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Analysis And Comment

Child health and survival in the Eastern Mediterranean region

BMJ 2006; 333 doi: (Published 19 October 2006) Cite this as: BMJ 2006;333:839

Progress towards eliminating measles in the Middle East

In their article on "Child health and survival in the Eastern
Mediterranean region" Bhutta et al address the issue of preventable
causes of child mortality in the region. (1) They present data on
mortality from measles and estimate that this disease still causes 56,000
deaths yearly in children under 5 years in Eastern Mediterranean countries
with high child mortality rates. They estimate that at least 42,000 of
these deaths could be prevented by an emphasis on community based
interventions and innovative delivery strategies.

This region has many hard-to-reach populations, causing difficulties
in the provision of adequate immunization coverage. However, targeted
programs in this region have made major gains over the past decade in
improving immunization coverage against measles, with a concommitant
decrease in morbidity and mortality from measles.

Countries belonging to the Eastern Mediterranean region of the World
Health Organization designed a programme in 1997 whose goal was to
eliminate measles by 2010.(2) The proposed programme included several
components: measles vaccination coverage of at least 95% at age 1 year;
one-time mass vaccination campaigns (catch-up campaign); periodic national
follow-up campaigns; and strengthening measles surveillance and laboratory
confirmation of cases. In 2001, WHO and UNICEF developed a joint strategy
for reducing mortality due to measles, with emphasis on high priority
countries. (3) Their approach included not only targets for high rates of
coverage for routine measles immunisation (>90%) but also, for the
first time, a recommendation for a second dose of measles immunisation.

According to UNICEF, 16 out of 20 countries and territories in the Middle
East and North Africa have already met the immunisation goal of 90%
coverage for first dose of measles immunisation. (4) Only Algeria,
Djibouti, Sudan, and Yemen did not reach the immunisation target goals.

That the Middle East and North Africa region of WHO, with a few
exceptions, has managed to reach the target goal for measles immunisation
in the short time of five years is impressive. This region has many
populations that are difficult to reach, in rural villages and in crowded
urban centres, as well as nomads who follow their herds of sheep, goats,
and camels from one grazing ground to another. The fact that these
populations can achieve high rates of immunisation coverage for measles
vaccine is shown by the success of the WHO/UNICEF initiative and is
supported by data from the Middle East documenting the success of a
targeted programme to improve immunisation coverage among semi-nomadic
Bedouin. (5)

An important component of the WHO/UNICEF initiative is the
recommendation for a second dose of measles immunisation. Since an
estimated 5-15% of infants who receive primary immunisation do not produce
protective antibodies the second dose is critical.(6)

The results of the targeted WHO/UNICEF programme for the Middle East
and North Africa region are encouraging. Measles mortality has fallen in
the region by 50% since 1999. (3) Laboratory data show that neither
primary nor secondary measles immunisation produces adverse effects on
humoral or cellular immunity, even among children of low socioeconomic
status, supporting the safety and feasibility of the programme.

The new goal of the global immunisation vision and strategy is a 90%
reduction in measles mortality over the decade ending in 2010. (3) On the
basis of the success of the Middle East and North Africa since 1999, the
region should manage to meet these goals. Hopefully, political unrest and
armed conflicts in the Middle East region will not prevent the achievement
of this goal. The children of the Middle East deserve a healthy life, free
of conflict, which will allow them to develop to their maximum potential.

Competing interests: None declared.

1. Bhutta ZA, Belgaumi A, Abdur Rab M, Karrar Z, Khashaba M, Mouane
N. Child health and survival in the Eastern Mediterranean region. BMJ

2. Centers for Disease Control and Prevention. Progress toward measles
elimination¡ªeastern Mediterranean region, 1980-1998. MMWR Morb Mortal
Wkly Rep 1999;48(47):1081-6.

3. World Health Organization. Progress in reducing global measles deaths:
1999-2004. Wkly Epidemiol Rec 2006;81(10):90-4.

4. Progress for children A report card on immunization. UNICEF: Middle
East and North Africa 2005(3).

5. Belmaker I, Dukhan L, Elgrici M, Yosef Y, Shahar-Rotberg L. Reduction
of vaccine-preventable communicable diseases in a Bedouin population:
summary of a community-based intervention programme. Lancet 2006;367:987-

6. Cutts FT, Grabowsky M, Markowitz LE. The effect of dose and strain of
live attenuated measles vaccines on serological responses in young
infants. Biologicals 1995;23:95-106.

Competing interests:
None declared

Competing interests: No competing interests

24 October 2006
Ilana Belmaker
Senior Lecturer in Division of Health in the Community
Elina Bazarsky, Larissa Dukhan, and Bracha Rager-Zisman
Ben-Gurion University of the Negev, Beer-Sheva, Israel