Consultation on Measles Elimination and Hepatitis B Control, Manila, Philippines, 17-20 April 2012 : report

Meeting Report Consultation on Measles Elimination and Hepatitis B Control

We are all immunized with measles and rubella vaccine!

Manila, Philippines 17–20 April 2012

WPR/DCC/EPI(02)/2012 Report series number: RS/2012/GE/16(PHL)

English Only

REPORT

CONSULTATION ON MEASLES ELIMINATION AND HEPATITIS B CONTROL

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 17 – 20 April 2012

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines April 2012

SUMMARY The Consultation on Measles Elimination and Hepatitis B Control was held from 17 to 20 April 2012 in Manila, Philippines. The meeting consisted of three sessions: an inauguration meeting of the Regional Verification Commission (RVC) for Measles Elimination in the WHO Western Pacific Region on 17 April, a consultation with national managers of Expanded Programmes on Immunization (EPI) on 18 and 19 April, and a broader consultation involving high-ranking officers from ministries of health on measles elimination, hepatitis B control and the Global Vaccine Action Plan on 20 April. The objectives of the consultation were to discuss and agree on regional verification mechanisms for measles elimination, review country progress towards measles elimination, discuss regional and country action plans for achieving and sustaining measles elimination and revision of measles elimination field guidelines. In addition, the consultation aimed to agree on a target year for the regional hepatitis B goal (<1% hepatitis B surface antigen (HBsAg) seroprevalence among five-year olds), and discuss and provide inputs to the Global Vaccine Action Plan. The meeting reviewed the progress towards establishing regional verification mechanisms for measles elimination in the WHO Western Pacific Region since 2010. It reached a consensus on the verification principle, process, structure, criteria, components of evidence and key indicators, with a draft of regional guidelines developed and distributed among the participants at the meeting. It was agreed that achievement of measles elimination should be verified independently, initially by countries and eventually for the Region. There will be two levels of verification bodies involved: RVC and national verification committee or subregional verification committee for the Pacific. It was decided that the verification criteria should include two elements: (1) zero endemic measles cases for three years nationally and for the Region in the presence of high quality surveillance, and (2) genotyping analysis indicating absence of endemic measles virus. The major components of evidence include incidence, epidemiologic and virologic characteristics, epidemiologic surveillance and laboratory performance, population immunity, and sustainability of measles elimination in the context of national immunization programme. Certain standard indicators were suggested as requirements under each of the above component; however, some alternative evidences may also be required sometimes. The meeting acknowledged that remarkable progress had been made towards measles elimination at both country and regional levels in the Western Pacific Region, despite the diversity of the country contexts. The number of measles cases declined sharply by 86% and measles incidence dropped from 82 to 12 per million population from 2008 to 2011. Regional and country action plans in achieving and sustaining measles elimination were reviewed and discussed. Country participants supported the proposal of establishing 2017 as a target year for the regional hepatitis B control goal of <1% HBsAg seroprevalence. They also recognized the great potential of the Global Vaccine Action Plan and appreciated the opportunity to be briefed on this critical global initiative. As next steps, WHO will seek opportunities for more inputs from Member States on verification of measles elimination, a target year of <1% hepatitis B control and the Global Vaccine Action Plan. WHO will finalize the regional verification guidelines on measles elimination and provide relevant orientation as early as possible. Countries will finalize their action plans for measles elimination in 2012-2013 and work on establishing national verification committees.

LIST OF ACRONYMS

AFP AFR CRS c-MYP DHS DoV ELISA EPI ERP GCC GVAP GIVS HBAS HBsAg IgM IgG IMCI JRF MCV1 MCV2 MICS MMR MR NCC NIP NML NT NVC PAHO PCR RCA RCC RCM RCV REC RED RRL RVC SIA SRCC SRVC TAG UNICEF UN Foundation VPD

Acute flaccid paralysis Acute fever and rash Congenital rubella syndrome Comprehensive Multi-Year Plan Demographic and Health Surveys Decade of Vaccines Enzyme-linked immunosorbent assay Expanded Programme on Immunization Expert Resource Panel Global Commission for the Certification of Poliomyelitis Eradication Global Vaccine Action Plan Global Immunization Vision and Strategy Hospital-based active surveillance Hepatitis B surface antigen Immunoglobulin M Immunoglobulin G Integrated Management of Childhood Illness Joint Reporting Form on Immunization First dose of measles-containing vaccine Second dose of measles-containing vaccine Multiple indicator cluster surveys Measles/mumps/rubella vaccine Measles-rubella National Committee for the Certification of Poliomyelitis Eradication National Immunization Programme National Measles Laboratory Neonatal tetanus National Verification Committee for Measles Elimination Pan American Health Organization Polymerase chain reaction Rapid coverage assessment Regional Commission for the Certification of Poliomyelitis Eradication Regional Committee Meeting Rubella-containing vaccine Reach Every Child Reach Every District Regional Reference Laboratory Regional Verification Commission for Measles Elimination Supplementary Immunization Activity Subregional Committee for the Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas Subregional Verification Committee Technical Advisory Group on Immunization and Vaccine Preventable Diseases United Nations Children's Fund United Nations Foundation Vaccine-preventable diseases

CONTENTS 1. Page INTRODUCTION ................................................................................................................. 1

1.1 Objectives.............................................................................................................................. 1 1.2 Organization.......................................................................................................................... 1 2. PROCEEDINGS ................................................................................................................... 2

2.1 Session 1: Inauguration meeting of the Regional Verification Committee on 17 April 2012 ................................................................................................ 2 2.2 Session 2: Consultation meeting on 18–19 April 2012....................................................... 13 2.3 Session 3: Consultation meeting on 20 April 2012............................................................. 34 3. ACTION POINTS ............................................................................................................... 38 ANNEXES: ANNEX 1 - TIMETABLE ANNEX 2 - LIST OF PARTICIPANTS ANNEX 3 - ACTION PLAN FOR ACHIEVING AND SUSTAINING MEASLES ELIMINATION AND ACCELERATING RUBELLA CONTROL IN THE WESTERN PACIFIC REGION: 2012–2020 ANNEX 4 - TEMPLATE OF COUNTRY PRESENTATION: MEASLES ELIMINATION STATUS, CURRENT AND PROPOSED PLANS ANNEX 5 - CONSOLIDATED INFORMATION FROM COUNTRY PRESENTATIONS ANNEX 6 - GUIDELINES ON COUNTRY PRESENTATION AND DEVELOPMENT OF ACTION PLAN ANNEX 7 - TEMPLATE FOR THE ACTION PLAN IN 2012–2013 FOR ACHIEVING AND SUSTAINING MEASLES ELIMINATION ANNEX 8 - COUNTRY UPDATES ON THE CURRENT AND PROPOSED MEASLES ELIMINATION PLANS ANNEX 9 - DRAFT GUIDELINES ON VERIFICATION OF MEASLES ELIMINATION IN THE WESTERN PACIFIC REGION Keywords: Malaria-prevention and control/ Hepatitis B-prevention and control/ Immunization programs/ Vaccination/ Rubella

1. INTRODUCTION

1.1

Objectives The objectives of the Consultation on Measles Elimination and Hepatitis B Control were: (1) to review, discuss and agree on regional verification mechanisms for measles elimination; (2) to discuss and agree on a regional strategic plan, action plan and updated guidelines following review of measles elimination status of countries and areas of the Region; (3) to discuss and agree on a target year for the hepatitis B control goal (i.e. less than one percent of hepatitis B surface antigen [HBsAg] seroprevalence among five-year olds); and (4) to review the budgeted Decade of Vaccines Collaboration's Global Vaccine Action Plan and provide further input and comments for consideration prior to presentation for endorsement at the May 2012 World Health Assembly.

1.2

Organization

The participants of the consultation meeting include 14 temporary advisers including 11 members of the Regional Verification Commission for Measles Elimination in the Western Pacific Region (RVC), 27 national officers from 14 countries and areas including high-level officers from ministries of health and the national managers of Expanded Programme on Immunization (EPI), 5 representatives from the partner agencies, 27 WHO staff from the country offices, the Regional Office and the WHO Headquarters. The consultation comprised of three consecutive meetings. The first meeting was organized on 17 April 2012, serving as the inauguration of the RVC; the second meeting on 18–19 April 2012 was a consultation session with the national EPI managers and officers; and in the last meeting, on 20 April, some high-level officers from the ministries of health joined, and measles elimination, hepatitis B control and the Global Vaccine Action Plan (GVAP) were all discussed. The timetable of the consultation is provided in Annex 1. The list of participants is included in Annex 2.

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2. PROCEEDINGS

2.1 2.1.1

Session 1: Inauguration meeting of Regional Verification Committee on 17 April 2012 Opening session

Dr John Patrick Ehrenberg, the Director of the Division of Combating Communication Diseases, on behalf of Dr Shin Young-soo, the Regional Director of the WHO Regional Office for the Western Pacific, presented the opening remarks. Dr Ehrenberg first welcomed the RVC members who were appointed by the Regional Director in January 2012 and expressed his appreciation for commitment and dedication of the members. He hoped that important agreements could be reached during the meeting on verification mechanisms for measles elimination in the Western Pacific Region including verification criteria, requirements on evidence and indicators, structures and processes of verification, and the terms of reference for both RVC and national verification committees (NVC). This agenda would serve as the essential basis for the following sessions. He also asked the RVC to share the findings of the meeting with the national counterparts and partners, as well as learn from country presentations the current country status with regard to measles elimination. He proposed Professor David Durrheim as the chair, Dr Hiroshi Yoshikura as the vice-chair and Dr Maria Rosario Zeta Capeding as the rapporteur for this RVC meeting. The proposal was endorsed by all participants. 2.1.2 Progress towards measles elimination in the Western Pacific Region

Dr David Sniadack reported the regional progress towards measles elimination in the Western Pacific Region. The number of measles cases in the Region dramatically declined in recent years. Measles incidence decreased from 82 per million population in 2008 down to 12 per million in 2011, and the annualized measles incidence for 2012 was only four per million population based on the surveillance data from January to March 2012. In terms of surveillance, there were encouraging improvements in adequate investigation and blood sample collection rates in 2012, while sensitivity of surveillance particularly at the subnational levels remained a concern. Reported coverage for the first and second dose measles-containing vaccine (MCV1 and MCV2) was 96% and 91% respectively in 2011 while coverage was not universally high across the countries and within some countries. He further reviewed the progress by country and area, highlighting the remarkable case reduction in Cambodia, China, Japan, the Philippines, and Viet Nam, and sustainable achievements in several other countries and areas, such as the Republic of Korea and Mongolia. Importation of measles virus poses an ongoing threat. Several countries in the Region often suffer from measles importations, including Australia, Japan, New Zealand and Singapore. High population immunity is critical to prevent measles virus from spreading, as demonstrated in Australia. 2.1.3 Overview of verification for measles elimination

Dr Peter Strebel, from the WHO headquarters, shared and summarized the regional experiences in the verification of measles elimination. In the recent years, four WHO regional offices (the Region of the Americas, European Region, Eastern Mediterranean Region and the Western Pacific Region) have been active in developing regional verification mechanisms for elimination of measles and rubella. The Region of the Americas has achieved its goal of elimination of measles and rubella and globally led the way in the verification of measles elimination. There are common approaches based on regional information exchanges in developing the regional verification mechanisms, while there are some minor differences in terms of verification criteria and components. For verification criteria, the absence of endemic

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measles transmission for at least three years and evidence supporting the absence of endemic measles virus are essentially required in all four regions. However, the Region of the Americas includes high quality of surveillance and the European Region includes high population immunity as additional criteria. In terms of verification components, five elements are commonly included, namely epidemiology, surveillance quality, laboratory performance, molecular epidemiology, population immunity and sustainability. The European Region particularly highlights public acceptance as another essential component. In terms of structure, all four regions apply verification commission or committee at both regional and country levels. Except the European Region where verification only applies to the regional level, all other three regions will verify the achievement of measles elimination first by country and then by region. Based on the regional experiences and a need for global standard approach as poliomyelitis (polio) eradication, the WHO headquarters is working on developing global verification framework to provide support to the regional initiatives and aim for common approaches and standards. 2.1.4 Lessons learnt from certification of polio-free status in the Western Pacific Region

Professor Anthony Adams, the Chair of the Regional Commission for the Certification of Poliomyelitis Eradication (RCC) in the Western Pacific, shared the lessons learnt from certification of polio-free status in the Region. Different from measles elimination, polio eradication is a top-down approach and the Global Commission for the Certification of Poliomyelitis Eradication (GCC) was first established to guide the development and implementation of certification at the regional level. Polio eradication is certified only by region, not by country. In the Western Pacific Region, the RCC was established and developed its Plan of Action in 1996. To prove the achievement or maintenance of polio-free status, providing sufficient evidence for high quality acute flaccid paralysis (AFP) surveillance is critically important and all countries must meet several basic and standard indicators, such as non-polio AFP reporting rate, adequate case investigation rate and adequate specimen collection rate. If any country or area can not meet the requirements, they need to conduct additional surveillance activities to provide complementary evidence, such as retrospective record reviews or active case searches. Each country or area established its National Committee for the Certification of Poliomyelitis Eradication (NCC) and the NCC developed its Plan of Action with guidance from the RCC. The RCC members met on annual basis since the establishment of RCC in 1996 to review the country progress and identify the programmatic gaps to be addressed. In 2000, countries submitted their first certification documentation to the RCC and the RCC certified the Western Pacific Region free from polio. Countries continue submitting annual progress report to the RCC till now. To sustain polio-free status, comprehensive risk-assessment is required by the RCC and should be included in the annual progress report, including the results of risk-assessment and action taken to close programmatic gaps. The RCC keeps reminding all countries that importation of polio virus continues to be a threat to the region and that high quality of immunization and surveillance activities are essential. 2.1.5 Verification of measles elimination: components and criteria

Dr David Sniadack discussed verification components and criteria, primarily based on the agreements from the first technical consultation meeting on verification of measles elimination organized by the Regional Office for the Western Pacific in June 2010. To verify measles elimination, comprehensive and sufficient evidence should be provided. The following components could be considered, including incidence, epidemiologic and virologic characteristics, surveillance and laboratory performance, high population immunity, and sustainability of measles elimination programme. Incidence is one of the most critical indicators. Measles elimination requires zero incidence of confirmed endemic cases; it is proposed that measles incidence should be less than one per million population if confirmed measles cases with

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unknown infection source are present. Good description of measles epidemiology is critical. Analysis should reveal changing trends in epidemiology over time, such as seasonality and features of outbreaks (e.g. size and duration). Genotyping information is important to help prove absence of endemic measles transmission. For surveillance, standard indicators were proposed, including discarded measles rate at national and subnational levels, adequate case investigation and adequate specimen collection rate. In terms of laboratory performance, it is proposed that all measles network laboratories should be WHO-accredited and specimens for genotypic analysis should be available from at least 80% of outbreaks (or "chains of transmission"). In addition, three complementary indicators were proposed. For population immunity, administrative coverage reports for MCV1, MCV2 and measles supplementary immunization activities (when conducted) will be required and the target should be at least 95%. Complementary evidence is encouraged, including coverage survey and serosurvey data when available. Estimated measles reproductive number is helpful if available. There is no standard measurement for sustainability of measles elimination programme, and the proposals from other regions were presented for discussion and decision. 2.1.6 Verification commission and committees: structure, function and terms of reference

Dr Wang Xiaojun presented the proposals on principle, process and structure of verification in the Western Pacific Region, based on the outcomes from the Technical Consultation Meeting organized by the Regional Office for the Western Pacific in June 2010. In principle, measles elimination should be verified independently by country and eventually for the region. Different countries may proceed for verification of measles elimination at different times. Standard procedures and criteria should be applied and documentation process should be standardized to guide preparation work at both country and regional levels. Two levels of external and independent expert bodies will be involved in the verification process—RVC and NVC. Members of RVC and NVC should be independent from direct management of national immunization programmes or measles surveillance, with outstanding expertise in one of the following areas: epidemiology, paediatrics, public health, virology or molecular biology. RVC is authorized to verify the status of measles elimination in countries and areas of the Western Pacific Region and the Region as a whole, and carries a responsibility in developing regional verification guidelines to define the verification mechanisms for the Western Pacific Region. RVC will also provide guidance to NVC and advocate for measles elimination at country and regional levels. NVC will advise the respective Ministry of Health, national immunization programme (NIP) and vaccine-preventable diseases (VDP) surveillance units on the requirements for verification, guide national verification documentation process, assess if the country/area is ready for verification, endorse the national verification document, and submit verification reports to the RVC. As it is done for polio eradication, 21 Pacific island countries and areas will be considered as one epidemiological block and will be verified as a group. Accordingly, a subregional verification committee will be formed. For China, due to its large population size, it is proposed that China may verify measles elimination by province if the country considers the approach appropriate. 2.1.7 Roundtable discussion on the verification components and criteria

Following the above presentations, Dr David Sniadack, Dr Youngmee Jee, Dr Jorge Mendoza Aldana, Dr Yoshihiro Takashima and Dr Wang Xiaojun led the discussions by component, and the following consensuses were reached. Two verification criteria were proposed and eventually agreed: (1) zero endemic measles cases for three years nationally and for the Region, and (2) genotype analysis indicating absence of endemic measles virus.

