Volume 6 • Issue 2 • February 2012
ISSN 1814 3601
News in Brief Progress towards measles elimination: Member States of the Western Pacific Region kept up the attack against endemic measles virus during 2011 through supplementary immunization activities (SIAs) and strengthened routine immunization services. Integrated, multi-antigen SIAs in Cambodia, the Lao People's Democratic Republic, the Federated States of Micronesia, the Philippines and Papua New Guinea reached 20.5 million people with measles containing vaccine and provided other essential child health interventions (for example, oral polio vaccine, vitamin A and deworming medicines). Measles incidence was 11.6 per million of population in 2011 compared with 27 per million in 2010. However, a dramatic reduction in cases occurred in the second half of the year that should continue in 2012 as a result of the SIAs mentioned above. Regional Consultation on Measles Elimination and Hepatitis B Control: The WHO Regional Office for the Western Pacific is bringing together the members of the Regional Verification Commission (RVC) on Measles Elimination and ministry of health officials from Member States and partners for a consultation on measles elimination 17–20 April. The RVC will meet alone on 17 April for an organizational meeting to be followed by the consultation with Member States and partners 18–20 April. The consultation will also address a proposed target year for achieving the Hepatitis B control goal of <1% seroprevalence of hepatitis B surface antigen prevalence among five-year-old children and the Decade of Vaccines Collaboration Global Vaccine Action Plan. GAVI supports rubella vaccine introduction: In response to increased demand from countries and World Health Organization (WHO) recommendations, in November 2011, the Global Alliance for Vaccines and Immunization (GAVI) Board approved to open a funding window for rubella vaccines, with a target of reaching 588 million children by 2015. GAVI will invite applications from eligible countries in 2012 for support of catch-up SIAs targeting children ages nine months to 14 years with measles-rubella vaccine and a one time vaccine introduction grant for each country to cover operational costs for routine introduction. Application guidelines will be available on 1 April, and applications are due by 31 August 2012. The decision on funding rubella vaccines supports the United Nations Secretary-General’s Global Strategy for Women and Children’s Health by increasing access to life-saving vaccines for women and children in the world’s poorest countries.
Data Reporting Timeliness and completeness of monthly data reporting National reports (Table 1A) During 2011, completeness and timeliness of monthly reporting of measles and rubella cases to the WHO Regional Office for the Western Pacific was 95% and 89%, respectively. Completeness of reporting for the Region ranged from 82% to 100% by month; and varied from 75% to 100% by country and area. Completeness of monthly reporting was particularly low for the Pacific island countries and areas, Papua New Guinea and Viet Nam (75% each) because of low reporting during the first half of the year. Timeliness of monthly reporting for the Region ranged from 76% to 100% by month and from 42% to 100% by country and area. Timeliness was particularly low for Papua New Guinea (42%) and Viet Nam (50%), primarily because of late or no reports during the first half of the year. National measles laboratory reports (Table 1B) During 2011, completeness and timeliness of data submitted by national measles laboratories (NMLs) to the Regional Office was 93% and 88%, respectively. Laboratories from China do not report laboratory data directly to the WHO Regional Office for the Western Pacific. All other NMLs achieved at least 80% Timeliness of monthly reporting was completeness. particularly low for NMLs in Fiji (58%), Papua New Guinea (67%) and Viet Nam (northern) (75%), but timeliness improved in the second half of the year.
Table 1A. Completeness and timeliness of national reporting, Western Pacific Region, 2009 - 2011 2009 Country Australia Brunei Darussalam Cambodia China Hong Kong (China) Japan Lao PDR Macao (China) Malaysia Mongolia New Zealand Papua New Guinea Philippines Republic of Korea Singapore Viet Nam Pacific island countries* Completeness Timeliness 1 2 3
