1. Do we need a measles vaccine stockpile for more effective measles outbreak response? Global Measles and Rubella Management Meeting Global Measles and Rubella Management Meeting Salle B, WHO Headquarters, Geneva, Switzerland, 15 - 17 March 2011 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

2. Measles Emergencies Disasters Measles Outbreaks

4. Funding Disasters through emergency funding Measles vaccination campaign part of initial response -SPHERE -Core Commitments For Children

5. Measles Outbreak Response http://whqlibdoc.who.int/hq/2009/WHO_IVB_09.03_eng.pdf WHO Measles Outbreak Response Guidelines (2009)

6. 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

7. Proportion Cases Prevented By Intervention Coverage & Time: 6 – 59 m, Niamey, Niger 0 10 20 30 40 50 60 70 80 90 100 30405060708090100 Intervention Coverage (%) Proportion of Cases Prevented (%) 2 months 3 months 4 months + 6 months

8. Proportion Cases Prevented By Intervention Coverage & Time: 6 – 15 y, Niamey, Niger 0 10 20 30 40 50 60 70 80 90 100 30405060708090100 Intervention Coverage (%) Proportion of cases prevented (%) 2 months 3 months 4 months

9. Recently Documented Experiences - MSF 2009 2005 2004 2003 47,000 + 8,015 40,857 2,505 10,880 Burkina Faso N’Djamena, Chad Kinshasa, DRC Adamawa, Nigeria Niamey, Niger Cases Length (mo) Year Place 1 6 12+

10. Overview Of Recent Outbreaks & Response Efforts

11. Measles Outbreaks in Africa Small fraction of number of cases compared to pre-SIA era 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 Reported Measles Cases by Month and WHO Regions, 2006-2010

12. Measles deaths, June 2009 – Dec 2010 (n = 1,463)

13. Type of Outbreak Response Immunization (ORI) by Number of Confirmed Cases

14. Timing Of Outbreak Response Immunization* Time period between confirmation of outbreak and ORI # of countries Countries 0-3 months1Rwanda 3 – 6 months6Burundi, Cameroon, Chad, Ethiopia, Namibia, Senegal, Zambia > 6 months5South Africa, Swaziland, Zimbabwe Malawi, Lesotho (Nationwide) Unknown12Benin, Botswana, DRC, Ghana, Liberia, Mali, Niger, Nigeria, Tanzania, Togo, Lesotho, Malawi (Initial local response) * Outbreaks reported cases between June 2009 and Dec 2010

15. Estimated Number of Doses Used for Outbreak Response in 2010 About 30 million doses About $11 million for bundled vaccines

16. Issues Lack of capacity and preparedness Insufficient use of Government Emergency funds Measles not always included in preparedness plans

17. Is a stockpile the solution? Learning from Meningitis

18. 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

19. 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?

20. 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

21. Pros and Cons Stockpile Managed at Global / Regional Level Pros Enabling systematic outbreak response Response time can be short, if mechanism well developed Potential new source of funds Cons No country ownership Time consuming at global level Possible disincentive for other non contributing donors to support outbreak response May detract countries from focusing on improving the quality of routine programmes

22. Stockpile Managed at National Level Requires: Full country buy-in to reserve % of RI stock for outbreak response preparedness

23. Pros Country buy in Part of program planning & preparedness Faster response, as vaccines are already in country Cons Quality of outbreak response depending on country level understanding of ORI Local politics may interfere in decision making Difficult to monitor & follow up from global & regional level Pros and Cons Stockpile Managed at National Level Pros and Cons Stockpile Managed at National Level

24. 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?

25. Acknowledgements EPICENTRE –Rebecca Freedman-Grais WHO –Peter Strebel –Alya Dabbagh –Balcha Masresha –William Perea –ICG secretariat CDC –Robb Linkins UNICEF –Robin Nandy –Rouslan Karimov

26. Extra slides

27. Simulated Measles Cases In Niamey, Niger (2003-2004) 8.1% [4.9, 8.9] averted with intervention on day 161

28. 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

29. Type Of Outbreak Response Immunization* Outbreak Response Immunization (ORI)Type # of countries Countries No ORI7Angola, Burkina Faso, Cote d’Ivoire, Guinea Conakry, Mauritania, Sierra Leone Selective ORI (6/9m – 59 m) in affected areas 6Benin, Botswana, Ghana, Mali, Mozambique (some DS) Nigeria, Zambia Non Selective ORI (6/9m – 59 m) in affected areas 5Cameroon, Chad, Ethiopia, Senegal, Togo Non selective wide age range ORI (6/9m – 14 y) in affected areas 4Burundi, DRC, Lesotho, Malawi Nationwide ORI (6/9m – 59 m) 2Liberia, Swaziland Nationwide wide age range ORI (6/9m – 14 y) 4South Africa, Zimbabwe, Lesotho, Malawi, following initial limited ORI ORI with unknown age range 6Kenya, Mozambique (some DS), Namibia, Niger, Rwanda, Tanzania * Outbreaks reported cases between June 2009 and Dec 2010

30. Measles reported cases, 2009-2010 (1 dot = 50 cases)

31. Measles confirmed cases, 2009-2010 (1 dot = 50 cases)