During May 11--12, 2000, World Health Organization (WHO), United Nations
Children's Fund (UNICEF), and CDC co-sponsored a technical working group meeting to review
the status of global measles control and regional elimination efforts and to formulate
recommendations to accelerate control activities, particularly in countries and regions with
a high disease burden.
After reviewing the epidemiologic data by WHO region and by selected
countries, participants concluded that vaccination coverage of >90% is required to achieve
measles control and that a one-dose measles policy is insufficient to achieve and sustain
measles control targets* (1). The average seroconversion rate of 85% following one dose at
age 9 months, the recommended strategy for routine vaccination in developing
countries, leaves many children susceptible
(2). The routine delivery system in many countries
also fails to reach many children with a dose at 9 months
(3). Therefore, in addition to the first dose at age 9 months, meeting participants recommended that a second opportunity
for measles immunization is essential to protect those children previously missed by
routine services and for those children who failed to respond to their first dose of
measles vaccine. The second opportunity can be provided through routine
programs, supplemental campaigns, or a combination of both.
Meeting participants developed recommendations for accelerating measles
by improving routine and supplemental vaccination, measles surveillance, and vitamin
A supplementation. Selected key recommendations follow. The full text of the
recommendations is available at http://www.who.int/wer/75_27_52.html§
Action Plans for Accelerating Measles Control
Action plans to reduce measles mortality through increasing vaccination
coverage should be part of each country's comprehensive long-term vaccination
strategy and should be incorporated into the 3--5 year Expanded Program on
Immunization plans of action.
Action plans should specify tasks and budgets for all recommended strategies
for measles control such as improving vaccination (i.e., two opportunities for
measles vaccination), intensifying surveillance, managing measles cases, and
providing vitamin A supplements.
Countries that qualify for support from the Global Alliance for Vaccines and
Immunization (GAVI) (4) should be encouraged to use these resources for
measles control activities.
In collaboration with its partners, the GAVI board should support measles
control and mortality reduction through strengthening vaccination services.
Routine and Supplemental Vaccination
Countries and donor agencies should assess the reasons for low coverage
and should improve routine coverage using appropriate strategies (i.e., fixed
posts, outreach services, door-to-door canvassing, and regular pulse
Management of vaccination services should be strengthened at all levels.
WHO should support the development of training courses and tools that cover
such topics as reducing missed opportunities and dropout rates**, canvassing
door-to-door, conducting outreach, and periodic supplementary campaigns.
When well implemented, mass measles vaccination campaigns are an
effective strategy to control measles. Depending on the coverage achieved during
the campaign and routine coverage, mass campaigns will need to be repeated
at regular intervals. Preliminary data suggest that targeted urban campaigns
have limited impact on measles transmission either in cities or in neighboring
rural areas (5). Campaigns should target large populations (entire nations or
large regions) and should achieve >90% coverage using safe injection practices
The target age group for mass campaigns should be based on the
susceptibility profile of the population, which can be determined from the history of
measles vaccination coverage, age-specific disease incidence data, and
Measles surveillance should include measles case counts by month and
geographic area, age and vaccination status of case-patients and deaths by
area, and timeliness and completeness of reporting.
In countries and regions that have implemented elimination strategies,
proposed methods for monitoring interruption of indigenous transmission of measles
virus (e.g., percentage imported cases, average outbreak size, number of chains
of transmission) should be applied to assess their usefulness
In countries in which vitamin A deficiency is a significant public health
problem, vaccination visits and measles campaigns should be used to provide vitamin
A supplements (8).
World Health Assembly. Executive summary: resolution of the 42nd World Health
Assembly. Geneva, Switzerland: World Health Organization, 1989 (resolution WHA 42.32).
Cutts FT, Grabowsky M, Markowitz LE. The effect of dose and strain of live
attenuated measles vaccines on serological responses in young infants. Biologicals 1995;23:95--106.
CDC. Global measles control and regional elimination, 1998--1999. MMWR
Global Alliance for Vaccines and Immunization. Immunize every child---GAVI strategy
for sustainable immunization services. Geneva, Switzerland: Global Alliance for Vaccines
and Immunization, 2000. Available at http://www.vaccinealliance.org. Accessed December 2000.
World Health Organization Intercountry Office for Eastern Africa. Summary of
presentations, reports, and recommendations of the East Africa measles strategy clarification
meeting. Nairobi, Kenya: World Health Organization, October 11--13, 1999.
World Health Organization, United Nations Children's Fund. Policy statement on
mass immunization campaigns. Geneva, Switzerland: World Health Organization, 1997
De Serres G, Gay NJ, Farrington CP. Epidemiology of transmissible diseases after
elimination. Am J Epidemiol 2000;151:1039--48.
World Health Organization, United Nations Children's Fund, and International Vitamin
A Consultative Group Task Force. Vitamin A supplements: a guide to their use in the
treatment and prevention of vitamin A deficiency and xeropthalmia. 2nd ed. Geneva,
Switzerland: World Health Organization, 1997.
* The World Health Assembly in 1989 set targets for measles morbidity and mortality
reduction of 90% and 95%, respectively, compared with prevaccine era levels.
In countries with vaccination programs capable of achieving and sustaining
measles vaccination coverage >90% through routine services, the second opportunity for
measles vaccination also can be provided by implementing a routine two-dose vaccination schedule.
§ References to sites of non-CDC organizations on the World-Wide Web are provided as
a service to MMWR readers and do not constitute or imply endorsement of these
organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is
not responsible for the content of pages found at these sites.
¶ Periodic vaccination campaigns, usually conducted within a limited geographic area
(e.g., a district), that target all children born since the last campaign.
** Usually calculated as the difference in vaccination coverage between the first and
third doses of combined diphtheria-tetanus-pertussis vaccine
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