Strategic plan
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- Bu səhifədəki naviqasiya:
- 331.4 384.8 227.7 137.5 177.9 139.3 130.1 2000
- GLOBAL MEASLES RUBELLA STRATEGIC PLAN 11
- GLOBAL MEASLES RUBELLA STRATEGIC PLAN 12
- GOALS By end 2015
- GLOBAL MEASLES RUBELLA STRATEGIC PLAN 13
- Figure 2
- GLOBAL MEASLES RUBELLA STRATEGIC PLAN 15
- POTENTIAL FUTURE WHO GLOBAL TARGETS
- GLOBAL MEASLES RUBELLA STRATEGIC PLAN 16
- GLOBAL MEASLES RUBELLA STRATEGIC PLAN 17
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3 GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 10 Figure 1:
Number of estimated measles deaths (in thousands) globally 2000-2010 535,3 528.8 373.8 484.3 331.4 384.8 227.7 137.5 177.9 139.3 130.1 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 74% decrease compared with 2000 (Figure 1), and a 23% decline in under-five deaths worldwide between 1990 and 2008 (6). The MR Initiative began supporting rubella control and CRS prevention activities in countries in central and eastern Europe in the early 2000s, and observed the increasing benefits of its efforts with respect to reducing the burden of rubella. As a result, the MR Initiative now includes rubella control goals as an integral part of its efforts, as demonstrated in this Strategic Plan. In 2010, the World Health Assembly committed to reduce measles deaths by 95% of the 2000 levels by 2015. By 2010, estimated global measles mortality decreased 74% from 535 300 deaths in 2000 to 139 300 in 2010. Measles mortality was reduced by more than three-quarters in all WHO regions except the WHO southeast Asia Region. India accounted for 47% of estimated measles mortality in 2010, and the WHO African region accounted for 36%. GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 11 This Plan presents a five-pronged strategy to reach the measles, rubella and CRS national, regional and global targets and goals. The strategies include high vaccination coverage, laboratory-backed surveillance, monitoring and evaluation, outbreak preparedness and response, communication and community engagement, and research and development. The Plan builds on 30 years of experience in implementing immunization programmes and reflects the lessons learned to date by the MR Initiative and other globally coordinated disease-management efforts, including the Global Polio Eradication Initiative (GPEI). It particularly seeks to extend the experience gained by the WHO Region of the Americas in eliminating measles, rubella and CRS, to all other regions. In addition to these strategies, the Plan outlines guiding principles that provide a foundation for all measles and rubella control efforts as well as a list of priority countries that require additional support to meet current goals. The Plan also identifies key challenges to measles and rubella control and elimination, and offers solutions to these challenges. It discusses the roles and responsibilities of stakeholders, and provides indicators to monitor and evaluate national, regional and global progress towards the vision and goals. The five spearheading partners of the MR Initiative — the American Red Cross (ARC), United States Centers for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF), United Nations Foundation (UNF) and World Health Organization (WHO) — endorse this Global Measles and Rubella Strategic Plan 2012–2020. The MR Initiative has developed the Plan through an extensive consultation process, aligned it with the WHO/UNICEF Global Immunization Vision and Strategy (GIVS) (7), and expects to include it in the operational plans for the Decade of Vaccines (8). The Plan reflects national and regional experiences and changes in disease epidemiology, and incorporates insights from research findings, guidance and recommendations available since the last Measles Strategic Plan published in 2005 (9). It particularly incorporates the guidance and recommendations of the WHO Strategic Advisory Group of Experts on Immunization (SAGE) on measles (10–13) and on rubella and rubella vaccine use and the need to integrate rubella control activities with measles elimination activities. The Plan also reflects the recommendations of the WHO ad hoc Global Measles Advisory Group to assess the feasibility of measles eradication (14). However, the MR Initiative remains concerned about the reduction in political and financial commitment since 2008 which is putting at risk the significant gains made and the global imperative to eliminate measles and rubella. Indeed, outbreaks of measles have been on the rise since 2009, particularly in the African, South-East Asia and European Regions and in North America (15). It is unacceptable that every day 380 children still die from measles and 300 children still enter the world with the disabilities of CRS despite the availability of effective, safe and inexpensive vaccines. Achieving MDG4 and global measles-mortality reduction goals will require a further increase in measles vaccine coverage. Through a combination of innovation, resources and political will, we can work together to achieve and maintain the global elimination of measles, rubella and CRS. GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 12 VISION, GOALS AND MILESTONES Strategic planning, coordination and cooperation at every level are essential to achieve a world without measles, rubella and congenital rubella syndrome. We must work together. 4 VISION Achieve and maintain a world without measles, rubella and congenital rubella syndrome (CRS).
