Epidemiology and Global

Control of Measles and

Rubella
Peter M. Strebel, MBChB
National Immunization Program
Centers for Disease Control and Prevention

Global Vaccine Research Forum

Montreux, Switzerland
8-10 June 2004
 Aim and Outline

Aim: introduction to session

Outline:
– Global disease burden
– Epidemiologic characteristics
– Vaccine properties
– Control strategies
Estimated Global Disease Burden: Vaccine
Preventable Diseases Among Children

Disease Global Burden

Measles (2002) 610,000 deaths
Hib 450,000 deaths
Pertussis 285,000 deaths
Neonatal tetanus 200,000 deaths
CRS (1996) 110,000 cases
Yellow fever 30,000 deaths
Diphtheria 5,450 deaths
Paralytic Polio (2003) 784 cases
Source: World Health Report 2004; data for 2002; Cutts & Vynnycky Int J Epidemiol 1999
 Disease Control Goals
Measles Rubella
Global Eradication No No
Global Control Yes* No
Regional Elimination
Americas 2000 2010
E. Mediterranean 2010
Europe 2010
W. Pacific Date to be set

*WHA 2003: 50% reduction in deaths by 2005 vs. 1999

Estimated measles deaths by WHO region, 2001

500,000
450,000
400,000 >98% occur in
350,000
300,000 eligible
250,000 countries
200,000
150,000
100,000
50,000
0
AFRO SEARO EMRO WPRO EURO PAHO
 WHO/UNICEF priority countries
for measles mortality reduction, 2001

45 countries representing 94 % of all measles deaths

 Countries/territories using a rubella containing
vaccine in their NIP, 2004*

Haiti

* May 2004 in the Americas

Yes (124 countries/territories, 57%, 99% children
one year old in the Americas)
No ( 91 countries/territories, 43%)
The boundaries and names shown and the designations used on this map do not imply the expression of
any opinion whatsoever on the part of the World Health Organization concerning the legal status of any
country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full
agreement.

Source: WHO Department of Vaccines and Biologicals, December 2003

 Epidemiologic Characteristics
Feature Measles Rubella
Occurrence worldwide worldwide
Reservoir human human
Transmission respiratory respiratory
person to person person to person
Communicability high* moderate**
Seasonality late winter late winter
Inter-epidemic interval† 2-3 years 6-9 years

*airborne droplet nuclei

**subclinical cases transmit and CRS cases may transmit for ~year
† prevaccine era
 Contagiousness of Common
Childhood Communicable Diseases
Average Age at Infection (years)
Less
Disease Industrialized Industrialized

Measles 5-6 (USA, 1955-8) 1-2 (Senegal, 1964)

1-2 (Bangkok, 1967)
Mumps 6-7 (England, 1975-7)
Chickenpox 6-8 (USA, 1912-28)
Rubella 9-10 (USA, 1966-8) 2-3 (Gambia, 1976)
Polio 12-17 (USA, 1955)

Source: Anderson & May, Nature 1985, 318:323-9.

 Herd Immunity Threshold

• Younger average age of infection, more

contagious the disease
• More contagious, higher herd immunity
level needed
• HI threshold = 1-1/Ro
Where Ro (basic reproductive no.) =average no.
secondary cases in a fully susceptible population
 Comparison of Herd
Immunity Thresholds

Measles Rubella

Basic Reproductive
Ro 12 – 18 Ro 6-10
number

Herd Immunity
92-95% 83-90%
threshold
Measles and Rubella Vaccines
Feature Measles Rubella
Composition Live virus* Live virus*
Effectiveness 85% (9m) 95-100% (9m)
95% (12m)
Waning antibodies Yes Yes
Duration of protection Lifelong Lifelong
Schedule 2 doses 1 dose
(or 2 opportunities)

*attenuated live virus

 Adverse Events Associated with
Measles and Rubella Vaccines
Event Measles/Rubella
Fever 5-15%
Rash 5%
Febrile seizure* 1/3000
Thrombocytopenia 1/30,000
Joint symptoms** 1%
25% (adult female)
Anaphylaxis ~1/1,000,000
Encephalitis ~1/1,000,000

*No association with residual febrile disorder

**No association with chronic arthropathy
 Control Strategies

• Country examples
– Finland
– Albania
– PAHO Region
 Purpose of Vaccination
Goal Measles Rubella
Control protect individual protect individual
prevent deaths prevent CRS
young children pregnant women
Elimination protect community protect community
stop transmission stop transmission
population immunity population immunity
 Finnish Experience
• 1982 2 dose MMR strategy
– At 14-18m and 6y
• Very strong public health system
• Very high coverage (~95%) with each dose
• 1986 last CRS case
• 1993 measles eliminated
• 1996 last rubella case

