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Role of mass campaigns in global measles control
Role of
mass
campaigns in global measles control
The World Summit for Children and the World Health Assembly (WHA) have challenged the world to control measles by 1995. Specifically, the goals are to reduce numbers of deaths by 95% and cases by 90% compared with pre-immunisation levels, as a step towards eradication in the longer term. Measles presently causes an estimated 45 million cases and kills more than 1 million children in developing countries each year. Analysis of the situation in early 1994 suggests that the goals set by the WHA will not be met in every country by the end of 1995. Some countries have already achieved the 90% case reduction target by reaching high coverage with measles vaccines administered at 9-11 months of age. However, it is likely that many developing nations will not reach this target in the next few years if only existing recommended strategies for measles control are pursued. Achieving high coverage with measles vaccine at national, district, and community levels has been the cornerstone of WHO’s measles control policy. This policy has been supplemented by promoting the identification and immunisation of high-risk areas and groups such as children in the urban poor environment and refugees.1 Further development of these strategies followed in the October, 1993, meeting of the Global Advisory Group (GAG) in Washington DC (panel). Panel: Recommendation
by QAQ for measles control2
"Achieving high levels of measles control, Regional elimination and eventually global eradication will require supplementary immunisation using strategies that have maximum impact on interrupting transmission of measles virus, such as non-selective campaigns in which all children below a certain age are immunized regardless of prior immunisation status."
In urban Africa, up to one-third of children may contract measles before they reach 9 months, and before they are old enough to receive the scheduled measles immunisation. Hopes that the high-titre measles vaccine might offer at least a partial solution to this crucial issue were not realised because of safety problems.3 Since then, discussions about measles control have focused on how to use the existing vaccine in innovative ways to achieve better control of the disease even in infants below the age of routine immunisation. In April, 1994, an informal consultation on strategies to accelerate global measles control, convened by WHO in Washington DC, agreed three main approaches to measles control-namely, raising routine coverage, identifying and immunising high-risk areas and groups, and using mass campaigns in certain circumstances.4 The consultation
Dr C J Clements, Expanded Programme on Immunization, Global Programme for Vaccines, World Health Organization, CH-1211 Geneva, Switzerland
Correspondence to:
174
concentrated especially on the role of mass campaigns, and recommended that such campaigns should be targeted to age groups identified through analysis of epidemiological data on measles cases, and should include all children in these age groups, irrespective of previous immunisation status. Mass campaigns should focus on urban areas and districts with high numbers of measles cases, on countries and districts with measles vaccine coverage less than 80%, and on countries with measles elimination goals. Thus, there would be an opportunity to reach children who may not have been immunised because of lack of access to services at fixed sites, to increase vaccine efficacy by providing an additional dose to some children, to immunise children outside the scheduled target age group, and hence to reduce the pool of susceptibles rapidly, thereby potentially interrupting transmission of the virus. Local analysis of measles surveillance data will guide the choice of age groups to be immunised during mass campaigns. In some situations the upper age limit may be reduced to 3 years, and the lower limit to 6 months, the choice depending on the local epidemiology of measles and resources available. Likewise, the frequency of campaigns should be determined by analysis of epidemiological data. The most cost-effective way to conduct a measles campaign is to do it in conjunction with a polio immunisation campaign, taking into account the local situation. Mass campaigns are not the only way to control measles. However, many developing countries are unable to achieve the high coverage needed through routine immunisation services, so innovative strategies such as mass campaigns are clearly needed. For countries with the least developed immunisation programmes, an integrated approach to increasing vaccine coverage and control for all diseases targeted by the national immunisation programmes will need to be pursued, with a blend of fixed, outreach, and campaign services being tailored to individual countries. Such a set of phased strategies will allow the most effective progress towards the 1995 goals and beyond, and will help the build-up of health infrastructures in countries where they are most needed. The success of measles mass campaigns has been well demonstrated in the Americas. Nonetheless, some caution is necessary before this model is applied globally. The cost of additional vaccine, equipment, and personnel for a measles mass campaign ranges from US$0-50 to$0-75 per child; if administered during a polio mass campaign the additional cost per child is about$0 30. Since the campaign strategy is not a one-time event, a long-term approach with respect to resources is needed. Implementation of periodic mass campaigns represents a serious strain on many poor countries and on the international donor community; if the recommendations are followed, this strategy will be needed for some years to come.
