This article describes the arc of global measles and rubella elimination since 2000 from the perspective of the founding partners of the Measles Initiative. The Measles Initiative was formed in 2001 as a partnership among the American Red Cross, the Centers for Disease Control and Prevention, UNICEF, the United Nations Foundation, and the World Health Organization with the aim to reduce measles deaths in low-income countries. Recognizing rubella as the leading infectious disease cause of congenital abnormalities globally and achievement of measles and rubella elimination in the region of the Americas, the partnership was renamed the Measles and Rubella Initiative (MRI) in 2012. The goals of the MRI were at least a 95% reduction in global measles mortality and elimination of measles and rubella in at least five of the six WHO regions. In January 2023, the membership of the partnership was expanded to include the Bill and Melinda Gates Foundation (BMGF) and Gavi the Vaccine Alliance, and its name changed to the IA2030 Measles and Rubella Partnership. We describe the role the partnership has had in measles partner effectiveness and its impact on measles and rubella disease burden, including how the partnership has strategically adapted to the evolving immunization landscape. We conclude with lessons learned regarding the role global partnerships can play in furthering the impact of disease control programs within the current global immunization environment.

BACKGROUND Malaria is a life-threatening parasitic disease and 40% of the world's population lives in areas affected by malaria. Insecticide-treated bednets (ITNs) effectively prevent malaria, however, barriers to their use have been identified. OBJECTIVES To assess the evidence on the effectiveness of available strategies that focus on delivery and appropriate use of ITNs. SEARCH METHODS We searched the EPOC Register of Studies, CENTRAL, MEDLINE, EMBASE, HealthStar, CINAHL, PubMed, Science Citation Index, ProQuest Dissertations and Theses, African Index Medicus (AIM), World Health Organization Library and Information Networks for Knowledge (WHOLIS), LILACS, Virtual Health Library (VHL), and the World Health Organization Library Information System (WHOLIS). Initial searches were conducted in May 2011, updated in March 2012 and February 2013. Authors contacted organizations and individuals involved in ITN distribution programs or research to identify current initiatives, studies or unpublished data, and searched reference lists of relevant reviews and studies. SELECTION CRITERIA Randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series evaluating interventions focused on increasing ITN ownership and use were considered. The populations of interest were individuals in malaria-endemic areas. DATA COLLECTION AND ANALYSIS Two authors independently screened studies to be included. They extracted data from the selected studies and assessed the risk of bias. When consensus was not reached, any disagreements were discussed with a third author. The magnitude of effect and quality of evidence for each outcome was assessed. MAIN RESULTS Of the 3032 records identified, 10 studies were included in this review. Effect of ITN cost on ownership:Four studies including 4566 households and another study comprising 424 participants evaluated the effect of ITN price on ownership. These studies suggest that providing free ITNs probably increases ITN ownership when compared to subsidized ITNs or ITNs offered at full market price. Effect of ITN Cost on appropriate use of ITNs:Three studies including 9968 households and another study comprising 259 individuals found that there is probably little or no difference in the use of ITNs when they are provided free, compared to providing subsidized ITNs or ITNs offered at full market price. Education:Five studies, including 12,637 households, assessed educational interventions regarding ITN use and concluded that education may increase the number of adults and children using ITNs (sleeping under ITNs) compared to no education.One study, including 519 households, assessed the effects of providing an incentive (an undisclosed prize) to promote ITN ownership and use, and found that incentives probably lead to little or no difference in ownership or use of ITNs, compared to not receiving an incentive.None of the included studies reported on adverse effects. AUTHORS' CONCLUSIONS Five studies examined the effect of price on ITN ownership and found moderate-certainty evidence that ownership was highest among the groups who received the ITN free versus those who purchased the ITN at any cost. In economic terms, this means that demand for ITNs is elastic with regard to price. However, once the ITN is supplied, the price paid for the ITN probably has little to no effect on its use; the four studies addressing this outcome failed to confirm the hypothesis that people who purchase nets will use them more than those who receive them at no cost. Educational interventions for promoting ITN use have an additional positive effect. However, the impact of different types or intensities of education is unknown.

