measles, mumps and rubella gone but not forgotten...z1994s dd fmmr i f 101994: second dose of mmr...
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Measles, mumps and rubella
Gone but not forgotten
David Isaacs
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Measles
Highly infectious human diseaseHighly infectious human disease1 in 15 cases develop complications
titi di i– otitis media, pneumonia, encephalitis, SSPE
Pre vaccine epidemiology2 5 year cycle of epidemics– 2 - 5 year cycle of epidemics
– most common in 5 - 9 year olds– world wide 7 - 8 million deaths annuallyy
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Measles
99.9% of unimmunised children get measles1 in 5,000 to 10,000 cases dieMortality : 888,000 deaths in 1998 (more than breast cancer, violence))Morbidity : encephalitis (0.1%), convulsions (0.5%), pneumonia (1-7%), otitis media (5-9%)( %), p ( %), ( %)
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Measles: a global perspective
Vaccine available for over 40 years
Still caused 197,000 estimated deaths in 2007– leading vaccine preventable killer of children
Highest disease incidence in Africa
Most deaths (98%) are in poorest countries – low vaccination coverage high case fatality ratio– low vaccination coverage, high case fatality ratio
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Measles in Australia
1000
1200NotificationsHospitalisations 50
60
2001
800
1000
r
p
10
20
30
40
Num
ber 2001 – young
adults program
600
Num
ber
0Jan 2000
Jan 2001
Jan 2002
Jan 2003
Jan 2004
Jan 2005
Jan 2006
Jan 2007
Jan 2008
Month
200
400
0Jan 1993
Jan 1994
Jan 1995
Jan 1996
Jan 1997
Jan 1998
Jan 1999
Jan 2000
Jan 2001
Jan 2002
Jan 2003
Jan 2004
Jan 2005
Jan 2006
Jan 2007
Jan 20081993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
MonthNov 1993 – 2nd dose introduced for 10-16 yo
Jul 1998 – 2nd dose moved to 4-5 yoMeasles Control Campaign conducted
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Measles elimination in Australia: 1
Th M l C t l i (MCC)The Measles Control campaign (MCC)– July-December 1998
– mass vaccination 1.7 million primary school children (96% vaccinated)
– reminder letter to overdue infants
– information pack to secondary school p ystudents
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Measles elimination in Australia: 2
Since the MCCSince the MCC– Outbreaks in young adults
– Cohort born in 1970s + early 1980s most susceptible
$20 illi f di t– $20 million funding to vaccinate 18-30 y/o in 2001
– Lowest rates on record inLowest rates on record in 2005 (10 cases) and 2007 (11 cases)
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Measles global control
Measles Initiative
g
– UN, Red Cross, CDC, WHO, Unicef– 74% ↓ measles deaths between 2000 & 2007– Goal: 90% ↓ measles deaths by 2010
Strategy– strong routine immunisationg– opportunity for 2nd dose to all children– effective surveillanceeffective surveillance– better treatment of measles
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Source: WHO/IVB databaseSeptember 2008
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Dear FriendsDear FriendsI have been thinking about organizing an approach to the Gates
Foundation about supporting the global elimination of measles and rubella.
Traditionally, Gates has been more interested in new technology than in using already proven vaccines, but as these are “low hanging fruit,” perhaps it would be willing to support activities other than vaccine p p g pp
purchase to accomplish elimination.
A recent modelling meeting at Princeton on the burden of measles and rubella should soon provide a report that will be usefulrubella should soon provide a report that will be useful.
The March of Dimes will support this effort, and I hope GAVI also.
Would you be willing to sign a letter in support of this initiative?
With kind regards,
Stanley
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Measles global eliminationg
Countries with low measles incidenceCountries with low measles incidenceStrategies1 prolonged high coverage (> 95%) with 2 doses of MMR1. prolonged high coverage (> 95%) with 2 doses of MMR
USA, Finland
2. mass vaccination- ‘catch up’ campaignp p gAmericas, UK, Australia
PLUS ‘keep-up’ coverage and ‘follow-up’ campaigns
Other requirements for elimination– surveillance, rapid outbreak response , p p
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Mumps
To mump is to mopeBefore vaccine:
500 admissions per year in Australiap yMeningitis or encephalitisPancreatitisPancreatitisOophoritisO hitiOrchitis
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History of mumps immunisation in Australiay p
1981: mumps vaccine for children > 1 year1981: mumps vaccine for children > 1 year
1983: replaced by a measles–mumps vaccine1983: replaced by a measles–mumps vaccine
1989: MMR vaccine1989: MMR vaccine
1994 S d d f MMR i f 10 161994: Second dose of MMR vaccine for 10-16y
1998 S d d d t 41998: Second dose moved to 4y
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Proportion of Australian population (n = 2787) seropositive for mumps in 1997, by birth cohort, age group and immunisation program history*†program history †
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Year of birth and susceptibilityp y
Born before 1970: natural immunity, low incidencey,
Born in 1980s: single dose, coverage 68% <5yBorn in 1980s: single dose, coverage 68% <5y– low coverage– decreasing exposure to wild-type virusg p yp– highest incidence
Born after 1990: good vaccine coverage– low incidence
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Mumps notifications, Australia 1991 - 2010p ,
700
500
600
ions
300
400
notif
icat
200
300
Mum
ps
0
100
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
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Mumps notifications by age & gender, Australia, 2007
8090
506070
tions
MaleFemale
304050
Not
ifica
t
102030N
010
0 - 4 5-9 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 85+ wn
0 - 5
10-1
15-1
20-2
25-2
30-3
35-3
40-4
45-4
50-5
55-5
60-6
64-6
70-7
75-7
80-8 85
Unknow
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Rubella
Mild illness with rash, cervical lymphadenopathy, arthritis, mild fever
Congenital rubella syndromemainly first trimester- mainly first trimester
- congenital cataracts- sensorineural deafness- cardiac defects- mental retardation
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Rubella (german measles)
Usually mild childhood diseaseI f ti iInfection in pregnancy
– fetal death– congenital rubella syndrome– congenital rubella syndrome
Pre-vaccination– seasonal (spring) epidemics every 5-9 years( p g) p y y– USA 1964/5 - 20,000 cases of CRS– Australia 120 cases of CRS per yr
Vaccination strategies– no vaccination
i t f hild b i– vaccinate women of child-bearing age– universal infant vaccination (coverage >80% required)
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Rubella in Australia
1400
80
901971 School girl vaccination
1000
1200
ns 60
70
80
ons
g1989 Infant vaccination 1993 2nd dose added for 10-16y1998 2nd dose moved to 4y
600
800
otifi
catio
n
40
50
pita
lisat
i
200
400No
10
20
30
Hos
p
NotificationsHospitalisations
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
0
10p
Jan
1
Jan
1
Jan
1
Jan
1
Jan
1
Jan
1
Jan
1
Jan
2
Jan
2
Jan
2
Jan
2
Jan
2
Jan
2
Jan
2
Jan
2
Year
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Rubella epidemic in Greece, 1983p ,
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Incomplete immunisation shifts age of infection to rightg
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Susceptiblesp
W b i t i t i b llWomen born in countries not using rubella vaccine, e.g. South-East Asia
Women born in Australia and never immunised
Serological screening disasters (very rare)
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Acknowledgement:
The epidemiology of vaccine gypreventable diseases
Helen QuinnHelen Quinn
Heather GiddingHeather Gidding
Nick WoodNCIRSNCIRSNational Centre for Immunisation Research and SurveillanceNational Centre for Immunisation Research and Surveillance
Nick WoodThe University
of Sydney