Vaccine 36 (2018) A35–A42

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Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Measles and Rubella Global Strategic Plan 2012–2020 midterm review

report: Background and summary q
Walter A. Orenstein a,⇑, Lisa Cairns b, Alan Hinman c, Benjamin Nkowane d, Jean-Marc Olivé e,
Arthur L. Reingold f
a
Emory Vaccine Center, Emory University School of Medicine, Emory University, 1462 Clifton Road NE, Suite 446, Atlanta, GA 30322, USA
b
2650 Bowker Avenue, Victoria, Canada
c
Center for Vaccine Equity, The Task Force for Global Health, 325 Swanton Way, Decatur, GA 30030, USA
d
40 chemin des Pralies, 1279 Bossey, Switzerland
e
Wellenau 11, 6900 Lochau, Austria
f
101 Haviland Hall, School of Public Health, University of California, Berkeley, CA 94720, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Measles, a vaccine-preventable illness, is one of the most infectious diseases known to man. In 2015, an
Immunization estimated 134,200 measles deaths occurred globally. Rubella, also vaccine-preventable, is a concern
Measles because infection during pregnancy can result in congenital defects in the baby. More than 100,000 babies
Rubella
with congenital rubella syndrome were estimated to have been born globally in 2010. Eradication of both
Evaluation
measles and rubella is considered to be feasible, beneficial, and more cost-effective than high-level con-
Recommendations
trol. All six World Health Organization (WHO) regions have measles elimination goals by 2020 and two
have rubella elimination goals by that year. However, the World Health Assembly has not endorsed a glo-
bal eradication goal for either disease. In 2012, the Measles and Rubella Initiative published a Global
Measles and Rubella Strategic Plan, 2012–2020, referred to hereafter as the Plan, which aimed to achieve
measles and rubella elimination in at least five WHO regions by end-2020 through the implementation
of five core strategies, with progress evaluated against 2015 milestones. When, by end-2015, none of these
milestones had been met, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) recom-
mended a mid-term review of the Plan to evaluate progress toward goals, assess the quality of strategy
implementation, and formulate lessons learned. A five-member team reviewed documents and conducted
interviews with stakeholders as the basis for the review’s conclusions and recommendations. This team
concluded that, although significant progress in measles elimination had been made, progress had slowed.
It recommended that countries continue to work toward elimination goals with a focus on strengthening
ongoing immunization systems. In addition, it concluded that the strategies articulated in the Plan were
sound, however full implementation had been impeded by inadequate country ownership and global
political will, reflected in inadequate resources. Detailed recommendations for each of the Plan’s five
strategies as well as the areas of polio transition, governance and resource mobilization are outlined.
Ó 2017 World Health Organization; licensee Elsevier Ltd. This is an open access article under the CC BY IGO
license (http://creativecommons.org/licenses/by/3.0/igo/).

1. Background

1.1. General considerations

In 2016, a midterm review of the Measles and Rubella

q
This is an Open Access article published under the CC BY 3.0 IGO license which
permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited. In any use of this article, there should be no
suggestion that WHO endorses any specific organisation, products or services. The
use of the WHO logo is not permitted. This notice should be preserved along with
the article’s original URL.
⇑ Corresponding author.
E-mail addresses: worenst@emory.edu (W.A. Orenstein), karenlisacairns@gmail.
com (L. Cairns), ahinman@taskforce.org (A. Hinman), drnkowa@gmail.com
(B. Nkowane), jmjolive@gmail.com (J.-M. Olivé), reingold@berkeley.edu (A.L. Reingold).
Initiative’s (M&RI’s)1 Global Measles and Rubella Strategic Plan,
2012–2020 (‘the Plan’) was undertaken at the request of the World
Health Organization’s (WHO’s) Strategic Advisory Group of Experts
on Immunization (SAGE). The purpose of this article is to summarize
1
The M&RI is a consortium led by WHO, the United Nations Children’s Fund, the
United States Centers for Disease Control and Prevention, the United Nations
Foundation, and the American Red Cross.

