Strategic plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region 2014–2020
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region
2014–2020
WHO Library Cataloguing-in-publication data World Health Organization, Regional office for South-East Asia. Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region. 1. Congenital Rubella Syndrome. 4. Rubella. ISBN 978-92-9022-491-4 2. Disease Elimination. 5. Vaccination 3. Measles. 6. South-East Asia. I. Title (NLM classification: WC 582)
© World Health Organization 2015 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: searolibrary@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India
Contents Acronyms........................................................................................................................................v Foreword....................................................................................................................................... vii Executive Summary........................................................................................................................viii 1. Background..............................................................................................................................1 2. Current status of measles, rubella and CRS...............................................................................3 3. Strategic goal, objectives and strategies....................................................................................6 4. National implementation of strategic plan..............................................................................17 5. Regional Office activities.........................................................................................................18 6. Verification of measles (and rubella) elimination.....................................................................19 7. Estimated budget and financing.............................................................................................20 8. Contributions to child health and health systems strengthening..............................................22
ANNEXES Annex 1 Annex 2 Annex 3 Annex 4 Key definitions .........................................................................................................23 Basic minimum indicators..........................................................................................25 Minimum core variables for reporting to the South-East Asia Regional Office............28 Routine measles vaccination schedules (2012) and coverage (1990–2011), by country, SEAR 1990–2011....................................................................................30 History of measles and rubella supplementary immunization activities, by country, SEAR 2000–2012....................................................................................31 Measles case and outbreak classification and incidence, SEAR 2008–2012*.............32 Estimated schedule, scale and cost of SIAs, SEAR 2013–2020...................................35 Estimated schedule, scale and cost of measles and rubella SIAs, SEAR 2013–2020......................................................................................................40 Estimated schedule, scale and cost of SIAs, by state, India 2015–2020.....................45 Estimated schedule, scale and cost of SIAs, by state, India 2015–2020.....................49
Annex 5
Annex 6 Annex 7A Annex 7B
Annex 8A Annex 8B
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Annex 9
Estimated costs for outbreak response immunization, by country, SEAR 2016–2020....................................................................................53 Estimated measles and rubella surveillance costs, SEAR 2013–2020..........................55 Summary of estimated SIA, ORI, and meales and rubella surveillance costs, by country and year, SEAR 2013–2020.....................................................................61 Summary of estimated costs to eliminate measles and prevent rubella and CRS, SEAR 2013–2020.......................................................................................65 Guidelines for Congenital Rubella Surveillance in the South-East Asia Region............69
Annex 10 Annex 11
Annex 12
Annex 13
Annex 13A Flow chart of classification of CRS cases depending on age group............................75 Annex 13B Congenital rubella syndrome case investigation form................................................76
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Acronyms AD Auto-disable AEFI CBAW CRS EPI GFIMS GIVS GVAP IgM IMCI ITAG JRF MCV1 MCV2 MDG MMR MR NML NRAs NVC RC RCV RED RRLs RT-PCR RVC SEAR SIAs VPD UNICEF WHO Adverse events following immunization Child Bearing Aged Women Congenital rubella syndrome Expanded Program on Immunization Global Framework for Immunization Monitoring System Global Immunization Vision and Strategy Global Vaccine Action Plan Immunoglobulin M Integrated management of childhood illness SEAR Immunization Technical Advisory Group Joint reporting form First dose of measles-containing vaccine Second dose of measles-containing vaccine Millennium Development Goal Measles, mumps and rubella vaccine Measlesrubella / measles and rubella National measles-rubella laboratory National regulatory authorities National Verification Committee (For measles elimination) Regional Committee Rubella-containing vaccine Reaching every district Regional reference laboratories Reverse transcription polymerase chain reaction Regional Verification Commission (for measles elimination) South-East Asia Region Supplementary immunization activities Vaccine preventable diseases United Nations Children Fund World Health Organization
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
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Foreword In 2012, the World Health Assembly (WHA) endorsed the Global Vaccine Action Plan (GVAP) and its objective to eliminate measles in 4 WHO Regions by 2015. Since then, Member States of all 6 WHO Regions, including the South-East Asia Region have adopted measles elimination goals. The Strategic Plan for Measles Elimination and Rubella and CRS Control in the South East Asia Region provides a framework for the 11 Member States towards strengthening surveillance systems to meet the measles elimination and rubella/CRS control goal by 2020 (Resolution SEA/ RC66/R5, Sept 2013). This Strategic Plan is based on years of experience in implementing immunization programmes and incorporates lessons learned from polio eradication activities. The strategy stresses the importance of strong routine immunization systems supplemented by campaigns, laboratory-based surveillance, outbreak preparedness and case management, as well as linkage and partnerships and building public trust. To achieve measles elimination, the strategies outlined in this document will need to be implemented. Policy and practice gaps leading to missed opportunities for measles vaccination need to be addressed. To continue on the trajectory of progress towards achieving the 2015 MDGs, global measles control targets and regional measles elimination goals, the 11 Member States in this Region and partners need to increase the visibility of measles elimination activities and make the investments needed to strengthen health systems and achieve equitable access to immunization services. Measles elimination and rubella/congenital rubella syndrome control is one of our flagship programs in this Region and will be supported and monitored by WHO. With strong partnerships, resources and political will, we can, and will work together to achieve and maintain the elimination of measles, and control of rubella and CRS in the South East Asia Region by 2020. Let us use this Strategic Plan to expand equitable access to measles and rubella vaccines to reach the unreached population to save many more precious lives that are our are the future of the globe. I believe that this goal, endorsed by the Sixty-sixth Session of the WHO Regional Committee for South-East Asia in September 2013 will protect and improve the lives of children and their mothers throughout the South-East Asia Region, rapidly and sustainably through well-known and tested interventions.
Dr Poonam Khetrapal Singh Regional Director
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Executive Summary This strategic plan for measles elimination and rubella and congenital rubella syndrome (CRS) control in the South-East Asia Region (SEAR), from 2014 to 2020, fulfils the Regional Committee (RC) request to the Regional Director “to mobilize financial resources and build on the existing partnership in support of measles elimination and rubella/CRS control” (Resolution SEA/RC66/ R5). The dramatic improvements in immunization coverage, case-based measles and rubella surveillance, and regional measles and rubella laboratory network over the past decade have prepared the Region to move forward towards the declared goal of measles elimination and rubella/CRS control by 2020. Most countries in the Region have begun the activities needed to eliminate measles and many are also addressing CRS. All 11 countries in the Region already have measles elimination goals with established target dates, as do the six World Health Organization (WHO) Regions. The measles elimination and rubella/CRS control goal may be reached if four strategic objectives are achieved: (1) achieve and maintain at least 95% population immunity with two doses against measles and rubella within each district of each country in the Region through routine and/or supplementary immunization; (2) develop and sustain a sensitive and timely integrated measles and rubella case-based surveillance system and CRS surveillance in each country in the Region that fulfils recommended surveillance performance indicators; (3) develop and maintain an accredited measles and rubella laboratory network that supports every country or area in the Region; and (4) strengthen support and linkages to achieve the above three strategic objectives. Numerous strategies in line with existing global guidelines are suggested to achieve these four objectives. Guiding principles of country ownership, strengthening routine immunization and health systems; equity and critical linkages with other health sectors; line ministries and civil society are emphasized as being the largest contributors of measles elimination and rubella/ CRS control activities to child health and for achieving the fourth Millennium Development Goal (MDG) 4. Total costs to achieve regional measles elimination and rubella/CRS control are estimated to be US$ 803.1 million, of which US$ 572.8 million (71%) is for supplementary immunization activities (SIAs); US$ 199.5 million (25%) is for measles-rubella (MR) surveillance, including laboratory support; and US$ 26.0 million (3%) is for outbreak response immunization. Costs for the other budget components are estimated to be US$ 4.8 million (1%). These estimates do not include direct support to strengthen routine immunization services.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
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Background
Measles remains a significant cause of morbidity and mortality worldwide. Of the estimated 122 000 global measles deaths in 2012, 43% occurred in the South-East Asia Region and India alone accounted for 14%.1 The importance of measles prevention and control to the achievement of MDG 4 is reflected in the key indicator of measles immunization coverage as a measure of progress towards this MDG. Although rubella is a mild disease, rubella infection during early pregnancy can severely affect the fetus, resulting in spontaneous abortion, stillbirth or an infant born with a combination of birth defects known as CRS. In 2010, an estimated number of 103 000 infants with CRS were born globally, of which 46% were in the South-East Asia Region.2 In September 2013, the WHO Regional Committee for South-East Asia at its Sixty-sixth session noted the progress made in the Region towards measles mortality reduction and rubella control. Having considered the feasibility and associated challenges of eliminating measles and rubella/ CRS, the Committee decided to adopt the goal of measles elimination and rubella/CRS control in the South-East Asia Region by 2020 (Resolution SEA/RC66/R5). With numerous initiatives in immunization and primary health care still in progress, including the intensification of routine immunization, the Region is well-positioned to achieve this goal. With this Resolution, the six WHO Regions have measles elimination goals with established target dates endorsed by their respective Regional Committees. Among the other Regions, the Region of the Americas has already eliminated both measles and rubella. The Western Pacific Region has set a target for measles elimination by 2012, and 32 out of 37 Member States are in the process of verifying the achievement of this target. The target year for the European Region and the Eastern Mediterranean Region is 2015, and for the African Region, it is 2020. The European Region also has a rubella elimination target and the Western Pacific Region has an accelerated rubella control and CRS prevention goal by 2015. Measles elimination activities present unique opportunities to accelerate control of or eliminate rubella and CRS. Because rubella is less infectious than measles, if countries use combined MR vaccines, then when measles is eliminated rubella and CRS will also be eliminated. The strategies for both are similar and can be integrated. Rubella vaccine is highly effective (95% with one dose), safe (whether given independently or in combination) and affordable. The effectiveness of integrated measles and rubella/CRS elimination strategies has been amply demonstrated in other regions. Several countries of the South-East Asia Region have already
1 World Health Organization. Global Control and Regional Elimination of Measles, 2000–2012. WER 2014; 6:45-52. 2 Vynnycky E., Adam E. Report on the Global Burden of Rubella and Congenital Rubella Syndrome, 1996–2010. (Unpublished data).
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introduced the combined measles/rubella vaccine in their national immunization schedule with more likely to follow due to an increasing trend towards combination vaccines that is driven by market forces. Countries in the South-East Asia Region have used different strategies to introduce the rubella-containing vaccine (RCV) including: (1) routine childhood immunization, either one or two doses; (2) selective vaccination among young adolescent and susceptible adult females; (3) incorporating RCV into measles SIAs; and (4) different combinations of the above-mentioned strategies. The recent GAVI (Global Alliance for Vaccination and Immunization) commitments to fund rubella vaccine introduction through national, wide age-range SIAs and a one-time routine introduction grant should lead to increase the use of RCV and thereby a dramatic reduction of rubella virus circulation and children born blind, deaf, mentally retarded, with heart defects and other manifestations of CRS.
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Current status of measles, rubella and CRS
The South-East Asia Region has made dramatic improvements in immunization coverage, casebased measles and rubella surveillance, and establishing a regional laboratory network between 2000 and 2013. Immunization coverage with first dose of measles-containing vaccine (MCV1) increased from 65% in 2000 to 78% in 2013. As per WHO/UNICEF estimates in 2013 (JRF), MCV1 coverage was over 90% in six countries, among which three had more than 80% coverage while two had more than 70%. Nine countries offer a second dose of measles-containing vaccine (MCV2) through routine immunization. By August 2014, all countries except Thailand have conducted national or subnational wide age-range measles SIAs targeting measles susceptible populations with Bangladesh, Bhutan, Maldives, Nepal and Sri Lanka conducting campaigns with combination measles and rubella vaccines. Between 2010 and 2013, India conducted a measles supplementary immunization campaign targeting 139 million children aged 6 months to 10 years (about half that age cohort) in 14 states followed by the introduction of a second dose of MCV2 through routing immunization services and introduced the second dose of MCV2through routine immunization without a preceding campaign in the remaining 21 states (Annex 2). Seven countries offer rubella vaccine through routine immunization in combination with measles and/or mumps vaccine. Four small states in India also offer rubella vaccine through routine immunization. Surveillance capabilities and performance have improved considerably over the last decade. Currently, all countries except India conduct case-based surveillance for measles and rubella among health facilities, and all countries conduct case-based surveillance for measles and rubella cases occurring in the setting of outbreaks. While the magnitude of the burden of rubella/CRS is not fully known, measles surveillance has “unmasked” a substantial burden of rubella in the Region. Among the 10 countries conducting case-based surveillance in facilities, the discarded measles rate was 3.3 per 100 000 population in 2011 based on feedback in a regional meeting in February 2012 (target > 2/100 000), with five countries exceeding the target 2/100 000 population (Annex 3). However, only 34% of suspected cases had serologic specimens collected and tested, and only four of nine countries met the specimen collection rate of 80%. CRS surveillance is routinely conducted in two countries in the Region, Bangladesh and Sri Lanka. In 2014, Nepal established CRS surveillance in five sentinel sites, while Indonesia conducted pilot CRS surveillance and plans to expand its CRS surveillance by the end of 2015. Special studies have been conducted in other countries; between 2000 and 2002, Myanmar conducted active surveillance that documented the presence of CRS during an inter-epidemic period. In India, a review of all studies related to CRS was published in 2012.3 In Maldives, a retrospective review of CRS was conducted in 2003.4
3 Dewan P, Gupta P. Burden of Congenital Rubella Syndrome (CRS) in India: a systematic review. Indian Pediatr. 2012 May; 49(5):377–99. 4 Retrospective rubella review, Maldives. Wkly Epidemiol Rec. 2005 Mar 11; 80(10):88–92.
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The South-East Asia Region laboratory network has a total of 37 laboratories with at least one national measles-rubella laboratory (NML) in each of the 11 countries, and with capacity for virus isolation and genetic sequencing. Three regional reference laboratories (RRLs) include, one in Bangkok, Thailand, for serology and molecular sequencing; one in Chennai, India, for serology; and one in Pune, India, for sequencing and genotyping. Most countries have one NML, except for India, which has 11 and Indonesia, which has four. Among these 37 laboratories, 20 are accredited by WHO and three new laboratories in India (Guwahati, Patna and Bhopal) are pending accreditation. Additionally, Thailand has established a subnational measles laboratory network of 14 laboratories that are guided by the RRL in Bangkok. In 2013, the network tested 15 235 specimens for measles and/or rubella, with 89% of results available within seven days of receipt by the lab (target > 80%). Given a target discarded measles rate of 2 per 100 000 population, the laboratory network will need to evaluate at least 37 500 specimens per year in the absence of measles virus transmission. The network is capable of handling this quantity of specimens and more. The Region’s outbreak preparedness and response capacity has been demonstrated in part by the more than 500 suspected measles or rubella outbreaks reported and investigated in 8 of the 11 Member States during 2013 (Bhutan, Democratic People’s Republic of Korea, Maldives and Timor-Leste did not report any outbreaks). Among 248 confirmed measles outbreaks, 10 108 cases were identified throughout the Region. However, very few specimens were collected for virus detection (target > 80% of outbreaks with specimens collected for virus detection). Some countries, such as Timor-Leste, have been able to mount effective measles outbreak response immunization activities. WHO has provided extensive human resource support for polio eradication to five Member States (Bangladesh, India, Indonesia, Myanmar and Nepal) for over a decade. In 2011, over 1400 people were either contracted or given additional financial support to provide technical and operational support to maintain polio-free status and address other immunization initiatives in the Region. This support is considered to have been critical to achieving polio-free status and likely will be needed to achieve measles elimination and rubella/CRS control. The impact of the operational progress over the past decade has been a 57% reduction in the estimated number of measles deaths from 2000 to 2012 among all countries in the Region except India. India experienced a 71% reduction over the same time period.5 This is expected to significantly increase once the impact of India’s recent measles campaign is factored in. Between 2000 and 2013, the number of measles cases (excluding India) reported in the WHOUNICEF Joint Reporting Form (JRF) decreased by 79% and the measles incidence rate declined by 82% from 163 to 29 per million population. The actual incidence is significantly greater due to underreporting, but the actual decrease in cases may be greater, as measles and rubella surveillance and case detection has improved considerably since 2000. Current and recently circulating measles genotypes appear to be primarily D5 in Myanmar and Thailand; D8 in Bangladesh, India and Nepal; and D9 in Indonesia and Myanmar. In addition, D4 (commonly associated with Europe) has been identified in India and Nepal; D7 in India; G2 5 WHO. Global control and regional elimination of measles, 2000–2012, WER No. 6, 2014, 89, 45–52.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
in Indonesia and Thailand; and G3 in Indonesia. It is important to note that specimens for virus detection are collected rarely during measles and rubella outbreaks and the actual genotype distribution is therefore unknown. As for rubella, the number of reported rubella cases was 6670 in 2012 and 9405 in 2013. Most cases were reported from Bangladesh (3034), India (2568), Indonesia (2456), Nepal (755) and Thailand (539) in 2013. Rubella genotypes include 2B in Bangladesh, India, Nepal and Sri Lanka and 1E in Sri Lanka.
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3 Goal
Strategic goal, objectives and strategies
Elimination of measles and rubella and CRS control by 2020.
Objectives to achieve the goal 1. Achieve and maintain at least 95% population immunity with two doses against measles and rubella within each district of each country in the Region through routine and/or supplementary immunization. 2. Develop and sustain a sensitive and timely case-based measles and rubella and CRS surveillance system in each country in the Region that fulfils recommended surveillance performance indicators. 3. Develop and maintain an accredited measles and rubella laboratory network that supports every country or area in the Region. 4. Strengthen support and linkages to achieve the above three strategic objectives.
Strategies to achieve the objectives Strategic and tactical approaches to achieve measles elimination and rubella and CRS control incorporate principles contained in several global guidance documents including the Global Strategic Plan for Measles and Rubella Elimination, 2012–2020,1 Global Immunization Vision and Strategy (GIVS),2 Global Framework for Immunization Monitoring and Surveillance (GFIMS),3 WHO position papers on measles and rubella vaccines,4,5 WHO guidelines on monitoring progress towards measles elimination,6 the Global Vaccine Action Plan(GVAP) and others. Strategies are listed below their respective target objectives.
Objective 1: Achieve and maintain at least 95% population immunity against measles and rubella within each district of each country in the Region through routine and/or supplementary immunization 1 Use a combination of approaches Depending on the country-specific context, a combination of approaches will be used to effectively reach all children with all vaccines provided by the national immunization programme by their first birthday and beyond, and other populations as determined by their susceptibility profile measured through immunization coverage, surveillance information and studies as appropriate.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
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The emphasis will be on using the routine immunization system to deliver the vaccine, this being a routine activity or campaign. Other opportunities for vaccination may include The World Immunization Week and country-specific child health days. Additional approaches for targeting older ages may include vaccinating at schools, universities, military installations, health-care facilities and factories. Other innovative approaches should be developed based on local circumstances.
