Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella Meeting report 6–7 July 2020 (Virtual) SEA-IMMUN-102 The Regional Verification Commission (RVC) for measles and rubella elimination for the WHO South-East Asia Region was established by the WHO Regional Director in March 2016 to verify progress towards measles and rubella elimination. The SEA-RVC meets annually to review progress made by Member Statesd towards measles and rubella elimination. This report outlines the conclusions and the recommendations made by the SEA-RVC during its Fifth Annual Meeting in July 2020. The SEA-RVC concluded that significant progress has been made in the Region, and five countries have sustained mealses elimination while two countries have also achieved rubella eliminaton. SEA-Immun-102 Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella Meeting report 6–7 July 2020 (Virtual) Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella SEA-Immun-102 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Printed in India Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella iii Contents Acronyms .............................................................................................................iv Executive summary ................................................................................................v 1. Background ................................................................................................ 1 2. Objectives of the meeting ........................................................................... 2 3. Organization of the meeting ...................................................................... 3 4. Methodology of the review of country progress .......................................... 4 4.1 Prior to the meeting ........................................................................... 4 4.2 During the meeting ............................................................................ 5 5. Conclusions and recommendations ............................................................. 7 5.1 Categorization of countries ................................................................ 8 5.2 Overarching recommendations by SEA-RVC....................................... 9 6. Country-specific information for the next meeting ..................................... 11 Annexes 1. Agenda ..................................................................................................... 17 2. Regional Director’s opening remarks ......................................................... 18 3. Links to country reports and reviewers’ comments .................................... 20 4. Endorsement of the SEA-RVC .................................................................... 21 5. List of participants ..................................................................................... 22 Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubellaiv Acronyms COVID coronavirus disease CRS congenital rubella syndrome DQA data quality assessment EPI Expanded Programme on Immunization IVD Immunization and Vaccine Development LQMS laboratory quality management system MCV measles-containing vaccine MR measles-rubella MRCV measles and rubella-containing vaccine NVC National Verification Committee PT proficiency testing RCV rubella-containing vaccine RVC Regional Verification Commission SEA South-East Asia SEA-RVC South-East Asia Regional Verification Commission SIA supplementary immunization activity US CDC United States Centers for Disease Control and Prevention UTC coordinated universal time UNICEF United Nations Children’s Fund WHO World Health Organization WHO HQ WHO headquarters Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella v Executive summary The Regional Verification Commission (RVC) for measles and rubella elimination for the WHO South-East Asia Region (SEA-RVC) was established by the Regional Director in March 2016 to verify progress towards measles and rubella elimination and rubella/ congenital rubella syndrome (CRS) control in the Region. The name of this Commission was changed in 2020 to “WHO South-East Asia Regional Verification Commission for measles and rubella elimination (SEA-RVC)” following the adoption of the resolution on “Measles and rubella elimination by 2023” by all Member States at the Regional Committee for South-East Asia in September 2019. The Fifth Meeting of the SEA-RVC was held virtually on 6–7 July 2020. The key objective of the meeting was to review the country progress reports on measles elimination and rubella/CRS control, submitted by national verification committees (NVCs), and verify the progress made. The methodology for review of individual country progress reports was based on the framework for verification of measles and rubella elimination in the Region endorsed by the SEA-RVC during its Fourth Meeting in 2019 and published in February 2020. Following an extensive review of the reports, the SEA-RVC verified Maldives and Sri Lanka as having eliminated endemic rubella. The Commission also verified that measles elimination has been sustained in Bhutan, the Democratic People’s Republic of Korea (DPR Korea), Maldives, Sri Lanka and Timor-Leste. It also categorized the remaining countries as endemic for measles and rubella. The SEA-RVC also recognized that significant progress has been made towards measles and rubella elimination in the remaining countries of the Region. The SEA-RVC acknowledged the significant progress made by all countries in the Region towards measles and rubella elimination and requested the World Health Organization (WHO), NVCs and Member States to provide some additional country- specific information at the next meeting to ensure better review of progress towards achieving the 2023 goal of measles and rubella elimination in the SEA Region.
Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 1 1 Background The Sixty-sixth session of the WHO Regional Committee for South-East Asia, in 2013, adopted the regional goal of measles elimination and rubella control by 2020. To provide impetus to progress towards this goal, in 2014, the Regional Director announced “Measles Elimination and Rubella Control by 2020” as one of the Flagship Priority Programmes for the Region. During the Seventy-second session of the WHO Regional Committee for South-East Asia, the goal of “measles elimination and rubella/ CRS control by 2020” was revised to “measles and rubella elimination by 2023”. The Regional Director established an independent “WHO South-East Asia Regional Verification Commission for measles elimination and rubella/CRS control (SEA-RVC)” in March 2016 in order to monitor progress towards measles elimination and rubella/CRS control, as well as to verify countries that have stopped the transmission of measles and/or have controlled rubella/CRS. The First Meeting, held at New Delhi India in August 2015, developed the framework for verification of measles elimination and rubella/CRS control, and the templates for national verification committees of countries in the Region to report on the annual progress made towards achieving the goal of measles elimination and rubella/CRS control. Following the adoption of the new target of “Measles and rubella elimination by 2023” in 2019, the Commission was renamed as the “WHO South-East Asia Regional Verification Commission for measles and rubella elimination (SEA-RVC)”. The Fourth Meeting of the SEA-RVC drafted the regional framework for verification of measles and rubella elimination, published in February 2020, to report on the annual progress made towards achieving the goal of measles and rubella elimination. The Fifth Meeting of the SEA-RVC was held virtually on 6–7 July 2020. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella2 2 Objectives of the meeting The overall objective of the Fifth Meeting of the SEA-RVC was to review reports submitted by NVCs of all countries in the SEA Region on the progress made towards measles elimination and rubella/CRS control and provide feedback. The specific objectives of the meeting were: in-depth review of the reports submitted by the NVC of each country on the progress towards measles and rubella elimination; assessment of country performance against criteria/lines of evidence as per the revised SEA Regional Framework for measles and rubella elimination; classification of countries into one of the mutually exclusive categories for measles/rubella: verified elimination; eliminated (absence of transmission for >12 months but not verified by RVC); re-established transmission (post-verification); and endemic; and comments of the Regional Verification Commission on recommendations made by the NVCs on the performance of measles/rubella elimination programmes in each country. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 3 3 Organization of the meeting The Fifth Meeting of the SEA-RVC was originally planned to be conducted on 21–23 April 2020 in Dhaka, Bangladesh. However, due to the emerging situation of the COVID-19 pandemic and the imposition of global travel restrictions, following consultations with SEA-RVC members, the meeting was postponed until July 2020. It was also agreed that the meeting would be conducted virtually. The meeting was organized using the Zoom virtual platform. It was a two-day virtual meeting, with sessions of two hours each day. The meeting was followed by a virtual closed-door session of SEA-RVC members only to finalize the conclusions and recommendations. The meeting was chaired by the Chairperson of the SEA-RVC and attended by all 11 members of the Commission. The chairpersons/representatives of 10/11 NVCs of the Region and representatives from WHO headquarters, United Nations Children’s Fund (UNICEF) headquarters, UNICEF Regional Office for South Asia, UNICEF Regional Office for East Asia and Pacific Region, and the United States Centers for Disease Control and Prevention, Atlanta (US CDC), participated in the meeting. The Secretarial support was provided by the Immunization and Vaccine Development (IVD) team of the WHO Regional Office for South-East Asia. The list of participants is available in Annex 5. The WHO Regional Director for South-East Asia, Dr Poonam Khetrapal Singh, addressed the opening session of the meeting (Annex 2). A presentation on the objectives of the meeting and the components of the regional framework for verification of measles and rubella elimination was made by the Secretariat. Subsequently, presentations were made by the Secretariat on the global and regional updates on the measles and rubella situation. Following the presentations, reviews of country progress towards measles and rubella elimination for all 11 Member States were conducted (See Meeting Agenda in Annex 1). Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella4 4 Methodology of the review of country progress The methodology of the review of country progress was based on the guidelines laid out in the “Framework for verification of measles and rubella elimination in the WHO South-East Asia Region”.1 4.1 Prior to the meeting The annual reporting template on progress towards measles and rubella elimination, that was revised based on feedback from SEA-RVC members during the Fourth Meeting of SEA-RVC held in Kathmandu in 2019, was put forth. The revised annual reporting template was shared by the SEA-RVC Secretariat with all the NVCs through the WHO country offices in January 2020. The filled-in and signed annual reports were submitted by all 11 NVCs to the SEA-RVC Secretariat at the WHO Regional Office for South-East Asia (SEARO) by June 2020 inspite of the COVID-19 pandemic situation in the respective countries and the related competing priorities of responding to the pandemic. The SEA-RVC appreciated this. All country progress reports were initially reviewed by the SEA-RVC Secretariat along with the US CDC for consistency and quality check. Two SEA-RVC members were assigned as reviewers for each country report, except for Bhutan, Maldives and Sri Lanka, for which three SEA- RVC members were assigned. 1 Framework for verification of measles and rubella elimination in the WHO South-East Asia Region available at https://www.who.int/publications/i/item/framework-for-verification-of-measles-and-rubella-elimination-in-the-who- south-east-asia-region Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 5 Electronic versions of the country progress reports were made available to the SEA-RVC members through a weblink as well as email. The link to access the reports are provided in Annex 3. All SEA-RVC members were provided with a review checklist template to independently review the assigned country’s progress towards measles and rubella elimination. The SEA-RVC members provided written comments on the country progress reports and also requested clarifications on the report. These clarifications requested by SEA-RVC were shared with respective NVC Chairs through the WHO country offices. Table 1: Countries and SEA-RVC members allocated for review Country name Reviewer 1 Reviewer 2 Reviewer 3 Bangladesh Prof. Hinky Hindra Satari Dr Joe Icenogle Bhutan Dr Kumnuan Ungchusak Prof. Sujeewa Amarasena Dr Natasha Crowcroft Democratic People’s Republic of Korea Dr Kinzang Tshering Prof. Soe Lwin Nyein India Dr Joe Icenogle Dr Kumnuan Ungchusak Indonesia Prof. Soe Lwin Nyein Dr Natasha Crowcroft Maldives Prof. Rupa Singh Prof. Hinky Hindra Satari Prof. Shahina Tabassum Myanmar Prof. Dr AP Dubey Prof. Rupa Singh Nepal Dr Jon Andrus Prof. A.P. Dubey Sri Lanka Prof. Soe Lwin Nyein Dr Jon Andrus Dr Kinzang Tshering Thailand Prof. Sujeewa Amarasena Dr Jon Andrus Timor-Leste Prof. Shahina Tabassum Dr Kumnuan Ungchusak 4.2 During the meeting All SEA-RVC members attended the meeting. The SEA-RVC Chairperson and members acknowledged the high level of commitment to measles and rubella elimination by the countries. Reviews of the country progress were made on the basis of the time zone whereby the country with the highest offset from coordinated universal time (UTC) started first, and the ones with the lowest offset from UTC came later. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella6 Each SEA-RVC reviewer of the respective designated country in order, as presented in the Agenda, provided an initial comment that lasted for not more than five minutes and included: — one or two key highlights of the country report; — country classification; — comment on recommendations made by the NVC and additional comments, if any; and — any clarification required from the NVC based on review of the annual progress report. The respective NVC Chair or the representative was then requested to respond within seven minutes of allotted time. The response included: — one or two key highlights on the measles and rubella programme in the country; — response to the queries from the reviewer (if any); and — any queries to the reviewer related to the country classification or comments made by the reviewer. Dedicated closed-door sessions were conducted by SEA-RVC members on Day 2, after all the presentations of the NVCs were made, to discuss and finalize the conclusions and recommendations of the meeting. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 7 5 Conclusions and recommendations Following an extensive review of the reports from NVCs to assess the status of progress towards measles and rubella elimination in the Region, the SEA-RVC concluded that significant progress has been made towards measles and rubella elimination in all the countries in the Region. It also appreciated all countries for their dedication and commitment towards measles and rubella elimination. The SEA-RVC also requested the NVCs to convey their appreciation to the national programmes on immunization for the significant progress made towards measles and rubella elimination. The SEA-RVC congratulated Maldives and Sri Lanka for being verified as having eliminated endemic rubella and on being the first two countries to achieve the regional goal of “Measles and rubella elimination by 2023”. The SEA-RVC also appreciated Bhutan, DPR Korea, Maldives, Sri Lanka and Timor-Leste for maintaining their status of measles elimination. The SEA-RVC also commended all the NVCs on the production of high-quality annual progress reports, with special mention of India and Thailand. The details of the comments made by the SEA-RVC on respective country reports are available in the links provided in Annex 3. The endorsement of the conclusions and the recommendations of the meeting is available in Annex 4. