Challenges to Reducing Measles, Rubella, and CRS Worldwide

Reductions in Measles Deaths—A Major Achievement at Risk

This late 1960s photograph shows a Nigerian mother and her child who was recovering from measles; note that the skin is sloughing on the child as he heals from his measles infection.

Despite the successes in global measles control, progress toward reducing the numbers of measles cases and deaths stagnated between 2008 and 2010. This happened largely due to numerous prolonged measles outbreaks in Africa and Europe and the continued high measles disease burden in India. The number of measles cases in Europe, primarily in western European countries, grew from 7,499 in 2009 to more than 30,000 in both 2010 and 2011, contributing to a rise in the global number of reported cases. The outbreaks in Africa during the same time period represent a widespread resurgence of measles that affected 28 countries in sub-Saharan Africa. In these countries, more than 250,000 measles cases and more than 1,500 measles-associated deaths were reported. Estimated underreporting of measles suggests that true numbers of cases and deaths may be as much as 10 to 50 times higher.

Why is this happening?

Simply stated, the underlying cause of measles outbreaks is not enough vaccination. Countries cannot achieve and maintain uniformly high levels of population immunity when they have both low routine first-dose coverage and reduced-quality or delayed supplementary immunization campaigns, which provide a second opportunity for measles vaccination. For example, 19 million infants (mostly in Africa and South-East Asia) did not receive MCV1 in 2010 and now remain at risk for infection and death. The outbreaks in Africa, along with the continued high numbers of measles deaths occurring in India, threaten to reverse the progress made in reducing measles mortality worldwide.

Although past decreases in measles deaths have made a critical contribution toward achieving the Millennium Development Goal #4, experts’ fears are growing that these gains could be lost because of declining political and financial commitment to measles control.

• Financial support for the Measles and Rubella Initiative decreased from US $160 million in 2007 to US $80 million in 2011.
• Many countries have not sustained national public health resource commitments to ensure high first-dose routine measles vaccination coverage as well as the provision of many other routine immunizations.
• Many countries with a high-priority need for measles control programs have not been able to raise the expected 50% of operational costs for campaigns, resulting in postponement of scheduled vaccination campaigns and cutbacks in the range of targeted age groups.
• The gains made in reducing measles mortality over the past decade will be lost unless more resources are provided now to fully implement planned vaccination activities and set up laboratory-backed surveillance for measles cases. In addition, the introduction of rubella vaccines is needed in 30 additional countries in the next 3 years.

Hope for the Future

Despite these losses, many encouraging developments in 2011 and 2012 suggest there are still opportunities to meet the 2015 goal of reducing measles mortality by 95% and subsequent 2020 measles and rubella elimination goals. These developments include the following:

• The progress made in just a decade that resulted in a 74% decline in measles deaths, mostly between 2000 and 2007, demonstrates that when correctly applied, measles control strategies work rapidly.
• India’s efforts to add a second dose of measles vaccine in routine immunization programs in 21 states and to reach an additional 134 million children with measles vaccine in catch-up campaigns through early 2013 will help to rapidly reduce measles deaths by 2015.   
• Successful follow-up campaigns in several Western Pacific Region countries during 2010–2011, including a  nationwide campaign in 2010 in China that vaccinated 103.4 million children, resulted in a dramatic decline in regional measles incidence to just 5 cases per million (annualized) during the first half of 2012.   
• The large outbreaks in southern Africa in 2009 and 2010 were largely brought back under control through supplementary immunization campaigns in 2011.
• Fifteen countries in sub-Saharan Africa are conducting nationwide immunization campaigns against measles in 2012, targeting over 42 million children and adolescents.
• The new Measles and Rubella Strategic Plan provides a roadmap for not only reducing, but eliminating, both measles and rubella while strengthening routine immunization programs.
• A new commitment from the GAVI Alliance to pay for combined measles and rubella vaccination campaigns should increase the number of campaigns and introduce a rubella vaccine in as many as 30 countries by 2015.
• Additional WHO regions are establishing goals for the elimination of rubella and CRS.