2010 Completeness 100% 100% 75% 100% 100% 100% 83% 100% 92% 100% 100% 67% 100% 92% 100% 92% 92% 93.6% 60.8% 78.9% Timeliness 100% 100% 42% 58% 100% 100% 75% 100% 83% 92% 92% 33% 92% 92% 100% 25% 58% Jan 10 Feb 08 Feb 08 Feb 10 Feb 14 Feb 09 Feb 04 Feb 09 Feb 07 Feb 09 Feb 09 Feb 07 Feb 16 Feb 06 Feb 10 Feb 02 Feb 10 Feb 10 Feb 100% 94% 10 Mar 94% 88% 88% 88% 82% 76% 88% 88% Feb 10 Mar 10 Mar 09 Mar 10 Mar 10 Mar 09 Mar 07 Mar 10 Mar 04 Mar 07 Mar 07 Mar 07 Mar 29 Mar 14 Mar 08 Mar 01 Mar 10 Apr 07 Apr 06 Apr 10 Apr 03 May 09 May 05 May 03 Jun 10 Jun 06 Jun 02 Jun Mar 10 Apr 08 Apr 07 Apr 10 Apr 12 Apr 07 Apr 05 Apr 08 Apr 06 Apr 08 Apr 09 Apr 05 Apr Apr 10 May 06 May 09 May 10 May 11 May 06 May 06 May 10 May 05 May 06 May 05 May 12 May May 10 Jun 09 Jun 07 Jun 08 Jun 13 Jun 09 Jun 10 Jun 10 Jun 07 Jun 09 Jun 07 Jun 08 Jun Jun 10 Jul 07 Jul 09 Jul 10 Jul 10 Jul 08 Jul 08 Jul 10 Jul 01 Jul 15 Jul 10 Jul 05 Jul 14 Jul 07 Jul 10 Jul 04 Jul 10 Jul 22 Jul 100% 88% Jul 10 Aug 09 Aug 09 Aug 31 Aug 10 Aug 09 Aug 10 Aug 06 Aug 05 Aug 10 Aug 05 Aug 24 Aug 04 Aug 03 Aug 08 Aug 03 Aug 11 Aug 10 Aug 100% 82%
2011 Aug
1
Completeness 100% 100% 100% 92% 100% 100% 58% 100% 58% 100% 100% 67% 75% 50% 100% 83% 67% 85.3%
Timeliness 100% 100% 83% 0% 100% 92% 42% 83% 42% 75% 92% 17% 58% 17% 67% 25% 42%
Sep 10 Oct 07 Oct 08 Oct 10 Oct 12 Oct 07 Oct 10 Oct 07 Oct 07 Oct 05 Oct 07 Oct 06 Oct 07 Oct 10 Oct 07 Oct 04 Oct 07 Oct 11 Oct 100% 100%
Oct 10 Nov 09 Nov 08 Nov 10 Nov 15 Nov 09 Nov 09 Nov 02 Nov 09 Nov 10 Nov 04 Nov 04 Nov 09 Nov 04 Nov 04 Nov 02 Nov 03 Nov 94% 94%
Nov 10 Dec 09 Dec 08 Dec 10 Dec 15 Dec 08 Dec 07 Dec 09 Dec 05 Dec 15 Dec 10 Dec 08 Dec 07 Dec 03 Dec 06 Dec 06 Dec 09 Dec 94% 88%
Dec 10 Jan 09 Jan 09 Jan 10 Jan 15 Jan 06 Jan 10 Jan 10 Jan 05 Jan 10 Jan 09 Jan 10 Jan 17 Jan 03 Jan 04 Jan 09 Jan 11 Jan 10 Jan 100% 88%
10 Sep 07 Sep 07 Sep 10 Sep 13 Sep 09 Sep 10 Sep 05 Sep 02 Sep 10-Sep 09 Sep 08 Sep 06 Sep 06 Sep 14 Sep 06 Sep 02 Oct 15 Sep 100% 88%
Completeness 100% 100% 100% 100% 100% 100% 92% 100% 100% 100% 100% 75% 100% 100% 100% 75% 75% 95.1%
2
Timeliness 100% 100% 92% 100% 100% 100% 92% 100% 92% 100% 83% 42% 92% 92% 92% 50% 67% 88.7%
3
Monthly reports received through March 2012
Legend: black = timely report; red = untimely report
Completeness is defined as the number of reports received by the end of the reporting month divided by the number of expected reports for the year Countries and areas should submit reports by the 10th (or the next working day) of the following month; Pacific island countries and China may report to the Regional Office by the 15th (or the next working day) of the following month
Table 1B. Completeness and timeliness of laboratory reporting, Western Pacific Region, 2009 - 2011 Country Australia Cambodia China Hong Kong (China) Japan Lao PDR Macao (China) Malaysia Mongolia New Zealand Papua New Guinea Philippines Republic of Korea Singapore Viet Nam (northern) Viet Nam (southern) Fiji Completeness Timeliness 1 2 3
2009 Completeness 100% 50% 0% 100% 0% 8% 100% 75% 92% 83% 0% 100% 75% 100% 92% 92% 67% 66.7% 45.6% Timeliness 83% 17% 0% 100% 0% 0% 92% 8% 92% 8% 0% 33% 50% 100% 58% 75% 58% 100% 42% 0% 100% 0% 58% 100% 92% 100% 100% 75% 100% 100% 100% 100% 83% 67% 77.5%
2010 Completeness Timeliness 100% 25% 0% 100% 0% 58% 100% 58% 100% 33% 33% 83% 100% 100% 58% 50% 50% 61.8% 09 Feb 04 Feb 10 Feb 07 Feb 09 Feb 08 Feb 09 Feb 10 Feb 08 Feb 10 Feb 07 Feb 08 Feb 09 Feb 09 Feb 94% 94% 09 Mar 07 Mar 10 Mar 04 Mar 07 Mar 04 Mar 11 Mar 08 Mar 10 Mar 09 Mar 07 Mar 21 Mar 10 Mar 10 Mar 94% 82% 09 Apr 05 Apr 08 Apr 07 Apr 08 Apr 06 Apr 08 Apr 12 Apr 08 Apr 08 Apr 08 Apr 09 Apr 08 Apr 11 Apr 94% 82% 09 May 06 May 10 May 05 May 10 May 04 May 10 May 09 May 10 May 10 May 06 May 10 May 10 May 04 May 94% 94% 82% 76% 25 May 08 Jun 07 Jun 16 Jun 08 Jun 09 Jun 10 Jun 10 Jun 08 Jun 09 Jun 07 Jun 10 Jun Jan 08 Feb 07 Feb Feb 03 Mar 07 Mar Mar 05 Apr 07 Apr Apr 04 May 09 May May 03 Jun 09 Jun Jun
2011 01 Jul 09 Jul 09 Jul 08 Jul 10 Jul 07 Jul 10 Jul 09 Jul 07-Jul 01 Jul 10 Jul 10 Jul 08 Jul 12 Jul 08 Jul 22 Jul 94% 82%
1
Jul 08 Aug 05 Aug 10 Aug 10 Aug 10 Aug 05 Aug 09 Aug 05 Aug 10 Aug 09 Aug 09 Aug 09 Aug 05 Aug 09 Aug 09 Aug 10 Aug 94% 94%
Aug 06 Sep 07 Sep 09 Sep 10 Sep 03 Sep 05 Sep 09 Sep 07 Sep 08 Sep 09 Sep 09 Sep 09 Sep 09 Sep 09 Sep 08 Sep 15 Sep 94% 88%
Sep 03 Oct 08 Oct 08 Oct 10 Oct 10 Oct 08 Oct 10 Oct 07 Oct 10 Oct 02 Oct 10 Oct 10 Oct 07 Oct 05 Oct 10 Oct 11 Oct 94% 88%
