Sustaining the Elimination of Measles, Rubella and Congenital Rubella Syndrome in the Americas, 2019-2023: From Challenges to Opportunities.

This report reviews national data from all Member States on measles, rubella, and congenital rubella syndrome (CRS) elimination in the Region of the Americas during 2019-2023. It includes an analysis of compliance with vaccination coverage, surveillance indicators, and measles outbreaks, as well as an analysis of the response capacity of the laboratory network and a country case study that meets all indicators. The sources of information were the integrated epidemiological surveillance system for measles and rubella of the Pan American Health Organization (PAHO)/World Health Organization (WHO) and the Joint Reporting Form (eJRF), among others. From 2020 to 2022, regional coverage with first (MMR-1) and second doses (MMR-2) decreased to rates below 90%. The regional suspected case notification rate was maintained above the minimum expected 2.0 suspect cases per 100,000 population, except in 2021. During 2019 to 2023, 18 countries experienced outbreaks, with two of the outbreaks resulting in re-established endemic transmission. In conclusion, two countries in the Americas have not maintained measles elimination, but by the end of 2023 no country showed endemic measles transmission. One of the countries that lost its certification of elimination in 2018 managed to be reverified in 2023; the other is pending reverification. All countries maintained rubella elimination. Despite these challenges, the sustainability of the elimination of these diseases remains a health priority in the Region.

Accelerating Global Measles and Rubella Eradication-Saving Millions of Lives, Preventing Disability, and Averting the Next Pandemic.

No vaccine has been more effective in reducing disease burden, especially in preventing child deaths, than measles-containing vaccine. The return on investment makes measles-containing vaccine one of the most cost-effective public health measures available. Exhaustive reviews of biological, technical, economic and programmatic evidence have concluded that measles can and should be eradicated, and by including rubella antigen in measles-containing vaccine, congenital rubella syndrome will also be eradicated. All World Health Organisation Regions have pledged to achieve measles elimination. Unfortunately, not all countries and global partners have demonstrated an appropriate commitment to these laudable public health goals, and the negative impact of the COVID-19 pandemic on coverage rates has been profound. Unsurprisingly, large disruptive outbreaks are already occurring in many countries with a global epidemic curve ominously similar to that of 2018/2019 emerging. The Immunization Agenda 2030 will fail dismally unless measles and rubella eradication efforts are accelerated. Over half of all member states have been verified to have eliminated rubella and endemic rubella transmission has not been re-established in any country to date. In 2023, 84 countries and areas were verified to have sustained elimination of measles. However, without a global target, this success will be difficult to sustain. Now is the time for a global eradication goal and commitment by the World Health Assembly. Having a galvanising goal, with a shared call for action, will demand adequate resourcing from every country government and global partners. Greater coordination across countries and regions will be necessary. Measles, rubella and congenital rubella syndrome eradication should not remain just a technically feasible possibility but rather be completed to ensure that future generations of children do not live under the shadow of preventable childhood death and lifelong disability.

Addressing the Dangerous Consequences of the Resurgence of Measles and Rubella: The Critical Need for a Global Target.

I am delighted and honored to be Guest Editor of this Vaccines Special Issue on measles and rubella elimination [...].

Measles and rubella elimination: protecting children through immunization in South-East Asia Region (SEAR).

The South-East Asia Region (SEAR) adopted the goal of "measles and rubella elimination by 2023". The goal was revised in 2019 to 'measles and rubella elimination by 2023' The strategies adopted to reach the goal included achieving ≥95% coverage with 2 doses of measles- and rubella-containing vaccine (MCV2; RCV2); establishing effective case-based surveillance supported by an accredited laboratory network; and implementing rapid response measures to control measles outbreaks. Of the 11 countries in the Region, to date five countries have eliminated measles and rubella and two more have controlled rubella. An estimated 242 million cases and 4.7 million deaths due to measles were averted between 2014 and 2022. The high-level political commitment, programmatic infrastructure and partnerships developed for the elimination of polio and maternal and neonatal tetanus played a critical role in this achievement. WHO, supported by key partners, provided technical support and strategic guidance for programmatic improvements, generated evidence to guide policy and strategic shifts, strengthened capacity of health workforce and conducted periodic programmatic reviews. However, unexpected occurrence of COVID-19 pandemic impacted vaccine coverage and quality of surveillance, thereby delaying achievement of the goal, and necessitating a revision of the target date of elimination.

