1. Introduction
2. Current Sitution - Routine Measles Immunization
                             - Supplemental Measles Immunization Activities
3. Partners and Resources
4. Challenges and Issues
5. The Way Forward

1. Introduction

In 1998, WHO AFRO initiated accelerated measles control activities in some countries in the Southern African epidemiological block and scaled it up to regional level by 2001.  The Regional Strategic Plan for 2000-2005 laid out the goal of reducing the number of annual measles deaths by half by 2005 in the context of health systems strengthening.

The following strategies were adopted to attain the goal of measles mortality reduction in the Region

* WHO/UNICEF estimates available at  http://www.who.int/vaccines/globalsummary/immunization/countryprofileselect.cfm.

Figure 1. Estimated reduction in Measles mortality (all ages) in the African Region, 2000-2006

The proportion of children below 1 year of age immunized against measles is one of the key indicators used to measure the progress towards reducing child mortality in the Millennium Development Goals (MDGs). In the African Region, the regional routine measles vaccination coverage has improved from 53% in 2000 to 84% in 2006 according to administrative coverage figures sent by countries to WHO and UNICEF. (Figure 2)

The WHO UNICEF best estimate for measles coverage in the African Region in 2006 is 73%, and has shown a steady increase in the past years. This improvement in coverage is mainly due to intensive country support through the Reaching Every District (RED) approach.

Figure 2.  DPT-3 & measles administrative coverage. African Region. 1982 – 2006.

Thirty two countries have attained an increase in administrative coverage in 2006 as compared to 2005, while 8 have seen some reduction of coverage rates. As of the end of 2006, 26 countries have coverage levels of more than 80% while 4 countries (Angola, Gabon, Equatorial Guinea, and Swaziland) have administrative coverage below 60%. (Figure 3)

Despite the improvements mentioned above at Regional and national levels, there still are major gaps in immunization coverage at subnational levels even in the countries that have high national level coverage figures. These gaps continue to create pools of susceptibles and result in periodic measles outbreaks and need to be addressed.

Figure 3. Measles vaccination coverage by category. Countries in AFR. 1983 – 2006. WHO UNICEF best estimates

b) Second Opportunity – supplemental measles immunization activities

The Regional strategy for measles control recommends that a second opportunity for measles immunization be provided to all children irrespective of their vaccination status or history of clinical measles. The preferred method of provision of a second opportunity is through Supplemental Immunization Activities (SIAs) targeting children 9 months to 14 years in catch-up campaigns and 9 months to 4 or 5 years during periodic follow-up campaigns. As of November 2007, all countries in the region have already conducted catch-up SIAs, and are now following up with periodic SIAs (follow-up SIAs) in order to prevent the accumulation of susceptibles in the inter-campaign interval. The periodicity of these campaigns is determined by the routine EPI coverage, the coverage during catch-up SIAs and the results of measles surveillance.

Between 2001 and 2006, 42 countries have had one catch-up and at least one follow-up Supplemental Immunization Activities (SIAs), reaching over 304 million children. In 2007 alone, follow-up SIAs were implemented in 16 countries targeting a total of 31.6 million children. (Figure 4)


Figure 4. Children reached in measles SIAs from 2001 – 2007, and projected target population for 2008. African Region

Measles SIAs have provided an opportunity for supplying additional health interventions such as the administration of Vitamin A and de-worming tablets to children under 5 years of age, tetanus toxoid vaccination of women of child-bearing age, and distribution of Insecticide Treated Nets (ITNs) for the prevention of malaria in children and pregnant mothers. These interventions have been integrated with synergistic results and attaining the desired goals in almost all countries (Table 2).

Measles SIAs have also contributed to efforts to strengthen health systems by forging and strengthening local partnerships, improving the cold chain systems, promoting and building capacity for injection safety, strengthening disease surveillance systems and promoting the use of surveillance data for program management.

Table 2. Child survival interventions integrated with Measles SIAs in the African Region (2006 – 2007)

Over the last six years of this initiative, the formation and strengthening of partnerships has been a cornerstone for implementation of SIAs. The Measles Partnership - whose core members are the WHO, UNICEF, US Centers for Disease Control (CDC), the American Red Cross (ARC), the UN Foundation (UNF) - has provided the international forum for technical coordination and fund raising at global level. However, other agencies have joined the partnership to contribute to the achievements of the measles initiative, and these include the International Federation of Red Cross and Red Crescent Societies (IFRC), Canadian International Development Agency (CIDA), Right to Play, US agency for International development (USAID), Immunisation BASICS, Becton Dickinson and national Red Cross Societies among others. In addition factories, private small businesses, cellular telephone network operators, Ministries of Defense, and Ministries of Education in different countries have successfully collaborated to support immunization activities.

In the years 2001 - 2007, the program has received funding from the Measles Partnership as well as direct financing for personnel, the lab network and surveillance from the CDC. Funding from the Global Alliance for Vaccines and Immunisation (GAVI) has supported activities between 2005 and 2007, while funding from the International Finance Facility for Immunisation (IFFIm) has supported the majority of SIAs in 2007 and 2008; these funds all came through the UNF.

These external funds are supplemented with locally raised resources in order to meet 50% of the budget needs for operational costs of the SIAs. However, not all countries have been successful in raising these required resources from government sources or from local partners. In a number of countries, campaign plans had to be reviewed and some activities had to be scaled down as a result of the funding gaps, unfortunately not without adverse consequences to the quality of the SIAs.

The African region has attained the Regional measles control goals defined in the Strategic plan and is in the process of reviewing the performance and looking forward to setting new goals. Amongst the major issues to be considered in this exercise are the changes in the epidemiology of measles, the routine immunization performance, the quality of surveillance, the strength of the health systems and the global context.

In order to maintain the gains attained so far in reducing measles deaths in the Region, it is imperative that the population immunity be kept high through high coverage routine immunization of infants and periodic follow-up SIAs. The Reaching Every District (RED) approach, which has been proved useful to improve immunization services and coverage, needs to be widely implemented and supported.

Countries need to ensure that the build up of susceptibles does not get to critical levels by conducting high quality follow-up SIAs. Realising the immense gains achieved so far, countries need to invest in routine immunization as well as in the periodic follow-up SIAs by allocating more local funding for the timely implementation of SIAs. While efforts to maintain the current level external funding should continue, more and more local resource mobilization needs to be done.

The possible introduction of a second dose of measles vaccine (MCV2) in routine immunization programs in the Region will have to be given serious thought as a way of ensuring sustainable reduction of measles deaths.  However, evidence points out that the introduction of MCV2 will significantly contribute to the measles control efforts only if it is introduced in the background of high first dose measles immunization coverage; i.e., in a setting where there are no major gaps in geographic or utilization access to services, which unfortunately is the situation with most of the countries in the African Region.

Disease surveillance has remained seriously under-funded in the last few years, and needs to be given more attention as countries achieve better quality of control, try to identify and manage small sized outbreaks, and use the information to manage the control program.

Measles control has provided the platform for the integration of multiple child survival interventions and will continue doing so during the periodic follow-up SIAs. However, there is room for improvement among the different programs and elements in terms of planning, coordination, funding… in order to achieve the required
synergy.

The second Regional Measles Technical Advisory Group (TAG) will meet in May 2008 to deliberate on these issues and to provide guidance to the Region.

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