Oct 07 Nov 08 Nov 10 Nov 09 Nov 10 Nov 08 Nov 08 Nov 04 Nov 10 Nov 10 Nov 10 Nov 08 Nov 07 Nov 10 Nov 03 Nov 88% 88%
Nov 02 Dec 09 Dec 10 Dec 07 Dec 10 Dec 05 Dec 07 Dec 09 Dec 09 Dec 02 Dec 08 Dec 09 Dec 06 Dec 08 Dec 09 Dec 09 Dec 94% 94%
Dec 03 Jan 05 Jan 09 Jan 10 Jan 10 Jan 08 Jan 10 Jan 09 Jan 10 Jan 24 Jan 05 Jan 10 Jan 06 Jan 09 Jan 09 Jan 10 Jan 94% 94%
Completeness 100% 100% 0% 100% 100% 100% 100% 100% 100% 100% 83% 100% 100% 100% 100% 100% 92% 92.6%
2
Timeliness 100% 100% 0% 100% 100% 100% 100% 100% 100% 92% 67% 100% 100% 100% 75% 100% 58% 88.2%
3
Monthly reports received through March 2012 Completeness is defined as the number of reports received by the end of the reporting month divided by the number of expected reports for the year National measles and rubella laboratories should submit monthly reports by the 10th (or the next working day) of the following month
Incidence and Deaths (Table 2A) A total of 21 048 confirmed measles cases were reported in the Region during 2011, corresponding to a measles incidence of 11.6 per million of population, a 57% decrease compared to the 27.0 per million incidence in 2010. The countries with the highest incidence were New Zealand (135.7), the Philippines (69.1), Malaysia (54.4), Cambodia (50.4), and Singapore (27.6). Classification is pending for 45 cases. Clinically confirmed cases accounted for 5447 (26.3%) of all confirmed cases in the Region with classification data (Australia and Singapore do not report clinically confirmed cases). Countries and areas with a large percentage of clinically confirmed cases included Viet Nam (86.2%), the Lao People's Democratic Republic (74.3%), Cambodia (55.8%), the Philippines (48.0%), and Hong Kong (China) (46.2%). Clinically confirmed cases are considered failures of surveillance because either specimens were not collected or contact tracing was inadequate to establish epidemiologic linkage to other confirmed cases. Forty-seven measles related deaths were reported during 2011 (case fatality rate [CFR]=0.2%): 28 were reported from the Philippines (CFR=0.4%), 10 from China (CFR=0.1%), four from Viet Nam (CFR=0.5%) and four from Malaysia (CFR=0.2%) and one from Cambodia (CFR=0.1%)
Surveillance Performance Indicators (Table 2B) Case reporting rate The annualized discarded measles rate during 2011 was 2.8 per 100 000 population for the Region, an increase from 1.7 in 2010 and exceeding the target of 2 per 100 000. Countries and areas achieving or exceeding the target included Fiji (59.3), Cambodia (20.2), Viet Nam (16.0), Malaysia (11.6), Mongolia (6.5), the Lao Peoples Democratic Republic (5.2), Hong Kong (China) and the Philippines (3.1), and M a c a o ( C h i n a ) ( 2 . 7 ). C o u n tri e s w i t h di s c a rd e d measles rates well below the target included
2
Table 2A. Measles case classification and incidence, by country and area, Western Pacific Region, 2010—2011 1 2010 Country
2011 Discarded cases 0 7 2416 18 529 13 31 179 28 1028 153 0 26 3988 132 0 2919 0 0 46 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 29 495
1
Population (in millions) 2
Suspected measles 3 cases No data
Confirmed measles cases Lab 65 0 451 26 297 4 306 6 0 68 0 15 0 2883 95 54 757 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 31 002
Epi-linked 5 0 0 116 0 3 0 0 2 0 21 0 137 16 0 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 390
Clinical 0 0 705 11 768 7 121 147 0 4 7 12 0 3368 3 0 979 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17 121
Total 70 0 1 156 38 181 11 430 153 0 74 7 48 0 6388 114 54 1826 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 48 513
Measles Pending Deaths due to incidence per classification measles 1 million pop. 0 0 0 56 0 0 0 0 0 0 0 0 0 0 0 1683 0 0 28 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1767 0 0 6 39 0 0 0 0 0 0 0 0 34 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 80 3.1 0.0 81.8 28.5 1.6 3.4 24.7 0.0 2.6 2.5 11.0 0.0 68.5 2.4 10.6 20.8 0.0 0.0 1.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 27.0 Green Yellow Red
Population (in millions) 2 22.61 0.41 14.31 1347.57 7.12 126.50 6.29 0.56 28.86 2.80 4.41 7.01 94.85 48.39 5.19 88.79 0.07 0.02 0.87 0.27 0.18 0.10 0.05 0.11 0.01 0.25 0.00 0.06 0.02 0.18 0.55 0.00 0.10 0.01 0.25 0.01 1808.80
Suspected measles 3 cases No data
