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Reaching the unreached with measles vaccination
Comment
Reaching the unreached with measles vaccination
www.thelancet.com Vol 366 September 3, 2005
averting disease and deaths. In addition to the benefit on measles-specific mortality, several researchers have suggested that the benefits of measles vaccination might extend well beyond that attributable to the protective effect of the vaccine against the measles virus alone.9 This effect might be because of a nonspecific immune boost; further research is needed to confirm whether the mortality benefit of measles vaccination is substantially greater than assumed previously and to investigate the specific mechanisms of these beneficial effects.10 The challenge remains to achieve and sustain measles mortality reduction in all countries, which will require greater efforts to improve implementation of all four parts of the strategy. Emphasis should be on improving routine immunisation, conducting safe and effective supplemental immunisation campaigns, and using measles supplemental immunisation campaigns to strengthen the cold chain and surveillance, as well as to increase demand for routine measles vaccination and clinical services. Higher routine coverage will allow follow-up campaigns to be less frequent. Quality will remain central to success; poor supervision and training might amplify the risk for adverse events, which can harm children and damage community confidence in immunisation for years to come. Measles control programmes and, immunisation programmes more generally, must be strengthened in the context of broader strengthening of health systems. Such pro-
See Articles page 832
Rights were not granted to include this image in electronic media. Please refer to the printed journal
Christine Nesbitt/Africaimages.net
In today’s Lancet, Mac Otten and colleagues1 show the dramatic success achieved in the acceleration of efforts to reduce measles mortality in Africa between 2000 and 2003. The authors describe a decline in reported measles cases of 91% and estimate that the number of absolute deaths averted in 2003 was around 90 000. In other terms, that measles-specific mortality was reduced by 20% for Africa as a whole. The authors also conclude that initial supplemental immunisation campaigns targeting children aged 9 months to 14 years are more effective in reducing measles mortality than those targeting children aged 9 months to 5 years. Furthermore, in conjunction with continued routine immunisation, follow-up campaigns sustain and strengthen the gains made in measles mortality reduction. The results represent a significant achievement for the 19 governments involved and for the innovative partnership, known as the Measles Initiative,2 that has provided funding and technical assistance. In 2001, the joint UNICEF and WHO global plan for measles mortality reduction was released and included four major strategies: improved routine immunisation, a second opportunity for measles vaccination (usually through supplemental immunisation campaigns), optimum measles case-management, and enhanced measles surveillance.3 The target was a 50% reduction in annual measles deaths by 2005 compared with 1999 levels—to less than 440000. This target will be achieved on time and a more ambitious target of a 90% reduction by 2010 will be set. Further substantial progress in Africa needs focused efforts on the few large countries, including Nigeria and the Democratic Republic of the Congo, which account for most of the remaining burden of measles disease. The Lancet child survival series estimated that measles causes 1–9% of the 10·8 million deaths in children aged under 5 years every year.4 Of the preventable causes of deaths listed in The Lancet series, measles is perhaps the disease for which we have the most cost-effective and most readily available intervention.5 Studies in South Africa6 and Zambia,7 and recent work in emergencies in Afghanistan,8 confirm these cost estimates. The cost of delivering measles vaccine in a campaign was about US$0·60–1·00 a child, with overall cost savings by
787
Comment