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Four components proposed earlier were supported and it was suggested that alternative evidence of elimination is admissible. (1) Incidence, epidemiologic and virologic characteristics

Country or area should be able to describe the incidence and epidemiology of measles within its borders over time, leading to a logical and convincing conclusion on absence of endemic measles virus transmission. Ideally, the time period would begin prior to the year of measles vaccine introduction and conclude in the year in which verification of elimination is being considered. The last five years should be particularly highlighted. (a) Incidence

In describing incidence of measles it is necessary to classify confirmed measles by source of infection and by method of confirmation. Source of infection may be endemic, imported, import-related, or unknown. Method of confirmation may be by laboratory, epidemiologic linkage, or clinical criteria (Table 1). Table 1. Source and method of measles case confirmation Method confirmed Source of infection Clinically compatible

Laboratoryconfirmed

Epidemiologic linkage

Endemic

A

B

I

Unknown

C

D

J

Imported

E

F

K

Import-related

G

H

L

Every confirmed or clinically compatible case of measles may be represented in one of the cells in Table 1. When measles surveillance performs well, for example, when adequate case investigation with contact tracing is routinely performed and adequate specimens are routinely collected, the numbers of clinically compatible cases populating cells I, J, K and L (depicted in brown), should be small. Measles elimination status will be determined ultimately by the absence of endemic cases corresponding to cells A and B, depicted in red. However, as cases of unknown infection source may also result from endemic transmission, cases populating cells C and D (depicted in yellow) may also be considered as possibly endemic. Imported and import-related cases are likely to continue to varying degrees after endemic measles virus has been eliminated, depending on migration patterns into and out of the country or area. Hence, cells E, F, G and H corresponding to these sources of infection (depicted in green) would be expected to be populated by a variable number of cases. A large number of confirmed cases of

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unknown origin (i.e. cells C and D), as well as large numbers of clinically compatible cases (i.e. cells I, J, K and L), raise questions regarding the quality of surveillance and the ability of a country to confidently determine the absence of endemic measles virus transmission. Hence, an incidence of less than one per million of laboratory-confirmed and epidemiologically-linked measles cases of unknown source may be considered an additional indicator of measles elimination. Indicator: Proportion of confirmed and clinically compatible cases of known source of infection (Target: ≥ 80%). (b) Epidemiologic and virologic characteristics

Descriptive epidemiologic characteristics of measles cases corresponding to time, place and person are important indicators of measles elimination. Demonstrating changes in spatial and personal characteristics of measles cases (e.g. age distribution, vaccination status) over time may be suggestive of achievement of measles elimination. Genotype and genetic characteristics also are important to verify the absence of endemic measles virus transmission. Genotypes known to be endemic in the Western Pacific Region in 2011 included at a minimum D9 (Cambodia, Malaysia, Philippines) and H1 (China, Lao People's Democratic Republic, Viet Nam). However, other genotypes including D4 and D8 are frequently imported from the European and South East Asia Region, respectively. Virologic surveillance and genetic sequencing, together with good epidemiologic investigations, are important to help differentiate endemic from imported and import-related cases and to determine if and when endemic transmission may be re-established. Epidemic curves of confirmed cases (regardless of source) are a simple way to show the evolution of measles incidence. Epidemic curve features consistent with progress leading to elimination normally include increasing intervals between clusters/outbreaks, decreasing numbers of cases in clusters/outbreaks, decreasing duration of clusters/outbreaks, increases in percentage of sporadic cases and a loss of seasonality. If many clinically-confirmed cases are reported, it is often helpful to stack bars by method of confirmation. Spot maps may be prepared indicating index cases separately from secondary, tertiary and subsequent generations of cases, as well as indicating source. Consistent decreases in geographic spread of measles virus over consecutive time intervals can help confirm progress towards and eventual achievement of measles elimination. Tables and bar charts indicating age distribution and vaccination status of cases over time may also suggest progress toward elimination. As countries and areas near elimination, an increasing percentage of cases are likely to occur at the extremes of age (infants and adults) and the percentage of cases that were previously vaccinated (usually with a single MCV dose) is likely to increase. Indicator: Wide range and multiple years of epidemiologic and virologic analysis in support of achievement of elimination of endemic measles virus. (2) Surveillance and laboratory performance

In the setting of elimination, surveillance for measles must be sufficiently sensitive to detect any suspected measles cases and have adequate capacity for timely and proper case investigation and laboratory analysis. The credibility of elimination depends on epidemiologic and laboratory surveillance quality. Standard indicators of surveillance performance have been

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described and include (1) national and subnational reporting rates of at least two discarded measles cases per 100 000 population; (2) adequate specimen collection from at least 80% of suspected measles cases; (3) adequate specimens for virus detection from at least 80% of laboratory-confirmed outbreaks; and (4) adequate investigations of at least 80% of suspected cases. The measles laboratory network in the Western Pacific Region consists of 383 laboratories including one global specialized laboratory, three regional reference laboratories (RRLs) 17 national measles laboratories (NMLs) and, in China, 31 provincial and 331 prefectural laboratories. The WHO Regional Office of the Western Pacific conducts accreditation of RRLs, NMLs, and the 31 Chinese provincial laboratories; almost all network laboratories were accredited as of March 2012. The network is critical for serologic testing (e.g. ELISA) for anti-measles and anti-rubella IgM, and also for virologic surveillance of virus detected from cases. WHO accredits network laboratories using well-established criteria. Indicators and suggested targets for epidemiologic surveillance quality Indicator Discarded measles rate at national level Discarded measles rate at subnational level Percent of suspected cases with adequate investigation Percent of suspected cases with adequate specimen collection Specimens for genotypic analysis are available from cases associated with outbreaks (or "chains of transmission”) Complementary Concurrence of IgM-positive and IgMnegative cases between surveillance and laboratory units For countries without systems in place to collect the data required to calculate the above indicators, additional evidence may be submitted to demonstrate measles surveillance sensitivity and quality. For countries where substantial numbers of measles cases present to the private sector, additional evidence should be submitted to demonstrate that cases identified by the private sector are captured by national surveillance systems. Target ≥ 2 per 100 000 population ≥ 2 per 100 000 population for ≥ 80% of 2nd level administrative unit ≥ 80% of suspected cases ≥ 80% of suspected cases, excluding epidemiologically-linked cases ≥ 80% of outbreaks or “chains of transmission”

Target: 100% concurrence

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Indicators of laboratory performance

Indicator Measles network laboratories are WHOaccredited for serologic and, if relevant, for virologic work. Specimens for genotypic analysis are available from cases associated with outbreaks (or "chains of transmission"). Complementary: Proportion of laboratories (government and private) that conduct measles diagnostic testing that have adequate quality assurance mechanisms in place. Suspected case specimens are tested in a WHO-accredited laboratory. Complementary: Proportion of virus detection and genotyping results (where appropriate) that are completed within two months of receipt of specimen. Complementary: Completeness and timeliness of data reported monthly to the WHO Regional Office (including zero reporting) for specimens received for serologic and virologic testing. (3) Population immunity

Target 100% of laboratories

≥ 80% of outbreaks or “chains of transmission”

100% of laboratories

≥ 80% of suspected case specimens ≥ 80% of results specimens received

≥ 80% of specimens received in the laboratory

Achieving and sustaining adequately high levels of population immunity against measles in every district is a fundamental strategy to interrupt endemic measles virus transmission and prevent re-establishment of measles virus transmission when imported cases are introduced. Population immunity may be measured by annual administrative reports of routine vaccination coverage for MCV1 and MCV2 at the national and subnational levels and supplementary immunization activity (SIA) coverage as reported in the WHO and United Nations Children's Fund (UNICEF), Joint Reporting Form on Immunization (JRF), as well as annual WHO-UNICEF estimates of national coverage that sometimes differ from reported coverage. Population-based surveys of routine and SIA coverage also can be useful and include WHO recommended 30-cluster surveys, Demographic and Health Surveys (DHS), and UNICEF-sponsored multiple indicator cluster surveys (MICS). However, limitations of population-based surveys may include lack of representativeness of all geographic areas (e.g. districts), strata of society and an inability to identify potentially large pockets of susceptible individuals. Sero-epidemiologic surveys are also useful, but suffer from the same potential limitations as coverage surveys and also potential limitations of sensitivity, specificity and

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predictive value of the laboratory tests for anti-measles immunoglobulin G (IgG) as correlates of immunity. Finally, data from rapid coverage assessments (RCAs) may be an additional source of information to assess local level coverage. An indirect method for estimating population immunity relies on measles surveillance using the distribution of outbreak size as an indicator when population immunity is high: at least 80% of measles chains of transmission have < 10 cases. Additional data such as distribution of outbreak duration, number of generations of transmission, proportion of imported and import-related cases, and sero-epidemiologic survey data may feed into models that determine effective reproduction numbers (R). Experiences in several countries in the Western Pacific Region, including Viet Nam and the Philippines, suggest that very high levels of protection may not be required among all adults to interrupt measles virus transmission if high coverage exists among children and adolescents, as young and school-age children appear to be a critical link in sustaining chains of measles virus transmission. An accurate description of vaccine and natural immunity by individual birth cohort beginning from the year when measles vaccine was first introduced into the country is useful to assess potential immunity gaps. Such a description should consider SIAs and changes in schedule in specific years. Special additional analysis may also be done for vulnerable population groups who potentially have less access to vaccination services, e.g. migrants, urban or rural poor, people in remote areas. Indicators of population immunity • Administrative reports of MCV1 coverage, national and by district (target: ≥ 95% nationally and in every district) Administrative reports of MCV2 coverage, national and by district (target: ≥ 95% nationally and in every district) Administrative reports of SIA coverage, national and by district/province (target: ≥ 95% nationally and in every district) Complementary evidence: coverage and/or survey and sero-epidemiologic survey data (e.g. DHS, MICS, WHO 30 cluster surveys, etc.); and descriptions of intensified efforts made to identify and reach high-risk populations (migrants, remote, poor, ethnic minorities, etc.) through routine and supplementary immunization (4) Sustainability

•

•

•

Verification of measles elimination should include an assessment of whether elimination can be sustained. The assessment aims to (1) highlight strengths and weaknesses of national immunization programmes that are linked to maintaining high routine and/or supplementary immunization coverage and high quality surveillance, and (2) encourage the preparation of costed preparedness plans for needed responses to potential outbreaks resulting from measles virus importations. Sources of information for national immunization programme (NIP) sustainability include JRF reports, comprehensive multi-year plans (c-MYPs) for immunization, national EPI reviews, and other sources. This last verification component is indicative of measles elimination's role in strengthening routine immunization and surveillance systems, and ensuring equity in

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immunization service delivery. Such sustainability assessments may be incorporated into larger programme reviews and feasibility assessments of new immunization-related initiatives, and can also be used to strengthen health systems overall. Indicators • Inclusion of measles elimination sustainability in c-MYPs or the equivalent evidence of plans and financing for routine immunization and achieving and sustaining measles elimination including surveillance, laboratory work, and immunization activities (including SIAs when required), while fostering cooperation with other relevant sectors Documented evidence of monitoring and reviewing progress against the above plans Documented programmatic risk-assessment Budgeted importation and outbreak preparedness and response plans in place

• • •

2.1.8 Roundtable discussion on verification commission and committee structure, function and terms of reference Roundtable discussion continued the further agreement was reaching as the following: Two levels of external and independent expert bodies will involve in verification process, namely RVC and NVC. The RVC and Subregional Verification Committee (SRVC) members will be appointed by the Regional Director, and NVC members will be appointed by their ministries of health. The RVC and the NVCs/SRVC will work together to verify measles elimination in each country and area, and for the Pacific island countries and areas as a group (Figure 2). The RVC will be the only body authorized to verify measles elimination in countries and areas, and for the region as a whole. A NVC will determine when its respective country or area is ready for verification, submit the necessary documentation to the RVC for its consideration, and coordinate the collection of relevant data that demonstrate measles elimination. NVCs and SRVC report to the RVC.

Figure 2: Organizational Structure of RVC and NVC Regional Verification Commission

National Verification Committee

National Verification Committee

National Verification Committee

National Verification Committee

Sub-regional Verification Committee (for the Pacific)

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The terms of reference for RVC were proposed as the following: • To serve in an honorary capacity and verify the progress and status of measles elimination in countries and areas of the Western Pacific Region and for the Region as a whole. To establish criteria and procedures required for verification of measles elimination in the Western Pacific Region. To contribute to the formulation and endorsement of guidelines on verification on measles elimination in the Western Pacific Region. To provide guidance to national/subnational verification committees of measles elimination, and conduct field visits when needed. To advise on various issues related to verifying measles elimination. To monitor progress toward rubella control and eventual elimination. To advocate for measles elimination at the country and/or regional level.

•

•

•

• • •

The terms of reference for NVC were proposed as the following: • To advise respective Ministry of Health, National Immunization Programme and the Vaccine-Preventable Disease surveillance units on the requirements for verification of measles elimination; To compile and analyze relevant information to monitor progress towards measles elimination and assess if the country and areas has eliminated endemic measles virus transmission in accordance with established criteria and components; To conduct field visits when needed to monitor progress, assess data quality and validate analyses and assessments; To guide the annual verification documentation process at the country level, propose feasible alternatives if standard verification data area insufficient and inconsistent, and endorse annual verification report for submission to the RVC; To monitor progress towards accelerated rubella control and congenital rubella syndrome prevention and, if established as a national or regional goal, rubella elimination; and To provide programmatic guidance consistent with verification criteria and components.

•

•

•

•

•

2.1.9

Summary and RVC workplan

Based on the above consensuses reached during this one-day meeting, the RVC members, with support from the WHO Secretariat, outlined the regional verification mechanisms, including principles, process, structures and functions, verification criteria, verification components (or lines of evidence) and indicators, and summarized them into two presentations prepared for the following sessions where national officers would present.

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RVC requested the WHO Regional Office for the Western Pacific to revise the regional verification guidelines as soon as possible after the meeting based on the above consensuses for RVC's further review and comments. At an appropriate time, RVC will consider providing orientation to NVCs and request countries to submit their first measles elimination progress report in 2013 for review of RVC.

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2.2 2.2.1

Session 2: Consultation meeting on 18–19 April 2012 Opening session

Dr Hans Anders Troedsson, Director of Programme Management, delivered the opening remarks on 18 April 2012 on behalf of the Regional Director. He appreciated the great efforts and achievements made towards measles elimination by all countries in the region, and thanked the RVC members for their hard working and contribution to formulating regional verification mechanisms. He encouraged the national officers to update country progress and their plans for achieving and sustaining measles elimination. He acknowledged the involvement and contribution from Dr Robert Hall, the chair of Technical Advisory Group on Immunization and Vaccine-Preventable Diseases (TAG), Dr Anthony Adams, the chair of RCC and Dr Lisi Tikaduadua, the chair of Subregional Committee for the Certification of Poliomyelitis Eradication in Pacific Island Countries and Areas (SRCC) and thanked them. Dr Troedsson briefly explained that the consultation meeting would focus on achieving and verifying measles elimination, but would also discuss a target year for achieving the final goal of hepatitis B control to reduce HBsAg < 1% and a new Global Vaccine Action Plan that will be presented for endorsement at the upcoming World Health Assembly. Finally, he thanked all for their commitment and contribution to eliminating measles in the Region. He proposed Professor David Durrheim as the chair, Dr Hiroshi Yoshikura as the vice-chair and Dr Maria Rosario Zeta Capeding as the rapporteur for this meeting. 2.2.2 Progress towards measles elimination in the Western Pacific Region

Dr David Sniadack reported the regional progress towards measles elimination in the Western Pacific Region. The number of measles cases dramatically declined in the recent years in the region. Measles incidence decreased from 82 per million population in 2008 down to 12 per million in 2011, and the annualized measles incidence for 2012 was only four per million population based on the surveillance data from January to March 2012. In terms of surveillance, there were encouraging improvements in 2012 in adequate investigation and sample collection rates, while sensitivity of surveillance particularly at the subnational levels remained a concern. Reported coverage for MCV1 and MCV2 was 96% and 91%, respectively, in 2011 while coverage was not universally high across the countries and within some countries. He further reviewed the progress by country and area, highlighting the remarkable case reduction in Cambodia, China, Japan, Philippines, and Viet Nam and sustainable achievements in several other countries and areas, such as Mongolia and the Republic of Korea. Importation of measles virus poses an ongoing threat. Several countries in the Region often suffer from measles importations, including Australia, Japan, New Zealand and Singapore. High population immunity is critical to prevent measles virus from spreading, as demonstrated in Australia.

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Figure 1:

2.2.3

Summary of verification components and criteria

Professor David Durrheim reported the consensuses reached during the RVC meeting held one day earlier on verification criteria and components. To verify measles elimination, comprehensive and sufficient evidence should be provided. The criteria for verification of measles elimination include zero endemic measles cases for three years nationally and for the region in presence of high quality surveillance and genotype analysis indicating the absence of endemic measles virus. Four verification components could be considered, including (1) incidence, epidemiologic and virologic characteristics, (2) surveillance and laboratory performance, (3) high population immunity, and (4) sustainability of measles elimination programme. Under the component one, two indicators were suggested: proportion of confirmed and clinically compatible cases of known source of infection (target: > 80%) and wide range and multiple years of epidemiological and virological analysis to support achievement of elimination. Good description of measles epidemiology is critical, including time (epidemic curve, by week), pace (spot maps) and person (e.g. age, vaccination status in bar charts), risk factor analysis for residual transmission or outbreaks and other supporting data. For surveillance, the standard indicators would be applied, including discarded measles rate at national and subnational levels, adequate case investigation, adequate specimen collection rate and availability of specimens for genotypic analysis from cases associated with outbreaks (or "chains of transmission"). Additional evidence would be required for the countries without systems in place to collect data required to calculate the above indicators or for countries where the private sector plays an important role in reporting and confirming measles cases. In terms of laboratory performance, three indicators would be applied: proportion of measles network

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laboratories accredited by WHO for serologic test, proportion of laboratories conducting measles diagnostic testing in the countries that have effective quality assurance in place, and proportion of virus detection and genotyping results (whenever appropriate) completed within two months of receipt of specimen. For population immunity, administrative coverage reports for MCV1, MCV2 and measles supplementary immunization activities (when conducted) will be required and the target should be at least 95%. Complementary evidence is encouraged, including coverage survey and serosurvey data whenever available. Estimated measles reproductive number is also helpful. The RVC also suggested to describe intensified efforts made to identify and reach the high-risk population (e.g. migrants, remote, poor, ethnic minorities) through routine and supplementary immunization. To measure the sustainability of measles elimination, it was suggested to provide the following evidences: (1) plans and financing for routine immunization and achieving and sustaining measles elimination including immunization (including SIAs), surveillance and laboratory, while fostering cooperation with other relevant sectors; (2) documentary evidence of monitoring and reviewing progress against plans; (3) documented programmatic risk-assessment; and (4) budgeted importation and outbreak preparedness and response plans in place. 2.2.4 Summary of structure, function, terms of reference of RVC and NVCs

Dr Hiroshi Yoshikura reported on the RVC's agreements on principle, process, and structure for verification of measles elimination in the Western Pacific Region, based on the RVC meeting held one day earlier. In principle, progress towards measles elimination and sustained elimination status of countries and areas will be reviewed annually. Different countries may proceed for verification of measles elimination at different times. Verification for the Western Pacific Region only becomes possible as a result of successful verification process being accomplished for all Western Pacific Region countries and areas. Two levels of external and independent expert bodies will involve in verification process, including RVC and NVCs. Members of RVC and NVCs should be independent from the direct management of national immunization programme or measles surveillance, with outstanding expertise in one of the following areas, epidemiology, paediatrics, public health, virology or molecular biology. RVC is authorized to verify the status of measles elimination in countries and areas and the Region as a whole. The terms of reference for RVC were proposed as the following: (1) to serve in an honorary capacity and verify the progress and status of measles elimination in countries and areas of the Western Pacific Region and the Region as a whole; (2) to establish criteria and procedures required for the verification of measles elimination in the Western Pacific Region; (3) to contribute to the formulation and endorsement of guidelines on verification on measles elimination in the Western Pacific Region; (4) to provide guidance to national/subnational verification committees of measles elimination, and conduct field visits when needed; (5) to advise on various issues related to measles elimination;

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(6) (7)

to monitor progress toward rubella control and eventual elimination; and to advocate for measles elimination at the country and regional level.

