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Johns Hopkins Bloomberg School of Public Health


Date: Apr 2014

The Measles Ward at the University Teaching Hospital in Lusaka, Zambia (2003)


Bill Moss, MD, MPH

BillMossDr. Bill Moss is a Professor at the Johns Hopkins Bloomberg School of Public Health and Director of Epidemiology at IVAC. He is a pediatrician and global health expert in childhood infectious diseases and has worked extensively in the areas of measles control and eradication, malaria control, and HIV treatment.

The Measles Ward was empty. The Measles Ward at the University Teaching Hospital in Lusaka, Zambia was always full of children, particularly now at the start of the measles season. But several months after the Government of Zambia conducted their first national mass measles vaccination campaign in 2003, the ward was empty. I was astounded. I took a photograph of the empty ward. It is difficult to see the absence of something, but this was a striking image of the absence of measles – an empty hospital ward – and an image that captured the power of vaccines. A successful mass vaccination campaign can provide sufficient protection to vaccinated children and herd immunity to those few who are not immunized, demonstrating that measles virus transmission can be stopped and a measles ward emptied. Approximately 5% of the hundreds of children admitted to that ward died of measles every year, with more dying who never made it to the hospital, others dying after leaving the hospital, and children weakened by measles. These deaths were stopped. It was invisible, but real.

Measles is a viral infection caused by measles virus and characterized by fever, cough, runny nose, red eyes and a distinctive rash. Well-nourished children with good access to health care rarely die of measles, but about 1 in 1000 can get a severe neurological disease as a result of an immune reaction to measles virus. Undernourished children, however, are at high risk of death from measles. In the most extreme circumstances, such as refugee camps, as many as one quarter of children with measles can die. In the absence of vaccination, almost all children will get measles because of its high contagiousness. Today, it is difficult to imagine that prior to the introduction of measles vaccine fifty years ago, measles killed millions of children each year, with some estimates as high as six to eight million deaths per year due to measles. This is far higher than the number of deaths due to AIDS, tuberculosis, and malaria.

Remarkably, a measles virus strain isolated in the mid-1950s, which formed the basis for most of the commonly used measles vaccines around the world today, continues to provide protection against measles five decades later. We do not need to develop new measles vaccines each year as we do for influenza virus. The vaccine is safe and inexpensive, and two doses are sufficient to provide protection to nearly everyone.

So why does measles still kill tens of thousands of children each year? Why is it still occurring in some of the richest countries of the Americas and Europe? Why, in 2014, do we have more measles cases in the United States during the first quarter of the year than we have had since 1996?

The problem is invisibility, as successful public health programs undermine themselves. The disease goes away, political and public attention are directed elsewhere, rumors and misinformation spread, and risks of the vaccine are perceived to be higher than the risk of disease. Along with the high contagiousness of measles virus, a small drop in the number of vaccinated children can lead to outbreaks.


Photo Credit: Dr. James Chipeta (2010)

Sadly, the empty Measles Ward in Lusaka was full again in 2010, overflowing with children in the hallways, as a result of a large measles outbreak that swept through much of sub-Saharan Africa that year. Routine immunization coverage was not sustained at sufficient levels, vaccination campaigns were postponed, and susceptible people accumulated. Once this tinder was ignited by the introduction of measles virus, a massive epidemic had exploded. In the Americas and Europe, misconceptions about the safety of measles vaccine continues to result in low measles vaccine coverage in some communities, which have led to recent measles outbreaks in California, New York, and Washington state and have put children unable of receiving measles vaccine due to serious medical conditions at high risk.

We have the tools to defeat measles, even the tools to eradicate measles. The global public health community now faces a stark choice: to continue to make progress in measles reduction with the ultimate goal of measles eradication, or have recent successes in measles control lead to a loss in public interest, donor support, and political motivation. This year, World Immunization Week’s challenge to everyone, no matter where you live, is to know which vaccines you need, check that you are up-to-date on your vaccinations, and continue to protect yourself by getting timely vaccinations.. Meeting this challenge will be necessary to ensure that future generations of children do not die of measles and that all measles wards are emptied.



