Table 1.

Key lessons learned and components for moving forward a diagonal approach to measles and rubella elimination.

High-quality data and surveillance	• In 2016, the midterm review of the Global Measles and Rubella Strategic Plan 2012–2020 concluded that the basic strategic approaches articulated in the plan are valid to achieve the goals, and encouraged a greater focus on using measles incidence as a key indicator, along with vaccination coverage, to guide elimination efforts.
	• Having high-quality vaccination coverage and surveillance data, and identification and knowledge of susceptible subpopulation is critical for targeting tailored immunization strategies for achieving elimination.
	• Measles-rubella case-based surveillance indicators should be closely monitored with weekly data reported by countries to WHO.
	• The narrowing of genomic diversity necessitates expanding the capacity for viral sequencing, molecular data management, and developing advanced methods for higher resolution analyses to monitor global transmission patterns of defined lineages within the remaining circulating virus genotypes. Sequencing of expanded windows will help track transmission pathways; however, there is a need to increase the number of specimens collected to be able to identify virus origins and spread.
	• Expand global capacity to analyze high-quality measles-rubella case-based surveillance with information systems for better strategic use of data for guiding elimination. Cases should be categorized as program or strategy failures. Program failures indicate the need to better reach persons for whom vaccine is recommended. Strategy failures should prompt evaluations of the strategy such as whether the recommended ages for vaccine doses are optimal.
Data-driven outbreak response	• Establish global guidelines and monitoring indicators for rapid outbreak response and enhanced surveillance.
	• Implement coordinated multi-country synchronized campaigns to target contiguous epidemiological blocks crossing national borders, defined by population dynamics, ethnography, and migration patterns.
Building acceptance and demand for vaccines	• Develop a robust capacity for identifying communities with vaccine hesitancy, develop context-specific communications strategies, and forge local partnerships with traditional, religious, and community leaders to engage communities to improve access for all, and increase coverage and equity for all vaccines.
	• Ensure an appreciation of the contagiousness of measles virus, the severity of disease and its complications, the household and economic costs of measles infection, and the role individuals play in sustaining virus transmission within households and communities
	• Move beyond traditional immunizations communication strategies of printing ‘posters and banners’ to electronic communications methods, including mobile phone reminders and social media platforms
Research and innovation	• Build and maintain a capacity for research, innovation, and epidemiological studies that provides critical evidence to establish policy and strategies for EPI strengthening and disease elimination.
	• Fully resource the Measles & Rubella Initiative (M&RI) Research and Innovation Working Group to establish current research priorities, solicit and recommend selected projects to be funded by M&RI, and convene semi-annual meetings for sharing research findings, proposed studies, and coordinating research activities with partners.
	• Investments in research and innovation would spur progress; and specifically, expeditious development and licensure of the MR microarray patch for vaccination, a potential gamechanger for elimination, should be of highest priority.
	• Build capacity for rapid mathematical modeling, using high-quality surveillance data, for strategic decision-making.
Program management, governance, oversight, and accountability	• Ramp-up M&RI capacity, with a structure similar to the Global Polio Eradication Initiative (GPEI) for polio eradication, including high level oversight bodies.
	• Further develop and broaden the M&RI partnership with highly motivated, technically skilled people working to establish strategic plans, program management, oversight, accountability, and an ability to adapt and evolve.
	• Strengthen program management by using multiyear planning and budgeting cycles, and developing strategic plans for specific phases of elimination.
	• Establish predictable, sustained funding.
	• Further develop operational oversight and high-level accountability, by forming an oversight board composed of the heads of agencies of core M&RI partners, and an independent monitoring board to assess and guide progress toward interrupting measles and rubella virus transmission globally.
International Health Regulations (IHR), Global Health Security, and travel requirements for vaccination	• International spread of measles virus via international travelers could be considered a public health emergence of international concern, allowing for important measures that could be recommended under IHR, to interrupt measles virus transmission and to protect global public health.
Global partnerships, shared vision, and political will	• The midterm review of the Global Measles and Rubella Strategic Plan 2012–2020 concluded that the strategies have not been fully implemented, largely due to lack of global political will, that is reflected in inadequate resources and in some cases, a lack of country ownership.
	Strengthen global partnership that has a shared vision by all partners for a world free of measles, rubella, and CRS.
	• Build political will by all partners and countries to achieve the Global Vaccine Action Plan and regional elimination goals.
	• Establish National Verification Committees and Regional Verification Commissions to build country ownership and accountability.
Providing benefits for immunization systems strengthening	• A ‘diagonal approach’ will strengthen health systems to ensure on-time routine delivery of all recommended immunizations, strengthening overall EPI, followed by SIAs when routine coverage is suboptimal, and using measles surveillance data with a ‘canary in the coalmine’ approach to identify areas and populations where overall immunization services are weak or challenging.
	• MCV2 delivery, often given last in the childhood series during the second-year of life, is a major opportunity to catch up on any missed vaccines and improve coverage with all recommended vaccines, and to deliver other child health interventions. MCV2 coverage should be used as a key performance indicator for EPI.
	• School entry vaccination checks and laws supporting vaccination requirements have proven to be a highly effective for increasing vaccination coverage and achieving measles elimination. Global guidelines should be developed to establish the necessary legislation and design a strategy for implementing school-entry immunization checks or other requirements to ensure receipt of the recommended two doses of MCV and all other recommended vaccines.
Improving infection prevention and control	• Strengthen infection prevention and control practices, particularly during outbreaks, with clear guidance for appropriate case referral, effective triage and isolation facilities, and procedures to reduce the risk of nosocomial exposures and transmission.
	• Measles and rubella elimination efforts would improve overall infection prevention and control systems in health-care facilities, particularly for other airborne pathogens.
Polio transition and going forward	• It is essential to transition GPEI assets, eradication infrastructure, and lessons learned to support MR elimination.
	• A global measles and rubella eradication goal established prior to GPEI termination would minimize potential losses of polio eradication technical expertise, institutional memory, experience, and know-how.
	• Global measles and rubella eradication would be cost-effective and save an estimated US$8 billion per year that is currently spent for treatment costs and US$88 billion per year in losses due to disability-adjusted life-years that is currently caused by measles and rubella infections.
	• Although a true eradication-level effort will likely not occur until a WHA resolution formally sets an eradication goal and adequate predictable, sustained funding is made available, the optimal strategy would be to ‘go big and go fast’ to best manage population immunity and interrupt virus transmission, by preventing accumulation of susceptibility spread across many age groups and large geographic areas.
	• Although a true eradication-level effort will likely not occur until a WHA resolution formally sets an eradication goal and adequate predictable, sustained funding is made available, the optimal strategy would be to ‘go big and go fast’ to best manage population immunity and interrupt virus transmission, by preventing accumulation of susceptibility spread across many age groups and large geographic areas.
	• Concentrate resources for focused efforts to interrupt virus transmission in known persistent reservoirs, to avoid the diversion of resources in the program caused by sporadic outbreaks following virus importations in post-elimination settings.
	• The 2016 Mid-term Review of the Global Measles and Rubella Strategic Plan 2012–2020 concluded that by no later than 2020, a comprehensive evaluation should be undertaken to determine if an eradication goal with a timeframe should be set. The review concluded that elimination strategies were sound and what is needed most is better implementation with adequate predictable sustained investments.