The terms of reference for NVC are proposed as the following: (1) to advise respective Ministry of Health, National Immunization Programme and the Vaccine-Preventable Disease surveillance units on the requirements for verification of measles elimination; (2) to compile and analyze relevant information to monitor progress towards measles elimination and assess if the country and areas has eliminated endemic measles virus transmission in accordance with established criteria and components; (3) to conduct field visits when needed to monitor progress, assess data quality and validate analyses and assessments; (4) to guide the annual verification documentation process at the country level, propose feasible alternatives if standard verification data area insufficient and inconsistent, and endorse annual verification report for submission to the RVC; (5) to monitor progress towards accelerated rubella control and congenital rubella syndrome prevention and, if established as a national or regional goal, rubella elimination; and (6) to provide programmatic guidance consistent with verification criteria and components. For SRVC, established for verification of measles elimination in 21 Pacific island countries and areas, its function will be similar to NVCs but responsible for a group of countries and areas and the Regional Director will nominate its chairperson and members. The WHO Regional Office for the Western Pacific would serve as the secretariat for the RVC. The WHO Office in South Pacific would serve as the secretariat for SRVC. The NVCs may establish their own secretariats (for example, NIPs). In countries with WHO country offices, the relevant WHO offices would provide support to the NVCs and the national secretariats for verification of measles; and for the countries/areas without WHO country offices, the NVCs would be welcome to consult with the Regional Office. As next steps, countries would need to establish NVCs as soon as possible and the Regional Office for the Western Pacific Region would facilitate the orientation for NVCs by RVC. Then countries would be required to submit their first progress reports in 2013. 2.2.5 Proposed updates to Field Guidelines for Measles Elimination (2004)

Dr Wang Xiaojun shared a plan and some preliminary ideas on developing a new measles elimination field guide using the 2004 version of Measles Elimination Filed Guidelines as an important reference. The 2004 field guidelines provided excellent guidance to countries in formulating national strategies and action plans. Tremendous progress has been made towards measles elimination in the past eight years in the Region, with significant changes in measles epidemiology and some new global development in measles elimination and rubella control. Also countries require guidance in developing effective and specific strategic approach to addressing the remaining programmatic gaps to accelerate progress. Achieving high population

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immunity remains a priority. It was proposed to further provide intensified and innovative approaches to closing existing or preventing any emerging immunity gaps based on good country practices. More guidance on enhancing surveillance and integrating rubella control activities would be considered. Global standard indicators for monitoring surveillance performance would be adopted, and some programmatic areas would be more emphasized such as case detection at community level. More concrete instructions, such as case classification, would be developed. Significant attentions will be given to outbreak preparedness and responses, likely expanding the section into a chapter. How to incorporate verification related components was open for discussion. 2.2.6 Global Strategic Plan and Regional Action Plan for Measles and Rubella

Dr David Sniadack shared a draft version of Action Plan for Achieving and Sustaining Measles Elimination and Accelerating Rubella Control in the Western Pacific Region: 2012–2020 (Annex 3). He first briefly discussed a recent published Global Strategic Plan for Measles and Rubella in 2012–2020, including goals, strategies and guiding principles. This document served as a good reference for developing the regional action plan. The regional action plan includes the following areas: achieving and maintaining high population immunity; conducting high quality, case-based measles, rubella and congenital rubella syndrome (CRS) surveillance; ensuring high quality laboratory performance, outbreak preparedness and response, communication and demand creation; conducting research and strengthening linkages to achieve the perceived goals. The strategic approaches or priority activities are emphasized under the above each programmatic area. The WHO Regional Office for the Western Pacific will provide assistance needed to countries, including strategic assistance such as development of national guidelines or action plans, focused programmatic assistance to routine and supplementary immunization activities, epidemiologic and laboratory surveillance, involvement of workshop or monitoring activities in the field, advocacy and resource mobilization. Funding need was also presented, about US$ 87 million would be needed to achieve and sustain measles elimination and accelerate rubella control in the Western Pacific Region during the period of 2012–2020, with US$ 62 million needed for the period of 2012–2015. Eighteen percent of funding gaps would be expected, requiring more support from external donors. Finally, he invited comments from the participants.

2.2.7

Country-wise review of measles elimination status

All fourteen attending countries prepared their reports on progress towards measles elimination following a template developed by the WHO Regional Office for the Western Pacific (Annex 4) and presented in the meeting. The WHO Office for the South Pacific gave an overview on progress of measles elimination in the Pacific. A consolidated summary of country reports was presented as Annex 5.

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Republic of Korea Measles surveillance was initiated in 1954. Since 2001, the surveillance system was strengthened with increased reporting, case-based epidemiological investigation, blood sampling, and virus isolation/genotyping. The laboratory has been WHO-accredited since 2006. The Republic of Korea started measles immunization in 1965, with routine second dose introduced in 1994. Since 1997 the NIP has provided MCV1 (as measles, mumps and rubella [MMR]) at 12–15 months and MCV2 (as MMR) at 4–6 years of age. Measles routine immunization coverage rates are >95% in all districts. A nationwide wide-age range measles catch-up campaign was conducted in 2001 targeting 5.8 million children from 8 to 16 years of age. Following the 2001 catch-up campaign, measles incidence decreased to <1 per million population, which has been sustained with the exception of outbreaks in 2007 and 2010. Measles vaccination school laws and provision of hospital services to measles-infected persons has been in place since 2001. The main challenges for the country to sustain measles elimination are to (1) improve immunization timeliness, (2) manage under-immunized populations, (3) ensure physician reporting of suspected cases, (4) maintain high specimen collection rate, (5) conduct investigations to identify source of infection, and (6) rapidly address and prevent outbreaks.

Figure 2:

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Japan In Japan, measles surveillance was initiated for paediatric cases in 1981, and expanded to include adult cases in 1991. Nationwide case-based surveillance was initiated in 2008. Samples of suspected cases are tested by polymerase chain reaction (PCR) in the Institute of Public Health. Genotypes identified since May 2010 include D4, D8, D9, and G3. The number of reported confirmed cases decreased dramatically between 2008 and 2012. However, the number of adult cases is relatively increasing especially among young adults in their 20s and 30s. Japan started measles immunization in 1978 with introduction of routine second dose (given as MR) in 2006. The current immunization schedule includes MCV1 at 12–23 months of age and MCV2 at 5–6 years of age. As of 2011, routine measles immunization coverage is estimated at 95.6% for MCV1 and 92.2% for MCV2. Catch-up immunization targeting children in grades 7 to 12 have been ongoing since 2008. The main challenges for Japan to achieve measles elimination are (1) improving immunization rate by promoting routine vaccination and time limited catch-up vaccination, (2) improving coverage for catch-up vaccination among adolescents 12–13 years of age (80%) and 17–18 years of age (70%), (3) promoting routine use of RT-PCR, and (4) redefining imported cases.

Figure 3:

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Macao (China) All surveillance performance indicators have been achieved since 2008. In 2011, the rate of non-measles suspected measles cases reported was 2.68 per 100 000 total population. All cases were fully investigated and adequate blood specimens were collected. From 2008 to 2012, there have been six confirmed cases; four were imported cases and two were local cases related to the importations. Before 1989, a single dose of monovalent measles vaccine was given at nine months of age. Routine second dose was introduced in 1989 at school entry to primary 1. In 1995, a third routine dose was recommended at 15 months of age. Since 2003, two doses of MCV have been recommended at 12 and 18 months. Coverage for both doses is approximately 90%. No SIAs were reported. Measles immunization school laws are in place. Measles vaccine is offered at no cost to children less than 18 years of age and women of child bearing age. The main challenges for Macao are (1) sporadic cases that mostly occur among recent immigrants and non-resident workers, (2) conducting an immunization coverage survey to determine coverage among various age groups, and (3) reporting of all suspected cases by treating clinicians.

Figure 4

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Hong Kong (China) Measles surveillance was initiated in Hong Kong (China) in 1946. Genotyping of measles isolates has been conducted since 1997. The National Measles Laboratory was accredited by WHO, and the Measles Regional Reference Laboratory was accredited in 2007. The number of confirmed measles cases has declined steadily from 2006 (106 cases) to 2011 (13 cases). In 2012, four measles cases were reported; two were laboratory-confirmed. Hong Kong initiated MCV1 at six months of age in 1967. In 1990, monovalent measles vaccine was replaced with MMR and a routine second dose for students entering primary 1 was introduced in 1997. Currently, the vaccination schedule includes two doses of MMR at one year of age and at primary 1. Measles routine immunization coverage rates have remained above 98% for both doses since 1995. A wide-age range catch-up campaign targeting 1.2 million persons one to 19 years of age was conducted in 1997 with reported coverage of 76.9%. Since 2009, annual serosurveys show seroprevalence of measles antibodies to be close to 95% among persons five years of age and above. MMR is provided free of cost to children <1 and at 6–7 years of age. The main challenges for Hong Kong (China) are (1) sustaining low measles incidence (<1 case per 1 million), (2) maintaining the proportion of clinically-confirmed measles case to <10%, and (3) adequate investigation and specimen collection.

Figure 5

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Brunei Darussalam Measles case-based surveillance started in 2000, with mandatory reporting since 2008. Specimens are sent abroad and genotyping is not performed. Incidence has remained low, with only nine confirmed cases since 2008; none in 2012. Brunei Darussalam has met all applicable surveillance performance indicator targets. Brunei Darussalam initiated measles immunization in 1974 with the introduction of measles monovalent vaccine at nine months of age, which was switched to MMR at one year of age in 1988. Routine second dose of MMR was introduced to 12–13 year olds in 1996, but since 2007, is given at age three years. A catch-up campaign targeting children up to primary grade six was conducted in 2008. Measles routine immunization coverage rates have been >90% for the last five years. School entry immunization requirements are planned for introduction in 2012–2013. Additionally, a measles serosurvey among primary grade 4 students is planned in 2011–2012. The main challenges for Brunei Darussalam are (1) need for continued monitoring, (2) ensuring ability to vaccinate at the first opportunity, (3) timely notification of suspected measles, (4) adequate blood sample collection, (5) adherence to suspected measles clinical case definition, and (6) measles IgM and IgG tests are done at a virology laboratory.

Figure 6

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Mongolia Reporting of measles has been mandatory since 1998. Genotyping has been available since 2001, and the laboratory has been accredited by WHO since 2004. Measles case-based surveillance started in 2008. There have been no confirmed cases since 2010. All surveillance performance indicators have been achieved. Mongolia introduced monovalent measles vaccine in 1973 with introduction of routine second dose in 1986. In 2009, the monovalent vaccine was replaced with MMR. The current schedule is administration of MMR at nine months and two years of age. Measles routine immunization coverage was >98% for both doses in 2011. Measles SIAs were conducted nationally in 1994, 1996, and 2007 with a subnational SIA in 2000. The SIA in 2007 targeted 400 000 children 2 to 10 years of age with coverage of 97%. The main challenges for Mongolia are (1) lack of funds for measles SIAs and serosurvey, (2) increased surveillance sensitivity, (3) low MMR2 coverage in some district, (4) absence of laboratory capacity at regional level, and (5) atypical clinical manifestation. Planned activities include measles-rubella SIA in 2012 and expansion of RED strategy in 2013–2014.

Figure 7

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Fiji Measles reporting has been mandatory since 1976 and case-based surveillance started in 2007. In 2010, the laboratory was accredited by WHO. There have been only five confirmed cases from 2007 to 2012. Fiji started measles immunization in 1982 with the introduction of measles vaccine at nine months of age and introduction of routine second dose (MR) in 2003. The current schedule is MR at 12 months and before school entry. Measles routine immunization coverage rates have varied from 72% to 94% over the last five years. SIAs were conducted in 1997, 2001, and 2006. The most recent targeted children 6 months to 14 years of age and achieved coverage of 98%. Annual Immunization Week has been conducted since 2006. Integrated Management of Childhood Illness (IMCI) training for nurses has emphasized routine immunization. The main challenges for Fiji are (1) sustaining outreach activities for hard to reach children, (2) conducting reassessment of appropriate age for MCV2, (3) increasing timeliness and completeness of case investigations, including serological tests and genotyping, (4) guaranteeing/maintaining high turnover rates among human resources, (5) competing priorities with introduction of newer vaccines, and (6) gaining donor support for the measles elimination plan. Figure 8

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Pacific island countries and areas The Hospital-Based Active Surveillance (HBAS) system for the Pacific islands was established in 1997 and currently includes 61 hospitals and >200 paediatric clinics in 20 Pacific island countries and areas. In 2001, surveillance was expanded from “suspected measles” to acute fever and rash (AFR) surveillance. The laboratory in Fiji is WHO-accredited. Samoa, Solomon Islands and Kiribati have requested to have serum specimens sent to Fiji. Niue and Tokelau send specimens to New Zealand. MCV1 coverage varies by country, but six countries are listed as high priority for low coverage: Kiribati, the Federated States of Micronesia, Palau, Samoa, Solomon Islands, and Vanuatu. Planned SIAs include Samoa; Solomon Islands (MR June 2012, targeting children 12–59 months); Vanuatu (MR August–September 2012, targeting children 12–59 months); Solomon Islands (2012); Vanuatu (2013); and Kiribati (2014).

Figure 9

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China Mandatory reporting of measles cases was initiated in China in 1950 with introduction of case-based surveillance in 2009. The laboratory was accredited by WHO in 2001. Genotyping of measles virus isolates has been available since 1993. Incidence has decreased to the lowest level in history. There were 819 confirmed cases in 2012. China introduced measles vaccination in 1978 at eight months of age, with the routine second dose introduced in 1986 at seven years of age. In 2005, this schedule was adjusted to the current schedule of eight months (MR) and 18–24 months (MMR/M). Measles routine immunization coverage rates are >98% for both the first and second dose since 2007. From 2004–2009, China conducted SIAs in 27 provinces, targeting 185.7 million people. In September 2010, the first nationwide SIA targeting 103 million was conducted with 97.5% coverage. Measles vaccination status is checked prior to school entry. SIAs are now conducted in response to measles outbreaks. The main challenges for China are (1) achieving high routine immunization among children in Western and poor areas, (2) addressing immunity gaps in adults due to large numbers and high mobility among migrants, (3) addressing lack of, and shifting of, staff, (4) dealing with insufficient support for laboratory, (5) providing high quality serology kits to prefecture laboratories, (6) ensuring proper communication exists between EPI and laboratory in some provinces, and (7) recognizing the need for more political advocacy.

Figure 10

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Philippines Case-based surveillance was initiated in 1982, with laboratory testing starting in 1999. In 2009, the National Measles Laboratory was accredited by WHO, and in 2010, virus isolation was started. The predominant genotypes are D9 and G3. The Philippines experienced a large outbreak in 2010 and 2011. The Philippines introduced measles vaccination in 1982 and 1983 with the phased introduction of measles monovalent vaccine at nine months of age. Routine second dose was introduced in 2009. The current immunization schedule is monovalent measles vaccine at nine months and MMR at 12 to 15 months of age. Measles routine immunization coverage is estimated at 79% for MCV1 and 28% for MCV2. The Philippines conducted four SIAs in 1998, 2004, 2007, and 2011 with coverage >90%. The 2011 SIA targeted 15.6 million children between the ages of nine months and eight years of age with 84% coverage. Nationwide preschool and school based screening and vaccination is ongoing. Monitoring and supportive supervision of vaccination has been intensified. The main challenges for the Philippines are (1) changing epidemiology and unexpected outbreaks, (2) the varied performance of routine immunization and surveillance in different provinces/cities, (3) timely transport of specimens from remote locations, and (4) the shift from EPI to NIP.

Figure 11

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Malaysia Measles case-based surveillance was initiated in 2005. The laboratory was WHO-accredited in 2008. Malaysia experienced a measles outbreak with 1470 confirmed cases reported in 2011, and another 300 in January and February 2012. Genotypes D8, D9, and G3 were identified. Since 2004, the current immunization schedule includes two doses of MMR given at one and seven years of age. Currently, 51% of the districts have achieved >95% coverage for MCV1. A nationwide SIA targeting children 8 to 15 years of age was conducted in 2004 with 93% coverage. SIAs are currently being conducted in response to outbreaks in affected areas. The Ministry of Health is supporting review of cards and registration books in high-risk districts, and increased public awareness. Regular mopping-up vaccination activities are ongoing targeting children at six months, 12 months, and seven years of age. The main challenges for Malaysia are (1) 50% districts with low-MCV1 coverage, (2) lack of herd immunity, and (3) unvaccinated immigrants.

Figure 12

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Viet Nam Measles case-based surveillance and mandatory reporting started in 2002. Genotyping has been available since 2000. The laboratory has been accredited by WHO since 2003. No cases were reported in 2012. In 1981, Viet Nam introduced measles vaccination at nine months of age. Routine second dose was introduced in 2006 for six year olds, and in 2011, the age for the second dose was changed to 18 months of age. Measles routine immunization coverage rates have improved over the last five years, with coverage at 96.5% (MCV1) and 92.8% (MCV2) in 2011. Greater than 91% of districts report coverage over 90% for MCV1. Five subnational SIAs have been conducted from 2002 to 2008. A nationwide SIA targeting children one to five years of age was conducted in 2010 with 96.5% coverage. To prepare for outbreaks, there are 500 000 doses of vaccine stockpiled. An SIA targeting high-risk areas is planned for 2012–2013, and in 2013–2014, an MR campaign is planned targeting children nine months to 14 years of age. The main challenges for Viet Nam are (1) achieving and sustaining adequate population immunity in high-risk areas, (2) achieving and maintaining adequate surveillance to detect and classify imported, import-related and endemic transmission, (3) developing outbreak preparedness and response, and (4) coping with limited budget for measles elimination activities.

Figure 13

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Cambodia Cambodia’s measles control activities started in 1986 with the introduction of measles vaccine at nine months of age, with routine second dose introduced at 18 months of age in 2012. Measles routine immunization coverage rates have increased steadily, with over 50% of districts reporting higher than 90% MCV1 coverage in 2011. Measles SIAs were conducted in 2002 to 2004, 2007 and 2011. The impact of measles vaccines will be further maximized from 2012 through the NIPs’ “High-Risk Community Strategy” that will use village health volunteers in high-risk socioeconomic communities to identify children due for their 18-month measles dose and assess their full immunization status at the time of vaccination. Measles surveillance in Cambodia has improved since 2009, with more cases classified based on laboratory results. In 2012, no laboratory-confirmed measles cases were reported, but the majority of provinces have not yet reported (in February 2012) any suspected cases. The main challenges for Cambodia are (1) immunity gaps remaining in older-age cohorts that are likely to arise in young children if high coverage is not achieved with the MCV2 throughout the country, (2) surveillance needing strengthening to address silent reporting areas and reduce excessive reporting of suspected cases, and (3) proper functioning of the measles laboratories. However, it is dependent on WHO financial support.

Figure 14

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Lao People’s Democratic Republic The Lao People’s Democratic Republic introduced measles vaccination at nine months of age in 1984. Measles routine vaccination coverage rates have increased steadily to 69% at national level in 2011. National measles SIAs were conducted in 2000–2001 but the first national wide-age-range catch-up SIA was conducted in 2007 targeting children 9 months to 14 years of age and achieved 96% coverage. The country introduced measlesrubella vaccine through a national SIA targeting all children 9 months to 19 years of age in late 2011 with 97% coverage. Measles surveillance in Lao People’s Democratic Republic started in a concerted way in 2007. In 2012, no laboratory-confirmed measles cases have been reported to date. The main challenges for the Lao People’s Democratic Republic are (1) funding gaps for routine immunization and measles elimination activities, (2) development of immunity gaps in younger children due to low routine immunization coverage and existing immunity gaps in older age groups that have not yet received immunization, (3) having to continue to conduct SIAs because the country is not yet able to introduce a second dose with high coverage, (4) surveillance needing further improvement, (5) not having an accredited national measles laboratory and being dependent on WHO financial support, and (6) increasing number of underimmunized migrants.

Figure 15

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Papua New Guinea In Papua New Guinea, measles case-based surveillance started in 2008. The Central Public Health Public Laboratory was accredited by WHO in 2011, and no laboratory cases have been detected since 2008. Papua New Guinea started measles immunization in 1982 with the introduction of MCV1 at nine months of age. In 1992, another dose was introduced at six months of age. The current schedule includes two doses administered at six months and nine months of age. Measles routine immunization coverage rates have been around 60% for the last five years. SIAs were started in 2003, and have been conducted every two years since 2008. The latest SIA, conducted in 2010, targeted children six months to two years of age with 84% coverage. An ongoing SIA for 2012 is targeting all children six months to three years of age in most locations, but up to five years of age in five low-coverage provinces. A new initiative of RED to REC (Reach Every District to Reach Every Child) was scaled up in five low-performing provinces with initial improvements seen in 2011. Introduction of measles-containing vaccine and rubella-containing vaccine (MCV/RCV) in the second year of life is planned as well as a strengthening of AFR surveillance. The main challenges for Papua New Guinea are (1) addressing importation, (2) decreasing deterioration in community service delivery, (3) decrease in human resources with the national EPI team reduced in number, (4) provincial autonomy dictating implementation of programme at district and community levels, (5) targeted disease SIA being resource intensive, (6) surveillance performance being variable, (7) an increased expectation from EPI for introduction of new vaccines resulting in competing priorities for the country, and (8) lack of funding.

