Eradicating Measles: A Call for an Exceptional Coordinated Global Effort

Abstract

There are compelling epidemiological, economic, and ethical arguments for setting a global measles eradication goal. The 6 chairpersons of Regional Verification Commissions for Measles and Rubella elimination advocate that the time for courageously accelerating efforts to ensure a world where no child dies of measles, is NOW!

measles, rubella, elimination, eradication, epidemiology

The Global Vaccine Action Plan (GVAP) was launched with an unparalleled stated political commitment by the 194-member states of the World Health Assembly in May 2012 [1]. This visionary initiative aimed to “extend the benefits of vaccination to all people everywhere”, a truly aspirational global public health endeavor. Measles elimination featured prominently among the core GVAP priorities, with an interim goal of achieving interruption of measles virus circulation in 4 World Health Organization (WHO) Regions by 2015 and verification of elimination in 5 Regions by 2020.

This focus on measles elimination was well founded. Not only had interruption of endemic transmission already been achieved in one Region, the Americas [2], but many individual countries in the other Regions had also interrupted endemic measles virus circulation with the available vaccine and existing tools. Thus, elimination in every Region was considered technically and programmatically feasible by a global expert consultation in 2010 [3], but this was dependent on appropriate political commitment and financial investment to ensure trusted health systems could metronomically deliver potent vaccine to all children. Despite the absence of a global eradication target, all Regions’ measles elimination goals were on or before 2020, thus effectively committing to global measles eradication. This is not a “top down” initiative. The Regions and many countries have acted! Having a global goal could exert peer performance pressure on countries that are lagging behind.

Effective measles immunization requires administration of temperature-assured, safe, and effective vaccine with a needle and syringe by trained health professionals. Measles virus’ daunting transmissibility demands homogeneous coverage of almost all children in every birth cohort, to achieve measles elimination. Primary healthcare systems need to be strong everywhere. Moreover, primary reliance on supplemental immunization activities will not maximize the potential gains offered by the whole-of-health service strengthening focus that is really required to achieve and sustain measles elimination. Thus, the serious pursuit of measles elimination will result in massive attendant health system strengthening gains.

Increasing measles immunization coverage has had an indisputable impact on reducing global childhood mortality. An estimated 20.4 million lives were saved between 2000 and 2016 by measles vaccination alone [4]. In addition, in terms of health dollars invested, the return on investment afforded by measles vaccine is profound, with an estimated $58 saved in future costs for every $1 spent [5].

Aside from the disease burden and huge costs averted, other benefits of measles, when coupled with rubella elimination, can be realized. Operational and technical feasibility in achieving both have been proven. Eliminating the devastating consequences of congenital rubella syndrome is a side benefit that is also highly cost effective [6]. The strategies are basically the same because both require high-quality immunization services. There is nothing “routine” in attempting to reach every child with high-quality services, but elimination cannot be achieved unless essential immunization services, including disease surveillance, are prioritized. Without surveillance strengthening, efforts to use measles epidemiology to detect, understand, and fill measles immunity gaps will be misplaced and resources will be wasted. Herein lies a key benefit, disease surveillance strengthening will also contribute to greater health security in every country.

Thus, the conclusions of the recent audit of the GVAP progress by the Strategic Advisory Group of Experts (SAGE) on Immunization are truly disappointing [7]. The SAGE emphasized how easily hard-won gains can be lost, graphically illustrating this by the lack of progress towards measles elimination goals. Global measles first dose coverage has plateaued at approximately 85% coverage for the past 8 years [8], well short of the 95% homogeneous coverage of each birth cohort recommended by SAGE, which is the critical population immunity threshold required to achieve and sustain elimination. Four Regions (the Americas, Europe, South East Asia, and Eastern Mediterranean) experienced massive measles outbreaks in 2017, whereas the only Region to have achieved measles elimination lost that status with re-established transmission in at least 1 country, Venezuela, and in the European Region, both Germany and Russia, previously verified to have interrupted measles transmission, experienced over 12 months of re-established transmission in 2017. Furthermore, the WHO has consistently noted that the quality of measles (and rubella) surveillance remains inadequate in many countries [9].

Essentially, the initial global solidarity and commitment has waned. Governments in a number of higher income countries are nonchalantly relying on uninspired routine immunization program performance and neglecting to use every mechanism available to promote the benefits of immunization. This may include (1) policy levers to incentivize immunization for immunizers and families and (2) embracing the power of the social media platform to engage and inform young families. Civil society and professional societies are critical partners for mobilizing the additional resources required and contributing to building the confidence of communities and families who are being challenged by antiscientific and, often vitriolic, antivaccination rhetoric.

Mindless conflict, resource mismanagement, and inadequately supported and extremely poorly managed immunization programs are colossal challenges to delivering life-saving vaccines in many countries. There is a pressing need for a resurrected focus on the value of each child’s life. This alone might encourage episodic tranquil periods in areas of insecurity and enthusiastic dedication to delivering high-quality child health services where they are most needed.

Major donors appear to have retreated from the bold and noble measles elimination goals of the Decade of Vaccines; timidity excused by the pedestrian pace towards polio eradication and the “need to complete this first”. Unfortunately, the tyranny of sequential thinking has replaced visionary collaboration. Global agencies, such as WHO and UNICEF, are cowering at this nonappetite of some key donors for an eradication goal. As the guardians of global health, these agencies cannot afford to kowtow to the whims of influential and powerful donors; they need to again assume bold and resolute leadership, because the cost of delaying measles eradication will be enormous! A strategy of marking time and then accelerating efforts when the donor community considers the time is ideal is fraught with peril. Measles will not wait without exacting an enormous toll in the following:

• lost lives—over 89 000 children are estimated to have died due to measles in 2016 alone;

• misspent finances—>15 million DALYs (disability adjusted life years) lost each year that eradication is delayed valued at >$63 billion (US) that poses a horrendous opportunity cost [10]; and

• pernicious epidemiological trends—Inadequate coverage of infants and children under 24 months of age has resulted in a protracted susceptibility to measles, with an overall decline in case numbers but a greater proportion of cases occurring in older teenagers and young adults in many countries, particularly in the European and Western Pacific Regions [11]. Immunizing these age groups is notoriously difficult, and the immunity gaps that are opening in this demographic are much harder to fill.

The ethical case for completing eradication has been made [12], and the rule of rescue obligates governments and donors to make every effort to save the lives of children by forever ridding the world of the scourge of measles virus. The equity case is equally compelling. Because the most marginalized and fragile children are particularly vulnerable to severe measles complications, an argument can be made that global vaccine coverage benefits them relatively more; greater need demands greater effort and investment [13].

Now is the time to accelerate coordinated efforts in pursuit of the achievable goal of a world where no child dies due to measles. Yes, it will be difficult—extremely difficult—because measles virus is proving the formidable foe its astonishing reproduction number predicted it would be [14]. However, a growing number of countries have shown that this challenge is not insurmountable. A renewed emphasis on essential immunization and surveillance systems, as envisaged in the recent Astana [15] call to arms, can make it possible. It is time for resolute courage and the invictus spirit epitomized by Nelson Mandela: “There is no passion to be found playing small–in settling for a life that is less than the one you are capable of living.”

Notes

Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.