SPECIAL FEATURE - October 2003
Measles meets its match
An Africa-wide initiative against the continent's biggest vaccine preventable killer is already exceeding its targets for reaching more children and preventing deaths, as Karen Emmons reports
Up for it: Children at the campaign in Eritrea
UNDER September’s gruelling sun and the sound of distant gunfire, 90 camels chased through the Eritrean mountains after a pestilent killer that last year took the lives of some 370,000 children across the African continent. Laden with vaccine carriers and health workers, the four-legged mobile units searched for nomadic families in what is part of a massive five-year effort aimed at halving measles deaths in Africa by 2005.
Down in the lowlands the task was easier. Children lined up under their striped umbrellas by the hundreds. Explained one mother at the Seboo post: “The vaccine is important because it protects against the measles, which causes blindness…and lots of deaths.”
In Geza Hamle, a recently trained health worker gently filled each auto-disable syringe, promptly pricked a child and, fingers crossed, sent her into a future safe from measles. Returning the syringe to its safety box that would later be burned and buried, the Eritrean health worker turned to the next arm, knowing that these vaccinations fail the first time in about 10%-15% of children (see Box 1). “None of us cried, except the very young,” beamed nine-year-old Gebre who with his friends showed off their just pricked arms.
Health officials know that the best possible protection occurs when more than 90% of a population is vaccinated against the highly contagious virus, creating a “herd” immunity that can indirectly safeguard the minority who remain unvaccinated or in whom the vaccine doesn’t work. Establishing that herd immunity is especially difficult in Africa where routine measles coverage has been feeble - under 60% in about 17 countries.
Experiences in South America and Southern Africa have proven, however, that providing all children aged between nine months and five years with two opportunities to be immunized can achieve the protection needed for near-zero levels of measles mortality. Following those experiences, so began the Measles Initiative in 2001. The initiative, which is backed by a group of partners led by WHO, UNICEF, the US Centers for Disease Control and Prevention (CDC), the UN Foundation and the American Red Cross is targeting all 32 sub-Saharan African countries where measles is the leading vaccinepreventable killer of children. The Eritrean camels and nomadic families are part of the 24th country campaign in a strategy to immunize 200 million African children that, according to Mark Grabowsky of the American Red Cross, “is ahead of schedule, exceeding targets and under cost”.
1: When is the right time to vaccinate?
The ideal age for the first measles vaccination is after a child’s first birthday. But in communities where the chances of being exposed to the virus are high, there’s a dangerous “window” for babies after they reach about six months of age when they have no protection against it. Babies inherit antibodies against measles from their mother at birth, but these wear off by around six or seven months. If a child is vaccinated before the antibodies die out, the vaccine will be neutralized and the child will not be immunized.
“In Africa, when measles vaccine first became available, we had to balance effectiveness with the chance of an infant being exposed to the virus,” says Bradley Hersh, a medical officer at WHO. Officials came up with nine months as the necessary age to begin vaccinating. “In a developed country where there is minimal threat of exposure, 12-15 months would be the ideal age,” adds Hersh.
In an area with a high burden of disease, such as Africa, the routine system is not strong enough to stop the circulation of the measles virus. To create the herd immunity in which very young children are indirectly protected requires coverage of at least 90%. It is now widely accepted that the only effective way to achieve this level is to give all children two opportunities for measles immunization.
Some campaigns conducted in the early 1990s in Southern Africa were restricted to children younger than five years, because most deaths occurred among those aged one to four years. “Those campaigns weren’t successful for very long because they allowed transmission to continue in older kids, who then became sources of infection to infants,” Hersh says. To provide direct protection and indirect herd immunity, officials set nine months to 15 years as the necessary range for vaccinating during the catch-up campaigns.
WHO and UNICEF have also targeted an additional 13 measles-endemic countries outside Africa. Earlier this month, in a sign of the success of the initiative in Africa so far, representatives from all 45 measlesendemic countries met in Cape Town, sponsored by WHO and UNICEF, to discuss how to engage new partners for sustainable measles mortality reduction in other regions of the world.
After three years, the list of the Measles Initiative’s achievements is lengthy: by December, 28 countries will have vaccinated 115 million children with a coverage range of between 93% and 97%. As a result, they have cut the number of measles cases in each country by at least 58%, rising to 96% in some countries, and have averted an estimated 270,000 deaths. Total costs for the five-year strategy are estimated to reach beyond US$160 million (or about 80 cents per child), shared largely by the five partnering organizations, with inputs from other donors and governments.
Stronger routine immunization
But the campaigns do more than vaccinate children. They are also designed to build up sustainable protection against measles and other priority diseases by improving countries’ systems for delivering routine immunization. The Measles Initiative urges governments to put immunization high on their development agenda. It has prompted governments to plan for waste management, systematized the use of auto-disable syringes, strengthened the cold chain process, improved surveillance, upgraded laboratories for handling blood specimens and increased various partnerships in funding and implementation. For example, health workers giving measles immunization have also provided families with insecticide-treated mosquito nets, de-worming pills and vitamin A supplements at the same time.