Confirmed measles cases Lab 164 4 319 8951 6 322 12 1 1445 0 428 0 3239 40 143 22 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15 098
Epi-linked 24 0 0 13 1 9 17 0 82 0 105 0 171 0 0 81 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 503
Clinical 0 0 402 979 6 79 84 0 42 0 66 0 3144 3 0 642 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5447
Total 188 4 721 9 943 13 410 113 1 1569 0 599 0 6554 43 143 745 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21 048
Discarded cases 0 6 2885 24 692 222 399 326 15 3341 183 0 44 2952 131 0 1 4208 0 0 515 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49 919
Pending Deaths due to classification measles 0 0 7 7 0 0 0 0 0 0 4 6 0 0 0 0 0 0 21 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 45 0 0 1 10 0 0 0 0 4 0 0 0 28 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 47
Measles incidence per 1 million pop. 8.3 9.9 50.4 7.4 1.8 3.2 18.0 1.8 54.4 0.0 135.7 0.0 69.1 0.9 27.6 8.4 0.0 0.0 2.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 11.6
Australia 22.27 Brunei Darussalam 0.40 Cambodia 14.14 China 1341.34 Hong Kong (China) 7.05 Japan 126.54 Lao PDR 6.20 Macao (China) 0.54 Malaysia 28.40 Mongolia 2.76 New Zealand 4.37 Papua New Guinea 6.86 Philippines 93.26 Republic of Korea 48.18 Singapore 5.09 Viet Nam 87.85 Pacific island countries and areas American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Marshall Islands Micronesia, Federated States of Nauru New Caledonia Niue Northern Mariana Islands Palau Samoa Solomon Islands Tokelau Tonga Tuvalu Vanuatu Wallis and Futuna Western Pacific Region 1 2 3 4 4
7 3572 56 766 24 461 332 28 1102 160 No data
10 3613 34 642 232 809 439 16 4910 183 No data
26 10 376 246 No data
50 9506 174 No data
6428 0 0 75 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 79 603
14 954 0 0 538 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 70 076
0.07 0.02 0.86 0.27 0.18 0.10 0.05 0.11 0.01 0.25 0.00 0.06 0.02 0.18 0.54 0.00 0.10 0.01 0.24 0.01 1798.34
Monthly reports with data through March 2012 Population figures from United Nations World Population Prospects: The 2010 Revision Australia, New Zealand and Singapore report only confirmed cases Classification is provisional based on laboratory data only
<1 confirmed measles case / 1 000 000 population 1-9.9 confirmed measles case / 1 000 000 population >= 10 confirmed cases / 1 000 000 population
3
Table 2B. Measles surveillance performance indicators, by country and area, Western Pacific Region, 2010—2011 1 2010 Country Discarded measles rate per 100 000 pop ≥2 Australia 4 Insufficient data Brunei Darussalam 1.8 Cambodia 17.1 China 1.4 Hong Kong (China) 0.2 Japan 0.0 Lao PDR 2.9 Macao (China) 5.2 Malaysia 3.6 Mongolia 5.6 Insufficient data New Zealand 4 Papua New Guinea 0.4 Philippines 4.3 Republic of Korea 0.3 Insufficient data Singapore 4 Viet Nam 3.3 Pacific island countries and areas American Samoa 0.0 Cook Islands 0.0 Fiji 5.3 French Polynesia 0.0 Guam 0.0 Kiribati 0.0 Marshall Islands 0.0 Micronesia, Federated States of 0.0 Nauru 0.0 New Caledonia 0.0 Niue 0.0 Northern Mariana Islands 0.0 Palau 0.0 Samoa 0.0 Solomon Islands 0.0 Tokelau 0.0 Tonga 0.0 Tuvalu 0.0 Vanuatu 0.0 Wallis and Futuna 0.0 Western Pacific Region 1.7 Second level units with ≥ 1 discarded cases per 100 000 pop ≥ 80% Insufficient data
2011 Suspected cases with adequate blood specimens ≥ 80% Insufficient data 2
1
Suspected cases with adequate investigation ≥ 80% Insufficient data
Percent clinically confirmed Discarded measles rate per 3 100 000 pop cases ≤ 10% Insufficient data Not applicable
Second level units with ≥ 1 discarded cases per 100 000 pop (annualized) ≥ 80% Insufficient data
Suspected cases with adequate investigation ≥ 80% Insufficient data
Suspected cases with adequate blood specimens ≥ 80% Insufficient data 2
Percent clinically confirmed cases 3
≥2 Insufficient data
≤ 10% Insufficient data
100.0% 75.0% 51.6% 0.0% 0.0% 35.3% 100.0% 87.5% 31.8% Insufficient data
85.7% 60.1% 91.1% 45.8% Insufficient data
100.0% 79.3% 72.6% 66.7% Insufficient data
19.3% 100.0% 71.7% 65.0% Insufficient data
23.8% 100.0% 81.7% 92.5% Insufficient data
61.0% 30.8% 63.6% 28.1% 96.1% Not applicable
5.4% 100.0% 25.0% Not applicable
1.5 20.2 1.8 3.1 0.3 5.2 2.7 11.6 6.5 Insufficient data
100.0% 75.0% 71.0% 100.0% 4.3% 70.6% 100.0% 93.8% 36.4% Insufficient data
70.0% 41.8% 94.4% 76.7% Insufficient data
