A Killer A reconstruction of Maldives’ triumph over measles
Cover photo: © Ibrahim Asad
A Killer
NAILED A reconstruction of Maldives’ triumph over measles
ISBN 978-92-9022-594-2
© World Health Organiza on 2017 Some rights reserved. This work is available under the Crea ve Commons A ribu on-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; h ps:// crea vecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this license, 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 sugges on that WHO endorses any specific organiza on, products or services. The use of the WHO logo is not permi ed. If you adapt the work, then you must license your work under the same or equivalent Crea ve Commons license. If you create a transla on of this work, you should add the following disclaimer along with the suggested cita on: “This transla on was not created by the World Health Organiza on (WHO). WHO is not responsible for the content or accuracy of this transla on. The original English edi on shall be the binding and authen c edi on.” Any media on rela ng to disputes arising under the licence shall be conducted in accordance with the media on rules of the World Intellectual Property Organiza on. Suggested cita on. Coffee table book to showcase elimina on of Measles and rubella/CRS control from Maldives. New Delhi: World Health Organiza on, Regional Office for South-East Asia; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publica on (CIP) data. CIP data are available at h p://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publica ons, see h p://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see h p://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is a ributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resul ng from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designa ons employed and the presenta on of the material in this publica on do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authori es, or concerning the delimita on of its fron ers or boundaries. Do ed and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The men on of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not men oned. Errors and omissions excepted, the names of proprietary products are dis nguished by ini al capital le ers. All reasonable precau ons have been taken by WHO to verify the informa on contained in this publica on. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpreta on and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
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Contents Foreword Introduc on Picking up the challenge Laying the founda on Leadership Planning Infrastructure Let’s start building! Vaccina on Immuniza on campaigns Community par cipa on Partnerships Surveillance and tes ng Surveillance Laboratories Moving in Verifica on commi ee Closing the door on measles Lessons learnt Protec ng the future v 1 3 5 5 7 8 11 12 15 17 18 20 21 23 24 24 25 26 27
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Immunization is a basic right of children in the Republic of Maldives. The government regards children as one of the most important assets of the nation and therefore every effort should be made, without discrimination of a person’s gender and socioeconomic status, to promote welfare and full development of their potential. –from the Immunization Policy Statement of Maldives
“ © Ibrahim Asad
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Foreword Maldives has once more shown us that when dedicated men and women come together under commi ed leadership, they can achieve their goals, surely and convincingly. Through visionary leadership and strategic planning, the country has built a strong edifice of immuniza on against measles, far in advance of the targets set in September 2013, when Member States of the South-East Asia Regional Commi ee, during the Sixty-sixth Mee ng of the Commi ee, resolved to eliminate measles by 2020. Close to four decades ago, Maldives, in collabora on with WHO, started its programme of immuniza on, with the introduc on of MCV 1 as part of the Expanded Programme on Immuniza on. At that me, people would hide in the jungles to escape from being immunized. Today, Maldives has over 95% immuniza on coverage, with an informed popula on that understands the need for and benefits of immuniza on. This journey itself is a tribute to the sustained efforts made at country and local levels to establish effec ve health systems, gain the confidence of the people, and make ini a ves such as the elimina on of measles a success. But this is not the end of the tale. Maldives has sharpened its surveillance and response systems to ensure that every suspected case of measles is reported within 48 hours of presenta on. In any situa on, this would be commendable but, given the challenges of a dispersed popula on spread over close to 200 inhabited islands, it is truly a testament to the visionary leadership and passionate, well-trained and hard-working health staff that have overcome such odds. Maldives has not seen a case of endemic measles since 2009 and in April 2017, the WHO South-East Asia Regional Verifica on Commission was convinced that endemic measles transmission has been interrupted throughout the country, making Maldives one of the first two countries of the Region to achieve this success. Certainly, it is a me to celebrate and I extend my hearty congratula ons to the people of Maldives on this remarkable achievement.
