What will it take to end fatalities from measles?
Authors: Kimberly M Thompson
Journal: The Lancet Global Health (2019)

In The Lancet Global Health, Allison Portnoy and colleagues1Portnoy A Jit M Ferrari M Hanson M Brenzel L Verguet S Estimates of case-fatality ratios of measles in low-income and middle-income countries: a systematic review and modelling analysis.Lancet Glob Health. 2019; (published online Feb 20.)http://dx.doi.org/10.1016/S2214-109X(18)30537-0Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar developed a multivariate, time-dependent epidemiological model to estimate case-fatality ratios for measles in low-income and middle-income countries on the basis of historical data, and they used the model and assumptions (eg, future measles vaccination coverage) to project declines in case-fatality ratios up to 2030. Their results showed a substantial decline between 1990 and 2015, but small expected declines between 2016 and 2030 (from a mean predicted case-fatality ratio of 2·2% [95% CI 0·7–4·5] in 1990–2015 to a mean projected ratio of 1·3% [0·4–3·7] in 2016–2030).1Portnoy A Jit M Ferrari M Hanson M Brenzel L Verguet S Estimates of case-fatality ratios of measles in low-income and middle-income countries: a systematic review and modelling analysis.Lancet Glob Health. 2019; (published online Feb 20.)http://dx.doi.org/10.1016/S2214-109X(18)30537-0Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar The authors suggested that this model could support future assessments of the benefits of investments in measles control and elimination efforts. The model developed by Portnoy and colleagues differs from the approach of a previous descriptive epidemiological review2Wolfson LJ Garis RF Luquero FJ Birmingham ME Strebel PM Estimates of measles case fatality ratios: a comprehensive review of community-based studies.Int J Epidemiol. 2009; 38: 192-205Crossref PubMed Scopus (147) Google Scholar that estimated static case-fatality ratios for measles stratified for different countries, which provided the reference assumptions for the WHO annual measles fatality estimates since 2012.3Simons E Ferrari M Fricks J et al.Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data.Lancet. 2012; 379: 2173-2178Summary Full Text Full Text PDF PubMed Scopus (223) Google Scholar This approach followed the recognition that multiple models produced very different annual estimates of measles fatalities4Chen WJ Comparison of list measles mortality model and WHO/IVB measles model.BMC Pub Health. 2011; 11: S33Crossref PubMed Scopus (6) Google Scholar and highlighted the lack of comprehensive surveillance for measles infections and attributed deaths. This new model by Portnoy and colleagues also differs from an independent that supports the characterisation and valuation of both mortality and morbidity effects of measles and rubella infections as a function of age, sex, time, and World Bank income level.5Thompson KM Odahowski CL The costs and valuation of health impacts of measles and rubella risk management policies.Risk Anal. 2016; 36: 1357-1382Crossref PubMed Scopus (21) Google Scholar Unfortunately, we might continue to improve our ability to estimate measles-related fatalities and other adverse health outcomes, while failing to eliminate them. As projected by Portnoy and colleagues, measles fatalities will probably continue to slowly decline over the next decade. With more than 100 000 estimated measles deaths still occurring each year,6Dabbagh A Laws RL Steulet C et al.Progress toward regional measles elimination—worldwide, 2000–2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 1323-1329Crossref PubMed Scopus (2) Google Scholar a slow decline is still very bad news for many individuals in low-income and middle-income countries. Additionally, despite complacency about measles vaccination in many developed countries, the ongoing transmission of measles and rubella globally continues to pose real threats to unvaccinated and under-vaccinated individuals and to lead to associated individual and population health and financial costs.7Thompson KM Badizadegan ND Modeling the transmission of measles and rubella to support global management policy analyses and eradication investment cases.Risk Anal. 2017; 37: 1109-1131Crossref PubMed Scopus (13) Google Scholar How much longer will the world fall short of what we could achieve with a real commitment to measles and rubella eradication?8Thompson KM What will it take to end human suffering from measles?.Lancet Infect Dis. 2017; 17: 1013-1014Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 9Durrheim DN Andrus JK Pfaff G Tabassum S Bashour H Githanga D Eradicating measles—a call for an exceptional coordinated global effort.J Infect Dis. 2019; (published online Jan 7.)DOI:10.1093/infdis/jiz011Crossref PubMed Scopus (9) Google Scholar Sadly, instead of progress, we are losing ground. In the past year, the WHO region of the Americas lost its status as certified free of indigenous measles transmission because of the continued