https://doi.org/10.1016/j.vaccine.2017.10.065
0264-410X/Ó 2017 World Health Organization; licensee Elsevier Ltd.
This is an open access article under the CC BY IGO license (http://creativecommons.org/licenses/by/3.0/igo/).
A36 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42
the major findings and recommendations of that review, the report
of which is published in toto in (Vaccine, Volume 35, Supplement
3). As the audience for this article may encompass those with an
interest in overall health delivery systems and not solely measles
and rubella experts, basic information on measles and rubella and
their control is included here.
Measles, a viral illness, is one of the most highly infectious dis-
eases known to man. Complications of measles include pneumonia,
diarrhea and encephalitis. Case fatality ratios from measles vary
from 0.1% in the developed world to 15% in the less developed
world [1]. Population immunity of 92–95% is considered necessary
to interrupt measles transmission [2]. Although a highly-effective
measles vaccine has existed since 1963, in 2015, an estimated
134,200 measles deaths occurred globally [3]. This burden is
unevenly distributed across WHO regions, within regions, and even
within countries. Due to its highly infectious nature, measles effec-
tively seeks out unvaccinated individuals and is often considered
to be the indicator disease or the ‘canary in the coal mine’, able
to identify individuals and subpopulations who remain unreached
by immunization programs. Measles vaccination coverage serves
as an indicator of the quality of immunization programs [4], while
the epidemiology of measles cases highlights specific geographic
areas and populations in which immunization services require fur-
ther strengthening. Although measles is often perceived as a child-
hood disease, the introduction of measles vaccine with partial
disease control has allowed unimmunized individuals in many
countries to remain unexposed to measles virus into adulthood
and thus still be susceptible to infection, resulting in a much wider
age distribution of measles cases than had historically been the
case [1].
Rubella, another vaccine-preventable viral disease, is primarily
a concern because infection during pregnancy can result in fetal
death or severe congenital defects, including heart defects, catar-
acts, deafness, and cleft palate, in the baby. Rubella is one of the
few known causes of autism [5]. In 2010, more than 100,000 babies
with congenital rubella syndrome (CRS) were estimated to be born
globally. As is the case with measles, the burden of disease is
unevenly distributed across WHO regions [6].
The concept of measles eradication has been reviewed by the
International Task Force for Disease Eradication (ITFDE), as well
as by an independent group of experts and the SAGE, resulting in
the affirmation of the feasibility and desirability of eventual erad-
ication of measles. The ITFDE also reviewed progress towards
rubella eradication, concluding that this was technically feasible
and that the economic literature demonstrated that eradication
of both measles and rubella was more cost-effective than indefinite
high level control of either of these diseases [7–10]. All WHO
regions now have measles elimination goals, while two have
rubella elimination goals. The Global Vaccine Action Plan (GVAP),
the implementation plan for the Decade of Vaccines, has targets
to achieve measles elimination in four WHO regions and rubella
elimination in two WHO regions by 2015, and to achieve measles
and rubella elimination in five WHO regions by 2020 [11].
Nonetheless, at present no global measles or rubella eradication
goal has been endorsed by the World Health Assembly.
Measles-containing vaccines (MCV) are currently part of the
schedule of childhood vaccinations in all countries. The most com-
prehensive approach to preventing both rubella and CRS includes
use of rubella-containing vaccine (RCV) in childhood immunization
schedules as well as targeting rubella-susceptible older age groups
for vaccination [12]. A recent focus on CRS prevention has led to an
acceleration of the introduction of RCV into childhood vaccination
schedules globally. Measles and rubella vaccines are routinely
administered subcutaneously as combined measles rubella vaccine
(MR) or measles, mumps and rubella vaccine (MMR). The very high
levels of population immunity needed to assure interruption of
measles transmission require delivery of two doses of MCV [2].