90.0% 84.9% 88.0% 97.8% Insufficient data
40.5% 100.0% 71.9% 60.7% Insufficient data
43.1% 100.0% 83.8% 100.0% Insufficient data
0.0% 55.8% 9.8% 46.2% 19.3% 74.3% 0.0% 2.7% Not applicable
11.0% Not applicable
5.0% 94.1% 6.3% Insufficient data
46.2% 14.5% 61.8% Insufficient data
100.0% 67.8% 73.9% Insufficient data
52.7% 2.6% Insufficient data
0.6 3.1 0.3 Insufficient data
20.0% 88.2% 0.0% Insufficient data
42.0% 51.3% 73.0% Insufficient data
82.0% 76.3% 85.6% Insufficient data
48.0% 7.0% Insufficient data
53.1% 0.0% 0.0% 75.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 39.3%
58.9% Not applicable Not applicable
59.8% Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable
53.6% Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable
16.0 0.0 0.0 59.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.8
84.4% 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 52.3%
22.3% Not applicable Not applicable
31.7% Not applicable Not applicable Insufficient data Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable
86.2% Not applicable Not applicable Insufficient data Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable
0.0% Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable
0.0% Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable
76.2% Green Yellow Red
71.3%
35.4%
67.3%
73.5%
26.3%
Monthly reports received through March 2012 2 Excludes epi-linked cases 3 4
1
Among all confirmed cases Reports only confirmed cases
Reached or surpassed target Nearly reached target: 1.00-1.99 for non-measles suspected case rate; 10.1-25% for percent clinically confirmed cases; 60-79% for other indicators Substantially below target
4
Table 3. Measles and rubella laboratory performance, Western Pacific Region, 20111 Measles Measles and rubella Serum Country Samples tested for measles Total number Total number IgM of cases of samples tested received No. Measles IgM (+) Measles IgM equiv Measles IgM (-) Measles IgM pending Serology Blood Results ≤ 7 days Virus detection Measles Virus isolation/ detection (swab, urine, PBMC) No. of samples tested 0 0 Rubella Serum and blood (includes DBS) Samples Total number tested for of lab rubella IgM confirmed cases No. Rubella IgM (+) Rubella IgM pending
DBS samples
Measles RT - PCR
Rubella IgM equiv
No.
No.
No.
%
No.
No. received 0 170
No. (+) 8
%
No. of isolates 0 0
No. of samples tested 167 0
No. of (+)
No.
No.
No.
Australia Cambodia China Hong Kong (China) Japan Lao PDR Macao (China) Malaysia Mongolia New Zealand Papua New Guinea Philippines Republic of Korea Singapore Viet Nam (northern) Viet Nam (southern) Fiji Total 1
159 3201
254 3208
77 3038
25 288
6 2
46 2748
59.7% 90.5%
0 0
100% 55.6%
134 0
111 296
40 3038
5 1048
1 60
0 0
379
434
342
6
5
331
96.8%
0
0
-
98.2%
19
2
29
6
7
352
41
2
4
181 47 4923 182 1175 144 7620 243 581 2466 1729 527 23 557
181 47 5009 182 1424 144 7620 288 831 2466 1739 528 24 355
181 47 4975 182 693 60 7620 227 239 1460 1475 518 21 134
12 1 1582 0 161 0 3829 41 56 8 6 2 6017
0 0 109 0 11 0 424 21 2 4 9 1 594
169 46 3284 182 520 60 3367 165 181 1447 1460 515 14 521
93.4% 97.9% 66.0% 100% 75.0% 100.0% 44.2% 72.7% 75.7% 99.1% 99.0% 99.4% 68.7%
0 0 0 0 1 0 0 0 0 1 0 0 2
0 0 0 0 2 84 0 0 0 0 0 10 266
0 0 0 8
82.1% 97.9% 100% 100% 99.0% 30.7% 72.6% 98.2% 97.6% 62.4% 92.9% 47.2% 78.6%
0 0 4145 0 17 0 179 17 273 55 10 0 4715
0 0 118 0 2 0 30 1 42 0 0 0 195
0 0 481 0 701 0 0 79 65 0 10 0 1532
0 0 114 0 389 0 0 13 4 0 0 0 660
12 1 1582 0 467 0 3829 42 95 8 6 2 6458
181 47 3360 182 95 144 3831 227 376 2465 1721 527 16 586
37 1 383 14 4 8 1115 19 9 1413 1084 151 5332
21 1 193 5 1 9 322 32 18 134 110 57 966
0 0 1 1 12 2 0 0 0 0 0 0 20
Monthly reports received through March 2012
5
Table 4A. Measles genotype distribution, Western Pacific Region, 2010—20111 2010 Country Total confirmed cases 2 70 0 1156 38 181 11 430 153 0 75 7 48 0 6384 114 54 1823 0 48 506
2011 3
1 3
GENOTYPES Total Lab confirmed 2 B3 7 1 1 9
Pending D4 3 3
Total
D8 4 1 1 3 9
D9 21 11 2 1 4 1 11 13 64
D11 2 2
G3 3 2 5
H1 2 277 2 1 5 38 1 23 349
A 1 2 2 2 1 8 9 9 47 0 11 283 5 6 5 0 7 0 5 0 11 39 16 23 0 458
Total confirmed cases 2 188 4 722 9943 13 410 113 1 1,470 0 597 0 6552 43 143 1,075 2 21 276
GENOTYPES Total Lab confirmed 2 B3 -
Pending D4 31 51 22 1 105
Total
D8 25 1 7 1 9 3 9 55
D9 38 2 3 35 33 12 24 12 33 192
D11 1 1
G3 1 1 1 3
H1 1 3 175 1 6 2 188
A 5 2 4 1 1 13 3 2 5 103 0 5 178 5 98 6 1 44 0 37 0 24 13 46 2 0 562