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Strategies to achieve rubella and CRS control may differ by country depending on the history of RCV use by the national immunization programme and the age groups currently protected, in addition to other factors specific to the country. However, general strategic immunization approaches likely would be based on the population immunity status as described by the categories listed below. 1. For countries with long-term rubella vaccination programmes or that have conducted national wide age-range SIAs such that female birth cohorts through 40 years of age or older and male birth cohorts up to 22 years of age are protected against rubella as of 2014: ¢¢
Continue to maintain high vaccination coverage through the routine childhood programme Assess susceptibility in child bearing age women (CBAW) to ensure immunity Monitor for outbreaks among adult males
¢¢ ¢¢
2. For countries that have protected both female and male birth cohorts up to at least 15 years and under 20 years of age as of 2014: ¢¢
Continue to maintain high vaccination coverage through the routine childhood programme Assess susceptibility in CBAW to ensure immunity
¢¢
3. For countries that have not yet introduced RCV or have introduced RCV recently such that protected birth cohorts have not yet reached child bearing age: ¢¢
SIAs may be used to target appropriate age groups of both male and female birth cohorts to achieve the rubella and CRS control goal Introduce RCV into the routine childhood programme with MCV1 For countries and areas with susceptible CBAW: ¤¤
¢¢ ¢¢
Vaccinate CBAW of any age with RCV at convenient times (e.g. premarital vaccination, post-partum or when bringing newborn children for vaccination)
4. For all countries and areas: ¢¢
Ensure immunity in health workers to prevent nosocomial transmission of rubella
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Using the reaching every district “RED” approach is a way of not only successfully delivering the vaccine but also strengthening the immunization service delivery system. A school entry requirement for a completed immunization series, especially for measles and rubella, is very effective in preventing transmission of vaccine preventable diseases when children enter communal educational settings. Such requirements also benefit the educational system by reducing absenteeism from school and benefit the economy by reducing parental absenteeism from work as they care for their sick children. 2 Optimize two-dose schedules of measles and rubella-containing vaccines Recommendations for optimal routine MCV1 and MCV2 schedules are included in the WHO measles position paper (2009). MCV1 should be administered at age 9 months in countries with ongoing transmission in which the risk of measles mortality among infants remains high. MCV1 may be administered at age 12 months in countries with low rates of measles transmission (i.e. those near elimination) in which infants have a low risk of infection. MCV2 should be administered during the second year of life, ideally at age 15–18 months, particularly in countries and areas providing MCV1 at 9 months, to reduce the percentage of susceptible children at an early age. Rubella vaccination should be integrated with measles vaccination and this will require the use of either MR or measles, mumps and rubella vaccine (MMR). Currently, WHO recommends that one dose of RCV should be administered (MCV1) either at 9 months or 12 months of age.6 The age depends on the schedule of measles immunization in a country. Giving rubella vaccine only with the second MCV dose results in lower coverage and leaves children unprotected. SAGE (Strategic Advisory Group of Experts) on Immunization also recommends that countries use the same vaccine (either MR or MMR) for both MCV doses. This simplifies vaccine procurement, logistics and recording and decreases vaccine wastage. These recommendations should be taken into consideration in the development of Member States’ national plans of action for measles elimination and rubella/CRS control. 3 Strengthen vaccine management systems Accurate demand forecasting for vaccines, injection equipment and supplies and cold chain at district, provincial and national levels is critical for providing uninterrupted immunization services and avoiding preventable spoilage and wastage. Appropriate temperature maintenance of heatsensitive and cold-sensitive vaccines, and keeping light-sensitive vaccines away from sunlight should be assured. 4 Increase community demand Advocacy and programme communication are critical to the success of the elimination initiative. Advocacy to decision-makers, social mobilization of relevant sectors and interest groups, and culturally appropriate communication strategies and activities should be planned and conducted regularly and at every level to ensure optimal utilization of immunization services. Regular reliable
6 World Health Organization. Meeting of the Strategic Advisory Group of Experts on Immunization, November 2013—Conclusions and Recommendations, WER, 2014; 1(89):1–20.
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delivery of safe immunization services is also important to build trust among parents and the greater community. 5 Improve vaccine, immunization and injection safety Safe immunization requires safe and potent vaccines, safe injection practices and proper waste disposal. Vaccines should be procured from manufacturers that meet internationally recognized standards. National regulatory authorities (NRAs) should perform their necessary functions. Surveillance and response to adverse events following immunization (AEFI) should be able to identify and correct programme errors and ensure programme credibility to the public, and should be a key component of every national plan of action. Auto-disable (AD) syringes and safe disposal of used needles and syringes should be ensured. 6 Monitor and evaluate Programme monitoring and evaluation at every level will identify problems in a timely manner so that adjustments and/or feedback may be provided to staff and local partners on performance, obstacles and opportunities for improvement. Local level monitoring may include routine reviews of EPI registration books and community-based rapid coverage assessments to ensure high-quality immunization programme performance. Operations’ research can help validate proposed strategic or tactical changes in programme implementation before universal application. Periodic independently-conducted coverage surveys may validate administrative coverage and assess programme quality. Appropriate basic training and regular in-service training for vaccinators and other involved health workers including communication skills (new technology, risk communication, etc.).
Objective 2: Develop and sustain a sensitive and timely case-based measles and rubella surveillance system and CRS surveillance in each country in the Region that fulfils recommended surveillance performance indicators 1 Conduct case-based surveillance for measles and rubella The regional consultation, which was held in Delhi in September 2013, forged a consensus on the surveillance standards, agreement on the targets and core indicators and the reporting requirements. The standards and reporting requirements are available as Annexes 2 and 3. All countries will report case-based surveillance data of measles and rubella to the South-East Asia Regional Office by December 2015 and make the required adjustments to their surveillance systems, including case investigation forms, if needed, to ensure sensitive, timely, and complete case-based reporting and investigation of measles and rubella to the national levels facilitating the fulfilment of this requirement. Every country will be supported by at least one NML and will be served by an RRL.
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Expansion of reporting sites to local level facilities and private sector providers is needed to identify additional if any suspected measles cases. Case investigations should include a thorough search for an investigation of additional cases among contacts (both before and after each case) and other potentially exposed people. Details will be available in the regional surveillance guidelines under development. 2 Establish and/or expand CRS surveillance CRS surveillance is necessary to document the impact of rubella vaccination and to identify children with disabilities, early, to provide an opportunity for medical care. Sentinel surveillance may be adequate to provide a baseline and demonstrate programmatic impact. As countries progress toward control and countries gain experience in identifying infants with CRS, the number and location of reporting sites may be extended to other appropriate facilities (e.g. secondary care hospitals and tertiary care centres such as eye, ENT) to increase the sensitivity of the surveillance system. Another approach to identifying infants with CRS is through the identification and active follow-up of pregnant women that are suspected rubella cases or contacts of suspected rubella cases. A national or local registry of pregnant women with confirmed or suspected rubella should be established to record pregnancy outcomes and the clinical and laboratory assessment of the infants. Countries may need to ensure appropriate follow-up measures for children identified as having CRS. The CRS surveillance should be enhanced during outbreaks of rubella regardless of the level of national rubella control. Countries without existing CRS surveillance systems should consider the following steps to establish CRS surveillance (Guidelines for establishing/ strengthening CRS surveillance (Annex 13)). 1. Identify national CRS surveillance coordinator(s) responsible for epidemiological and laboratory components of the system. 2. Determine the health-care facilities at which infants with CRS are likely to be seen and enroll these facilities as sentinel surveillance sites; identify a CRS surveillance coordinator at each facility or group of facilities. 3. Conduct initial and refresher training for participating providers. 4. Initiate CRS surveillance activities. 5. Establish a reporting mechanism. 6. Conduct quality assessment and monitoring of CRS surveillance. 7. Expand CRS surveillance and include other sites, as appropriate. 8. Analyse CRS surveillance data on a quarterly basis, or more frequently if necessary. 9. Provide periodic feedback to all stakeholders involved in the CRS surveillance system. 10. Ensure infection control measures for CRS cases. 3 Provide training in case identification and investigation, and data management and analysis for responsible officials Training of health officials at all levels provides opportunities for advocacy and to integrate other health initiatives.
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4 Provide adequate operational resources to ensure case investigation with collection and transport of specimens for case confirmation and virus detection Travel and required allowances should be provided for case investigations, additional case finding and outbreak response. Specimen collection equipment, shipping containers and shipping costs also should be provided. This can be integrated with the current VPD surveillance system. 5 Assure quality of surveillance data by routine monitoring and supervision Local, district, state/province and national units should monitor data received by lower-level units/ staff and review findings with relevant staff. Identification and correction of logical inconsistencies and/or missing data in case investigation forms, summaries and computerized data bases, in a timely manner, will ensure appropriate interpretation of data for decision-making at every level. Regular supervision may ensure adherence to standard operating procedures. Provide regular feedback of surveillance data and performance to all levels of the system. Feedback may consist of text messages, phone calls, memos, periodic newsletters or bulletins and/or periodic review meetings in which data quality, performance indicators and results of epidemiologic analysis are reviewed and discussed. Regular communication should also be established between surveillance units, programme units and laboratory staff to reconcile data or classification discrepancies and ensure up to date and uniform knowledge and agreement of measles incidence and epidemiology. A CRS case registry should be established at a central place.
Objective 3: Develop and maintain an accredited measles and rubella laboratory network that supports every country or area in the Region 1 Annual accreditation of NMLs and RRLs. Accreditation of NMLs will be conducted annually and accreditation status is given according to WHO criteria based on laboratory performance during the preceding 12 months. Accreditation of RRLs uses similar criteria. Specifically, the criteria for NML accreditation include: 1. Results are reported by the laboratory on at least 80% of samples for measles and rubella Immunoglobulin M (IgM) tests within seven days of receipt. 2. Serological tests are performed on at least 50 specimens annually. 3. The accuracy of measles and rubella IgM detection is at least 90% (as determined from parallel testing on a sample [usually 10%] of positive, equivocal and negative specimens at the RRL). 4. Internal quality control procedures for IgM assays are implemented. 5. The score on the most recent WHO proficiency test is at least 90%. 6. Results from virus detection and genotyping (if performed) are completed within two months of receipt of specimen and data are reported to WHO monthly, for 80% or more, of the samples appropriate for genetic analysis.
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7. The score from the annual on-site review of laboratory operating procedures and practices is at least 80% (may be conducted less frequently for consistently goodperforming laboratories). 2 Case-based laboratory reporting from NML to the National Programme and to the South-East Asia Regional Office on a monthly basis. NMLs should submit a case-based line list report for measles and rubella laboratory data at least on a monthly basis and regularly share virus isolation and genotyping/sequencing data of measles viruses. Timeliness and completeness of reporting laboratory data to the South-East Asia Regional Office will be monitored. 3 WHO and the national authorities will provide adequate operational support for supplies, equipment and specimen transport costs. Operational support includes providing funds and procurement assistance to priority countries in the Region for consumables (including testing kits), operational and shipping costs, and laboratory equipment related to both serologic and molecular laboratory needs. 4 WHO will provide technical support to RRLs and NMLs to obtain baseline genetic information on measles and rubella viruses using stored samples as well as genetic information from both outbreaks and sporadic cases in order to verify the absence of endemic measles virus transmission. Technical support will include but not be limited to meetings, workshops and hands-on training. Regular updates of laboratory methods and techniques related to measles and rubella case confirmation and virus detection will be provided to network laboratory members.
Objective 4: Strengthen support and linkages to achieve the above three strategic objectives 1 Advocacy, social mobilization and communication 1. Advocacy, social mobilization and communication foster community ownership and demand for immunization that is necessary to increase coverage, identify, report and respond to suspected measles, rubella and CRS cases and ultimately to achieve measles, rubella and CRS goals. 2. Budgeted national plans for advocacy, social mobilization and communication should be prepared to address the needs for measles elimination and control of rubella/CRS. 3. National and subnational coordination and advisory bodies for measles elimination and rubella/CRS control should be formed (that includes government, nongovernment, bilateral and international partners). Members of existing interagency coordinating committees and advisory bodies would be logical members of measles elimination and rubella/CRS control coordination and advisory bodies. Terms of reference should be explicitly described; meeting minutes with action points specifying responsible people and timelines should be prepared and distributed after every meeting.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
4. Representatives from ministries of education, defence and labour as well as from individual schools and universities, military installations and factories are all logical partners interested in measles elimination and rubella control and can help organize special immunization initiatives for their staff and identify and report suspected measles and rubella cases. 5. A regional verification commission (RVC) and national verification committees (NVC) for measles (and rubella/CRS) elimination should be well-formed ahead of achieving elimination. These can be effective advocacy and communication instruments to government and professional societies. 6. Communication strategies may incorporate traditional media channels, lessons from commercial and public marketing campaigns and social media. Strategies should address the nature and threat of measles, rubella and CRS, the safety, efficacy and contraindications of the vaccines and strategies to manage AEFI. 2 Outbreak preparedness and response WHO has developed guidelines for measles outbreak investigation and response in mortality reduction settings that are also applicable to elimination settings.7 Once a country reaches the elimination or near-elimination stage, however, an outbreak is defined by evidence of any measles transmission within an area, i.e. two temporally and geographically linked confirmed cases. The approach to outbreak response immunization (ORI) varies depending on the level of susceptibility in the population, the risk for spread and complications and the existing healthservice infrastructure and resource availability. Small localized self-limited outbreaks may occur following importations. Detailed analysis of available measles/rubella surveillance data, timely and thorough case and outbreak investigations with contact tracing, and laboratory confirmation of suspected cases are needed to accurately characterize outbreaks. An accurate understanding of population immunity and surveillance quality through rapid district and/or provincial risk assessments by age group would provide valuable information in determining the need, timing and extent to be covered of ORI. A budgeted outbreak preparedness plan for locally funded outbreak response and provision of vaccine stocks should be established at national and subnational levels for emergency use. Risk or vulnerability assessments that assess population immunity, surveillance performance and migration patterns should be conducted periodically. Ideally, supplementary immunization interventions should occur based on such periodic vulnerability assessments before outbreaks occur. Measles and rubella outbreak response efforts should also seek to reduce morbidity and mortality by providing appropriate case management. Administration of Vitamin A to people with measles decreases the severity of the disease and the risk of death or xerophthalmia, and its possible progression to blindness. All suspected measles cases should receive two doses of Vitamin A (three doses if the child presents with ocular complications), following guidelines for the integrated management of childhood illness (IMCI) and supportive care at the first referral level, including additional fluids (such as oral rehydration solution), antipyretics and, when appropriate (for secondary bacterial infections), antibiotics and referral to the next level of care.8
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During and following rubella outbreaks, active CRS surveillance should be implemented with special attention to investigation and active follow-up of pregnant women with suspected rash illness in the affected area. Additional measures could include investigation and vaccination of susceptible contacts to reduce the risk of exposure to pregnant women. 3 Measles immunization in an emergency7 An emergency is a situation in a subnational area, a country, a region or a society where there is considerable or even total breakdown of infrastructure, civil society or other authority. Emergencies can be caused by natural disasters, human events or a combination of both. Common natural disasters that cause emergencies include floods, typhoons/cyclones, forest fires, earthquakes, tsunamis and even volcanic eruptions. Some of these can be anticipated and prepared for; there are areas that are affected by floods every year, while other areas are hit by typhoons/cyclones every year. Other natural disasters such as earthquakes, tsunamis and volcanic eruptions are unpredictable and more difficult to prepare for. Emergencies caused by human events – war, revolution, famine – are much less predictable. All these events frequently result in displaced people living in overcrowded conditions with poor sanitation and shelter and with food and safe water in short supply. In the short term, four types of communicable diseases cause 50% to 95% of deaths: diarrhoeal disease, acute respiratory infections (ARIs), measles and malaria. The very young, the very old, pregnant women, the malnourished and people with other chronic diseases are disproportionately affected. The primary reason for high measles morbidity and mortality in emergencies is the failure to immunize against measles before the crisis. In a crisis, the local immunization programme may be disrupted, resulting in even more of the youngest children vulnerable to measles. In such an environment, measles can spread rapidly and result in high morbidity and mortality. The first core commitment for children in emergencies is to vaccinate all children 6 months through 14 years against measles. If any case, it is imperative that all children 6 months through 4 years be immunized. Vitamin A supplementation must be provided also. The Region suffers multiple natural disasters every year and Member States have disaster emergency response plans. Measles vaccination is a key part of the health response in many situations. Activities before an emergency should include comprehensive planning, adequate funding, identification of adequate and accessible resources and supplies and staff training. As countries eliminate measles, it is possible that the target age range for measles vaccination in an emergency response will decrease, but until all countries have eliminated measles, all children 6 months through 4 years in affected populations should be immunized against measles. 4 Research and development Research helps define effective strategies and tactical interventions to achieve the measles elimination and rubella/CRS control goal. Potential research topics might include certain steps. 1. Evaluate the causes of and risk factors (by age group) for measles outbreaks in post-SIA and high coverage settings, especially among adults.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
2. Determine the transmission patterns and role of minorities, marginalized groups and migrants in sustaining measles transmission. 3. Evaluate the impact of different measles outbreak response triggers and strategies to interrupt measles virus transmission. Potential factors that could trigger a response include number of cases, generations/duration of transmission, geographic extent of outbreak, MCV coverage/population immunity in surrounding areas. Response strategies include timing, geographic scope and targeted ages of response. 4. Evaluate the soundness and feasibility of currently proposed and alternative criteria for verification of measles elimination in large and small countries, and assess which of these are relevant to verification of rubella control and elimination. 5. Compare acute fever and rash with clinical measles and rubella case definitions for positive and negative predictive value and acceptability by health workers and laboratory staff. 6. Evaluate the operational feasibility of using aerosolized measles vaccine during SIAs or routine immunization sessions. 7. Determine the CRS burden of disease in priority countries. 8. Evaluate the usefulness and feasibility of potential indicators to monitor CRS surveillance sensitivity (e.g. congenital cataract rates). 9. Susceptibility of children born to mothers who did not have natural infection but previously had only MCV1; the age their immunity starts waning. 5 Improve management of human resources at all levels; specially at middle level Monitoring of human resource capacity and availability is an important component of overall programme monitoring, particularly if frequent staff turnover exists. Extensive collaboration with other programme units is important to effectively plan capacity-building and efficiently utilize available staff at all levels. 6 Identify and utilize synergistic linkages of integrated programme efforts Maternal and child health programmes, nutritional support programmes, pandemic, avian and seasonal influenza initiatives, malaria prevention and others all have mutual interests in effective delivery systems, surveillance and data management. With limited financial resources, collaboration with other programmes is likely to be necessary to achieve complementary programme objectives and promote programme synergies. 7 Programme monitoring and oversight The Regional Immunization Technical Advisory Group (ITAG) will serve as the oversight body for measles elimination and rubella/CRS control. The ITAG will meet annually and ad hoc to review progress and provide advice on issues and the way forward.
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In addition to the agreed targets and indicators, the following operational milestones will be monitored. 1. By the end of 2014: a. Regional surveillance guidelines and national action plans will be in place. b. All countries will have initiated case-based reporting of measles/ rubella and CRS. c. All countries will plan to have adequate access to an accredited national and reference laboratory. 2. By the end of 2015: a. Case-based surveillance for measles and rubella will have been established in all countries. b. All countries will have initiated sentinel surveillance for CRS. c. Susceptibility profile of populations to measles and rubella in all countries will have been determined. d. RVC and NVC established in all countries. e. All countries will have adequate access to an accredited national and reference laboratory. 3. By the end of 2016: a. All countries in the Region will have an optimized two-dose measles immunization schedule that includes rubella vaccine. b. All countries with large susceptible populations to measles or rubella will have conducted high-quality wide-age range immunization campaigns against both measles and rubella. 4. By the end of 2018: a. All countries will have undergone a comprehensive surveillance and immunization reviews. 5. By the end of 2019: a. All countries will have updated their national plan of action. b. The NVC in each country will produce a comprehensive report on the status of measles elimination and rubella and CRS control. c. The RVC will report on the status of all countries and the prospects for meeting the 2020 goals. 6. By the end of 2020: a. All NVCs will fully assess their country for measles elimination and rubella and CRS control. b. New regional plan of action for measles and rubella and CRS for ensuring sustainability of the achievements.
