Measles Mortality Reduction and Pre- Elimination in the African Region,

SUPPLEMENT ARTICLE Measles Mortality Reduction and Pre- Elimination in the African Region, 2001 2009 Balcha G. Masresha, 1 Amadou Fall, 2 Messeret Eshetu, 3 Steve Sosler, 4 Mary Alleman, 2 James L. Goodson, 5 Reggis Katsande, 1 and Deogratias Nshimirimana 1 1 Immunisation and Vaccines Development Programme, Regional Office for Africa, World Health Organization, Brazzaville, The Republic of the Congo; 2 Immunisation and Vaccines Development Programme, West Africa Inter-Country Support Team, World Health Organization, Ouagadougou, Burkina Faso; 3 Immunisation and Vaccines Development Programme, East and South Africa Inter-Country Support Team, World Health Organization, Harare, Zimbabwe; 4 Immunisation and Vaccines Development Programme, Central Africa Inter-Country Support Team, World Health Organization, Libreville, Gabon; and 5 Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia Introduction. In 2001, countries in the African region adopted the measles-associated mortality reduction strategy recommended by the World Health Organization and the United Nations Children s Fund. With support from partners, these strategies were implemented during 2001 2009. Methods. To assess implementation, estimates of the first dose of measles vaccination through routine services (MCVI) and reported coverage for measles supplemental immunization activities (SIAs) were reviewed. Measles surveillance data were analyzed. Results. During 2001 2009, regional MCV1 coverage increased from 56% to 69%, and.425 million children received measles vaccination through 125 SIAs. Measles case-based surveillance was established in 40 of 46 countries; the remaining 6 have aggregated case reporting. From 2001 through 2008, reported measles cases decreased by 92%, from 492,116 to 37,010; however, in 2009, cases increased to 83,625. Conclusions. The implementation of the recommended strategies led to a marked decrease in measles cases in the region; however, the outbreaks occurring since 2008 indicate suboptimal vaccination coverage. To achieve high MCV1 coverage, provide a second dose through either periodic SIAs or routine services, and to ensure further progress toward attaining the regional measles pre-elimination goal by 2012, a renewed commitment from implementing partners and donors is needed. Measles vaccination was introduced in Africa during the 1960s through mass campaigns as part of the Smallpox Eradication and Measles Control Programme [1, 2]. In 1978, the Expanded Programme on Immunization was established in the region and facilitated introduction of the first dose of measles-containing vaccine (MCV1) for infants,1 year of age through routine health services [3]; all 46 countries in the World Health Organization (WHO) African region (AFRO) provide routine measles vaccination [4]. In 1988, 12 of the 46 countries in the region had R75% MCV1 coverage according to the WHO and United Potential conflicts of interest: none reported. Correspondence: Balcha G. Masresha, MD, Regional Office for Africa, World Health Organization, Immunisation and Vaccines Development Programme, Boite Postale 6, Brazzaville, The Republic of the Congo (masreshab@zw.afro.who.int). The Journal of Infectious Diseases 2011;204:S198 S204 Ó The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com 0022-1899 (print)/1537-6613 (online)/2011/204s1-0025$14.00 DOI: 10.1093/infdis/jir116 Nations Children s Fund (UNICEF) estimates [5]. In 1994, MCV1 coverage was estimated to be R75% in 16 countries; 10 of the 16 were in the WHO AFRO southern subregion [5]. In this subregion, 7 countries, Botswana, Lesotho,Malawi,Namibia,SouthAfrica,Swaziland,and Zimbabwe, each sustained 80% national MCV1 coverage for R3 years and experienced a dramatic decrease in measles incidence [6, 7]. In 1996, these countries embarked on a measles elimination initiative based on the strategy that had been used to achieve measles elimination in the region of the Americas and included (1) attaining high MCV1 coverage through routine health services, (2) providing a second opportunity for measles vaccination through supplemental immunization activities (SIAs), (3) laboratory-supported measles case-based surveillance, and (4) improved case management [6, 7, 8]. After implementation of these strategies in the 7 southern African countries, reported measles cases and deaths decreased further [7]. S198 d JID 2011:204 (Suppl 1) d Masresha et al