grammes need to receive adequate attention in sectorwide and poverty-reduction strategies, and need to be incorporated into national plans and budgets so that reliance on external donor funding gradually decreases. In May, 2005, WHO and UNICEF released a global strategic framework for immunisation, the Global Immunization Vision and Strategy.11 The framework highlights the importance of immunisations for achieving Millenium Development Goal 4: reducing under-5 mortality by two-thirds by 2015. It emphasises measles mortality reduction and reiterates that the supplemental immunisation campaigns’ platform should be used to deliver other child survival interventions, which might include insecticide-treated bednets, vitamin A and iron/folate supplementation, and antihelmintic drugs. The framework also emphasises equity in immunisation programmes, reaching the most vulnerable and marginalised—the unreached. In the future, new vaccines, such as rotavirus and pneumococcal vaccines, will be added to the menu of available interventions to combat under-5 mortality through campaigns and routine immunisation services. With sustained support for the strategies elaborated and reaffirmed in the Global Immunization Vision and Strategy, most deaths from measles globally can be prevented by the end of the decade, thus virtually removing a major infectious disease scourge affecting children in developing countries. This success, especially
if combined with other interventions, will represent a major contribution to achieving Millennium Development Goal 4. *Peter Salama, Jeff McFarland, Kim Mulholland UNICEF, New York, NY 10017, USA (PS, JM); and London School of Hygiene and Tropical Medicine, London, UK (KM) [email protected] We declare that we have no conflict of interest. 1 2 3
4 5
6
7
8
9
10 11
Otten M, Kezaala R, Fall A, et al. Public-health impact of accelerated measles control in the WHO African region 2000–03. Lancet 2005; 366: 832–39. Measles Initiative. 2005: http://www.measlesinitiative.org (accessed Aug 11, 2005). WHO/UNICEF. Measles: mortality reduction and regional elimination. Strategic plan 2001–2005. Geneva: WHO, 2001. September, 2001: http://www.who.int/vaccines-documents/DocsPDF01/www573.pdf (accessed Aug 11, 2005). Black RE, Morris S, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226–34. Jamison DT, Mosely WH, Measham AR, Babodilla JL, eds. Disease control priorities in developing countries. Washington DC: World Bank/Oxford University Press, 1993. Uzicanin A, Zhou FJ, Eggers R, Webb E, Strebel P. Economic analysis of the 1996–1997 mass measles immunization campaigns in South Africa. Vaccine 2004; 22: 3419–26. Dayan GH, Cairns L, Sangrujee N, Mtonga A, Nguyen V, Strebel P. Cost-effectiveness of three different vaccination strategies against measles in Zambian children. Vaccine 2004; 22: 475–84. Vijayaraghavan M, Lievano F, Cairns L, et al. Economic evaluation of measles catch-up and follow-up campaigns in a country affected by a complex emergency: Afghanistan, 2002 and 2003. Disasters (in press). Aaby P, Samb B, Simondon F, Seck AM, Knudsen K, Whittle H. Non-specific beneficial effect of measles immunization: analysis of mortality studies from developing countries. BMJ 1995; 311: 481–85. Aaby P, Jensen H. Do measles vaccines have non-specific effects on mortality? Bull World Health Organ 2005; 83: 238. WHO/UNICEF. Global immunization vision and strategy. Geneva: WHO, 2005. April 28, 2005: http://www.who.int/vaccines/GIVS/english/ full_en.pdf (accessed Aug 2, 2005).
Skin construct or biological bandage? See Research Letters page 840
788
In today’s Lancet, Judith Hohlfeld and colleagues1 describe the use of cultured fetal skin fibroblasts embedded within sheets of insoluble collagen to treat burns in young children. Benefits claimed for this procedure include rapid healing with cosmetically satisfactory results (ie, lack of scarring) and the avoidance of autografting. The success of the procedure is ascribed at least in part to the biological activities of growth factors secreted by the donor fibroblasts that are transiently present in the wounds. Within the burn-treatment community there is much interest in “skin substitutes” to cover, especially, large wounds. Because of improvements in resuscitation, infection control, nutritional support, and surgical aspects of wound management, even 95% burns of the body
surface area are now survivable by children 50% of the time.2 With this enhanced survivability come short-term and long-term complications: the increased demand for material to cover the wounds (to control pain, reduce fluid loss, and deter infection) and the increased risk of hypertrophic scarring. This last issue has been characterised as “the single most important unresolved problem in burn care”.3 While autologous split-thickness skin grafts are likely to be the treatment of choice in large second-degree and third-degree burns for some time to come, the lack of suitable donor tissue in the most severely injured patients fuels the demand for alternative temporary or permanent wound coverings. Those coverings currently available commercially or in development range from the acellular composite synthetic and www.thelancet.com Vol 366 September 3, 2005