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National implementation of strategic plan
Budgeted national measles elimination and rubella/CRS control plans of action should be developed or updated based on this regional strategic plan and global guidelines. Plans should be prepared jointly with other concerned health sectors, line ministries, civil society stakeholders and partners. Action plans may be used to guide incorporation of measles and rubella specific activities and resource needs in other planning documents such as: 1. comprehensive multi-year plans for EPI; 2. detailed EPI implementation/operational plans (with budgets) that include health and other sectors; and 3. annual immunization (EPI) operational/work plans. Annual EPI operational/work plans are necessary at the national and subnational level to translate strategic plans into action, strengthen collaborative mechanisms with other programmes and partners, and effectively mobilize resources from government and national and international partners. National immunization programmes and ministry of health officials need to play a leading role in advocating for the human, material and financial resources required to achieve measles elimination and rubella/CRS control.
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5
Regional Office activities
WHO’s South-East Asia Regional Office, in collaboration with UNICEF and technical partners, will continue to provide technical assistance to countries in support of their efforts to eliminate measles by 2020 and control rubella/CRS transmission, and maintain elimination thereafter. Specific assistance will be provided as needed to support routine and SIAs and epidemiologic and laboratory surveillance through on-site visits, electronic communication and periodic training workshops, reviews or technical consultation meetings. The South-East Asia Regional Office will coordinate regional epidemiologic and laboratory surveillance data management to monitor regional and country-specific progress towards achieving and sustaining measles elimination and rubella/CRS control and provide feedback to Member States and partners as appropriate through electronic publications and direct correspondence. WHO’s South-East Asia Regional Office, in collaboration with UNICEF, will conduct advocacy and resource mobilization efforts at the regional level while country offices and national counterparts do so at the national level. WHO’s South-East Asia Regional Office will also convene the ITAG and establish and convene meetings of the Regional Commission for verification of measles elimination.
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Verification of measles (and rubella) elimination
Verification criteria and processes will be needed to eventually verify achievement of the goal at both regional and national levels. RVCs and NVCs should be established early on at regional level and in all countries to identify and recognize countries that achieve elimination before 2020 and provide guidance and encouragement for those that have not yet achieved elimination. As some countries may very likely eliminate rubella in the process of eliminating measles, RVCs and NVCs should be empowered to verify rubella elimination as well. The Regional Director will appoint RVC members and a Chair, while respective ministers of health will appoint NVC members and chairs. Members of national certification committees for polio eradication could be recruited to serve on NVCs. Terms of reference should be explicitly described. WHO’s South-East Asia Regional and country offices will serve as secretariats to the RVC and NVCs, respectively.
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7
Estimated budget and financing
It is assumed that countries will conduct large-scale SIAs and ORIs as needed, and implement ongoing case-based surveillance for measles, rubella and CRS. Assumptions are also made about the need for technical support, advocacy and communication strategies in the Region.
Projected costs Estimated costs for proposed SIAs, ORIs, measles and rubella surveillance including laboratory support, CRS surveillance, communication, research, technical support, and verification are provided in Annexes 7 to Annex 12. In summary, total estimated costs for SIAs, ORIs and measles and rubella surveillance, by country, during 2013 through 2020 are given in Table 1. These costs do not include current costs for the India SIAs that are being completed in 2013, and assume that India and Indonesia will conduct future SIAs and ORIs with MR. Table 1 Estimated costs for SIAs, ORI and MR surveillance, by country, SEAR, 2013–2020 (In US dollars) SIA 102 814 211 0 0 290 899 737 121 342 575 0 15 664 547 9 522 430 0 31 287 679 1 247 148 572 778 327 ORI 4 141 806 25 620 636 223 9 005 080 7 397 251 9 588 1 390 490 1 294 807 615 509 1 413 239 84 917 26 014 530 MR Surveillance 14 323 926 552 858 836 528 149 261 957 10 130 164 179 308 7 447 232 11 435 892 444 160 4 622 367 276 386 199 510 780 Total 121 279 943 578 479 1 472 751 449 166 774 138 869 990 188 897 24 502 269 22 253 129 1 059 669 37 323 285 1 608 451 798 303 636
Country Bangladesh Bhutan DPR Korea* India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Total
*Democratic People’s Republic of Korea
Total estimated costs to eliminate measles and control rubella/CRS for the Region by cost category and year are summarized below in Table 2. As above, these costs also assume that India and Indonesia will use MR vaccine in future SIAs and ORIs, and do not include the current costs for phase 3 of India’s SIA that is being completed in five states in 2013.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Total costs are estimated to be US$ 803.1 million, of which US$ 572.8 million (71%) is for SIAs, US$ 199.5 million (25%) is for MR surveillance, including laboratory support, and US$ 26.0 million (3%) is for ORIs. Costs for the other budget components are estimated to be US$ 4.8 million (1%). These estimates do not include direct support to strengthen routine immunization services. Table 2 Summary of Estimated Costs to Eliminate Measles and Rubella and CRS Control, SEAR 2013–2020 (In US dollars) 2013 62 708 959 0 1 4 191 491 160 000 50 000 50 000 50 000 0 77 210 450 2016 41 408 263 2 585 761 20 159 351 276 480 50 000 50 000 50 000 50 000 64 629 856
2012–2015 SIA ORI MR Surveillance CRS Surveillance Communication Research Tech Support Verification Total 2016–2020 SIA ORI MR Surveillance CRS Surveillance Communication Research Tech Support Verification Total Summary SIA ORI MR Surveillance CRS Surveillance Communication Research Tech Support Verification Total
2014 121 463 489 0 14 275 401 192 000 50 000 50 000 50 000 200 000 136 280 890 2017 305 091 3 721 898 27 129 298 331 776 50 000 50 000 0 50 000 31 638 064
2015 196 918 757 0 21 208 767 230 400 50 000 50 000 150 000 100 000 218 707 924 2019 51 736 846 6 064 527 34 339 400 477 757 50 000 50 000 100 000 100 000 92 918 530
Total 381 091 204 0 49 675 659 582 400 150 000 150 000 250 000 300 000 432 199 263 2020 30 180 143 9 838 730 34 188 736 573 309 50 000 50 000 100 000 200 000 75 180 919
2018 68 056 778 3 803 613 34 018 336 398 131 50 000 50 000 100 000 50 000 106 526 858
Total 191 687 122 26 014 530 149 835 121 2 057 454 250 000 250 000 350 000 450 000 370 894 227
2013–2015 381 091 204 0 49 675 659 582 400 150 000 150 000 250 000 300 000 432 199 263
2016–2020 191 687 122 26 014 530 149 835 121 2 057 454 250 000 250 000 350 000 450 000 370 894 227
2013–2020 572 778 327 26 014 530 199 510 780 2 639 854 400 000 400 000 600 000 750 000 803 093 490
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8
Contributions to child health and health systems strengthening
An investment in measles elimination provides multiple benefits to child survival in addition to decreased morbidity and mortality from measles. The Joint WHO/UNICEF South-East Asia/ Western Pacific Regional Child Survival Strategy identifies measles immunization coverage as one of the core indicators to track progress in child survival, and IMCI protocols seek to utilize opportunities to provide MCV and other vaccines to children presenting to health facilities. Measles elimination contributes to achieving MDG 4: “Reduce by 2/3, between 1990 and 2015, the under-five mortality rate.” One of the three indicators for monitoring progress towards achieving MDG 4 is the “proportion of one year-old children immunized against measles.” Benefits provided by measles elimination are many. First, control of measles infection prevents the increased susceptibility to and mortality from pneumonia and diarrhoea that lasts for months following infection. At a global level, diarrhoea and pneumonia cause 36% of deaths among children under five years old. Second, the need to achieve 95% coverage with two doses of MCV requires programme managers at every level to refocus efforts on strengthening routine immunization service coverage and quality, using strategies recommended in the (GIVS). Third, measles and rubella SIAs can and should be used to strengthen routine immunization services by identifying and developing strategies for reaching high-risk areas and populations, strengthening vaccine and cold-chain management, providing additional training on important immunization and health system components, including routine immunization monitoring together with SIA coverage monitoring and other areas. Fourth, administering MCV2 at 15–24 months of age creates a platform for other interventions such as DTP4, OPV4, Vitamin A, deworming medicine, and growth monitoring. Fifth, provision of nutritional supplements such as Vitamin A with routine MCV1 and during SIAs provides additional protection of children against disease. Sixth, establishing school-entry requirements provides an opportunity to ensure fully immunized status of children with all antigens, decreases child absenteeism from school and parental absenteeism from work and strengthens collaboration between health and education ministries establishing relationships that will help promote school health overall. Finally, use of standardized monitoring indicators and requirements to report, analyze, interpret and feedback data builds capacity to strengthen monitoring and surveillance systems and data management over all, thereby, strengthening health systems.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Annex 1 Key definitions For the purpose of case-based surveillance for measles and rubella in the South-East Asia Region, a measles suspect case definition will be used as the starting point. However, the testing algorithm will include testing first for measles, then all measles-negative samples will be automatically tested for rubella. 1. Starting case-based reporting from January 2014 with weekly reporting from subnational level to national level, and from national levels to the WHO Regional Office 2. A suspected measles case: A suspected measles case is any person in whom a health worker suspects measles, or any person with fever and maculopapular rash (non-vesicular) with cough, coryza or conjunctivitis. 3. A suspected measles outbreak: A suspected measles outbreak is the occurrence of five or more suspected measles cases over a period of one month in a population size of at least 100 000. [However, countries that are already advanced in their measles elimination activities, lower than five suspected cases, may be used]. 4. A confirmed measles outbreak: A confirmed measles outbreak is the occurrence of three or more laboratory confirmed measles cases over a period of one month in a population size of at least 100 000, and even in a situation where less than three laboratory cases are confirmed, if epidemiologically linked, it would still be considered an outbreak. [In a large outbreak, in order to manage the pressure on laboratories, 10 cases will be tested by serology. If an outbreak has less than 10 cases, all should be tested]. 5. An adequately investigated measles outbreak: An outbreak is considered adequately investigated when the following activities are completed: ¢¢ ¢¢ ¢¢ ¢¢
initial visit to the cases within 48 hours of report; house-to-house search for cases within one week of report; information collected on all core epidemiological data variable; samples for serology from 10 suspect cases, or all suspected cases if fewer than10 cases, collected; urine and nasopharyngeal samples are collected for viral isolation and characterization from at least five suspected cases.
¢¢
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6. Case classification (a) Laboratory confirmed: A case that meets the clinical case definition and is laboratory confirmed. (b) Epidemiologically confirmed: A case that meets the clinical case definition and is linked to a laboratory-confirmed case. (c) Clinically confirmed: A case that meets the clinical case definition and for which no adequate blood specimen was taken. (d) Discarded non-measles non-rubella: A suspected case that has been investigated and discarded as non-measles and non-rubella case using: i. laboratory testing in a proficient laboratory; or ii. epidemiological linkage to a laboratory-confirmed outbreak of another communicable disease that is neither measles nor rubella.
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Annex 2 Basic minimum indicators
Indicator
Target Absence of indigenous measles transmission
Definition The numerator is the confirmed number of measles or rubella cases for the year and the denominator is the population in which the cases occurred multiplied by 1 000 000. When numerator is zero, the target incidence would be zero.
1. Disease Incidence (i) Annual incidence of confirmed measles cases (per one million population)
(ii) Annual incidence of confirmed rubella cases (per one million population)
(iii) Report annually 2. Adequacy of investigation (i) Proportion of all suspected measles and rubella cases that have had an adequate investigation initiated within 48 hours of notification > 80% The numerator is the number of suspected cases of measles or rubella for which an adequate investigation was initiated within 48 hours of notification and the denominator is the total number of suspected measles and rubella cases, multiplied by 100.
(ii) Report as often as routine reports – weekly
3. Outbreak investigation (i) Percentage of suspected measles outbreaks fully investigated > 80% > 80%
(i) The numerator is the number of confirmed outbreaks that meet the fully investigated outbreak criteria and the denominator is the total number of suspected outbreaks multiplied by 100
(ii) Percentage of suspected outbreaks tested for virus detection
(ii) The numerator is the number of confirmed outbreaks tested for virus detection and the denominator is the total number of suspected outbreaks multiplied by 100 The numerator is the number of infants who received MCV1 & MCV2 and the denominator is the surviving birth cohort multiplied by 100
(iii) Report as often as routine reports -- weekly
4. Immunization coverage (i) MCV1 & MCV2 coverage nationally and by subnational administrative units 95% nationally, 90% subnationally
(ii) Report annually
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Indicator
Target
Definition
5. Timeliness of reporting (i) Proportion of surveillance units > 80% reporting to the national level on time
(i) The numerator is the number of surveillance units reporting on time and the denominator is the total number of surveillance units in the country multiplied by 100 [Remember each reporting unit will report 52 times a year]
(ii) Proportion of countries reporting to their WHO Regional level on time
100%
(iii) Report as often as routine reports -- weekly
(ii) The numerator is the number of countries reporting on time to the Regional Office and the denominator is the total number of countries multiplied by 100 The numerator is the number of non-measles non-rubella discarded cases and the denominator is the total population of the country multiplied by 100 000
6. Reporting rate of discarded nonmeasles non-rubella cases
(i) A national reported discarded rate of non-measles, nonrubella per 100 000 population
> 2%
(ii) Report monthly 7. Representativeness of reporting (i) Proportion of subnational administrative units reporting at least two discarded nonmeasles, non-rubella cases per 100 000 population > 80% The numerator is the number of subnational units reporting at least two discarded non-measles non-rubella cases per 100 000 and the denominator is the total number of subnational units multiplied by 100
(ii) Report monthly 8. Laboratory confirmation (i) Proportion of suspected cases with adequate specimens for detecting acute measles or rubella infection collected and tested in a proficient laboratory > 80% The numerator is the number of suspected cases from whom adequate specimens for detecting measles or rubella were collected and tested and the denominator is the total number of suspected measles or rubella cases multiplied by 100 [Epi linked cases should be removed from the denominator]
(ii) Report as often as routine reports -- weekly
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Indicator
Target
Definition The numerator is the total number of specimens received in the laboratory within five days of collection and the denominator is the total number of specimens received by the laboratory multiplied by 100 The numerator is the total number of specimens for which laboratory results were available within four days of receiving the specimen and the denominator is the total number of specimen received for testing multiplied by 100
9. Timeliness of specimen transport (i) Proportion of specimens received at the laboratory within five days of collection > 80%
(ii) Report monthly 10. Timeliness of reporting laboratory results
(i) Proportion of results reported by the laboratory within four days of receiving the specimen
> 80%
(ii) Report monthly
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Annex 3 Minimum core variables for reporting to the South-East Asia Regional Office ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤
Case EPID ID/Outbreak Identifier ID Country, state, district, sub-district, block Sex Date of birth/age Date of onset of fever Date of onset of rash Cough, coryza or conjunctivitis [Yes/No] Date of notification Date of investigation Vaccination: ¢¢ ¢¢
Number of MCV doses, date of last dose Number of RCV doses, date of last dose
¤¤ ¤¤
Travel history Serology: ¢¢ ¢¢ ¢¢ ¢¢ ¢¢
Specimen ID for serology Date and type of specimen collected Date of serology specimen sent to lab Date of serology specimen received at lab Adequate specimen sample
¤¤
Virology: ¢¢ ¢¢ ¢¢ ¢¢ ¢¢
Specimen ID for virology Date and type of virology specimen collection Date of virology specimen sent to lab Date of virology specimen received at lab Adequate specimen sample
¤¤
Laboratory result ¢¢ ¢¢ ¢¢
Date result sent to national programme Results (Neg, Equiv, Measles IgM+, Rubella IgM+) Measles virus detection: Positive, Negative
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
¢¢ ¢¢ ¢¢ ¢¢ ¢¢
Genotype of measles Date Genotype result of measles sent to national programme Rubella virus detection: Positive, Negative Genotype of rubella Date genotype result of rubella sent to national programme
¤¤
Final classification ¢¢ ¢¢ ¢¢ ¢¢ ¢¢ ¢¢
Measles lab confirmed Measles epidemiological link Measles clinically compatible Rubella lab confirmed Rubella epidemiological link Discarded
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Annex 4 Routine measles vaccination schedules (2012) and coverage (1990–2011), by country, SEAR 1990–2011
Country 93 95 99 74 85 98 84 86 99 98 73 62 66 70 73 63 98 98 98 98 96 96 61 99 99 97 98 98 99 99 96 48 88 86 90 79 81 85 74 73 96 96 55 88 88 87 82 81 78 84 86 80 75 99 96 55 96 97 98 97 97 97 97 97 96 97 77 71 99 94 56 80 78 74 76 76 79 77 76 74 72 76 98 73 71 99 94 76 99 84 71 99 94 74 74 74 74 69 71 59 68 62 56 57 59 58 77 97 86 81 95 96 99 99 98 98 99 96 96 95 95 98 92 78 63 49 57 77 98 89 67 94 96 95 95 94 99 95 90 93 87 88 78 78 78 77 71 84 34 55 77 96 88 73 94 93 91 88 93 92 89 83 88 81 76 75 77 74 71 71 72 69 85 50 66 79 95 86 65 89 92
Age for MCV1
Vax Ags
2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 79 85 67 72 63 96 82 56 87 91 78 81 83 67 66 97 77 58 84 86 74 84 99 59 68 86 71 58 86 80 69 86 99 51 65 98 68 58 82 74 68 89 98 43 61 97 67 57 79 79 65 93 98 56 58 96 68 57 80 80
Bangladesh
38w
mr
93
Bhutan
9m
mr
94
DPR Korea*
9m
m
99
India
9-12m
m
74
Indonesia
9m
m
84
Maldives
9m
mmr
99
Myanmar
9m
m
86
Nepal
9m
mr
88
Sri Lanka
9m
mmr
99
Thailand
9m
mmr
99
Timor-Leste
9m
m
70
*Democratic People’s Republic of Korea
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
MCV1 coverage data from 2001-2013 for member states are WHO-UNICEF estimates; MCV2 coverage data is from country JRF reports
Source: Brief Status Report of South-East Asia Region on Measles and Rubella Control/Elimination, Table 1; http://apps.who.int/immunization_monitoring/en/globalsummary/timeseries/ tswucoveragemcv.htm and http://apps.who.int/immunization_monitoring/en/globalsummary/timeseries/tscoveragemcv2.htm. Accessed on 16 July 2014
Annex 5 History of measles and rubella supplementary immunization activities, by country, SEAR 2000–2012
Country Rolling-national National National Sub–national National National Rolling–national Rolling–national Sub–national National Rolling–national National National Rolling–national National National Rolling –national Rolling –national National Rolling –national National National mr m mr m m m m m m 9 M–5 Y 9 M–5 Y 9 M–5 Y 9 M–15 Y 9 M–5 Y 9 M–15 Y 10–14 Y 16–20 Y 6–12 M 6 M–15 Y 9–59 M 6 M– 14 Y mr, mmr 6–34Y, 4–6Y m 9–59 M m 6M–15 Y m 9 M–10 Y mr m 9 M–44 Y 6 M–45 Y 338 040 16 123 376 139 490 164 42 710 910 59 663 573 174 526 5 670 597 6 056 000 6 432 064 9 671 113 3 903 515 9 958 196 1 987 847 1 890 326 176 587 519 005 167 136 494 427 m 0 M–14 Y 214 128 mr 9 M–14 Y 51 745 231 m 9–59 M 18 136 066 m 9 M–10 Y 35 680 911
Year
Type
National or Sub-national
Vax Ags
Target Ages
SIA Target pop (no.) No. vax 36 012 154 18 085 685 53 644 603 214 128 332 041 16 109 432 118 566 640 40 425 408 57 235 120 140 104 4 910 950 5 706 351 6 267 535 9 985 161 3 634 277 9 991 152 1 897 173 1 362 108 173 187 285 126 126 823 454209
Cov (% of SIA target) 101 100 104 100 98 100 85 95 96 80 87 94 97 103 94 100 95 72 98 55 76 92
2005–2006
Catch up
Bangladesh
2010
Follow Up
2014
Catch up
Bhutan
2000
Catch Up
DPRK*
2006 2007
Catch Up Catch Up
India
2010–2013
Catch Up
Indonesia
2000–2007
Catch Up
2008–2011
Follow Up
Maldives
2005 2007
Catch Up
2002–2004
Catch Up
Myanmar
2007
Follow Up
2012
Follow up
2004–2005
Catch Up
Nepal
2008
Follow Up
2012
Catch up
2003
Catch Up
Sri Lanka
2004
Catch Up
2013
Campaign
Thailand
None
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
2003–2006
Catch Up
Timor-Leste
2009
Follow Up
2011
Catch up
*Democratic People’s Republic of Korea
Source: Brief Status Report of South –East Asia Region on Measles and Rubella Control/Elimination, Table 7.