The
conclusions and recommendations of the Washington DC report are helpful because they specify further the settings in which measles immunisation campaigns will be needed, because they give advice on proper implementation that will definitely lead to better control of measles, and because they represent the uniform advice of a very strong group of experts.
References
Expanded Programme on Immunization. Global Advisory Group. Part II. Weekly Epidemiol Rec No 3. 1991: 9-11. 2 Expanded Programme on Immunization. Global Advisory Group. Part II. Weekly Epidemiol Rec No 5. 1994: 29-35. 3 Expanded Programme on Immunization. Safety of high titer measles vaccine. Weekly Epidemiol Rec No 48. 1992: 357-61. 4 Expanded Programme on Immunization. Accelerated measles strategies. Weekly Epidemiol Rec (in press). 1
Viewpoint Health-care reform: the issues and the role of donors
Governments world wide are attempting reform of their health sector. Reform-as distinct from gradual or incremental change-is underway in the US with the Clinton health-care reforms, in the UK, in central and eastern Europe, and in the republics of the former Soviet Union. In several African and other developing countries, reforms are being implemented, some under the Bamako Initiative, which is proposing to introduce user fees to improve quality of services, and eventually to increase access. Health is not generally viewed with the same sentimentality as it was a generation ago; governments are now interested in ensuring that health care will lead to health gain. Many health systems are undergoing economic liberalisation, being reformed as some form of quasi-market in which health care purchasers and providers operate independently. This change, in turn, demands new mechanisms for financing healthcare. We discuss some of the reasons for the worldwide trend towards reform, describe some common features, and highlight the issues that health sector reform raises for donor agencies and developing countries. Governments have embarked on health sector reforms for various reasons, many of which are linked to the worldwide economic crisis and recession. In some developing countries, health sector reform is a part of wider government reform that often involves a redefinition of the role of government, the services it should provide, and the degree to which it should be involved in production. The World Bank and the International Monetary Fund have promoted structural adjustment programmes for developing countries and these have usually involved decreasing government spending. These changes have often reduced the role of government, limited the government workforce, and generally meant a small government budget. In addition, most structural adjustment programmes have involved devaluing the currency to increase exports and decreasing or eliminating subsidies, including those for food. London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT (Susan Foster MA, Prof Charles Normand DPhil); Health Services Management Unit, Manchester University, Oxford Road, Manchester M13, UK (Rod Sheaff DPhil)
Correspondence to: Susan Foster
All these measures have influenced the ability to provide health services. A smaller workforce, a lack of imported drugs and materials, rises in the price of petrol, and removal of subsidies contribute to an overall rise in poverty. The World Bank has admitted that early structural adjustment programmes "were indiscriminate and failed to preserve those elements of the health system with the strongest long-term benefits for health. Drugs were often cut more heavily than personnel because it is difficult to lay off public employees. In rural clinics already precarious supplies of basic consumables became even scarcer."1
Scarcity of resources Scarcity of resources is a perpetual problem for developing and industrial countries alike. World-wide recession and slow economic activity have coincided with an increased demand for health care. Unemployment reduces the tax base from which health funding flows and brings its own health problems, especially those related to alcohol and tobacco abuse. Pressure on health resources is increasing everywhere, partly because of the high cost of recent advances in technology that is becoming routine, such as coronaryartery bypass grafts or hip replacements. An ageing population increases demands for life-prolonging and life-enhancing interventions and for long-term nursing care. Developing countries are also affected by the ages of their populations. The proportion over 65 years will increase from 4% in 1990 to 9% by 2030-in absolute numbers, from 184 million to 678 million.1 The burden of noncommunicable disease is also increasing sharply and developing countries are bearing the brunt of the AIDS epidemic. In some cities of east and central Africa up to 25% of the adult population are HIV seropositive and will probably die within the next 8-10 years. Their care places heavy demands on health services; in 1990 one-third of health budgets were spent on the care of HIV-positive people, a percentage that has increased in several countries. Developing countries face increasing drug resistance to malaria, tuberculosis, and sexually transmitted diseasesdiseases that are prevalent and whose treatment requires more expensive drugs than 10 or 15 years ago.3 In eastern and central Europe there is a growing appreciation of the 175
mass
campaigns in global measles control