Reaching the unreached with measles vaccination
www.thelancet.com Vol 366 September 3, 2005
averting disease and deaths. In addition to the benefit on measles-specific mortality, several researchers have suggested that the benefits of measles vaccination might extend well beyond that attributable to the protective effect of the vaccine against the measles virus alone.9 This effect might be because of a nonspecific immune boost; further research is needed to confirm whether the mortality benefit of measles vaccination is substantially greater than assumed previously and to investigate the specific mechanisms of these beneficial effects.10 The challenge remains to achieve and sustain measles mortality reduction in all countries, which will require greater efforts to improve implementation of all four parts of the strategy. Emphasis should be on improving routine immunisation, conducting safe and effective supplemental immunisation campaigns, and using measles supplemental immunisation campaigns to strengthen the cold chain and surveillance, as well as to increase demand for routine measles vaccination and clinical services. Higher routine coverage will allow follow-up campaigns to be less frequent. Quality will remain central to success; poor supervision and training might amplify the risk for adverse events, which can harm children and damage community confidence in immunisation for years to come. Measles control programmes and, immunisation programmes more generally, must be strengthened in the context of broader strengthening of health systems. Such pro-
See Articles page 832
Rights were not granted to include this image in electronic media. Please refer to the printed journal
Christine Nesbitt/Africaimages.net
In today’s Lancet, Mac Otten and colleagues1 show the dramatic success achieved in the acceleration of efforts to reduce measles mortality in Africa between 2000 and 2003. The authors describe a decline in reported measles cases of 91% and estimate that the number of absolute deaths averted in 2003 was around 90 000. In other terms, that measles-specific mortality was reduced by 20% for Africa as a whole. The authors also conclude that initial supplemental immunisation campaigns targeting children aged 9 months to 14 years are more effective in reducing measles mortality than those targeting children aged 9 months to 5 years. Furthermore, in conjunction with continued routine immunisation, follow-up campaigns sustain and strengthen the gains made in measles mortality reduction. The results represent a significant achievement for the 19 governments involved and for the innovative partnership, known as the Measles Initiative,2 that has provided funding and technical assistance. In 2001, the joint UNICEF and WHO global plan for measles mortality reduction was released and included four major strategies: improved routine immunisation, a second opportunity for measles vaccination (usually through supplemental immunisation campaigns), optimum measles case-management, and enhanced measles surveillance.3 The target was a 50% reduction in annual measles deaths by 2005 compared with 1999 levels—to less than 440000. This target will be achieved on time and a more ambitious target of a 90% reduction by 2010 will be set. Further substantial progress in Africa needs focused efforts on the few large countries, including Nigeria and the Democratic Republic of the Congo, which account for most of the remaining burden of measles disease. The Lancet child survival series estimated that measles causes 1–9% of the 10·8 million deaths in children aged under 5 years every year.4 Of the preventable causes of deaths listed in The Lancet series, measles is perhaps the disease for which we have the most cost-effective and most readily available intervention.5 Studies in South Africa6 and Zambia,7 and recent work in emergencies in Afghanistan,8 confirm these cost estimates. The cost of delivering measles vaccine in a campaign was about US$0·60–1·00 a child, with overall cost savings by
787
Comment
