Towards a world without Measles and Rubella
© UNICEF Liberia/2011/Scott|
Wonsen, 5, receives a measles vaccination during a UNICEF-supported immunization campaign in Liberia.
Achieve 95% measles mortality reduction by 2015, as compared to 2000.
Exceed 90% measles vaccination coverage nationally and 80% in every district.
Reduce the incidence of measles to less than 5 cases per million.
Achieve regional measles, rubella and Congenital Rubella Syndrome (CRS) elimination in at least five WHO regions by 2020.
Measles and rubella goals are aligned with the Global Vaccine Action Plan and endorsed by the world Health Assembly in May 2012.
Global Programming Context
To achieve these goals, UNICEF and its partners are improving routine measles immunization, and conducting vaccination campaigns in the high-risk regions of Africa and Asia every two to four years. Rubella vaccination is being introduced in countries that are not yet using rubella containing vaccine, using a combined measles and rubella vaccine, in some cases measles mumps and rubella.
Measles vaccination is an indicator of progress towards achieving Millennium Development Goal 4 (MDG4) which aims at reducing child mortality by two-thirds by 2015 compared with the level in 1990. Progress towards MDG4 must, therefore, include improvement in measles vaccination coverage.
Measles vaccination is also the most critical health intervention under UNICEF’s Core Commitments for Children as measles has been one of the major causes of child deaths among under-nourished children.
Measles is a viral respiratory infection that attacks the immune system, making children vulnerable for deadly infections. Exceptionally contagious, children who are not immunized will suffer from the disease when exposed. Most people see measles as a disease that causes temporary illness, requiring time off from school or work. But it is deadly: as many as five out of every hundred measles cases among children can cause death. Survivors of measles are often left with life-long disabilities, such as blindness, deafness or brain damage. 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. Unvaccinated children under the age of five are most at risk of death. Older susceptible children may sustain transmission and put the youngsters at risk for measles.
By contrast to measles, rubella infections cause a relatively mild disease in 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.
These children are usually found in the most vulnerable, poorest areas in the world. Immunization can protect millions of children against this deadly disease.
In the year 2000, the World Health Organization (WHO) estimated that 542,000 children died of measles, the majority in developing countries, and this burden accounted for 7% of all under five mortality. In some developing countries, case-fatality rates for measles among young children may still reach 5-6%. 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.
In 2011, an estimated 158,000 people -433 a day- died from measles. Through that number is far cry from the 2.6 million global measles deaths in 1980, it is still much too high. More than 95% of measles deaths occur in countries with low per capita incomes and weak health infrastructures. Measles deaths are clustered primarily in Africa and India, as a result of sub-optimal implementation of immunization strategies. The introduction of a second dose of measles containing vaccine (MCV2) in India in 2010 through campaigns or routine services is an important step in reducing global measles mortality. Africa is stepping up efforts to improve the routine immunization systems as well as the quality of the campaigns.
Global estimates of the burden of rubella suggest that the number of infants born with CRS in 2008 exceeded 110,000 which makes rubella a leading cause of preventable congenital defects. The 2008 estimates suggest that the highest CRS burden is in South East Asia (approximately 48%) and African (approximately 38%) regions. Countries that did not introduce rubella containing vaccine in the national immunization programme account for the vast majority of the global CRS burden.
Measles deaths and babies born with Congenital Rubella Syndrome (CRS) are easily prevented through immunization. To vaccinate a child against measles and rubella costs less than $1.50.
The Global Measles and Rubella Strategic Plan 2012-2020 presents a five-pronged strategy to reach the measles, rubella and CRS national, regional and global targets and goals. (Watch video)
- Achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles and rubella-containing vaccine.
- 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 cost-effective operations and improve vaccination and diagnostic tools.
In addition to these strategies, the Plan outlines guiding principles that provide a foundation for all measles and rubella control efforts: country ownership and sustainability, routine immunization and health system strengthening, equity and linkages. 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 Plan builds on 30 years of experience implementing immunization programmes and reflects the lessons learned to date by the Measles and Rubella Initiative (MRI) 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.
The highly effective, safe and relatively inexpensive measles and rubella containing vaccines protect individuals from infection, and the widespread use can completely stop the spread of the viruses in populations that achieve and maintain high levels of immunity. Countries began using measles vaccine in the 1960s, and immediately identified its use as 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.
The Measles Initiative
The Measles Initiative has supported the vaccination of over a billion children against measles since 2001. This initiative, which combines the efforts of UNICEF with American Red Cross, the World Health Organization, the US Centers for Disease Control and Prevention (CDC), the UN Foundation, and UNICEF has proven so successful that the work has expanded from Africa to Asia. The donor investment of $876 million in measles mortality reduction (Financial Resource Requirements of the MRI of March 2012) has contributed to the prevention of 9.6 million deaths were averted by measles vaccination during 200-2010. (Ferrari et al 2012).
By working with national ministries of health and other local government agencies, the Initiative partners are increasing routine vaccination services, conducting nationwide immunization days and mobilizing entire communities in order to get each child vaccinated. Good quality campaigns are particularly important for reaching the previously unvaccinated children. In addition to immunizing against measles, the Initiative is providing other health interventions, including Vitamin A, de-worming tablets, vaccination against polio (OPV) and insecticide-treated bed nets for malaria prevention.
For its part, UNICEF uses its logistical and procurement capacity to support the purchase and delivery of syringes, vaccine and other items to vaccination sites. UNICEF further provides cold-chain logistics and maintenance and social mobilization.
In 2000, 542,000 children died annually from measles. Over 95% of these deaths occurred in 47 countries. All these countries provided only one dose of measles vaccination. UNICEF as a key partner, implemented a 2nd dose through campaigns in 47 of the priority countries, resulting in a 71% reduction of measles deaths between 2000 and 2011 (from 542,000 to 158,000).
"This programme has achieved incredible results. In short, it has resulted in about 1,500 less children dying every day from measles worldwide", said Dr. Kezaala, senior advisor measles and rubella at UNICEF. The expansion of measles vaccination in routine and supplementary campaigns has done its job protecting vulnerable children. From 1990 to 2008, the programme contribution to MDG4 has been 23 percent.
Measles vaccination intervention has been the most successful public health programme in the last decade, with Africa leading the way in the achievement of 89% mortality reduction between 2000 and 2010. In 201, India endorsed the full measles strategy and introduced a second dose of measles in the country and will complete catch-up campaigns in early 2013. Vaccination coverage for measles reached 84% in 2011, up from 72% in 2000. Measles supplemental immunization activities reached over a billion children in 2011.
Though important gains have been made during the last decades, the poorest, most marginalized children, especially in hard-to-reach areas, have been left behind. Reaching the 2015 goal requires increasing measles immunization coverage in countries with weak health infrastructures, sustaining quality campaigns to ensure reaching the unreached, and ensuring full implementation of the measles control strategy in India. To sustain the gains and to ensure that no child goes unprotected, measles vaccination campaigns must be offered every two to four years until the routine immunization system is capable of reaching all children with two doses of measles vaccine.
The Bottom Line
It is unacceptable that every day 433 children still die from measles and 300 children still enter the world with disabilities of CRS despite the availability of effective, safe and inexpensive vaccines. This is even more disturbing once we realize the most disadvantaged children are most at risk for disastrous risk of measles and rubella. All children have the right for protection against these diseases and UNICEF is committed to fulfill this right, in particular for the most disadvantaged children. Achieving MDG4 and global measles and rubella goals, as outlined in the GVAP, 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.