Revising the goal for measles elimination and rubella/congenital rubella syndrome control

REGIONAL COMMITTEE Provisional Agenda item 8.2 Seventy-second Session SEA/RC72/7 New Delhi 2–6 September 2019 15 July 2019 Revising the goal for measles elimination and rubella/congenital rubella syndrome control The Sixty-sixth session of the WHO Regional Committee for South-East Asia in 2013 adopted resolution SEA/RC66/R5, in which the Region committed itself to the goal of measles elimination and rubella/congenital rubella syndrome (CRS) control by 2020. This became a Flagship Priority of the Regional Director in 2014. The Strategic Plan for Measles Elimination and Rubella/CRS Control 2014–2022 was developed for providing technical guidance. The SEA Regional Verification Commission (RVC) for measles elimination and rubella/CRS control was established in 2016 and set norms and standards to verify measles elimination and rubella/CRS control. Measles elimination and rubella/CRS control has also been incorporated in the SEA Regional Vaccine Action Plan 2016–2020 as one of its eight goals. Five countries in the Region have eliminated measles and six have controlled rubella and CRS. There has been an estimated 75% reduction in mortality due to measles in 2017, compared with 2000. In 2018, coverage with measles containing vaccines (MCV) was 89% for first dose (MCV1) and 80% for second dose (MCV2), compared with 63% and 3% respectively in 2000. An estimated 366 million children were reached through mass vaccination campaigns with a measles-rubella (MR) vaccine in the Region since 2017. All Member States are administering two doses of MCV and 10 Member States have introduced rubella-containing vaccine (RCV). DPR Korea has plans to introduce RCV by the end of 2019. All Member States have initiated laboratory supported case-based surveillance and have at least one proficient national laboratory for measles and rubella. The main challenges are suboptimal implementation of strategies advocated in the Strategic Plan leading to immunity gaps for measles in various areas and population groups, low surveillance sensitivity in some Member States, financial insufficiency and dependence on WHO for procurement of laboratory diagnostic kits. The midterm review of the Strategic Plan in 2017, the Regional Immunization Technical Advisory Group (ITAG) meeting in 2018 and SEA-RVC in 2018 recommended that the Region should adopt the goal for rubella elimination and should realign the measles elimination target with that of the rubella elimination goal. High-level consultation with Member States in March 2019 has concluded that it is feasible to achieve interruption of rubella transmission by 2023. The Region, therefore, is in a position to revise the “rubella control by 2020” goal to the goal of “rubella elimination by 2023” and align the goal of measles elimination with this new date. A draft Strategic Plan for Measles and Rubella Elimination 2020–2024 has been developed for achieving and sustaining measles and rubella elimination in the South-East Asia Region. The attached Working Paper was presented to the High-Level Preparatory (HLP) Meeting for its review and recommendations. The recommendations made by HLP for consideration by the Seventy-Second Session of the Regional Committee are as follows: Actions by Member States (1) Adopt the revised goal of “measles and rubella elimination by 2023 in WHO South-East Asia Region” (2) Endorse and fully implement the Strategic Plan for achieving and maintaining Measles and Rubella elimination in WHO South-East Asia Region: 2020–2024. (3) Mobilize political, societal and financial support to achieve measles and rubella elimination by 2023. Actions by WHO (1) Provide the needed technical support to Member States in their efforts to develop and implement policy and strategies, including strengthening their immunization and surveillance systems to achieve measles and rubella elimination by 2023. (2) Report to the Regional Committee every year until 2023 on the status of progress towards measles and rubella elimination. The working paper is being submitted to the Seventy-second Session of the Regional Committee for its consideration. SEA/RC72/7 Introduction 1. In September 2013, the Sixty-sixth session of the WHO Regional Committee for South-East Asia endorsed resolution SEA/RC66/R5, in which the 11 Member States of the WHO South-East Asia Region adopted the goal of measles elimination and rubella/congenital rubella syndrome (CRS) control by 2020. 2. Measles elimination and rubella/CRS control by 2020 is one of the Flagship Priorities for the Region. 3. To ensure adequate technical guidance to accelerate progress towards the goal, the Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control 2014–2020 (henceforth referred to as the Strategic Plan) was developed. 4. The South-East Asia Regional Vaccine Action Plan 2016–2020 (SEA-RVAP) has incorporated measles elimination and rubella/CRS control as one of its eight goals. 