Figure 16

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2.2.8

Developing or updating national action plans for measles elimination

Before the meeting, all attending countries and areas were requested to develop or update their national action plan on achieving and sustaining measles elimination in 2012–2013, including activities and budget lines under four major programmatic areas, namely improving population immunity, strengthening epidemiological and laboratory surveillance, outbreak preparedness and response, and verification of measles elimination. Guidelines and a template were provided for this purpose (Annex 6, 7). During the meeting, every country or area reported its measles elimination action plan as part of its country presentation. Country action plans were consolidated as Annex 8. Following individual country presentations, country action plans were discussed and reviewed through group work. During group work, participants were divided into six groups and each group was composed of certain country participants and one or two designated facilitators. All countries and areas were asked to finalize their action plans soon after the meeting and share them with WHO Regional Office for the Western Pacific. A few countries have finalized their action plans and shared them even during the meeting.

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2.3 2.3.1

Session 3: Consultation meeting on 20 April 2012 Opening session

On 20 April 2012 when the high-level officers from ministries of health joined the meeting, Dr Shin Young-soo, the Regional Director of the WHO Western Pacific Region, delivered the opening remarks. Dr Shin welcomed the national officers, RVC members, temporary advisers and partners, and congratulated the extraordinary achievements made by Member States, and especially the 25 countries and areas that may be ready for verification of measles elimination. He expressed his appreciation on tremendous efforts by Member States and particularly mentioned the historic nationwide measles campaign immunizing over 100 million children in China, innovative and effective five-year measles elimination plans and interruption of transmission caused by endemic measles virus strain in Japan, impressive reduction of measles cases following nationwide supplementary immunization activities in Cambodia, the Philippines, Viet Nam, and sustained achievement in Brunei, Fiji, Hong Kong (China), Macao (China), Mongolia, Papua New Guinea and other Pacific island countries and areas. He said he was confident that by the close of the consultation all participants would reach a consensus and common commitment on the way forward, and called for achieving the regional goal of measles elimination. He reminded us that we have another regional EPI goal on hepatitis B control to reduce HBsAg prevalence in children to <1% and to reach an interim milestone of <2% by 2012. The participants would be expected to review and discuss the feasibility of a target year recommended by the regional hepatitis B Expert Resource Panel. He emphasized that the twin goals of measles elimination and hepatitis B control were developed in the context of strengthening immunization programmes. He indicated that in this meeting the WHO headquarters would brief on Global Vaccine Action Plan (GVAP) in preparation for its presentation to the upcoming World Health Assembly for endorsement. He highlighted that it would be a good opportunity for all national officers to provide final comments and consider possible interventions during the World Health Assembly, in line with fulfilling the resolutions of the Regional Committee for the Western Pacific to elimination measles and control hepatitis B. Dr Shin proposed Dr Robert Hall as the chair, Dr Hiroshi Yoshikura as the vice-chair and Dr Maria Joyce Ducusin (the National EPI manager in the Philippines) as the rapporteur to the sessions on GVAP and hepatitis B control. The proposal was endorsed by all participants. 2.3.2 Overview of Global Vaccine Action Plan

Dr Thomas Cherian from the WHO headquarters presented a global overview on GVAP, starting by providing a brief background history of the Decade of Vaccines (DoV), a name given by Bill Gates during his January 2010 announcement speech at the Davos meeting where he committed US$ 10 billion towards the initiative. Echoing Bill Gates’s announcement, WHO Director-General supported the initiative and the later formed global partnership forum. The presenter highlighted that DoV builds on Global Immunization Vision and Strategy (GIVS) and he also provided rational supporting the timing of the initiative and the wide consultation process that has taken place to convert the Global Vaccines Action Plan into a formal document, with over 1000 people from over 100 Member States participating, a process coordinated by the New York and Geneva missions. The presenter highlighted the initiative’s vision, principles, the four specific goals, namely achieve a world free of polio, stopping global transmission in 2015 and global certification in 2020; neonatal tetanus (NT) eliminated by 2015; elimination of measles and rubella by 2020; and development and introduction of new vaccines.

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Following the presentation, some questions were raised from country participants from China, Hong Kong (China), Japan, the Lao People’s Democratic Republic and Papua New Guinea. Questions focused on clarification upon the country ownership theme, particularly on the establishment of laws to facilitate the implementation of the DoV action plan; on whether a consultation with manufacturers have taken place and on what manufactures has committed; and on accountability by vaccine manufacturers. 2.3.3 Operationalizing the Global Vaccine Action Plan

Further discussions followed on how to make the GVAP operational with comments and questions by participants from Brunei Darussalam, Hong Kong (China), Japan, the Lao People’s Democratic Republic, Malaysia, and Philippines. The main point of discussion was the indicator on introduction of legal mechanisms (laws) to enforce immunization uptake by the population. In some countries this indicator conflicts or may conflict with current laws, few other have legislations on vaccination with diverse scope; but the majority felt that the indicator needs to be reformulated and should reflect flexibility on expressing country ownership. Other issues addressed were vaccination hesitancy, financing, mass media role, the participation of people other than ministries of health in the upcoming World Health Assembly. The chair summarized the discussion, highlighting the following: (1) the need for flexibility on legislation to demonstrate political commitment; (2) the need for more work with the mass media and vaccine hesitancy; (3) the need for options, like the revolving fund in Pan American Health Organization (PAHO), to ensure accessibility to vaccines and financing; and (4) the need to explore the concept on the role of government in terms of leadership and the role of manufacturers, civil society and others. 2.3.4 Preparation for the World Health Assembly and next steps

In the afternoon, the session continued with the participation of Dr Jean Marie Okwo Bele, Director, Immunization, Vaccines and Biologicals, WHO headquarters, who drew attention to the array of available vaccines and those being recommended as well as to the draft and non-prescriptive nature of the document on country ownership to be presented to the World Health Assembly. Reasoning that achieving EPI goals is something that goes beyond EPI programme, he justified the role of other stakeholders like civil society and vaccine manufacturers, noting that the latter had just released a communiqué. On the civil society’s role, he could foresee street manifestations demanding vaccination. Dr Cherian made remarks on the legislation issues, informing that American countries have immunization laws and that this region could, at least, have some provisions to ensure immunization services. He also emphasized the need to proactively engage the media and to address the reasons for vaccine hesitancy, and briefly highlighted, within the context of technology development, the importance of reminders for vaccination to ensure that children receive their vaccines. As the accountability theme was still to be completed he invited participants and Member States to provide their inputs. To the invitation for comments and questions by the WHO headquarters representatives, Hong Kong (China), Malaysia and the Philippines representatives took the floor. They voiced their concerns that discussion of vaccines must be done in a manner that will not be seen as collusion with manufacturers (given their questionable attitudes and behaviour during the H1N1 pandemic and regarding new vaccines) that refer to WHO recommendations to justify their increased and continued pressure on countries and civil society.

- 36 -

The GVAP session closed with the chairperson acknowledging the complexity of different issues raised by participants and the unintended consequences of some points that are being advocated. 2.3.5 Hepatitis B Expert Resource Panel (ERP) proposal for a target year for the Hepatitis B control goal The purpose of this session was to begin engaging Member States in the process of establishing a target year for the hepatitis B control goal to reduce chronic infection hepatitis B rates to <1% in 5 year old children. As background, status of the 2012 milestone to reduce infection prevalence to <2% was presented to provide context for setting a target year. Considering seroprevalence and immunization data, it is likely that the Region as a whole and at least 30 Member States will meet the <2% milestone. The remaining six priority countries (Kiribati, Papua New Guinea, the Philippines, Samoa, Solomon Islands, Vanuatu) have been classified as such because they have not met the coverage targets of at least 65% timely birth-dose coverage and 85% three-dose. Three other countries (Cambodia, the Lao People’s Democratic Republic, Viet Nam) conducted serosurveys in 2011 and have preliminary results suggesting they have <2% prevalence despite not having met the immunization targets. Papua New Guinea and the Philippines are planning to conduct serosurveys this year which will help determine if they have met the 2012 milestone based on seroprevalence data. In August of 2011, the Technical Advisory Group (TAG) recommended that the Region’s hepatitis B ERP propose a target year for the <1% goal. In February 2012, the ERP recommended 2017 as the goal’s target year. The 2017 target year was based on the following considerations: (1) the target year should be in the near future, to build on the important progress made thus far and help focus and mobilize attention, energy and resources for achieving it, and (2) the target year should be feasible for the region as a whole and most countries representing most of the population but not necessarily every country. The ERP feels that 2017 is feasible for all or almost all countries in the Region and several countries have already been verified to reach the <1% goal. The ERP recognizes that a few countries have substantial challenges reaching a high proportion of newborns and children. However, it is encouraging that many priority countries have been making progress in increasing birth-dose and three-dose coverage over the last five years and recent surveys show reduced infection rates. This session provided the first opportunity to inform Member States of the ERP 2017 recommendation and begin the consultative process for setting the target year for the <1% goal. Other potential plans include: (1) sending a letter to Member States on setting a target year and invite comments, (2) continuing to seek Member States input at the August 2012 Technical Advisory Committee, (3) TAG making a recommendation based on ERP recommendation and Member State input, (4) arranging individual country consultation and discussion as needed, and (5) if a Member State consensus is achieved, proposing a target year at the sixty-fourth session of the WHO Regional Committee for the Western Pacific in 2013. During discussion there was general agreement that it is a good time to set a target for the 1% goal. Participants agreed with 2017 and the proposed path. Some key priority countries noted that 2017 would be challenging but supported a target date of 2017. Participants recommended a mid-term assessment to guide activities. Follow-up items from this session include drafting language to represent a mid-term assessment for priority countries as part of the process. Additionally, it was recommended that the TAG or ERP provide guidance for sustaining gains that have been made thus far, especially in countries that have been verified to achieve the goal.

- 37 -

After completing the sessions on GVAP and hepatitis B, the consultation again focused on measles elimination. Professor David Durrheim, Dr Hiroshi Yoshikura and Dr Maria Rosario Zeta Capeding resumed their roles as the chair, the vice-chair and the rapporteur, respectively. 2.3.6 Summary and discussion on Field Guidelines for Measles Elimination

Dr Wang Xiaojun summarized the key discussion points in relation to developing a new measles elimination filed guidelines based on the 2004 version. The new guidelines will aim for providing practical guidance to countries on how to address the remaining programmatic gaps to achieve and sustain measles elimination. Achieving high population immunity remains a priority. Efforts will be considered to provide guidance on how to systematically identify and reach the underserved and vulnerable populations based on the existing country experiences. In terms of surveillance, the recent global development and country-level experiences and lessons learnt in enhancing measles related surveillance will be reviewed and incorporated. Efforts will also be made to provide guidance on integrating measles and rubella surveillance under different local situations and capacity. More attentions will be given to outbreak preparedness and responses. Programmatic risk-assessment will be discussed to provide the guidance to national and field staff aiming for timely corrective actions. If feasible, the new field guidelines will include standard operational procedures for certain critical activities/aspects, such as for management of surveillance and outbreak response. Regional Office for the Western Pacific Region considers this work as one of priority activities in 2012 and wishes to provide a draft during the upcoming TAG for countries' further input and comments. 2.3.7 Summary and discussion on regional and national action plans for measles elimination Dr David Sniadack briefed a draft version of Regional Action Plan for Measles and Rubella in 2012–2020. He first briefly the recent published Global Strategic Plan for Measles and Rubella in 2012–2020, including goals, strategies and guiding principles. The regional action plan includes the following areas: achieving and maintaining high population immunity; conducting high quality, case-based measles, rubella and CRS surveillance; ensuring high quality laboratory performance, outbreak preparedness and response; communication and demand creation; research and strengthening linkages to achieve goals. The strategic approaches or priority activities are emphasized under the above each programmatic area. The WHO Western Pacific Regional Office will provide assistance needed to countries, including strategic assistance such as development of national guidelines or action plans, focused programmatic assistance to routine and supplementary immunization activities, epidemiologic and laboratory surveillance, involvement of workshop or monitoring activities in the field, advocacy and resource mobilization. Funding need was also discussed. During the period of 2012–2020, about US$ 87 million may be needed to achieve and sustain measles elimination and accelerate rubella control in the Western Pacific Region, with US$ 62 million needed in 2012–2015. Eighteen percent funding gaps were expected, requiring support from external donors. He also summarized the discussions during the sessions on 18 April on the same topic and on country action plans, including urgent actions to interrupt measles transmission in several priority countries, development of outbreak preparedness and response plans, organizing cross-border consultation and establishment of national verification committees. 2.3.8 Summary and discussion on verification of measles elimination

Professor David Durrheim, on behalf of the Regional Verification Commission, summarized the outcomes from the consultation on verification of measles elimination. He observed that during the meeting the RVC reviewed the regional progress towards measles

- 38 -

elimination, verification process and verification indicators (evidence); country participants and other experts provided valuable inputs and guidance; and also country participants presented their progress towards measles elimination and action plans for achieving and sustaining measles elimination in 2012–2013. He emphasized the remarkable progress being made in reducing measles incidence in the region; and summarized the key consensuses made in relation to regional mechanisms on verification of measles elimination, including principles, process, structure, verification criteria, four verification components with certain proposed indicators. RVC will verify countries independently and then the region as a whole. Documentation process should be standardized to guide preparation work at both country and regional levels. There will be two levels of verification bodies with defined terms of references, including regional verification commission and national (and subnational) verification committees. All those consensuses would be incorporated into a regional verification guideline which will be revised further, based on the discussion and agreement made in this consultation meeting. A draft of the regional verification guidelines is attached as Annex 9. 2.3.9 Partner statements

Mrs Andrea Gay, representing the United Nations Foundation (UN Foundation), congratulated the remarkable progress towards measles elimination in all countries and areas in the Western Pacific Region, and expressed appreciation to all the countries and areas as well as to WHO at country and regional levels for all tremendous efforts made in the past. She emphasized the contribution from the progress achieved in the Western Pacific Region to the global measles control, and encouraged the Western Pacific Region to accelerate the progress to make the Western Pacific Region the second region to achieve measles elimination. UN Foundation, together with other Measles and Rubella Initiative partners, remains strongly committed to supporting the Western Pacific Region countries to eliminating measles. 3. ACTION POINTS

The chair thanked for the great contributions from the RVC members, national counterparts, temporary advisers, partners and the WHO Secretariat. He concluded the meeting with the following action points which were endorsed by the meeting participants: (1) WHO to seek other opportunities (such as TAG and the Regional Committee in 2012) to obtain more inputs to verification of measles, target year for the <1% hepatitis B goal and the Global Vaccine Action Plan; (2) WHO to further update regional verification guidelines based on future comments;

(3) Countries to finalize and submit their national action plan for achieving and sustaining measles elimination in 2012–2013, by mid-May 2012. WHO may send official letters to countries for this purpose; (4) WHO to develop a measles elimination field guide as soon as possible;

(5) WHO to send official letters to countries calling for the establishment of national verification committees; (6) Countries to establish national verification committees in 2012;

- 39 -

(7) If possible, WHO to work together with the Ministry of Health and the WHO Office in China to pilot verification documentation process in selected provinces in China; and (8) WHO to organize subsequent RVC meetings and provide orientation to the NVCs on verification of measles elimination at appropriate time.

TIMETABLE CONSULTATION ON MEASLES ELIMINATION AND HEPATITIS B CONTROL, 17-20 April 2012, MANILA Manila, Philippines 17–20 April 2012 RVC, NIP, Partners (Conference Hall) 7.30‑8.00 8.00‑8.30 18 April (Wed) Registration 1. Opening session ·    Opening remarks ·    Introductions ·    Nominations ·    Administrative announcements 2. Progress towards measles elimination in the WPR (D Sniadack) 3. Summary of verification components and criteria, and discussion (RVC) Coffee break 8.15‑8.30 8.30‑8.45 8.45‑9.00 9.00–9.15 9.15‑9.30 9.30‑10.00 10.00‑10.30 10.30-10:45 7.12 Viet Nam 7.13 Cambodia 19 April (Thu) Summary of previous day's session (RVC) 7.30‑8.00 Country-wise review (cont'd) 7.9 China Discussion and feedback 7.10 Philippines 7.11 Malaysia Discussion and feedback 8.00‑8.30

ANNEX 1

7.30‑8.00 8.00‑8.30

RVC (MFR) 17 April (Tue) Registration 1. Opening session ·   Opening remarks ·    Introductions ·    Nominations ·    Administrative announcements ·    Group photo

RVC, NIP, MOH (Conference Hall) 20 April (Fri) Registration 1. Opening session ·   Welcome address ·    Introductions ·    Nominations ·    Administrative announcements ·    Group photo 2. Overview of GVAP (T Cherian, IVB) 3. Operationalizing the GVAP (R Hall, TAG Chair; S Diorditsa) Coffee break

8.30‑9.00

8.30‑9.00 9.00‑9.30 9.30‑10.00

2. Progress towards measles elimination in the 9.00‑9.45 WPR (D Sniadack) 3. Overview of verification of measles elimination 9.45‑10.15 (P Strebel) 4. Lessons learned from certification of polio free 10.15‑11.00 status in the WPR (A Adams) 11.00‑11:30 Coffee break

Coffee break

8.30‑9.00 9.00‑10.30 10.30‑11.00

4. Summary of structure, function, terms of 10.45‑11.00 reference of RVC and NVCs, and discussion (RVC) 5. Proposed updates to Field Guidelines for 11.00‑11.30 Measles Elimination (2004), and discussion (X Wang) 6. Global Strategic Plan & Regional Action Plan for 11.30‑11.45 Measles Elimination & Rubella Control 2012-20, & discussion (D Sniadack) Lunch 7. Country-wise review of measles elimination status, current plans and proposed updates (15 mins each) 7.1 Republic of Korea 11.45-12.00 12.00‑12.15

10.00‑10.30

Discussion and feedback

11.00‑11.30

10.30‑11.00

5. Verification of measles elimination: components and criteria (D Sniadack) 6. Verification commission and committees: structure, function, and terms of reference (X Wang)

11.30‑12:00

7.14 Lao PDR

11.30-11.45

4. Preparation for the World Health Assembly and next steps (JM Okwo-Bele, IVB) 5. ERP proposal for a target year for the Hepatitis B control goal & discussion (K Hennessey) Discussion Lunch

11.00‑11.30

12.00‑01.00 1.00-1.15

7.15 Papua New Guinea Discussion and feedback

11.45‑12.15 12.15‑1.15

11.30-12.00

7. Roundtable discussion on the verification components and criteria (Facilitators) 7.1 Incidence and epidemiologic characteristics (D Sniadack) 1.15‑1.30

12.15‑1.15 Lunch

1.15‑1.45

7.2 Japan

1.15‑1.30

12.00-1.00 1.00‑1.30 1:30-2.00 2.00‑2.30 2.30‑3.00 3.00‑3.30 3.30-4.30

Lunch 7.2 Epidemiologic surveillance quality (X Wang) 7.3 Laboratory performance and molecular epidemiology (Y Jee) 7.4 Population immunity (JA-Mendoza) 7.5 Sustainability (YTakashima) Coffee break 8. Roundtable discussion on verification commission and committee structure, function and terms of reference (RVC Chair) 9. Verification workplan (RVC Chair) Summary (S Diorditsa) Working dinner-prepare for consultation (2nd Floor Lounge, Conference Hall)

1.30‑1.45 1.45‑2.00 2.00‑2.15 2.15‑2.30 2.30‑3.00 3.00‑3.15 3.15‑3.30

Discussion and feedback 7.3 Macau (China) 7.4 Hong Kong (China) Discussion and feedback Coffee break 7.5 Brunei Darussalam 7.6 Mongolia

