Article Text

Towards better targeting: lessons from a posthoneymoon measles outbreak in Madagascar, 2018–2019
  1. Antso Raherindrasana1,2,
  2. C Jessica Metcalf3,4,
  3. Jean-Michel Heraud5,
  4. Simon Cauchemez6,
  5. Amy Winter7,
  6. Amy Wesolowski7,
  7. Richter Razafindratsimandresy5,
  8. Lea Randriamampionona1,
  9. S A Rafalimanantsoa1,
  10. Yolande Masembe8,
  11. Charlotte Ndiaye8,
  12. Julio Rakotonirina1,2
  1. 1Ministry of Public Health, Antananarivo, Madagascar
  2. 2Faculty of Medicine of Antananarivo, University of Antananarivo, Antananarivo, Madagascar
  3. 3Dept of Ecology and Evol. Biology, Princeton University, Princeton, New Jersey, USA
  4. 4Princeton School of Public and International Affairs, Princeton University, Princeton, New Jersey, USA
  5. 5Virology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
  6. 6Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Paris, France
  7. 7Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  8. 8Madagascar Office, World Health Organization, Antananarivo, Madagascar
  1. Correspondence to Dr C Jessica Metcalf; cmetcalf{at}princeton.edu

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Summary box

  • After many years of very low measles incidence, a measles outbreak began in the central region of Madagascar in September 2018.

  • The outbreak reached all 22 regions of the island, causing nearly 1000 deaths, with more than 100 000 cases reported.

  • The magnitude of the outbreak, the age profile of cases and the history of incidence and vaccination in Madagascar align with a core expectation from epidemiological theory, the concept of a ‘posthoneymoon period’ outbreak where large outbreaks can occur following years of (apparently) successful control.

  • An emergent important public health challenge is how to characterise the risk of post-honeymoon outbreaks for measles and other vaccine preventable infections, and how to learn from this outbreak to build preparedness for future outbreak prevention and response strategies.

  • Madagascar’s experience indicates that investment in relevant data streams (from case surveillance, to vaccination deployment and serology) alongside efforts to develop national capacity for integrative analysis of such diverse data could help enable deployment of timely targeted vaccination campaigns to prevent such outcomes in the future.

Measles and outbreak risk

Measles vaccination is often referred to as a ‘best buy’ in public health, because of the high case fatality rate associated with infection, alongside the existence of a safe and inexpensive vaccine. The current WHO recommendation is that all children have access to two doses of the measles vaccine.1 In 2011, countries in the WHO African region adopted a measles elimination goal to be reached by 2020. In the last decades, substantial gains have been made in numbers of cases and deaths averted. Yet, an important feature of measles epidemiology is that large outbreaks can occur following years of (apparently) successful control. This phenomenon is known as a ‘posthoneymoon period’ outbreak.2 The ‘honeymoon’ consists of the period following vaccine introduction where cases drop substantially. This ‘honeymoon’ is at …

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