MEASLES BULLETIN World Health Organization, Western Pacific Regional Office, Manila, Philippines Issue 10 August 2006
World Health Organization Regional Office for the Western Pacific Expanded Programme on Immunization
ISSN 1814 3601
Measles elimination recommendations from the 16th Technical Advisory Group meeting
T
he 16 th Meeting of the Technical Advisory Group (TAG) on Immunization and Vaccine Preventable Diseases in the Western Pacific Region was held from 20 to 22 June 2006 in Manila, Philippines. One of the primary objectives of the meeting was to review the technical and programmatic strategies adopted by Member States and areas and progress made towards Regional measles elimination by 2012. The Western Pacific Region uses the Global Immunization Vision and Strategies (GIVS), maintaining polio-free status, measles elimination, and hepatitis B control goals and strategies as guiding frameworks in assisting national governments to strengthen national immunization programmes while achieving and/or sustaining disease eradication, elimination and control goals. 16th TAG recommendations on measles elimination: (1) Plans of action for measles elimination should be developed or updated and incorporated into Expanded Programme on Immunization (EPI) multi-year plans. Measles elimination plans of action should include a current epidemiologic and programmatic situation analysis followed by clear plans to increase routine MCV1 and MCV2 coverage, conduct supplementary immunization activities (SIA) as needed, and achieve elimination appropriate measles surveillance that satisfies recommended performance indicators as described in the Western Pacific Regional Office Field Guideline for Measles Elimination. (2) A routine second dose of MCV should be introduced in all countries with a routine service delivery system that consistently achieves MCV1 coverage of 80% or greater. Countries approaching 80% MCV1 coverage should plan and prepare for introduction of MCV2 while working to increase routine MCV1 coverage. (3) Until the routine programme is capable of achieving high routine coverage with MCV2 (>90%) periodic follow-up SIAs will be necessary to maintain high population immunity. These SIAs should be linked with other health interventions and used as a platform for strengthening health systems.
(4) To monitor progress towards the regional measles elimination goal, countries should strengthen measles surveillance and reporting with the aim of establishing casebased systems. Such systems ideally should submit data on each case as recommended by the Western Pacific Regional Office and described in the Regional Field Guidelines for Measles Elimination. Data should be submitted from subnational to national level on a weekly basis for analysis at and feedback to every level.
Laboratory Network to discuss progress and issues, clarify terms of reference, and facilitate cooperation and coordination between laboratories and among laboratories, epidemiologists, and EPI programme managers. (7) As recommended by the Global Measles Laboratory Network Meeting (July 2004), alternative sampling collection methods (e.g. dried blood spots may be useful for the confirmation of outbreaks in remote settings with limited expertise or supplies for blood specimen collection and difficulties with specimen transportation.)
(5) Currently, case-based data necessary to monitor surveillance performance indicators should be submitted to the Western Pacific Regional Office monthly as soon as countries are capable. Countries that still have high incidence should report aggregate rather than casebased data to the Western Pacific Regional Office. The TAG recommends that in the future the Region consider weekly reporting from country to the Western Pacific Regional Office. (6) The TAG recommends that the Western Pacific Regional Office develop closer links within the Regional Measles
(8) Although much progress has been made through implementation of currently recommended measles immunization strategies, these strategies may need to be adapted as countries approach elimination. The Western Pacific Regional Office secretariat should work with Headquarters and the Strategic Advisory Group of Experts Sub-Group on Measles to develop recommendations for adapting measles immunization strategies, e.g. the optimal age for administration of the first and second doses and the interval between SIAs.
Figure 1. Average Incidence of Reported Measles Cases 2000-2002 compared to 2003-2005 (per 100,000 population)
Incidence Rate = 0 (2000-2005) > 50% decrease 0-50% decrease Increased
Figure 1 shows the change in avg incidence over last 3 year periods ( 2000-2002 vs. 2003-2005), demonstrating that (with exception of Marshall Islands outbreak’s confirmed cases and sporadic non-lab confirmed cases in other pacific countries) only 2 countries increased incidence over this time period.
MEASLES BULLETIN Figure 2. Reported MCV1 and MC2 Coverage for 2005 Republic of Korea Mongolia Brunei Hong Kong Viet Nam Australia Singapore Macao Malaysia China New Zealand Philippines Cambodia Papua New Guinea Laos Japan 0 No Data 10 20 30 40 50 60 70 80 90 100
Figure 2 shows the MCV1 and MCV2 country official estimate coverage for 2005. Several countries have reached or very nearly reached the coverage of 95% recommended to eliminate measles. Many countries report less and two report less than 50% coverage for measles vaccine. These countries have populations at risk for large measles outbreaks.