Kh l Si Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region
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Population
340 000
Islands
1192
Administrative atolls
20
Became a republic in
1968
Tourists in 2016
1 286 135
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INTRODUCTION Measles – a killer disease. The virus hides in the air or on infected surfaces, wai ng for as long as two hours to a ack an unprotected host. Considered an almost inescapable life event in the age before vaccina on, measles, the manifesta on of infec on by the minuscule, hardy, o en deadly paramyxovirus, remained unchallenged, plaguing genera on a er genera on. When did measles first occur? We do not know for sure, but as early as the 11th century CE, Abu Bakr Mohammad ibn Zakariya al-Razi, court physician and director of a large hospital in Baghdad, described measles as a disease “more dreaded than smallpox”. In the 1950s, a quarter of the children in Maldives did not survive to celebrate their first birthday. Measles was a major killer. Cases of measles in the Maldives gradually decreased a er the measles vaccine was introduced in 1981, but this did not sufficiently rein in the virus and in 2002 and 2005, it showed its strength in outbreaks that affected 926 and 1395 people, respec vely. Clearly, business as usual was not effec ve at keeping the virus at bay. An ancient myth from Maldives tells of Bihidhaitha, the dhevi whose appearance causes smallpox and measles. Her preferred victims are young and growing girls. She sometimes appears dressed in bright red robes and, at other times, in the avatar of a bent, old crone. But in either case, she brings misery and suffering in her wake. Adapted from Folk Tales of the Maldives by Hasan Ahmed Manik
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Significant events 2017 CERTIFICATION OF MEASLES ELIMINATION
2007 MMR CAMPAIGN; MMR (MCV2) INTRODUCED IN ROUTINE IMMUNIZATION (RI)
2009 LAST ENDEMIC MEASLES CASE
2005 OUTBREAK: SECOND MEASLES CAMPAIGN (MR) STARTED
2002 OUTBREAK
2000 MEASLES SEROLOGY STARTED IN INDIRA GANDHI MEMORIAL HOSPITAL (IGMH)
1995 OUTBREAK: FIRST MEASLES CAMPAIGN
1985 OUTBREAK: EPI LAUNCHED
1983 MCV1 INTRODUCED IN NPITH
1981 OUTBREAK
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NATIONAL PROGRAMME ON IMMUNIZATION AND TRAVEL HEALTH (NPITH) LAUNCHED WITH SUPPORT FROM WHO AND DANISH SCOUT AID
© Ibrahim Asad
1976
PICKING UP THE CHALLENGE Faced with the recurrent threat of measles, Maldives decided to build a house. Not a brick and mortar house, of course, but a complex structure of immuniza on protec on that would shelter all its ci zens and keep the pernicious measles virus at bay. No easy task, this, given a popula on sca ered over 198 inhabited islands separated by large tracts of a res ve ocean! Adding to this complexity is the varying number of people on the different islands, from a mere handful of families living on remote islands such as Felidhoo (pop 506; 2014) to over 130 000 people living in the approximately 5 sq.km. Malé city, all of whom have to be provided protec on. You can imagine how complex this house was to build. Yet, through careful planning and me culous execu on, the master cra spersons leading this ini a ve set about their task and, with the support and coopera on of an en re na on, build it they did. Before the measles vaccina on was introduced globally, close to 90% of all children under the age of 15 years were infected with measles. Treatment did not, and s ll does not, exist. Once infected, the disease took its course, leaving its vic m to suffer a troublesome rash, fever, runny nose, red eyes and other such ills, malnutri on or even death. In 2000, WHO es mated that globally, 5% of all under-five deaths were caused by measles. Reducing this number was closely linked to the vision of Millennium Development Goal 4 and aimed to fight against measles in the WHO South-East Asia Region.
