Do we need a measles vaccine stockpile for more effective measles

Report
Do we need a measles
vaccine stockpile for more
effective measles outbreak
response?
 Global Measles and Rubella Management Meeting

Salle B, WHO Headquarters, Geneva, Switzerland, 15 - 17 March 2011
Maya Van den Ent, PharmD, MPH
Robin Nandy, MBBS, MPH
Edward Hoekstra, MD. MSc
Measles and Emergencies , Health Section, UNICEF HQ
Measles Emergencies
Disasters
Measles Outbreaks
Funding Disasters through
emergency funding
Measles vaccination campaign part of initial
response
- SPHERE
- Core Commitments For Children
Measles Outbreak Response
WHO Measles Outbreak
Response Guidelines
(2009)
http://whqlibdoc.who.int/hq/2009/WHO_IVB_09.03_eng.pdf
Critical Aspects Of Measles Outbreak Response
Immunisation
 Timing
– As soon as possible after confirmation of the outbreak
 Age range
– Based on susceptibility profile, analysis of outbreak data, etc
 Geographical area
– Affected areas plus adjacent areas
– Other high risk areas or population groups
 Campaign coverage/quality
Proportion of Cases Prevented (%)
Proportion Cases Prevented By Intervention
Coverage & Time: 6 – 59 m, Niamey, Niger
100
2 months
3 months
90
4 months
+ 6 months
80
70
60
50
40
30
20
10
0
30
40
50
60
70
Intervention Coverage (%)
80
90
100
Proportion Cases Prevented By Intervention
Coverage & Time: 6 – 15 y, Niamey, Niger
Proportion of cases prevented (%)
100
90
80
70
60
50
40
2 months
30
20
3 months
4 months
10
0
30
40
50
60
70
Intervention Coverage (%)
80
90
100
Overview Of Recent Outbreaks & Response
Efforts
Measles Outbreaks in Africa
 Small fraction of number of
cases compared to pre-SIA era
Reported Measles Cases by Month and
WHO Regions, 2006-2010
AFR
SEAR
AMR
EMR
EUR
WPR
35000
30000
25000
20000
15000
10000
5000
0
Jan
2006
Apr
Jul
Oct
Jan
2007
Apr
Jul
Oct
Jan
2008
Apr
Jul
Oct
Jan
2009
Apr
Jul
Oct
Jan
2010
Apr
Jul
Oct
 28 countries experience
outbreaks in June 2009 – Dec
2010
– Malawi, S. Africa,
Zimbabwe, Zambia,
Lesotho, Nigeria, DRC,
Angola…
– > 200,000 reported cases
– > 127,000 confirmed cases
– > 1,400 measles deaths
Measles deaths, June 2009 – Dec 2010 (n = 1,463)
Type of Outbreak Response Immunization
(ORI) by Number of Confirmed Cases
ORI unknown age range
Nationwide Non Selective ORI <15 years
Nationwide Non Selective ORI <5 years
Localized Non Selective ORI <15 years
Localized Non Selective ORI <5 years
Selective ORI
No ORI
-
20,000
40,000
60,000
Timing Of Outbreak Response Immunization*
Time period
between
confirmation of
outbreak and ORI
# of
countries
0-3 months
1
Rwanda
3 – 6 months
6
Burundi, Cameroon, Chad, Ethiopia,
Namibia, Senegal, Zambia
> 6 months
5
South Africa, Swaziland, Zimbabwe
Countries
Malawi, Lesotho (Nationwide)
Unknown
12
Benin, Botswana, DRC, Ghana, Liberia,
Mali, Niger, Nigeria, Tanzania, Togo,
Lesotho, Malawi (Initial local response)
* Outbreaks reported cases between June 2009 and Dec 2010
Estimated Number of Doses Used for
Outbreak Response in 2010
 About 30 million doses
 About $11 million for
bundled vaccines
Issues
 Lack of capacity and preparedness
 Insufficient use of Government Emergency
funds
 Measles not always included in
preparedness plans
Is a stockpile the solution?
Learning from Meningitis
Global Stockpile Meningitis
 Global shortage of vaccines as compared to
demand
– Mechanism to ensure access for most in need
 Processing requests full time job during
outbreak season
– WHO-HQ hosts ICG secretariat
