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[Thorpe] Welcome to Beyond The Data.
I'm Dr. Phoebe Thorpe and here
with me today is Dr. Peter Strebel from the WHO in Geneva.
Thank you very much for joining us, Peter.
We're here to talk about measles and eliminating measles.
Many Americans have never seen measles but it happens in a lot
of other places in the world.
Can you tell our audience a little bit about the variability
in measles across the world?
[Strebel] Yeah. Sure
So, I think it's important to recognize
that measles manifest itself very differently depending
on the underlying nutritional status of the child.
So in the United States where there's good nutrition,
good access to healthcare,
complications are relatively rare
and often measles is transient lasts about a week.
Fever rash, sore eyes, cough, and the child gets better.
However, of course, occasionally in about one
in a thousand cases can get an inflammation of the brain.
And probably one in, one to two thousand may actually die.
So while severe complications are rare, they do occur.
But, the general perception among parents
and even providers is that it's a relatively mild illness.
Contrast that with the developing countries setting,
Vitamin A deficiency.
Protein energy malnutrition
where children are really malnourished.
Here the picture's very different.
Children get severe pneumonia on top of the measles.
And the proportion who die can be as much as one in ten.
So, you're looking at one in a thousand, one in five thousand
in the U.S, verses one in ten.
Very different disease, and so parents in the developing world,
really are fearful of measles.
A very different perception of risk if you're
in industrialized setting with good nutrition versus, you know,
a much tougher socio-economic setting.
[Thorpe] They do say about measles though
that a case anywhere means a case everywhere.
What can you say about that?
Cause, that's an interesting saying.
[Strebel] Yeah, so this is the other thing you know that's
really important.
Measles is very infectious.
And so in pre-vaccine era, basically everybody got measles.
It's very rare to get to age fifteen...twenty
without having had measles.
It's that infectious.
And so, as a result if you have an outbreak
and for example we have an outbreak now in Mongolia,
we've seen cases have occurred in the U.S. as importations.
So, and this is how easily measles spreads,
because it's that infectious.
The flipside is that for vaccination,
basically all children must be vaccinated because if one
in twenty or one in thirty people
in the population have not vaccinated, measles can get
in and can still spread.
So, the level of immunity
in the population vaccination has to be extremely high.
And it's higher than pretty much any other vaccine
preventable disease.
So that infectious capacity, the ability to a person who is.
And also early on in measles you're not symptomatic.
You don't feel sick for four days before you get the rash.
You feel fine.
And you can travel around but you can spread.
Hence, spread on airplanes, you know, in public places.
So the measles anywhere is a, you know, is a risk everywhere.
[Thorpe] Everywhere.
[Strebel] Is a real, is a reality we face all the time.
[Thorpe] That is very interesting
because that makes me wonder about what strategies you have
to do because it almost sounds like you have
to vaccinate everyone.
And, that's a, that's a hard goal to reach.
Can you tell me about some of the strategies
that you know are working and then maybe some of the areas
that are having difficulty making those strategies work?
[Thorpe] Right, right, right.
So our fundamental strategy is to vaccinate children soon
as they turn twelve months of age.
That's in the U.S. for example.
And, that's because maternal protection wears off during the
first months of life.
And by about nine, twelve months,
the infants are susceptible.
So prime recent strategy is on time vaccination
with the first dose at twelve months here in the U.S.
and the second dose at school entry.
And the timing is really important
because you can imagine if children are late,
or miss their dose they build up in the population
and there's a risk of outbreaks.
And as I mentioned before, you need one in 20 susceptible
and you can have an outbreak that continues to, spread.
[Thorpe] I'm sorry.
So, when you say one in twenty, you mean, if there were,
say there were 100 children in a room
and only five were not vaccinated that would be enough
to spread, to continue to spread it.
[Strebel] Correct, correct, correct [Thorpe] Wow,
five out of a hundred is all you need.
[Strebel] So your program goal, practically, is all children
because there's some children cannot get vaccinated
because their immune suppressed for example, so those few,
so programmatically we really have to stress
on time routine vaccination with the first dose
and with the second dose.
This is really critical.
And in the U.S. this really works well
because you have the school entry check
and very high coverage at that stage.
In developing countries,
where programs are weaker maybe only one in three,
or one in two children are getting vaccinated
so your coverage can be quite low in some places.
We use what we call a campaign strategy
so periodically every two to five years,
we'll do what you call a mass vaccination campaign,
where you target children,
target all children particularly those
who missed their routine vaccinations even if, say,
four out of five children getting routine vaccinations
that's enough over a three to four year period to build
up susceptibles and so that's what we do,
what we call preventive campaigns.
And in the sort of last strategy, the fallback strategy,
is if you have missed them in routine if you miss them
in the campaigns then you have an outbreak.
