Hi, I'm James Goodson. Senior measles scientist in the Global Immunization Division at the Center of Global Health at the US Centers for Disease Control and Prevention. Today, we'll discuss measles and immunization against the disease. Despite the availability of a highly effective vaccine, measles remains a leading cause of child mortality. Measles virus exists only in humans and survives by transmission from person to person via the airborne route. Measles virus infection is systemic, causes immunosuppression, is associated with sever or the after effect in all organs in the body. Measles can be prevented by vaccination with a safe and a highly effective vaccine that was licensed in 1963. The vaccine must be kept cold through all stages of shipping and storage to retain its potency. High vaccination coverage, greater than 90%, can prevent outbreaks, interrupt the transmission of the virus. And the World Health Organization, or WHO, recommends that all children receive 2 doses of measles containing vaccine. There are ongoing efforts globally to eliminate measles. In 2002, the last endemic case occurred in the region of the Americas, measles is gone from the Western hemisphere. And in 2011, the World Health Assembly concluded that measles eradication can and should be done. In 2012, the World's Health Assembly the Global Vaccine Action Plan that established a goal for measles elimination in at least 5/6 WHO regions of the world by 2020. All 6 regions have adopted a goal for measles elimination, with target dates by or before 2020. Globally, there's been a dramatic decline in measles cases with increasing coverage. Vaccination coverage is the proportion of one year olds who have received the first and second does of measles containing vaccine. We refer to these two dose as MCVI and MCV2. However, since 2009 measles cases have decreased minimally, and the MCV1 coverage has stagnated globally between 84 to 85%. On a positive note, MCV2 coverage recently has been increasing, and in 2015 was 61%. This chart shows the global trend of measles mortality since the introduction and use of measles vaccine. There's been a 90% decrease since 1985. And between 2000 and 2014, because of measles vaccination, 79% decrease in measles mortality has occurred. That's an estimated 17 million deaths prevented just since the year 2000. This map shows the ten countries with the largest number of measles cases during June 2015 and May 2016. Measles is a dynamic disease and causes periodic large outbreaks. In the pre-vaccine era, before the use of vaccine, nearly everyone was infected with measles as a child. Today, measles disproportionately impacts the most vulnerable communities where vaccination coverage is low, or where there's poor access to services or insecurity. Measles is a RNA virus for which humans are the only reservoir. And since there are no animal reservoirs, measles virus survives only via airborne transmission of aerosolized respiratory secretions from person-to-person through coughing and sneezing. After an incubation period that ranges from 7-21 days, the illness begins with non-specific prodromal symptoms like fever, malaise, cough, coryza or runny nose, and conjunctivitis, or red eyes. After 2-4 days of intensifying prodromal symptoms, the characteristic maculopapular rash appears. The infectious period last from 4 days before rash onset to 4 days after rash onset. The rash starts on the face and and neck and progresses down the arms and trunk to the distal extremities. Concurrently, fever rises sharply, often as high as 104 to 105.8 degrees Fahrenheit. The rash lasts for three to seven days and then fades in the order of appearance. Once the measles rash fades, there can be desquamation, or peeling of the skin. Measles deaths are caused by complications from either the primary measles infection or secondary viral or bacterial infections that can follow the initial infection. These complications include otitis media, or ear infection, pneumonia, diarrhea, and encephalitis or brain inflammation. Other complications include enteritis or intestinal inflammation, karatitis corneal inflammation, and blindness. Also, corneal scarring is associated with measles and a vitamin A deficiency. And historically, was the most common cause of blindness in children in some parts of the world. Encephalitis can occur particularly in older children, which can lead to death, and survivors have a high rate of disability. Measles is particularly devastating in vulnerable, malnourished populations. Generally, measles case fatality rations, or the proportion of cases that die, range from 0.1 to 4%, depending on co-morbidities and access to treatment. However, during humanitarian disasters, measles CFRs can range up to 10% and have been reported as high as 30%. Risk factors for measles deaths are common in refuge settings, and include malnutrition, vitamin A deficiency, poor access to treatment, non-vaccination, and delays in case detection and treatment, which can occur in settings with poor surveillance. Intense exposure from overcrowding is another risk factor for measles transmission. And consequently, outbreaks of measles can be frequent in closed settings like refugee camps. The appropriate treatment of measles infection and its complications is critical for reducing the high mortality associated