Peltola et al., NEJM, 1994;331:1397-1402

 Albanian Experience
• Population 3.4 mil, isolated until 1990s
• No rubella vaccination prior to 2000
• Nov 2000 MR mass campaign
– 1-14 years
– Coverage >95%
• Jan 2001 MMR at 12m and 5 years
• Sep 2001 MR women 16-35y (routine services)
– Ongoing post-partum vaccination
Reported Incidence of Rubella
and CRS in Albania
• 1960 rubella notifiable
• Pre-vaccine era
– Outbreaks every 5-7 years
– School children, majority <15 years
• 2001 10 rubella cases
• 2002-3 zero confirmed measles or rubella cases
• 2002-3 zero CRS cases

ÎMeasles and rubella eliminated ??

 PAHO Experience
Vaccination Strategies for Elimination
Measles
• Catch-up campaign (1-14y)
• Keep-up - achieving and maintaining
high routine vaccination coverage using
MMR vaccine
• Follow-up campaigns at least every 4
years, targeting 1-4 year olds, using MR
vaccine
Rubella
• Introduction of MMR into the routine
childhood program
• Adults males and females mass
campaigns using MR vaccine
(The upper age range for men and women
targeted for vaccination will depend on the year
of the introduction the vaccine, follow-up
campaigns, epidemiology and fertility rates in
their country.)
 Vaccination Coverage & Reported Number of
Measles Cases, The Americas, 1990 – 2003*

Catch-up campaigns
300000 100

Routine vaccination coverage (%)

Confirmed cases (thousands)

250000
80

200000
Follow-up campaigns
60
150000
40
100000

20
50000
105
0 0
90 91 92 93 94 95 96 97 98 99 2000 2001 2002 2003
Cases Coverage

Source: PAHO/WHO: Data sent by countries; 50 cases confirmed as of 10 April 2004 PAHO
 Confirmed Measles in the Americas by Rash Onset and Genotypes,
January 2001 - May 2004*

250 Genotypes

D9
D6
200
H1 (Import, Asia)
Others, unknown

End of transmission of genotype D9

End of transmission of genotype D6

150
Cases

100

50
Importations

0
1 5 9 13 17 21 25 29 33 37 41 45 49 1 5 9 13 17 21 25 29 33 37 41 45 49 1 5 9 13 17 21 25 29 33 37 41 45 49 1 5 9 13 17

2001 2002 2003 2004

EPI Weeks
*Source: Country reports
As of EPI week 19
Annual number of reported rubella cases and number of
countries reporting rubella, the Americas, 1982-2004*
Measles Accelerated
eradication goal is Rubella Control
set

140
120 40

Countries reporting
Reported cases

100 30
Thousands

80
60 20
40
10
20
0 0
82 84 86 88 90 92 94 96 98 '00 '02 '04

Source: PAHO-MoH
Year
*As of EPI Week 19 Cases Countries reporting
 Trends in reported measles and rubella cases
Region of the Americas, 1982-2003*

300,000
140,000

Measles Rubella
250,000
120,000

200,000 100,000

Reported rubella cases

Reported measles cases

80,000
150,000

60,000
100,000
40,000

50,000
20,000

0 0
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 '00 '01 '02 '03

* Three year moving averages

Reported measles cases & deaths by year,
7 Southern African Countries, 1980-2003

Cases Deaths
90 2,000
80 Catch-up 1,800
Cases (in thousands)

Campaigns 1,600
70
60 1,400
1,200

Deaths
50
1,000
40
800
30 600
20 350 400
10 20 200
4 0 0 2 12
0 0
80 82 84 86 88 90 92 94 96 98 00 2
Year
 Partnership for Reduction of Measles
Mortality in Africa 2001–2003

Nationwide

Sub-national
• Partners: ARC, UNF,
UNICEF, WHO & CDC
•Measles campaigns in 29 countries
•112 million children immunized
•Est.170,000 deaths averted annually*

*WHO Weekly Epi Rec, 2004

 Percent reduction in estimated measles deaths by WHO
region between 1999 and 2002

0
-5 AFR EMR SEAR Others Global
-10
% reduction

-15
-20
-25
-30
-35
-40
Region
 Summary
• Significant preventable disease burden
• Due to failure to vaccinate with measles and rubella
vaccines
• Extensive experience with safety and effectiveness
• Elimination possible with existing vaccines and strategies
– High coverage 2 dose and 2nd opportunity strategies
• As measles is controlled rubella “emerges” as a public
health problem
• Progress toward 2005 mortality reduction goal
 Acknowledgements

Drs Jon Andrus and Carlos Castillo, PAHO

Drs Brad Hersh and Susan Robertson, WHO/HQ

Drs Susan Reef and Mark Papania, NIP, CDC