• Reduce global measles mortality by at least 95% compared with 2000 estimates. • Achieve regional measles and rubella/CRS elimination goals. By end 2020 • Achieve measles and rubella elimination in at least five WHO regions. MILESTONES By end 2015 • Reduce annual measles incidence to less than five cases per million and maintain that level. • Achieve at least 90% coverage with the first routine dose of measles-containing vaccine (or measles- rubella-containing vaccine as appropriate) nationally, and exceed 80% vaccination coverage in every district or equivalent administrative unit. • Achieve at least 95% coverage with M, MR or MMR during supplementary immunization activities (SIAs) in every district. • Establish a rubella/CRS elimination goal in at least three additional WHO regions. • Establish a target date for the global eradication of measles. By end 2020 • Sustain the achievement of the 2015 goals. • Achieve at least 95% coverage with both the first and second routine doses of measles vaccine (or measles- rubella-containing vaccine as appropriate) in each district and nationally. • Establish a target date for the global eradication of rubella and CRS. GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 13 GLOBAL CONTEXT MEASLES VACCINATION Despite the availability of a safe, heat-stable, effective and inexpensive measles vaccine, and the substantial progress towards measles control, measles remains one of the leading causes of preventable death globally among children. In 2000, the World Health Assembly adopted a resolution to reduce global measles deaths by half compared with 1999 levels, from 2000–2005. This goal was achieved globally following the implementation of a five-year strategic plan to increase coverage with measles vaccination through routine immunization and SIAs. Concurrently, the delivery of other safe, effective and affordable child-survival health interventions were scaled up (such as combining measles vaccine with vitamin A supplementation, deworming medicine, insecticide-treated bednets and polio vaccine) in the highest burden countries (16). The targeted countries supported the strategy with strong political commitment. Following this achievement, the MR Initiative supported a five-year strategic plan in 2006 with a more ambitious goal to reduce estimated measles mortality by 90% by 2010 compared with 2000 levels. Considerable progress was achieved by 2010[1] : about 9.6 million deaths were averted by measles immunization during 2000-10 including routine and SIAs, and with the exception of the South-East Asia Region, all WHO regions have achieved at least 75% reduction in measles mortality in 2010 compared to 2000. The 90% measles mortality reduction goal was not achieved mainly due to delayed implementation of measles control activities in India and large-scale measles outbreaks in Africa. By 2011, all 194 WHO Member States had introduced or begun the process of introducing a two-dose measles vaccination strategy delivered through routine immunization services and/ or SIAs. According to WHO and UNICEF estimates, global routine coverage with a first dose of measles vaccine (MCV1) increased from 72% in 2000 to 85% in 2010 (Figure 2) (17). During this same period, coverage increased from 58% to 78% in the 47 countries with the highest burden of measles
. By the end of 2010, the routine immunization schedules of 139 countries included two doses of measles-containing vaccine (MCV), and in 2011, GAVI supported 11 more countries to introduce a routine second dose of measles (MCV2). The timing of MCV2 serves as an important contact between the child and the Expanded Programme on Immunization (EPI) because it provides an opportunity to catch up on any missed vaccinations and deliver boosters, e.g. diphtheria-tetanus-pertussis (DTP) vaccine to older age groups.