– ICG: IFRC, MSF, UNICEF and WHO
 Time between outbreak and response : 4 - 8 weeks
Measles Stockpile?
 Measles stockpile
– Make funding available to respond to outbreaks
– Questionable whether donors are willing to fund
 Where should it be managed?
– At global level?
– In AFRO?
– At national level?
 What are criteria for allocation?
 Does stockpile address the current problems?
Stockpile Managed at Global/Regional Level
(The Meningitis & YF Model)
Requires:
 Clear decision mechanism
– Outbreak investigation standards
– Risk analysis standards
– Outbreak response standards
 Interagency decision body
 Emergency shipping mechanism
 Monitoring and Evaluation
Pros and Cons
Stockpile Managed at Global / Regional Level
Pros
Cons
 Enabling systematic outbreak
response
 No country ownership
 Time consuming at global
 Response time can be short, if
level
mechanism well developed
 Possible disincentive for other
 Potential new source of funds
non contributing donors to
support outbreak response
 May detract countries from
focusing on improving the
quality of routine programmes
Stockpile Managed at National Level
Requires:
 Full country buy-in to reserve % of RI stock for outbreak
response preparedness
Pros and Cons
Stockpile Managed at National Level
Pros
Cons
 Country buy in
 Quality of outbreak response
depending on country level
understanding of ORI
 Part of program planning &
preparedness
 Faster response, as vaccines
are already in country
 Local politics may interfere in
decision making
 Difficult to monitor & follow up
from global & regional level
Questions
Measles Stockpile?
 Can we raise the funds?
– $ 10 - 15 million annually
– Revolving Fund?
 What is the best mechanism?
– Global / Regional vs National
– Country/region specific?
 Will the stockpile address the problems in Outbreak
Response Immunization?
Acknowledgements
 EPICENTRE
– Rebecca Freedman-Grais
 WHO
–
–
–
–
–
Peter Strebel
Alya Dabbagh
Balcha Masresha
William Perea
ICG secretariat
 CDC
– Robb Linkins
 UNICEF
– Robin Nandy
– Rouslan Karimov
Extra slides
Simulated Measles Cases In Niamey, Niger
(2003-2004)
8.1% [4.9, 8.9] averted with intervention on day 161
Reasons for outbreaks
1. Still gaps in routine immunization coverage
2. Suboptimal coverage during recent SIAs (ZIM, NAM, ANG, BOT)
3. Too long (> 3 yrs) interval between SIAs (ZAM, LES, SEN)
4. Pockets of unvaccinated & resistant populations (ZIM)
5. Lower demand due to disappearing disease
6. Accumulation of susceptibles in older age groups
Type Of Outbreak Response Immunization*
Outbreak Response
Immunization (ORI)Type
# of
countries
Countries
No ORI
7
Angola, Burkina Faso, Cote d’Ivoire, Guinea
Conakry, Mauritania, Sierra Leone
Selective ORI (6/9m – 59
m) in affected areas
6
Benin, Botswana, Ghana, Mali, Mozambique
(some DS) Nigeria, Zambia
Non Selective ORI (6/9m –
59 m) in affected areas
5
Cameroon, Chad, Ethiopia, Senegal, Togo
Non selective wide age
range ORI (6/9m – 14 y) in
affected areas
4
Burundi, DRC, Lesotho, Malawi
Nationwide ORI (6/9m –
59 m)
2
Liberia, Swaziland
Nationwide wide age
range ORI (6/9m – 14 y)
4
South Africa, Zimbabwe,
Lesotho, Malawi, following initial limited ORI
ORI with unknown age
range
6
Kenya, Mozambique (some DS), Namibia, Niger,
Rwanda, Tanzania
* Outbreaks reported cases between June 2009 and Dec 2010
Measles reported cases, 2009-2010 (1 dot = 50 cases)
Measles confirmed cases, 2009-2010 (1 dot = 50 cases)

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