1.30‑3.00 3.00‑3.30 3.30‑4.45 4.45-5.00 5.00-5.30 5.30-8.30

8. Guidelines to update national action plans for measles elimination (with indicative budgets) during 2012-13 (XWang) Group work on national plan updates Coffee break Review and discuss national actions plan updates (RVC) Summary of two-day consultation and homework assignments (RVC) Transfer to reception venue Reception (Pan Pacific, 6th floor)

1.45‑2.45

6. Summary & discussion of Field Guidelines for Measles Elimination and Rubella Control (2012) (X Wang) 7. Summary & discussion of Regional & National Action Plans for Measles Elimination (D Sniadack) Coffee break 8. Summary & discussion of verification of measles elimination (RVC member) 9. Partner statements (S Diorditsa) Wrap up of consultation and next steps (RVC) Closing

2.45‑3.15 3.15-4.15 4.15-4.45 4.45‑05.15 5.15-5:30

4.30-5.00 5.00-5.30 5.30-7.00

3.30‑3.45 3.45-4.00 4.00-4.30 4.30-5.00 5.00

Discussion and feedback 7.7 Fiji 7.8 Pacific island countries and areas Discussion and feedback End of day

ANNEX 2 WORLD HEALTH ORGANISATIONS MONDIALE

ORGANIZATION

DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

LIST OF PARTICIPANTS, TEMPORARY ADVISERS AND SECRETARIAT

1. PARTICIPANTS BRUNEI DARUSSALAM CAMBODIA Dr Chee Tee Yung, Child Health Program Manager, Department of Health Services, Ministry of Health, Commonwealth Drive, Bandar Seri Begawan BB3910. Tel. No. (673) 238 1640 Ext. 7712. E-mail: cheetee@yahoo.com Professor Sann Chan Soeung, Deputy Director General for Health, Ministry of Health, 151-152 Kampuchea Krom Avenue, Phnom Penh Tel. No. (855) 12 933344. Fax No. (855) 23 426167 E-mail: workmoh@gmail.com Dr Morn Chheng, Deputy Manager, National Immunization Program, National Maternal and Child Health Center, Ministry of Health, 151-152 Kampuchea Krom Avenue, Phnom Penh. Tel. No. (855) 12 913794 E-mail: chheng_morn@yahoo.com CHINA Dr Quan Le Li, Director, Bureau of Disease Prevention Control, Ministry of Health, No. 1 Xi Zhi Men Wai Nan Lu Xicheng District Beijing 100044. Tel. No. (86-10) 68792958. Fax no. (86-10) 68792357 E-mail: Li_quanle@163.com Dr Fuqiang Cui, Deputy Director, National Immunization Programme, Ministry of Health, Nanwei Road 27, Xuanwu District, Beijing Tel. No. (86-10) 83133690. Fax No. (86-10) 83133797 E-mail: Cuifuq@126.com HONG KONG (CHINA) Dr Vivian Chan, Senior Medical Officer (Surveillance Section) Department of Health, Government of the Hong Kong Special Administrative Region, Room 452, Center for Health Protection, 147C Argyle Street, Kowloon, Hong Kong. Tel. No. (852) 21252230. Fax No. (852) 27110927 E-mail: smo_ss3@dh.gov.hk Dr Ho-fai Tsang, Controller, Centre for Health Protection, Department of Health, Government of the Hong Kong Special Administrative Region, Wu Chung House, 17th & 21st Floors, 213 Queen's Road East, Wan Chai, Hong Kong. Tel. No. (852) 29618889. Fax No. (852) 25730585 E-mail: thomas_tsang@dh.gov.hk MACAO (CHINA) Dr Iek Hou Leong, Public Health Specialist, Government of the Macao Special Administrative Region, CDC-NDIV, Health Bureau, 7th Floor, Building "Hot Line", No. 335-341, Alameda, Dr. Carlos d'Assumpcao, Macao Tel. No. (853) 28533525. Fax No. (853) 28533524. E-mail: ihleong@ssm.gov.mo

FIJI

Dr Prem Singh, Acting Senior Medical Officer, Ministry of Health, Dinem House, 88 Amy Street, Toorak, Suva. Tel. No. (679) 3320066 Fax No. (679) 3320344. E-mail: premdrsingh@gmail.com Ms Pulotu Suka, Senior Health Sister, Labasa Health Centre, Ministry of Health, Labasa. Tel. No. (679) 9009385. Fax No. (679) 8818115. E-mail: pulotu.lebaivalu@govnet.gov.fj Dr Frances Bingwor, National Advisor, Family Health, Ministry of Health, 2nd Floor Dinem House, 88 Amy Street, Suva, Fiji. Tel. No. (679) 3315633 Fax No. (679) 3315568. E-mail: fbingwor@health.gov.fj

JAPAN

Dr Yosuke Kita, Medical Officer for Vaccination Policy, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916 Tel. No. (813) 35952257. Fax No. (813) 35816251 E-mail: kita-yousuke@mhlw.go.jp Dr Geun-Ryang Bae, Director of Vaccine-Preventable Disease Control and National Immunization Programme, Korea Centers for Disease Control and Prevention, Osong Health Administration Complex 187 Osongsaengmyeong 2-ro, Gangoe-myeon, Cheonwon-gun, Chungcheongbuk-do 363-951. Tel. No. (82) 43-7197340 Fax No. (82) 43-7197379. E-mail: bgr824@naver.com Dr Young Joon Park, Medical Officer, Division of Vaccine-Preventable Disease Control and National Immunization Programme, Korea Centers for Disease Control and Prevention, Osong Health Administration Complex, 187 Osongsaengmyeong 2-ro, Gangoe-myeon, Cheonwon-gun, Chungcheongbuk-do 363-951. Tel. No. (82) 43-7197354. Fax No. (82) 43-7197379. E-mail: pahmun@hanmail.net

KOREA, REPUBLIC OF

LAO PEOPLE'S DEMOCRATIC REPUBLIC

Dr Phengta Vongphrachanh, Director, National Center for Laboratory and Epidemiology, Ministry of Health, Km 13, Thade 12 Road, Vientiane Tel. No. (856) 21315858. Fax No. (856) 21315858 E-mail: v.phengta@gmail.com Dr Anonh Xeuatvongsa, Manager, National Immunization Program, Ministry of Health, Thadeua Road, Thaphalanxay Village, Vientiane Tel. No. (856) 21312352. Fax No. (856) 21312120. E-mail: anonhxeuat@gmail.com Dr Somchith Akkhavong, Deputy Director General, Department of Hygiene and Prevention, Ministry of Health, Vientiane. Tel. No. (856) 99801754 E-mail: svilayrack@yahoo.com

MALAYSIA

Dr Chong Chee Keong, Director of Disease Control, Ministry of Health Malaysia, Level 8, Block E10, Complex E, Federal Government Administrative Centre, 62590 Putrajaya. Tel. No. (603) 88834419 Fax No. (603) 88880643. E-mail: drchongck@moh.gov.my Dr Rohani Binti Jahis, Senior Principle Assistant Director Disease Control Division, Ministry of Health Malaysia, Level 8, Block E10, Complex E, Federal Government Administrative Center, 62950 Putrajaya Tel. No. (603) 88834441. Fax No. (603) 88891013 E-mail: rohbj@moh.gov.my

MONGOLIA

Dr Narangerel Dorj, Senior Officer, Communicable Diseases Control Ministry of Health, Government Building VIII, Olympic Street-2 Sukhbaatar District, Ulaanbaatar 51. Tel. No. (976) 99164451 Fax No. (976) 11263631. E-mail: naraa61us@yahoo.com Dr Dashpagam Otgonbayar, Head of Immunization Department National Center for Communicable, Nam yan ju Street, 14 Khoroo Bayanzurkh District 210648, Ulaanbaatar. Tel. No. (976) 88081464. E-mail: dashka_as@yahoo.com

PHILIPPINES

Dr Enrique A. Tayag, Assistant Secretary, Department of Health San Lazaro Compound, Sta Cruz, Manila Dr Maria Joyce Ducusin, Medical Specialist IV, National Center for Disease Prevention and Control, Department of Health, San Lazaro Compound, Sta. Cruz, Manila. Tel. No. (632) 7329956. E-mail: juducusin@yahoo.com Ms Dulce Elfa, Nurse, National Epidemiology Center, Department of Health San Lazaro Compound, Sta. Cruz, Manila. Tel. No. (63) 9195703263 Fax No. (632) 7329057. Email: elfad721@yahoo.com

PAPUA NEW GUINEA VIET NAM

Mr Enoch Posanai, Executive Manager - Public Health, Department of Health, P.O. Box 807, Waigani, National Capital District. Tel. No. (675) 3013703 Fax No. (675) 3239710. Email: enoch_posanai@health.gov.pg Dr Nguyen Minh Hang, Chief, Division of Vaccines, Biologicals and Biosafety, General Department of Preventive Medicine, Ministry of Health 135 Nui Truc, Ba Dinh, Hanoi. Tel. No. (844) 3842364 Fax No. (844) 37367379. Email: haminhvn@yahoo.com Dr Nguyen Van Cuong, Deputy Manager, National Institute of Hygiene and Epidemiology, 1 Yersin, Hanoi. Tel. No. (844) 39725745 Fax No. (844) 8213782. Email: vancuong@fpt.vn

2. REGIONAL VERIFICATION COMMITTEE Dr Maria Rosario Capeding, Head, Department of Microbiology, Research Institute for Tropical Medicine, Philinvest Corporate City, Alabang, Muntinlupa City, Philippines Mobile No. (63) 9178509788. Tel. No. (632) 7724916. Fax No. (632) 7724916 E-mail: lerosecap@yahoo.com.ph Prof David N. Durrheim, Director of Health Protection and Health Medicine, Professor of Public Health Medicine, Hunter New England Population Health, P.B. 10, Wallseed, 2287 NSW, Australia. Tel. No. (612) 49246395. Fax No. (612) 49246215 E-mail: David.Durrheim@hnehealth.nsw.gov.au, David.Durrheim@newcastle.edu.au Dr Kee Tai Goh, Senior Consultant, Ministry of Health, College of Medicine Building, 16 College Road, Singapore 169854, Republic of Singapore. Tel. No. (65) 63258450. Fax No. (65) 62241677 E-mail: GOH_Kee_Tai@moh.gov.sg Dr Duk Hyoung Lee, Director, Disease Prevention Center, Korea Centre for Disease Control and Prevention, Osong Health Technology Administration Complex, Cheongwon-gun, Chungbuk-do 363-951, Republic of Korea. Tel. No. (82) 43-7197300. Fax No. (82) 43-7197339 E-mail: leeduk0125@daum.net

Dr Mark Papania, Medical Epidemiologist, Laboratory Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, United States of America. Tel. No. 1 (770) 265 6483 Fax No. : 4046398761. E-mail: myp7@cdc.gov Dr Phan Trong Lan, Deputy Director General, Department of Preventive Medicine, Ministry of Health, Hanoi, Viet Nam. Tel. No. (844) 37368439; (84) 913002797. Fax No. (844) 37367379 E- mail: ptlan2000@yahoo.com Dr Bounpheng Philavong, Deputy Director of Cabinet, Ministry of Health, Vientiane, Lao People's Democratic Republic. Tel. No. (856) 21-217849. Fax No. (856) 21-2140001 E-mail: bounpheng@moh.gov.la, bounphengphilavong@yahoo.com Dr Paul Rota, Lead Scientist, Measles Team, Measles, Mumps, Rubella and Herpesviruses Laboratory Branch, Centers for Disease Control and Prevention, MS-C-22, 1600 Clifton Rd., Atlanta GA 30333, United States of America. Mobile No. 1 (678) 6443234. Tel. No. 1(404) 6394181. Fax No. 1 (404) 6394187. E-mail: par1@cdc.gov Dr Thian Lian Soo, Senior Consultant Paediatrician, and Head of Department, Sabah Women and Children's Hospital, 88996 Kota Kinabalu, Malaysia. Tel. No. (6088) 522600 Fax No. (6088) 437185. E-mail: mtkinabalu@yahoo.com Dr Hiroshi Yoshikura, Adviser, Department of Food Safety, Ministry of Health Labour and Welfare 1-2-2 Kasumigaseki Chiyoda-ku, Tokyo 100 8916, Japan. Tel. No. (813) 35952326 Fax No. (813) 35037965. E-mail: yoshikura-hiroshi@mhlw.go.jp Dr Aiqiang Xu, Deputy Director, Shandong Center for Diseases Prevention and Control 16992 Jingshi Road, Jinan, Shandong Province 250014, China. Tel. No. (86)-531-82679606 Fax No. (86)-5312964512. E-mail: aqxuepi@163.com

3. TEMPORARY ADVISERS Dr Anthony Adams, Chairman, Regional Certification Commission, No. 6/2-4 Chapman Crescent, Avoca Beach, New South Wales 2251, Australia. Tel. No. (612) 43826516 Email: aarr@netspeed.com.au Dr Robert Hall (TAG Chair), School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia Tel. No. (613) 99030452. Fax No. (614) 05073061. E-mail: robert.hall@monash.edu Dr Adi Lisikoveni Vesikula Tikoduadua (Polio SRCC Chair), Consultant Paediatrician, Department of Paediatrics, Commonwealth Memorial Hospital, Box 115, Suva, Fiji. Tel. No. (679) 9925082 Fax No. (679) 3303232. E-mail: ltikoduadua@health.gov.fj; liztiko@gmail.com

4. REPRESENTATIVES AND OBSERVERS UNITED NATIONS FOUNDATION Dr Andrea Gay, Executive Director, Children's Health United Nations Foundation, 1800 Massachusetts Avenue, N.W. Suite 400, Washington D.C. 20036. Tel. No. 1 (202) 8879040 Fax No. 1( 202) 8879021. Email: agay@unfoundation.org

NATIONAL INSTITUTE OF INFECTIOUS DISEASES, JAPAN DEPARTMENT OF HEALTH, PHILIPPINES

Dr Makoto Takeda, Director, Department of Virology III National Institute of Infectious Diseases, 4-7-1, Gakuen, Musashimurayama, Tokyo 208-11, Japan Email: mtakeda@nih.go.jp Ms Luzviminda Garcia, Supervising Health Program Officer National Center for Disease Prevention and Control Department of Health, San Lazaro Compound, Sta. Cruz Manila, Philippines. Tel. No. (632) 7329956 Email: luzgarcia@yahoo.com Ms Joanne Bel Oriel, Nurse, Department of Health San Lazaro Compound, Sta. Cruz, Manila, Philippines Mr Rex Centeno, Research Institute for Tropical Medicine Philinvest Corporate City, Alabang, Muntinlupa City, Philippines

DELEGATION OF THE EUROPEAN UNION TO THE PHILIPPINES

Ms Rita Bustamante, Programme Officer, Delegation of the European Union to the Philippines, 30/F Tower II, RCBC Plaza 6819 Ayala Avenue cor. Gil Puyat, Makati City 1200, Philippines Tel. No. (632) 8595139. Fax No. (632) 8595179 Email: Rita.BUSTAMANTE@eeas.europa.eu Dr Somvang Bounphaphanh, Technical Staff, National Immunization Programme, Ministry of Health Vientiane, Lao People's Democratic Republic Tel. No. (856-21) 312352, 350067. Fax No. (856-21) 212120; (86-20) 22403642. E-mail: s_somwg@hotmail.com Dr Miyuki Tsuruoka, WHO Fellow, Expanded Programme on Immunization, c/o WHO Representative Office, Hanoi, Viet Nam Tel. No. (844)00203 943-3734. Fax No. (844) 3943 3740 E-mail: tsuruokam@wpro.who.int

MINISTRY OF HEALTH, LAO PEOPLE'S DEMOCRATIC REPUBLIC

WHO VIET NAM

5.

SECRETARIAT

Dr John Ehrenberg, Director, Combating Communicable Diseases, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9701 Fax No. (632) 521-1036. E-mail ehrenbergj@wpro.who.int Dr Sergey Diorditsa, Team Leader, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9745. Fax No. (632) 521-1036. E-mail sergeyd@wpro.who.int Dr David Sniadack, Medical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9748. Fax No. (632) 521-1036. E-mail sniadackd@wpro.who.int Dr Kimberley Fox, Medical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9033. Fax No. (632) 521-1036. E-mail: foxk@wpro.who.int

Dr Yoshikuni Sato, Medical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-89742. Fax No. (632) 521-1036. E-mail: satoy@wpro.who.int Dr Youngmee Jee, Scientist, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-89744 Fax No. (632) 521-1036. E-mail: jeey@wpro.who.int Dr Jorge Mendoza-Aldana, Data Manager, WHO Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9751. Fax No. (632) 521-1036. E-mail mendozaaldanaj@wpro.who.int Dr Yoshihiro Takashima, Medical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9746. Fax No. (632) 521-1036. E-mail: takashimay@wpro.who.int Dr Md Shafiqul Hossain, Medical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9750. Fax No. (632) 521-1036. E-mail: hossains@wpro.who.int Dr Fem Julia Paladin, Medical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9737. Fax No. (632) 521-1036. E-mail: paladinf@wpro.who.int Dr Karen Hennessey, Technical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9034. Fax No. (632) 521-1036. E-mail: hennesseyk@wpro.who.int Dr Xiaojun Wang, Medical Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9747. Fax No. (632) 521-1036. E-mail: wangxia@wpro.who.int Mr Gabriel Anaya, Programme Officer, Expanded Programme on Immunization, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528-9740. Fax No. (632) 521-1036. E-mail: anayag@wpro.who.int Mr Richard Duncan, Technical Officer, Expanded Programme on Immunization, Office of the WHO Representative Office in Cambodia, P.O. Box 1217, Phnom Penh, Cambodia Tel. No. (632) 528-8001. Fax No. (632) 521-1036. E-mail:duncanr@wpro.who.int Dr An Zhijie, Technical Officer, Expanded Programme on Immunization, Office of the WHO Representative Office in China, 401 Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, 100600 Beijing, China. Tel. No. (8610) 6532 7189 Fax No. (8610) 6532 3259. E-mail: anz@wpro.who.int Dr Keith Feldon, Technical Officer, Expanded Programme on Immunization, Office of the WHO Representative Office in Lao People's Democratic Republic, P.O. Box 343, Vientiane, People's Democratic Republic. Tel. No. (856) 21 353902. Fax No. (856) 21 353-905. E-mail: feldonk@wpro.who.int Dr Sodbayar Demberelsuren, Medical Officer, Expanded Programme on Immunization, Office of the WHO Representative Office in Mongolia, Post Box – 663, Ulaanbaatar – 13, Mongolia Tel. No. (976) 11-327870. Fax No. (976) 11-327870. E-mail: demberelsurens@wpro.who.int Ms Maricel Castro, Technical Officer, Expanded Programme on Immunization, Office of the WHO Representative in the Philippines, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, Philippines. Tel. No. (632) 3387479. Fax No. (632) 338 8605. E-mail: castrom@wpro.who.int

Dr Jayaprakash Valiakolleri, Medical Officer, Expanded Programme on Immunization, Office of the WHO Representative in the South Pacific, P.O. Box 113, Suva, Fiji. Tel. No. (679) 3 304600 Fax No. (679) 3 234166. E-mail: valiakollerij@wpro.who.int Dr Kohei Toda, Medical Officer, Expanded Programme on Immunization, Office of the WHO Representative in Viet Nam, P.O. Boz 52, Hanoi, Viet Nam. Tel. No. (844) 3 943-3734 Fax No. (844) 3 943 3740. E-mail: todak@wpro.who.int Dr Jean-Marie Okwo-Bele, Director, Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland. Tel. No. +41 22 79 12779. Fax No. +41 22 791 4193 E-mail: okwobelej@who.int Dr Thomas Cherian, Coordinator, Expanded Programme on Immunization Plus, World Health Organization, Geneva, Switzerland. Tel. No. +41 22 79 14460. Fax No. +41 22 791 4193 E-mail: cheriant@who.int Dr Peter Strebel, Group Leader, Accelerated Disease Control, Expanded Programme on Immunization, Department of Immunization, Vaccines and Biologicals, World Health Organization Geneva, Switzerland. Tel. No. +41 22 79 11338. Fax No. +41 22 791 4193. E-mail: strebelp@who.int