In 2001, a global goal was set by the WHO member states to reduce estimated measles-associated mortality by 50% by 2005, compared with the 1999 estimate; this goal was also adopted by the WHO African region [9]. Implementation of the recommended strategies led to an estimated 60% reduction in measlesassociated mortality worldwide and an estimated 75% reduction in Africa by 2005 [10]. After this remarkable progress, in 2006, the African region adopted a goal, outlined by WHO, UNICEF, and partners in the Global Immunization Vision and Strategy (GIVS) for 2006 2015, to achieve 90% measles-associated mortality reduction by 2010, compared with the estimate for 2000 [11, 12]. By 2008 in the African region, reported measles cases decreased by 93% and estimated measles mortality decreased by 92%, compared with 2000 [13]. In May 2008, the African regional measles technical advisory group (TAG) reviewed the progress in measles control and made recommendations related to (1) securing funds for implementation of the GIVS, (2) improving vaccine procurement and management, and (3) strengthening routine vaccination service delivery and the collection and use of measles surveillance data [14]. In addition, the TAG established new measles disease reduction targets and defined a pre-elimination goal to reduce measles-associated mortality by.98% by 2012, compared with the 2000 estimate, and to reduce the annual measles incidence to,5 cases per million population in all countries by 2012. To achieve these goals, benchmarks for vaccination coverage achieved through routine services and SIAs and surveillance performance indicators were established. The TAG recommendations and preelimination goal were adopted by the African Regional Task Force for Immunization at the end of 2008 [15]. This report summarizes progress toward implementation of measles control strategies in the African region during 2001 2009. A review of vaccination coverage through routine services and SIAs, recent outbreaks, and progress toward strengthening measles case-based surveillance was conducted. In addition, this report outlines the challenges faced by efforts to sustain the achievements and to make further progress toward the measles pre-elimination goal in Africa. REGIONAL STRATEGIES AND METHODS The WHO and UNICEF recommended strategies for measlesassociated mortality reduction include providing MCV1 at or shortly after 9 months of age through routine services and a second dose of measles vaccine through either routine services (MCV2) or SIAs [16]. Ten percent to fifteen percent of children vaccinated at 9 months of age do not experience seroconversion [17]. During SIAs, vaccination is provided to children in the target age group irrespective of previous vaccination, and special efforts are made to reach children who do not routinely access health services [18]. The recommended SIA strategy includes an initial nationwide catch-up campaign targeting children 9 months to 14 years of age and periodic nationwide follow-up SIAs targeting children 9 months to 4 years of age [16]. Followup SIAs are conducted every 3 4 years; the frequency is based on the measles epidemiology and estimates of the number of individuals susceptible to measles [16]. Measles vaccination is provided using standard safe injection practices, including the use of auto-disable syringes and safety boxes for disposal of materials [18]. Field trainings are conducted to ensure safe injection practices and appropriate management of adverse events after vaccination. Routine Vaccination Services In Africa, routine vaccination services are provided during scheduled sessions at health facilities, by mobile teams, or during periodic outreach vaccination service delivery sessions. The number of doses administered is tallied and reported monthly to a central administrative level, where they are aggregated to calculate national administrative vaccination coverage. National administrative coverage is reported annually using the WHO/ UNICEF Joint Reporting Form (JRF) [19]. WHO and UNICEF, in collaboration with national Ministries of Health, generate vaccination coverage estimates based on the reported national administrative coverage, available surveys, and results from independent coverage verification [20]. To prevent measles epidemics, it is estimated that population immunity needs to be maintained at. 93% 95% in all districts [16]. In measles-associated mortality reduction settings, achieving and maintaining R90% MCV1 coverage nationally and R80% in each district is recommended; in countries with a regional measles elimination goal, R95% coverage with 2 doses in every district is recommended [16]. In 2008, the African regional measles TAG recommended that countries consider the introduction of MCV2 through routine services when the following 2 criteria are met: (1) national level MCV1 coverage of.80% is maintained for at least 3 consecutive years based on the WHO and UNICEF estimates and (2) the annual target is achieved for at least 1 of the 2 primary measles surveillance indicators for at least 2 consecutive years [14]. The 2 primary surveillance indicators are the proportion of districts reporting R1 suspected measles case with a blood specimen collected (target, R80% annually) and the national annualized rate of nonmeasles febrile rash illness (target,.2 cases per 100,000 population) [14]. After the introduction of MCV2, continued implementation of follow-up SIAs every 3 4 years is recommended until R90% MCV1 and MCV2 coverage nationally are achieved and sustained for at least 2 years and the 2 primary measles surveillance performance indicators are met and sustained for at least 2 years [14]. Supplemental Immunization Activities SIAs are typically conducted as nationwide activities over a period of several days; however, some countries have conducted Measles Mortality Reduction in Africa 2001 2009 d JID 2011:204 (Suppl 1) d S199