transmission of measles in Venezuela for over 12 months, and five of six WHO regions reported an increase in measles cases in 2016–17 compared with those in the year before.6Dabbagh A Laws RL Steulet C et al.Progress toward regional measles elimination—worldwide, 2000–2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 1323-1329Crossref PubMed Scopus (2) Google Scholar Continued delays in global polio eradication cast a shadow on the prospect of eradication of other vaccine-preventable diseases, including measles and rubella.9Durrheim DN Andrus JK Pfaff G Tabassum S Bashour H Githanga D Eradicating measles—a call for an exceptional coordinated global effort.J Infect Dis. 2019; (published online Jan 7.)DOI:10.1093/infdis/jiz011Crossref PubMed Scopus (9) Google Scholar We need to decide the kind of world we want to create for ourselves and future generations—one with a continued burden of diseases that we failed to eliminate, including a growing global death toll from measles, or one in which impatient optimists and visionaries worked together to end the burden of vaccine-preventable diseases. Now, instead of fully focusing on programme performance to achieve polio eradication and ensure a successful polio endgame by using whatever means required, the Global Polio Eradication Initiative (GPEI), as part of its transition, appears to be already turning its focus and shifting resources towards so-called health system strengthening. Calls to strengthen national immunisation programmes need to come with clear accountability criteria, to ensure performance regarding stopping and preventing transmission of polio, measles, rubella, and other priority pathogens, so that the world can finally achieve its established eradication, elimination, and control objectives. Resource investments need to be accounted for, and donors should know what they are buying. Focusing on performance should drive immunisation activities that encompass unvaccinated and under-vaccinated individuals of all ages, including those living within national borders who are poorly (or not at all) covered by the national health system (eg, displaced populations, immigrants, and poor and underserved individuals). One lesson that the high control of polio continues to teach us is that we must overcome the failure to vaccinate, find ways to immunise unvaccinated and under-vaccinated subpopulations, and achieve peak programmatic performance (as seen in reports from the GPEI Independent Monitoring Board10GPEI Independent Monitoring BoardGPEI Reports.http://polioeradication.org/tools-and-library/policy-reports/imb-resources/reports/Date: 2019Date accessed: January 20, 2019Google Scholar for the past several years). The lessons learned by the GPEI should translate directly into lessons learned by national immunisation programmes in their efforts to meet regional targets to achieve and maintain national and regional measles elimination,10GPEI Independent Monitoring BoardGPEI Reports.http://polioeradication.org/tools-and-library/policy-reports/imb-resources/reports/Date: 2019Date accessed: January 20, 2019Google Scholar but this does not appear to be occurring systematically. The world still has not learned that performance is what counts, not the reported (and often inflated) coverage estimates of children served by the health system (ie, while ignoring the ones left out). Estimating measles fatalities offers an opportunity not only to highlight the large numbers of deaths likely to occur because of our failure to eliminate measles transmission in all regions of the world,1Portnoy A Jit M Ferrari M Hanson M Brenzel L Verguet S Estimates of case-fatality ratios of measles in low-income and middle-income countries: a systematic review and modelling analysis.Lancet Glob Health. 2019; (published online Feb 20.)http://dx.doi.org/10.1016/S2214-109X(18)30537-0Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar but also to value the life-saving results associated with our incremental successes. However, the questions still remain: what will it take to end fatalities (and human suffering) from measles,8Thompson KM What will it take to end human suffering from measles?.Lancet Infect Dis. 2017; 17: 1013-1014Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar and is not the time to take action now?9Durrheim DN Andrus JK Pfaff G Tabassum S Bashour H Githanga D Eradicating measles—a call for an exceptional coordinated global effort.J Infect Dis. 2019; (published online Jan 7.)DOI:10.1093/infdis/jiz011Crossref PubMed Scopus (9) Google Scholar I declare no competing interests. Estimates of case-fatality ratios of measles in low-income and middle-income countries: a systematic review and modelling analysisCase-fatality ratios for measles have seen substantial declines since the 1990s. Our study provides an updated estimation of case-fatality ratios that could help to refine assessment of the effect on mortality of measles control and elimination programmes. 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