31
32 Monthly Aggregate VPD Surveillance Reports Confirmed measles cases (Routine+Outbreak) Lab 55 560 1 445 43 30 – 13 10 21 6 – – – – – – – – – – – – – – – – – – 36 64 – – – – – – – – – – 70 – – – 66 0.3 0.3 0.1 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 – 8 8 50 0.2 – – 0.0 1 1 8 68 9.5 11.2 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 – 5 26 66 9.1 35.8 – – 10 88 11.9 13.5 – 2 15 70 9.3 20.0 0 0 1 0 0 0 ND 0 0 ND 0 315 128 243 231 177 174 – – – 99 13.2 0.0 – – 0.0 0.0 81 48 562 640 14 807 10.1 4.4 170 1 1 1 189 58 186 186 68 101 – 484 527 14 673 9.9 3.5 217 0 2 802 310 4 557 10 299 6.8 30.3 333 91 2 802 48 132 13 6 485 2 580 8 589 8 240 4 228 6 364 1 092 152 1 804 6 716 4.4 11.8 185 33 1 092 156 77 288 5 033 3.3 1.9 146 7 156 Epi-linked Clinical Total Incidence No. No. outDiscarded Discarded / per million outbreaks breaks lab cases 100K pop* pop. reported confirmed 22 33 31 48 132 13 34 44 46 44 62 63 Measles Outbreaks** Rubella Outbreaks** No. No. cases from Mean no. JRF report- No. out- cases from Mean no. lab-concases/ ed rubella breaks lab lab-concases/ firmed outbreak cases confirmed firmed outbreak outbreaks outbreaks 3 034 3 245 5 631 12 963 13 076 5 526 6 2 3 9 15 2 0 1 5 0 82 3 698 1 232 ND ND ND ND 87 66 89 193 145 59 0 0 0 ND ND ND ND 66 23 16 15 56 24 2 787 2 683 4 744 12 467 13 076 5 526 2 568 1 066 777 709 4 454 1 615 32 41 53 65 90 94 39 46 49 47 80 67 1.5 13.0 8 520 14 856 15 200 15 447 99 85 98 92 76 58 66 70 36 64 37.4 5.3 4.9 18.3 0.0 1.3 13.5 28.9 8.4 10.0 0.0 0.0 0.0 0.0 10.8 14.8 27.1 25.7 46.5 37.2 5 321
Annex 6 Measles case and outbreak classification and incidence, SEAR 2008–2012*
JRF Reports
Country
Year
Population JRF (in millions) 1 Reported Incidence Suspected per million measles measles pop cases cases
2013
154.4
237
2012
152.4
1 986
Bangldesh
2011
150.5
5 625
2010
148.7
788
2009
147.0
718
2008
145.5
2 660
2013
0.8
0
2012
0.8
1
Bhutan
2011
0.7
10
2010
0.7
21
2009
0.7
6
2008
0.7
7
2013
24.6
0
2012
24.6
0
DPRK*
2011
24.5
0
2010
24.3
0
2009
24.2
0
2008
24.1
0
2013
1 275.1
13 822
2012
1 258.4
18 668
India
2011
1 241.5
33 634
2010
1 224.6
31 458
2009
1 207.7
56 188
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
2008
1 190.9
44 258
JRF Reports Confirmed measles cases (Routine+Outbreak) Lab 689 429 1 175 659 3 376 3 690 – – – – – – – 217 219 690 186 130 – 278 1 404 1 225 814 1 782 – 618 326 49 278 – 617 52 72 – 4.0 2.7 6.1 0.0 2.9 2.9 0.2 0.3 0.0 4.5 0.9 0.0 0.0 1.5 16.6 35.7 6.9 6.4 0.0 160.7 15.5 2.3 13.5 264 0.0 0.3 4.2 0.4 3.1 1.4 37.4 38 12 18 9 3 68 63 33 66 39 1 10 1 2 2 0.4 44.4 50 0.4 20.4 15 0.0 0.0 0 12 50 36 9 11 7 0 16 21 6 2 6 1 0 0 0 0 0.0 0.0 0 0.0 0.0 0 945 1 208 842 101 118 275 0 365 683 68 19 205 2 107 0.0 0.0 0 0.0 0.0 0 0.0 0.0 0 79 24 23 11 11 39 23 33 11 10 34 2 107 0.0 0.0 107 28 725 26 1.6 72.2 190 27 1 078 40 1.4 188 73 1 627 22 247 – – – – 55 871 879 48 6 8 66 71 25 12 1 759 6 31 14 – – 18 – 320 – 1 681 3 440 – 19 158 189 68 115 208 797 219 1 087 365 84 515 – 38 46 – 181 11 198 102 – 150 873 58 1 810 1 209 84 2 164 945 – 1 000 – – – – – – – – – – – – – – 1 122 15 766 2 066 16 054 78.3 1 323 2 090 340 0 0 0 0 0 ND 23 21 103 11 13 5 755 801 1 175 510 1 275 781 24 416 68 143 79 3 747 18 588 4 765 2.0 97.0 328 212 2 617 12 1 959 1 117 15 240 4 340 1.8 68.6 162 58 1 119 19 1 020 25 65 34 51 21 1 0 2 0 2 0 0 32 33 17 57 27 0 10 1 2 2 803 8 601 3 105 1.3 40.8 87 35 365 10 2 355 14 Epi-linked Clinical Total Incidence No. No. outDiscarded Discarded / per million outbreaks breaks lab cases 100K pop* pop. reported confirmed 210 738 345 473 874 234 9 22 12 580 638 299 1 052 601 410 51 143 52
Monthly Aggregate VPD Surveillance Reports
Measles Outbreaks**
Rubella Outbreaks**
Country
Year
Population JRF (in millions) 1 Reported Incidence Suspected per million measles measles pop cases cases 34.1 13 198 21 126 28 275 22 155 20 825 – – – – 1 217 2 383 2 500 336 328 324 1 919 2 312 1 022 1 971 4 058 943 101 350 63.3 90.3 78.7 87.7 65.4 0.0 0.0 0.0 0.0 19.2 6.5 20.6 44.6 42.3 4.0 4.6 7.0 59.1 108.4 77.4 6.3 6.4 72.3 98.5 2.9 3.8 1.0 1.6
No. No. cases from Mean no. JRF report- No. out- cases from Mean no. lab-concases/ ed rubella breaks lab lab-concases/ firmed outbreak cases confirmed firmed outbreak outbreaks outbreaks 15 30 5 14 17 11 9 11 6 18 19 18 18 22 41 51 72 26
2013
247.2
8 419
2012
244.8
15 489
Indonesia
2011
242.3
21 893
2010
239.9
18 869
2009
237.4
20 818
2008
235.0
15 369
10 093 16 786 23 510 18 779 17 135 –
2013
0.3
0
2012
0.3
0
Maldives
2011
0.3
0
2010
0.3
0
2009
0.3
6
2008
0.3
2
2013
49.1
1 010
2012
48.7
2 175
Myanmar
2011
48.3
2 046
2010
48.0
190
2009
47.6
217
2008
47.3
333
2013
31.5
1 861
2012
31.0
3 362
Nepal
2011
30.5
2 359
2010
30.0
190
2009
29.4
189
2008
28.9
2 089
2013
21.4
2 107
Sri Lanka
2011
21.0
60
2010
20.9
79
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
2009
20.7
21
2008
20.5
33
33
34 Monthly Aggregate VPD Surveillance Reports Confirmed measles cases (Routine+Outbreak) Lab 271 799 67 – – 1 – – – – #REF! 2 738 3 653 827 315 20 756 – 0.0 3.6 0 0 0 0 1 371 21 902 23 588 2 236 18 949 22 012 19 208 3.3 12.2 13.2 0.0 9 004 22 280 34 937 18 206 3.1 19.1 3 829 18 801 25 368 14 085 2.5 13.8 #REF! #REF! #REF! #REF! #REF! #REF! #REF! 597 1 032 683 658 434 – – 0.0 0.0 0 #REF! 219 551 275 122 143 – – – 11 1.0 0.0 0 – – – 5 0.4 0.0 0 #REF! 6 544 15 627 10 049 5 660 7 701 763 1 764 – 0.0 662.1 1 0 – 12 12 – 0.0 10.1 0 – 3 4 – 0.0 3.4 ND – – 0.0 0.0 22 0 – 5 140 5 140 132 0.2 74.8 35 13 169 13 #REF! 30 28 37 46 54 – 2 273 2 273 – 0.0 32.9 0 ND 22 2 784 2 873 452 0.7 41.3 16 5 94 19 46 3 227 4 072 1 270 1.8 58.3 4 4 180 45 493 517 387 594 621 0 8 0 0 2 0 #REF! 6 823 9 809 15 271 17 208 7 436 #REF! 150 219 260 319 133 39 1 746 2 056 636 0.9 29.3 8 4 50 13 539 Epi-linked Clinical Total Incidence No. No. outDiscarded Discarded / per million outbreaks breaks lab cases 100K pop* pop. reported confirmed 2 4 4 6 0 0 #REF! 5 105 7 055 13 999 19 707 8 028 Measles Outbreaks** Rubella Outbreaks** No. No. cases from Mean no. JRF report- No. out- cases from Mean no. lab-concases/ ed rubella breaks lab lab-concases/ firmed outbreak cases confirmed firmed outbreak outbreaks outbreaks 12 37 119 96 1 1 6 9 30 16 #REF! 34 32 54 62 60 37.6 2 692 5 342 3 325 2 273 5 272 4 12 764 5 11 #REF! 39 453 53 143 41 220 44 344 0 74.4 45.4 37.4 88.4 114.1 3.4 13.5 661.3 44.5 9.1 0.0 25.6 38.0 30.0 47.2 41.2
JRF Reports
Country
Year
Population JRF (in millions) 1 Reported Incidence Suspected per million measles measles pop cases cases
2013
70.2
2 641
2012
69.9
5 197
Thailand
2011
69.5
3 156
2010
69.1
2 583
2009
68.7
6 071
2008
68.3
7 790
2013
1.2
4
2012
1.2
16
Timor-Leste
2011
1.2
763
2010
1.1
50
2009
1.1
10
2008
1.1
0
SEAR
2013
#REF!
#REF!
#REF!
2012
1 832.0
46 894
2011
1 830.4
69 546
Total
2010
1 807.6
54 228
2009
1 785.0
84 244
2008
1 762.4
72 541
1
Population figures from United Nations World Population Prospects: The 2010 Revision. (For 2011 and 2012 population estimates medium fertility variant was used)
* Democratic People’s Republic of Korea
**SEAR Region discarded rate excludes India population
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Reported through SEARO AERF/JRF
Annex 7A Estimated schedule, scale and cost of SIAs, SEAR 2013–2020
2013 Ag MR M 45 793 918 $32 942 912 92 609 37 970 60 196 $29 766 047 $98 166 $62 708 959 Total 9m–24y MR 9m–14y MR 64 411 293 22 348 342 86 759 635 45 701 309 32 904 942 29 705 851 $62 610 793
2014 Ops Total Age Ag Target Pop 48 308 470 16 761 257 $65 069 726
Country Target Pop Bundled vaccine Bundled vaccine
Total Pop 2012
Age
Ops 41 867 340 14 526 422
Total $90 175 810 $31 287 679 $56 393 763 $121 463 489
Bangladesh
152 408 774
9m–14y
Bhutan
750 443
DPRK*
24 553 672
India
1 231 758 096
Indonesia
244 769 110
Maldives
324 313
Myanmar
48 724 387
Nepal
31 011 137
Sri Lanka
21 223 550
Thailand
69 892 142
Timor-Leste
1 187 194
9m–35m
Total
1 826 602 818
Total
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
35
36 2015 Bundled vaccine Ops 9–59m MR 14 390 164 11 153 636 Total Age Ag Target Pop Bundled vaccine Ops 9 666 485 2016 Total $20 820 121 63 833 959 8 391 722 2 096 175 565 408 $74 745 912 $58 338 886 424 056 367 515 $791 571 $133 084 798 Total 1 816 685 $3 912 860 7 272 825 $15 664 547 42 736 077 48 881 861 $112 715 820 9–59m M 28 345 913 $18 597 557 7 443 921 $15 366 785 5 700 300 $33 964 342 13 144 221 2 794 900
Annex 7A continued
Country
Age
Ag
Target Pop
Bangladesh
Bhutan
DPRK*
India
9m–14y
M
255 214 264
Indonesia
Maldives
Myanmar
9m–14y
MR
11 188 962
Nepal
9–59m
MR
Sri Lanka
Thailand
9m–14y
MR
Total
269 763 534
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
Annex 7A continued 2017 Bundled vaccine Ops Total Age Ag Target Pop Ops Bundled vaccine 2018 Total
Country
Age
Ag
Target Pop
Bangladesh
Bhutan
DPRK* 399 886 399 886 $110 310 $84 472 $194 781 9–59m Total MR 231 578 70 136 260 9–59m MR 20 193 927 110 310 84 472 194 781 9–35m; 9–59m M 49 710 755 14 411 144 16 696 481 191 470 $31 299 095 11 035 561 14 470 284 165 941 $25 671 785 25 446 705 $31 166 764 $357 411 $56 970 880
India
9–35m
M
Indonesia
Maldives
Myanmar
Nepal
Sri Lanka
Thailand
Total
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
37
38 2019 Bundled vaccine Ops 9–59m MR 11 805 878 10 383 909 Total Age Ag Target Pop Bundled vaccine Ops 8 999 388 2020 Total $19 383 297 16 677 940 3 522 735 $19 683 067 $15 375 839 $35 058 906 3 005 127 2 604 443 $5 609 570 Total 12 771 396 29 449 336 9–35m M 12 175 502 23 981 380 3 903 746 $14 287 655 2 989 355 $11 988 743 6 893 101 $26 276 397
Annex 7A continued
Country
Age
Ag
Target Pop
Bangladesh
Bhutan
DPRK*
India
9–35m; 9–59m
M
54 716 992
Indonesia
Maldives
Myanmar
Nepal
9–59m
MR
Sri Lanka
Thailand
Total
58 239 727
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
Annex 7A continued Total: 2016–2020 Total 62 610 793 42 547 061 32 581 083 26 196 042 $21 537 545 $18 665 872 $40 203 418 Target Pop Bundled vaccine Ops Total Target Pop Ops Bundled vaccine Total: 2013–2020 Total
Total: 2013–2015 Ops 29 705 851 48 881 861 112 715 820 145 349 049 41 867 340 90 175 810 20 193 927 $16 696 481 $14 470 284 $31 166 764
Country
Target Pop
Bundled vaccine
Bangladesh
45 701 309
32 904 942
71 897 351 $54 442 488 $48 371 723 $102 814 211
Bhutan
DPRK*
255 214 264
63 833 959
75 128 144 400 563 313 $106 381 020 $81 462 943 $187 843 963 84 605 220 $65 004 951 $56 337 624 $121 342 575
India
64 411 293
48 308 470
Indonesia
Maldives 7 272 825 1 816 685 3 912 860 3 522 735 $3 005 127 $2 604 443 15 664 547 $5 609 570 11 188 962 6 317 635 $8 391 722 $5 101 302 $7 272 825 $4 421 128 $15 664 547 $9 522 430
Myanmar
11 188 962
8 391 722
Nepal
2 794 900
2 096 175
Sri Lanka 14 526 422 427 711 889 737 231 578 $191 470 31 287 679 $165 941 $357 411 22 348 342 $16 761 257 $14 526 422 889 595 $653 496 $593 652 $31 287 679 $1 247 148
Thailand
22 348 342
16 761 257
Timor-Leste
658 017
462 026
Total
402 317 087 $172 758 550 $144 498 695 $317 257 245 195 493 331 $83 977 684 $68 487 623 $152 465 308 597 810 418 $256 736 234 $212 986 319 $469 722 553
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
39
40 2013 Bundled vaccine Ops 29 705 851 60 196 $29 766 047 $98 166 $62 708 959 9m–24y Total MR 9m–14y MR 64 411 293 22 348 342 86 759 635 $62 610 793 48 308 470 16 761 257 $65 069 726 Total Age Ag Target Pop 32 904 942 37 970 $32 942 912 Bundled vaccine 2014 Ops 41 867 340 14 526 422 $56 393 763 Total $90 175 810 $31 287 679 $121 463 489 45 701 309 92 609 45 793 918
Annex 7B Estimated schedule, scale and cost of measles and rubella SIAs, SEAR 2013–2020
Country
Age
Ag
Target Pop
Bangladesh
9m–14y
MR
Bhutan
DPRK*
India
Indonesia
Maldives
Myanmar
Nepal
Sri Lanka
Thailand
Timor-Leste
9–35m
M
Total
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
Annex 7B continued 2015 Bundled vaccine Ops 127 667 918 8 391 722 2 096 175 565 408 $138 579 871 $58 338 886 424 056 367 515 $791 571 $196 918 757 Total 1 816 685 $3 912 860 7 272 825 $15 664 547 42 736 077 $26 041 479 48 881 861 $176 549 779 9–59m MR 28 345 913 14 887 842 $15 366 785 5 700 300 $41 408 263 9–59m MR 14 390 164 11 153 636 Total Age Ag Target Pop Ops 9 666 485 20 588 142 Bundled vaccine 2016 Total $20 820 121
Country
Age
Ag
Target Pop
Bangladesh
Bhutan
DPRK*
India
9m–14yr; 9-59m
MR
255 214 264
Indonesia
Maldives
Myanmar
9m–14y
MR
11 188 962
Nepal
9m–59m
MR
2 794 900
Sri Lanka
Thailand
Timor-Leste
9m–14y
MR
Total
269 763 534
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
41
42 2017 Bundled vaccine Ops 220 620 $220 620 $84 472 $305 091 9m–59m Total MR 9m–59m MR 84 472 305 091 9–35m; 9–59m MR 49 710 755 20 193 927 231 578 70 136 260 25 497 042 16 696 481 191 470 $42 384 993 Total Age Ag Target Pop 399 886 399 886 Bundled vaccine Ops 11 035 561 14 470 284 165 941 $25 671 785 2018 Total 36 532 602 $31 166 764 $357 411 $68 056 778
Annex 7B continued
Country
Age
Ag
Target Pop
Bangladesh
Bhutan
DPRK*
India
9–35m
MR
Indonesia
Maldives
Myanmar
Nepal
Sri Lanka
Thailand
Timor-Leste
Total
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
Annex 7B continued 2019 Bundled vaccine Ops 33 355 880 3 005 127 $36 361 007 $15 375 839 $51 736 846 Total 2 604 443 $5 609 570 23 981 380 12 771 396 46 127 276 9–35m MR 12 175 502 7 807 492 $18 191 401 9–59m MR 11 805 878 10 383 909 Total Age Ag Target Pop Ops 8 999 388 2 989 355 $11 988 743 Bundled vaccine 2020 Total $19 383 297 10 796 847 $30 180 143
Country
Age
Ag
Target Pop
Bangladesh
Bhutan
DPRK*
India
9–35m; 9–59m
MR
54 716 992
Indonesia
Maldives
Myanmar
Nepal
9m–59m
MR
3 522 735
Sri Lanka
Thailand
Timor-Leste
Total
58 239 727
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
43
44 Total: 2016–2020 Total Target Pop Bundled vaccine Ops Total Target Pop Bundled vaccine Total: 2013–2020 Ops Total Ops 29 705 851 48 881 861 176 549 779 145 349 049 41 867 340 7 272 825 1 816 685 14 526 422 427 711 889 737 231 578 31 287 679 $191 470 3 912 860 3 522 735 $3 005 127 15 664 547 $2 604 443 $165 941 90 175 810 20 193 927 $16 696 481 $14 470 284 $31 166 764 $5 609 570 $357 411 81 768 876 62 610 793 26 196 042 $21 537 545 $18 665 872 $40 203 418 71 897 351 $54 442 488 $48 371 723 $102 814 211 32 581 083 114 349 959 400 563 313 $209 436 794 $81 462 943 $290 899 737 84 605 220 $65 004 951 $56 337 624 $121 342 575 11 188 962 6 317 635 $8 391 722 $5 101 302 $7 272 825 $15 664 547 $4 421 128 $9 522 430 22 348 342 $16 761 257 $14 526 422 $31 287 679 889 595 $653 496 $593 652 $1 247 148
Annex 7B continued
Total: 2013–2015
Country
Target Pop
Bundled vaccine
Bangladesh
45 701 309
32 904 942
Bhutan
DPRK*
India
255 214 264 127 667 918
Indonesia
64 411 293
48 308 470
Maldives
Myanmar
11 188 962
8 391 722
Nepal
2 794 900
2 096 175
Sri Lanka
Thailand
22 348 342
16 761 257
Timor-Leste
658 017
462 026
Total
402 317 087 $236 592 509 $144 498 695 $381 091 204 195 493 331 $123 199 499 $68 487 623 $191 687 122 597 810 418 $359 792 008 $212 986 319 $572 778 327
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
* Democratic People’s Republic of Korea
Annex 8A Estimated schedule, scale and cost of SIAs,* by state, India 2015–2020