MCV1 MCV2
Figure 3.Incidence of Reported* Measles Cases per 100,000 Population, 2005
< 1 1-5 5-10 > 10 No Data
* Lab Confirmed and Clinical Cases Figure 3 shows incidence of reported (lab and clinically confirmed) cases per 100,000 population across the Region. The focus of measles endemicity in the Region is 3 areas : Papua New Guinea, Indochina area, and China. 2
MEASLES BULLETIN Figure 4. Incidence Rate of Suspect and Confirmed Measles Cases 2005 200 180 160 140 120 100 80 60 40 20 0 PNG CHN MAA LAO BRU CAM HOK SIN NEZ VTN PHL AUS KOR MOG MAC JPN
~~~
~~~ Suspect Cases Confirmed Cases
Figure 4 shows the incidence rate of suspect and confirmed measles cases per million population. Several countries are approaching the 1 confirmed case/million level. The peak in suspect measles cases in Viet Nam was determined to be rubella. As measles cases decline it is expected that countries maintain the surveillance system and still report suspect cases.
Figure 5. Proportion of Suspect Measles Cases with Samples sent to Laboratory, 2005 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% No Data on Lab Samples
0% PNG MAA BRU SIN NEZ AUS JPN MAC LAO VTN CAM CHN PHL HOK KOR MOG
Figure 5 shows proportion of suspect cases sent to laboratory for testing - expected to be 80% of cases (not including those linked in outbreaks) 3
MEASLES BULLETIN Solomon Island reports high coverage in measles supplemental immunization activity, vaccinating over 60 000 children Nearly all Solomon lslands children, aged 1 to 4 years, are now protected against measles, due to a recent three-month immunization campaign organized by the Solomon Islands Ministry of Health. Solomon Islands, as a Member State of the Western Pacific Region, is committed to eliminating measles by 2012. A single dose of measles vaccine is part of the Ministry of Health’s routine immunization programme. However, not all Solomon Islands children received the vaccine on time according to the current schedule of age nine months (WHO/United Nations Children’s Fund [UNICEF] estimates 72% in 2004). Insufficient measles coverage, combined with only one dose of measles in the routine expanded programme on immunization (EPI) schedule, and recent outbreaks in surrounding countries pose a major risk to Solomon Islands although the measles campaigns in 2001 (88% vaccine coverage) and 2003 (92% vaccine coverage) reported good coverage. Recognizing an additional dose of measles vaccine was needed to prevent a severe measles outbreak, the Ministry of Health decided to deliver this dose via a Supplemental Immunization Activity (SIA). The immunization campaign was initiated in late March and completed by the end of July 2006. Through technical support and close cooperation with international partners such as the Australian Agency for International Development, the Japanese International Cooperation Agency, UNICEF, the US Centers for Disease Control and Prevention, and WHO, the SIA exceeded the 95% goal. Reaching 97% of the target group (60 040/61 858 children) made this the most successful campaign in the history of the country. Additionally, the campaign served as a platform for the integration of other interventions, including administration of routine vaccination and the distribution of insecticide treated bed-nets to protect children and pregnant mothers from malaria. These integrated efforts conferred financial and logistical advantages, while providing additional incentives for parents to immunize their children. Prior to the campaign, micro-planning workshops were conducted in six provinces and consisted of map development, appropriate strategies (fixed, outreach or mobile), a time frame for reaching far flung populations, identifying barriers that could impede the SIA, logistical planning, including estimating SIA supplies, and equipment and personnel needs. Participants also received training on vaccine handling and administration, injection safety, waste disposal, and monitoring and evaluation of campaign activities. Strategies for mobilizing hard-to-reach communities were emphasized for members of national and provincial health promotion teams during a comprehensive training conducted by UNICEF. Social mobilization materials, including posters, leaflets, stickers and Tshirts were developed and distributed for public education and to increase awareness. Mass media was used to target communities and promote participation in campaign activities. Press releases and updates were published in the national newspaper with local and national radio discussion programmes also promoting the campaign. Social mobilization at the community level included various forms and complemented the practices and culture of each community, for example village chiefs and elders were notified and encouraged to assemble parents for public announcement and education. Churches and women’s groups helped inform the public on the importance of the campaign. In many cases, health workers went house-to-house in villages explaining the importance of measles vaccination. 4
Provincial EPI coordinators, with assistance from local area health centre staff, monitored the SIA using coverage charts and reported data weekly to the national EPI coordinator. Immunization teams were also responsible for conducting Rapid Coverage Assessments (RCA) to validate high coverage and to ensure that all children were reached before the vaccination team departed. To conduct the RCA, houses were randomly selected and vaccination booklets reviewed to determine if children had been vaccinated. Rapid Coverage Assessments indicated that the most common reason for non-vaccination was a lack of awareness about the campaign and where and when to take children for measles vaccine. Social mobilization efforts were modified based upon qualitative information gathered from the RCA. Over 100 RCA were conducted to detect missed children and to validate high coverage in the targeted population. Field activities posed challenges for outreach teams in hardto-reach areas. Health workers often faced geographic constraints, travelling by road or boat and then proceeding on foot to reach remote villages. Many provinces experienced staffing shortages and unreliable transportation in conducting outreach. Despite these challenges, leadership mobilized teams to implement mop-up activities in order to achieve high coverage. That each province successfully reached or exceeded its goal of 95% coverage is a significant achievement. Solomon Islands has proven its capability to achieve aims and goals. The Ministry of Health announced that the 2006 Measles SIA was “the most successful immunization campaign in the history of Solomon Islands, and shows the commitment of both the Government and parents to protect the health of the country’s infants and children”. The success in immunizing 97% of children during this measles campaign serves as a platform to strengthen the routine immunization programme. The Ministry of Health is now working with key international agencies to further expand the protection provided by the routine immunization programme through the introduction of a new vaccine in 2007.