Seasonal Influenza Prevention and Control Progress in Latin America and the Caribbean in the Context of the Global Influenza Strategy and the COVID-19 Pandemic.

Each year in Latin America and the Caribbean, seasonal influenza is associated with an estimated 36,500 respiratory deaths and 400,000 hospitalizations. Since the 2009 influenza A(H1N1) pandemic, the Region has made significant advances in the prevention and control of seasonal influenza, including improved surveillance systems, burden estimates, and vaccination of at-risk groups. The Global Influenza Strategy 2019-2030 provides a framework to strengthen these advances. Against the backdrop of this new framework, the University of Colorado convened in October 2020 its Immunization Advisory Group of Experts to review and discuss current surveillance, prevention, and control strategies for seasonal influenza in Latin America and the Caribbean, also in the context of the COVID-19 pandemic. This review identified five areas for action and made recommendations specific to each area. The Region should continue its efforts to strengthen surveillance and impact evaluations. Existing data on disease burden, seasonality patterns, and vaccination effectiveness should be used to inform decision-making at the country level as well as advocacy efforts for programmatic resources. Regional and country strategic plans should be prepared and include specific targets for 2030. Existing investments in influenza prevention and control, including for immunization programs, should be optimized. Finally, regional partnerships, such as the regional networks for syndromic surveillance and vaccine effectiveness evaluation (SARInet and REVELAC-i), should continue to play a critical role in continuous learning and standardization by sharing experiences and best practices among countries.

The ethical case for global measles eradication-justice and the Rule of Rescue.

Measles causes a substantial disease burden for all countries, while mortality is greatest in underserved, marginalized populations. Global measles eradication is feasible and the strategies critically rely upon well-functioning national immunisation programs and surveillance systems. All six regions of the World Health Organisation have adopted measles elimination targets. The Rule of Rescue and the principle of justice leave no ethical place for health programs, governments, global public health bodies or donors to hide if they impede efforts to eradicate measles globally by not taking all necessary actions to establish a global eradication target and committing the resources essential to achieve this goal.

Global vaccine action plan lessons learned I: Recommendations for the next decade.

The Global Vaccine Action Plan 2011-2020 (GVAP) was developed to realize the ambitions of the Decade of Vaccines - that all individuals and communities enjoy lives free from vaccine-preventable diseases. It included a comprehensive monitoring and evaluation/accountability framework to assess progress towards global targets with recommendations for corrective actions. While many of the GVAP targets are very unlikely to be met by the end of 2020, substantial progress has nevertheless been made, establishing a strong foundation for a successor global immunization strategy, the Immunization Agenda 2030 (IA2030). The Strategic Advisory Group of Experts on immunization has made a series of recommendations to ensure that the lessons learned from GVAP inform the development and implementation of IA2030.

Arbovirosis emergentes y reemergentes transmitidas por Aedes en la Región de las Américas: implicaciones en materia de políticas de salud / Emerging and reemerging Aedes-transmitted arbovirus infections in the Region of the Americas: implications for health policy

[RESUMEN]. El aumento en la incidencia y distribución geográfica de las arbovirosis constituye uno de los principales problemas de salud pública en la Región de las Américas. La incidencia del dengue ha experimentado una tendencia creciente en los últimos decenios en la Región, donde se ha pasado de una endemicidad baja a hiperendemicidad. También, la incidencia de la fiebre amarilla se ha intensificado en este período, y ha pasado de una actividad restringida a zonas selváticas a presentar brotes urbanos. El chikunguña comenzó a propagarse de forma pandémica en el 2005 a un ritmo sin precedentes y llegó al continente americano en el 2013. Al año siguiente, la infección por el virus del Zika irrumpió también en la Región con un brote explosivo acompañado de gravísimas anomalías congénitas y trastornos neurológicos, hasta convertirse en una de las mayores crisis de salud en los últimos años. La inadecuada vigilancia de las arbovirosis en la Región y la carencia de pruebas serológicas para diferenciar entre los distintos virus plantean retos considerables. Sigue habiendo pocas evidencias científicas en respaldo de las intervenciones de control de vectores. El manejo clínico sigue siendo la piedra angular del control de estas enfermedades. En la actualidad, solo están autorizadas en la Región de las Américas las vacunas contra la fiebre amarilla y contra el dengue, si bien hay varias vacunas experimentales en fase de investigación en ensayos clínicos. El Grupo Mundial de Expertos en Arbovirus ofrece en este artículo un panorama de los progresos, los retos y las recomendaciones sobre prevención y control de las arbovirosis en los países de la Región de las Américas.