State/Union Territory Ag M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M 16 738 783 2 294 053 1 694 268 3 223 917 11 141 485 15 505 369 7 611 779 19 577 23 169 792 29 352 642 291 446 1 029 844 379 073 688 160 11 742 297 320 325 6 854 969 211 141 16 501 488 1 275 500 3 513 548 23 820 379 255 214 264 4 186 689 573 786 423 769 806 363 2 786 698 3 878 189 1 903 851 4 897 5 795 207 7 341 656 72 896 257 584 94 813 172 122 2 936 973 80 119 1 714 559 52 810 4 127 337 319 027 878 805 5 957 931 $63 833 959 3 206 023 439 386 324 508 617 485 2 133 958 2 969 784 1 457 904 3 750 4 437 771 5 621 989 55 821 197 249 72 605 131 805 2 249 033 61 353 1 312 950 40 440 3 160 573 244 300 672 959 4 562 380 $48 881 861 0 7 392 712 1 013 172 748 276 1 423 848 4 920 656 6 847 973 3 361 755 8 646 10 232 979 12 963 645 128 717 454 832 167 418 303 927 5 186 006 141 472 3 027 509 0 93 251 7 287 910 563 327 0 1 551 765 10 520 311 $112 715 820 9–59m 9–59m M M 4 626 326 1 157 132 886 092 2 043 225 7 106 374 21 239 539 28 345 913 38 764 439 315 984 2 483 466 107 193 75 946 9 695 726 79 034 621 162 26 811 18 996 7 424 655 60 521 475 665 20 531 14 546 17 120 381 139 555 1 096 827 47 342 33 542 9 575 028 2 394 897 1 833 930 4 228 828 1 866 205 5 577 716 $7 443 921 97 798 21 307 862 480 388 18 731 4 081 151 92 010 43 192 9 410 654 212 164 Target Pop Ops Total Age Ag Target Pop
Age
2016 Bundled vaccine
Ops 1 429 076 4 271 224 $5 700 300
Total 3 295 281 9 848 940 $13 144 221
Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh
9m–14y 9m–14y 9m–14y
2015 Bundled vaccine 24 461 5 329 503 120 154
Assam
9m–14y
Bihar Chandigarh Chhattisgarh Dadra And Nagar Haveli Daman And Diu
9m–14y 9m–14y 9–59m 9m–14y 9m–14y
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Delhi
9m–14y
Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttarakhand West Bengal Total
None 9m–14y 9–59m 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9–59m 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y 9m–14y
* Assumes India uses monovalent measles vaccine
45
46 2017 Ag M M M 399 886 211 026 58 212 $110 310 103 982 28 684 21 965 44 577 $84 472 50 649 102 789 $194 781 9–59m 9–59m 9–35m 9–59m 9–59m M M M M M 9–59m M 9–59m M 5 438 688 2 433 777 1 018 987 3 765 013 7 838 946 357 203 11 470 325 49 710 755 9–59m M 14 209 273 9–59m M 3 178 545 921 460 4 119 267 1 576 675 705 552 295 404 1 091 477 2 272 510 103 553 3 325 246 $14 411 144 84 877 23 414 17 929 41 343 Target Pop Bundled vaccine Ops Total Age Ag Target Pop Bundled vaccine Ops 705 622 3 154 394 1 207 364 540 287 226 210 835 816 1 740 210 79 297 2 546 360 $11 035 561 2018 Total 1 627 082 7 273 661 2 784 039 1 245 839 521 615 1 927 293 4 012 720 182 850 5 871 606 $25 446 705
Annex 8A continued
State/Union Territory
Age
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
9–35m
Assam
Bihar
Chandigarh
Chhattisgarh
Dadra And Nagar Haveli
Daman And Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
9–35m
Odisha
Pondicherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Tripura
9–35m
Uttar Pradesh
Uttarakhand
West Bengal
Total
Annex 8A continued 2019 Ag M M M M M M M M M M M M M M M M M M M M M M 54 716 992 7 465 421 1 181 177 360 027 2 275 488 $16 677 940 217 297 66 233 5 430 229 1 655 154 66 674 20 323 7 573 274 2 308 362 2 139 922 652 256 110 583 33 706 25 811 499 475 1 767 664 15 562 1 267 460 50 719 275 696 1 742 491 $12 771 396 3 773 098 1 150 054 880 672 196 225 59 810 45 801 129 928 39 602 30 326 69 929 105 611 2 030 726 59 517 1 151 731 4 076 026 35 885 2 922 614 116 952 635 723 4 017 978 $29 449 336 313 806 95 649 73 245 168 894 9 903 255 3 018 549 2 311 501 5 330 050 9–35m 5 813 1 772 1 357 3 129 5 049 814 1 539 202 1 178 668 2 717 870 M 12 175 502 12 175 502 1 577 968 480 970 368 311 849 281 48 933 14 915 11 421 26 337 2 715 593 827 723 633 842 1 461 565 98 569 30 044 23 007 53 051 3 903 746 $3 903 746 89 335 27 230 20 852 48 081 6 601 466 2 012 151 1 540 836 3 552 987 2 989 355 $2 989 355 28 612 8 721 6 678 15 399 Target Pop Bundled vaccine Ops Total Age Ag Target Pop Ops Bundled vaccine 2020 Total 6 893 101 $6 893 101
State/Union Territory
Age
Andaman and Nicobar Islands
9–59m
Andhra Pradesh
9–59m
Arunachal Pradesh
9–35m
Assam
Bihar
Chandigarh
9–59m
Chhattisgarh
9–59m
Dadra And Nagar Haveli
9–59m
Daman And Diu
Delhi
9–59m
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
9–59m
Kerala
Lakshadweep
9–59m
Madhya Pradesh
Maharashtra
9–59m
Manipur
9–59m
Meghalaya
Mizoram
9–59m
Nagaland
9–35m
Odisha
9–59m
Pondicherry
9–59m
Punjab
9–59m
Rajasthan
9–59m
Sikkim
9–59m
Tamil Nadu
9–59m
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Tripura
9–35m
Uttar Pradesh
Uttarakhand
9–59m
West Bengal
9–59m
Total
47
48 Total: 2013–2015 Bundled vaccine Ops 18 731 4 081 151 92 010 1 833 930 7 424 655 60 521 475 665 20 531 14 546 886 092 0 3 206 023 439 386 324 508 617 485 2 133 958 2 969 784 1 457 904 3 750 4 437 771 5 621 989 55 821 197 249 72 605 131 805 2 249 033 61 353 1 312 950 0 40 440 3 160 573 244 300 0 672 959 4 562 380 141 472 3 027 509 0 93 251 7 287 910 563 327 0 1 551 765 10 520 311 $48 881 861 $112 715 820 5 186 006 303 927 167 418 454 832 357 203 129 928 300 208 3 773 098 110 583 2 139 922 14 679 648 66 674 5 430 229 428 323 44 885 366 1 181 177 7 465 421 145 349 049 128 717 313 806 12 963 645 9 903 255 10 232 979 7 838 946 8 646 5 813 1 772 2 272 510 3 018 549 95 649 103 553 39 602 88 494 1 150 054 33 706 652 256 4 174 567 20 323 1 655 154 124 445 12 806 708 360 027 2 275 488 $42 547 061 3 361 755 0 0 6 847 973 5 049 814 1 539 202 4 920 656 3 765 013 1 091 477 1 423 848 1 018 987 295 404 748 276 0 0 0 226 210 835 816 1 178 668 0 1 357 1 740 210 2 311 501 73 245 79 297 30 326 67 766 880 672 25 811 499 475 3 196 740 15 562 1 267 460 95 296 9 806 939 275 696 1 742 491 $32 581 083 1 013 172 2 433 777 705 552 540 287 7 392 712 5 438 688 1 576 675 1 207 364 0 0 0 0 2 043 225 1 577 968 480 970 368 311 849 281 0 2 784 039 1 245 839 0 521 615 1 927 293 2 717 870 0 3 129 4 012 720 5 330 050 168 894 182 850 69 929 156 260 2 030 726 59 517 1 151 731 7 371 307 35 885 2 922 614 219 741 22 613 647 635 723 4 017 978 $75 128 144 33 542 0 0 0 0 47 342 48 933 14 915 11 421 26 337 1 096 827 2 715 593 827 723 633 842 1 461 565 139 555 98 569 30 044 23 007 53 051 414 553 5 199 060 156 126 75 946 6 204 294 0 22 177 471 4 727 830 1 694 268 4 242 904 14 906 497 20 555 183 7 611 779 25 390 31 008 738 39 255 897 605 252 1 387 047 509 001 988 368 15 515 395 430 908 8 994 891 14 679 648 277 815 21 931 717 1 703 823 44 885 366 4 694 725 31 285 800 17 120 381 14 209 273 4 119 267 3 154 394 7 273 661 52 973 711 4 228 828 3 178 545 921 460 705 622 1 627 082 12 753 573 212 164 174 212 50 643 38 781 89 424 654 600 9 410 654 6 601 466 2 012 151 1 540 836 3 552 987 27 909 328 7 341 654 170 798 3 316 357 13 814 993 109 078 1 448 885 41 726 18 996 1 638 103 0 5 763 364 1 279 338 423 769 1 101 767 3 878 175 5 417 391 1 903 851 6 668 8 067 717 10 360 205 168 545 361 137 134 416 260 616 4 087 027 113 826 2 366 815 4 174 567 73 133 5 782 491 443 472 12 806 708 1 238 832 8 233 419 43 192 28 612 8 721 6 678 15 399 126 410 33 182 Total Target Pop Ops Total Target Pop 24 461 5 329 503 120 154 2 394 897 9 695 726 79 034 621 162 26 811 18 996 1 157 132 0 4 186 689 573 786 423 769 806 363 2 786 698 3 878 189 1 903 851 4 897 5 795 207 7 341 656 72 896 257 584 94 813 172 122 2 936 973 80 119 1 714 559 0 52 810 4 127 337 319 027 0 878 805 5 957 931 $63 833 959 Bundled vaccine Bundled vaccine Total: 2016–2020 Total: 2013–2020 Ops 25 410 5 621 987 130 791 2 539 553 10 579 049 83 528 1 109 507 31 952 14 546 1 254 403 0 4 413 387 979 673 324 508 843 696 2 969 774 4 148 452 1 457 904 5 106 6 177 982 7 933 490 129 066 276 546 102 931 199 571 3 129 705 87 164 1 812 426 3 196 740 56 003 4 428 034 339 596 9 806 939 948 655 6 304 870 Total $58 592 $12 963 641 $301 588 $5 855 910 $24 394 042 $192 606 $2 558 392 $73 679 $33 542 $2 892 506 $0 $10 176 752 $2 259 012 $748 276 $1 945 463 $6 847 948 $9 565 843 $3 361 755 $11 775 $14 245 699 $18 293 695 $297 612 $637 683 $237 347 $460 187 $7 216 732 $200 989 $4 179 240 $7 371 307 $129 136 $10 210 524 $783 068 $22 613 647 $2 187 488 $14 538 290 400 563 313 $106 381 020 $81 462 943 $187 843 963 0 0 0
Annex 8A continued
State/Union Territory
Target Pop
Andaman and Nicobar Islands
97 798
Andhra Pradesh
21 307 862
Arunachal Pradesh
480 388
Assam
9 575 028
Bihar
38 764 439
Chandigarh
315 984
Chhattisgarh
2 483 466
Dadra And Nagar Haveli
107 193
Daman And Diu
75 946
Delhi
4 626 326
Goa
Gujarat
16 738 783
Haryana
2 294 053
Himachal Pradesh
1 694 268
Jammu and Kashmir
3 223 917
Jharkhand
11 141 485
Karnataka
15 505 369
Kerala
7 611 779
Lakshadweep
19 577
Madhya Pradesh
23 169 792
Maharashtra
29 352 642
Manipur
291 446
Meghalaya
1 029 844
Mizoram
379 073
Nagaland
688 160
Odisha
11 742 297
Pondicherry
320 325
Punjab
6 854 969
Rajasthan
Sikkim
211 141
Tamil Nadu
16 501 488
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Tripura
1 275 500
Uttar Pradesh
Uttarakhand
3 513 548
West Bengal
23 820 379
Total
255 214 264
Annex 8B Estimated schedule, scale and cost of SIAs,* by state, India 2015–2020 2015 Ag MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR 3 513 548 23 820 379 255 214 264 1 275 500 16 501 488 211 141 0 105 621 8 254 674 638 054 0 1 757 611 11 915 863 127 667 918 6 854 969 3 429 117 320 325 160 239 11 742 297 5 873 945 688 160 344 244 379 073 189 627 72 605 131 805 2 249 033 61 353 1 312 950 40 440 3 160 573 244 300 672 959 4 562 380 48 881 861 1 029 844 515 167 197 249 291 446 145 792 55 821 29 352 642 14 683 312 5 621 989 23 169 792 11 590 415 4 437 771 19 577 9 793 3 750 13 543 16 028 186 20 305 301 201 614 712 416 262 232 476 049 8 122 978 221 592 4 742 067 0 146 061 11 415 247 882 354 0 2 430 570 16 478 243 176 549 779 7 611 779 3 807 702 1 457 904 5 265 607 15 505 369 7 756 378 2 969 784 10 726 162 9–59m 9–59m 11 141 485 5 573 396 2 133 958 7 707 354 3 223 917 1 612 726 617 485 2 230 212 1 694 268 847 537 324 508 1 172 045 MR MR 2 294 053 1 147 573 439 386 1 586 959 16 738 783 8 373 378 3 206 023 11 579 401 0 0 4 626 326 2 314 265 886 092 3 200 357 75 946 37 991 14 546 52 537 107 193 53 622 20 531 74 153 7 106 374 21 239 539 28 345 913 2 483 466 1 242 325 475 665 1 717 989 315 984 158 067 60 521 218 588 38 764 439 19 391 452 7 424 655 26 816 107 9 575 028 4 789 795 1 833 930 6 623 725 480 388 240 309 92 010 332 319 3 732 410 11 155 432 14 887 842 21 307 862 10 659 006 4 081 151 14 740 157 97 798 48 922 18 731 67 654 Target Pop Bundled vaccine Ops Total Age Ag Target Pop Ops 1 429 076 4 271 224 5 700 300 Bundled vaccine 2016 Total 5 161 486 15 426 656 20 588 142
State/Union Territory
Age
Andaman and Nicobar Islands
9m–14y
Andhra Pradesh
9m–14y
Arunachal Pradesh
9m–14y
Assam
9m–14y
Bihar
9m–14y
Chandigarh
9m–14y
Chhattisgarh
9–59m
Dadra And Nagar Haveli
9m–14y
Daman And Diu
9m–14y
Delhi
9m–14y
Goa
None
Gujarat
9m–14y
Haryana
9–59m
Himachal Pradesh
9m–14y
Jammu and Kashmir
9m–14y
Jharkhand
9m–14y
Karnataka
9m–14y
Kerala
9m–14y
Lakshadweep
9m–14y
Madhya Pradesh
9m–14y
Maharashtra
9m–14y
Manipur
9–59m
Meghalaya
9m–14y
Mizoram
9m–14y
Nagaland
9m–14y
Odisha
9m–14y
Pondicherry
9m–14y
Punjab
9m–14y
Rajasthan
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Sikkim
9m–14y
Tamil Nadu
9m–14y
Tripura
9m–14y
Uttar Pradesh
Uttarakhand
9m–14y
West Bengal
Total
9m–14y
* Assumes India uses monovalent measles vaccine
49
50 2017 Ag MR MR MR 211 026 399 886 116 425 220 620 103 982 57 368 21 965 44 577 84 472 79 333 161 002 305 091 9–59m 9–59m 9–59m 9-59m 9–35m 9–59m 9–59m MR MR MR MR MR MR MR 5 438 688 2 433 777 1 018 987 3 765 013 7 838 946 357 203 11 470 325 49 710 755 9–59m MR 14 209 273 9–59m MR 3 178 545 84 877 46 827 17 929 64 757 1 842 920 8 238 534 3 153 351 1 411 103 590 808 2 182 954 4 545 019 207 106 3 325 246 25 497 042 Target Pop Bundled vaccine Ops Total Age Ag Target Pop Bundled vaccine Ops 705 622 3 154 394 1 207 364 540 287 226 210 835 816 1 740 210 79 297 2 546 360 11 035 561 2018 Total 2 548 542 11 392 928 4 360 715 1 951 391 817 019 3 018 769 6 285 230 286 403 5 871 606 36 532 602
Annex 8B continued
State/Union Territory
Age
Andaman And Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
9–35m
Assam
Bihar
Chandigarh
Chhattisgarh
Dadra And Nagar Haveli
Daman And Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
9–35m
Odisha
Pondicherry
Punjab
Rajasthan
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Sikkim
Tamil Nadu
Tripura
9–35m
Uttar Pradesh
Uttarakhand
West Bengal
Total
Annex 8B continued 2019 Ag MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR MR 54 716 992 7 465 421 1 181 177 217 297 5 430 229 3 310 308 132 466 720 054 4 550 975 33 355 880 66 674 40 645 7 573 274 4 616 723 2 139 922 1 304 512 110 583 67 412 3 773 098 2 300 108 880 672 25 811 499 475 1 767 664 15 562 1 267 460 50 719 275 696 1 742 491 12 771 396 196 225 119 620 45 801 129 928 79 205 30 326 313 806 191 298 73 245 109 531 165 421 3 180 780 93 223 1 803 987 6 384 388 56 207 4 577 768 183 185 995 750 6 293 466 46 127 276 9 903 255 6 037 097 2 311 501 8 348 598 264 543 5 813 3 544 1 357 4 900 9–35m 5 049 814 3 078 404 1 178 668 4 257 072 MR 12 175 502 12 175 502 1 577 968 961 941 368 311 1 330 251 48 933 29 830 11 421 41 252 2 715 593 1 655 446 633 842 2 289 287 98 569 60 088 23 007 83 095 7 807 492 7 807 492 89 335 54 459 20 852 75 311 6 601 466 4 024 302 1 540 836 5 565 138 28 612 17 442 6 678 24 120 2 989 355 2 989 355 Target Pop Bundled vaccine Ops Total Age Ag Target Pop Ops Bundled vaccine 2020 Total 10 796 847 10 796 847
State/Union Territory
Age
Andaman and Nicobar Islands
9–59m
Andhra Pradesh
9–59m
Arunachal Pradesh
9–35m
Assam
Bihar
Chandigarh
9–59m
Chhattisgarh
9–59m
Dadra and Nagar Haveli
9–59m
Daman And Diu
Delhi
9–59m
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
9–59m
Kerala
Lakshadweep
9–59m
Madhya Pradesh
Maharashtra
9–59m
Manipur
9–59m
Meghalaya
Mizoram
9–59m
Nagaland
9–35m
Odisha
9–59m
Pondicherry
9–59m
Punjab
9–59m
Rajasthan
9–59m
Sikkim
9–59m
Tamil Nadu
9–59m
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Tripura
9–35m
Uttar Pradesh
Uttarakhand
9–59m
West Bengal
9–59m
Total
51