At present, supplementary immunization activities (SIAs) (mass
immunization campaigns) against measles targeting all persons
in a given age group regardless of prior vaccination status are an
integral part of national immunization program activities in many
countries. Current WHO policy is that ‘‘Reaching all children with 2
doses of measles vaccine should be the standard for all national
immunization programs. . .In addition to the first routine dose of
MCV (MCV1), all countries should include a second routine dose
of MCV (MCV2) in their national vaccination schedules regardless
of the level of MCV1 coverage. . .Countries conducting regular cam-
paigns to achieve high population immunity should consider ces-
sation of campaigns only when >90–95% vaccination coverage
has been achieved at the national level for both MCV1 and
MCV2, as determined by accurate coverage data for a period of at
least 3 consecutive years.” [13] In theory, target age groups for SIAs
are selected based upon the age distribution of susceptibility to
measles in the population, however, in practice the availability of
resources is also taken into consideration. The frequency with
which SIAs must be conducted to maintain herd immunity
depends upon the population immunity existing in the targeted
population [13].
Surveillance data are critical to guiding measles and rubella
control and eradication efforts. Surveillance enables the establish-
ment of burden of disease and mortality, and thus plays an impor-
tant role in advocacy for and prioritization of activities targeting
measles and rubella. Measles cases detected by surveillance iden-
tify un- or under-vaccinated populations, highlighting geographic
areas or sub-populations in which vaccination programs overall –
not only those targeting measles and rubella – require further sup-
port. Surveillance measures disease incidence, the best outcome
indicator of disease control and eradication programs. Well-done
outbreak investigations are an important aspect of surveillance,
allowing understanding of who is transmitting disease to whom,
information which is critical to formulating effective vaccination
strategy. Well-done outbreak investigations can also provide infor-
mation to be used for economic analyses of the societal impact of
measles or rubella. WHO provides guidance to countries on
measles and rubella surveillance, and has developed indicators to
monitor the quality of these activities [14,15].
Surveillance and outbreak investigations are underpinned by
the diagnostic services of the Global Measles and Rubella Labora-
tory Network (GMRLN). This network of 723 labs provides confir-
mation of suspected measles and rubella cases by serologic
testing to measure IgM antibody or significant rises in antibody
and molecular methods to detect virus, as well as providing infor-
mation on global genotype distribution and evidence of interrup-
tion of transmission of endemic genotypes. Historically, disease
confirmation was based upon serological testing. However, new
diagnostic methods based, for example, on dried blood spots or oral
fluid have been developed and may be better adapted for use in cer-
tain settings than serology. Dried blood spots on filter paper offer
the added advantage of not having to use a reverse cold chain for
transporting clinical specimens to the laboratory. The same holds
true for oral fluid (gingival crevicular fluid) which can be collected
through non-invasive techniques. Both sample types can be used
for either IgM antibody detection or molecular analysis [16].
National governments have the primary responsibility for man-
agement and governance of their national immunization programs.
Interagency Coordinating Committees also play a central role in
ensuring strong governance of immunization programs in countries
that rely on external partner support. At national and regional
levels, important roles are played by National Verification Commit-
tees (NVCs) and Regional Verification Commissions (RVCs) for elim-
ination of measles and rubella. As yet, no global verification
committee has been established. The M&RI and Gavi, the Vaccine
 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42
Alliance (Gavi) have played critical roles in measles and rubella con-
trol and elimination efforts since 2000: The M&RI, formed in 2001
by the United Nations Foundation, WHO, United Nations Children’s
Fund (UNICEF), United States Centers for Disease Control and
Prevention (CDC) and the American Red Cross (ARC), has as its mis-
sion to lead and coordinate global efforts to achieve a world without
measles and rubella [17]. Gavi, founded in 2001 by the Bill &
Melinda Gates Foundation (BMGF), the World Bank, UNICEF and
WHO, aims to save children’s lives and protect people’s health by
increasing equitable use of vaccines in lower-income countries [18].