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4 4 © Public Service Media
LAYING THE FOUNDATION Leadership A strong founda on gives an edifice the strength to withstand onslaughts and protect its inhabitants. In 2008, the Cons tu on of Maldives, under Ar cle 23, guaranteed every ci zen the right to universal and quality health care. This right was strengthened by the introduc on of universal health insurance in December 2011 and further in 2014 with the launch of Husnuvaa Aasandha – health insurance without ceiling. All vaccine and rou ne immuniza on costs are borne by the Government of Maldives. Poli cal commitment, combined with high budgetary alloca on, ensured that immuniza on delivery func oned splendidly in the country. The present leadership wears the mantle of commitment to measles elimina on and sustainability with determina on. On 26 February 2017, the President of Maldives, Mr Abdulla Yameen Abdul Gayoom, launched the Catch-up Vaccina on Campaign from his office in the presence of the Vice President, Mr Abdulla Jihad and the Minister for Health, Mr Abdullah Nazim Ibrahim, and the WHO country representa ve, Dr Arvind Mathur. Mr Ibrahim has been a vital force in energizing the measles elimina on effort, not only by coordina ng the mul sectoral response, but by personally engaging with people and encouraging those le out to get immunized. It is a matter of great satisfaction that Maldives achieved the status of measles elimination well before the regional target of 2020. This achievement is the result of the strong political commitment and dedication of our health-care workers at every level of the health system, combined with the collaboration and cooperation of UN agencies and other partners. I congratulate each Maldivian for this remarkable success and thank every citizen for playing their part to ensure that we maintained measles vaccination coverage above 98% since several years. Maldives is committed to sustaining a measles-free status by maintaining high vaccination coverage status amid the challenges of the unique geography and limited human resources. Mr Abdullah Nazim Ibrahim Health Minister
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6 © Ministry of Health/Maldives
Planning Protec ng a na on against disease requires mul ple layers of planning to ensure a coordinated and effec ve response. When the na on comprises close to 1200 sca ered islands, the complexity of the task mul plies. Realizing this, Maldives put in place mul layered plans, such as the Health Master Plans of 1996–2005 and 2006–2015, and more recently 2016–2025, which provided informa on, ranging from wider na onal-level strategies to detailed community-level plans, to ensure the successful execu on of its immuniza on programme. The Ministry of Health is at the helm of planning and provision of health care in the country. It is ably assisted by the Maldives With a primary health centre (PHC) on every inhabited island, our task of eliminating measles by 2020 became easier. We mobilized the entire system, built a detailed elimination strategy and ensured that the guidelines therein were followed all the way down to the microplan for each island. Permanent Secretary Ministry of Health
Technical Advisory Group on Immuniza on (MTAGI) in planning ac vi es for immuniza on and surveillance in the country, including the development of a comprehensive mul -year plan (cMYP) for immuniza on. Periodic EPI programme reviews in 1994, 2006 and 2013 allowed for con nuous improvement and accelerated ac ons to achieve the desired results. The Maldivian health establishment focuses on close coordina on for achievement of results, using not only tradi onal means but also innova ve technology and social media pla orms, such as conduc ng regular teleconferences, and using Viber, Twi er, Instagram and Facebook for social mobiliza on and awareness to overcome the challenges inherent in the country se ng.
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Infrastructure A dispersed popula on presents a conundrum in providing shelter from disease. In earlier mes, when few islands had health facili es, hospital boats, such as the Golden Ray, were the lifeline for health care to the islands. Subsequently, with the expansion of the public health-care system, the human and material capaci es also expanded. Each inhabited island is now provided with a health facility, permanently manned by at least one medical doctor, who also provides support for the diagnosis and management of vaccine-preventable diseases (VPDs) such as measles or rubella. In addi on, surveillance ac vi es or an outbreak response are reinforced. Trained nurses are available on the islands and it is their responsibility to administer vaccines. Each island has a health facility for basic health services, equipped with a pharmacy that provides prescribed drugs free of cost. Atolls also have adequate facili es for maintaining the cold chain when transpor ng vaccines, medicines or samples for tes ng to the laboratory. Specialty hospitals, catering to 5000–15 000 people, are available for groups of 2–4 atolls, while ter ary care and a WHO-accredited laboratory are available in Malé. Health infrastructure in Maldives is largely the domain of the public sector, although the private and voluntary sectors do play a role, especially in Malé, where more than 70% of the 65 registered private health-care facili es are located!