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella8 5.1 Categorization of countries The SEA-RVC categorized countries into one of the four mutually exclusive categories for both measles and rubella as per the updated “Framework for Verification of measles and rubella elimination in WHO South-East Asia Region”:2 Verified as eliminated: No endemic transmission for >36 months in the presence of well-performing surveillance system and verified by the SEA-RVC. Eliminated: Absence of endemic transmission for >=12months, but not verified by the SEA-RVC. Re-established transmission post verification: Presence of a chain of transmission of a virus strain that continues uninterrupted for ≥12 months in areas where endemic transmission had been eliminated previously. Endemic: Existence of continuous transmission of virus, that persists for ≥12 months in areas where transmission had not been eliminated previously. The SEA-RVC members extensively discussed the classification for rubella status for DPR Korea. The NVC report suggested that there was no rubella transmission for more than 36 months, but the evidence and information on routine vaccination coverage for rubella vaccine at the subnational level, and other evidence on population immunity for rubella, were not available in the report. Thus, the SEA-RVC could not determine the status as “eliminated”, and classifying it as “endemic” would undermine all the gains made by the country. The SEA-RVC deferred the country classification for rubella for DPR Korea to the next meeting, requesting the country to present additional evidence on population immunity for rubella. The SEA-RVC members also discussed the classification category of “Rubella and CRS controlled” and how this will be reflected in the current classification strata. This status was provided to six countries in the Region – Bangladesh, Bhutan, Maldives, Nepal, Sri Lanka and Timor-Leste – by the SEA-RVC in the previous meetings. The SEA-RVC members agreed that the rubella and CRS control status has been maintained in the six countries, but with the change of the regional goal from control to elimination, the classification of “controlled” was dropped as it only denotes a low 2 Framework for Verification of measles and rubella elimination in the WHO South-East Asia Region available at https://apps.who.int/iris/handle/10665/332737 Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 9 level of transmission. But the virus is still endemic, and thus “Endemic classification” was adopted for these countries. However, this does not undermine the gains made by these countries to maintain the status of rubella control. Table 2: Categorization of countries by SEA-RVC Country Country categorization Measles elimination Rubella/CRS control Bangladesh Endemic Endemic Bhutan Verified elimination Endemic Democratic People’s Republic of Korea Verified elimination Not classified* India Endemic Endemic Indonesia Endemic Endemic Maldives Verified elimination Verified elimination Myanmar Endemic Endemic Nepal Endemic Endemic Sri Lanka Verified elimination Verified elimination Thailand Endemic Endemic Timor-Leste Verified elimination Endemic *Classification deferred to the next SEA-RVC meeting. 5.2 Overarching recommendations by SEA-RVC The SEA-RVC made the following recommendations to WHO and all Member States of the Region: It endorsed all the recommendations suggested by the respective NVCs of all the Member States in their annual progress report, and requested for an update on the status of implementation of these recommendations in the next meeting. It recommended that the country visits of SEA-RVC members that have been postponed due to the COVID-19 pandemic be reorganized as soon as possible/feasible. In addition, it proposed that in-depth analyses of measles and rubella transmission be conducted in Bangladesh, Bhutan, DPR Korea, Myanmar, Thailand and Timor-Leste. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella10 It proposed that the next RVC report include post-COVID-19 mitigation strategies taken by all countries to ensure smooth functioning of immunization services with high coverage as well as activities conducted for laboratory supported case-based surveillance strengthening, including rash and fever reporting linked to IgM (Immunoglobulin M) testing. All countries make efforts to establish molecular epidemiology and classify cases by its origin (imported, import-related, endemic or unknown) and report this at the next meeting. It recommended that the Regional Office work with the countries in the Region to develop an implementation framework for cross-border surveillance for measles and rubella and support the Member States to implement the framework. Further recommended that countries where the private health sector plays a significant role in providing primary health care and immunization services produce evidence of fever rash discard rate for at least the high- risk groups, such as below 9–12 months (before administering measles and rubella-containing vaccine or MRCV1), and in adolescent/adult populations with vaccination status for measles and rubella. Alternatively, that countries show evidence of population immunity profile in these selected high-risk groups to ensure that target groups are identified in order to prevent re-emergence of measles and rubella disease, especially in eliminated or verified countries. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 11 6 Country-specific information for the next meeting The SEA-RVC requested that additional information related to the following actions from countries be included in the next annual report. Bangladesh A more complete description of how a single laboratory (the National Polio and Measles Laboratory) manages polio, measles, rubella and CRS surveillance for the entire country would be useful. Classification of cases and outbreaks by source (imported, import related, endemic, unknown) up to subnational level, and the efforts made for genotyping of measles and rubella cases and outbreaks. Information on efforts made to strengthen the collaboration among laboratory and surveillance team and data triangulation among the teams. Strategies implemented to achieve high coverage (>95%) of MRCV-1 and MRCV-2 at the second administrative level. Molecular epidemiology information from cases of CRS is needed. Bhutan NVC to review the classification for rubella and produce additional evidence to confirm that rubella transmission has stopped. Continue with efforts made to strengthen surveillance for rubella particularly to detect/isolate rubella virus and genotype them from confirmed rubella cases and additional strategies adopted for testing to rule out false positive cases. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella12 Action taken on microplanning for vaccinating migrant workers In-depth analysis of rubella cases that have received rubella vaccination and the rubella transmission pattern and review of progress towards rubella elimination. Information on data quality assessment conducted and actions taken. Efforts made to ensure high MRCV2 coverage in all districts to close immunity gaps for both measles and rubella in various age groups. Report back on efforts made to ensure better cross-border collaboration for measles and rubella surveillance activities, especially for Bhutanese nationals residing across the border with India. Democratic People’s Republic of Korea Considering no evidence of circulating rubella virus in the country, additional evidence must be provided for population immunity profile for rubella in women of child-bearing age who have not received vaccine. For instance, age-stratified serological survey for rubella be conducted and the results (as was requested earlier) reported. Review of immunity profile against rubella and rubella vaccine coverage at the subnational level. Information on actions taken to strength CRS surveillance. Information on actions taken towards recommendation of the data quality self-assessment be included. India Efforts made by the country to support Laboratory Quality Management System (LQMS) implementation to maintain quality of laboratory network, national PT programme of both serology and molecular testing, and onsite accreditation review by national assessors. More detailed information on improvement plans and actions taken for CRS surveillance. Measures taken to improve vaccine hesitancy in some districts that have reported the issue. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 13 More information on plan for improvement of rubella molecular surveillance. Efforts made for inter-state and cross-border collaboration for measles and rubella surveillance. Indonesia Efforts made to strengthen surveillance at the subnational level, including information on the role of the private sector on MR surveillance and the plan to expand the measles and rubella laboratory network. Efforts made to support LQMS implementation to maintain quality of laboratory network, as well as to meet the key laboratory surveillance quality indicators, and submission of genotype information in MeaNS (Measles nucleotide surveillance system) and RubeNS (Rubella nucleotide surveillance system) on time. Information on use of subnational risk assessment and how strategies were tailored, based on the assessment to accelerate measles and rubella elimination. Implementation of the recommendations of the “data quality review” conducted in 2019. Maldives Outcome of the planned, selective MR campaign including vaccination of migrant-workers to close the immunity gap for measles and rubella. Efforts to intensify surveillance system, including involvement of private health sector in MR surveillance; training to health-care workers, especially at the second-level administrative unit as well as strengthening laboratory support (addition of laboratory). Outcome of data quality review for routine immunization and surveillance. Review of the CRS surveillance efforts, including the case definitions and testing protocols currently used. Efforts taken to strengthen outbreak preparedness and outbreak response measures. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella14 Measures taken to mitigate the risk of high turnover of public health and clinical staff at all levels. Efforts made to deal with emerging vaccine hesitancy in the country. Myanmar Efforts made to strengthen case-based surveillance; case investigation; case-classification; serological testing and genotyping for rubella and CRS; involvement of the private sector; and to ensure no stock-out of laboratory supplies and reagents. Actions taken to collaborate with Mekong Basin Diseases Surveillance system to strengthen cross-border MR surveillance. Implementation of strategies to address low coverage in high-risk areas/ populations including older age groups, ethnic minorities, peri-urban areas, satellite townships and geographically hard-to-reach areas. Efforts made to reduce vaccine hesitancy and improve outbreak preparedness. Advocacy and demand generation activities undertaken in 2020. Nepal NVC Nepal to submit on time the annual progress report so that the SEA- RVC reviewers have adequate lead time to review them. Progress towards achieving high-quality rash and fever surveillance linked to IgM testing. Evaluated coverage of the recently conducted MR supplementary vaccination campaign at the subnational level and actions taken to close any gaps on coverage identified post-MR vaccination campaign. Additional information on the “accountability” line of evidence in the context of decentralization and support to peripheral health workers, including community health extension workers and volunteers, on measles and rubella elimination. Efforts made to close immunity gaps in age groups that were not covered by the current SIA. Efforts to strengthen country capacity on molecular detection and genotyping of measles and rubella cases, especially in the border areas. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 15 Sri Lanka Innovations in the national strategy to sustain measles and rubella elimination. Review of the non-measles, non-rubella discard rate at the national and subnational level to ensure sensitivity of the surveillance system. Efforts made to strengthen collaboration between laboratory and surveillance. Thailand Efforts made to close the immunity gap for measles and rubella in multiple age groups, including migrant populations, and discussions on this with the policy- and decision-makers. Considerations about revising the target for elimination in line with the regional resolution. Report on external review of the immunization and surveillance strategy in the country (also addressing to what extent the revised case definitions are being used, the private sector is engaged, and high-risk populations are being covered). Efforts made to strengthen MR surveillance, including training of health officers. Efforts made to ensure adequate funding support to accelerate progress towards measles and rubella elimination. Efforts to enhance the country capacity and collaboration on the use of molecular epidemiology to identify the source of transmission. Timor-Leste Efforts to strengthen laboratory capacity for viral detection and genotyping of the measles and rubella virus. Efforts made to sustain measles elimination status as the current coverage of MRCV1 and MRCV2 are suboptimal. Identify pockets of low MRCV coverage such as in Dili and add tailored interventions and SIAs to fill the gap. This will close the immunity gap and prevent further outbreaks of measles. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella16 Plans to develop rubella elimination strategy. Efforts to ensure data quality through data review/DQA and especially address any issues with denominator. In-depth field review of rubella transmission in the country, including review of all rubella cases and their classification. The signed endorsement of the conclusions and the recommendations made by the SEA-RVC members are available as Annex 4. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 17 Annex 1 Agenda Day and activity Remarks Day 1 Opening session Opening address from RD Objectives of the meeting and introduction of the participants Administrative announcements WHO Regional Office for South-East Asia Update on measles and rubella • Regional • Global WHO Regional Office for South-East Asia WHO headquarters Presentation on the modus operandi of the review of country progress Chair SEA-RVC Review of the country progress reports • Maldives • Sri Lanka • Bhutan SEA-RVC members and NVC Chairs Day 2 Review of the country progress reports • DPR Korea • Timor-Leste • Indonesia • Thailand • Myanmar • Bangladesh • Nepal • India SEA-RVC members and NVC Chairs/ members Closing remarks by the Chair Closing session – remarks by the WHO headquarters, UNICEF, US CDC, WHO Regional Office for South-East Asia WHO Regional Office for South-East Asia Closed-door session of SEA-RVC members only to finalize conclusions and recommendations WHO Regional Office for South-East Asia Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella18 Annex 2 Regional Director’s opening remarks Opening address by Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region Let me commend you for your willingness to adapt and hold this meeting online. It is testament to your commitment to the task at hand. The work of all national verification committees in the Region to gather evidence and submit their reports on time, despite COVID-related challenges, is to be commended. The delivery and review of these reports is essential to achieving the Region’s Flagship Priority on eliminating measles and rubella by 2023, which as you know was updated last year to reflect the Region’s progress. I thank Commission members for rapidly reviewing the reports, and for developing and finalizing the Regional Framework for achieving our goal, which very clearly delineates the evidence and criteria required for verification. Our progress has indeed been strong, which your deliberations will highlight. Five countries have eliminated measles. Six have controlled rubella. Children in all countries of the Region have access to two doses of measles-containing vaccine and at least one dose of rubella-containing vaccine. First-dose