MEASLES BULLETIN Regional Measles Monitoring of Country Surveillance Data (January-July 2006)* Reported Confirmed cases suspected cases Laboratory Epi-linked Clinical confirmed Classification Φ Incidence rate (Total confirmed) 2005 2006 Indicators Suspected cases Ω immunized Latest date reported by Type of report Deaths country
Discarded Pending
Australia Brunei Darussalam Cambodia China Hong Kong (China) JapanX Lao People's Democratic Republic Macao (China) Malaysia Mongolia New Zealand Papua New Guinea Philippines Republic of Korea Singapore Viet Nam Pacific Island Countries: American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Marshall Islands Micronesia, Federated States of Nauru New Caledonia Niue Northern Mariana Islands Palau Samoa Solomon Islands Tokelau Tonga Tuvalu Vanuatu Wallis and Futuna Western Pacific Region X
97 110 38 22 3 383 9 7 46 65 16 1029
97 0
†
0 0 0 0 0 0 0 1 0 0 0 44
0 74 14 18 0 91 0 3 27 0 0 0
0.04 (8) 0.30 (43) 0.55 (39) 4.56 (258) 0.00 (0) 0.00 (0) 0.18 (7) 0.05 (40) 0.00 (0) 0.42 (18) 0.02 (19)
0.48 (97) 0.52 (74) 0.41 (29) 0.30 (18) 0.44 (2) 0.00 (0) 0.10 (4) 0.03 (27) 0.04 (21) 0.37 (16) 0.14 (119)
34 9 0 1 259 9 0 19 37 756
2 0 4 0 0 0 3 0 7 154
14% (14) 36% (40) 39% (15) 18% (4) 33% (1) 89% (8) 0% (0) 43% (20) 52% (34) 59% (611)
0 0 0 0 0 0 0 0 0 0 0 0
02-Jun-06 26-May-06 30-May-06 05-Jun-06 30-Jun-06 09-Jun-06 23-May-06 26-May-06 21-Jul-06 05-Jun-06 25-May-06 02-Jun-06
case data case data case data aggregate case data aggregate case data case data case data case data case data case data
15 0 2 33 0 0 0 21 16 75
3.60 (879) 0.48 (124)
0 132 1 0 0 2 2 0 0 1 0 0 0 0 0 0 1963 Φ
0 22 0 0 0 0 0 0 0 0 0 0 0 0 0 0 281
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 45
0 110 0 0 0 0 0 0 0 0 0 0 0 0 0 0 337
0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) -
0.00 (0) 15.57 (132) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0) 0.00 (0)
0 1 0 0 2 1 0 0 0 0 0 0 0 0 0 1128
0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 172
6% (8) -
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
09-Aug-06 zero-reporting 02-Jun-06 09-Aug-06 aggregate aggregate
09-Aug-06 zero-reporting 09-Aug-06 zero-reporting 09-Aug-06 09-Aug-06 aggregate aggregate
09-Aug-06 zero-reporting 09-Aug-06 zero-reporting 09-Aug-06 aggregate
09-Aug-06 zero-reporting 09-Aug-06 zero-reporting 09-Aug-06 zero-reporting 09-Aug-06 zero-reporting 09-Aug-06 zero-reporting 09-Aug-06 zero-reporting
* Data are based on country reports and other sources available to EPI/Western Pacific Regional Office. Incidence rate per 100 000 population (population figures from World Population Prospects: The 2004 Revision, New York, United Nations, 2005). Ω Suspected cases immunized does not distinguish between 1 or 2 doses. † Lab confirmed or epidemiologically linked to a laboratory confirmed case X Sentinel surveillance system
Expanded Programme on Immunization WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific, United Nations Avenue, P.O. Box 2932, 1000 Manila, Philippines Fax No. (632) 5211036, 5260279, 5260362 Tel. No. (632) 5288001 Comments may be sent to WHO/WPRO Measles Bulletin measles_bulletin@wpro.who.int. 4 Please send quarterly data to Mr Dexter Bersonda at bersondad@wpro.who.int