Measles and rubella elimination efforts are closely tied to global
efforts to eradicate polio. The infrastructure built through these
efforts not only supports polio eradication, but also measles,
rubella, and other immunization activities. As polio eradication
draws to a close, discussions are ongoing as to how polio assets
can be transitioned to contribute to future health goals.
1.2. Current status of immunization program, disease surveillance, and
program funding
Globally, coverage with the first dose of MCV (MCV1) has lar-
gely stagnated since 2008 (Fig. 1). This figure hides heterogeneity
in MCV1 coverage among and within WHO regions, as well as
within large countries such as China and India. Between 2010
and 2015, the number of countries with MCV1 coverage 90% rose
from 84 (44%) of 193 countries to 119 (61%) of 194 countries.2 By
2015, a second dose of MCV administered through ongoing immu-
nization services (MCV2) was offered in 160 (82%) of 194 Member
States, up from 97 (51%) in 2000. In many countries, the ongoing
immunization system has been bolstered by SIAs. However, among
41 countries that conducted SIAs in 2015, only 21 (51%) reported
coverage 95% based on doses delivered and only one (Timor-
Leste) achieved 95% based on a coverage survey. At times, SIAs
have also been delayed due to funding gaps [19] (P. Strebel, personal
communication). From 2012 to 2015, global coverage with the first
dose of RCV rose from 42% to 46% (Fig. 2). Of 192 countries, 147
(74%) had RCV in their ongoing immunization services as of end
2015 [20].
Case-based surveillance for measles, i.e., surveillance systems
that collect information about each individual case [21], exists in
189 (97%) of 194 countries. Actual cases reported by country from
January through December 2016 are shown in Fig. 3. This surveil-
lance is often integrated with the acute flaccid paralysis (AFP)
surveillance conducted for poliovirus, and, in many countries,
relies on resources from the Global Polio Eradication Initiative
(GPEI). The quality of measles case-based surveillance is highly
variable and the percentage of cases investigated varies a great
deal among and within countries. Although 94% of WHO Member
States report data monthly to regional WHO offices, at present,
88 (45%) of 194 countries do not report case-based data to WHO
headquarters. While case-based surveillance for rubella exists,
the quality of this surveillance cannot be assessed at the global
level as data have not been officially requested from regions. Not
unexpectedly, given the fact that a global focus on rubella is rela-
tively recent, surveillance for rubella remains weaker than that
for measles.
In addition to the resources provided by national governments,
funding for measles and rubella control mobilized by the M&RI
and Gavi has amounted to over USD 1.5 billion over the period
2001 to 2016. Estimates by the M&RI in October 2015 showed a pro-
jected budget shortfall of USD 431 million for the six-year period
2015–2020. Since that time, Gavi has pledged an additional USD
2
Between 2010 and 2015, the number of WHO Member States increased from 193
to 194.
A37
220 million towards measles and rubella activities, bringing the
total investment to nearly USD 1 billion for the period 2016–2020.
1.3. Global Measles and Rubella Strategic Plan, 2012–2020
In 2012, the M&RI published the Plan [17]. This document had,
as a goal for end-2020, to achieve measles and rubella elimination
in at least five WHO regions. Five core strategies to reach this goal
were articulated, as follows:
 achieve and maintain high levels of population immunity by
providing high vaccination coverage with two doses of
measles- and rubella-containing vaccines;
 monitor disease using effective surveillance and evaluate pro-
grammatic efforts to ensure progress;
 develop and maintain outbreak preparedness, respond rapidly
to outbreaks and manage cases;
 communicate and engage to build public confidence and
demand for immunization;
 perform the research and development needed to support cost-
effective operations and improve vaccination and diagnostic
tools.