the SIAs in phases covering different geographical areas during periods of 2 4 years because of large populations, expansive geography, or resource constraints [18]. During SIAs, vaccination is provided through permanent health facilities, temporary vaccination posts, and mobile teams. SIA administrative coverage at the subnational and national level is calculated by tallying the numbers of administered doses and dividing by the target population. Target population (denominator) figures are often projections from old census data and are prone to inaccuracy. Post-SIA coverage surveys are recommended to validate the administrative vaccination coverage achieved during the SIA [18]. SIA coverage of.95% in all districts is recommended by the African regional measles TAG [14]. Measles Surveillance Measles surveillance in Africa is conducted nationally through 2 surveillance systems: (1) integrated disease surveillance (IDS) and (2) measles case-based surveillance [21]. In the IDS system, clinically diagnosed measles cases are recorded with information on age and vaccination status in health facility registers. The registry data are tallied each month on a summary form and transmitted to the district level; the data are aggregated and reported to the national level and submitted to the WHO attheendoftheyearwithuseofthewho/unicefjrf[19,21]. Measles case-based surveillance, in accordance with WHO regional guidelines, was started in each country during the year after implementation of the initial catch-up SIA [21]. Measles case-based surveillance was integrated into existing acute flaccid paralysis (AFP) surveillance systems for polio detection. For measles case-based surveillance, each suspected case is investigated. The suspected measles case definition is generalized maculopapular rash and fever plus one of the following: cough, coryza (runny nose), or conjunctivitis [21]. For each suspected measles case, an individual case investigation form is completed and a blood specimen collected and sent to the national laboratory for testing for measles-specific immunoglobulin M (IgM) antibody [21]. A laboratory-confirmed case of measles is defined as a suspected case with serological confirmation of measles-specific IgM antibody in a person who had not received measles vaccination within 30 days before the specimen collection [21]. A measles-associated death in the case-based surveillance system is defined as any death from illness in a confirmed case of measles within 1 month after the onset of rash [21]. National measles laboratories in Africa are supported by regional reference laboratories in Côte d Ivoire, South Africa, and Uganda for quality control, virus isolation, and genotyping of specimens collected during outbreaks. The national laboratories undergo annual accreditation to ensure standard implementation according to WHO guidelines [21]. The WHO African regional measles surveillance guidelines define a suspected measles outbreak as the occurrence of R5 reported suspected measles cases in a health facility or district in 1 month, and a confirmed outbreak of measles is defined as R3 laboratory-confirmed measles cases in a health facility or district in 1 month [21]. After an outbreak has been confirmed as measles, laboratory confirmation of cases and individual case investigations are discontinued; subsequent suspected cases are confirmed by epidemiological linkage and are reported, with information on age and vaccination status, in line-list format [21]. In the context of an outbreak, an epidemiologically linked case is one without a blood specimen collected and is linked in person, place, and time to a laboratory-confirmed case. WHO guidelines for outbreak response recommend action based on the epidemiological features of the outbreak [22]. Case-based surveillance data are compiled at the national level into a computerized database that is shared monthly with WHO AFRO. WHO AFRO monitors case-based surveillance performance indicators, including (1) the proportion of districts reporting R1 suspected measles case for which a blood specimen was collected (annual target, R80%) and (2) the annualized rate of nonmeasles febrile rash illness (annual target,.2 cases/ 100,000 population) [23]. The rate of nonmeasles febrile rash illness was introduced to the surveillance system in 2007 to monitor its sensitivity [23]. Case Management Appropriate management of clinical measles cases, including vitamin A supplementation, is essential for reducing morbidity and mortality. It is recommended that all children with measles infection receive 2 doses of vitamin A and that all patients are provided with supportive treatment, including fluids and antipyretics [22]. Antibiotics are only recommended for cases complicated by otitis media or pneumonia [22]. RESULTS Routine Vaccination According to WHO/UNICEF estimates, MCV1 coverage for infants 1 year of age in the African region increased from 56% in 2001 to 69% in 2009 (Figure 1). In 2009, of the 46 countries in the region, estimated MCV1 coverage was,60% in 6 (Chad, Equatorial Guinea, Gabon, Guinea, Mauritania, and Nigeria), 60% 79% in 23, 80% 89% in 4, and R90% in 13 [5]. Of the 6 countries that provided MCV2 through routine services in 2009, reported MCV2 coverage was 70% for Lesotho; R85% for Mauritius, the Seychelles, and South Africa; and not reported by Algeria and Swaziland. In 2009, the countries that were eligible for introduction of MCV2 after the attainment of the criteria established by the regional measles TAG were Ghana, Eritrea, Malawi, São Tomé and Principe, and Zambia; introduction of MCV2 in these countries awaits securing of funding from the GAVI Alliance [14]. 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Figure 1. Number of measles cases reported and estimated percentage of children who received measles vaccine through routine services, 1980 2009, World Health Organization African Region. Cases of measles as reported to the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) through the Joint Reporting Form [24]. Vaccination coverage data are from WHO and UNICEF estimates [5]. Supplemental Immunization Activities Before 2000, 7 countries (Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland, and Zimbabwe) in the region completed a measles catch-up SIA. As of the end of 2009, catch-up SIAs and/or R1 follow-up SIAs had been conducted by all countries except Algeria, Mauritius, and the Seychelles (Table 1). During 2001 2009, a total of 425,336,965 children were vaccinated during a total of 125 measles SIAs in the region; of these, 236,417,893 (56%) were vaccinated during catch-up SIAs in 34 countries and 188,919,072 (44%) during follow-up SIAs in 41 countries (Table 1). Of the 125 SIAs during 2001 2009, SIA administrative coverage was,90% for 25, 90% 94% for 17, 95% 100% for 45,.100% for 35, and not available for 3. Eleven countries conducted the catch-up SIA in phases (Benin, Cameroon, Central African Republic, Chad, the Democratic Republic of the Congo, Ethiopia, Ghana, Niger, Nigeria, the United Republic of Tanzania, and Zambia); in general, the phases covered different geographical areas over various periods that ranged from 2 to 4 years. Measles SIAs have provided a platform for the integrated delivery of other essential child survival interventions, especially vitamin A supplementation, in many countries. In addition to vitamin A, other SIA-integrated interventions have included oral polio vaccine, yellow fever vaccine, tetanus toxoid vaccine for women of child bearing age, deworming tablets, insecticidetreated bed nets, and praziquantel in areas where schistosomiasis is endemic. During 2006 2009, 39 of 68 SIAs had at least 2 integrated interventions; since 2006, all except one included R1 integrated intervention. Measles Surveillance The annual number of measles cases reported through the WHO and UNICEF JRF in Africa decreased from.1 million during the early 1980s to 520,102 in 2000 (Figure 1). During 2001 2008, reported cases decreased from 492,116 cases to 37,010 cases, a 92% decrease and a historic low for Africa. However, in 2009, suspected cases increased to 83,625 among the 46 countries of the region. The number of countries with established measles case-based surveillance in accordance with the WHO African regional measles surveillance guidelines increased from 26 in 2004 to 40 in 2009 (Table 2). The annual number of confirmed measles cases in the region detected through case-based surveillance ranged from 2787 in 2004 to 14,445 in 2009. The regional annual incidence of confirmed measles ranged from 0.7 cases per 100,000 population in 2004 to 1.9 cases per 100,000 population in 2009 (Table 2). In 2009, of the 40 countries with case-based surveillance, 20 (50%) met the target of R80% of their districts reporting R1 suspected measles case accompanied by a blood specimen, 21 (53%) had a nonmeasles febrile rash illness rate of.2 cases per 100,000 population, and 14 (35%) met targets for both of these main measles case-based surveillance performance indicators (Table 2). Measles Outbreaks During 2008 2009, large measles outbreaks occurred in Angola, Burkina Faso, the Democratic Republic of the Congo, Ethiopia, Mali, Namibia, and South Africa, with the number of reported cases ranging from 3511 in Ethiopia in 2008 to 54,118 in Burkina Measles Mortality Reduction in Africa 2001 2009 d JID 2011:204 (Suppl 1) d S201