[ABSTRACT]. The increasing geographical spread and disease incidence of arboviral infections are among the greatest public health concerns in the Americas. The region has observed an increasing trend in dengue incidence in the last decades, evolving from low to hyperendemicity. Yellow fever incidence has also intensified in this period, expanding from sylvatic-restricted activity to urban outbreaks. Chikungunya started spreading pandemically in 2005 at an unprecedented pace, reaching the Americas in 2013. The following year, Zika also emerged in the region with an explosive outbreak, carrying devastating congenital abnormalities and neurologic disorders and becoming one of the greatest global health crises in years. The inadequate arbovirus surveillance in the region and the lack of serologic tests to differentiate among viruses poses substantial challenges. The evidence for vector control interventions remains weak. Clinical management remains the mainstay of arboviral disease control. Currently, only yellow fever and dengue vaccines are licensed in the Americas, with several candidate vaccines in clinical trials. The Global Arbovirus Group of Experts provides in this article an overview of progress, challenges, and recommendations on arboviral prevention and control for countries of the Americas.

Emerging and Reemerging Aedes-Transmitted Arbovirus Infections in the Region of the Americas: Implications for Health Policy.

The increasing geographical spread and disease incidence of arboviral infections are among the greatest public health concerns in the Americas. The region has observed an increasing trend in dengue incidence in the last decades, evolving from low to hyperendemicity. Yellow fever incidence has also intensified in this period, expanding from sylvatic-restricted activity to urban outbreaks. Chikungunya started spreading pandemically in 2005 at an unprecedented pace, reaching the Americas in 2013. The following year, Zika also emerged in the region with an explosive outbreak, carrying devastating congenital abnormalities and neurologic disorders and becoming one of the greatest global health crises in years. The inadequate arbovirus surveillance in the region and the lack of serologic tests to differentiate among viruses poses substantial challenges. The evidence for vector control interventions remains weak. Clinical management remains the mainstay of arboviral disease control. Currently, only yellow fever and dengue vaccines are licensed in the Americas, with several candidate vaccines in clinical trials. The Global Arbovirus Group of Experts provides in this article an overview of progress, challenges, and recommendations on arboviral prevention and control for countries of the Americas.

Eradicating Measles: A Call for an Exceptional Coordinated Global Effort.

There are compelling epidemiological, economic, and ethical arguments for setting a global measles eradication goal. The 6 chairpersons of Regional Verification Commissions for Measles and Rubella elimination advocate that the time for courageously accelerating efforts to ensure a world where no child dies of measles, is NOW!

Leadership in global health: the case of Ciro de Quadros, a testament to values, valor, and vision