To measure progress toward the 2020 goal, specific milestones
for 2015 were established. These milestones and an assessment of
progress towards these are summarized in Table 1. Because the
2015 milestones were not being met, WHO’s SAGE recommended
a midterm review (MTR) of the Plan. The objectives of the MTR
were to:
 provide a candid review of progress towards, and key political,
financial and technical reasons for not attaining, 2015 World
Health Assembly targets and regional elimination goals;
 assess the quality of implementation of the Plan’s five key
strategies and provide recommendations on how the strategies
and principles should be refined to address weaknesses in
immunization systems and to accelerate progress towards the
global and regional goals;
 formulate a set of lessons learned, risks, and financial, political
and programmatic priorities over the next five years (2016–
2020) for countries and partners in order to execute the work.
2. Methodology
The MTR was conducted by a team of five individuals. The team
undertook a comprehensive document review, and held interviews
with and received presentations from stakeholders. These stake-
holders included representatives of the ARC, BMGF, CDC, Gavi,
Kid Risk, Inc., the Pennsylvania State University, United Nations
Foundation (UNF), UNICEF, and WHO. Each team member (with
the exception of the chairperson) was tasked with contacting
specific Regional Offices of WHO to develop an in-depth under-
standing of the region’s experiences in pursuing measles elimina-
tion and rubella control through the use of a standardized
questionnaire. Inferences were drawn based on discussions among
team members following factual presentations from stakeholders
and a review of the information received from WHO Regional
Offices. The team’s conclusions and recommendations were pre-
sented to SAGE, the Measles and Rubella SAGE Working Group,
and the M&RI. All recommendations for revisions from SAGE were
accepted; other recommendations were discussed internally by the
team and incorporated as considered appropriate.
The MTR report examines each of the Plan’s five strategies, sum-
marizing relevant background, progress and challenges to date, the
deliberations of the MTR team, and recommendations for midterm
corrections. In addition, in the context of measles and rubella elim-
A38 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42

Fig. 1. Measles cases reported to the World Health Organization, by year, and first (MCV1) and second (MCV2) dose measles vaccine coverage, 1980–2015.

Fig. 2. Coverage with first dose of rubella-containing vaccine, globally and by World Health Organization region, 1980–2015.

ination, the report addresses the critical questions of building on
the polio transition, governance, and resource mobilization. The
overarching conclusions of the report as well as the major recom-
mendations for each of the Plan’s five core strategies as well as
polio transition, governance and resource mobilization are
summarized below. The complete report is available at (Vaccine,
Volume 35, Supplement 3) and through WHO at the website
http://www.who.int/immunization/sage/meetings/2016/October/
1_MTR_ Report_Final_Color_Sept_20_v2.pdf
3. Overarching conclusions
 The Plan set the ambitious goal of achieving measles and rubella
elimination in at least five WHO regions by 2020 through the
implementation of five core strategies. Significant gains toward
measles elimination have been made. From 2012–2014, more
than 4 million measles-related deaths are estimated to have
been averted through measles vaccination. By end 2015, RVCs
in the American, European and Western Pacific Regions had ver-
ified elimination of measles in 61 Member States and elimina-
tion of rubella in 55 Member States.
 Although all six WHO regions now have measles elimination
goals by 2020 and two have rubella elimination goals by this date,
recent years have seen a slowing of progress. No region except
the Americas has yet achieved its 2015 milestones. All countries
should continue to work toward elimination goals with a partic-
ular focus on strengthening routine immunization systems.
 The basic strategies articulated in the Plan are sound, however
these require full implementation. The main impediments to
full implementation have been inadequate country ownership
and global political will, reflected in inadequate resources.
 Although all six regions have measles elimination goals with the
ultimate vision of a world free of measles, it is premature to set
a timeframe for eradication at this point. Instead, the annual
review of progress toward the GVAP goals should be used to
assess progress toward measles elimination. A determination
should be made, not later than 2020, whether a formal global
goal for measles eradication should be set with timeframes for
achievement. In the meantime, all regions should work toward
achieving the regional elimination goals.