with disease in these settings. In particular, vitamin A supplementation has been shown to reduce measles mortality drastically. Proper measles case management includes administration of vitamin A. Providing antibiotics for bacterial secondary infections, which can cause pneumonia and diarrhea. And treating dehydration with oral rehydration solutions, or if available, IV fluids. Immunization of children against measles is probably the single most important (and cost-effective) preventative measure in emergency-affected populations, especially those living in camps. Accordingly, to address this need, the Sphere Project, which establishes standards for emergency response, identified one of the most important immediate public health actions as immunizations of all children between six months and 15 years of age with measles vaccine and the administration of vitamin A. In acute emergency settings it is critically important that a mass vaccination campaign be initiated as soon as possible. This initial campaign should focus on the administration of measles vaccine and vitamin A. In addition, it is important to vaccinate all new arrivals upon entry into the camp. The establishment of vaccination posts should be considered at all entry sites through distribution sites and non-food commodities distribution sites. As well as supplementary feeding centers. Measles vaccination campaign strategies are well established and should be adapted to the particular setting for implementation. Detailed planning to ensure readiness are crucial for high quality implementation. The WHO field guides and planning tools are available to help with planning logistics and implementation. The campaign target age group can be extended and should be determined based on the epidemiology and estimated vaccinated coverage of the population. The dates and duration of the campaign should be established early to ensure proper lead time for planning. Detailed microplanning should be done with maps, schedule and vaccination posts, staffing requirements, and training needs. Communication is critical to achieve high campaign coverage and should include a plan for social mobilization through media, posters, flyers, banners, and engagement with the community and traditional leaders. Other vaccines, such as oral polio vaccine, also may be considered for mass vaccination depending on the context of the emergency. In some settings, the meningitis vaccine is administered when the baseline threshold of cases has been exceeded in the population. Yellow fever vaccine is often considered if confirmed cases have been documented in endemic areas. Vaccination for cholera and typhoid is not routinely recommended. A long-term strategy should be developed to establish immunization service delivery for the administration of all vaccines recommended by the expanded program for immunization, or EPI. And this includes the recommended 2 doses of measles vaccine. These services should be set up with in or near feeding centers, prenatal clinics, well or sick child care sites and traditional health clinics. The frequency of service will depend on availability and dependability of cold chain equipment. Also, the population movement, availability of supplies and staff resources. And an EPI program in refugee settings should comply with the National EPI program wherever possible. And health authorities of the host country should also be involved if possible. Tracking is also an important part of any long-term vaccination program. It's important to monitor for dropouts, that's children who received one vaccine, but not all. And to recall those children that have not received a complete series of the vaccination schedule. It is also important to monitor newborns and to enroll these children into the EPI register. New arrivals should also be tracked and monitored for vaccination. And these children should be vaccinated as soon as possible upon arrival. In addition to immunization services, a surveillance system for vaccine preventable diseases should be initiated immediately to allow the rapid detection and confirmation of any VPD outbreaks. This system should include surveillance guidelines for case definitions, data collection forms, establishing a clear reporting chain for notification and investigation of any outbreaks. If surveillance data reveals any potential case of a vaccine-preventable disease, each case must be thoroughly investigated. A thorough investigation is particularly important in regards to measles, where even one case represents an outbreak. In an outbreak investigation, the diagnosis should be confirmed with laboratory testing if possible. Also, outbreak preparedness and response plans should be established to ensure a rapid response once an outbreak is detected. So, in summary, measles is a severe disease that is fully preventable through vaccination. There's been tremendous progress toward measles elimination, with more than 17 million deaths prevented just since the year 2000. However, measles outbreaks continue to occur in many parts of the world. And since measles is especially deadly in vulnerable populations, until measles is eradicated, a failure to deliver two doses of measles vaccine to all children will allow measles virus transmission to continue with devastating consequences. Thank you for your time and attention.