5. The South-East Asia Regional Verification Commission for measles elimination and rubella/CRS control (SEA-RVC) was established in 2016. The SEA-RVC, in its first meeting held in 2018, set the norms and standards to verify measles elimination and rubella /CRS control. 6. In 2019, the Regional Office conducted a high-level consultation with Member States on the feasibility of adopting the goal of rubella elimination and harmonizing the goal of measles elimination with that of rubella elimination. Regional situation 7. Five countries in the South-East Asia Region – Bhutan, DPR Korea, Maldives, Sri Lanka and Timor-Leste – have been verified by the SEA-RVC as having eliminated endemic measles. 8. Six countries of the Region – Bangladesh, Bhutan, Maldives, Nepal, Sri Lanka and Timor- Leste – have been verified as having controlled rubella and CRS. 9. An estimated 75% reduction in mortality due to measles has occurred in 2017 compared with 2000. And a nearly 23% decline in mortality was recorded during the period 2014–2017.1,2 10. Coverage with the first dose of measles-containing vaccine (MCV1) in the Region in 2018 was 89% compared with 63% in 2000. Six out of the 11 Member States of the Region (Bangladesh, Bhutan, DPR Korea, Maldives, Sri Lanka and Thailand) achieved more than 95% coverage for MCV1 in 2018, while three (India, Myanmar and Nepal) reported coverage between 80%–95% and two (Indonesia and Timor-Leste) have coverage between 75%–80%.3 1 Progress towards regional measles elimination, worldwide, 2000–2014.Wkly Epidemiol Rec. 2015 Nov 13; 90 (46):623-631. English, French. PubMed PMID: 26567399. Available at https://www.who.int/wer/2015/wer9046.pdf?ua=1 Last accessed on 20 May 2019 2 Progress towards regional measles elimination, worldwide, 2000–2017.Wkly Epidemiol Rec. 2018 Nov 30; 93 (48):649-660. English, French. PubMed PMID: 26567399. Available at ttps://apps.who.int/iris/bitstream/handle/10665/276217/WER9348.pdf Last accessed on 20 May 2019 3 World Health Organization. UNICEF. WHO/UNICEF estimates of national immunization coverage (WUENIC). Geneva, Switzerland: World Health Organization; New York, NY: UNICEF; 2019. Last accessed 20 May 2019. http://www.who.int/immunization/monitoring_surveillance/data/en/ SEA/RC72/7 Page 2 11. Similarly, the coverage of the second dose of measles-containing vaccine (MCV2) in the Region was 80% in 2018 compared with 59% in 2014 and only 3% in 2000. Three Member States (DPR Korea, Maldives and Sri Lanka) have achieved more than 95% coverage for MCV2, five Member States (Bangladesh, Bhutan, India, Myanmar and Thailand) have achieved coverage between 80%–95%, and in three Member States (Indonesia, Nepal and Timor-Leste) the coverage is less than 80%. 3 12. An estimated 400 million children will be reached through mass vaccination campaigns with measles and rubella (MR) vaccine in the Region by the end of 2019. Almost 366 million children have already been reached through mass vaccination campaigns with a measles-rubella (MR) vaccine in the Region since January 2017. Of these, nearly 305 million children were in India and around 58 million in Indonesia.4 13. As of end-2018, all Member States in the Region are administering two doses of MCV under their routine immunization programmes and 10 Member States have introduced rubella- containing vaccine (RCV) in their programme. DPR Korea, the only remaining Member State, has plans to introduce RCV before the end of 2019. 14. Laboratory supported case-based surveillance for measles and rubella has been initiated in all Member States in alignment with the Regional guidelines, with India and Indonesia expected to complete the expansion by end-2019. Congenital rubella syndrome (CRS) surveillance has been initiated in all 11 Member States, either as sentinel surveillance or as part of the case-based surveillance system. 15. All Member States in the Region have at least one proficient national laboratory to support measles and rubella case-based surveillance. The measles-rubella laboratory network has expanded from 23 laboratories in 2013 to 50 in 2018 with 41 laboratories accredited as “proficient” for measles and rubella testing. Challenges 16. Immunity gaps for measles and rubella remain in various population groups in a number of Member States due to suboptimal coverage of measles- and rubella-containing vaccines under the routine immunization programme. 17. Surveillance sensitivity was below the desired targets in four of the 11 Member States in 2018, leading to under-reporting and under-estimation of the exact disease burden in these countries. 18. Financial insufficiency to accelerate implementation of activities for measles elimination and rubella/CRS control remains a challenge in the way of achieving the 2020 target. 19. Laboratory network support including for diagnostic kit procurement services is becoming a challenge. The majority of Member States are still dependent on WHO for procurement of laboratory diagnostic kits for measles and rubella. 