52 Total: 2013–2015 Bundled vaccine Ops 18 731 4 081 151 92 010 1 833 930 7 424 655 60 521 475 665 20 531 14 546 886 092 0 3 206 023 439 386 324 508 617 485 2 133 958 2 969 784 1 457 904 3 750 4 437 771 5 621 989 55 821 197 249 72 605 131 805 2 249 033 61 353 1 312 950 0 40 440 3 160 573 244 300 0 672 959 4 562 380 48 881 861 221 592 4 742 067 0 146 061 11 415 247 882 354 0 2 430 570 16 478 243 176 549 779 8 122 978 476 049 262 232 712 416 357 203 129 928 300 208 3 773 098 110 583 2 139 922 14 679 648 66 674 5 430 229 428 323 44 885 366 1 181 177 7 465 421 145 349 049 201 614 313 806 20 305 301 9 903 255 16 028 186 7 838 946 13 543 5 813 3 544 4 545 019 6 037 097 191 298 207 106 79 205 176 988 2 300 108 67 412 1 304 512 8 349 134 40 645 3 310 308 248 890 22 288 170 720 054 4 550 975 81 768 876 5 265 607 0 0 10 726 162 5 049 814 3 078 404 7 707 354 3 765 013 2 182 954 2 230 212 1 018 987 590 808 226 210 835 816 1 178 668 0 1 357 1 740 210 2 311 501 73 245 79 297 30 326 67 766 880 672 25 811 499 475 3 196 740 15 562 1 267 460 95 296 9 806 939 275 696 1 742 491 32 581 083 1 172 045 0 0 0 1 586 959 2 433 777 1 411 103 540 287 11 579 401 5 438 688 3 153 351 1 207 364 0 0 0 0 3 200 357 1 577 968 961 941 368 311 1 330 251 0 4 360 715 1 951 391 0 817 019 3 018 769 4 257 072 0 4 900 6 285 230 8 348 598 264 543 286 403 109 531 244 754 3 180 780 93 223 1 803 987 11 545 874 56 207 4 577 768 344 186 32 095 109 995 750 6 293 466 114 349 959 52 537 0 0 0 0 74 153 48 933 29 830 11 421 41 252 1 717 989 2 715 593 1 655 446 633 842 2 289 287 218 588 98 569 60 088 23 007 83 095 414 553 5 199 060 156 126 75 946 6 204 294 0 22 177 471 4 727 830 1 694 268 4 242 904 14 906 497 20 555 183 7 611 779 25 390 31 008 738 39 255 897 605 252 1 387 047 509 001 988 368 15 515 395 430 908 8 994 891 14 679 648 277 815 21 931 717 1 703 823 44 885 366 4 694 725 31 285 800 400 563 313 26 816 107 14 209 273 8 238 534 3 154 394 11 392 928 52 973 711 6 623 725 3 178 545 1 842 920 705 622 2 548 542 12 753 573 332 319 174 212 101 287 38 781 140 067 654 600 14 740 157 6 601 466 4 024 302 1 540 836 5 565 138 27 909 328 14 683 308 341 595 6 632 715 27 629 986 218 155 2 897 770 83 452 37 991 3 276 206 0 11 526 729 2 558 676 847 537 2 203 535 7 756 350 10 834 781 3 807 702 13 337 16 135 434 20 720 409 337 091 722 273 268 832 521 232 8 174 053 227 651 4 733 629 8 349 134 146 266 11 564 982 886 944 22 288 170 2 477 665 16 466 838 209 436 794 67 654 28 612 17 442 6 678 24 120 126 410 66 364 Total Target Pop Ops Total Target Pop 48 922 10 659 006 240 309 4 789 795 19 391 452 158 067 1 242 325 53 622 37 991 2 314 265 0 8 373 378 1 147 573 847 537 1 612 726 5 573 396 7 756 378 3 807 702 9 793 11 590 415 14 683 312 145 792 515 167 189 627 344 244 5 873 945 160 239 3 429 117 0 105 621 8 254 674 638 054 0 1 757 611 11 915 863 127 667 918 Bundled vaccine Bundled vaccine Total: 2016–2020 Total: 2013–2020 Ops 25 410 5 621 987 130 791 2 539 553 10 579 049 83 528 1 109 507 31 952 14 546 1 254 403 0 4 413 387 979 673 324 508 843 696 2 969 774 4 148 452 1 457 904 5 106 6 177 982 7 933 490 129 066 276 546 102 931 199 571 3 129 705 87 164 1 812 426 3 196 740 56 003 4 428 034 339 596 9 806 939 948 655 6 304 870 81 462 943 Total 91 774 20 305 295 472 386 9 172 267 38 209 035 301 683 4 007 277 115 405 52 537 4 530 609 0 15 940 116 3 538 350 1 172 045 3 047 230 10 726 123 14 983 233 5 265 607 18 443 22 313 416 28 653 899 466 157 998 820 371 763 720 803 11 303 759 314 815 6 546 055 11 545 874 202 269 15 993 015 1 226 540 32 095 109 3 426 320 22 771 709 290 899 737 0 0 0
Annex 8B continued
State/Union Territory
Target Pop
Andaman and Nicobar Islands
97 798
Andhra Pradesh
21 307 862
Arunachal Pradesh
480 388
Assam
9 575 028
Bihar
38 764 439
Chandigarh
315 984
Chhattisgarh
2 483 466
Dadra and Nagar Haveli
107 193
Daman and Diu
75 946
Delhi
4 626 326
Goa
Gujarat
16 738 783
Haryana
2 294 053
Himachal Pradesh
1 694 268
Jammu and Kashmir
3 223 917
Jharkhand
11 141 485
Karnataka
15 505 369
Kerala
7 611 779
Lakshadweep
19 577
Madhya Pradesh
23 169 792
Maharashtra
29 352 642
Manipur
291 446
Meghalaya
1 029 844
Mizoram
379 073
Nagaland
688 160
Odisha
11 742 297
Pondicherry
320 325
Punjab
6 854 969
Rajasthan
Sikkim
211 141
Tamil Nadu
16 501 488
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Tripura
1 275 500
Uttar Pradesh
Uttarakhand
3 513 548
West Bengal
23 820 379
Total
255 214 264
Annex 9 Estimated costs for outbreak response immunization,* by country, SEAR 2016–2020 2016 Ops 2 756 57 543 692 828 $1 492 244 898 129 094 118 885 58 160 133 452 7 284 $15 689 MR 11 161 8 938 7 746 $287 436 MR 195 737 156 747 135 848 $125 268 MR 84 973 68 047 58 974 $256 060 MR 177 515 142 155 123 201 $265 356 $127 021 $292 595 $16 684 $278 048 MR 190 910 152 881 132 497 $285 379 MR MR MR MR MR $1 935 MR 1 330 1 065 923 $1 988 MR MR 1 022 067 818 476 709 346 $1 527 822 MR 1 009 696 1 313 189 767 176 937 83 870 192 659 11 579 $123 938 MR 86 256 69 074 59 864 $128 938 MR 86 840 834 824 1 086 156 901 146 293 69 344 159 292 9 574 2 388 $5 144 MR 3 541 2 835 2 457 $5 293 MR 3 504 MR 716 348 573 655 497 168 $1 070 823 MR 708 315 585 639 2 897 71 800 Total Ag Target Pop Ops Total Ag Bundled vaccine Target Pop Bundled vaccine Ops 2017 2018 Total 507 554 $1 093 194 2 510 62 227 723 514 $1 558 338 941 135 981 126 787 60 098 138 053 8 297 $2 026 $292 882 $273 081 $129 443 $297 345 $17 871 2 464 481 $2 037 650 $1 765 963 $3 803 613 $5 407 $134 027
Country
Ag
Target Pop
Bundled vaccine
Bangladesh
Bhutan
MR
3 556
DPRK**
MR
85 662
66 395
India
Indonesia 1 036
MR
1 031 389
799 417
Maldives
MR
1 337
Myanmar
MR
192 177
148 954
Nepal
MR
176 980
137 175
Sri Lanka
MR
86 581
67 108
Thailand 8 405
MR
198 666
153 983
Timor-Leste
MR
10 843
Total
1 787 191 $1 385 229 $1 200 532 $2 585 761
2 489 838 $1 993 874 $1 728 024 $3 721 898
* Assuming all countries use MR vaccine
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
**Democratic People’s Republic of Korea
53
54 2019 Ops 454 519 2 248 56 812 846 116 648 047 $1 395 794 839 122 564 114 489 53 851 123 333 7 803 $16 807 MR 12 378 9 572 $265 641 MR 187 204 144 762 125 461 8 295 $115 988 MR 81 601 63 101 54 688 $246 591 MR 175 771 135 921 117 798 $263 985 MR 187 186 144 748 125 449 $270 197 $253 719 $117 789 $270 223 $17 867 $1 808 MR 1 269 981 850 $1 831 MR MR MR MR MR MR MR 985 855 762 350 660 703 $1 423 052 MR 2 651 742 MR 7 164 600 4 594 271 1 759 068 6 353 339 $122 365 MR 87 951 68 012 58 943 $126 955 MR 434 113 $4 843 MR 3 418 2 643 2 291 $4 934 MR 17 476 $978 965 MR 691 960 535 084 463 740 $998 824 MR 2 815 884 2 218 824 13 725 340 834 6 399 897 3 962 813 6 540 948 601 883 340 419 874 964 009 57 966 5 137 744 905 693 647 329 737 757 092 45 491 Total Ag Target Pop Ops Total Ag Bundled vaccine Target Pop Bundled vaccine 2020 Total: 2016–2020 Ops 1 922 981 11 895 295 389 2 605 183 3 434 438 4 452 645 585 601 160 285 772 656 147 39 426 Total 4 141 806 25 620 636 223 9 005 080 7 397 251 5 046 003 9 588 1 390 490 1 294 807 615 509 1 413 239 84 917 22 383 452 $15 512 102 $10 502 428 $26 014 530 2 594 MR 10 789 647 968 9 004 9 579 193 $6 461 445 $3 377 285 $9 838 730
Annex 9 continued
Country
Ag
Target Pop
Bundled vaccine
Bangladesh
MR
699 261
524 445
Bhutan
MR
3 459
DPRK**
MR
87 403
65 553
India
MR
3 625 047
1 805 626
Indonesia
MR
996 996
747 747
Maldives
MR
1 291
Myanmar
MR
188 561
141 420
Nepal
MR
176 137
132 103
Sri Lanka
MR
82 848
62 136
Thailand
MR
189 743
142 308
Timor-Leste
MR
12 005
Total
6 062 750 $3 633 904 $2 430 623 $6 064 527
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
**Democratic People’s Republic of Korea
Annex 10 Estimated measles and rubella surveillance costs, SEAR 2013–2020
2013
2014
Country Lab cost Total Ops Surv Training cost Total Total Ops Lab Training cost Expected Shipping no. of susp Investigation cost @ 80% Lab cost cases @ cost of cases 4/100K* Surv Training cost
Expected Shipping no. of Investigation cost @ 80% susp cases cost of cases @ 4/100K*
WHO staff & SSA costs (personnel & ops)
Lab Training cost
WHO staff & SSA costs (personnel & ops)
Total
Bangladesh $51 610 $354 222 44 570 $5 000 $567 500 $971 292 6 255 $206 422 $100 083 $51 610 $358 115
6 176
$203 800
$98 812
44 570
$5 000
$567 500
$975 185
Bhutan $6 537 $8 031 58 380 $5 000 $71 411 31 $1 021 $495 $6 537
30
$1 006
$488
$8 053
58 380
$5 000
$71 433
DPRK** $14 988 $63 310 54 932 $5 000 $123 242 990 $32 676 $15 843
986
$32 544
$15 779
$14 988
$63 506
54 932
$5 000
$123 438
India 312 942 $50 000 $5 274 250 $9 965 060 51 045 $3 164 788
50 149
$3 109 256
$802 389 $416 223 $4 327 868
$816 720 $416 223 $4 397 731
312 942
$50 000 $5 274 250 $10 034 923
Indonesia $99 903 $742 592 135 062 $20 000 $219 250 $1 116 904 9 983 $329 424
9 888
$326 288
$316 401
$319 441
$99 903
$748 768
135 062
$20 000
$219 250 $1 123 080
Maldives $6 537 $7 667 11 948 $5 000 $24 615 13
13
$710
$421
$719
$426
$6 537
$7 681
11 948
$5 000
$24 629
Myanmar $21 731 $171 055 86 750 $5 000 $273 750 $536 555
1 965
$117 887
$31 437
1 981
$118 834
$31 689
$21 731
$172 254
86 750
$5 000
$273 750
$537 754
Nepal $14 988 $76 797 20 390 $5 000 $513 750 $615 937
1 261
$41 627
$20 183
1 282
$42 318
$20 518
$14 988
$77 823
20 390
$5 000
$513 750
$616 963
Sri Lanka $14 988 $56 920 10 106 $5 000
856
$28 240
$13 692
$72 026
862
$28 454
$13 796
$14 988
$57 237
10 106
$5 000
$72 343
Thailand $24 976 $266 613 385 814 $5 000
2 810
$151 725
$89 911
$657 427
2 823
$152 434
$90 331
$24 976
$267 741
385 814
$5 000
$658 555
Timor-Leste $8 329 $10 728 21 294 $5 000
49
$1 615
$783
$37 022
50
$1 666
$808
$8 329
$10 803
21 294
$5 000
$37 097
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020 $115 000 $6 848 500 14 191 491 75 316 $4 078 754 $1 410 149 $680 809 $6 169 713 $1 142 188
Total
74 183
$4 014 699
$1 390 295 $680 809 $6 085 803 $1 142 188
$115 000 $6 848 500 $14 275 401
**Democratic People’s Republic of Korea
55
56 2015 2016 Lab cost Total Lab cost Total Ops Surv Training cost Total Ops Lab Training cost WHO staff & SSA costs (personnel & ops) Investigation cost Surv Training cost Expected no. of susp cases @ 2/100K* Shipping cost @ 80% of cases Lab Training cost WHO staff & SSA costs (personnel & ops) Total $51 610 $361 911 $44 570 $5 000 $1 135 000 $1 546 481 3 204 $105 726 $51 261 $28 305 $185 293 $44 570 $0 $1 135 000 $1 364 863 $6 537 $8 074 $58 380 $5 000 $71 454 16 $524 $254 $6 537 $7 315 $58 380 $0 $65 695 $14 988 $63 702 $54 932 $5 000 $123 634 499 $16 470 $7 985 $11 659 $36 114 $54 932 $0 $91 046 $416 223 $4 468 923 $312 942 $50 000 $10 548 500 $15 380 365 52 888 $3 279 043 $846 205 $249 758 $4 375 005 $312 942 $0 $10 548 500 $15 236 447 $99 903 $754 792 $135 062 $20 000 $438 500 $1 348 354 5 083 $167 729 $162 646 $59 952 $390 327 $135 062 $0 $438 500 $963 889 $6 537 $7 695 $11 948 $5 000 $24 643 7 $368 $218 $6 537 $7 123 $11 948 $0 $19 071 $21 731 $173 432 $86 750 $5 000 $547 500 $812 682 1 006 $60 335 $16 089 $15 039 $91 463 $86 750 $0 $547 500 $725 713 $14 988 $78 846 $20 390 $5 000 $1 027 500 $1 131 736 662 $21 847 $10 592 $11 659 $44 098 $20 390 $0 $1 027 500 $1 091 988 $14 988 $57 538 $10 106 $5 000 $72 644 437 $14 423 $6 993 $11 659 $33 075 $10 106 $0 $43 181 $24 976 $268 788 $385 814 $5 000 $659 602 1 423 $76 850 $45 541 $18 317 $140 708 $385 814 $0 $526 522 $8 329 $10 879 $21 294 $5 000 $37 173 27 $885 $429 $8 329 $9 643 $21 294 $0 $30 937 $680 809 $6 254 579 $1 142 188 $115 000 $13 697 000 $21 208 767 65 251 $3 744 200 $1 148 214 $427 749 $5 320 163 $1 142 188 $0 $13 697 000 $20 159 351
Annex 10 continued
Country
Expected no. of susp cases @ 4/100K*
Investigation cost
Shipping cost @ 80% of cases
Bangladesh
6 333
$208 978
$101 323
Bhutan
31
$1 035
$502
DPRK**
994
$32 807
$15 907
India
51 958
$3 221 377
$831 323
Indonesia
10 075
$332 482
$322 407
Maldives
13
$728
$431
Myanmar
1 996
$119 764
$31 937
Nepal
1 303
$43 006
$20 852
Sri Lanka
868
$28 656
$13 894
Thailand
2 835
$153 091
$90 721
Timor-Leste
52
$1 717
$833
Total
76 459
$4 143 642
$1 430 128
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
**Democratic People’s Republic of Korea
Annex 10 continued 2017 2018
Country Lab cost Total Ops Total Lab cost Surv Training cost Total Ops Lab Training cost WHO staff & SSA costs (personnel & ops) Investigation cost Surv Training cost Lab Training cost Shipping cost @ 80% of cases
Expected no. of susp cases @ 2/100K*
Investigation cost
Shipping cost @ 80% of cases
Expected no. of susp cases @ 2/100K*
WHO staff & SSA costs (personnel & ops)
Total
Bangladesh $28 305 $187 083 $44 570 $5 000 $1 702 500 $1 939 153 3 276 $108 108 $52 416 $28 305 $188 829
3 240
$106 932
$51 846
$44 570
$0
$2 270 000 $2 503 399
Bhutan $6 537 $7 324 $58 380 $5 000 $70 704 16 $536 $260 $6 537
16
$530
$257
$7 333
$58 380
$0
$65 713
DPRK** $11 659 $36 212 $54 932 $5 000 $96 144 503 $16 603 $8 050 $11 659
501
$16 536
$8 018
$36 311
$54 932
$0
$91 243
India $249 758 $4 375 005 $312 942 $50 000 $15 822 750 $20 560 697 54 802 $3 397 695 $876 824
52 888
$3 279 043
$846 205
$249 758 $4 524 277
$312 942
$0
$21 097 000 $25 934 219
Indonesia $59 952 $393 179 $135 062 $20 000 $657 750 $1 205 991 5 169 $170 586
5 127
$169 177
$164 050
$165 417
$59 952
$395 955
$135 062
$0
$877 000 $1 408 017
Maldives $6 537 $7 130 $11 948 $5 000 $24 078 7
7
$372
$221
$377
$223
$6 537
$7 136
$11 948
$0
$19 084
Myanmar $15 039 $92 021 $86 750 $5 000 $821 250 $1 005 021 1 020
1 013
$60 775
$16 207
$61 204
$16 321
$15 039
$92 563
$86 750
$0
$1 095 000 $1 274 313
Nepal $11 659 $44 607 $20 390 $5 000 $1 541 250 $1 611 247
672
$22 189
$10 759
683
$22 531
$10 924
$11 659
$45 113
$20 390
$0
$2 055 000 $2 120 503
Sri Lanka $11 659 $33 208 $10 106 $5 000
440
$14 513
$7 036
$48 314
442
$14 596
$7 077
$11 659
$33 332
$10 106
$0
$43 438
Thailand $18 317 $141 158 $385 814 $5 000
1 428
$77 133
$45 708
$531 972
1 433
$77 394
$45 863
$18 317
$141 574
$385 814
$0
$527 388
Timor-Leste $8 329 $9 683 $21 294 $5 000
28
$912
$442
$35 977
28
$939
$455
$8 329
$9 724
$21 294
$0
$31 018
Total
65 360
$3 748 113 $1 150 748
$427 749 $5 326 610 $1 142 188
$115 000 $20 545 500 $27 129 298
67 380
$3 870 568 $1 183 831
$427 749 $5 482 148 $1 142 188
$0
$27 394 000 $34 018 336
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
**Democratic People’s Republic of Korea
57
58 2019 2020 Lab cost Total Ops Total Lab cost Surv Training cost Total Ops Lab Training cost WHO staff & SSA costs (personnel & ops) Investigation cost Surv Training cost Expected no. of susp cases @ 2/100K* Shipping cost @ 80% of cases Lab Training cost WHO staff & SSA costs (personnel & ops) Total $31 634 $193 867 $44 570 $5 000 $2 270 000 $2 513 437 3 345 $110 389 $53 522 $31 634 $195 545 $44 570 $2 270 000 $2 510 115 $6 537 $7 341 $58 380 $5 000 $70 721 17 $547 $265 $6 537 $7 349 $58 380 $65 729 $11 659 $36 409 $54 932 $5 000 $96 341 507 $16 735 $8 114 $11 659 $36 507 $54 932 $91 439 $249 758 $4 601 057 $312 942 $50 000 $21 097 000 $26 060 999 56 789 $3 520 922 $908 625 $249 758 $4 679 305 $312 942 $21 097 000 $26 089 247 $179 806 $518 513 $135 062 $20 000 $877 000 $1 550 575 5 251 $173 296 $168 044 $59 952 $401 292 $135 062 $877 000 $1 413 354 $6 537 $7 143 $11 948 $5 000 $24 091 7 $385 $228 $6 537 $7 149 $11 948 $19 097 $15 039 $93 091 $86 750 $5 000 $1 095 000 $1 279 841 1 034 $62 025 $16 540 $15 039 $93 604 $86 750 $1 095 000 $1 275 354 $11 659 $45 618 $20 390 $5 000 $2 055 000 $2 126 008 703 $23 208 $11 253 $11 659 $46 120 $20 390 $2 055 000 $2 121 510 $11 659 $33 448 $10 106 $5 000 $48 554 447 $14 747 $7 150 $11 659 $33 555 $10 106 $43 661 $18 317 $141 959 $385 814 $5 000 $532 773 1 442 $77 858 $46 138 $18 317 $142 314 $385 814 $528 128 $8 329 $9 766 $21 294 $5 000 $36 060 30 $996 $483 $8 329 $9 809 $21 294 $31 103 $550 933 $5 688 212 $1 142 188 $115 000 $27 394 000 $34 339 400 69 572 $4 001 108 $1 220 362 $431 078 $5 652 548 $1 142 188 $0 $27 394 000 $34 188 736
Annex 10 continued
Country
Expected no. of susp cases @ 2/100K*
Investigation cost