1 Afghanistan, Angola, Bangladesh, Benin, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Guinea- Bissau, India, Indonesia, Kenya, Lao People’s Democratic Republic, Liberia, Madagascar, Mali, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Rwanda, Senegal, Sierra Leone, Somalia, Sudan, Timor-Leste, Togo, Uganda, United Republic of Tanzania, Viet Nam, Yemen and Zambia.
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global coverage 78 58 coverage in priority countries Figure 2: 1st Dose Measles Coverage Globally and in 47 Measles Priority Countries 2000-2010 GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 14 Between 2001 and 2011, the MR Initiative partners provided financial and technical support to more than 80 high-burden countries which enabled the vaccination of one billion children during SIAs over 10 years. In addition, the integration of other health interventions led to children receiving more than 41 million insecticide-treated bednets, 94 million deworming tablets, 127 million doses of polio vaccine and 213 million doses of vitamin A
. The MR Initiative and its partners continue to work towards the goal of achieving and maintaining high levels of population immunity through routine immunization. In addition, SIAs conducted every two, three or four years, depending on the quality of routine immunization, currently play an important role in protecting children in countries unable to achieve high and homogenous vaccination coverage through routine immunization systems. These periodic, preventive SIAs reduce the number and size of outbreaks and consequently reduce the costs, disruption, and fear outbreaks cause both to the public and to the health-care system.
As for measles, a safe, heat-stable, effective and inexpensive rubella vaccine exists, and substantial progress has been made towards rubella control. However, rubella infections remain one of the leading causes globally of preventable congenital birth defects. As of December 2010, 131 of the 194 WHO Member States included rubella-containing vaccines (RCVs) in their routine immunization programmes, in the form of MR or MMR (18) 2 . In the countries yet to introduce rubella vaccine, most children already receive two doses of measles vaccine through a combination of routine immunization and SIAs as part of accelerated measles-mortality reduction or regional elimination efforts. Switching from M to MR or MMR vaccine in these countries represents an opportunity that should not be missed to prevent rubella and CRS. In addition, in November 2011, GAVI opened a funding window to support the introduction of RCVs using the strategies recommended by SAGE in 2011 (13). These strategies comprise conducting an initial wide age range catch-up vaccination campaign, combined with introducing MR vaccine in the routine childhood immunization programme, using MR vaccine in all subsequent follow-up campaigns, and introducing rubella and CRS monitoring activities. LABORATORY NETWORK Rapid and accurate diagnosis of measles and rubella remains essential for monitoring progress and detecting outbreaks. Based on the structure and practices of the successful polio laboratory network, the WHO Global Measles and Rubella Laboratory Network (LabNet) provides valuable global information about the circulation of measles and rubella infections (19). As of October 2011, the LabNet included 690 national, sub-national and regional laboratories, serving 183 countries. All laboratories follow a standardized set of testing protocols and reporting procedures that are constantly reviewed and improved as technological innovations occur. The LabNet relies on a strong quality assurance programme that monitors the performance of all laboratories through annual proficiency testing and continuous assessment. In the five-year period between 2005 and 2009, the LabNet provided the results of over one million measles immunoglobulin M (IgM) tests and shared sequence information on over 10 000 measles and 1000 rubella viruses (20). The LabNet is a vital resource for immunization programmes as it documents the successes of vaccination efforts to interrupt measles and rubella transmission nationally and internationally and is able to monitor virus transmission patterns and help document successful elimination strategies. 2 Africa: 2/46 states; Americas: all states; South-East Asia: 4/11 states; Europe: all states; Eastern Mediterranean: 15/21 states; Western Pacific: 21/27 states. 1 MR Initiative (unpublished data). GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 15 CURRENT WHO GLOBAL AND REGIONAL TARGETS All six WHO regions have committed to measles elimination and five regions have set target dates. The WHO Region of the Americas achieved the goal in 2002; the Western Pacific Region aims to eliminate measles by end of 2012; and the European and Eastern Mediterranean Regions are accelerating their measles control activities in order to eliminate measles by 2015. In 2011, countries in the African Region took on the goal to eliminate measles by 2020, and in 2010 the South-East Asia Region adopted a resolution urging countries to mobilize resources to support the elimination of measles, the target date for which was under discussion. In May 2010, the World Health Assembly endorsed a series of interim measles control targets for 2015 (21). These targets, which include exceeding 90% coverage with MCV1 nationally, and exceeding 80% vaccination coverage in every district, highlighted the critical role of strong routine immunization systems as a cornerstone for sustainable measles control/elimination efforts. The targets also include reducing annual measles incidence to <5 cases per million, maintaining that level, and reducing measles mortality by more than 95% compared with 2000 estimates. As of the publication of this plan, three of the six WHO regions had set control or elimination targets for rubella. The Americas and Europe targeted rubella and CRS elimination by 2010 and 2015, respectively. The Western Pacific Region aims to have significantly accelerated rubella and CRS prevention by 2015, and the Eastern Mediterranean Region is currently discussing the establishment of a target date for rubella elimination. The African and South-East Asia Regions have yet to establish rubella elimination, control or prevention goals (Figure 3).