grammes need to receive adequate attention in sectorwide and poverty-reduction strategies, and need to be incorporated into national plans and budgets so that reliance on external donor funding gradually decreases. In May, 2005, WHO and UNICEF released a global strategic framework for immunisation, the Global Immunization Vision and Strategy.11 The framework highlights the importance of immunisations for achieving Millenium Development Goal 4: reducing under-5 mortality by two-thirds by 2015. It emphasises measles mortality reduction and reiterates that the supplemental immunisation campaigns’ platform should be used to deliver other child survival interventions, which might include insecticide-treated bednets, vitamin A and iron/folate supplementation, and antihelmintic drugs. The framework also emphasises equity in immunisation programmes, reaching the most vulnerable and marginalised—the unreached. In the future, new vaccines, such as rotavirus and pneumococcal vaccines, will be added to the menu of available interventions to combat under-5 mortality through campaigns and routine immunisation services. With sustained support for the strategies elaborated and reaffirmed in the Global Immunization Vision and Strategy, most deaths from measles globally can be prevented by the end of the decade, thus virtually removing a major infectious disease scourge affecting children in developing countries. This success, especially
if combined with other interventions, will represent a major contribution to achieving Millennium Development Goal 4. *Peter Salama, Jeff McFarland, Kim Mulholland UNICEF, New York, NY 10017, USA (PS, JM); and London School of Hygiene and Tropical Medicine, London, UK (KM) [email protected] We declare that we have no conflict of interest. 1 2 3
4 5
6
7
8
9
10 11
Otten M, Kezaala R, Fall A, et al. Public-health impact of accelerated measles control in the WHO African region 2000–03. Lancet 2005; 366: 832–39. Measles Initiative. 2005: http://www.measlesinitiative.org (accessed Aug 11, 2005). WHO/UNICEF. Measles: mortality reduction and regional elimination. Strategic plan 2001–2005. Geneva: WHO, 2001. September, 2001: http://www.who.int/vaccines-documents/DocsPDF01/www573.pdf (accessed Aug 11, 2005). Black RE, Morris S, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226–34. Jamison DT, Mosely WH, Measham AR, Babodilla JL, eds. Disease control priorities in developing countries. Washington DC: World Bank/Oxford University Press, 1993. Uzicanin A, Zhou FJ, Eggers R, Webb E, Strebel P. Economic analysis of the 1996–1997 mass measles immunization campaigns in South Africa. Vaccine 2004; 22: 3419–26. Dayan GH, Cairns L, Sangrujee N, Mtonga A, Nguyen V, Strebel P. Cost-effectiveness of three different vaccination strategies against measles in Zambian children. Vaccine 2004; 22: 475–84. Vijayaraghavan M, Lievano F, Cairns L, et al. Economic evaluation of measles catch-up and follow-up campaigns in a country affected by a complex emergency: Afghanistan, 2002 and 2003. Disasters (in press). Aaby P, Samb B, Simondon F, Seck AM, Knudsen K, Whittle H. Non-specific beneficial effect of measles immunization: analysis of mortality studies from developing countries. BMJ 1995; 311: 481–85. Aaby P, Jensen H. Do measles vaccines have non-specific effects on mortality? Bull World Health Organ 2005; 83: 238. WHO/UNICEF. Global immunization vision and strategy. Geneva: WHO, 2005. April 28, 2005: http://www.who.int/vaccines/GIVS/english/ full_en.pdf (accessed Aug 2, 2005).
Skin construct or biological bandage? See Research Letters page 840
788
In today’s Lancet, Judith Hohlfeld and colleagues1 describe the use of cultured fetal skin fibroblasts embedded within sheets of insoluble collagen to treat burns in young children. Benefits claimed for this procedure include rapid healing with cosmetically satisfactory results (ie, lack of scarring) and the avoidance of autografting. The success of the procedure is ascribed at least in part to the biological activities of growth factors secreted by the donor fibroblasts that are transiently present in the wounds. Within the burn-treatment community there is much interest in “skin substitutes” to cover, especially, large wounds. Because of improvements in resuscitation, infection control, nutritional support, and surgical aspects of wound management, even 95% burns of the body
surface area are now survivable by children 50% of the time.2 With this enhanced survivability come short-term and long-term complications: the increased demand for material to cover the wounds (to control pain, reduce fluid loss, and deter infection) and the increased risk of hypertrophic scarring. This last issue has been characterised as “the single most important unresolved problem in burn care”.3 While autologous split-thickness skin grafts are likely to be the treatment of choice in large second-degree and third-degree burns for some time to come, the lack of suitable donor tissue in the most severely injured patients fuels the demand for alternative temporary or permanent wound coverings. Those coverings currently available commercially or in development range from the acellular composite synthetic and www.thelancet.com Vol 366 September 3, 2005