Nisha    Hariharan 

Nisha-photoNisha  is  a second year MSPH (master of science in public health) student at the Johns Hopkins Bloomberg School of Public Health in the Department of International Health. Nisha worked on the m-SIMU trial as a graduate research assistant in the Epidemiology team at IVAC.

September 12, 2013 was no ordinary day for me as a graduate research assistant working on the mobile solutions for immunization (m-SIMU) trial. Instead of going out to the field to visit a health facility or working on our SMS appointment reminder system, I found myself in a room with live music, laughter, dancing, and over 100 community advisory board members and village chiefs. This was the scene of the m-SIMU public randomization ceremony, a true moment of “public health in practice". It was an amazing sight to witness, as several months of preparation and hard work had gone into ensuring the successful execution of this event. For me, it was a gratifying experience to see the community so excited for the start of the m-SIMU trial.  

The community approval of the public randomization ceremony meant that the m-SIMU trial was ready to begin. m-SIMU is a village-randomized controlled trial to assess the impact of short message services (SMS) reminders and cash incentives to improve childhood immunization coverage rates and timeliness in Siaya County, Western Kenya. It will add to the existing evidence base for mHealth and conditional cash transfers, two novel strategies in the field of public health.

The project will aim to enroll about 2,000 infants under the age of four weeks across 152 villages in Western Kenya. These children will be followed over 12 months during which time their vaccination status for routine EPI immunizations will be documented. The 152 villages are assigned to one of four arms:

  1. Control
  2. SMS reminders
  3. SMS reminders + 75 Kenyan Shillings (Ksh), which is just under USD 1, for every vaccine dose received on time
  4. SMS reminder + 200 Ksh (approximately USD 2.50) for every vaccine dose received on time.

The trial is a collaboration between IVAC and Kenya Medical Research Institute/Centers for Disease Control and Prevention (KEMRI/CDC).

The public randomization ceremony was held to assign 152 villages to the four study arms. We chose to do the randomization publicly to assure the community that the process for allocating villages to study arms was fair.  We also saw the ceremony as an important way to boost community morale and raise excitement and acceptance of the m-SIMU trial.


Dustin Gibson, m-SIMU co-investigator and PhD candidate at the Johns Hopkins Bloomberg School of Public Health, with the community advisory board members after selecting villages for each trial arm

Preparation for the randomization ceremony involved using our epidemiologic toolbox and some creative thinking. We worked with Dr. Larry Moulton, Professor and Biostatistician at Johns Hopkins Bloomberg School of Public Health, to identify randomization sequences that adjusted for confounders. The next two steps necessary for assigning villages to the study arms were to randomly pick one of the sequences and then randomly assign each of the groups to a study arm. These steps were to occur during the public randomization ceremony and the selection would be done by community members themselves. During the ceremony, the community members enjoyed the suspense and excitement that came along with selecting the sequences, as they had to draw balls out of a cloth sack. 

The randomization ceremony was a unique approach to engage the community and really helped to make the m-SIMU trial “come alive”. While we had previously attended meetings to inform the community members about the m-SIMU trial, in some ways, it felt as though we were just another KEMRI/CDC study to them. The ceremony made a memorable impression on the community and the m-SIMU trial had distinguished itself in a positive light. One of my favorite memories from that day was when a community advisory board member approached and thanked us for including her community in the trial and for holding the ceremony. 


Nisha and the field supervisor, Jully Odhiambo, at the public randomization ceremony

As a student and a young public health professional, being able to be part of the community mobilization process and the randomization ceremony was an extremely important learning experience. Gaining community approval and investing the time to inform and engage community members are crucial to the success of any intervention or trial. The effort involved here should not be underestimated. From debating over the right size of the cloth sack to rehearsing the explanation of the randomization process – we contemplated and planned every detail in advance. I will definitely stick to these principles as I begin my career in public health.

The m-SIMU trial officially started on October 14, 2013 and has now enrolled over 900 children.