Measles in the WHO African Region, 2017–2021: The 2020 Elimination Goal Missed

In brief

• The World Health Organization (WHO) African Region set a goal of measles elimination by 2020. In 2016, 68% of children had a first dose of measles-containing vaccine (MCV), and 40% of countries met surveillance targets.
• The 2020 goal was not met. In 2021, first-dose coverage was below 95% in all but two countries, measles incidence exceeded 2017's after a 2019 global resurgence, and the share of countries meeting surveillance targets fell from 62% (2017) to 22% (2021).
• Reaching every child with two doses and strengthening surveillance are critical to the renewed goal: elimination in at least 80% of African countries by 2030.

The goal

The highest measles incidence in the world is in the African Region. In 2011, its 46 member states set out to eliminate measles by 2020 through 95% coverage with two MCV doses in every country and district, through routine vaccination or supplementary immunization activities (SIAs); confirmed incidence below 1 case per million people; and case-based surveillance meeting performance targets. Those targets are finding at least two discarded non-measles rash illnesses per 100,000 people a year, and testing a blood sample from at least one suspected case in at least 80% of districts.

Vaccination

Figure 1. Estimated first- and second-dose measles vaccine coverage and confirmed measles cases, WHO African Region, 2000–2021. CDC, MMWR.

About 341 million people were vaccinated in 69 SIAs in 41 countries. Administrative reports claimed 95% or more coverage in 42 (61%) campaigns, but only 2 of 29 follow-up coverage surveys confirmed it. In 2017, three countries — Mauritius, Rwanda and Seychelles — had 95% second-dose coverage; by 2021, none did. Vaccination averted an estimated 4.5 million measles deaths in 2017–2021.

Surveillance

42 (88%) countries reported weekly case-based data. The number meeting both surveillance targets fell from 26 (62%) in 2017 to 19 (45%) in 2019 and 9 (22%) in 2021, as the COVID-19 pandemic pulled immunization programs away; reported cases and specimens tested dropped too. Planned cuts in Global Polio Eradication Initiative resources, which support vaccine-preventable disease surveillance, may deepen the decline.

Figure 2. Measles case-based surveillance performance by country, WHO African Region, 2017, 2019 and 2021. CDC, MMWR.

Cases and deaths

Reported cases rose more than sevenfold, from 72,603 in 2017 to 618,595 in 2019, then fell to 88,789 in 2021 — still 22% higher than in 2017. Three countries reported 87% of confirmed cases: the Democratic Republic of the Congo (57%), Madagascar (23%) and Nigeria (6%). Confirmed incidence went from 69.2 per million (2017) to 559.8 (2019) and 81.9 (2021). The regional laboratory network — 52 labs in 43 countries — found genotypes B3 and D8.

Modeling estimates cases rose 22%, from 3,623,869 in 2017 to 4,430,595 in 2021 (peaking at 6,377,451 in 2019), and deaths from 61,166 to 66,230 (peaking at 104,543 in 2019). The gap between reported and estimated cases shows how much surveillance misses. No country had been verified as having eliminated measles by December 2021; the regional verification commission, created in 2017, did not meet in 2020–2021 because of the pandemic.

What it means

The region has cut measles cases and deaths greatly since 2000, but the 2020 goal was missed and the pandemic made things harder. In 2021 its Regional Strategic Plan for Immunization 2021–2030 reset the target to elimination in at least 80% of countries by 2030.

Low coverage in populous countries — DRC, Ethiopia and Nigeria, nearly 40% of the region's people — holds the regional figure down. In 2021, about half (12.3 million) of the world's children who missed a first dose lived in the region, and another 21.1 million there missed their second. Reaching them means stronger routine vaccination at fixed and outreach sites, more demand for vaccine, and periodic preventive campaigns where coverage is below 95% and data are unreliable. The explosive 2019 outbreaks in DRC and Madagascar showed the need for timely campaigns, good surveillance, and outbreak preparedness; since 2020 WHO's regional office has helped priority countries plan for outbreaks.

Sources

Based on Balcha G. Masresha, Cynthia Hatcher, Emmaculate Lebo, Patricia Tanifum, Ado M. Bwaka, Anna A. Minta, Sebastien Antoni, Gavin B. Grant, Robert T. Perry and Patrick O'Connor, "Progress Toward Measles Elimination — African Region, 2017–2021," MMWR Morbidity and Mortality Weekly Report, volume 72, Centers for Disease Control and Prevention; a work of the United States government in the public domain.