4 Based on the annual reporting by countries in the WHO UNICEF Joint Reporting Form to WHO SEARO for 2017 and 2018. SEA/RC72/7 Page 3 20. A mid-term review, conducted in 2017, of the Strategic Plan for Measles Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region (2014–2020) concluded that the measles elimination and rubella/congenital rubella syndrome (CRS) control programme is unlikely to be achieved in the Region due to suboptimal implementation of the strategies in some Member States. Response 21. The mid-term review made several recommendations to strengthen efforts, including the strong recommendation that SEA Region Member States consider adopting a regional rubella/CRS elimination goal concurrent with the existing regional measles elimination goal. This goal will leverage the momentum and political will that exists for measles elimination to eliminate rubella, the leading cause of vaccine-preventable birth defects. In addition, this new added focus will accelerate the drive for measles elimination while maximizing available financial, technical, and logistical resources. This sentiment was also echoed by the Regional Immunization Technical Advisory Group meeting in Delhi in 2018. 22. The third meeting of the WHO South-East Asia Regional Verification Commission (SEA- RVC) for measles elimination and rubella/congenital rubella syndrome was held in 2018. After careful review of the progress towards measles elimination and rubella and congenital rubella syndrome control in all Member States, it recommended that the Region should adopt the goal of rubella elimination and should realign the measles elimination target with that for the rubella elimination goal. 23. The Regional Office conducted a high-level consultation in March 2019 with Member States on the feasibility of adopting the goal of rubella elimination and harmonizing the goal of measles elimination with that of rubella elimination. The consultation reviewed the feasibility of rubella elimination in the Region and discussed a position paper on “Establishing a rubella elimination goal and aligning measles and rubella elimination goals in the WHO South-East Asia Region”. Representatives from Member States, technical experts and professional bodies agreed on revising the goal of rubella control by 2020 to rubella elimination by 2023 and harmonizing the goal of measles elimination with this new date. 24. A draft Strategic Plan for Measles and Rubella Elimination 2020–2024 has been developed for achieving and sustaining measles and rubella elimination in the South-East Asia Region. The key elements of the plan are to: (1) strengthen immunization systems for increasing and sustaining high level of population immunity against measles and rubella at both the national and subnational level through well laid-out subnational plans and their optimal implementation; (2) enhance and ensure highly sensitive laboratory-supported case-based surveillance systems so that high-quality epidemiological assessments of population susceptibility to measles and rubella are conducted to inform policy and better plan strategies to increase population immunity levels uniformly at the national as well as subnational levels; SEA/RC72/7 Page 4 (3) ensure preparedness for response activities for measles and rubella outbreaks through development and effective implementation of outbreak preparedness and response plans for measles and rubella; (4) develop national measles and rubella elimination policy strategies addressing subnational variations using evidence-based data in line with the Regional Strategic Plan; and (5) mobilize political, societal and financial support to ensure interruption of transmission of indigenous measles and rubella virus by 2023. The way forward 31. Significant progress has been made in the South-East Asia Region towards measles elimination and rubella and congenital rubella syndrome control. High-level political and programmatic commitment to eliminate measles and rubella continues to drive the agenda in the Region. 32. The high-level consultation with Member States in March 2019 concluded that it is feasible to achieve interruption of measles and rubella transmission by 2023. The Region, therefore, is in a position to revise the goal of “measles elimination and rubella control by 2020” to the goal of “measles and rubella elimination by 2023”. 33. The high-level consultation with Member States in March 2019 has concluded that the draft “Strategic Plan for Achieving and Sustaining Measles and Rubella Elimination in the WHO South-East Asia Region: 2020–2024” is an essential element to achieve the goal and will have to be adopted and fully implemented by all countries to ensure that the 2023 goal is achieved. Conclusion 34. The Regional Committee is requested to review the proposed way forward and provide recommendations on the proposed revision of the goal of measles and rubella/CRS control in the Region as well as on the draft “Strategic Plan to achieve and sustain measles and rubella elimination in WHO South-East Asia Region: 2020–2024” and consider the draft resolution to effect the revised goal.