There is no quick fix -- we need good routine immunization and campaigns
While parents have loudly demanded action, the successes are credited largely to the partnership of national governments, donors and implementers orchestrating the move against measles. “It is good - we got the amount of money we requested. It really was helpful,” says Filli Said Filli, immunization programme manager in Eritrea, where 1.3 million young people were targeted in the recent campaign. “We have developed a five-year plan and after two years, we’ll have a follow-up campaign for under three- year-olds.”
Catch up, keep up, follow up - the strategy
For years a debate lingered on whether to attack measles by strengthened routine immunization or by polio-style campaigns. The experiences in the Americas showed a need to combine both. “There is no quick fix,” explains Bradley Hersh, at the World Health Organization. Campaigns alone cannot solve the problem, nor can the routine delivery of vaccinations alone.
In this approach, a countrywide campaign supplements routine vaccination for children at nine months of age, “cleaning” the environment. This catching-up clears a safe path for very young children to survive to receive the routine dose of vaccine. The key to sustained protection remains with vigilant routine coverage keeping up with all newly born children. A follow-up campaign three or four years later provides the opportunity for measles immunization for those who missed their vaccination at nine months or in whom the vaccine failed.
Developed by the Pan American Health Organization (PAHO) in the early 1990s, the strategy of “catch up, keep up and follow up” cut the region’s measles cases from more than 600,000 in 1990 to 500 a decade later. So far this year, there has been no transmission of measles in the Americas.
UNICEF and the World Health Organization officials adopted that strategy as an experimental response to requests by health officials in seven southern African countries in 1997 to add a single mass campaign for children younger than 15 years to the routine dose at age nine months, thus offering the two opportunities for immunization. The number of reported measles cases across the seven countries dropped from over 50,000 per year before the campaigns to 100 cases in 1999; measles deaths decreased from an estimated 3,700 to two in 1999 and zero in 2000. The question then became, how far up the continent could the strategy work?
2: Personal digital assistants make a difference
Thirty Red Cross volunteers in Ghana had never touched a computer or conducted a field survey. But two days of training with a personal digital assistant (PDA) changed the nature of follow up. While the burden of data collection and entry with paper and pen limits the size and accuracy of surveys, the hand-held computers allowed a survey of more than 2,400 families in three days. Within six hours of the surveyors returning from the field, the data were analyzed and the report available to the Ministry of Health, a process than normally takes weeks to months.
The approach was so innovative that it won the Stockholm Challenge award in 2002 for information technology. One of the barriers to wider use of PDAs is the cost and complexity of the software. The American Red Cross is working with CDC to create shareware that can help field staff to do PDA surveys without external technical support.
People who have never touched a computer pick up the PDA and “love it”, says Grabowsky. “They immediately understand its power and value.”
With governments asking for assistance, a handful of officials who had experience in PAHO or who were then working in Africa shared a resolve that “something had to be done” for controlling measles. “We had an excellent, safe and cheap vaccine,” says Hersh. “The challenge was the implementation - making sure all kids are vaccinated.”
In January 2001 they agreed to mobilize resources for Africa through a novel collaboration between the five key partners. They set up a weekly conference call (that will continue through 2005), open to any stakeholder, in which plans are fine-tuned, problems identified and decisions made. Within months they had pooled together US$20 million and the first supplemental campaign vaccinated 3.7 million Tanzanian children in seven days the following September.
Each of the seven southern African countries that experimented with the strategy in the late 1990s has successfully started implementing follow-up campaigns every four years. This is to protect all children born after the initial catch-up campaign.
In action: a vaccination campaign post in Eritrea
The initiative in Africa
The Partnership covers the costs of bundled vaccines and most of the operational costs through funds provided by CDC, the UN Foundation, the American Red Cross and Vodafone, which then are channelled through UNICEF and WHO. Each country contributes to its campaign as well, though the portion is based on its economic situation. To ensure resources for the long-term needs, governments have been asked to increase their budget for routine immunization.
To receive Partnership funds, health officials in each targeted country must meet certain requirements very similar to those required by GAVI and the Vaccine Fund for support with new and under-used vaccines. They must draft a three- to five-year strategy for measles control, as part of their overall immunization plan. In addition, they must draft a one-year plan of action, from the district level upwards, for the campaign. This plan must be approved by the country’s Inter-agency Coordinating Committee. The plan is then submitted to the WHO Regional Office for Africa for technical review. The action plan requires an assessment of existing infrastructure and sometimes, as in Angola where there had been no census for 30 years, a population and health facility count.