[ABSTRACT]. When Dr. Bill Foege wrote “When Words Fail,” he was referring to how difficult it was for him to describe adequately, in written words, all the effort that is involved from the scientific conceptualization of a new vaccine, to eventual bench discovery and development, to the training and supply chain logistics, and ultimately to the moment the needle pricks the skin to save a life of a child (1). He called it the “chain of perfection”. He was “at a loss” to describe this cascade of events with due justice. I have been asked to describe the leadership attributes of Dr. Ciro de Quadros as a case study in best practice and lessons to be learned. Similarly, I too am at a loss. Simply put, Ciro broke the mold. I should disclose that what I am about to write is influenced by decades of either working directly for Ciro, as was the case during the polio eradication era in the Americas, to collaborating with Ciro more recently on various projects that included measles and rubella elimination, the introduction of new vaccines, and surveillance of infectious diseases. The work evolved into a relationship that bridged from professional mentorship, to actual friends with a deep sense of admiration, love, and mutual respect. In global health, leadership is somewhat like the “self-actualization” of public health practice. The “leader” must have all those attributes that embodies a fully realized individual, positioned in the system to make things happen, such as in Ciro’s case, to help create a world of equitable access to life-saving vaccines. Ciro always kept such a vision in mind. He was unrelenting when seemingly unsurmountable forces impeded his way. Like a hurricane, he would uproot naysayers, but with a clear sense of knowing exactly where he was going. I will attempt to describe what made Ciro this “force of nature”, including, perhaps, what arguably may have been some of his deficiencies. The three “V’s”, values, vision, and valor, have been used to describe broadly the attributes of effective leaders. For Ciro, volumes could be written on each, especially if we think of his career in its entirety, spanning more than four decades.

[RESUMO]. Quando o Dr. Bill Foege escreveu “When Words Fail”, ele estava se referindo ao fato de que para ele era difícil descrever adequadamente, com palavras, todo o esforço envolvido desde a conceitualização científica de uma nova vacina, passando pela descoberta e desenvolvimento no laboratório, treinamento e logística da cadeia de suprimento até, finalmente, o momento em que a agulha fura a pele para salvar a vida de uma criança (1). Ele a chamava de “cadeia da perfeição”. Ele “não tinha palavras” para descrever essa cascata de eventos de maneira adequada. Pediram-me para descrever os atributos de liderança do Dr. Ciro de Quadros como um estudo de caso em boas práticas e lições a serem aprendidas. Do mesmo modo, eu também não tenho palavras. Em resumo, Ciro é um cara fora de série. Devo confessar que este texto é influenciado por décadas de trabalho direto com Ciro, como aconteceu durante a era de erradicação da poliomielite nas Américas, e colaboração com Ciro recentemente em vários projetos que incluíram a eliminação do sarampo e da rubéola, introdução de novas vacinas e vigilância de doenças infecciosas. O trabalho se transformou numa relação que passou de mentoria profissional a amizade, com um profundo sentido de admiração, amor e respeito mútuo. Na saúde global, liderança é algo como a “autorrealização” da prática de saúde pública. O “líder” deve ter todos os atributos que caracterizam um indivíduo plenamente realizado, posicionado no sistema para fazer com que as coisas aconteçam, como no caso de Ciro, para ajudar a criar um mundo de acesso equitativo a vacinas que salvam vidas. Ciro sempre teve em mente essa visão. Ele era incansável quando forças aparentemente insuperáveis bloqueavam seu caminho. Como um furacão, ele afastava as pessoas do contra, mas com um sentido claro de saber exatamente para onde estava indo. Tentarei descrever o que fez dele essa “força da natureza”, inclusive, talvez, o que pode ter sido uma de suas deficiências. Os três “vês”, valores, visão e valentia, têm sido usados para descrever amplamente os atributos de líderes efetivos. No caso de Ciro, podemos escrever tratados sobre cada um deles, especialmente se pensarmos em toda a sua carreira, que cobre mais de quatro décadas.

The past, present, and future of immunization in the Americas

The Pan American Journal of Public Health recognizes with appreciation the contributions of the members of the Editorial Committee, and authors of the Overview article. Their contributions and dedication to this issue on immunization in the Region of the Americas were extraordinary and helped make the manuscripts more interesting, more accurate, and more useful to our readers and all others who work to improve the health of the peoples of the Americas. The Journal would like to give special thanks to the General Coordination of the National Immunization Program, Department of Transmissible Disease Surveillance, Health Surveillance Secretariat, Ministry of Health, Brazil, whose financial and programmatic contributions were essential to the publication of this special issue.