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We are pleased to share that the National Immunization Programme has contributed to the good health of the Maldivians. Importantly, the programme is exclusively funded by the Government of the Maldives. Polio has been eradicated, and neonatal tetanus and measles have been eliminated. The country has maintained near 100% coverage for vaccines in its programme during a decade or more. The programme has added hepatitis B, rubella, mumps and Haemophilus influenzae B vaccines in its package. Further, the Maldives also provides traveller’s vaccine, e.g., influenza, yellow fever, meningitis, and vaccination for Hajj and Umrah pilgrimages. Director General of Public Health © Health Protection Agency/Maldives/Portrait Gallery
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3070
Number of cases of measles
1500 1395 1250
Number of cases
1000
926
750
500
250 47 0 © Ibrahim Asad
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6
1995
2002
2005 2006
2008 2009
0 2010–2016
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LET’S START BUILDING! In 1976, with a partnership between Scout Aid Denmark and WHO, the Na onal Programme on Immuniza on and Travel Health (NPITH) started in Maldives. However, measles vaccine was not part of this immuniza on programme. In 1981, another big measles outbreak was reported in Maldives, where 1479 people were affected. This was a major eye-opener for the government. Measles vaccine was introduced in parts of the country and in 1983, the vaccine was included in the NPITH, and con nued as part of the Na onal Expanded Programme on Immuniza on (EPI) in 1985. This marked the official beginning of the fight against measles in Maldives. The Na onal Immuniza on Programme, with technical support from WHO and Maldives Technical Advisory Group on Immuniza on (MTAGI), conceptualized, planned and implemented ac vi es that resulted in the decline of measles cases in the country. As a result of the massive public health response to the goal of eradica on of poliomyeli s, set during the Forty-first World Health Assembly in 1988, a blueprint was established against vaccine-preventable diseases. This provided the framework for the measles elimina on campaign. Through our network of PHC workers, we cover every inhabited island with the routine vaccines. The key areas on which we focus are logistics and capacity-building of health staff. We give a lot of importance to maintaining routine immunization and other PHC activities in such a way that scheduled events are not disrupted. We were all motivated by the goal of being the first country in the Region to eliminate measles. Dr Nashiya Abdul Gafoor EPI Programme Manager
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Vaccination In Maldives, the 12 years between 1976 and 1988 saw intense ac vity in immuniza on. The immuniza on programme, or pillar, started in 1976 as the NPITH comba ng five vaccinepreventable diseases – diphtheria, whooping cough, tetanus, poliomyeli s and tuberculosis. Measles vaccine was introduced in Malé in 1981. In 1985, the EPI took immuniza on to all the 198 then-inhabited islands. Since 1994, it has been made compulsory to have all childhood vaccines completed for entry of children to schools, thus increasing the felt need for vaccina on in the community. The second dose of measles vaccine was introduced as MMR in 2007. I always ensure that vaccines are properly handled, maintaining the appropriate temperature and hygiene standards from the time the vaccine is received till the child gets vaccinated. I also always ensure that each and every one is given full information about the importance of maintaining immunization coverage by getting his/her child vaccinated at regular intervals. A vaccinator
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“My grandmother had 12 children – 4 of them are alive; my mother had 5 children but 2 died. I had 9 children and all of them are alive and healthy.” Jeeza, 34-year-old mother of 9 children, Nilandhoo, South Maldives
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© WHO/Maldives/Ahmed Hassaan Hassan
© President's Office,/Maldives
© President's Office/Maldives
14 © Ministry of Health/Maldives
“Maves Jahaifin: the Measles and Rubella Campaign 2017” Maldives launched the Measles and Rubella Mass Vaccination Campaign 2017 with the slogan “Maves Jahaifin”. The campaign was launched by the President of the Republic of Maldives, His Excellency Abdulla Yameen Abdul Gayoom, at the Presidential Office. The campaign was simultaneously launched in Dharumabantha School and at STELCO by HE Dr Aisath Shiham, Minister of Education. The launching events and support for the campaign were aired live in the State media, radios and social media. The measles campaign was held from 26 February to 11 March 2017 throughout the country. About 70 000 Maldivians were targeted to be reached during the campaign. The National Immunization Programme, with technical support from WHO, Maldives Technical Advisory Group on Immunization (MTAGI) and National Verification Committee (NVC), have conceptualized, planned and implemented the campaign as part of the broader work of validating and sustaining measles elimination in the country.
Immunization campaigns The early years of the measles immuniza on campaign are a tes mony to the grit and determina on of the Maldivian health force, which faced insurmountable odds to deliver vaccina ons to popula ons across the country. Vaccinators would set sail for the islands, in water taxis and boats, to carry out supplementary immuniza on ac vi es during 1995–1997, armed with cold boxes and other equipment. They travelled as much as 8–10 hours between islands, staying away from home and family for extended periods of me, struggling against all sorts of hazards – turbulent seas, fire on board, long walks inland carrying their precious cargo of vaccines, and poor communica on facili es. But however bad the experiences they faced, the vaccinators never gave up. Through their valiant efforts, the number of measles cases reduced over the years, although the disease never quite went away. And then, in 2002 and 2005, measles raised its head, reminding the health authori es that it was s ll there. A er the campaign of 2017, Maldivians could proudly say, “I got my dose!” as the country was ready to achieve a measles elimina on status.