Background Efficiently delivered interventions to reduce HIV, malaria, and diarrhea are essential to accelerating global health efforts. A 2008 community integrated prevention campaign in Western Province, Kenya, reached 47,000 individuals over 7 days, providing HIV testing and counseling, water filters, insecticide-treated bed nets, condoms, and for HIV-infected individuals cotrimoxazole prophylaxis and referral for ongoing care. We modeled the potential cost-effectiveness of a scaled-up integrated prevention campaign. Methods We estimated averted deaths and disability-adjusted life years (DALYs) based on published data on baseline mortality and morbidity and on the protective effect of interventions, including antiretroviral therapy. We incorporate a previously estimated scaled-up campaign cost. We used published costs of medical care to estimate savings from averted illness (for all three diseases) and the added costs of initiating treatment earlier in the course of HIV disease. Results Per 1000 participants, projected reductions in cases of diarrhea, malaria, and HIV infection avert an estimated 16.3 deaths, 359 DALYs and $85,113 in medical care costs. Earlier care for HIV-infected persons adds an estimated 82 DALYs averted (to a total of 442), at a cost of $37,097 (reducing total averted costs to $48,015). Accounting for the estimated campaign cost of $32,000, the campaign saves an estimated $16,015 per 1000 participants. In multivariate sensitivity analyses, 83% of simulations result in net savings, and 93% in a cost per DALY averted of less than $20. Discussion A mass, rapidly implemented campaign for HIV testing, safe water, and malaria control appears economically attractive.

Background: Integrated disease prevention in low resource settings can increase coverage, equity and efficiency in controlling high burden infectious diseases. A public-private partnership with the Ministry of Health, CDC, Vestergaard Frandsen and CHF International implemented a one-week integrated multi-disease prevention campaign.Method: Residents of Lurambi, Western Kenya were eligible for participation. The aim was to offer services to at least 80% of those aged 15-49. 31 temporary sites in strategically dispersed locations offered: HIV counseling and testing, 60 male condoms, an insecticide-treated bednet, a household water filter for women or an individual filter for men, and for those testing positive, a 3-month supply of cotrimoxazole and referral for follow-up care and treatment.Findings: Over 7 days, 47,311 people attended the campaign with a 96% uptake of the multi-disease preventive package. Of these, 99.7% were tested for HIV (87% in the target 15-49 age group); 80% had previously never tested. 4% of those tested were positive, 61% were women (5% of women and 3% of men), 6% had median CD4 counts of 541 cell/mL (IQR; 356, 754). 386 certified counselors attended to an average 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age, and was more likely with an ended marriage (e. g. widowed vs. never married, OR. 3.91; 95% CI. 2.87-5.34), and lack of occupation. In men, quantitatively stronger relationships were found (e. g. widowed vs. never married, OR. 7.0; 95% CI. 3.5-13.9). Always using condoms with a non-steady partner was more common among HIV-infected women participants who knew their status compared to those who did not (OR. 5.4 95% CI. 2.3-12.8).Conclusion: Through integrated campaigns it is feasible to efficiently cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services simultaneously achieving various national and international health development goals.

BACKGROUND:An increasing number of malaria-endemic African countries are rapidly scaling up malaria prevention and treatment. To have an initial estimate of the impact of these efforts, time trends in health facility records were evaluated in selected districts in Ethiopia and Rwanda, where long-lasting insecticidal nets (LLIN) and artemisinin-based combination therapy (ACT) had been distributed nationwide by 2007.METHODS:In Ethiopia, a stratified convenience sample covered four major regions where (moderately) endemic malaria occurs. In Rwanda, two districts were sampled in all five provinces, with one rural health centre and one rural hospital selected in each district. The main impact indicator was percentage change in number of in-patient malaria cases and deaths in children < 5 years old prior to (2001-2005/6) and after (2007) nationwide implementation of LLIN and ACT.RESULTS:In-patient malaria cases and deaths in children < 5 years old in Rwanda fell by 55% and 67%, respectively, and in Ethiopia by 73% and 62%. Over this same time period, non-malaria cases and deaths generally remained stable or increased.CONCLUSION:Initial evidence indicated that the combination of mass distribution of LLIN to all children < 5 years or all households and nationwide distribution of ACT in the public sector was associated with substantial declines of in-patient malaria cases and deaths in Rwanda and Ethiopia. Clinic-based data was a useful tool for local monitoring of the impact of malaria programmes.

For years the global malaria effort has been asking for more resources. Now the field needs to figure out a systematic strategy for spending the money effectively, says Mark Grabowsky.