 Strengthening of immunization systems is critical to achieving
regional elimination goals. Working to achieve measles and
 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42
Fig. 3. Incidence of reported measles cases, World Health Organization, January – December 2016 (12 months), with case-counts of reported outbreak areas indicated (2015
outbreak data included for Dem Rep Congo and Somalia).
rubella elimination can help strengthen health systems in gen-
eral and immunization systems in particular. Two examples of
this are the role of measles elimination in increasing immuniza-
tion coverage in the United States, and the impact of school
entry vaccination record checks in Shandong Province, China.
[22,23] The latter were implemented to check for measles vac-
cination as part of a study to evaluate the feasibility of measles
elimination, but resulted in increased coverage for all recom-
mended vaccines. The ways in which measles and rubella elim-
ination strengthens programs should continue to be carefully
documented.
 Disease incidence, in the presence of an effective surveillance
system, is the most important indicator of progress. The pres-
ence or absence of measles is one of the best indicators of over-
all immunization program performance.
 A costed implementation plan in response to these recommen-
dations should be developed by the M&RI not later than twelve
months after the release of this report.
4. Recommendations
Strategy 1. Monitor disease using effective surveillance and
evaluate programmatic efforts to ensure progress.
 A top priority for achieving the goals of the Measles and Rubella
Strategic Plan is to enhance integrated case-based, laboratory-
supported surveillance for measles and rubella. All countries
must implement case-based surveillance for measles and
rubella, and report case information to the WHO Regional Office
on a weekly basis.
A39
 A working group on surveillance and outbreak investigation and
response should be developed at global level.
 Protocols should be updated or, when necessary, developed, to
guide surveillance and outbreak investigation and response.
Countries need to dedicate resources for surveillance and part-
ners need to supplement resources as needed, including
resources for staffing, laboratory support, training, and other
operational costs.
 CRS surveillance, either sentinel or national level, should be
implemented, especially in countries using MR.
 As the GPEI winds down, at a minimum the current level of
measles and rubella surveillance should be maintained.
Wherever possible, the polio transition should be capitalized
on to further strengthen measles and rubella surveillance, as
well as surveillance for other vaccine preventable diseases
(VPDs).
 Both in outbreak investigations as well as in routine surveil-
lance, all cases should be classified to determine the proportion
of cases attributable to program failure – that is, cases in per-
sons who should have been vaccinated according to the national
schedule, but were not.
Strategy 2. Achieve and maintain high levels of population
immunity by providing high vaccination coverage with two doses
of measles- and rubella-containing vaccines.
 Measles and rubella control and elimination activities at
national level should be located within the overall immuniza-
tion program.
A40 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42
Table 1
Status of Global Measles and Rubella Strategic Plan: 2012–2020 2015 milestones. Legend: Black: Little or no progress. Gray: Moderate progress but
inadequate to meet 2015 milestone.
2015 Milestone
Reduce annual measles incidence to
less than five cases per million and
maintain that level
Achieve at least 90% coverage with
measles-containing vaccine (or
measles-rubella-containing vaccine
as appropriate) naonally, and
exceed 80% vaccinaon coverage in
every district or equivalent
administrave unit
Achieve at least 95% coverage with
measles, measles-rubella or
measles-mumps-rubella vaccine
during supplementary
immunizaon acvies (SIAs) in
every district
Establish a rubella/congenal
rubella syndrome eliminaon goal
in at least three addional World
Health Organizaon regions (i.e., in
addion to the Region of the
Americas and the European Region
that had established goals before
2012)
Establish a target date for the
global eradicaon of measles
 Two doses of MCV or measles-rubella–containing vaccine
(MRCV) delivered through ongoing services is the standard for
all national immunization programs. Preventive SIAs should
be conducted on a regular basis, if routine two dose coverage
is insufficient to achieve and maintain high population
immunity.
 Efforts to enhance measles and rubella prevention should take
into account the importance of strengthening the overall immu-
nization delivery system.