The MR Initiative recognizes the dynamic and iterative nature of the strategic planning and target-setting process, and seeks to maintain a management strategy that uses available resources optimally to achieve the largest possible health benefits associated with the reduction of measles, rubella and CRS. In 2009, progress towards regional targets led the WHO Executive Board to request an assessment of the feasibility of measles eradication. The areas covered by the assessment included the biological, technical, socio-political and operational feasibility of measles eradication; the cost-effectiveness of measles eradication; the adequacy of global vaccine supply; and the impact of such an initiative on immunization services and health systems. In late 2010, the WHO ad hoc Global Measles Advisory Group and the SAGE concluded that measles can, and should, be eradicated, and that measles eradication activities should be used to accelerate rubella control and the prevention of CRS, conclusions endorsed in January 2011 by the WHO Executive Board.. The 63 rd
of measles, conditional on achieving measurable progress towards reaching the 2015 global targets and the regional measles elimination goals (21). The MR Initiative continues to explore the best timing and approach for launching a measles eradication initiative, particularly in the context of possible cost-sharing opportunities with the GPEI. GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 16 2000 2010
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* SEAR adopted a 95% mortality reduction goal by 2015
* 2020
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Figure 3:
Current WHO Regional Measles and Rubella Elimination/Control Goals In 2009, SEAR Regional Committee endorsed a resolution to mobilize support toward measles elimination. Note: EMRO is in the process of adopting a target for rubella elimination by 2020. GLOBAL MEASLES & RUBELLA STRATEGIC PLAN 17 RECENT SETBACKS AND RISK OF RESURGENCE Despite the successes in global measles control, progress towards a reduction in the numbers of measles cases and deaths stagnated between 2008 and 2010 [15], largely due to numerous prolonged measles outbreaks in Africa and Europe and the continued high measles disease burden in India (Figure 4). 0 100000 200000 300000
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2000 Number of reported cases The outbreaks in Europe contributed to a rise in the global number of reported cases from 7499 in 2009 to 30 625 in 2010, with most cases and outbreaks occurring in western European countries. The outbreaks in Africa over the same time period represent a widespread resurgence of measles that affected 28 countries in sub-Saharan Africa, with more than 250 000 reported measles cases and more than 1500 reported measles-associated deaths. Estimated underreporting of measles suggests that true numbers of cases and deaths may be as much as 10–50 times higher. The failure to vaccinate children and thus achieve and maintain high levels of population immunity uniformly throughout countries, either through routine immunization services or SIAs, is the underlying cause of the outbreaks. For example, 19 million infants (mostly in Africa and South-East Asia) did not receive MCV1 in 2010 and remain at risk of infection and death. Furthermore, since 2008, major funding shortfalls have contributed to delays and the deterioration of the quality of SIAs. The outbreaks in Africa, together with continuing high numbers of measles cases and deaths in India, threaten to undermine the contribution of measles-mortality reduction to the achievement of MDG4. If financial and political commitments decrease from 2010 to 2013, WHO estimates an additional 200 000 measles deaths in 2011, rising to more than 500 000 worldwide by 2013 (22).
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