United Nations selected routine measles vaccination coverage as an indicator of progress towards MDG4, given the potential of measles vaccination to reduce child mortality, and because it serves as an indicator of access to child health services. The infectiousness of measles easily leads to global spread, and even countries that eliminated their indigenous transmission remain vulnerable to outbreaks from importations. This is exemplified in the WHO Region of the Americas, which successfully eliminated all indigenous transmission of measles viruses in 2002 and rubella viruses in 2009. The Region is currently seeking to verify the successful elimination of both diseases. However, since adoption and coverage of measles- and rubella-containing vaccines remain uneven around the world, measles and rubella continue to pose a significant threat to the lives of children and families everywhere. Global estimates of the burden of rubella suggest that the number of infants born with CRS in 2008 exceeded 110 000 1 which makes rubella a leading cause of preventable congenital defects. The 2008 estimates suggest that the highest CRS burden is in the South-East Asia (approximately 48%) and African (approximately 38%) Regions. Recognizing that deaths and disabilities caused by measles and rubella are completely preventable with safe and inexpensive vaccines, and spurred by the success of countries in the Americas in stopping the spread of measles, the MR Initiative (formerly, the Measles Initiative) was launched in 2001 to support technically and financially accelerated measles control activities. As a result of its efforts, measles deaths dropped to approximately 139 000 per year in 2010, representing a
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