The World Summit for Children and the World Health Assembly (WHA) have challenged the world to control measles by 1995. Specifically, the goals are to reduce numbers of deaths by 95% and cases by 90% compared with pre-immunisation levels, as a step towards eradication in the longer term. Measles presently causes an estimated 45 million cases and kills more than 1 million children in developing countries each year. Analysis of the situation in early 1994 suggests that the goals set by the WHA will not be met in every country by the end of 1995. Some countries have already achieved the 90% case reduction target by reaching high coverage with measles vaccines administered at 9-11 months of age. However, it is likely that many developing nations will not reach this target in the next few years if only existing recommended strategies for measles control are pursued. Achieving high coverage with measles vaccine at national, district, and community levels has been the cornerstone of WHO’s measles control policy. This policy has been supplemented by promoting the identification and immunisation of high-risk areas and groups such as children in the urban poor environment and refugees.1 Further development of these strategies followed in the October, 1993, meeting of the Global Advisory Group (GAG) in Washington DC (panel). Panel: Recommendation
by QAQ for measles control2
"Achieving high levels of measles control, Regional elimination and eventually global eradication will require supplementary immunisation using strategies that have maximum impact on interrupting transmission of measles virus, such as non-selective campaigns in which all children below a certain age are immunized regardless of prior immunisation status."
In urban Africa, up to one-third of children may contract measles before they reach 9 months, and before they are old enough to receive the scheduled measles immunisation. Hopes that the high-titre measles vaccine might offer at least a partial solution to this crucial issue were not realised because of safety problems.3 Since then, discussions about measles control have focused on how to use the existing vaccine in innovative ways to achieve better control of the disease even in infants below the age of routine immunisation. In April, 1994, an informal consultation on strategies to accelerate global measles control, convened by WHO in Washington DC, agreed three main approaches to measles control-namely, raising routine coverage, identifying and immunising high-risk areas and groups, and using mass campaigns in certain circumstances.4 The consultation
Dr C J Clements, Expanded Programme on Immunization, Global Programme for Vaccines, World Health Organization, CH-1211 Geneva, Switzerland
Correspondence to:
174
concentrated especially on the role of mass campaigns, and recommended that such campaigns should be targeted to age groups identified through analysis of epidemiological data on measles cases, and should include all children in these age groups, irrespective of previous immunisation status. Mass campaigns should focus on urban areas and districts with high numbers of measles cases, on countries and districts with measles vaccine coverage less than 80%, and on countries with measles elimination goals. Thus, there would be an opportunity to reach children who may not have been immunised because of lack of access to services at fixed sites, to increase vaccine efficacy by providing an additional dose to some children, to immunise children outside the scheduled target age group, and hence to reduce the pool of susceptibles rapidly, thereby potentially interrupting transmission of the virus. Local analysis of measles surveillance data will guide the choice of age groups to be immunised during mass campaigns. In some situations the upper age limit may be reduced to 3 years, and the lower limit to 6 months, the choice depending on the local epidemiology of measles and resources available. Likewise, the frequency of campaigns should be determined by analysis of epidemiological data. The most cost-effective way to conduct a measles campaign is to do it in conjunction with a polio immunisation campaign, taking into account the local situation. Mass campaigns are not the only way to control measles. However, many developing countries are unable to achieve the high coverage needed through routine immunisation services, so innovative strategies such as mass campaigns are clearly needed. For countries with the least developed immunisation programmes, an integrated approach to increasing vaccine coverage and control for all diseases targeted by the national immunisation programmes will need to be pursued, with a blend of fixed, outreach, and campaign services being tailored to individual countries. Such a set of phased strategies will allow the most effective progress towards the 1995 goals and beyond, and will help the build-up of health infrastructures in countries where they are most needed. The success of measles mass campaigns has been well demonstrated in the Americas. Nonetheless, some caution is necessary before this model is applied globally. The cost of additional vaccine, equipment, and personnel for a measles mass campaign ranges from US$0-50 to$0-75 per child; if administered during a polio mass campaign the additional cost per child is about$0 30. Since the campaign strategy is not a one-time event, a long-term approach with respect to resources is needed. Implementation of periodic mass campaigns represents a serious strain on many poor countries and on the international donor community; if the recommendations are followed, this strategy will be needed for some years to come.