ANNEX 3

DRAFT – APRIL 16, 2012

Action Plan for Achieving and Sustaining Measles Elimination and Accelerating Rubella Control in the Western Pacific Region: 2012-2020

EPI Unit WHO Regional Office of the Western Pacific Manila, Philippines

April 2012

Executive Summary This Plan for Achieving and Sustaining Measles Elimination and Accelerating Rubella Control in the Western Pacific Region: 2012 – 2020 updates the 2010–2020 plan based on evolving epidemiologic and technical developments, updated UN population estimates and a new Global Measles & Rubella Strategic Plan 2012-2020. Unlike the prior plan, it also incorporates the strategies and budget needed to accelerate rubella control in accordance with Regional Committee resolution WPR/RC61.R07. Implementation of measles elimination plans in the Region has resulted in an estimated 98% decrease in measles cases from 1980 to 2011, with an all time low of 21 053 (11.6 per million population) confirmed measles cases in 2011, and a further decrease in annualized incidence to 4.0 during the first quarter of 2012. These decreases are attributable to implementation of the recommended strategies of large scale, wide age-range supplementary immunization activities (SIAs) in 31 countries and areas, and increasing routine coverage with a first and second dose of measles containing vaccine (MCV1 and MCV2) to 98% regionally in 2011. However, routine MCV1 and MCV2 coverage remains low in some countries and at subnational levels in many others, requiring catch-up and/or follow-up SIAs to achieve and/or maintain 95% population immunity against measles. Surveillance performance also has improved regionally, with a discarded measles rate of 2.8 (target ≥ 2) per 100 000 population and 74% of suspected cases with adequate blood specimens (target ≥ 80%). However, many countries and areas need to strengthen surveillance to ensure reporting and investigation of all suspected measles cases and determine the source of virus as imported, import-related or endemic. The measles laboratory network includes 382 laboratories, and demands on laboratory services are increasing . The plan provides a framework for achieving and sustaining the measles elimination goal during 2012 – 2020 and articulates strategies and budgeted activities in the context of the Global Measles & Rubella Strategic Plan 2012-2020. The guiding principle of country ownership is emphasized, while estimated resource needs for SIAs, surveillance, laboratory networks, and other areas requiring partner support are also enumerated. The total 2012 – 2020 budget is US$ 86.6 million, of which US$ 70.9 million (82%) is for SIAs, US$ 8.1 million (9%) is for measles-rubella surveillance and US$ 2.4 million (3%) is for CRS surveillance. The estimates do not include needed activities in China and other countries that may need to conduct supplementary immunization activities such as New Zealand and Singapore. Nor do the estimates include direct support to strengthen routine immunization services. Nearly 80% of the planned budget has donor commitments or is expected to be self-financed: US$35.2 million from GAVI, US$ 30.9 million from self-financing and US$ 2.2 million already committed. This investment in measles elimination and rubella control will contribute to reducing under five mortality and achieving millennium development goal no. 4. Long-lasting benefits for immunization system strengthening will also be realized.

List of Acronyms AD AEFIs DTP4 ELISA GIVS GSL HIB IgM IMCI JRF LabNet M MCV1 MCV2 MDG MM MMR MR NML NRA OPV4 PICs POA PT RC RCV RED RRLs RT-PCR RVC SIAs TAG VIDRL WHO Auto-disable adverse events following immunization fourth dose of diphtheria–tetanus–pertussis vaccine enzyme-linked immunosorbance assays Global Immunization Vision and Strategy global specialized laboratory Haemophilus influenzae type b immunoglobulin M integrated management of childhood illness Joint Reporting Form laboratory network measles first dose of measles containing vaccine second dose of measles containing vaccine millennium development goal measles-mumps vaccine measles, mumps, rubella vaccine measles-rubella national measles-rubella laboratory National regulatory authority fourth dose of oral poliovirus vaccine Pacific island countries and areas Plan of Action proficiency testing Regional Committee rubella containing vaccine Reach Every District regional reference laboratories reverse transcription polymerase chain reaction Regional Verification Commission (for Measles Elimination) Supplementary Immunization Activities Technical Advisory Group Victoria Infectious Diseases Reference Laboratory World Health Organization

Table of Contents 1. Background…………………………………………………………. 2. Definitions for measles elimination and accelerated rubella control and CRS prevention ……………………..…….. 3. Progress to date …………………………………………………… 1

3 4

4. Primary and implementation strategies for measles elimination and accelerated rubella control and CRS prevention …….……………………………………………… 11 5. Managing infectious wastes ……………………………………. 21

6. Benefits to child survival and development……………….…. 22 7. Preparing and updating national plans………………………… 23 8. Regional Office activities……..…………………………...……… 24 9. Financing……………………………………………………..……… 25 Annexes 1. 2. 3. 4. 5. 6. Routine measles vaccination schedules (2011) and coverage (2003-2011), by country and area, Western Pacific Region History of measles supplementary immunization actvities, by country and area, 1994-2012 Measles case classification and incidence, Western Pacific Region, 2011- 2012 Measles surveillance performance indicators, Western Pacific Region, 2011-2012 Estimated budget for proposed measles-rubella SIAs, by country and area, Western Pacific Region, 2012-2020 Estimated budget for case-based measles –rubella surveillance and laboratory network, by country and area, Western Pacific Region, 2012-2020 Summary Budget to Achieve and Sustain Measles Elimination and Accelerated Rubella Control, Western Pacific Region, 2012-2020 Logical Framework to Achieve and Sustain Measles Elimination and Accelerated Rubella Control, Western Pacific Region, 2012-2020

7. 8.

1. Background The World Health Organization Western Pacific Region's 37 countries and areas have been engaged in intensified efforts against measles through "accelerated control" since 1996 and, with Regional Committee (RC) resolution WPR-RC54.R3, "elimination" since 2003. In 2004, the Regional Office published Field Guidelines for Measles Elimination. 1 A second RC resolution in 2005 (WPR-RC56.R8) established 2012 as the target date for measles elimination and the hepatitis B control milestone. 2 In 2010, a 3rd RC resolution reaffirmed the 2012 measles elimination goal; and urged Member States to accelerate the control of rubella and congenital rubella syndrome (CRS) (WPR-RC61.R7). In 2012, WHO Headquarters published the Global Measles & Rubella Strategic Plan 2012-2020. The Strategic Plan articulates the following global goals by end 2015: • •

Reduce global measles mortality by at least 95% compared with 2000 estimates; Achieve regional measles and rubella/congenital rubella syndrome (CRS) elimination goals; and Achieve measles and rubella elimination in at least five WHO regions.

by end 2020: •

The plan also describes five components of a strategy to eliminate measles, rubella and CRS: 1. Achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles- and rubella-containing vaccines. 2. Monitor disease using effective surveillance and evaluate programmatic efforts to ensure progress. 3. Develop and maintain outbreak preparedness, respond rapidly to outbreaks and manage cases. 4. Communicate and engage to build public confidence and demand for immunization. 5. Perform the research and development needed to support cost-effective operations and improve vaccination and diagnostic tools. The plan also articulates four guiding principles to achieve measles, rubella and CRS elimination. 1. Country ownership and sustainability 2. Routine immunization and health systems strengthening 3. Equity 4. Linkages with other health interventions

This action plan is intended to operationalize the Global Measles and Rubella Strategic Plan in keeping with Western Pacific Regional Committee resolutions for measles elimination by 2012 and accelerating rubella control. 2. Definitions for measles elimination and accelerated rubella control and CRS prevention Measles elimination: 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. Endemic measles transmission: the existence of continuous transmission of indigenous or imported measles virus that persists for ≥ 12 months in any defined geographical area. Re-establishment of endemic transmission: occurs when epidemiological and laboratory evidence indicates the presence of a chain of transmission of a virus strain 1 that continues uninterrupted for ≥ 12 months in a defined geographical area where measles had previously been eliminated. Measles outbreak in countries with an elimination goal: 2 when ≥ 2 confirmed cases are temporally related (with dates of rash onset occurring between 7 and 21 days apart) and are epidemiologically or virologically linked, or both. Accelerated rubella control and CRS prevention: the reduction of confirmed rubella to < 10 cases per million population and confirmed CRS to < 10 cases per million live births in the setting of well-performing surveillance systems. 3. Progress to Date 3.1 Routine immunization Reported routine coverage from the Region’s 36 countries and areas that report through the WHO-UNICEF Joint Reporting Form (JRF) indicate that regional MCV1 coverage among 30 countries reporting was 96% in 2011; 21 (70%) of these reported ≥ 90% and 12 (40%) reported ≥ 95% MCV1 coverage (Annex 1). Among 24 countries reporting 2011 district level data, 88% of districts reported ≥ 90% MCV1 and 83% reported ≥ 95% coverage. In 2011, 31 countries and areas were using MCV2; coverage was 91% among 24 countries reporting. Reported MCV2 coverage was ≥ 90% among 13 (54%) and ≥ 95% among 9 (38%) of countries and areas. Cambodia will introduce MCV2 in 2012. 3.2 Supplementary Immunization Activities (SIAs) From 1997-2011, 31 countries and areas conducted one or more SIAs with measles, measles and rubella (MR) or measles mumps and rubella (MMR) vaccines, reaching 359 million children with measles vaccine (Annex 2). SIA coverage has been generally higher since the Region established its 1 A virus strain comprises viruses with N gene (450) sequences that are at least 99.7% identical (1 nucleotide change). 2 This definition may vary across countries

elimination goal in 2003. During 2010 and 2011 alone, 131 million children and adolescents were vaccinated in Cambodia, China, Federated States of Micronesia, Lao People's Democratic Republic, Papua New Guinea, Philippines, Tuvalu and Viet Nam. In many countries and areas of the Western Pacific Region, SIAs have been used to provide vitamin A, oral polio vaccine, anti-helminthics and insecticide treated bednets where needed. 3.3 Rubella containing vaccine use Countries in the Western Pacific Region have used different strategies to introduce RCV including: (1) routine childhood immunization, (2) selective vaccination among young adolescent and susceptible adult females, and (3) incorporating RCV into SIAs. According to WHO-UNICEF Joint Reporting Form (JRF) submissions, as of 2011 RCV was used in combination with MCV during routine immunization in 32 of 37 countries and areas in the Western Pacific Region (Annex 1). RCV has been incorporated into measles SIAs in many countries during the past 10 years. Prior to the 2003 RC resolution to use measles elimination to prevent CRS, from 2000 to 2002, only Republic of Korea and Tonga used RCV (measles-rubella vaccine [MR]) during SIAs in 2001 and 2002, respectively. Tonga's SIA was conducted in response to a large rubella outbreak in which cases of encephalitis were reported. From 2003 to 2011, another ten countries (Cook Islands, Fiji, Guam, Japan, Kiribati, Federated States of Micronesia, Marshal Islands, Niue, Samoa, Tokelau, Tuvalu) conducted 17 SIAs using RCV (Annex 2). Child bearing age women (CBAW) and sometimes men also were targeted with RCV in 9 (53%) of these 17 SIAs. Countries and areas of the Western Pacific Region may be categorized according to population immunity against rubella of female and male birth cohorts based on the historical introduction and scale of different RCV immunization strategies: 1. Sixteen countries and areas with long standing RCV immunization programmes have likely protected female and male birth cohorts up to at least 20 years as of 2010; these include Hong Kong (China), Macao (China), New Zealand, Republic of Korea, Singapore and 11 Pacific island countries and areas (PICs); 2. Five countries that have protected female but not male birth cohorts up to at least 20 years of age by 2010; these include Australia, Brunei Darussalam, Malaysia and two PICs (Cook Islands and Fiji); 3. Four PICs are believed to have introduced RCV more than 10 years ago and protected both female and male birth cohorts up to at least 15 years but under 20 years of age as of 2010: French Polynesia, New Caledonia, Nieue, and Wallis and Futuna; 4. Five countries have introduced RCV more recently, and protected birth cohorts have not yet reached child bearing age (i.e., age 15 years) as of 2012. Among PICs, these include Tokelau, which introduced MR in 1998 (for 12 and 15 month olds) and has likely protected children up to 12 years old, and Nauru, which introduced MR for 12 and 15 month old children in 2006 and has likely protected children up to four years old.

Mongolia introduced measles-mumps-rubella vaccine (MMR) for 9 and 24 month old children in 2009, thereby protecting children up to 5 years. However, previous subnational campaigns likely have protected females up to 43 years old and males up to 26 years old in Ulaanbaatar. China introduced RCV in 2008 and scaled up vaccine production to cover the entire country by 2010 such that children up to four years old are likely to be protected. Philippines began a phased introduction of MMR for 12 month old children in 2009, but conducted an MR SIA targeting children 9 months to 7 years old in 2011 so that in 2012, children up to 8 years old are likely to be protected. 5. Six countries have not incorporated RCV into their routine immunization programmes. These include Cambodia, the Lao People's Democratic Republic, Papua New Guinea, Solomon Islands, Vanuatu and Viet Nam. Among these, the Lao People's Democratic Republic conducted a catch up supplementary immunization activity (SIA) reaching 2.7 million persons 9 months to 19 years old (97% of target) with measles-rubella (MR) vaccine in November 2011, and will introduce routine MR in 2012. Cambodia and Viet Nam will apply for GAVI funding in 2012 to conduct an MR catch up SIA in 2013 to be followed by routine MR introduction, and PNG will apply to GAVI in 2013 to conduct a planned catch-up SIA in 2014 followed by routine introduction. Both Solomon Islands and Vanuatu are conducting MR SIAs in 2012. 3.4 Epidemiologic surveillance Surveillance performance quality can be monitored through indicators. In December 2010, WHO published recommendations on monitoring progress toward measles elimination and included surveillance performance indicators. 3 Similar indicators by country and area are published monthly in the Measles & Rubella Bulletin and have been since September 2007 4. Table 1 lists the key indicators, targets, and regional results. Table 1: Indicators of Progress Towards Measles Elimination, Western Pacific Region 2007-2012¹ Category Incidence (per million population) Confirmed measles cases (confirmed by lab, epidemiologic linkage or clinically) High Quality Surveillance National reporting of discarded measles cases % of 2nd level admin units reporting ≥ 1/100 000 discarded measles cases % of suspected cases with adequate investigation % of suspected cases with adequate blood specimens Proportion of clinically confirmed measles cases High Population Immunity National MCV1 coverage National MCV2 coverage > 95% > 95% > 2 per 100 000 > 80% > 80%

Target

2007

2008

2009

2010

2011

2012* (annualized)

Percent of countries meeting target (2011)

73.7

81.6

34.0

27.0

11.6

4.0 N=17

2.5 31% 13% 65%

1.6 27% 29% 62% 48%

2.8 43% 25% 72% 25%

1.7 38% 72% 71% 35%

2.8 52% 63% 73% 27%

1.5 17% 81% 84% 17%

53% 41% 12% 53% 29%

> 80%

83% <10%

92% 86%

93% 88%

96% 94%

97% 91%

96% 91%

¹ Data from reports received through April 2012

Source: WPRO surveillance database

3.5 Congenital rubella syndrome surveillance CRS surveillance is not conducted extensively in the Western Pacific Region and therefore the magnitude of congenital rubella syndrome (CRS) in the WPR is not precisely known. Until recently, slightly more than half of the 36 countries and areas submitting JRF reports indicated the existence of national CRS surveillance systems. CRS surveillance was initiated recently in Viet Nam and Cambodia. In Viet Nam, 161 confirmed CRS cases were identified from three sentinel during July – December 2011; 158 of these were laboratory-confirmed. In Cambodia, 20 suspected CRS cases were identified from two sentinel sites during September 2011 – February 2012. A study to assess the global burden of CRS using mathematical modeling estimated that a mean of 12 600 CRS cases (range 1500 – 21 400 cases) likely occurred in the Western Pacific Region in 1996 *. Increasing use of RCV since then would have led to a decrease in CRS incidence. Given the large percentage of rubella cases among young adult women in several Western Pacific Region countries, that up to 90% of rubella infections occurring in the first trimester of pregnancy may result in a baby born with CRS, and the early results of CRS surveillance in Viet Nam and Cambodia, the magnitude of unrecognized or unreported CRS is likely to be great. 3.6 Laboratory The Western Pacific Region measles and rubella laboratory network (LabNet) performs critical functions for measles elimination by confirming or discarding suspected measles cases, identifying measles genotypes, and helping to determine potential geographic routes of transmission. The LabNet includes 382 laboratories, including one global specialized laboratory in Japan, three regional reference laboratories (RRLs) in Australia, China, and Hong Kong, 16 functional national measles-rubella laboratories (NMLs) and, in China, 31 provincial and 331 prefecture laboratories. Regional Office Laboratory Support The Regional Office has provided extensive support to build and maintain a high quality measles-rubella laboratory network. Labnet meetings have been organized periodically to review and discuss progress and challenges and to share updated information. Regional and subregional hands-on training courses have been conducted to update and maintain laboratory technical skills in enzyme-linked immunosorbance assays (ELISA), cell culture and reverse transcription polymerase chain reaction (RT-PCR) assays. In addition, China CDC also has hosted annual workshops for measles laboratories for the 331 prefectural and 31 provincial CDCs. Laboratory Accreditation Quality assurance for network laboratories is conducted through an annual accreditation process. Seven criteria for accreditation of NMLs include 1. Results are reported by the laboratory on at least 80% of samples for Cutts FT, Vynnycky E. Modelling the incidence of congenital rubella syndrome in developing countries. Int J Epidemiol 1999; 28:1176-84. *

measles immunoglubin M (IgM) tests within 7 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%. 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 2 months of receipt of specimen and data are reported to WHO monthly, for ≥80% of the samples appropriate for genetic analysis. 7. The score from the annual on-site review of laboratory operating procedures and practices is at least 80%. Accreditation for WHO RRLs for measles and rubella is also conducted using similar and additional criteria. As of April 2012, among 48 fully functional measles network laboratories including 31 provincial laboratories in China, 47 are fully accredited based on site review by WHO. All network laboratories in the Region passed the proficiency test in 2011 and confirmatory testing has been implemented by all NMLs in the Region. In 2011, concordance rates of confirmatory testing results of samples from almost all NMLs were >90% for both measles and rubella. Laboratory Workload The LabNet tests a large number of specimens annually. In 2011, Western Pacific Region network laboratories (not including laboratories in China and Japan) tested 21 135 samples for measles immunoglobulin M, 16586 samples for rubella immunoglobulin M, and 4822 samples for virus detection. 3.7 Incidence reduction The Regional Office has collected data on measles cases reported from Member States annually at least since 1980. From 1980 to 2011, the number of measles cases reported from all countries and areas in the Region decreased by 98% from 1 322 000 to 21 048. Implementation of measles elimination plans in Member States, particularly Cambodia, China, Japan, the Lao People's Democratic Republic, Papua New Guinea, the Philippines, and Viet Nam, dramatically reduced the number of measles cases and incidence from 82 per million population in 2008 to just 4 per million in 2012 (annualized for data reported through April) (Figure 1).