 A standardized method to categorize countries based on their
level of disease control and likelihood of achieving and sustain-
ing achievement of measles and rubella elimination goals
should be developed. Immunization strategies and surveillance
strategies should be tailored to the country categorization.
 All countries should institute a school entry check for immu-
nization, including vaccination against measles and rubella as
well as against other VPDs. Vaccination should be provided to
children who have not received vaccine. The ways in which this
provides an opportunity for children who have missed not only
measles and rubella but other vaccines to be brought up to date
with their immunizations has been described in both the United
States and China [22,23].
 Every opportunity should be taken to vaccinate people not ade-
quately vaccinated, particularly those under 15 years of age.
2015 Data Evaluaon
Global incidence of 39.3 per
million
119 (61%) countries have
coverage with first dose of
measles-containing vaccine
exceeding 90% at naonal level
Of 34 countries conducng SIAs
between 2012 and 2014 and
conducng coverage evaluaons
of the SIA, 16 (47%) reached 95%
naonal coverage
One addional region, the
Western Pacific Region, has
established a rubella eliminaon
goal but no date is associated
with it
No target date for global measles
eradicaon established
Strategy 3. Develop and maintain outbreak preparedness,
respond rapidly to outbreaks and manage cases.
 Emphasis should be placed on prevention of outbreaks through
monitoring of risk status and increased attention to vaccination
of underserved communities and in high risk settings.
 All measles outbreaks should be promptly investigated and
used to develop a susceptibility profile of the population to bet-
ter inform measles control and elimination strategies, including
outbreak prevention and response immunization.
 Based on existing experience, training materials should be
developed for use at global, regional and country levels to
perform outbreak investigations as well as to understand
the underlying reasons that outbreaks are occurring and dis-
seminate results of these investigations to all levels of the
system.
 There must be adequate financial, human and laboratory
resources to conduct adequate outbreak investigations. Coun-
tries eligible for funding from Gavi (Gavi-eligible countries)
should consider using Health System and Immunization
Strengthening funds for this.
 Financial resources should be urgently mobilized to support
outbreak investigation and control in non–Gavi-eligible coun-
tries. Countries should develop national measles outbreak pre-
 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42
paredness and response plans. Funding requirements for the
implementation of these Plans should be included in measles
and rubella program financial resource requirements (FRR).
 When outbreaks are detected, in addition to investigation,
countries should take steps to mitigate the outbreak through
vaccination. The magnitude of the response should be based
on the characteristics of the outbreak, the stage of measles con-
trol, and the category to which countries belong (see Strategy 2,
bullet 4 above).3
Strategy 4. Communicate and engage to build public confidence
and demand for immunization.
 Increased resources are needed for communication to raise the
visibility of VPDs, with a focus on measles and rubella.
 Creating and promoting demand for immunization requires
long term investment and should be an integral part of routine
immunization strategy.
 Communication plans may target many different audiences
(e.g., politicians, public health leaders and workers, healthcare
providers, caregivers, etc.). Plans targeting each of these audi-
ences should be developed and audience-specific messages
developed and tested.
 Data on measles incidence, including complications and deaths,
as well as information on the costs associated with outbreaks,
should be the focus of educating various audiences about the
importance of preventing the illness. Data should be supple-
mented by stories of actual cases to illustrate the statistical
data. Collection of information on cases of CRS can also be a
powerful advocacy tool.
 In advocating for improved prevention of measles and rubella, it
will be important to collect stories of how a focus on those dis-
eases not only improved their control but also helped to
enhance overall immunization and health systems (see
Resource Mobilization Section below).
Strategy 5. Perform the research and development needed to
support cost- effective operations and improve vaccination and
diagnostic tools
 Programmatically-oriented operations research, in addition to
technologically-oriented research, should be used to determine
how to best interrupt measles transmission. Such operations
research should include achieving optimal uptake of vaccina-
tion in populations, which populations should be targeted for
special immunization efforts, how to optimize surveillance sys-
tems, and the economic impact of disease.