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16 © Ministry of health/Maldives
Community participation When community involvement in a government-led ac vity is high, the results tend to be spectacular. As Maldives waged its challenge to keep measles out, it ran special campaigns to increase coverage of the vaccine, including among men up to the age of 25 years and women up to the age of 35 years. The campaign in 2005 achieved 82% coverage, but this was not enough. The follow-up campaign in May 2006 targeted 144 997 people. Although this may not seem large, it included more than a quarter of all Maldivians. The coverage crept up to 85% . When one addi onal dose of MMR vaccine was introduced in the na onal immuniza on schedule at the age of 18 months in 2007, Maldives was on the home stretch. The incidence of measles reduced to zero and no case of measles has been reported since 2009. In Maldives, communi es are highly commi ed and par cipate in the immuniza on campaigns. Atoll-level staff works closely with the island-level health staff who, in turn, work with the community to iden fy mings and loca ons that suit local needs. Care is also taken to ensure that the rou ne work of the health facility is not disrupted. Widespread publicity campaigns on TV, FM radio, social networking sites such as Facebook, Viber and others, ensure that people are informed of the ac vity well in me. Groups of volunteers go from house to house, distribu ng invita on cards to members of the target group and urging people to par cipate in the campaign. At one me, in the 1980s and 1990s, when people heard there was to be an immuniza on campaign, they would run and hide in the jungles, but today, thanks to effec ve informa on-sharing and educa on, people come out voluntarily to par cipate in the ac vity, helping to achieve the >95% target coverage. Volunteers play an ac ve role to ensure community par cipa on and make vaccina on drives effec ve, such as the Catch-up Vaccina on Campaign for measles. They also assist in spreading informa on about vaccina on events, managing vaccina on booths and allaying fears among people regarding vaccina on. Photo opportuni es and camaraderie lend immuniza on campaigns in Maldives an almost celebratory tenor!
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Partnerships Partnerships lie at the heart of the successful health structure in Maldives. As early as the 1950s, the World Health Organiza on (WHO) started working in the country. The first UN agency to open its office in Malé in 1965, its ac ve engagement has helped align the country’s health programme with ongoing developments in the world. As its engagement expanded, WHO, together with other UN agencies such as UNICEF and interna onal partners such as Centre for Disease Control (CDC) and Federa on of Red Cross and Red Crescent, provided significant technical assistance for the EPI and other public health ini a ves. WHO, playing a guiding role in building the island’s capacity for strengthening the surveillance and immuniza on systems, provided guidance and inputs on formula on of the Na onal Development Plans and Health Master Plan, addressed equity concerns as well as specific health problems, and integrated health and human development issues into public policies. The WHO Country Office in Maldives has played a crucial and diverse role in the fight against measles. Through provision of technical and financial resources at all levels of planning, review, training and opera ons, it has helped the Ministry of Health to establish a robust framework for measles elimina on. WHO’s assistance has accelerated efforts to rid Maldives of measles in 2017, well before the regional target of measles elimina on by 2020. WHO helped to develop key strategies, providing exper se in conduc ng training on the EPI and vaccine-preventable diseases, establishing surveillance protocols, reviewing the programme, building laboratory capacity and logis cs management, crea ng community awareness, and suppor ng programme-related ac vi es.