Shipping cost @ 80% of cases
Bangladesh
3 311
$109 259
$52 974
Bhutan
16
$542
$263
DPRK**
505
$16 669
$8 082
India
55 786
$3 458 725
$892 574
Indonesia
5 211
$171 959
$166 748
Maldives
7
$381
$226
Myanmar
1 027
$61 620
$16 432
Nepal
693
$22 871
$11 089
Sri Lanka
445
$14 674
$7 115
Thailand
1 438
$77 636
$46 006
Timor-Leste
29
$967
$469
Total
68 468
$3 935 302 $1 201 977
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
**Democratic People’s Republic of Korea
Annex 10 continued Total 2013–15 Total 2016–20
Country Lab cost Total Ops Total Lab cost Total Ops Surv Training cost Lab Training cost WHO staff & SSA costs (personnel & ops) Investigation cost Surv Training cost Expected no. of susp cases Shipping cost @ 80% of cases
Expected no. of susp cases
Investigation cost
Shipping cost @ 80%
WHO staff Lab Train- & SSA costs ing cost (personnel & ops)
Total
Bangladesh $154 831 $1 074 248 $133 710 $15 000 $2 270 000 $3 492 958 16 376 $540 414 $262 019 $148 184 $950 618
18 764
$619 200
$300 218
$222 850
$10 000
$9 647 500
$10 830 968
Bhutan $19 610 $24 157 $175 140 $15 000 $214 297 81 $2 679 $1 299 $32 683 $36 661
93
$3 063
$1 485
$291 900
$10 000
$338 561
DPRK** $44 964 $190 519 $164 796 $15 000 $370 315 2 516 $83 012 $40 248 $58 293
2 971
$98 027
$47 528
$181 553
$274 660
$10 000
$466 213
India $938 826 $150 000 $21 097 000 $35 380 347 273 152
153 152
$9 495 421 $2 450 431 $1 248 669 $13 194 521
$16 935 427 $4 370 433 $1 248 790 $22 554 650 $1 564 710
$100 000 $89 662 250 $113 881 610
Indonesia $299 710 $2 246 153 $405 186 $60 000 $877 000 $3 588 339 25 841 $852 747 $826 906
29 945
$988 194
$958 249
$419 613
$2 099 265
$675 310
$40 000
$3 727 250
$6 541 825
Maldives $19 610 $23 044 $35 844 $15 000 $73 888 35 $1 882
40
$2 156
$1 278
$1 116
$32 683
$35 681
$59 740
$10 000
$105 421
Myanmar $65 193 $516 741 $260 250 $15 000 $1 095 000 $1 886 991 5 099
5 941
$356 485
$95 063
$305 959
$81 589
$75 193
$462 742
$433 750
$10 000
$4 653 750
$5 560 242
Nepal $44 964 $233 466 $61 170 $15 000 $2 055 000 $2 364 636 3 414
3 847
$126 951
$61 552
$112 646
$54 616
$58 293
$225 555
$101 950
$10 000
$8 733 750
$9 071 255
Sri Lanka $44 964 $171 695 $30 318 $15 000 $217 013
2 586
$85 350
$41 382
2 211
$72 953
$35 371
$58 293
$166 617
$50 530
$10 000
$227 147
Thailand $74 927 $803 141 $1 157 442 $15 000
8 468
$457 251
$270 963
$1 975 583
7 164
$386 871
$229 257
$91 586
$707 714 $1 929 070
$10 000
$2 646 784
Timor-Leste $24 988 $32 409 $63 882 $15 000
151
$4 998
$2 423
$111 291
142
$4 700
$2 279
$41 647
$48 625
$106 470
$10 000
$165 095
Total
225 958 $12 237 095 $4 230 572 $2 042 428 $18 510 095 $3 426 564
$345 000 $27 394 000 $49 675 659
336 031
$19 299 291 $5 905 133 $2 265 257 $27 469 681 $5 710 940
$230 000 $116 424 500 $149 835 121
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
**Democratic People’s Republic of Korea
59
60 Grand toal 2013–2020 Shipping cost @ 80% of cases Lab cost Total Ops Surv Training cost Lab Training cost WHO staff & SSA costs (personnel & ops) $11 917 500 $250 000 $100 000 $95 584 $694 000 $163 120 $338 312 $1 510 855 $81 034 $4 307 686 $45 979 776 $80 848 $3 086 512 $170 352 $9 137 504 $25 000 $25 000 $25 000 $25 000 $25 000 $25 000 $575 000 $110 759 250 $4 604 250 $5 748 750 $10 788 750 $143 818 500 Total $562 237 $2 784 $87 776 $6 820 864 $1 785 155 $2 393 $176 652 $116 168 $76 753 $500 220 $4 702 $10 135 704 $166 513 $66 634 $103 257 $103 257 $459 022 $140 386 $979 482 $52 293 $58 724 $719 322 $4 345 418 $1 080 496 $2 497 459 $35 749 171 $2 503 536 $103 257 $372 072 $439 456 $52 293 $60 818 $467 040 $25 000 $25 000 $303 015 $2 024 866 $356 560 $25 000 $14 323 926 $552 858 $836 528 $149 261 957 $10 130 164 $179 308 $7 447 232 $11 435 892 $444 160 $4 622 367 $276 386 $199 510 780 $5 742 $181 039 $4 038 $662 445 $239 597 $158 303 $844 122 $9 698
Annex 10 continued
Country
Expected no. of susp cases
Investigation cost
Bangladesh
35 140
$1 159 614
Bhutan
174
DPRK**
5 486
India
426 304
$26 430 848
Indonesia
55 786
$1 840 941
Maldives
75
Myanmar
11 041
Nepal
7 261
Sri Lanka
4 797
Thailand
15 632
Timor-Leste
294
Total
31 536 385
$31 536 385
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
**Democratic People’s Republic of Korea
Annex 11 Summary of estimated SIA,* ORI,* and meales and rubella surveillance costs, by country and year, SEAR 2013–2020
2013 Surv 971 292 71 411 123 242 9 965 060 1 116 904 24 615 536 555 615 937 72 026 657 427 37 022 14 191 491 76 900 450 135 187 657 427 31 287 679 121 463 489 0 72 026 615 937 536 555 24 615 24 629 537 754 616 963 72 343 658 555 37 097 1 116 904 90 175 810 1 123 080 9 965 060 10 034 923 10 034 923 91 298 890 24 629 537 754 616 963 72 343 31 946 233 37 097 14 275 401 135 738 890 123 242 123 438 123 438 71 411 71 433 71 433 176 549 779 15 664 547 3 912 860 791 571 196 918 757 0 63 582 085 975 185 975 185 Total SIA ORI Surv Total SIA ORI
2014
2015 Surv 1 546 481 71 454 123 634 Total 1 546 481 71 454 123 634 15 380 365 191 930 143 1 348 354 24 643 812 682 1 131 736 72 644 659 602 37 173 1 348 354 24 643 16 477 229 5 044 596 72 644 659 602 828 744 21 208 767 218 127 524
Country
SIA
ORI
Bangladesh
62 610 793
Bhutan
DPRK**
India
Indonesia
Maldives
Myanmar
Nepal
Sri Lanka
Thailand
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Timor-Leste
98 166
Total
62 708 959
0
* Assumes India uses MR for SIAs and ORI
** Democratic People’s Republic of Korea
61
62
Annex 11 continued 2016 Surv 0 65 695 91 046 305 091 305 091 265 356 127 021 292 595 16 684 285 379 1 988 24 078 1 005 021 1 611 247 48 314 531 972 35 977 1 527 822 1 205 991 214 984 128 938 96 144 225 082 70 839 5 293 70 704 75 997 1 364 863 22 184 984 1 070 823 1 939 153 3 009 976 1 093 194 5 407 134 027 0 Total SIA ORI Surv Total SIA ORI 2017 2018 Surv 2 503 399 65 713 91 243 25 934 219 1 408 017 26 066 1 290 399 1 876 603 175 334 824 567 52 661 3 721 898 27 129 298 31 156 288 357 411 2 026 292 882 273 081 129 443 297 345 17 871 19 084 1 274 313 2 120 503 43 438 527 388 31 018 Total 3 596 593 71 120 225 270 62 466 821 34 133 120 21 111 1 567 195 2 393 584 172 881 824 733 406 300 68 056 778 3 803 613 34 018 336 105 878 727
Country
SIA
ORI
Bangladesh
20 820 121
Bhutan
5 144
DPRK** 0 15 236 447 35 824 590 963 889 19 071 725 713 1 091 988 43 181 526 522 30 937 46 626 813 958 168 449 1 348 047 1 003 760 21 006 2 456 133
123 938
India
20 588 142
0 20 560 697 20 865 789 36 532 602
Indonesia
1 492 244
2 733 813 31 166 764 1 558 338
Maldives
1 935
Myanmar
278 048
Nepal
256 060
Sri Lanka
125 268
Thailand
287 436
Timor-Leste
15 689
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Total
41 408 263 2 585 761 20 159 351 64 153 376
** Democratic People’s Republic of Korea
Annex 11 continued 2019 ORI 978 965 4 843 122 365 2 651 742 1 395 794 1 808 263 985 246 591 115 988 265 641 16 807 6 064 527 34 339 400 36 060 532 773 48 554 164 541 798 414 52 866 92 140 773 30 180 143 2 126 008 7 982 170 1 279 841 1 543 826 24 091 25 899 1 550 575 2 946 369 26 060 999 74 840 017 10 796 847 6 353 339 1 423 052 1 831 270 197 253 719 117 789 270 223 17 867 9 838 730 96 341 218 706 126 955 70 721 75 563 4 934 2 513 437 3 492 402 19 383 297 998 824 2 510 115 65 729 91 439 26 089 247 1 413 354 19 097 1 275 354 2 121 510 43 661 528 128 31 103 34 188 736 Surv Total SIA ORI Surv 2020 Total 22 892 236 70 662 218 394 43 239 432 2 836 406 20 928 1 545 551 2 375 229 161 451 798 350 48 970 74 207 610
Country
SIA
Bangladesh
Bhutan
DPRK**
India
46 127 276
Indonesia
Maldives
Myanmar
Nepal
5 609 570
Sri Lanka
Thailand
Timor-Leste
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Total
51 736 846
** Democratic People’s Republic of Korea
63
64
Annex 11 continued 2013-15 Surv 3 492 958 66 103 752 40 203 418 214 297 370 315 35 380 347 211 930 126 114 349 959 3 588 339 93 764 149 31 166 764 73 888 1 886 991 17 551 538 2 364 636 217 013 1 975 583 33 263 262 111 291 1 001 028 357 411 217 013 615 509 1 413 239 84 917 6 277 496 5 609 570 1 294 807 1 390 490 5 560 242 73 888 9 588 105 421 7 397 251 370 315 636 223 466 213 1 102 436 214 297 25 620 338 561 364 181 4 141 806 10 830 968 55 176 191 102 814 211 Total SIA ORI ORI Total SIA ORI 2016-20 2013-2020 Surv Total
Country
SIA
ORI
Bangladesh
62 610 793
4 141 806 14 323 926 121 279 943 25 620 636 223 552 858 836 528 578 479 1 472 751 9 005 080 149 261 957 449 166 774 7 397 251 10 130 164 138 869 990
Bhutan
DPRK**
India
176 549 779
9 005 080 113 881 610 237 236 649 290 899 737 6 541 825 45 105 840 121 342 575 115 009 6 950 732 15 664 547 9 522 430 227 147 2 646 784 165 095 842 656 4 060 022 31 287 679 607 423 1 247 148
Indonesia
90 175 810
Maldives
9 588 1 390 490
179 308
188 897 7 447 232 24 502 269 1 294 807 11 435 892 22 253 129 615 509 1 413 239 84 917 444 160 1 059 669 4 622 367 37 323 285 276 386 1 608 451
Myanmar
15 664 547
Nepal
3 912 860
9 071 255 15 975 633
Sri Lanka
Thailand
31 287 679
Timor-Leste
889 737
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Total
381 091 204
49 675 659 430 766 863 191 687 122 26 014 530 149 835 121 367 536 773 572 778 327 26 014 530 199 510 780 798 303 636
** Democratic People’s Republic of Korea
Annex 12 Summary of estimated costs to eliminate measles and prevent rubella and CRS, SEAR 2013–2020
2013 Surv 971 292 71 411 123 242 9 965 060 1 116 904 24 615 536 555 615 937 72 026 657 427 37 022 14 191 491 135 187 76 900 450 121 463 489 657 427 31 287 679 72 026 0 615 937 536 555 24 615 24 629 537 754 616 963 72 343 658 555 37 097 1 116 904 90 175 810 1 123 080 9 965 060 10 034 923 123 242 123 438 123 438 10 034 923 176 549 779 91 298 890 24 629 537 754 616 963 72 343 31 946 233 37 097 791 571 14 275 401 135 738 890 196 918 757 15 664 547 3 912 860 71 411 71 433 71 433 63 582 085 975 185 975 185 0 Total SIA ORI Surv Total SIA ORI
2014
2015 Surv 1 546 481 71 454 123 634 Total 1 546 481 71 454 123 634 15 380 365 191 930 143 1 348 354 24 643 812 682 1 131 736 72 644 659 602 37 173 1 348 354 24 643 16 477 229 5 044 596 72 644 659 602 828 744 21 208 767 218 127 524
Country
SIA
ORI
Bangladesh
62 610 793
Bhutan
DPRK**
India
Indonesia
Maldives
Myanmar
Nepal
Sri Lanka
Thailand
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Timor-Leste
98 166
Total
62 708 959
0
* India uses MR for SIAs and ORI
** Democratic People’s Republic of Korea
65
66
Annex 12 continued 2016 Surv 0 65 695 91 046 305 091 305 091 265 356 127 021 292 595 16 684 285 379 1 988 24 078 1 005 021 1 611 247 48 314 531 972 35 977 1 527 822 1 205 991 214 984 128 938 96 144 225 082 70 839 5 293 70 704 75 997 1 364 863 22 184 984 1 070 823 1 939 153 3 009 976 1 093 194 5 407 134 027 Total SIA ORI Surv Total SIA ORI 2017 2018 Surv 2 503 399 65 713 91 243 0 25 934 219 1 408 017 26 066 1 290 399 1 876 603 175 334 824 567 52 661 357 411 2 026 292 882 273 081 129 443 297 345 17 871 19 084 1 274 313 2 120 503 43 438 527 388 31 018 Total 3 596 593 71 120 225 270 62 466 821 34 133 120 21 111 1 567 195 2 393 584 172 881 824 733 406 300 3 721 898 27 129 298 31 156 288 68 056 778 3 803 613 34 018 336 105 878 727
Country
SIA
ORI
Bangladesh
20 820 121
Bhutan
5 144
DPRK** 0 15 236 447 35 824 590 963 889 19 071 725 713 1 091 988 43 181 526 522 30 937 46 626 813 958 168 449 1 348 047 1 003 760 21 006 2 456 133
123 938
India
20 588 142
0 20 560 697 20 865 789 36 532 602
Indonesia
1 492 244
2 733 813 31 166 764 1 558 338
Maldives
1 935
Myanmar
278 048
Nepal
256 060
Sri Lanka
125 268
Thailand
287 436
Timor-Leste
15 689
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Total
41 408 263
2 585 761 20 159 351 64 153 376
** Democratic People’s Republic of Korea
Annex 12 continued 2019 ORI 978 965 4 843 122 365 2 651 742 1 395 794 1 808 263 985 246 591 115 988 265 641 16 807 6 064 527 34 339 400 36 060 532 773 798 414 52 866 92 140 773 48 554 164 541 2 126 008 7 982 170 1 279 841 1 543 826 30 180 143 24 091 25 899 1 550 575 2 946 369 26 060 999 74 840 017 10 796 847 6 353 339 1 423 052 1 831 270 197 253 719 117 789 270 223 17 867 9 838 730 96 341 218 706 126 955 70 721 75 563 4 934 2 513 437 3 492 402 19 383 297 998 824 2 510 115 65 729 91 439 26 089 247 1 413 354 19 097 1 275 354 2 121 510 43 661 528 128 31 103 34 188 736 Surv Total SIA ORI Surv 2020 Total 22 892 236 70 662 218 394 43 239 432 2 836 406 20 928 1 545 551 2 375 229 161 451 798 350 48 970 74 207 610
Country
SIA
Bangladesh
Bhutan
DPRK**
India
46 127 276
Indonesia
Maldives
Myanmar
Nepal
5 609 570
Sri Lanka
Thailand
Timor-Leste
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Total
51 736 846
** Democratic People’s Republic of Korea
67
68
Annex 12 continued
2013–15 Surv 3 492 958 214 297 370 315 35 380 347 211 930 126 114 349 959 3 588 339 73 888 1 886 991 2 364 636 217 013 1 975 583 111 291 1 001 028 33 263 262 357 411 217 013 6 277 496 5 609 570 1 294 807 615 509 1 413 239 84 917 17 551 538 1 390 490 73 888 9 588 105 421 5 560 242 93 764 149 31 166 764 7 397 251 370 315 636 223 466 213 1 102 436 214 297 25 620 338 561 364 181 66 103 752 40 203 418 4 141 806 10 830 968 55 176 191 102 814 211 Total SIA ORI ORI Total SIA ORI
2016–20
2013–2020 Surv Total
Country
SIA
ORI
Bangladesh
62 610 793
4 141 806 14 323 926 121 279 943 25 620 636 223 552 858 836 528 578 479 1 472 751 9 005 080 149 261 957 449 166 774 7 397 251 10 130 164 138 869 990
Bhutan
DPRK**
India
176 549 779
9 005 080 113 881 610 237 236 649 290 899 737 6 541 825 45 105 840 121 342 575 115 009 6 950 732 15 664 547 9 071 255 15 975 633 227 147 2 646 784 165 095 842 656 9 522 430 4 060 022 31 287 679 607 423 1 247 148
Indonesia
90 175 810
Maldives
9 588 1 390 490
179 308
188 897 7 447 232 24 502 269 1 294 807 11 435 892 22 253 129 615 509 1 413 239 84 917 444 160 1 059 669 4 622 367 37 323 285 276 386 1 608 451
Myanmar
15 664 547
Nepal
3 912 860
Sri Lanka
Thailand
31 287 679
Timor-Leste
889 737
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Total
381 091 204
49 675 659 430 766 863 191 687 122 26 014 530 149 835 121 367 536 773 572 778 327 26 014 530 199 510 780 798 303 636
** Democratic People’s Republic of Korea
Annex 13 Guidelines for Congenital Rubella Surveillance in the South-East Asia Region
1 Rationale CRS surveillance allows for detection of infants with clinically apparent manifestations and can be standardized for regional and global reporting, and for comparison. Rapid identification of infants with CRS is necessary to ensure that appropriate testing can be conducted and that the infant is entered into the CRS surveillance system. Detection of infants with CRS is necessary to ensure infection control and prevent further spread of rubella, as infants with CRS may shed the virus for a prolonged period – up to one year of age or longer. Immediate diagnosis of CRS also facilitates early intervention for specific defects. All Member States should develop a CRS surveillance system that captures the majority of infants with suspected CRS within the country. If there is no surveillance in place, countries may opt to establish CRS surveillance in a few sentinel sites first followed by broadening the surveillance and adding additional sites to include more of the population.