Table 1. Measles Supplementary Immunization Activities by Country, 2009, World Health Organization African Region SIA Target Children vaccinated in target Country Year Type Age group Area No. % Angola 2009 Follow-up 9 59 months Nationwide 3,469,806 101 Botswana 2009 Follow-up 9 59 months Nationwide 187,380 111 Burundi 2009 Follow-up 9 59 months Nationwide 1,321,915 95 Cameroon 2009 Follow-up 9 59 months Nationwide 3,315,076 96 Cape Verde 2009 Follow-up 12 47 months Nationwide 47,667 87 Chad 2009 Follow-up 6 59 months Nationwide 1,782,689 93 DR Congo 2009 Follow-up 6 59 months Sub-national 2,412,168 93 Equatorial Guinea 2009 Follow-up 9 59 months Nationwide 70,500 80 Eritrea 2009 Follow-up 9 59 months Nationwide 285,285 82 Ethiopia 2009 Follow-up 9 59 months Sub-national 266,621 93 Guinea 2009 Follow-up 9 59 months Nationwide 1,977,225 101 Guinea-Bissau 2009 Follow-up 6 59 months Nationwide 208,608 101 Kenya 2009 Follow-up 9 59 months Nationwide 5,525,400 82 Namibia 2009 Follow-up 9 59 months Nationwide 298,025 102 Rwanda 2009 Follow-up 9 59 months Nationwide 1,350,125 101 Sierra Leone 2009 Follow-up 9 59 months Nationwide 829,842 101 Swaziland 2009 Follow-up 9 47 months Nationwide 91,662 96 Uganda 2009 Follow-up 9 47 months Nationwide 4,894,484 104 Zimbabwe 2009 Follow-up 9 59 months Nationwide 1,408,584 92 Total 29,743,062 NOTE. A complete list of measles supplementary immunization activities (SIAs) by country, 2001 2009, conducted in the World Health Organization African Region can be found in the Supplementary Data, available online. Faso in 2009, according to a combination of IDS and case-based surveillance data. During these outbreaks, case-reporting through the case-based surveillance system was incomplete; therefore, epidemiologic analyses and incidence figures from the case-based data did not fully represent all measles cases in these countries. DISCUSSION After the adoption of the WHO measles mortality reduction strategy in 2001, MCV1 coverage, based on WHO/UNICEF estimates, increased in nearly all countries in the African region by 2009; 17 had R80% coverage, and 13 had R90% coverage. Table 2. Measles Case-Based Surveillance Reports and Performance Indicators, 2004 2009, World Health Organization African Region Year 2004 2005 2006 2007 2008 2009 Number of countries with measles case-based surveillance 26 29 35 38 40 40 Number of suspected measles cases reported 17,100 14,185 21,580 24,636 37,162 35,984 Number of confirmed measles cases a 2787 3257 7707 7200 16,286 14,445 Incidence of confirmed measles per 100,000 population 0.7 0.7 1.2 1 2.2 1.9 Annualized non measles febrile rash illness rate (target:.2 per 2 2 2 1.9 2.4 2.1 100,000 population) b Number of countries that met target: R80% of reported cases 20 28 33 36 29 36 investigated with blood specimens Number of countries that met target: R80% of districts 12 15 15 20 21 20 reporting R1 suspected case with blood specimen collected Number of countries that have met the target:.2 per 100,000 2 2 2 25 24 21 population non-measles febrile rash illness reporting rate Number of countries that met both targets: R80% of districts reporting R1 suspected case with blood specimen collected and.2 per 100,000 population nonmeasles febrile rash illness rate 2 2 2 9 16 14 NOTE. a Confirmed by either laboratory testing or epidemiological link. b Indicator introduced in 2007. S202 d JID 2011:204 (Suppl 1) d Masresha et al

Since 2001,.425,336,965 children have received measles vaccination through SIAs. By 2008, reported cases had decreased by 93% to a historic low for Africa, and estimated measles-related mortality had decreased by.92% in the region, compared with estimates for 2000 [13]. These achievements prompted the adoption of a pre-elimination goal to achieve 98% mortality reduction by 2012, compared with 2000 [15]. Routine immunization services benefited overall from financial resources through the GAVI Alliance awards for health systems strengthening to attain improved vaccination coverage. The Reaching Every District (RED) approach to strengthening routine vaccination services at the district level ensures that sustained demand is created through appropriate programmatic decision making and community linkages to service delivery [25, 26]. The RED approach is currently being implemented in 45 countries in the region. Despite improvements in MCV1 coverage at the national level, subnational gaps in coverage persist, with nearly 7.8 million infants in the African region not receiving MCV1 in 2008 [5]. National level administrative coverage achieved during measles SIAs was R95% in 80 of the 125 SIAs. However, inaccurate target populations have led to overestimates of coverage in some countries. Efforts are under way to improve the estimation of population denominators and to identify best practices in SIA planning and implementation. Supervision and monitoring during SIAs can identify gaps in campaign performance and quality and provide the opportunity to implement corrective measures while the SIA is ongoing [18]. Population-based post-campaign coverage surveys should be routinely conducted to verify coverage and identify areas with low vaccination coverage [27]. Since 2001, countries in the region have conducted measles SIAs with the technical and financial support of the Measles Initiative, a partnership led by the American Red Cross, the