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In Maldives, leading from the front, the Health Minister coordinated efforts to make measles elimina on a mul sectoral triumph with many ministries joining hands with the Ministry of Health to ensure the success of the most recent MR vaccina on drive. The Ministry of Educa on provided assistance in reaching out to schools, the Ministry of Tourism facilitated vaccina on in resort islands through mobile teams of vaccinators, as did the Ministry of Housing and Infrastructure, and the Ministry of Economic Development for the industrial islands. Ministry of Tourism, including private resorts too, did their bit, working with local hospitals on health issues as required, providing resources when there was a shor all and, of course, at the most basic level, coopera ng to ensure their workers were sent for immuniza on. At the local level, the councils worked closely with the local health authori es on immuniza on and other basic health services. The adage “many hands make light work” has been truly effec ve in the context of Maldives. © WHO/Maldives,/Ahmed Hassaan Hassan
It is enthralling to be part of Maldives’ quest for eliminating measles. In the fight against diseases, it is important to dream of victories that benefit the nation but more importantly, her people. The Republic of Maldives dared to dream of such victories. It has not reported any cases of measles since 2009, maintained high immunization coverage and, with the MR Campaign in 2017, it surely has fast-tracked elimination of measles within this year – well before the regional goal of measles elimination. At the heart of this achievement lies the collaboration and partnership of several stakeholders – be it with the UN and international agencies, different ministries, private or public sector, schools or civil society, but most importantly, with the people who are committed to make Maldives a healthy nation with healthier generations. Dr Arvind Mathur WHO Country Representative
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SURVEILLANCE AND TESTING Measles elimination means that for 36 months, there has not been a single reported case of indigenous measles. Not a single case in the entire inhabited islands! How do we track this? It sounds akin to looking for a needle in a haystack. Who has the authority to decide this question and how would they know that the virus that held sway for many years has now lost its teeth?
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Surveillance Surveillance is a complex ac vity involving detec on, no fica on and inves ga on of suspected cases using standard case defini ons (a set of criteria that define a disease). In Maldives, due to an efficient surveillance system, detec ng even a single case of measles anywhere in the country within a mere 48 hours has become a ma er of course. Since 1 January 2017, and in keeping with WHO guidelines, Maldives widened its surveillance ac vi es to include all cases of fever and rash as “suspected measles cases”, an effec ve step in ensuring that measles does not sneak back into the country. Every public health facility is a repor ng site for measles. Within 48 hours of presen ng, a suspected case of measles is evaluated using the standard case format. Throat swabs and blood samples are collected for transporta on to the central laboratory at the Indira Gandhi Memorial Hospital (IGMH) in Malé, maintaining the cold chain, of course. All posi ve measles cases are immediately no fied to the Health Protec on Agency. This rolls out the response plan to detect any evidence of transmission of disease and to stop transmission. In addi on, registers and records are ac vely searched at the health facility to ensure that no case has been overlooked prior to filing their weekly report. Weekly reports are filed regularly and me culously, despite carrying the happy status of “zero cases”.
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22 © Health Protection Agency/Maldives
Laboratories Every modern edifice needs an alarm system to ensure early warning and rapid response to an emergency, whether it is external, like a burglary, or internal, like a fire. Laboratories sound the alarm when there is a confirmed case. At the same me, a virology profile is run on the blood sample that detects the type and source of the virus. Molecular epidemiology analyses the unique gene c profile of the virus in an infected person. Like fingerprints, these are unique. But when the laboratory finds a pa ern that is close, it can draw linkages between the cases and track its origin and movement across borders, atolls and islands. This helps surveillance track the movement of the virus from place to place. The Indira Gandhi Memorial Hospital (IGMH) in Malé was first accredited by WHO in 2010. Since then, it has been the only centre for measles tes ng in the en re country. With its comprehensive database of all suspected cases of measles, and as a part of the global measles–rubella network of laboratories that share informa on, the laboratory plays a significant role in measles elimina on, not only in Maldives but also in the South-East Asia Region. The IGMH laboratory is the national reference laboratory for measles. It started measles testing in 2000. It performs measles serological testing and supports case-based surveillance. The lab technologists have been trained to do measles testing according to the WHO protocols and are using kits provided by WHO. WHO accredited the measles lab in 2010 and 2014. We are also using the WHO proficiency panel for measles serology and molecular panel, and performing well. Dr Milza Abdul Muhusin Laboratory head
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Moving in No house can be occupied without being cer fied as safe and habitable. Maldives worked hard to achieve the status of “no measles”, but it needed an independent “pass” cer ficate before it could be sure it had eliminated the measles virus. We have not had a reported case of measles since 2009. The members of the National Verification Committee, with the combined mandate of measles and polio elimination and rubella control, worked hard to ensure that the National Verification met the standard of Regional Verification requirement set by the WHO Regional Office for South-East Asia. All the documents of fever with rash cases were scrutinized, field visits made and awareness programmes conducted for health professionals. The final push was given to monitoring of the MR campaign and political advocacy. I appreciate the committed high professional work of the NVC members in successfully eliminating measles from Maldives ahead of the regional target of 2020. Now that polio, neonatal tetanus and measles have been eliminated, we hope to be able to eliminate rubella ahead of regional rubella control date set by the Regional Office. Dr Abdul Azeez Yoosuf Chairman, National Verification Committee
Verification committee In 2015, the Na onal Cer fica on Commi ee for Polio Eradica on metamorphosed into the Na onal Commi ee for Verifica on of Measles, Rubella and Congenital Rubella Syndrome, based on the WHO South-East Asia Region Resolu on of 2013 that called for measles elimina on from the Region by 2020. This independent, three-member commi ee tracked the progress being made in elimina on of measles and other diseases, collec ng, analysing and valida ng na onal data, with the assistance of a na onal secretariat. Strong coordina on was maintained between the Na onal Verifica on Commi ee (NVC) and other branches of the ini a ve, such as immuniza on, surveillance, laboratory, atolls and islands, and school health, to pursue the goal of measles elimina on. In 2017, the NVC’s sa sfac on with the results paved the way for Maldives to approach WHO for the final touch – verifica on that it had successfully eliminated endemic measles.