Australia Brunei Darussalam Cambodia China Hong Kong (China) Japan Lao PDR Macao (China) Malaysia Mongolia New Zealand Papua New Guinea Philippines Republic of Korea Singapore Viet Nam Pacific island countries Total 1 2 3
65 0 451 26 297 4 306 6 0 69 0 15 0 2881 95 54 757 0 31 000
164 4 320 8951 6 322 12 1 1,277 0 427 0 3238 40 143 16 2 14 923
Monthly reports received through March 2012 Source: National measles surveillance reports (Table 2A) Sources: National and regional reference laboratory reports to WHO and to the Measles Nucleotide Sequence online database (MeaNS), whichever has the greater number
6
Table 4B. Rubella genotype distribution, Western Pacific Region, 2010—20111 2010 Country Samples tested for 2 rubella IgM 56 2580 120 84 57 844 156 62 34 4327 202 770 5018 48
2011 1 Samples tested for 2 rubella IgM 40
Rubella IgM 2 positive 12 71 11 26 2 110 7 1 5 1440 15 47 2302 1
Genotypes 3 Total 1E 52 6 1 5 2 -
1j 2 2 3 -
2B 4 1 1 1 0 0 4 54 8 1 5 0 0 2 0 0 4 0 1 1 0
Rubella IgM 2 positive 5
Genotypes 3 Pending 1E -
Total
1j 1 -
2B 18 8 2 4 5 2 15 2 0 0 0 172 15 5 1 0 4 0 5 2 0 0 0 15 2
Australia Brunei Darussalam Cambodia China Hong Kong (China) Japan Lao PDR Macao (China) Malaysia Mongolia New Zealand Papua New Guinea Philippines Republic of Korea Singapore Viet Nam
3038
1,048
154
351
40
7 2
181 47 3360 182 95 144 3831 227 376 4187 527
37 1 383 14 4 8 1115 19 9 2471 151
1 -
Pacific island countries Total 1 2 3
14 358
4050
66
7
7
80
16 586
5305
164
1
56
0
221
Monthly reports received through March 2012 Source: National laboratory reports to WHO (Table 3) Sources: National and regional reference laboratory reports to WHO and to the Measles Nucleotide Sequence online database (MeaNS), whichever has the greater number
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Papua New Guinea (0.6), Japan (0.3), and the Republic of Korea (0.3). China and Brunei Darussalam almost achieved the target with discarded rates of 1.8 and 1.5, respectively. None of the Pacific island countries and areas other than Fiji reported any discarded (or suspected) measles cases. Australia, New Zealand and Singapore do not report discarded measles cases. Representativeness of surveillance sensitivity at the subnational level improved in 2011 versus 2010, with 52% versus 39% of second-level administrative reporting units reporting ≥ 1 discarded measles cases per 100 000 population, respectively (target ≥ 80%). Seven countries and areas achieved or exceeded the target: Brunei Darussalam, Hong Kong (China), Macao (China), and Fiji (100% each); Malaysia (93.8%), the Philippines (88.2%), and in Viet Nam (84.4%). Cambodia (75.0%), China (71.0%) and the Lao People's Democratic Republic (70.6%) nearly achieved the target. Japan, Mongolia, Papua New Guinea and the Republic of Korea were well below the target. Adequate case investigation A case is considered adequately investigated if it is investigated within 48 hours of report and 10 core data variables are completed in the case investigation form. During 2011, 67.3% of suspected cases were adequately investigated. Macao (China) (100%) and
China (94.4%) exceeded the 80% target. Five countries and areas nearly achieved the target including Hong Kong (China) (76.7%), Republic of Korea (73.0%), Malaysia (71.9%), Brunei Darussalam (70.0%) and Mongolia (60.7%). Australia, Japan, New Zealand and Singapore do not report data in the standard format. Adequate specimens Adequate specimens were collected from 73.5% of suspected cases during 2011. Nine countries and areas achieved or exceeded the 80% target: Macao (China) (100%), Mongolia (100%), Hong Kong (China) (97.8%), Brunei Darussalam (90.0%), China (88.0%), the Republic of Korea (85.6%), Cambodia (84.9%), Malaysia (83.8%) and Papua New Guinea (82.0%). The Philippines collected adequate specimens from 76.2% of suspected cases, whereas Viet Nam and the Lao People's Democratic Republic reported 31.7% and 43.1%, respectively. Fiji, which reported 538 suspected measles cases, did not report date of rash onset for any of them and, although 518 specimens were tested for measles IgM, adequacy of specimen (that is, at least 0.5 ml of serum and collection within 28 days of rash onset) was unknown. Australia, Japan, New Zealand and Singapore do not report proportion of suspected cases with collection of adequate specimens.