The
conclusions and recommendations of the Washington DC report are helpful because they specify further the settings in which measles immunisation campaigns will be needed, because they give advice on proper implementation that will definitely lead to better control of measles, and because they represent the uniform advice of a very strong group of experts.
References
Expanded Programme on Immunization. Global Advisory Group. Part II. Weekly Epidemiol Rec No 3. 1991: 9-11. 2 Expanded Programme on Immunization. Global Advisory Group. Part II. Weekly Epidemiol Rec No 5. 1994: 29-35. 3 Expanded Programme on Immunization. Safety of high titer measles vaccine. Weekly Epidemiol Rec No 48. 1992: 357-61. 4 Expanded Programme on Immunization. Accelerated measles strategies. Weekly Epidemiol Rec (in press). 1
Viewpoint Health-care reform: the issues and the role of donors
Governments world wide are attempting reform of their health sector. Reform-as distinct from gradual or incremental change-is underway in the US with the Clinton health-care reforms, in the UK, in central and eastern Europe, and in the republics of the former Soviet Union. In several African and other developing countries, reforms are being implemented, some under the Bamako Initiative, which is proposing to introduce user fees to improve quality of services, and eventually to increase access. Health is not generally viewed with the same sentimentality as it was a generation ago; governments are now interested in ensuring that health care will lead to health gain. Many health systems are undergoing economic liberalisation, being reformed as some form of quasi-market in which health care purchasers and providers operate independently. This change, in turn, demands new mechanisms for financing healthcare. We discuss some of the reasons for the worldwide trend towards reform, describe some common features, and highlight the issues that health sector reform raises for donor agencies and developing countries. Governments have embarked on health sector reforms for various reasons, many of which are linked to the worldwide economic crisis and recession. In some developing countries, health sector reform is a part of wider government reform that often involves a redefinition of the role of government, the services it should provide, and the degree to which it should be involved in production. The World Bank and the International Monetary Fund have promoted structural adjustment programmes for developing countries and these have usually involved decreasing government spending. These changes have often reduced the role of government, limited the government workforce, and generally meant a small government budget. In addition, most structural adjustment programmes have involved devaluing the currency to increase exports and decreasing or eliminating subsidies, including those for food. London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT (Susan Foster MA, Prof Charles Normand DPhil); Health Services Management Unit, Manchester University, Oxford Road, Manchester M13, UK (Rod Sheaff DPhil)
Correspondence to: Susan Foster
All these measures have influenced the ability to provide health services. A smaller workforce, a lack of imported drugs and materials, rises in the price of petrol, and removal of subsidies contribute to an overall rise in poverty. The World Bank has admitted that early structural adjustment programmes "were indiscriminate and failed to preserve those elements of the health system with the strongest long-term benefits for health. Drugs were often cut more heavily than personnel because it is difficult to lay off public employees. In rural clinics already precarious supplies of basic consumables became even scarcer."1
Scarcity of resources Scarcity of resources is a perpetual problem for developing and industrial countries alike. World-wide recession and slow economic activity have coincided with an increased demand for health care. Unemployment reduces the tax base from which health funding flows and brings its own health problems, especially those related to alcohol and tobacco abuse. Pressure on health resources is increasing everywhere, partly because of the high cost of recent advances in technology that is becoming routine, such as coronaryartery bypass grafts or hip replacements. An ageing population increases demands for life-prolonging and life-enhancing interventions and for long-term nursing care. Developing countries are also affected by the ages of their populations. The proportion over 65 years will increase from 4% in 1990 to 9% by 2030-in absolute numbers, from 184 million to 678 million.1 The burden of noncommunicable disease is also increasing sharply and developing countries are bearing the brunt of the AIDS epidemic. In some cities of east and central Africa up to 25% of the adult population are HIV seropositive and will probably die within the next 8-10 years. Their care places heavy demands on health services; in 1990 one-third of health budgets were spent on the care of HIV-positive people, a percentage that has increased in several countries. Developing countries face increasing drug resistance to malaria, tuberculosis, and sexually transmitted diseasesdiseases that are prevalent and whose treatment requires more expensive drugs than 10 or 15 years ago.3 In eastern and central Europe there is a growing appreciation of the 175