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Closing the door on measles And so, on 20 April 2017, the South-East Asia Regional Verifica on Commission for Measles Elimina on and Rubella/CRS Control (SEA-RVC), an independent body of WHO, verified that Maldives is now free of measles. This spirited na on has shown that it is capable of reinven ng itself, finding new ways of dealing with old problems. It has the ability to protect its people and take them from the backwaters to the forefront of development, overcoming myriad challenges – whether related to climate change or disease.
© Ibrahim Asad
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Lessons learnt When quality building materials are cra ed by experts, the results are bound to be remarkable. In building the edifice of measles elimina on, leadership, planning and implementa on worked together to energize the en re na on in figh ng the measles virus. Leadership invigorates a programme. The commitment and involvement of the leadership of the country, bolstered by a strong immuniza on policy and strategic vision, brought focus to the measles elimina on effort and gave it the stature of a na onal campaign. Planning pays dividends. Detailed plans made for every level ensured that there was alignment with the na onal plan. It enabled efficient use of resources – human, financial and material – and prevented both overlap of responsibili es and “falling between the gaps”. Clarity of roles was ensured.
Today, you can breathe freely in Maldives without fearing that the sweet sea breeze or the warm handshake of a Maldivian carries with it a malicious and often deadly virus.
Returns on investment in health systems and infrastructure are high. Complete elimina on of diseases such as malaria, polio, filariasis and measles is a tes mony to how complete government financing can deliver and sustain achievements in the health sector.
Human capital is priceless. A highly mo vated, passionate and incen vized team of programme and surveillance managers and health staff are pivotal to the delivery of health services. Good human resource prac ces must be con nued, such as the apprecia on awards given to health facili es, acknowledging the contribu on of health workers to the Na onal Immuniza on Programme in 2012. Coordina on is the key. The strong coordina on among various ministries and departments, local government bodies, partners and with the Maldives Technical Advisory Group on Immuniza on, former Na onal Commi ee on Immuniza on Prac ces (NCIP) and the Na onal Programme ensured that every arm of the system worked together in a seamless fashion. Informa on-sharing ensures appropriate responses. No ma er how well individual components work, systems fail when they work in vacuums. In Maldives, the swi flow of informa on has been pivotal to the successful elimina on of measles in the country.
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Protecting the future The measles virus survives. Hidden in the shadows, this hardy antagonist waits for the door to be le ajar to slip in and spread its malaise once more. Vigil has to be maintained to hold this ny tyrant at bay. Genera ons later, when Maldives has been measles-free for many years, the high coverage of measles vaccine must be maintained – always above 95%; but the closer to 100% coverage, the be er. Hawk-eyed surveillance and con nued tes ng of suspected cases, combined with an aggressive and well-managed response to import-related cases, are crucial to preven ng the disease from jumping back into the system. The house must remain protected. Not only today, or tomorrow, but for genera ons to come.
© Ibrahim Asad
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© Ibrahim Asad
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I took my shot! I am proud to do my part to eliminate measles from Maldives.
This is a gift to the future generations, to be treasured.
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World Health House Indraprastha Estate Mahatma Gandhi Marg New Delhi-110002, India www.searo.who.int