coverage of measles-containing vaccine is now 88%. Second-dose coverage is 76%. Since 2017, almost 500 million additional children have been vaccinated with measles and rubella-containing vaccine. Surveillance for measles and rubella is much improved. We can be proud of our gains and the life-changing impact national immunization programmes have had, especially for the most vulnerable. We must maintain the momentum. Though COVID-19 is indeed an immense threat to our progress, I am inspired by the determination of Member States and their resolve. In a global survey, more than half of all countries reported moderate-to- severe disruptions, or a total suspension of vaccination services, in March and April. Preliminary information from our Region suggests that the picture here is similar, both in terms of immunization coverage and surveillance. However, I continue to be impressed by Member State efforts to close the gaps. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 19 Though mass vaccination activities have been postponed in several countries, I am pleased that efforts are underway to resume them at the soonest. I understand Nepal has already re-started a mass vaccination activity with adequate infection prevention measures and congratulate it on its efforts. As WHO and its Member States and partners continue to respond to the pandemic, my message remains steadfast: We cannot allow for our progress towards measles and rubella elimination to be put on hold or reversed. We must achieve our 2023 target. WHO is committed to supporting our Member States and partners to fully revive immunization and surveillance activities, and to refine the strategic, operational and policy guidelines that will facilitate progress towards our goal. We are committed to supporting the valuable work of this Commission, and to ensuring that it can continue to carry out its duties. Now more than ever, we must pull together to realize our vision of a Region in which no child suffers or dies from a disease as easily prevented as measles; where no pregnant woman loses her unborn baby due to a virus as avoidable as rubella; and where no neonate is born with a heart ailment or loss of hearing owing to a tragedy as needless as in-utero rubella infection. I once again thank you for not only guiding the Region’s verification process, but for also reviewing and providing feedback on the reports of the national verification committees. I wish you all success in this crucial meeting – the first under the updated target and the framework to achieve it. I look forward to being informed of the outcomes. Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella20 Annex 3 Links to country reports and reviewers’ comments All country progress reports and the comments of the SEA-RVC members in the report are available in the links below. (1) The link to all country progress reports as submitted by respective NVCs: https:/ /drive.google.com/drive/folders/1Tf0_a3YD9_ N6tCMosjc3I8UD2q0aqwQi?usp=sharing (2) The link to comments from the SEA-RVC reviewers: https://drive.google. com/drive/folders/17WDlTyEXiEn6k35JsbUluHe7kqaqGSwx?usp=sharing (3) The link to the laboratory proficiency and accreditation status of the Regional Measles and Rubella Laboratory Network: https://drive.google.com/drive/ folders/1CkZ2UzBnT1LoNSO0_1qBLgJ2MGa90Mdm?usp=sharing Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 21 Annex 4 Endorsement of the SEA-RVC We, the Members of the South-East Asia Regional Verifica�on Commission (SEA-RVC) for Measles and Rubella Elimina�on, hereby endorse the conclusions and recommenda�ons made by the Commission during its fi�h mee�ng conducted virtually between 6 and 7 July 2020. During the aforemen�oned mee�ng, the SEA-RVC for Measles and Rubella Elimina�on, adopted the revised framework for verifica�on of measles and rubella to conduct detailed review of the country reports submi�ed by the Na�onal Verifica�on Commi�ees (NVCs) of all eleven countries of the Region. The country reports submi�ed by the NVCs included progress towards two essen�al criteria and five line of evidences on measles and rubella elimina�on. Based on careful review and the follow-up discussions and interac�ons with representa�ves of the NVCs of all eleven countries, the commission verified Maldives and Sri Lanka as having eliminated endemic rubella. The commission also verified that Measles Elimina�on has been sustained in Bhutan, DPR Korea, Maldives, Sri -Lanka and Timor-Leste and categorized the remaining countries as endemic for measles and rubella. The SEA-RVC also recognized significant progress made in remaining countries including sustaining status of control in those countries that were verified as rubella/congenital rubella syndrome controlled. The Commission suggested a number of recommenda�ons for all countries to achieve and maintain measles and rubella elimina�on. WHO South-East Asia Regional Verifica�on Commission for Measles and Rubella Elimina�on ,2020 Prof. Shahina Tabassum, Chair, SEA-RVC Prof. A P Dubey Dr. Hinky Hindra Irawan Satari Dr. Joseph P. Icenogle Dr. Jon Andrus Dr. Kumnuan Ungchusak Dr Soe Lwin Nyein Dr. Natasha Crowcro� Prof. Rupa Singh Rajbhandari Prof Sujeewa AmarasenaDr. Kinzang P Tshering Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella22 RVC members Professor Dr Shahina Tabassum Chairperson SEA-RVC Professor and Chairman Department of Virology Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh Professor Dr A.P. Dubey