A global resurgence of measles, one of the world’s most contagious diseases, threatens the huge gains made in fighting the virus in recent years. Measles is preventable by vaccination, and between the years 2000 -2018, immunization against measles alone is estimated to have saved around 23 million lives.
Yet outbreaks in all regions and many countries - from the Democratic Republic of Congo (DRC), to Samoa and Ukraine - as well as stagnant, inadequate immunization rates, threaten to derail these crucial gains. The causes of the outbreaks vary but failing to vaccinate people is at the root of them all, and in 2018, case numbers swelled to a near ten-year peak; close to 10 million, with over 140 000 deaths globally.
By November 2019, case numbers had tripled compared with the same period in the previous year, with the most cases recorded worldwide since 2006. For a country to be safe from measles, 95% of the population must be immune. Yet global vaccination rates have stayed flat - at around 10% below the recommended threshold for the first dose and 25% for the second - for the last ten years.
To fill the gap in routine vaccination coverage, WHO, with other members of the Measles & Rubella Initiative as well as Gavi, helped vaccinate 346 million children in 37 countries through mass vaccination campaigns in 2018. WHO also works to reduce the risk of death through timely treatment, especially for complications like pneumonia, trains and deploys health workers, supports efforts to strengthen health systems and works with countries in all regions to strengthen routine immunization.
DRC is suffering the world’s largest, most severe measles outbreak.
All 26 provinces are affected, and in 2019 alone there have been over 250 000 cases and over 5000 deaths. The outbreak is compounded by low rates of immunization and high levels of malnutrition which push up the number of deaths.
WHO supports emergency vaccination drives, and around 2.2 million children are to be vaccinated against measles in the latest campaign in North Kivu, where efforts are concurrently underway to curb the world’s second-worst Ebola outbreak amid persistent insecurity.
“In the context of North Kivu, where the population is highly mobile, it is imperative that we reach out to travellers and ensure that their children are also covered. Every child should receive his or her vaccine so that they are well protected and can grow up healthy,” said Dr Deo Nshimirimana, WHO acting Representative in the DRC.
The five-day campaign is being implemented by the Ministry of Health with the support of WHO and partners and is fully funded by Gavi, the Vaccine Alliance. WHO has also helped to train emergency medical teams to respond to measles across the country, including doctors, nurses, emergency medical technicians, epidemiologists and logistics personnel.
The North Kivu campaign will be followed by a third and final phase planned to roll out across the 10 remaining provinces to be covered, with the mass follow-up campaign ultimately planned to reach 18.9 million children across the country by the end of the year.
“While the Ebola outbreak in the DRC has won the world’s attention and progress is being made in saving lives, we must not forget the other urgent health needs the country faces,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “This new vaccination campaign aims to protect children in North Kivu, as well as other parts of the country from a disease that is easily preventable with a vaccine.”
A rapid, deadly outbreak is underway in the Pacific island of Samoa, where, as of December 4th 2019, over 4,200 measles cases have claimed over 60 lives. Two weeks into an emergency vaccination drive, most of those at risk on the main islands of Upolu and Savaii have been vaccinated, including 76% of infants and children aged 6 months to 4 years.
In a final push to reach 95% coverage, all public bodies and businesses have been closed for two days as mobile vaccination teams go door to door to give life-saving vaccinations. To allow the mobile vaccination teams to quickly identify homes with unvaccinated people, the public have been asked to place red flags outside their homes.
WHO, in partnership with Australia, New Zealand, UNICEF and other partners, is aiding emergency vaccination efforts across the country. “Samoa’s health services are working stoically, day and night, to get life-saving vaccinations who need them and to give crucial treatment for those critically infected,” says Dr Rasul Baghirov, WHO Representative in Samoa.
“We’re helping to detect, map and stop measles’ spread, and have deployed our technical specialists in epidemiology, cluster coordination, infectious diseases, vaccination and risk communications to assist.” Yet for an island nation of just 195 000 people, the outbreak has severely stretched the health system.
At the national hospital in the capital, Apia, nurses are working 12-hour shifts, often without breaks. “With WHO support, 10 emergency medical assistance teams have been deployed to help with treatment, immunization and coordination,” says Ian Norton, who leads WHO’s Emergency Medical Team Unit.
“Overall, these teams include around 120 nurses, 30 doctors and other professionals such as physiotherapists, infectious disease experts and logisticians.” “This is about bringing in surge support, as well as strengthening the health system for the longer term.”
A WHO coordination officer is working with the teams from Australia, New Zealand and the United Kingdom from inside Samoa’s Ministry of Health. At Samoa’s national laboratory a WHO expert is helping to identify bacteria and which antibiotics to use for complications related to measles, like pneumonia, that also typically affect children.
Across the Pacific, Fiji, Samoa and Tonga have declared and are responding to measles outbreaks, while American Samoa has reported four cases of measles imported from Samoa. Ukraine suffered the second highest number of measles cases globally in 2018.
Back in 2016, just under a third of Ukrainian children scheduled for vaccination received their second measles vaccine, and immunization drives were further held back by disruption to vaccine supplies in earlier years. Yet with WHO support, the government set up a national measles task force, and streamlined the delivery of quality vaccines for urgent and routine immunization drives.
With better data collection, the expansion of access to measles vaccination for all children aged between 1 and 18 years, and, later, the verification of every child’s vaccination status in school, immunization rates have steadily increased across the country.
Today, 90% of Ukrainian parents ensure their children get their scheduled vaccinations against measles, yet for people displaced through conflict, as well as other groups, it can be harder for them to get access to immunization services. “One of the biggest challenges we have is to sustain the momentum and commitment we’ve seen in the last few years,” says Jarno Habicht, WHO Representative in Ukraine.
Just last week, with support from WHO and the United States Centers for Disease Control, Ukraine adopted a new national immunization strategy and action plan to reach 95% coverage for routine immunization by 2022. “We need to push harder to hit that 95% needed in every community - every year - to prevent future outbreaks,” says WHO’s Habicht.
“It’s also crucial to cover those that missed vaccination before, and to push forward progress on routine immunization programmes so we don’t see another spike in cases in the coming years.” Across the WHO European Region, four countries recently lost their status as having eliminated measles. The status is removed if the disease reappears and spreads in the country for over a year.
Beyond responding to outbreaks, nations and the global health community must continue to invest in high quality national immunization programmes and disease surveillance.The world has had a safe, proven measles vaccine for over 50 years. We need bold, clear and lasting political, practical and financial commitments to stamp out measles for good.