Summary Background Mass, free distribution (Catch‐up) of insecticide‐treated bednets (ITNs) during measles vaccination campaigns achieves immediate, high and equitable coverage for both ITNs and measles vaccine. Maintaining high coverage over time requires long‐term, routine access to new nets (Keep‐up). In many settings, only one approach – either campaign or routine delivery – has been available and have been seen as competing methods. Relying only on campaigns achieves high coverage at the cost of lack of later access. Relying solely on routine coverage builds a delivery infrastructure but may lead to slower rates of coverage and inequities. A combined Catch‐up/Keep‐up approach has been a common feature of vaccination programs for many years. We assessed the 3‐year effects of a one‐time Catch‐up campaign followed by clinic‐based social marketing for routine Keep‐up on ITN coverage and use. Methods In December 2002, ITNs were distributed to all children attending a measles vaccination campaign in a rural district of Ghana. In the 3 years following that campaign, the district began offering ITNs at a subsidized price to pregnant women attending ante‐natal clinics. This Keep‐up scheme did not become fully operational until 2 years after the campaign. A coverage survey was conducted 38‐month post‐campaign using a standard two‐stage cluster sampling method. Results Coverage of nets was high due to the combined contributions of both Catch‐up and Keep‐up. There were 475 households in the survey with at least one child less than 5 years of age. Among these households, coverage was 95.6% with any net, 83.8% with a campaign net, and 73.9% with an ITN. Of all children, 95.7% slept in a household that had a net, 86.1% slept in a household that had a campaign net. Not all available nets were used as only 59.6% of children slept under an ITN. The source of the nets was 77.7% from the campaign and 20% from routine clinics. Compared to households that participated in the campaign, households with children born after the campaign had higher rates of net ownership (75.1% vs. 67.7%, P = 0.04). Equity was high as the ratio of coverage in the lowest wealth quintile to that in the highest was 0.95 for ITN ownership and 1.08 for ITN use. These coverage and use rates were similar to those previously reported 5‐month post‐campaign, suggesting no decrease over 3 years. Conclusion A high level of ITN coverage and use was achieved and sustained by sequential community‐based mass campaign Catch‐up and clinic‐based Keep‐up distribution. The campaign nets covered virtually all extant households while clinic‐based distribution provided nets for the new sleeping spaces created post‐campaign. Because nets can be shared, and most children are born into families that already have a net, the number of new nets needed to sustain high coverage is substantially lower than the number of newborn children. A Catch‐up/Keep‐up strategy combining mass campaigns for children and clinic‐based distribution to pregnant women is an efficient strategy for achieving and sustaining high net coverage. Assuring proper use of nets is a remaining challenge.

A review of the main elements determining strategic choices for the large-scale distribution of insecticide-treated nets (ITNs) clearly shows the need for multiple strategies. Mass distributions of free nets provide a unique opportunity to achieve quickly high coverage rates. However, there is also a need for additional approaches to 1) provide continuous provision of ITNs for newly pregnant women and their babies and 2) provide protection for the rest of the population. Targeted subsidies will continue to be an important tool to achieve the first objective, either through direct distribution of ITNs or through vouchers. To achieve objective 2, a strong and competitive commercial sector for ITNs seems to be a good option. It is clear that "one size doesn't fit all," and more experience needs to be gathered and shared. With planning and good promotion campaigns, these strategies can co-exist and re-enforce each other.

A total of 255 bednets were collected 38 months after distribution in Lawra District of northwest Ghana to examine their physical condition and residual insecticide levels. Physical condition varied from nearly pristine to highly damaged. In 50 selected nets, 2023 holes > or = 0.5 cm and 31 holes > or = 10 cm were counted. The incidence of holes increases toward the bottom edge of the net. Seam failures were found in 50% of the nets. Repairs, mostly sewn, were evident in 64% of the nets. Using a combination of bromine x-ray fluorescence (XRF) spectrometry, high-pressure liquid chromatography, and cone bioassays, it was determined that 14.9% of the nets had retained full insecticidal strength. These results highlight the value of real-world data on bednet longevity to guide decisions regarding mosquito control strategies, bednet purchasing, frequency of bednet replacement, and product development.

PURPOSETo describe the epidemiology of measles in Kenya and evaluate the Measles Initiative's (MI's) mass immunization campaign and its impact on measles control in Kenya.METHODSThis descriptive study focused on evaluating the MI's simultaneous mass campaigns in the provinces of Kenya, the implementation process of the campaign strategy, post-campaign impact data, and pre-campaign measles trends. Secondary data were obtained from the Kenya Ministry of Health and MI documentation involving vaccine coverage, and morbidity and mortality rates. Analysis focused on program achievement with a comparison of immunization coverage results and program goals.OUTCOMESCampaign goals of vaccination coverage were successfully achieved, and subsequent surveillance data indicate significant decreases in measles morbidity and mortality. Barriers to participation, sociocultural factors, and environmental demographics were identified and addressed.IMPLICATIONSThe success of the MI immunization program was the result of the commitment of expert international public health agencies in partnership with the Kenyan government. The strategies used for this successful public health activity can be applied to improve vaccination programs in other countries.