Figure 1: Confirmed Measles Cases, by Month of Onset and Country, Western Pacific Region 2007—2012* 35,000

National SIAs conducted 30,000 CAM PHL LAO PNG

National SIAs conducted JPN PNG CHN VTN CAM PHL CAM LAO

25,000

Number of cases

20,000

15,000

10,000

5,000

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2007 2008 2009 2010 2011 2012

CHN

JPN

PHL

VTN

others

* Source: WPRO measles-rubella monthly country reports as of April 2012

3.8 Genotype findings and importations At a minimum, measles virus strains endemic to the Western Pacific Region in 2007 included D5, D9 and H1. However, D5 has not been detected in the Western Pacific Region since May 2010. In 2011, 192 measles cases were identified with measles genotype D9 from nine countries in the Region, 188 cases were infected with the measles H1 genotype in 6 countries and areas. Measles genotype D4 was identified from 105 cases in four countries, although at least 38 of these were reported as imported or import-related cases. Genotype D8 was identified from 55 cases in 7 countries and areas; at least 34 of these were reported either as imported or import-related. G3 was identified from 3 cases, each in a different country. D11 was identified once in China. 3.9 Present Status During the first 3 months of 2012, 26 countries and areas reported annualized measles incidence ≤ 1 per million, three (China, Hong Kong [China], Japan) reported 1–4.9 per million, and two (Macao [China], Philippines) reported 5–9.9 per million (Annex 3; Figure 2). Among the four remaining countries, Singapore reported an incidence of 11, New Zealand 33, the Lao People's Democratic Republic 38 and Malaysia 78 per million.

Figure 2: Measles Incidence,* Western Pacific Region 2012

* per million population

LEGEND: < 1.0 (26) 1.0 – 4.9 (4) 5.0 – 9.9 (2) 10.0 – 19.9 (1) 20.0 – 29.9 (0) 30.0 – 39.9 (2) 40.0 – 49.9 (0) ≥ 50.0 (1) Source: WPRO measles-rubella monthly country reports as of April 2012

Annualized Incidence = 4.0

Global perspective The Western Pacific Region, with 1.8 (26%) of the world's 6.8 billion inhabitants, plays a critical role in what has become an increasing global initiative of regional measles elimination. Five WHO Regions, and 10 of 11 countries in the South East Asia Region have measles elimination goals. The Western Pacific is the Region most likely to eliminate measles following the American Region's successful elimination of measles in 2002. The experience of importations into the American Region and, increasingly, into the Western Pacific Region, suggest that our Region has much to benefit from elimination in other Regions and eventually, global eradication, so that importations and import-related transmission ceases. Success in the Western Pacific Region will be an important catalyst to regional elimination elsewhere and global eradication. 4. Primary and implementation strategies for measles elimination and accelerated rubella control and CRS prevention 4.1 Primary strategies The primary strategies for achieving measles elimination remain 1. achieving very high (≥ 95%) vaccination coverage with a first and second dose of measles containing vaccine (MCV1 and MCV2) administered either through routine or supplementary immunization activities (SIAs); 2. sensitive and timely case-based measles surveillance; 3. utilization of an accredited measles laboratory network to confirm or discard suspected measles cases and detect measles virus genotypes and molecular structure. In addition, as noted in the Global Measles & Rubella Strategic Plan 2012-2020, outbreak preparedness and response, communication and demand creation, and research are also important components in an overall strategy to achieve and sustain measles elimination and rubella control or

elimination. The preferred approaches for accelerating rubella control and CRS prevention, and eventually eliminating rubella and CRS, are 1. providing rubella containing vaccine (RCV) in a wide-age range campaign, targeting age groups predominantly affected, followed immediately with introduction of at least one dose of RCV in the routine programme; MR or MMR vaccine should be used in any follow up SIA; 2. selective immunization for childbearing age women (CBAW); 3. integrating rubella with case based measles surveillance and establishing surveillance for CRS before or at the start of RCV introduction to provide baseline information and document the impact of the vaccination program; 4. integrating rubella into the accredited measles laboratory network, ensuring availability of laboratory testing of all reported cases of suspected measles and rubella and all reported cases of suspected CRS. For elimination, laboratories also will need to detect rubella virus genotypes and molecular structure. MCV and RCV may include measles, mumps, rubella, varicella (MMRV), measles, mumps, rubella (MMR), measles-rubella (MR), measles-mumps (MM) or single antigen monvalent measles (M) or rubella (R) vaccines. 4.2 Implementation strategies 1. Achieve and maintain 95% population immunity 1.1. Improve routine MCV1, MCV2 and RCV coverage 1.1.1. Use a combination of approaches A combination of fixed site, outreach, and mobile strategies often are required to reach children of different socio-economic backgrounds and geographic locations with all vaccines by their first birthday and beyond. Targeted multi-antigen activities such as child health weeks may also be useful. Additional approaches may involve other sectors such as schools, universities, military installations and factories for different age groups. Innovative approaches should be developed based on local circumstances. 1.1.2. Adopt school entry requirements A school entry requirement for a completed immunization series, especially against highly communicable diseases such as measles, rubella and pertussis, 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. 1.1.3. Expand vaccination beyond traditional age groups Population immunity profiles evolve over time depending on year of MCV1, MCV2 and RCV introduction into routine immunization

schedules, annual coverage since introduction, immunization of targeted age groups during large scale measles and rubella SIAs, and the extent of large scale measles epidemics. Targeted approaches for adolescents and adults that have not acquired natural immunity and have never received two doses of measles containing vaccine also may be needed if epidemiologic data point to transmission in older age groups. 1.1.4. Reach every district (RED) at least four times per year The “RED” approach involves five operational components: regular outreach services, supportive supervision with on the job refresher training, community linkages for service delivery, monitoring and use of data for action (e.g., identification and vaccination of drop-outs, microplanning, and mapping) and better planning and management of human and financial resources. 1.1.5. Strengthen supply chain management systems Accurate demand forecasting and stock management for vaccines, injection equipment and supplies at district, provincial and national levels is critical for providing uninterrupted immunization services and avoiding preventable spoilage and wastage. Appropriate temperature maintenance of heat-sensitive and cold-sensitive vaccines, and keeping light-sensitive vaccines away from sunlight should be assured. 1.1.6. Increase community demand 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 delivery of safe immunization services is also important to build trust among parents and the greater community. 1.1.7. 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 (AEFIs) should be able to identify and correct program errors and ensure programme credibility to the public. Auto-disable (AD) syringes and safe disposal of used needles and syringes should be ensured. 1.1.8. Evaluate national immunization programs 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. 1.2. Optimize MCV1, MCV2 and RCV schedules to maximize protection Recommendations for optimal routine MCV1 and MCV2 schedules are included in the latest WHO measles position paper published in 2009 and are summarized here. 5 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 that are near elimination) in which infants have a low risk of infection. MCV2 should be administered at age 15–18 months, particularly in countries and areas providing MCV1 at 9 months. MCV2 may be administered as late as school entry if o the country or area has low rates of measles transmission (i.e., is close to elimination o MCV1 is administered at 12 months or later o MCV1 coverage is at least 90% o School enrolment is high (>95%) (if given at school entry) Providing routine MCV2 to children at 15-18 months or during the second year of life reduces the rate of accumulation of susceptible children and the risk of outbreaks; it also provides a platform for administration of other vaccines such as fourth dose of diphtheria-tetanus-pertussis vaccine (DTP4), and fourth dose of Haemophilus influenzae type B (HIB), vitamin A administration, de-worming medicines, child health monitoring, and other health interventions. Combining such a two dose schedule with a school entry requirement for fully immunized children would achieve maximum population immunity at an early age, facilitate creation of an integrated disease prevention and health promotion platform, and effectively minimize the risk of measles virus circulation. RCV, because of its high immunogenicity and vaccine efficacy even at 9 months of age, may be given as a single dose with either MCV1 or MCV2. However, many countries prefer to give a 2-dose schedule in combination with measles for programmatic simplicity. Providing RCV to child bearing age women provides rapid protection against rubella infection during pregnancy. 1.3. High quality SIAs for children when inadequate MCV1 and MCV2 coverage allows accumulation in numbers of susceptible children greater than the size of one birth cohort. While many factors influence the probability and extent of outbreaks, planning to conduct follow-up SIAs before the number of susceptible children reaches the critical size of one birth cohort has been found to be programmatically useful and sufficiently accurate to prevent large

outbreaks and is also recommended in the WHO position paper on measles.10 1.4. Targeted high quality SIAs for adolescents and adults, when indicated, based on epidemiologic data Measles epidemiology evolves over time. Several countries in our Region including China, Japan, and Viet Nam have discovered that after substantially reducing measles virus transmission among children, outbreaks may occur involving to a large extent susceptible adolescents and young adults. While the role of adults in potentially sustaining measles virus transmission is not well defined, high quality SIAs (either through campaigns or routine systems) targeting adolescents and adults at high risk, such as students, health workers, transportation and hospitality workers, military and others living or working in communal settings, may be needed in some countries to finish the job of measles elimination and prevent rubella transmission. Wider age range SIAs also provide opportunities of addressing accelerated rubella control and prevention of congenital rubella syndrome. 1.5. Special immunization approaches against Rubella 1.5.1. Immunization approach #1 - for countries with long-term rubella vaccination programs or that have conducted national, wide age-range SIAs such that female birth cohorts through 20 years of age or older are protected against rubella as of 2012: Continue to maintain high vaccination coverage in the routine childhood program; assess susceptibility in CBAW to determine if additional CBAW strategies are needed 1.5.2. Immunization approach #2 - for countries that have protected both female and male birth cohorts up to at least 15 years but under 20 years of age as of 2010: SIAs targeting susceptible age groups or special routine strategies targeting older teenagers may be necessary to achieve coverage of all persons <20 years old, depending on a careful epidemiologic analysis of rubella cases 1.5.3. Immunization approach #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: If routine MCV1 coverage has been ≥ 80% for three consecutive years or if recent measles SIA coverage was ≥ 80%, provide RCV through a wide age range SIA (ideally up to 19 years of age) to rapidly increase population immunity followed by routine RCV introduction into the routine immunization program. 1.5.4. Additional Immunization approaches 1.5.4.1. for countries and areas with susceptible CBAW: Vaccinate CBAW of any age with RCV at convenient times (e.g., pre-marital vaccination, post-partum, when bringing newborn children for vaccination) 1.5.4.2. for all countries and areas:

Ensure immunity in health care workers to prevent nosocomial transmission of rubella 2. Conduct high quality case-based measles and rubella and CRS surveillance 2.1. Review and modify surveillance systems, including case investigation forms, if needed to ensure sensitive, timely, and complete case-based reporting throughout the country Countries and areas should aim to establish elimination-standard case-based measles and rubella surveillance supported by accredited national measles laboratories. Elimination-standard surveillance should be able to identify all suspected measles cases and should satisfy recommended performance indicators to validate high quality. Expansion of reporting sites to local level facilities and private sector providers is needed to identify all suspected measles cases; case investigation forms may need to be redesigned to ensure appropriate data collection and analysis. Case investigations should include a thorough search for additional cases among contacts and other potentially exposed persons. Good epidemiologic investigations are critical to identify cases (and virus) as imported, import-related, endemic or of unknown source. 2.2. Establish and/or expand CRS surveillance CRS surveillance is useful to document the impact of rubella vaccination and to help ensure that high-quality medical services are provided for children with disabilities. Sentinel surveillance is 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 centers) to increase the sensitivity of the surveillance system. Identification and aggressive follow-up of pregnant women that are suspected rubella cases or contacts of suspected cases should be a priority. Tools may be developed to help the identification of and response to suspected CRS 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. CRS surveillance should be enhanced following outbreaks of rubella regardless of level of national rubella control. 2.3. 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 2.4. Conduct intersectoral advocacy, social mobilization and program communication to ensure detection and investigation of cases of all ages. Representatives from ministries of education, defense, and labor as

well as individual schools & universities, military installations, and factories are all logical partners interested in measles elimination and can help identify and report suspected measles cases. 2.5. Provide adequate operational resources to ensure case investigation with collection and transport of specimens for case confirmation and virus detection Travel and daily allowances should be provided for case investigations, additional case finding and outbreak response. Specimen shipping containers and costs should also be provided. 2.6. 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. 2.7. 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, program units, and laboratory staff to ensure up to date and uniform knowledge and agreement of measles case classification. 3. Ensure high quality laboratory performance 3.1. Annual accreditation of NMLs and RRLs/global specialized laboratory (GSL) Accreditation of NMLs is conducted annually and accreditation status is given according to seven criteria (see section 3 above) of the WHO checklists for NMLs and six criteria for RRLs/GSL based on laboratory performance during the immediately preceding 12 months. Among these seven NML criteria, three criteria involve external verification procedures including: (1) on site review score using the WHO accreditation checklist, (2) annual proficiency testing, and (3) concordance of confirmatory testing results from RRLs. o On site reviews All laboratories are assessed annually using standardized WHO checklists. However, the Regional Laboratory Coordinator laboratories may waive annual onsite reviews for NMLs with consistently high accreditation scores and conduct these every 2–3 years instead o Annual proficiency testing

WHO provides proficiency testing (PT) samples with unknown samples for IgM ELISA to all network national laboratories. VIDRL, Australia produces PT samples fro all six WHO regions including the Western Pacific Region. From 2009, PT samples have been also provided to 31 provincial laboratories in China. All laboratories should report the final results to VIDRL and then submit their testing results to WHO and VIDRL within 14 days after the receipt of samples. A score of at least 90% is required to pass PT. o Regular confirmatory testing NMLs should send approximately 10% of tested samples for measles and rubella to RRLs once or twice each year for confirmatory testing. The actual number and frequency of samples to be sent for confirmatory testing to RRL may vary based on the number of samples and should be coordinated with the Regional Laboratory Coordinator. Confirmatory samples should include positive, equivocal and negative samples. Concordance rates of ≥ 90% is required for accreditation. 3.2. Case-based laboratory reporting from each national measles/ rubella laboratory (NML) to the Regional Office on a monthly basis NMLs should submit the case based line list report for measles and rubella laboratory data 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 regional office is monitored

3.3. Adequate operational support for supplies, equipment, and specimen transport costs Financial support is provided to priority countries in the Region for consumables (including testing kits), operational and shipping costs, and laboratory equipment. 3.4. Technical and logistics support to 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. 3.5. Meetings, workshops and hands on training 3.6. Regular updates of laboratory performances to achieve measles elimination goal will be provided to network laboratory members by organising meetings and workshops. Further hands on training courses for measles virus identification by molecular techniques will be also provided as needed. 4. Outbreak preparedness and response Timely and thorough case and outbreak investigations with contact tracing,

laboratory confirmation of suspected cases and detailed analysis of available measles/rubella surveillance data help to characterize outbreaks for an effective response. WHO has developed guidelines for measles outbreak investigation and response in mortality reduction settings that are also applicable to elimination settings, 6 except that the definition of outbreak size in elimination settings is smaller. In elimination settings, a single measles case may indicate the presence of an outbreak requiring a rapid investigation and response. However, the approach to outbreak response immunization (ORI) varies depending on the level of susceptibility in the population at different ages, the risk for spread and complications, and the existing health-service infrastructure. Small, localized self limited outbreaks have occurred in some countries (e.g., the Philippines) following nationwide SIAs, with many cases occurring among young adults and infants. ORI was not conducted, and transmission was limited to a few generations (2-3 months). Transmission continued, however, in areas where children represented a larger proportion of cases. A rapid district and/or provincial risk assessment by age group in response to two or more laboratory-confirmed or epidemiologically linked measles cases would provide valuable information in determining the timing and extent of ORI. Outbreak preparedness should include a plan for locally-funded outbreak response and provision of vaccine stocks for emergency use. Risk or vulnerability assessments may be conducted periodically that assess population immunity, surveillance performance and migration patterns. Ideally, supplementary immunization interventions would 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 and supportive care at the first referral level, including additional fluids (such as oral rehydration solution), antipyretics and, when appropriate, antibiotics and referral to the next level of care. During and following rubella outbreaks, countries not yet using rubella vaccine should implement active CRS surveillance, with special attention paid to evaluating the rubella immunization status of pregnant women with suspected rash illness. In countries using rubella vaccine, additional measures should be undertaken such as investigation and vaccination of contacts to reduce the risk of exposure to pregnant women. 5. Communication and demand creation Communication and social mobilization efforts aim to foster community ownership and demand for immunization, to increase coverage and to help achieve measles, rubella, and CRS goals. Vaccinating over 95% of the target population against measles and rubella requires well-conceived, professionally implemented communication strategies linked directly to

programme goals. A renewed emphasis should be given to effective communication and public engagement with parents, health professionals, community leaders and the media, to gain their trust, understand and address vaccine concerns and support vaccine acceptance. 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 AEFIs. 6. Research and development Research helps define strategies and shapes evidence-based policy. Research areas of interest include measles, rubella and CRS epidemiology; assessing vaccine efficacy and effectiveness; needle-free vaccine-delivery methods (e.g. aerosolized or powdered vaccines inhaled through the respiratory tract); improved methods for laboratory testing for measles, rubella and CRS; new immunization strategies; improved methods to monitor and evaluate measles and rubella vaccination programmes; effective advocacy tools to use with decision-makers; optimal messages and strategies to communicate with potential beneficiaries and their families; economic analyses of different strategic options; and mathematical modelling. 7. Strengthen linkages 7.1. Establish and/or strengthen national coordination and advisory bodies for measles elimination that includes government, non-government, bilateral and international partners. In addition, the early establishment of a national verification committee (NVC) for measles elimination will provide guidance and advocacy for measles elimination. Members of existing interagency coordinating committees and advisory bodies would be logical members of measles elimination coordination and advisory bodies. Members of national certification committees for polio eradication could also be recruited to serve on NVCs. Terms of reference should be explicitly described; meeting minutes with action points specifying responsible persons and timelines should be prepared and distributed after every meeting. 7.2. Improve management of human resources at all levels Monitoring of human resource capacity and availability is an important component of overall program monitoring, particularly if frequent staff turnover exists. Extensive collaboration with other program units is important to effectively plan capacity building and efficiently utilize available staff at all levels. 7.3. Identify and utilize synergistic linkages of integrated program efforts Maternal and child health programs, 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 programs is likely to be necessary to achieve complementary programme objectives and may promote programme synergies. 7.4. Jointly prepare and/or update national plans to achieve and sustain measles elimination and accelerated rubella control beyond 2012 that include these implementing strategies in close collaboration with all partners. Operational/work plans are necessary to translate ideas into action, to strengthen collaborative mechanisms with other programmes and partners, and for effective resource mobilization from government and partners. National immunization programs and Ministry of Health officials need to play a leading role in advocating to high level government officials and partners for the human and financial resources required to achieve measles elimination and accelerate control of rubella and CRS prevention. 5. Managing infectious waste Measles and rubella SIAs generate large amounts of infectious waste. The safe and sustainable management of health system waste is a public health imperative and a responsibility of all. Improper management of infectious waste poses a significant risk to patients, health-care workers, the community and the environment. The WHO core principles1 require that all associated with financing and supporting health-care activities should provide for the costs of managing health-care waste. Measles elimination activities provide opportunities to establish or strengthen systems for health-care waste management. WHO recommends that governments:  allocate a budget to cover the costs of establishment and maintenance of sound health-care waste management systems;  request donors, partners and other sources of external financing to include an adequate contribution towards the management of waste associated with their interventions; and  implement and monitor sound health-care waste management systems, support capacity building, and ensure worker and community health. 6. Benefits to child survival and development An investment in measles elimination provides multiple benefits to child survival in addition to decreased morbidity and mortality from measles. The WHO/UNICEF Western Pacific Regional Child Survival Strategy identifies measles immunization coverage as one of the core indicators to track progress in child survival, and integrated management of childhood illness (IMCI) protocols seek to utilize opportunities to provide MCV and other vaccines to children presenting to health facilities. Measles elimination contributes to achieving millennium development goal (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 1

These core principles were developed during the International Health Care Waste meeting hosted by WHO in Geneva on June 20 - 22, 2007.