We do outbreak response vaccination just to,
kind of dampen the spread and reduce severe cases and deaths.
So that's the basic, sort of, line up of strategies.
[Thorpe] Okay and so the other thing
that I've heard some today is about rubella.
So tell me why are they doing measles and rubella together?
[Strebel] Right, right.
Well, here we've got a great opportunity
because both diseases are manifests as fever and rash.
So when you're doing from a clinical point of view
or when you are doing surveillance,
you look for children with fever and rash
and you test them for both.
The other big advantage is the vaccine comes in the same vile
and in the same syringe.
In fact, here in the U.S. most children are getting,
all children are getting measles, mumps and rubella.
A sort of triple jab.
So we really have a two for one.
In some cases a three for one opportunity that if you're going
to vaccinate children against measles you might
as well do rubella and if it's economically possible mumps
as well.
Now, in the developing world because mumps is less severe
and also is not really eradicable because you avoid
that the protection wears off over time.
So internationally the focus is really
on combined measles - rubella.
Cause both are potentially eradicable and,
of course severe diseases
and the vaccine price is not that much more.
Single antigen measles about twenty U.S. cents per dose
and combined measles - rubella is
about fifty U.S. cents a dose.
[Thorpe] Ok.
[Strebel] So, this is an incremental cost,
but relatively small, when most
of the cost actually is related to the delivery...
[Thorpe] Campaign.
Getting the campaign...
[Strebel] ...or just getting the logistics, getting the staffing,
getting the cold chain in place.
So, yeah, our real focus now is a combined measles -
rubella effort in the industrializing,
the developing country, and world.
[Thorpe] I heard you talk about the strategies that you used
to work, and some, about the funding.
Are there barriers that you would like to talk about?
[Strebel] Sure.
So I think the situation with measles specifically has been,
it's been a little bit in the shadow of polio eradication
and international interest in introduction of new vaccines
such as vaccines against diarrhea and pneumonia.
So the real investment of the last five
or ten years has been in those areas.
And measles and rubella have been a bit overshadowed
by those priorities.
However things are getting better.
And GAVI, the global alliance for vaccines and immunization,
has recently put forward nearly seven hundred million dollars
over the next five years to support measles
and rubella vaccination.
So this is very welcome.
[Thorpe] Ok.
[Strebel] The reality is that there's still a shortfall.
We estimate roughly one point four billion U.S. dollars needed
for the supplementary control activities between now and 2020.
So GAVI's come up with nearly half of that,
the measles-rubella initiative has about 300 million.
So there's a shortfall of about three hundred
and seventeen million dollars still,
for critical mass vaccination campaigns against measles
and rubella between now and 2020.
[Thorpe] So, I think what I hear you saying is we,
and I don't want to put words in your mouth,
but we kind of know what works but it's gathering the resources
and putting them together and then moving forward on it.
[Strebel] Right.
I think, here, see the situation,
the vaccines we have are fantastic.
They really work.
They're safe.
Our real battle, our challenge is getting them used.
And, so this is where both the resources come, are important
and I think we'll suggest the commitment within the countries
to really take this
up particularly if they're war torn.
If they have other natural disasters.
These sorts of settings are where you really get children
who are unvaccinated, and measles is really a big risk.
[Thorpe] One of the points that came
out in the session today was that the WHO has set the goal
that five out of the six regions would have the
measles eliminated.
That's pretty close to eradication.
Can you tell me and it was by 2020.
Can you share a little bit your thoughts about that
with how reachable that is?
[Strebel] So, this essentially is called the global vaccine
action plan which defines the global efforts
across all vaccines from 2011 to 2020.
And, in there, five of the six WHO regions are targeted
to have eliminated measles and rubella.
But in fact, all member states in the six
WHO regions have individually established a target date
for measles elimination on or before 2020.
So from a biological point of view
if all the countries succeed at the same time,
we have global eradication.
So that's the technical biological stand
which as the experience
in the Americas shows us, this can be achieved.
However, what's missing is real consensus
and political commitment and financial commitment upfront
to go for global eradication now.
So, and I think the reason is obviously restoring the last
stages of the battle with polio eradication.
So, I think people are very mindful
of finishing that battle first.
I think that's a critical point
and also then mustering enough financing upfront,
Cause for eradication of measles,
it'd be very important to go fast and hard.
Because if you, what we learned from Polio,
if you drag this out, if this goes on for a long time,
it's very costly, it takes up a lot of time and resources.
So just make the point that we do not
yet have a global eradication goal.
We do have individual member countries
and the regions targeting elimination.
[Thorpe] Thank you very much for joining us.
I appreciate it.
[Strebel] Thanks for having me.
[Thorpe] And thank you, for joining us.
And we'll see you next time on Beyond The Data.
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