People are willing to queue for hours, for fear that the vaccine will run out
Equally important, countries must make proper provision for safely disposing of the needles and syringes and use safe injection practices, including auto-disable syringes. “We’ve made it an integrated part of the strategy. Without it, we won’t send funds,” says Edward Hoekstra, senior health advisor with UNICEF’s Global Measles Programme. With the Partnership’s resources, countries such as Mali, Togo, Burkina Faso, Ghana, Benin and Cameroon installed incinerators to burn used injection equipment in nearly all districts.
Before each campaign, health workers are trained in using the auto-disable syringes as well as other elements of routine immunization services, such as vaccine and cold chain management and planning. These practices have been noted in every government’s post-campaign impact assessment report as a permanent fixture in the routine system.
Getting people involved
In the months prior to the campaign, the Red Cross and other local partners begin collecting volunteers to mobilize children - in Kenya, more than 13,000 people offered to help; in Zambia, each of the vaccination sites had six to seven volunteers. An advertising blitz takes off a week before the vaccination blitz, using radio, television, plays, theatre, music and concentrated child-to-child activities in schools.
“We make extraordinary efforts to reach every child, especially the poorest and highest-risk,” say Grabowsky. The Red Cross volunteers knock door to door in some areas or drive village to village and find children. Volunteers write down the name of every eligible child in many villages and do individual follow-up to make sure they all were vaccinated. However, in most places achieving a high turnout has not been difficult. So great is the terror of measles among parents, people are willing to queue for hours in the first few days, for fear that the vaccine will run out.
To maximize the moment, health officials have exploited many of the campaigns to deliver other interventions at the same time. Vitamin A supplements have been provided in almost all campaigns. In Ghana’s Lawra district, officials distributed 14,000 insecticide treated mosquito nets during the measles campaign, bringing nets to 80% of households where previously they’d been available to only about 7%. Health officials distributed nearly 83,000 treated nets in Zambia and gave mebendazole (de-worming) tablets to 1.6 million children.
With guidance from WHO’s African regional office, each country has conducted surveys to assess the success of campaigns in terms of their coverage and their impact on the immunization system, as well as installing systems for monitoring adverse events following immunization. Hand-held computers have been used in three countries for exit interviews and field surveys, allowing community members to conduct the evaluations (see Box 2). In addition, countries have strengthened their measles surveillance activities, building on and extending surveillance structures originally developed as part of the Polio Eradication Initiative.
“It takes a lot of work to get the money to the ground on time,” admits Andrea Gay, whose role with the UN Foundation is to coordinate the donations. Uncertainty about when money would arrive resulted in delayed field orders for supplies and delays in the building of incinerators to destroy the syringes in time for most of the campaigns. Also, some shipments of vaccine were late being delivered and had to be airlifted, increasing the costs of the operation.
And there have been a few outbreaks of measles among children. Robert Kezaala, Medical Officer for the Expanded Programme on Immunization in WHO’s regional office for Africa, says there were outbreaks in Burkina Faso, Cameroon and Tanzania in 2003. These outbreaks were triggered by a relaxing of routine coverage, which left children vulnerable to becoming infected when children with measles entered the country from other countries where routine coverage is lower or where a campaign had not yet taken place. A significant proportion of the cases had not been vaccinated, with the majority in the target age group of under 15 years. Kezaala emphasizes the need for high levels of routine coverage, and for countries to act together in blocks to reduce the risk of major importations of measles cases.
Meeting the Millennium Development Goal
Now, the partners in the initiative are giving serious attention to strengthening the routine immunization systems in the countries. “We’re trying to reach all children in each district of the measles priority countries with the first routine dose by nine months of age. We’re already seeing a gradual increase in immunization coverage in countries targeted,” Hoekstra says.
Complaints about the initiative seem to be few. “It’s quite phenomenal what countries have done in two and a half years with Partnership support,” says Gay. She believes that the Partnership is a work in progress, improving campaign by campaign.
The Partnership has most of the funding to cover eight campaigns with a target population of 59 million children in 2004. Because of its size, only Nigeria remains unfunded, and thus unscheduled.
The measles campaign is expected to surpass its target of halving child mortality by 2005, compared to 1999 levels. Cutting measles deaths in Africa will certainly help to achieve the UN Millennium Development Goal to decrease under-five mortality. In the process, the Measles Initiative will have delivered a wide range of social benefits. Provided high routine coverage is maintained, the sharp reduction of measles cases will reduce demands on overburdened health care delivery services, freeing health workers and resources to deal with other priorities, such as malaria and HIV/AIDS.
With reporting from Rebecca Martin, WHO, in Eritrea.
Karen Emmons is a journalist based in Bangkok.
Other agencies contributing to the Measles Initiative are: International Federation of the Red Cross, Canadian International Development DA, Right to Play, USAID, JSI Incorporated, BASICS, national Red Cross societies and ministries of defense and education. Becton, Dickinson & Company, supplier of auto-disable syringes, assisted in injection-safety training in Ghana, Angola, Namibia and Zambia.
Immunization Focus October 2003 - Contents