Performance of national measles laboratory and genotype results (Tables 3 & 4A) Laboratory results within seven days During 2011, among 21 134 serum or blood and 266 dried blood spot (DBS) specimens received for testing of anti-measles IgM antibody, 78.6% had results within seven days after receipt of specimens by laboratory (target ≥ 80%). National laboratories with less than 80% timeliness of laboratory results included Papua New Guinea (30.7%), Fiji (47.2%), Cambodia (55.6%), Viet Nam (northern) (62.4%) and the Philippines (72.6%). Virus detection Among 4715 samples evaluated for virus isolation or detection in regional reference laboratories (RRLs) in Australia and Hong Kong (China) and in NMLs in Malaysia, New Zealand, the Philippines, the Republic of Korea, Singapore, and Viet Nam in 2011, 195 (4.1%) measles virus isolates were obtained. Measles virus was isolated among samples from Malaysia (118), Singapore (42), the Philippines (30), Hong Kong (China) (2), New Zealand (2) and the Republic of Korea (1). Genotypes may be determined from genetic sequence data collected by reverse transcriptase polymerase chain reaction (RT-PCR) following virus isolation or directly from specimens without virus isolation. Among 1532 specimens tested by RT-PCR, 660 were positive from laboratories in New Zealand (389), Australia (134), Malaysia (114), the Republic of Korea (13), Hong Kong (China) (6) and Singapore (4). Genotyping Measles genotypes are reported directly to the WHO Regional Office for the Western Pacific or to the Measles Nuleotide Sequence (MeaNS) online database. In all, 557 samples from 12 countries and areas were positive for D9 (192), H1 (188), D4 (105), D8 (55), G3 (3), D11 (1) and A (13). D9 was identified from cases in nine countries and areas including Australia (38), Japan (35), Malaysia (33), Singapore (33), the Philippines (24), New Zealand (12), the Republic of Korea (12), Hong Kong (China) (3), Cambodia (2). H1 was identified from cases in China (175), the Lao People's Democratic Republic (6), Cambodia (3), Viet Nam (2), Australia (1) and Hong Kong (China) (1). D4 was identified from cases in Japan (51), Australia (31), New Zealand (22), and Singapore (1). D8 was identified from cases in Australia (25), Malaysia (9), Singapore (9), Japan (7), New Zealand (3), Hong Kong (China) (1) and Macao (China) (1).
Rubella (Tables 3 & 4B) During 2011, among 16 586 specimens received for rubella testing, 5332 (32.2%) samples were positive and 966 (5.8%) were equivocal for anti-rubella IgM antibody; 20 were pending. Countries with the largest number of IgM-positive rubella specimens included Viet Nam (2497: 1413 from the north and 1084 from the south), the Philippines (1115), Cambodia (1048), Malaysia (383) and Fiji (151). In all, 221 specimens from seven countries and areas were positive for 1E (164), 2B (56) and 1j (1). Genotype 1E was identified from cases in China (154), Hong Kong (China) (7), Japan (2) and the Lao People's Democratic Republic (1). Genotype 2B was identified from cases in China (18), Viet Nam (15), Hong Kong (China) (8), New Zealand (5), Malaysia (4), Fiji (2) and Papua New Guinea (2). Genotype 1j was identified from a case in Japan.
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Special topic - Measles elimination and importations in the Western Pacific Region Measles elimination is defined as "the absence of endemic measles transmission in a defined geographical area (e.g. region) for ≥ 12 months in the presence of a well performing surveillance system."1 Endemic measles transmission is defined as "the existence of continuous transmission of indigenous or imported measles virus that persists for ≥ 12 months in any defined geographical area." Even after elimination of endemic transmission is achieved, importations of measles virus may occur and result in limited transmission. Re-establishment of endemic transmission occurs when "epidemiological and laboratory evidence indicates the presence of a chain of transmission of a virus strain2 that continues uninterrupted for ≥ 12 months in a defined geographical area where measles had previously been eliminated." In the Western Pacific Region, measles cases and outbreaks continue to occur in several countries that have low levels of measles virus transmission as a result of measles virus importations. We reviewed measles surveillance data on cases with rash onset in 2011 reported by Australia, Japan, and Singapore to better understand measles virus importations. A total of 741 confirmed measles cases were reported from these three countries: 119 (16.1%) were reported as imported cases, and another 48 (6.5%) were reported as import-related (Table 5).
Table 5: Reported measles importations in Western Pacific region, by Source region and country, 2011 No. Source imported Country Kenya or Tanzania 1 1 0 0 France 11 United Kingdom 2 Italy 1 1 Georgia Germany 1 Spain 1 EUR 17 SEAR Indonesia 24 India 14 Thailand 9 4 Bangladesh Myanmar 1 SEAR 52 WPR Philippines 18 New Zealand 8 5 Singapore Malaysia 4 Cambodia 2 Viet Nam 2 Australia 1 China 1 WPR 41 1 France, Portugal or Malaysia 1 Sri Lanka or Singapore 2 Uncertain 6 Unknown 119 TOTAL Percent of total imported genotypes Source Region AFR AFR AMR EMR EUR Percent of Total 1% 0% 0% 65% 12% 6% 6% 6% 6% 15% 46% 27% 17% 8% 2% 47% 44% 20% 12% 10% 5% 5% 2% 2% 37% D4 0 D8 0 Genotypes D9 H1 1 1 0 G3 0 UNK 0 No. importrelated 2 2 0 0 0 0 1 0 0 0 1 0 13 7 2 0 22 10 5 2 0 0 0 3 0 20 0 0 0 3 48 Grand Total 3 3 0 0 11 2 2 1 1 1 18 24 27 16 6 1 74 28 13 7 4 2 2 4 1 61 1 1 2 9 167 Percent of Grand Total 2% 0% 0% 61% 11% 11% 6% 6% 6% 12% 32% 36% 22% 8% 1% 47% 46% 21% 11% 7% 3% 3% 7% 2% 39%
6 2 1
0 0
0 0 1
0 0
5 0
1 1 10 0 2 1 0 3 0 7 0 2 0 0 9 0 2 7 4 2 15 0 0 0 0 1 1 2 1 9 0 0 0 9 8 0 3 1 1 0 13 1 1 2 0 26 38% 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 6 12 5 4 2 1 24 10 1 2 1 0 2 0 1 17
0
0 1 23 34%
0 1 18 26%
0 0 0%
0 0 1 1%
0 4 51
Source of importation Among 111 cases with reported source country of origin, 52 (47%) were imported from the WHO SouthEast Asia Region, 41 (37%) from the WHO Western Pacific Region, 17 (15%) from the WHO European Region and 1 (1%) from the WHO African Region. Among the 52 importations from the WHO South-East Asia Region, 24 (46%) originated from Indonesia, 14 (27%) from India, 9 (17%) from Thailand, 4 (8%) from Bangladesh and 1 (2%) from Myanmar. Among the 41 importations from within the WHO Western Pacific Region, 18 (44%) originated from the Philippines, 8 (20%) 1 2
from New Zealand, 5 (12%) from Singapore, 4 (10%) from Malaysia, 2 (5%) each from Cambodia and Viet Nam, and 1 (2%) each from Australia and China. Among 17 importations from the WHO European Region, 11 (65%) came from France, 2 (12%) from the United Kingdom of Great Britain and Northern Ireland, and 1 (6%) each from Georgia, Germany, Italy and Spain. One importation from the WHO African Region came from either Kenya or the United Republic of Tanzania. Thus, the most common source countries of reported importations of measles virus in 2011 were Indonesia (24), the Philippines (18), India (14), France (11), Thailand (9) and New Zealand (8).
