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Notice to Readers: Recommendations From Meeting on Strategies for Improving Global Measles Control, May 11--12, 2000

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 control 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§ .

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 vaccination).
  • 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 (6).
  • 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 seroprevalence studies.

Measles Surveillance

  • 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 (7).

Vitamin A

  • 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).


  1. World Health Assembly. Executive summary: resolution of the 42nd World Health Assembly. Geneva, Switzerland: World Health Organization, 1989 (resolution WHA 42.32).
  2. 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.
  3. CDC. Global measles control and regional elimination, 1998--1999. MMWR 1999;48:1124--30.
  4. 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 Accessed December 2000.
  5. 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.
  6. World Health Organization, United Nations Children's Fund. Policy statement on mass immunization campaigns. Geneva, Switzerland: World Health Organization, 1997 (WHO/EPI/LHIS/97.04).
  7. De Serres G, Gay NJ, Farrington CP. Epidemiology of transmissible diseases after elimination. Am J Epidemiol 2000;151:1039--48.
  8. 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 (1).

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