Knowing the scope of meningococcal disease in Latin America

[ABSTRACT]. Opportunities for strengthening surveillance of meningococcal disease exist between and within countries in Latin America. In August of 2015, a workshop was convened in the city of São Paulo, Brazil, to address the following objectives: 1) to review meningococcal disease burden and vaccine use in Latin America; 2) to evaluate the effectiveness of current meningococcal surveillance practices in the region; 3) to identify challenges to meningococcal surveillance in the region; and 4) to outline steps for strengthening meningococcal surveillance and disease control in the region. Based on the workshop’s discussions, recommendations for strengthening surveillance and controlling meningococcal disease in Latin America focus on improving: a) laboratory capabilities for diagnostic testing; b) communication regarding epidemiologic- and laboratory-based analyses; c) communication during outbreaks; d) monitoring of long-term disease outcomes; e) knowledge of vaccines against serogroup B disease; and f) criteria for defining and controlling meningococcal outbreaks. Overall, improving surveillance will help guide strategies for meningococcal disease prevention and control in Latin America.

[RESUMEN]. Existen distintas oportunidades para reforzar los procedimientos de vigilancia de la enfermedad meningocócica entre los países de América Latina y dentro de ellos. En agosto del 2015, se llevó a cabo un taller en la ciudad de São Paulo (Brasil) en el que se trataron los siguientes puntos: 1) examen de la carga de la enfermedad meningocócica y el uso de la vacuna en América Latina; 2) evaluación de la eficacia de los actuales procedimientos de vigilancia de la enfermedad meningocócica en la región; 3) especificación de los retos para la vigilancia de la enfermedad meningocócica en la región; y 4) definición de los pasos para fortalecer los procedimientos de vigilancia de la enfermedad meningocócica y el control de esta enfermedad en la región. Como resultado del taller se formularon recomendaciones para reforzar los procedimientos de vigilancia y control de la enfermedad meningocócica en América Latina que hacían hincapié en mejorar: a) las capacidades de laboratorio con respecto a las pruebas diagnósticas; b) la comunicación sobre los análisis epidemiológicos y de laboratorio; c) la comunicación durante los brotes; d) el seguimiento de las consecuencias de la enfermedad a largo plazo; e) el conocimiento sobre las vacunas contra la enfermedad causada por el serogrupo B; y f) los criterios para definir y controlar los brotes meningocócicos. En términos generales, la mejora de los procedimientos de vigilancia ayudará a delinear las estrategias para la prevención y el control de la enfermedad meningocócica en América Latina.

[RESUMO]. Existem oportunidades para o reforço da vigilância da doença meningocócica entre os países e em cada país na América Latina. Em agosto de 2015, foi realizado um seminário na cidade de São Paulo, Brasil, com os seguintes objetivos: 1) avaliar a carga da doença meningocócica e o uso da vacina na América Latina; 2) avaliar a eficácia das atuais práticas de vigilância da doença meningocócica na Região; 3) identificar os desafios para a vigilância meningocócica na Região e 4) definir medidas para reforçar a vigilância da doença meningocócica e o controle da doença na Região. Partindo dos debates realizados durante o seminário, foram feitas as seguintes recomendações para reforçar a vigilância e o controle da doença meningocócica na América Latina, dando-se ênfase a melhorar: a) a infraestrutura laboratorial para exames diagnósticos; b) a comunicação das análises epidemiológicas e laboratoriais; c) a comunicação nos surtos; d) o monitoramento dos desfechos da doença a longo prazo; e) o conhecimento sobre as vacinas contra o meningococo do sorogrupo B e f) os critérios para definir e controlar os surtos de doença meningocócica. Em geral, a melhoria da vigilância contribuirá para orientar as estratégias para prevenção e controle da doença meningocócica na América Latina.

National legislation and spending on vaccines in Latin America and the Caribbean.

This study examined the dynamics of vaccine spending and vaccine legislation in the Americas Region over the period 1980-2013. Annual vaccine expenditures from thirty-one countries were extracted from the Pan American Health Organization Revolving Fund database. Information on vaccine laws and regulations was provided by the PAHO Family, Gender, and Life Course Unit. Both time series and event history models were estimated. The results show that passing an immunization law led a representative country to increase its vaccine spending, controlling for income, infant mortality, population size, and DPT3 vaccine coverage. Countries with higher vaccine coverage were also more likely to have passed laws. Conversely, higher income countries were less likely to have vaccine laws. Vaccine legislation will likely play a similarly important role in other regions as more countries move towards immunization program ownership.