 Sustained commitment to adequately funding measles and
rubella research is required. An advocacy plan to secure funding
for research should be developed.
 A working group focusing in a sustained fashion on advocating
for, promoting, and prioritizing measles and rubella research,
similar to the Polio Research Committee, is critical. The natural
home for this working group is WHO.
Building on the polio transition
 Given the imminent reduction in polio eradication resources,
which can have an adverse impact on both measles and rubella
control/elimination efforts, a focus on transition of polio
resources is urgent and needs to be a top priority.
3
This categorization refers to that described under the fourth bullet, Strategy 2.
A41
 All stakeholders involved in control and elimination of measles
and rubella as well as those involved in immunization system
strengthening should engage in polio transition planning (at
all levels) to leverage the opportunity and avoid the risks of
the end of the GPEI.
 Strengthening immunization systems and the control
and elimination of measles and rubella should be designated
as high priorities for polio transition planning and
implementation.
Governance
 It is imperative that there be close collaboration and coordina-
tion between Gavi and the M&RI, as a central element in build-
ing the overall immunization system and in order to ensure that
measles and rubella control and elimination efforts are coordi-
nated and efficient.
 Efforts to control and eliminate measles and rubella should be
integrated with the general immunization system and should
be used to build and enhance the overall immunization system.
Resource mobilization
 A multi-year FRR document for measles and rubella in the con-
text of the overall immunization system should be developed.
The FRR should include demand-driven, country-driven projec-
tions on need, and reflect funding from Gavi, the M&RI, other
partners and domestic financing. This document should be com-
plemented by yearly work plans with detailed national part-
ners’ financial contributions.
 The recent welcome additional support from Gavi for measles
and rubella activities provides a major step forward for
achieving measles and rubella goals. However, it is not, in
itself, sufficient to provide adequate assistance globally, as
many countries are not Gavi-eligible or are graduating from
Gavi-eligibility and key global strategies such as surveillance
and research are under-resourced. Consequently, there is a
need for additional funding.
 Efforts should be made to identify examples of when a focus on
measles and rubella elimination has led to building of the over-
all immunization system (e.g., where a focus on measles and
rubella led to a school entry check for those vaccines as well
as other vaccines recommended for children, leading to
improved coverage for all recommended vaccines).
5. Conclusion
Despite the tremendous progress made towards both measles
and rubella elimination since 2001 and the significant gains
made during the period 2012–2015, neither measles nor rubella
elimination are on track to achieve the ambitious goals laid out
in the Plan, nor those in the Global Vaccine Action Plan. The basic
strategies articulated in the Plan are sound, but full implementa-
tion of them has been limited by lack of country and global
political will and country ownership, reflected in insufficient
resources. In principle, the 2020 goals can still be reached, but
doing so would require a substantial escalation of political will
and resources as well as heavy reliance on SIAs. The report rec-
ommends focusing on improving ongoing immunization systems
– although this may delay reaching measles and rubella elimina-
tion goals – in order to ensure that gains in measles and rubella
control can be sustained. Re-orienting the measles and rubella
elimination program to increase emphasis on surveillance so that
programmatic and strategic decisions can be guided by data is
critical.
A42 W.A. Orenstein et al. / Vaccine 36 (2018) A35–A42
Acknowledgments
We would like to acknowledge the invaluable assistance pro-
vided by the following WHO staff who served as the Secretariat
to the review: Peter Strebel, Kaushik Banerjee, Mick Mulders, Minal
Patel and Marta Gacic Dobo at WHO headquarters, and Deborah
Bettels, Nadia Teleb Badr, Desiree Pastor, Pamela Bravo Alcantara,
Balcha G. Masresha, Lawrence Rodewald, William Schluter, Yoshi-
hiro Takashima and Sudhir Khanal in WHO’s Regional and Country
Offices.
Conflict of Interest Statement
None declared.
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