2
Overview of CRS surveillance
Routine surveillance for CRS should focus on identifying infants less than one year of age, although some defects associated with CRS surveillance may not be detectable until older ages. The most common congenital defects related to CRS are cataracts, heart defects and hearing impairment. These are the primary conditions under CRS surveillance. These conditions are most likely to be seen at secondary and tertiary health-care facilities, which should be included as sentinel sites for CRS surveillance. National health authorities should define the objectives and overall structure of the CRS surveillance system, which should be aligned with the existing communicable-disease surveillance system, health- care structure and capacities. Member States should report CRS cases to WHO according to national surveillance system capacities, at least annually.
3
CRS: Case definitions and laboratory criteria for confirmation
Case definitions for CRS Classification of cases for CRS surveillance is based on clinical, epidemiological and laboratory data. The case definitions for CRS surveillance include the following categories: Suspected CRS case: Any infant less than one year of age that a health worker suspects of having CRS. A health worker should suspect CRS when an infant aged 0-11 months has heart disease and/or suspicion of hearing impairment and/or one or more of the following eye signs: white pupil (cataract), larger eye ball (congenital glaucoma) or pigmentary retinopathy. A health
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69
worker should also suspect CRS when an infant’s mother has a history of suspected or confirmed rubella during pregnancy, even when the infant shows no signs of CRS. Clinically confirmed CRS case: An infant in whom a qualified physician detects at least two of the complications listed in (a) below or one in (a) and one in (b): (a) cataract(s), congenital glaucoma, congenital heart disease, hearing impairment, pigmentary retinopathy; (b) purpura, splenomegaly, microcephaly, developmental delay, meningocephalitis, radiolucent bone disease, jaundice that begins within 24 hours after birth. Laboratory confirmed CRS case: An infant who is a suspected case (who has one condition from group A) who meets the laboratory criteria for CRS case confirmation. Congenital rubella infection (CRI): An infant who does not have clinical signs of CRS but has a positive rubella-specific IgM test is classified as having CRI. Criteria for laboratory confirmation of CRS Laboratory criteria for confirmation of suspected CRS cases include the following: ¤¤ ¤¤
rubella IgM antibody detected; or sustained rubella IgG antibody level as determined on at least two occasions between 6 and 12 months of age in the absence of receipt of rubella vaccine; or rubella virus detection (e.g. nucleic acid detection by reverse transcription polymerase chain reaction (RT-PCR) or rubella virus isolation) in an appropriate clinical sample (best results come from throat swabs, but nasal swabs, blood, urine, or cerebrospinal fluid specimens are also acceptable).
¤¤
Efforts should be made to obtain clinical specimens for antibody levels and for viral isolation from infants at the time of the initial investigation. The clinical and laboratory data will be used to determine the final classification of each of the suspected CRS cases. Depending on the age of the suspected CRS case at initial testing, the following consideration should be made interpreting laboratory results and determining final classification of suspected CRS cases (Annex 1): ¤¤
Infants with congenital rubella, even without clinical features of CRS will usually be positive for rubella-specific IgM at or shortly after birth. Although IgM antibodies may persist for up to one year, they normally peak within the first six months of life. Because IgM may not be detectable in some infants tested shortly after birth, IgM negative cases with suspected CRS should be retested at one month of age or shortly thereafter. Laboratory confirmation of CRS in an infant aged over six months should not rely on the IgM test alone if the result is negative. In such cases, serial IgG testing should also be included to check for a sustained level of antibody over several months. Infants with congenital rubella should also be tested for shedding rubella virus through virus isolation techniques. Congenitally infected infants may shed and transmit rubella virus for up to one year of age and be the source of rubella outbreaks. Therefore, it is important to continue testing the infant for virus throughout the first year of life so
¤¤
¤¤
70
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
that infection control measures can continue until virus shedding stops. This has to be confirmed by two negative results of viral testing of specimens obtained one month apart from infants at least three months of age.
4
Steps to establish a CRS surveillance system
The following steps should be implemented to establish CRS surveillance. 1. Identify national CRS surveillance coordinators responsible for epidemiologic and laboratory components of the system. Epidemiologic coordinator oversees: ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤
development of a protocol for CRS surveillance; development of necessary training materials; training on the CRS surveillance system; monitoring of surveillance performance and data quality; adequacy of collection and transportation of specimens for laboratory testing; maintenance of the CRS surveillance database; coordination with laboratory activities, to ensure linkage of laboratory and epidemiologic data; coordination of activities with national measles and rubella elimination programme in country, including reporting to WHO; feedback on the CRS surveillance to participating health-care providers and facilities and relevant public health authorities.
¤¤
¤¤
Laboratory coordinator oversees: ¤¤
adequacy of the laboratory testing, standard operating procedures (SOPs), necessary accreditations and an ongoing quality assurance programme; interpretation and reporting of test results for CRS; monitoring duration of virus shedding by CRS cases; coordination with epidemiological activities, to ensure linkage of laboratory and epidemiologic data; laboratory related training.
¤¤ ¤¤ ¤¤
¤¤
2. Determine facilities at which infants with CRS are most likely to be seen. 2.1 Consideration for determining facilities ¢¢
The facilities at which infants with most common defects associated with CRS – cataracts, heart defects, or deafness, as well as infants with maternal history of rubella during pregnancy, are likely to be seen and should be included in the CRS surveillance system. As these defects are most likely to be evaluated and treated
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
71
at secondary and tertiary care facilities, adequate sentinel surveillance for CRS can be conducted at these facilities without including primary health-care providers and facilities in the CRS surveillance system. This will help to avoid overwhelming general health-care providers by having to identify, report and follow up on cases of CRS. ¢¢
The types of facilities/providers most likely to evaluate and treat infants with CRS: ——
secondary care providers/facilities, particularly ophthalmologists, cardiologists, audiologists, neonatologists; tertiary care facilities, particularly those that provide surgical services for the eyes, ears, and heart; specialty care centres (e.g. Children’s Hospitals; Centres for Hearing and Blindness); obstetric centres or private clinics involved in care of pregnant women with rubella.
——
——
——
¢¢
If providers and facilities included in the CRS surveillance system capture the majority of infants with suspected CRS within a country, the CRS surveillance system can be considered adequate. It is recommended that countries with newly established CRS surveillance systems pilot test their system with a few facilities to ensure adequacy of developed protocols and standard operating procedures(SOPs). Protocols may then be updated with feedback from the piloted sites.
¢¢
2.2 Responsibilities of local surveillance coordinators at sentinel sites include certain steps. ¤¤ ¤¤ ¤¤
Ensure adherence to the national protocol and SOPs for CRS surveillance. Assist as needed in training health-care providers and staff at the respective facilities. Ensure collection of clinical and epidemiologic data and completion of case investigation forms (Annex 2). Ensure appropriate collection and transportation of specimens with and ensuring that laboratory data can be linked to clinical and epidemiologic information. Maintain a line listing of suspected CRS cases in the assigned facilities. Provide periodic feedback to health-care providers at their respective sites. Maintain contact with the national coordinator regarding identification and followup of suspected cases of CRS identified in the area.
¤¤
¤¤ ¤¤ ¤¤
3. Conduct initial and refresher trainings for participating providers. ¤¤
Trainings for the providers from the sentinel facilities participating in CRS surveillance activities should be conducted on an annual basis. Trainings should include information regarding clinical features of CRS, evaluation of infants with suspected CRS, appropriate laboratory testing of suspected cases, follow-up of CRS cases, the importance of completing case investigation forms, infection control
¤¤
72
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
measures to prevent rubella virus spread from infants with CRS and reporting cases in a timely manner. 4. Initiate CRS surveillance activities. ¤¤
Reporting of suspected CRS cases should be initiated once the coordinator and participating sites have been identified and participating providers have been trained in SOPs for CRS surveillance.
5. Conduct surveillance quality assessment and monitoring. ¤¤
Surveillance quality assessments need to be conducted at the sentinel sites at least every six months to assess completeness of CRS surveillance at the site. ¢¢
This should be done by reviewing hospital records by the site level coordinator to identify any missed cases. Missed cases can be identified by comparing the list of reported CRS cases with the list of all cases that meet the entry criteria for CRS surveillance (i.e. criteria for suspected CRS case). The proportion of missed cases at a sentinel site can be assessed as the percent of missed cases identified by the coordinator among all cases that meet the CRS surveillance entry criteria (total of both reported and unreported cases). Similarly, the proportion of suspected CRS cases that have been reported, but have not been tested by laboratory, can be assessed as the percentage of reported cases without laboratory testing among all reported suspected CRS cases (both tested and untested).
¢¢
¢¢
¤¤
Monitoring surveillance data quality. CRS surveillance case reports should be assessed for any missing variables. If records are incomplete, the findings should be discussed with providers at the site and the need for completeness of data and case reporting should be emphasized.
6. Expand CRS surveillance and include other sites, as appropriate. In countries that have conducted limited pilot testing of CRS surveillance systems, or in countries where assessments have shown that the majority of infants within the country are not included in CRS surveillance, the surveillance should be expanded to include more sites with the ultimate goal of establishing sentinel site surveillance that captures the majority of infants in the country. 7. Analyse the CRS surveillance data on an annual basis, or more frequently if necessary. Epidemiologic variables that should be assessed include: ¤¤ ¤¤ ¤¤ ¤¤ ¤¤ ¤¤
number of cases reported throughout time frame assessed (e.g. year); case classification status; geographic location of CRS cases within the country; whether or not cases were clustered and/or associated with rubella outbreaks; maternal characteristics (age, race/ethnicity, country of birth); location of maternal exposure to rubella.
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
73
8. Provide feedback to stakeholders involved in the CRS surveillance system. ¤¤
Feedback should include information on the status of the epidemiology of CRS including, if necessary any updates and recommendations for improvements.
9. Ensure infection control measure for CRS cases. ¤¤
Infants with CRS may shed rubella virus for up to one year and have been the cause of rubella outbreaks. Only persons immune to rubella should have contact with these infants. In the hospital, and infants should remain in isolation. Persons caring for the patient should wear a gown and gloves and should be immunized against rubella. Family members and friends involved in the care or handling of the infant should be immune to rubella.
5
Additional approach to identify CRS cases
Rubella in pregnancy registries Rubella in the pregnancy registry can be used for follow-up of pregnant women exposed to rubella and their pregnancy outcome(s), as well as for identification of CRS cases. Rubella in pregnancy registries should be maintained at the local level so that comprehensive follow-up of pregnant women can occur and infants born with CRS can be identified and diagnosed immediately and receive early interventions for any associated defects. The registry should include maternal contact, demographic data and pregnancy outcome (e.g. miscarriage, termination, infant with CRS, etc.).
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Annex 13A Flow chart of classification of CRS cases depending on age group Suspected CRS case
>6 months of age Blood sample not obtained* Does not meet clinical criteria for CRS Discarded Meet clinical criteria for CRS Clinically compatible IgM– Within 1st month of life, and high suspicion of CRS Follow up test 1-2 months laters IgM– *Every effort should be made to obtain a blood sample of adequate size (1ml) and that is kept cool during transport
6 to <12 months of age
Blood sample obtained (1ml) IgM+ Absence of >1 Presence of >1 defect from (A) defect from (A) Infection only (CRI) Confirmed
Discarded
IgM+ Confirmed
Discarded
Suspected CRS case
6 to <12 months of age Blood sample not obtained* IgG+ and IgM– 2n blood sample not obtained Does not meet clinical criteria for CRS Discarded Meet clinical criteria for CRS Clinically compatible 2n blood sample obtained IgG– IgG+
<6 months of age
Blood sample obtained (1ml) IgG+ and IgM+ IgG+ and IgM+/IgM– Discarded
Absence of >1 Presence of >1 defect from (A) defect from (A) Discarded Infection only (CRI) Confirmed
*Every effort should be made to obtain a blood sample of adequate size (1ml) and that is kept cool during transport
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
75
Annex 13B Congenital rubella syndrome case investigation form Recommended basic set of data for case-based reporting in national surveillance system Please fill in this form for investigation and reporting of a clinically suspected case of CRS Case ID: Region: Date of notification: / / A. Identification Name of the child: ____________________________________ Sex: Male ⬚ Female ⬚ Date of birth: ___ /___ /___ if not available – age in months_____ Address:_____________________________________________________________________________ Place infant delivered: __________________________ Name of mother:________________________________ B. Clinical signs and symptoms Gestational age (weeks) at birth:______ Birth weight (grams): __________________________ Group A (please complete all) Congenital heart disease: Yes ⬚ No ⬚ Unknown ⬚ If yes, please specify defect:____________________ Cataracts: Congenital glaucoma: Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Group B (please complete all) Purpura: Microcephaly: Meningoencephalitis Jaundice: Splenomegaly: Developmental delay: Radiolucent bone disease: Radiolucent bone disease: Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Yes ⬚ No ⬚ Unknown ⬚ Date of investigation: / / District: Date of reporting: / /
Pigmentary retinopathy: Yes ⬚ No ⬚ Unknown ⬚ Hearing impairment:
Other abnormalities: Yes ⬚ No ⬚ If yes, please describe:_____________________________________
Name of physician who examined infant:__________________________________________________ City/town/village:___________________________________________ Telephone:_______________________ Present status of infant: Alive _ Dead _ If dead, cause of death: ________________________________________________________________
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Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
Autopsy conducted: Yes ⬚ No ⬚ Unknown _ Autopsy findings:______________________________________________________________________ Autopsy date:_____/____/_______ C. Maternal history/Antenatal care Number of previous pregnancies: Mother’s age (years):
Vaccinated against rubella: Yes ⬚ No ⬚ Unknown ⬚ If yes, give date: ___/___/___ Rubella like illness during pregnancy: Yes ⬚ No ⬚ Unknown ⬚ If yes, month of pregnancy:___________ Maculopapular rash: Yes ⬚ No ⬚ Unknown ⬚ If yes, date of onset___/___/___ Lymph nodes swollen: Yes ⬚ No ⬚ Unknown ⬚ If yes, date of onset___/___/___ Arthralgia/arthritis: Yes ⬚ No ⬚ Unknown ⬚ If yes, date of onset___/___/___ Other complications Yes ⬚ No ⬚ Unknown ⬚ If yes, date of onset___/___/___ Was rubella laboratory-confirmed in the mother Yes _ No _ Unknown _ If yes, when (date): ___/___/___ Was the mother exposed during pregnancy to person(s) of any age with maculopapular (e.g. not vesicular) rash illness with fever Yes ⬚ No ⬚ Unknown ⬚ If yes, when (date): ___/___/___ Month of pregnancy:_______________________________ Describe where:___________________________________ Did the mother travel during pregnancy: Yes ⬚ No ⬚ Unknown ⬚ If yes, when (date): ___/___/___ Month of pregnancy:_______________________________ Describe where:______________________ D. Infant/child laboratory investigations Specimen collected: Yes ⬚ No ⬚ Unknown⬚_ If yes, please type of specimen: Serum ⬚ Throat swab ⬚ Urine ⬚ Cerebrospinal fluid ⬚ Other ⬚ Date of specimen collection: ___/___/___ Date specimen sent: ___/___/___ Rubella IgM: Not tested ⬚ Positive ⬚ Negative ⬚ In process ⬚ Inconclusive ⬚ Sustained IgG level*: IgG not tested ⬚ Yes ⬚ No ⬚ In process ⬚ (*sustained IgG level on at least 2 occasions between 6 and 12 months of age) Rubella virus isolation: Not tested ⬚ Positive ⬚ Negative ⬚ In process ⬚ Rubella PCR: Not done ⬚ Positive ⬚ Negative ⬚ In process ⬚ Genotype_______ Date of laboratory result (first validated result): ____/____/____ E. Final classification CRS ⬚ Discarded ⬚ If discarded, please specify:__________________________________________ Case classification as Laboratory-confirmed ⬚ Epidemiologically linked ⬚ Clinical ⬚ Classification by origin: Endemic ⬚ Imported ⬚ Import-related ⬚ Unknown ⬚ Date of final classification: ____/____/____ Investigator:__________________________________________________________________________
Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region, 2014–2020
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The Sixty-sixth WHO Regional Committee for South-East Asia in September 2013 resolved to adopt the goal of measles elimination and rubella/CRS control in the South-East Asia Region by 2020. In response, the WHO Regional Office for SouthEast Asia developed this Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region. This strategic document provides technical support to Member States in their efforts to develop elimination policy and strategies, while strengthening their immunization and surveillance systems and improving their programme performance. In this way, these ambitious 2020 goals can be met.
ISBN 978 92 9022 491 4
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