Through his work in EPI, measles and polio, Dr. Robert Kezaala is well known to many in the field of immunization. Unicef recently welcomed him as head of its measles and rubella programme, where he’ll be working closely with partners of the Measles & Rubella Initiative.
Before his Unicef appointment Robert served as a Medical Officer with the Polio Eradication Initiative at WHO headquarters for seven years. He was Head of Measles Control for the WHO Africa Region from 2001-2005.
He recently talked to the Measles & Rubella Initiative’s Christine McNab about the priorities and challenges that he sees going forward, while reflecting on the successes of measles control in the last decade. This is an edited transcript of an interview that took place in Unicef’s New York Headquarters on 27 June 2012.
Christine McNab (CM): Let’s talk first about the early days, between 2001 and 2005 when you were the Head of Measles Control for the Africa Region.
Robert Kezaala (RK): We gradually built up with the support of the Measles Initiative, and we managed to reduce measles mortality by as much as 70 per cent. Building on the experience from the seven countries which launched measles control in Southern Africa – South Africa, Namibia, Malawi, Zimbabwe, Zambia, Botswana and Swaziland– which showed that measles control can be realised in Africa: mass injections, the need to attain >95% coverage. Based on this work, and with the support of the Measles Initiative, we were able to go regionally into the other African countries which were facing much greater challenges and needed much more support.
CM: What did you achieve in those five years? You were really making huge progress in a short time.
RK: It is true that working with relatively little resources and building on the infrastructure of the Polio Eradication Initiative, the Measles Initiative was able to work with countries in a phased manner until we covered all of the Africa Region. The epidemiology of measles totally changed. We once had the Permanent Secretary of the Ministry of Health in Kenya come to a measles meeting in Washington. He said that the medical school no longer had measles cases on which to teach medical students. That was quite impressive. In the Lancet paper which we subsequently published we documented at least a 70 per cent reduction in measles mortality in the African region. By 2008, the Initiative had realised a 90 per cent reduction.
CM: Measles mortality reduction is maybe one of the least known African health success stories. What do you think?
RK: It is true. Back in the 1980’s when I was still in clinical practice, I served in a province in the northeast of Uganda called Karamoja. During the measles epidemic, I could easily have 90 to 100 children in the measles ward in varying stages of sickness – from mild to very severe, and sometimes even at the point of death. All that changed between 2003 and 2005. These achievements have now disappeared under the radar with other news. And yet, it is one of the landmark achievements in communicable disease control.
CM: What about now? There was some slippage from 2009-2011. There have been fairly major outbreaks in Southern Africa, India, DR Congo and even Europe. What do you see as the biggest challenges and the biggest opportunities?
RK: There have been major outbreaks but if you put those outbreaks in context – it is rather that the expectations have shifted. These days, when you see ten cases of measles, it really catches the media’s attention. The goalposts have shifted to a higher level of expectation that there should not be deaths from measles.
Ministries of Health have faced challenges with the current international financial environment. Governments which were supposed to pick up from where the Measles Initiative had left off were not able to see it through especially with routine immunization. Follow-up campaigns were either postponed, or not of such high quality as when the Initiative was more engaged.
I’m coming back to measles control at a time when we all need to re-energize the Initiative and with greater country ownership and commitment. The Initiative has achieved near-zero measles mortality.
Outbreaks happen when the first and second doses are not given on time or without reaching out to all these communities which tend to be underserved. We need to re-energize the governments and specifically Ministries of Health, and we need to go back and insist on quality. We also need to get communities to realize that although measles numbers have reduced, it is not gone. And that if we do not keep our guard up, it is going to come back.
CM: What can measles elimination do for routine immunization and what should it be doing?
RK: When you look at routine immunization, apart from delivering the vaccine on a day-to-day basis, there are some underlying principles. Like planning and forecasting for vaccinations and vaccines, training of health workers for example in safe injection handling, provision of materials as well as mobilizing the community behind immunization. These are some of the things which measles control has already been doing.
There are some indicators that we say you need to follow. Countries from now on should establish mechanisms for how each campaign improves routine immunization, with each making a commitment to three or four priorities which by the end of that campaign, they would have addressed. There should also be an evaluation afterwards to see if this has indeed happened. This has to be a conscious effort or it can be a lost opportunity.
CM: What are your priorities now? If you could achieve something in the next year, what would you like to see happen?
RK: I have joined at a time when in addition to the resources from the Measles & Rubella Initiative, GAVI has committed financing for measles and rubella activities. The priority right now will be to get the six priority countries which have got very low immunization performance – Democratic Republic of the Congo, Ethiopia, Chad, Pakistan, Afghanistan and Nigeria – to implement high quality immunization activities in order to reduce the measles burden with this GAVI support.
CM: How do you see the Measles & Rubella Initiative working now in this larger context with partners like GAVI and the Bill & Melinda Gates Foundation. What do you think the priorities should be for the Measles & Rubella Initiative?
RK: It is good to know that there are more partners. Historically, the Measles Initiative has been very inclusive. It is however not easy for the Initiative which has been surviving on quite a low budget to take over the whole infrastructure of the Polio Eradication Initiative. M&RI could engage GAVI and the Bill and Melinda Gates Foundation to develop a roadmap for transitioning the polio infrastructure after eradication or gradually as the workload reduces in polio eradication. I believe that we can transition to immunization and surveillance for both measles and rubella, and other vaccine-preventable diseases and routine immunization using the polio platform.
CM: The climate is difficult now in terms of money. GAVI has new funding now for measles, but there are still going to be some gaps. How do we continue to draw attention to measles and achieve the elimination goals?
RK: That will be tough. There are some schools of thought which say that disease specific control programmes consume resources at the expense of health systems. So there will be a lot of things to address at an international and global level, but also within the countries: advocacy for the allocation of resources to complete the job. That is going to be tough, but we will borrow from the experience of polio. We will borrow from the experience of the Measles Initiative over the last ten years. And we will need to keep tailoring the messages to keep up the attention. It will be tough in the current economic environment but it has to be done. And since it has to be done, we will do it.
CM: Any final thoughts?
RK: For me, personally it is very exciting to be back. I have been very welcomed by the partners. At the same time, I must admit that I have some anxiety. I have seen how difficult it was to reach the last child with polio which happens to be an easier vaccine to deliver. So I get back into measles control with a lot of hope, but knowing that we cannot afford to fail because measles is much more transmissible, and capable of much more mortality.