Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data

doi:10.1016/S0140-6736(12)60522-4

The Lancet

Volume 379, Issue 9832, 9–15 June 2012, Pages 2173-2178

https://doi.org/10.1016/S0140-6736(12)60522-4 Get rights and content

Summary

Background

In 2008 all WHO member states endorsed a target of 90% reduction in measles mortality by 2010 over 2000 levels. We developed a model to estimate progress made towards this goal.

Methods

We constructed a state-space model with population and immunisation coverage estimates and reported surveillance data to estimate annual national measles cases, distributed across age classes. We estimated deaths by applying age-specific and country-specific case-fatality ratios to estimated cases in each age-country class.

Findings

Estimated global measles mortality decreased 74% from 535 300 deaths (95% CI 347 200–976 400) in 2000 to 139 300 (71 200–447 800) in 2010. Measles mortality was reduced by more than three-quarters in all WHO regions except the WHO southeast Asia region. India accounted for 47% of estimated measles mortality in 2010, and the WHO African region accounted for 36%.

Interpretation

Despite rapid progress in measles control from 2000 to 2007, delayed implementation of accelerated disease control in India and continued outbreaks in Africa stalled momentum towards the 2010 global measles mortality reduction goal. Intensified control measures and renewed political and financial commitment are needed to achieve mortality reduction targets and lay the foundation for future global eradication of measles.

Funding

US Centers for Disease Control and Prevention (PMS 5U66/IP000161).

Introduction

In 2007, investigators reported that the global goal to reduce measles deaths by 50% by 2005, compared with 1999, had been achieved.¹ Building on this accomplishment, in 2008 the World Health Assembly endorsed a target of 90% reduction in measles mortality by 2010, compared with 2000. Endemic transmission of measles virus was interrupted in the Americas in 2002, and four of the remaining five WHO regions (all except southeast Asia) have set target dates for measles elimination by 2020 or earlier.² The establishment of a global measles eradication goal has been extensively discussed by the World Health Assembly and advisory committees to WHO and now hinges on progress towards regional elimination outside the Americas.³

Monitoring measles mortality is relevant for all partners involved in child survival. The fourth Millennium Development Goal (MDG4) aims to reduce deaths of children by two thirds by 2015 compared with 1990. The proportion of children vaccinated against measles was adopted as an indicator to measure progress towards MDG4; a rebound in measles deaths would pose a substantial threat to achieving this goal.4, 5

The rapid progress in measles control from 2000 to 2007 was based on implementation of recommended measles mortality reduction strategies, including increasing routine immunisation coverage, periodic supplemental immunisation activities (SIAs—ie, mass vaccination campaigns aimed at immunising 100% of a predefined population within several days or weeks), laboratory-supported surveillance, and appropriate management of measles cases.⁶ Countries that have fully implemented and sustained these strategies have experienced reductions in measles cases of greater than 90%.⁷ However, not all countries have managed to do so, and several of the largest recorded outbreaks of the past decade were during 2009–10.⁸

Because most measles deaths are in countries where vital registration systems cannot provide reliable information on cause-specific mortality, WHO has relied on mathematical models to estimate the global burden of measles.1, 9 Previous models have not objectively incorporated measles surveillance data and instead relied on vaccination coverage data as the primary indicator of local disease burden. Consequently, these models could neither consistently capture the effects of large outbreaks on measles mortality where high vaccination coverage was reported, nor show periods of low mortality between outbreaks when low vaccination coverage was reported. To assess progress towards the 2010 global measles mortality reduction goal, we developed a new model that, unlike previous models, uses surveillance data objectively to estimate both incidence and the age distribution of cases, accounts for herd immunity, and uses robust statistical methods to estimate uncertainty.

Section snippets

Estimating annual measles incidence

For 65 countries with adequate vital registration data (≥85% of estimated deaths of children younger than 5 years registered and coded), we used the reported number of measles deaths. These deaths accounted for less than 0·01% of global measles mortality, according to vital registration data and estimated mortality.¹⁰

For 128 remaining countries with inadequate vital registration data, we estimated country-specific measles deaths through a three-step process. We estimated annual measles

Results

The state-space model and adjusted surveillance data suggested that, from 2000 to 2010, annual estimated measles incidence aggregated across all countries fell 66% from 4·6 to 1·6 cases per 1000 total global population. During the same period, global MCV1 coverage increased from 72% to 85% and the reported number of measles cases declined 62% from 853 480 (140 per million total population) to 327 305 (48 per million total population; table).

In developing countries in the prevaccine era, roughly

Discussion

Our findings suggest that the goal of reducing measles mortality by 90% from 2000 to 2010 has not yet been met. Our conclusion was sustained under all alternative scenarios we assessed. Estimated global measles mortality declined substantially from 2000 to 2007, associated with increases in routine MCV1 coverage as well as the delivery of more than a billion doses of measles vaccine through SIAs. However, from 2008 to 2010, estimated global measles mortality did not diminish further and large

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ArticlesAssessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Estimating annual measles incidence

Results

Discussion

Lancet

Lancet

A World Without Measles

J Infect Dis

Meeting of the Strategic Advisory Group of Experts on Immunization, November 2010—summary, conclusions and recommendations

Wkly Epidemiol Rec

Road map towards the implementation of the United Nations Millennium Declaration: report of the Secretary-General

Measles mortality reduction contributes substantially to reduction of all cause mortality among children less than five years of age, 1990–2008

J Infect Dis

Progress in global measles control and mortality reduction, 2000–2007

Wkly Epidemiol Rec

Measles outbreaks and progress towards meeting measles pre-elimination goals: WHO African Region, 2009–2010

Wkly Epidemiol Rec

The global burden of measles in the year 2000—a model that uses country-specific indicators

J Infect Dis

WHO mortality data base

WHO vaccine-preventable diseases: monitoring system

A computational logic-based representation of the WHO and UNICEF estimates of national immunization coverage

Completeness of measles case reporting: review of estimates for the United States

J Infect Dis

Time series analysis via mechanistic models

Ann Appl Stat

Tracking measles infection through non-linear state space models

J R Stat Soc Ser C Appl Stat

Articles
Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data