World Health Organization. Monitoring progress towards measles elimination. Wkly Epidemiol Rec 2010; 85:490–4. A virus strain comprises viruses with N gene (450) sequences that are at least 99.7% identical (1 nucleotide change).
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The three countries varied in proportion of cases from particular WHO regions (Table 6). in the WHO South-East Asia Region were the most of importations into Singapore (82%). in the WHO Western Pacific Region were the
imported Countries source of Countries source of
most imported cases into Japan (59%). WHO SouthEast Asia Region and WHO Western Pacific Region countries accounted for a similar percentage of imported cases (43% and 37%, respectively) into Australia.
Table 6: Region of origin of imported measles virus, by affected country, Western Pacific Region 2011 WPR country Australia Japan Singapore Total Importation genotypes Among 111 imported cases with known source country, genotype data were available from 68 (57%) (Table 5). The most commonly imported genotype identified was D9, accounting for 26 (38%) importations and originated primarily from Indonesia and the Philippines (38% and 33% of imported D9, respectively). Genotype D4 was the next most common imported virus genotype, accounting for 23 (34%) importations, most of which originated from New Zealand and France (32% and 27% of imported D4 virus, respectively). Genotype D8 accounted for 18 (26%) importations and originated primarily from India and Thailand (41% and 24% of all D8 importations, respectively). One G3 importation came from Indonesia. Programmatic implications As countries and areas in the WHO Western Pacific Region continue to move closer towards measles elimination, sensitive and timely surveillance is increasingly important not only to identify residual chains of transmission of endemic virus, but also to identify the source of virus as imported, import-related or endemic. Distinguishing imported and import-related cases from endemic cases also is critical for verification of measles elimination. This requires high-quality epidemiological investigations that include contact tracing as well as specimens collected for virus detection. That 12 (80%) of 15 countries and areas with laboratory-confirmed measles cases were also able to identify virus genotypes (Table 4a) is a laudable achievement. However, specimens to detect and sequence measles virus are needed from more cases to assess the possible source of every chain of transmission. Number of cases imported 58 32 29 119 Number with known source country 54 29 28 111 1% Imported from AFR 2% Imported from EUR 19% 21% 4% 15% Imported from SEAR 43% 21% 82% 47% Imported from WPR 37% 59% 14% 37%
Eliminating measles virus transmission in the WHO Western Pacific Region will reduce a substantial number of imported and import-related cases and outbreaks within the Region. The large-scale SIAs in several countries in the Region in 2011 have dealt a critical blow to endemic measles transmission in these countries and the risk of importations from these to other countries. Countries with ongoing measles virus transmission in 2012 - including China, Malaysia, New Zealand and Singapore - likely will need to supplement routine immunization with special activities to interrupt measles virus transmission in 2012. Measles virus importations from other regions will continue after the Western Pacific Region achieves elimination. However, such importations need not result in re-established transmission, as repeated experience has demonstrated in the Americas. The Americas have sustained measles elimination since 2003. Moreover, the frequency of importations should decrease and eventually disappear as the African, Eastern Mediterranean and European regions progress toward achieving their measles elimination goals. In addition, although the South-East Asia Region does not yet have an elimination goal, 10 of its 11 Member States do have elimination goals. Moreover, two countries that represent major sources of importations into the Western Pacific Region - India and Indonesia - have been implementing strategies to reduce transmission substantially. India will complete catch-up SIAs targeting children nine months to 14 years old in 14 high-burden measles states as well as introduction of MCV2 in to the routine schedule nationwide in 2012. Indonesia completed the final phase of its three-phase follow-up SIA in 2011, achieving 97% coverage among 70% of the population nine to 59 months old. The Western Pacific Region is on the verge of achieving another important public health victory.
Expanded Programme on Immunization Regional Office for the Western Pacific World Health Organization P.O. Box 2932, 1000 Manila, Philippines Tel. No. (63 2) 5288001 Fax No. (63 2) 5211036, 5260279
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