Centers for Disease Control and Prevention, UNICEF, the United Nations Foundation, and the WHO [28]. The partners are continually seeking resources for SIAs and also advocate to governments and local organizations to gain their support. These support activities are critical, because SIAs will continue to be a strategy for filling gaps in population immunity in the African region. Measles case-based surveillance has been established in 40 of the 46 countries in the region; aggregate case surveillance is used in the remaining 6 countries. Despite steady improvements in performance, 20 of the 40 countries missed the targets for at least 1 of the main performance indicators in 2009, and surveillance remains suboptimal in several countries, including Angola, the Democratic Republic of the Congo, Guinea, Madagascar, Mozambique, and Tanzania. Efforts are being made to strengthen case-based surveillance in these and other countries through technical assistance, capacity building, performance monitoring at subnational levels, and fostering better integration with the AFP surveillance system. Well-functioning surveillance is essential for the early identification and epidemiological analysis of outbreaks and as a tool for analyzing the impact of control strategies. From 1 December 2009 through 30 June 2010, confirmed measles outbreaks were reported in 27 countries in the WHO African region through the IDS and case-based surveillance systems, including.79,000 suspected measles cases and.1100 measles-related deaths. The largest numbers of suspected cases were reported by South Africa (15,520 cases), Malawi (11,461), Zimbabwe (8173), Nigeria (6432), and Chad (5832). The largest numbers of deaths attributed to measles were reported by Zimbabwe (517) and Chad (230). Outbreak response activities, including strengthening case management and routine immunization services, were conducted in these countries. In addition, several countries, including Chad, Ethiopia, Mali, Malawi, Namibia, Swaziland, South Africa, and Zimbabwe, conducted outbreak response vaccination activities either in limited geographic areas or on a nationwide scale. The measles outbreaks that occurred in several countries since 2008 indicate low population immunity levels as a result of suboptimal routine and SIA vaccination coverage in some areas and countries. Reported national coverage.90% for MCV1 and SIAs in some of these countries (eg, Benin, Burkina Faso, and Tanzania) suggests overestimates of coverage. Outbreaks with a large proportion of cases in children,5 years of age that have occurred in countries (eg, Angola, Nigeria, and Zimbabwe) within 1 2 years after a follow-up SIA suggest suboptimal implementation of the SIAs. In Botswana, South Africa, Swaziland, and Zimbabwe, the outbreaks were partly related to vaccination refusals from some religious groups. Analysis of surveillance data from these countries found that the age distribution of cases in these outbreaks included older children and young adults; however, the highest age-specific attack rates were among children,5 years of age, and the proportion of patients who had been vaccinated was low. To sustain the gains achieved thus far and to attain the regional measles pre-elimination goal for 2012, ongoing commitment from the member states, implementing partners, and donors is needed. Competing national priorities and inadequate local and partner financing limit efforts to conduct timely SIAs, high-quality measles surveillance, and responses to outbreaks. The implementation of measles control activities has been possible through the financial and technical support of the Measles Initiative. Continued advocacy and resource mobilization by all stakeholders will be critical to ensure further progress toward achieving the pre-elimination goal in the African region. Supplementary Data Supplementary data are available at http://www.jid.oxfordjournals. org/ online. Measles Mortality Reduction in Africa 2001 2009 d JID 2011:204 (Suppl 1) d S203

Funding This work was supported by the World Health Organization (to B. M, A. F., M. E., R. K., and D. N.) and the Centers for Disease Control and Prevention (to S. S., M. A., and J. G.) Acknowledgments We thank all immunization officers, surveillance medical officers, and measles laboratory personnel across the African region who were involved in the implementation of the strategies for measles control and the Measles Initiative for providing financial and logistical support to member states towards measles mortality reduction and pre-elimination in the African region. References 1. Guyer B, McBean AM. The epidemiology and control of measles in Yaoundé, Cameroun, 1968 1975. Int J Epidemiol 1981; 10:263 9. 2. Cutts F, Henderson R, Clements C, Chen R, Patriarca P. Principles of measles control. Bull World Health Organ 1991; 69:1 7. 3. Bele O, Barakamfitiye DG. The Expanded Program on Immunization in the WHO African region: current situation and implementation constraints. 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