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					Opportunities to better align GAVI and Sustainable
    Measles Mortality Reduction Activities

       12th GAVI Board meeting, Geneva, 10 December 2003


Francisco F. Songane, M.D., M.P.H.
Minister of Health, Mozambique

Edward J. Hoekstra, M.D., M.Sc.
UNICEF HQ, New York

Bradley S. Hersh, M.D., M.P.H.
WHO HQ, Geneva
                               500,000
                               450,000
                               400,000

Leading killer of children     350,000
                               300,000
                               250,000
                               200,000
                               150,000

We know WHERE . . .            100,000
                                50,000
                                     0
                                         AFR   SEAR   EMR   WPR   EUR   AMR




                     > 98% occur in
                         eligible
                        countries



                 94 % of all measles deaths in 2000
      No second opportunity for measles immunization ( 45 )
 Global Targets

2000 - Millennium Development Goals
     Indicator: % of 1 year - old children immunised
     against measles


2002 - UN Special Session on Children
       World Fit for Children

2003 - World Health Assembly Measles
       Resolution
Overriding global goal is
  sustainable measles
   mortality reduction
We know HOW . . .
Strategy for sustainable
measles mortality reduction

              1. Strong routine immunization > 90%
              • Reaching Every District Strategy


              2. Provide second opportunity for
              measles immunization
              • One time only “catch-up” campaign ( < 15 )
              • “Follow-up” campaigns every 3-4 years ( < 5 )
              • Routine scheduled second dose / opportunity

               3. Surveillance
               4. Improved case management
  Projected impact of different measles vaccination strategies
    on measles deaths in 45 WHO UNICEF Priority Countries
                           2000 - 2025

Annual measles deaths
1,400,000


1,200,000
                                                                                                      “Catch-up” + Constant routine

1,000,000
                         Constant routine
 800,000
                                                                                                                        Strengthen routine only
 600,000


 400,000


 200,000                                                               Strengthen routine + “catch-up” + “second opportunity”
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          Note: routine strengthening assumes 2.5% annual improvement in routine
                immunization coverage until 95%
    Mean Routine Measles Coverage in
     45 Priority Countries 1999 - 2002
 Percent
   62%
   61%
   60%
   59%
   58%
   57%
   56%
   55%
             1999          2000           2001          2002

                              Coverage

Notes: (1) Source: WHO / UNICEF Joint Reporting Forms
       (2) Liberia had no coverage data for 1999
        Second Measles Opportunity
45 UNICEF / WHO Priority Countries 2001 - 2003




      Nation - wide second opportunity 2003 ( 21 )
      Partial implementation of second opportunity 2003 ( 8 )
      No second opportunity 2003 ( 16 )
   Percent reduction in estimated measles deaths
      by WHO region between 1999 and 2002
               0
               -5   AFR   SEAR   WPR    EMR   EUR   Global
              -10
% reduction




              -15
              -20
              -25
              -30
              -35
              -40
                                   Region
       Global Progress
Measles Mortality Reduction by 50% by 2005
   (compared to 1999 : 875,000 deaths)

      Estimated Measles Mortality by Year

     900000
     800000
     700000
     600000
     500000
     400000
     300000
     200000
     100000
          0
              1999   2000   2001   2002   2003   2004   2005
Measles Initiative Partnership
• Established in 2001
• Mobilised > $ 60 million
• Supported in 23 African countries
• Over 120 million African children
  vaccinated
• > 90% coverage in each country
• Combined with TT, OPV, Insecticide
  Treated Nets (ITNs), vitamin A,
  mebendazole
         Estimated Annual Doses of Measles Vaccine
          Required for SIAs in 45 Priority Countries
Millions                 2001 - 2015
Of Doses
200
180
160
140
120
100
 80
 60
 40
 20
  0
         2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015



      Source: World Population Prospects: The 2002 Revision, UN Population Division, Feb. 2003
Funding for Estimated Annual Doses of Measles Vaccine
          Required for SIAs in 45 Priority Countries
 Millions                2001 - 2015
Of Doses
200
180
160
140
120
100
 80
 60
 40
 20
  0
         2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

                     Pledges                           Shortfall                          GAVI ?
      Source: World Population Prospects: The 2002 Revision, UN Population Division, Feb. 2003
    WHO / UNICEF Global Meeting for Sustainable Measles
       Mortality Reduction and Immunization System
                      Strengthening
                               15-17 October 2003
                               Capetown, South Africa


•   > 200 meeting participants
•   Senior MOH representatives from 45 priority countries
•   14 partner agencies
•   WHO and UNICEF staff
•   Consensus on need for comprehensive strategy
•   Financial sustainability a priority
•   High demand from countries
   How measles mortality activities can
   “ add value “ to achieve GAVI goals
• Advocacy
     • Strengthening immunization systems
     • Improving injection safety
     • Promoting the “ fully immunized ” child
• Comprehensive approach
     • Implement the RED strategy for SIAs and routine services
     • Integration of other priority interventions
• Strengthen linkages
     •   Periodic replenishment of cold chain
     •   Build capacity of EPI staff
     •   Improved partner coordination
     •   Synergistic resource mobilization efforts
How GAVI can “ add value ” to achieve and
 sustain measles mortality reduction (1)

1. Advocacy and Communications
     – Advocate at policy level how measles mortality reduction
       activities can help strengthen routine immunization systems
     – Advocate for sustainable financing


2. Monitoring of global targets
     – Add monitoring of measles vaccination coverage
       for 1st and 2nd opportunity
     – Add number of annual estimated
       measles deaths to monitor 2005 goal
How GAVI can “ add value ” to achieve and
 sustain measles mortality reduction (2)
3. Funding for bundled measles vaccine
    –   Provide $ 10 million per year for two to five years
        ( 35 million bundled doses per year )

4. Innovation
    –   Operationalize the transition from periodic SIAs to routine two -
        dose schedule
    –   Increase complementary interventions during the second routine
        measles contact
        – Missed antigens
        – Vitamin A
        – Insecticide treated bed nets
        – Mebendazole

5. Coordination & consensus building
    –   Improve coordination among partners
Obrigado
Different estimates of < 5 measles mortality

                   Lancet (2003)                         WHO

    2000                  103 k
                                                          691 k
    estimate         ( 100 k – 972 k )
    Methods      Post-mortem interviews     Reported surveillance and
                  in 17 countries;            vaccine coverage data
                 Regression model           Peer reviewed methods
                                             Validation/calibration with
                                              independent data sources,
                                              where posssible

    Strengths    Confidence intervals       Global data
                                             Critically reviewed methods

    Weaknesses    Unproven methods            Incomplete reporting
                  Classification bias         Classification bias
                  ? validity/reliability      ? validity of assumptions
                  Wide conf. intervals        No confidence intervals

				
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