Director-Professor Department of Paediatrics Maulana Azad Medical College New Delhi 110002, India Dr Hinky Hindra Irawan Satari Division of Infectious Diseases and Tropical Paediatrics Department of Child Health Fakultas Kedokteran Universitas Indonesia, Jakarta, Indonesia Dr Jon Kim Andrus Adjunct Professor and Senior Investigator Center for Global Health University of Colorado Washington DC, USA Dr Joseph Parker Icenogle Virologist/Public Health Scientist Team Leader Rubella Virus Laboratory Centers for Disease Control and Prevention (CDC), USA Dr Kinzang P. Tshering President, Khesar Gyalpo University of Medical Sciences of Bhutan Thimphu, Bhutan Dr Kumnuan Ungchusak Adviser Department of Disease Control Ministry of Public Health Nonthaburi, Thailand Dr Natasha Sarah Crowcroft Professor Laboratory Medicine and Pathobiology and Dalla Lana School of Public Health, University of Toronto Ontario, Canada Dr Rupa Rajbhandari Singh Professor, Department of Paediatrics, B.P. Koirala Institute of Health Sciences Dharan, Nepal Professor Soe Lwin Nyein Adviser, Ministry of Health and Sports Htantapin-Shwekyapin Quarter Zabuthiri Township Nay Pyi Taw, Myanmar Professor T.S.D. Amarasena Dean, Faculty of Allied Health Science University of Ruhuna PO Box 70, Galle Sri Lanka NVCs for measles and rubella elimination Professor Mahmudur Rahman Chair, NVC Bangladesh Dr Sangay Thinley Chair, NVC Bhutan Dr Narendra Arora Chair, NVC New Delhi, India Professor Elisabeth S. Herini Chair, NVC Indonesia Dr Abdul Azeez Yoosuf Chair, NVC Maldives Dr Ye Hla Chair, NVC Myanmar Annex 5 List of participants Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella 23 Dr Govind Ojha Chair, NVC Nepal Dr Deepa Gamage Member, NVC Sri Lanka Dr Supachai Rerks-Ngarm Chairperson, NVC Thailand Dr (Mrs) Milena dos Santos Chair NVC Democratic Republic of Timor-Leste Ministries of Health Bhutan Dr Tshewang Dorji Tamang Senior Programme Officer, VPDP Department of Public Health Ministry of Health, Bhutan Mr Jit Bdr. Darnal Laboratory Officer Royal Centre for Disease Control (RCDC), Thimphu, Bhutan Maldives Dr Fathimath Nazla Rafeeg Medical Officer, Health Protection Agency, Male, Maldives Ms Aminath Aroosha Senior Public Health Programme Officer, Health Protection Agency Male, Maldives Sri Lanka Dr Paba Palihawadana Deputy Director-General Public Health Services Ministry of Health,Colombo, Sri Lanka Dr Sudath Samaraweera Chief Epidemiologist Epidemiology Unit Ministry of Health,Colombo, Sri Lanka Centers for Disease Control and Prevention (CDC) Dr David H. Sniadack Associate Chief, ADC Branch Centers for Disease Control and Prevention Atlanta, USA Dr Susan Reef Global Immunization Division Centers for Disease Control and Prevention Atlanta, USA Dr Jeffrey McFarland Team Lead, Measles Elimination Centers for Disease Control and Prevention Atlanta, USA Dr Michelle Morales Medical Officer Global Immunization Division Centers for Disease Control and Prevention Atlanta, USA UNICEF HQ Dr Imran Mirza Immunization Specialist UNICEF HQ, New York, USA UNICEF EAPRO Dr Khin Devi Aung Immunization specialist UNICEF East-Asia and Pacific Regional office,Bangkok, Thailand UNICEF ROSA Dr Saadia Farrukh Focal point for Measles UNICEF Regional Office for South Asia Kathmandu, Nepal WHO headquarters Dr Katrina Kretsinger Focal Point for Measles & Rubella Expanded Programme on Immunization WHO HQ, Geneva, Switzerland Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella24 Dr Miguel Norman Mulders Scientist Immunization Analysis and Insights WHO HQ, Geneva, Switzerland WHO Country Office, Bhutan Dr Sonam Wangdi National Professional Officer Communicable Diseases WHO Country Office, Maldives Dr Shushil Dev Pant Medical Officer Ms Aishath Thimna Latheef National Professional Officer (NPO) Health and Environment Dr Debashish Roy Consultant WHO Country Office, Sri Lanka Dr N. Janakan NPO, Communicable Diseases Dr Preshila Samaraweera Communicable Disease Control WHO Regional Office for South-East Asia, New Delhi, India Prof. Tjandra Yoga Aditama Senior Adviser and Ag Director Department of Communicable Disease (CDS) Dr Sunil Kumar Bahl Team Leader Immunization and Vaccine Development Department of Communicable Disease Ms Sirima Pattamadilok Scientist and Laboratory Coordinator Immunization and Vaccine Development Department of Communicable Disease Dr Sudhir Khanal Medical Officer, Measles Immunization and Vaccine Development Department of Communicable Disease Md Sharifuzzaman Data Management Officer Immunization and Vaccine Development Department of Communicable Disease Mr Rajiv Maken Executive Assistant Immunization and Vaccine Development Department of Communicable Disease Fifth Meeting of the WHO South-East Asia Regional Verification Commission for measles and rubella Meeting report 6–7 July 2020 (Virtual) SEA-IMMUN-102 The Regional Verification Commission (RVC) for measles and rubella elimination for the WHO South-East Asia Region was established by the WHO Regional Director in March 2016 to verify progress towards measles and rubella elimination. The SEA-RVC meets annually to review progress made by Member Statesd towards measles and rubella elimination. This report outlines the conclusions and the recommendations made by the SEA-RVC during its Fifth Annual Meeting in July 2020. The SEA-RVC concluded that significant progress has been made in the Region, and five countries have sustained mealses elimination while two countries have also achieved rubella eliminaton.