The Médecins sans frontières experience in measles outbreak response

1. The Médecins sans frontières experience in measles outbreak response Rebecca Freeman Grais March 16, 2011

2. Outline • Brief background • Guidelines • Three recent examples, three different experiences • Maroua, Cameroon • N’djamena, Chad • Malawi • Ways forward

3. Background (I) • Missions in 32 African countries • Vaccination • Support in primary care when relevant • Outbreak response • Case management • MSF vaccinated against measles • 1.5 million persons in 2009 • > 4.5 million persons in 2010 • Frustrating field reality

4. Backgound (II): Duration of epidemics, reported cases and timing of interventions Reported cases Place Year Duration (months) 1 12+ 6 Niamey, Niger 10880 2003 Adamawa, Nigeria 2505 2004 Kinshasa, DRC 2005 40857 N’Djamena, Tchad 2005 8015 2009 Burkina Faso 53000 +

5. Background (III): Burden of disease in pockets of high endemicity • Difficult to reach populations • High birthrates • Insufficient vaccination coverage • Morbidity and mortality burden • CFR of 7% in rural areas

6. Proportion cases prevented by intervention coverage and time: 6 to 59m, Niamey, Niger 100 2 months 3 months 90 4 months + 6 months 80 70 60 50 Proportion of Cases Prevented (%) 40 30 20 10 0 30 40 50 60 70 80 90 100 Intervention Coverage (%) Source: Grais et al, 2007

7. Proportion cases prevented by intervention coverage and time: 6 to 15y, Niamey, Niger 100 90 80 70 60 Proportion of cases prevented(%) 50 40 2 months 3 months 30 4 months 20 10 0 30 40 50 60 70 80 90 100 Intervention Coverage (%) Source: Grais et al, 2007

8. New WHO guidelines (March 2009) • There is time and benefit to intervening • Vaccination • Immediate selective vaccination (6m to 5y) • District level outbreak management team • decision about whether non-selective mass campaign needed

9. Next step is to evaluate and further improve on recent gains and prevent them from slipping

10. Jan – May 2008 39 cases Renforce EPI 1.Maroua, Cameroun 2008-2009 (872 cases) • 29 Jan. – 4 Feb. 2009 • MoH mass campaign • 6 mo to 15 years • Free treatment (MSF) 100 • October 2008 • Increase in cases • Campaign 6 to 59 months for certain wards 80 60 cases 40 20 0 0 5 10 15 20 25 30 35 40 45 50 2 7 12 17 week

11. 1. Vaccine coverage survey, Maroua, Cameroon, April 2009 (n=3,025) Vaccination coverage of mass campaign estimated at 90% Number of doses received among children 6-59 months 7% unvaccinated 25% 1 dose 47% 2 doses 21% 3 doses Source: Luquero et al, JID, in press

12. 1. Lessons learned from Maroua outbreak • Risk-assessment and interventions followed the guidelines • Close cooperation between MoH, WHO and MSF • Cases subsided but strategy still missed children

13. 2. Measles epidemics in Ndjamena, Chad • Rare context of subsequent interventions in the same city (2005, 2010) • LQAS surveys to estimate coverage, before and after interventions • 2005 non-selective mass campaign (6-59m) • 2010 non-selective mass campaign (6m – 15y)

14. 2. Reported cases, Ndjamena, Chad, 2005 and 2010 Campaign Campaign survey survey N=7822, AR = 64.6 per 10,000 N=8481, AR = 54.5 per 10,000

15. 2. Vaccination coverage before and after campaign (6-59 m), Ndjamena, Chad Source: Guerrier et al, Trop Med Int’l Health, in press

16. 2. Lessons learned, N’djamena, Chad • Intervention earlier, but still late • Chronically low vaccine coverage • Failure to reach older children through routine services • Measles-susceptibles built up and led to the 2010 epidemic • 18% received their first dose in 2010 • previously vaccinated children were easier to reach during the outbreak than unvaccinated children

17. SIA’s 3. Measles cases and coverage 1997 -2009, Malawi Source: Malawi MoH Next SIA planned for 2011 for 6-59 months old

18. 3. Weekly distribution of measles cases in Malawi, week 1 to week 35, 2010N=118.173, AR=847 per 100.000, CFR=0.2% Only ~250 deaths reported, 28/28 districts NB: 25% of districts with no report for week 32, 50% for week 34

19. 3. Weekly incidence in districts vaccinated by MSF, Malawi 2010 93.1 [90.9-95.2] 98.0 [97.4-98.6] 96.6 [95.6-97.6] 96.4 [95.0-97.9]

20. Reported measles cases & attack rates by region, sex and age group, Malawi 2010

21. 3. Lessons learned from Malawi • Accumulation of susceptible individuals • No large outbreak in 12 years • Outbreaks in the nineties of smaller scale • Vaccine effectiveness study found under 90% for EPI • High routine coverage but likely under 95% • Reduction immunity over time • Apostolic communities • Under estimation of the epidemic risk Source: Minetti et al, in press

22. Ways forward • EPI • possibility for catch up > 11 months • SIA • Strategies to adapt the changing epidemiology of measles • Flexible age range • Interval between campaigns • Outbreak response • Increased communication about new guidelines and importance of prompt response • Need for planning for outbreak response in budget • Evaluations