Measles control remains a great challenge in Uganda. We conducted a prospective study among household contacts aged 9–59 months to assess measles vaccination effectiveness. Index cases were measles patients seen in Kampala hospitals in 1999. Measles was diagnosed in 37/43 (86%) of unvaccinated and in 33/145 (23%) of vaccinated exposed contacts, respectively. Vaccination effectiveness was 74% (95% CI; 64–81), which was lower than expected. This may indicate the need for strengthening of the cold chain and/or introduction of a second opportunity for measles vaccination, either as part of the routine immunization program or in the form of supplementary immunization activities.

Health services can make an important contribution to improved health conditions among disadvantaged groups. Yet as the contents of this volume make clear, the health services supported by governments, and by agencies like ours too often fail to reach these people who need them most. This is not acceptable. Nor need it be accepted. The studies presented here point to numerous strategies that can help health programs reach the poor much more effectively than at present. In doing so, they strongly reinforce the messages of the 2004 World Development Report and other recent publications about the importance and possibility of making services work better for poor people. Different views will be formed about which of the strategies are most promising for a particular setting-whether, for example, one would be best advised to follow Brazil's approach of seeking universal coverage for basic health services, Cambodia's strategy of contracting with non-governmental organizations, Nepal's use of participatory program development, or some other approach. The report provides a discussion on issues like these, in order to build upon the important basic findings presented herewith, i.e., that better performance is possible. In brief, better performance in reaching the poor is both needed and feasible. These are the two messages from this report that will be discussed further.

Summary Population coverage of insecticide‐treated nets (ITNs) in Africa falls well below the Abuja target of 60% while coverage levels achieved during vaccination campaigns in the same populations typically exceed 90%. Household (HH) cost of ITNs is an important barrier to their uptake. We investigated the coverage, equity and cost of linking distribution of free ITNs to a measles vaccination campaign. During a national measles vaccination campaign in Zambia, children in four rural districts were given a free ITN when they received their measles vaccination. In one urban district, children were given a voucher, which could be redeemed for a net at a commercial distribution site. About 1700 HHs were asked whether they received vaccination and an ITN during a measles campaign, as well as questions on assets (e.g. type roofing material or bicycle ownership) to assess HH wealth. Net ownership was calculated for children in each wealth quintile. In the rural areas, ITN coverage among children rose from 16.7% to 81.1% and the equity ratio from 0.32 to 0.88 and in the urban area from 50.7% to 76.2% (equity ratio: 0.66–1.19). The operational cost per ITN delivered was $0.35 in the rural area with direct distribution and $1.89 in the urban areas with voucher distribution. Mass distribution of ITNs through vaccination campaigns achieves rapid, high and equitable coverage at low cost.

BACKGROUND:In 2000, the WHO African Region adopted a plan to accelerate efforts to lower measles mortality with the goal of decreasing the number of measles deaths to near zero. By June, 2003, 19 African countries had completed measles supplemental immunisation activities (SIA) in children aged 9 months to 14 years as part of a comprehensive measles-control strategy. We assessed the public-health impact of these control measures by use of available surveillance data.METHODS:We calculated percentage decline in reported measles cases during 1-2 years after SIA, compared with 6 years before SIA. On the basis of data from 13 of the 19 countries, we assumed that the percentage decline in measles deaths equalled that in measles cases. We also examined data on routine and SIA measles vaccine coverage, measles case-based surveillance, and suspected measles outbreaks.FINDINGS:Between 2000 and June, 2003, 82.1 million children were targeted for vaccination during initial SIA in 12 countries and follow-up SIA in seven countries. The average decline in the number of reported measles cases was 91%. In 17 of the 19 countries, measles case-based surveillance confirmed that transmission of measles virus, and therefore measles deaths, had been reduced to low or very low rates. The total estimated number of deaths averted in the year 2003 was 90,043. Between 2000 and 2003 in the African Region as a whole, we estimated that the percentage decline in annual measles deaths was around 20% (90,043 of 454,000).INTERPRETATION:The burden of measles in sub-Saharan Africa can be reduced to very low levels by means of appropriate strategies, resources, and personnel.