"proportion of 1 year-old children immunized against measles." Benefits provided by measles elimination are many. First, prevention of measles infection prevents the increased susceptibility to and mortality from pneumonia and diarrhea that lasts for months following infection. Diarrhea and pneumonia cause 36% of deaths among children under 5 years old globally, and 31% of all under five deaths in the Western Pacific Region. Second, the need to achieve 95% coverage with two doses of MCV requires program managers at every level to re-focus efforts on strengthening routine immunization service coverage and quality using strategies recommended in the Global Immunization Vision and Strategy. Third, administering a second dose of measles vaccine at 15-18 months of age creates a platform for other interventions such as DTP4, OPV4, vitamin A, de-worming medicine, and growth monitoring. Fourth, provision of nutritional supplements such as vitamin A with routine MCV1 and during SIAs provides additional protection of children against disease. Fifth, 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 overall, thereby strengthening health systems. 7. Preparing and updating national plans National plans should outline the necessary immunization and surveillance activities and required resources to achieve and sustain measles elimination. Strategic plans may be used to guide incorporation of measles specific activities and resource needs in other planning documents such as: (1) (2) (3) costed multi-year plans for EPI; detailed EPI implementation/operational plans (with budgets) that include multiple health and other sectors, and annual immunization (EPI) work plans.

In developing and/or updating national plans for measles elimination, the following activities or items may be included: For immunization only: (1) (2) (3) (4) (5) (6) Vaccines, syringes, needles and safety boxes (routine and SIAs) Waste disposal (routine and SIAs) Implementation of MCV2 Implementation of school entry requirements Travel and daily allowance for case investigation, contact tracing, and CRS follow up National measles-rubella laboratory supply, equipment and operational needs

For surveillance only:

For both immunization (routine and SIAs) and surveillance: (7) (8) (9) Cold chain and reverse cold chain and logistics needs Operations and service delivery AEFI investigations and response

(10) Training and re-training costs for immunization, surveillance and laboratory (11) Monitoring and supervision (12) Advocacy, social mobilization and communication Plans should carefully determine required resources for these component activities, where programmatic activities and funding sources may be integrated, what residual financial shortfalls remain and potential funding mechanisms for these. Clearly defined mechanisms and opportunities for collaboration with government and nongovernment sectors and with bilateral and international partners should be included. 8. Regional Office activities The Regional Office will continue to provide technical assistance to countries in support of their efforts to eliminate measles by 2012 and maintain elimination thereafter. Specific assistance will be provided as needed to support routine and supplementary immunization activities and epidemiologic and laboratory surveillance through on-site visits, electronic communication, and periodic training workshops or technical consultation meetings. The Regional Office will coordinate regional epidemiologic and laboratory surveillance data management to monitor regional and country-specific progress toward achieving and sustaining measles elimination and rubella control and provide feedback to Member States through electronic publications and direct correspondence. The Regional Office will conduct advocacy and resource mobilization efforts at the regional level while country offices and national counterparts do so at the national level. Verification of measles elimination will be conducted by an independent Regional Verification Commission for Measles Elimination (RVC), supported by individual national verification committees (NVCs). The Regional Office will serve as secretariat to the RVC. 9. Financing Eliminating measles from the Region will have substantial health and economic benefits for all countries. As Member States have committed to achieving the goal and will derive the greatest direct benefits from measles elimination, country ownership is essential to ensure that whatever activities are required to achieve the goal are financed and implemented well. Existing external financial support structures (e.g., GAVI, Global Fund, Pandemic Preparedness resources, etc.) may be useful, especially in regard to fulfilling common objectives of strengthening health and immunization services and improving the surveillance infrastructure. Additional funding for priority countries and areas with relatively limited economic resources will be needed to help finance special interventions for measles elimination such as SIAs and

surveillance. Additional funding will be required to improve sensitivity and timeliness of case based measles surveillance and the measles laboratory network so that foci of residual or new transmission of measles virus are quickly identified and eliminated, incidence is accurately measured, source of virus as imported, import-related or endemic is accurately determined and standard indicator targets of surveillance performance are achieved. Annexes 5-6 list expected activities, timeframes and estimated budgets for SIAs, surveillance, laboratory activities and training, by year, through 2020. Annex 7 is a summary budget (repeated in Table 2 below) that also includes outbreak response, CRS surveillance, RCV introduction, communication, research, technical support and verification in priority countries, also by year through 2020. Population estimates were based on United Nations Population Division estimates, 2010 revision. Development of more detailed national plans and budgets may lead to revisions in activities, timeframes and estimated budgets. Partner support is requested to partially fund these needs to achieve and sustain measles elimination and accelerate control of rubella and CRS prevention. A draft logical framework that can be adapted for the national level is provided in Annex 8. Detailed explanations of the plans and budgets follow. Annex 5 Timing of follow-up SIAs was based on current needs to interrupt transmission and the need to prevent the accumulation of susceptible children from reaching the threshold size of one birth cohort. Numbers of susceptible children were estimated based on routine MCV1 and MCV2 and SIA coverage data as reported by countries and areas in the JRF. SIA costs include bundled MR vaccine (i.e., vaccine, injection equipment and safety boxes) estimated at US$ 0.65 per targeted child and operational costs at US$ 0.63 per targeted child. Operational costs include social mobilization and communication, training, cold chain and logistics, travel and daily allowances for vaccination teams, supervision and monitoring (including rapid coverage assessments), and infectious waste disposal costs in accordance with WHO core principles. For PICs, estimated operational costs were increased to US$ 4.50 per child because of the numerous islands to be visited and experience from prior SIAs. In 2012, SIAs are expected in Malaysia, Papua New Guinea, Solomon Islands, and Vanuatu. China is also expected to conduct multiple subnational SIAs in areas of residual virus transmission, but its budget for these activities is not reflected in Annex 5 because of uncertainty regarding the scope and target number involved. PNG's SIA will be the last SIA in the Region expected to use monvalent measles vaccine (budgeted at $0.37 per targeted child). In 2013, Cambodia and Viet Nam are expected to conduct a catch up MR SIA largely funded by GAVI, and follow up SIAs are expected in Kiribati and Samoa. In 2014, PNG is expected to conduct a catch up MR SIA largely funded by GAVI, and Federated States of Micronesia may conduct a follow up SIA. In 2015, the Lao People's Democratic Republic and the Philippines are expected to conduct follow up SIAs four years after their

previous campaigns were conducted in 2011. Countries expected to conduct SIAs and their respective budgets during 2016 – 2020 are listed in Annex 5. Annex 6 Surveillance and laboratory needs were estimated assuming that countries report four suspected measles cases per 100 000 in 2012 and 2013 and two per 100 000 thereafter. Current national per diem rates were used to calculate case investigation costs. Shipping costs were determined from rates of national couriers and assumed that specimens would be collected from 80% of reported suspected cases. Laboratory costs were estimated based on the average number of specimens per week that would require testing for measles and rubella and the 2011 costs for measles test kits, rubella test kits, and supplementary reagent kits from Siemens plus 30% for airfreight and insurance costs. We estimated a maximum of 88 specimens tested per kit (each kit has two plates of 96 wells each; two wells are required for each specimen and eight wells are required for controls for each run), and a minimum of four specimens per week (each plate can be divided into six strips with 16 wells each), keeping in mind the need to determine laboratory results within 7 days of specimen receipt. Also included in the laboratory costs was the need to ship a proportion of specimens to regional reference laboratories (RRLs) every 6 months. RRL costs in Australia, China and Hong Kong were determined based on expected amounts of services to be supplied to national measles laboratories. Training costs for national health staff assumed two-day training in 2012 for 2 persons per second administrative level and for two persons per third administrative level, and two-day refresher training in 2013; national two-day surveillance review meetings for the same participants would be conducted during years when training is not provided and is included in the budget. Standard per diem and expected travel costs specific to each country as reported by WHO country staff were used to estimate training costs. Laboratory training needs are listed separately. Additional information is included the spreadsheet. Annex 7 The total estimated budget includes SIAs, outbreak response, measles-rubella surveillance (including laboratory networks), CRS surveillance, RCV introduction costs, communication, research, technical support and verification. Table 2 below is a copy of Annex 7. Monitoring and supervision costs for routine immunization and surveillance are not included. Table 2: Estimated resource needs to achieve and sustain measles elimination and accelerate rubella control and CRS prevention in priority countries, Western Pacific Region, 2012-2020 2012-2015 SIA Outbreak response MR Surveillance CRS Surveillance RCV Introduction Communication Research 2012 $6,250,778 $717,153 $1,050,322 $151,000 $80,785 $50,000 $500,000 2013 $30,600,804 $26,276 $1,044,360 $181,200 $193,381 $50,000 $50,000 2014 $3,522,937 $42,903 $867,694 $211,400 $831,377 $50,000 $50,000 2015 $13,317,267 $0 $858,104 $241,600 $123,164 $50,000 $50,000

Tech Support Verification Total 2016-2020 SIA Outbreak response MR Surveillance CRS Surveillance RCV Introduction Communication Research Tech Support Verification Total SUMMARY SIA Outbreak response MR Surveillance CRS Surveillance RCV Introduction Communication Research Tech Support Verification Total

$200,000 $300,000 $9,300,038 2016 $0 $860,300 $271,800 $50,000 $50,000 $50,000 $50,000 $1,332,100 2012-15 $53,691,786 $786,332 $3,820,481 $785,200 $1,228,707 $200,000 $650,000 $550,000 $550,000 $62,262,506

$150,000 $100,000 $32,396,021 2017 $1,641,531 $862,432 $302,000 $50,000 $50,000 $50,000 $50,000 $3,005,963 2016-2020 $17,117,522 $4,323,724 $1,661,000 $0 $250,000 $250,000 $450,000 $250,000 $24,302,246

$100,000 $75,000 $5,751,311 2018 $1,230,292 $864,611 $332,200 $50,000 $50,000 $100,000 $50,000 $2,677,103 2012-2020 $70,809,308 $786,332 $8,144,205 $2,446,200 $1,228,707 $450,000 $900,000 $1,000,000 $800,000 $86,564,752

$100,000 $75,000 $14,815,135 2019 $14,245,699 $867,019 $362,400 $50,000 $50,000 $200,000 $50,000 $15,825,118 2020 $0 $869,361 $392,600 $50,000 $50,000 $50,000 $50,000 $1,461,961

SIAs and MR surveillance costs were explained for Annexes 5 and 6. Although the nature of ORI depends on the epidemiology of the outbreak, ORI costs were estimated at 5% of the national population <5 years old. We assumed the Philippines would need to conduct ORI in 2012, Mongolia and Fiji in 2013 and the Lao People's Democratic Republic in 2014. We did not anticipate ORI costs beyond 2014. As Cambodia, PNG and Viet Nam will be conducting catch up MR SIAs in 2013 and 2014, we assumed these countries would not conduct ORI. CRS surveillance costs were estimated based on current support provided by WHO for sentinel site surveillance in Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam, with progressive expansion and a 20% budgetary increase annually through 2020. RCV introduction costs include new forms, registration books, guidelines, training, and operational costs estimated at $0.60 per surviving infant for the Lao People's Democratic Republic in 2012, Cambodia, Solomon Islands and Vanuatu in 2013, Viet Nam in 2014 and Papua New Guinea in 2015. Communication costs were estimated conservatively at US$50,000

annually and will support communication activities conducted by the Regional Office using various multimedia approaches as well as support for advocacy and social mobilization efforts. Research costs were estimated conservatively at US$ 50,000 annually. General areas of research were described above. Priority areas of research currently underway or under consideration by the Regional Office include but are not limited to the following: 1. Evaluate the causes of and risk factors (by age group) for measles outbreaks in post -SIA and high coverage settings, especially among adults 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). 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 assessments in priority countries 8. Evaluate the usefulness and feasibility of potential indicators to monitor CRS surveillance sensitivity (e.g. deafness rates, congenital cataract rates, heart defect rates) Technical support by the Regional Office will include duty travel for professional staff and short term consultants and temporary appointments to support national SIA planning, implementation and evaluation, MR and CRS surveillance systems, strengthen routine MCV1, MCV2 and RCV coverage, and prepare necessary documentation for verification of measles elimination. The verification budget includes costs of the Regional Verification Commission and consist primarily in travel and per diem for global, regional and national experts to participate initially in Regional consultations and later in meetings to assess verification status of individual countries and areas. In addition, RVC members may incur costs related to country visits for verification purposes. The total 2012 – 2020 budget to achieve and sustain measles elimination and accelerate the control and possibly elimination of rubella and CRS is US$ 86.6 million, of which US$ 70.9 million (82%) is for SIAs, US$ 8.1

million (9%) is for measles-rubella surveillance and US$ 2.4 million (3%) is for CRS surveillance. The US$ 86.6 million budget is front loaded, with US$ 62.3 million (72%) required from 2012-2015. These estimates do not include needed activities in China and other countries that may need to conduct supplementary immunization activities such as New Zealand and Singapore. Nor do the estimates include direct support to strengthen routine immunization services. Much of the projected costs already have donor commitments or are expected to be covered by the respective countries. US$35.2 million is expected from GAVI, US$ 30.9 million is expected to be self-financed, and US$ 2.2 million has already been committed totaling US$ 68.3 million (79%) of the total US$ 86.6 million budget. The 2012 budget of US$ 9.3 million is primarily for anticipated SIAs in Malaysia (US$ 5.3 million) and Papua New Guinea (US$ 491,000) and ORI in the Philippines (US$ 717,000). Malaysia and the Philippines are expected to self-finance, and Papua New Guinea has secured needed funding for its SIA, which began in April. Nearly 95% of the 2013 budget of US$ 32.4 million will be funded by GAVI, including catch up MR SIAs expected in Viet Nam (US$ 25.1 million) and Cambodia (US$ 5.4 million), as RCV introduction costs in Cambodia, Solomon Islands and Vanuatu (US$ 193 000). In 2014, GAVI likely will cover 80% of the total US$ 5.8 million budget including Papua New Guinea's MR SIA (US$ 3.5 million) and Viet Nam's RCV introduction costs (US$ 831 000). The major contribution to the 2015 budget of US$ 14.8 million is the expected SIA in the Philippines at US$ 12.6 million, which represents 85% of the Regional budget and is expected to be self-financed. Thus, the major requirement for achieving and sustaining measles elimination in the Western Pacific Region is not donor funding, but country ownership and commitment. These estimates are not adjusted for inflation and do not include potential costs for outbreak response immunization.

Notes 1

World Health Organization Regional Office of the Western Pacific. Field guidelines for measles elimination. Geneva, Switzerland: World Health Organization; 2004. Available at

http://www.wpro.who.int/nr/rdonlyres/0f24b92e-ae2c-4c9b-b73b-e16acb833c35/0/fieldguidelin es_for_measleselimination.pdf. 2

World Health Organization. Fifty-sixth session of the Regional Committee for the Western Pacific. Summary record of the eighth meeting. Resolution WPR/RC56.R8. Measles elimination, hepatitis B control, and poliomyelitis eradication. Manila, Philippines: World Health Organization; 2005. Available at http://www.wpro.who.int/nr/rdonlyres/185af547-3c1a-4510-96f2-94d4402355e9/0/rc56_r08.pd f. 3

World Health Organization. Monitoring progress towards measles elimination. Weekly Epidemiol Rec. 2010; 85: 490-494 WHO, Western Pacific Regional Office. Measles Bulletin. 2007 (September); 1 (13): 4 5 4

World Health Organization. Measles vaccines: WHO position paper. Weekly Epidemiol Rec. 2009; 84: 349–360

6

World Health Organization. Response to measles outbreaks in measles mortality reduction settings (WHO/IVB/09.03). Geneva: WHO (2009)

ANNEX 4

28/02/2013

Measles Elimination Status, Current and Proposed Plans

Country Name

Outline • Measles elimination status – – – – – – History Incidence & Epidemiology Virus detection and identification Epidemiologic and laboratory surveillance performance Immunity profile Sustainability

• Risks to achieving or maintaining measles elimination • Current and proposed plans through 2013 and beyond

1

28/02/2013

History of Measles Elimination, Country X, 19XX - 2012 • Routine and supplementary immunization – Year MCV1 and MCV2 introduced – Schedule – SIAs, by year

•

Surveillance – – – – Year case based surveillance started Year when mandatory reporting started Year lab was accredited by WHO Genotype data available from what year

•

Recent activities to interrupt measles virus transmission

Measles Incidence, Epidemiology and Virus Detection Incidence, by year, since 2000 Virus detection • Genotype data, by year • Description of measles virus importations 2000 No. confirmed cases Incidence Genotypes and no. detected No. importations and import related 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 (through March

2

28/02/2013

Measles Incidence, Epidemiology and Virus Detection Epidemiology (confirmed cases only) • Epidemic curve: 2008 – 2012 (March) • Spot map (2011, 2012) • Age distribution, stacked by immunization status (0, 1, 2+ Unknown) – Age group or by year of age

•

Other analysis 3-4 slides - WPRO will provide based on data sent to us – MAA example follows

Confirmed Measles Cases, by Month of Onset Malaysia 2008—2012* 250

2004 SIA: 7-14 y; 93% 200

150

number of cases

100

50

0

* Source: WPRO measles-rubella monthly country reports, data through February 2012

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 2008 (lab & Epi-linked = 93; clinically = 222) 2009 (Lab & Epi-linked = 50; clinically = 1) 2010(Lab & Epi-linked = 68; clinically = 4) 2011(Lab & Epi-linked = 1378; clinically = 92) 2012 La b-confirmed Epi -l inked Cl ini ca l ly confirmed 2012 Lab & Epi-Linked=267, Clinically=33

3

28/02/2013

Confirmed Measles Cases, by State Malaysia 2011—2012*

2011

1 dot = 1 case

Discarded measles per 100K population: ≥2 1.0 - 1.9 <1

2012

No suspected measles cases

* Source: WPRO measles-rubella monthly country reports, data through February 2012

Lab confirmed and Epi-linked measles cases, by age group and vaccination status, Malaysia, January 2011-February 2012 800 700 600 500 400 300 200 100 0 <12m 1-7yr 8-14yr 15-24yr 25-39yr ≥40 no data

Schedule: MCV1 @ 12 m; MCV2 @ 7y

0 dose

1 dose

2 doses

Unknown

Source: National surveillance report as of 26 March 2012

4

28/02/2013

Lab-confirmed and Epi-linked measles cases, by year of age and vaccination status, Malaysia, January 2011-February 2012 450 400

350

300

No of cases

250

200

150

Schedule: MCV1 @ 12 m; MCV2 @ 7y 100 50

0 12 m 31 34 22 13 12 14 10 11 17 18 19 20 21 24 26 27 28 29 30 36 37 38 39 40 no 40 da ta 32 33 23 15 16 25 35 1 2 3 4 5 6 7 8 9 < >

Age in year 0 dose Source: National surveillance report as of 26 March 2012

1 dose

2 doses

Unknown

Surveillance Performance • Epidemiology – Discarded non-measles rate (national, sub-national) – Adequate investigation – Adequate sample collection rate – …. Lab – Accreditation status – since what year – Percent of specimens with results within 7 days of receipt in lab – Percent of outbreaks with specimens for virus detection

•

References: 1. Measles and Rubella Bulletin, published by WHO regional office on monthly basis 2. Weekly Epidemiological record, No. 49, 2010, 85:489-496

See next slide for suggested template

5

28/02/2013

Surveillance Performance Indicators, Country X, 2007- 2012* 2008 Category Epidemiologic surveillance indicators National reporting of discarded measles cases % of 2nd level admin units reporting ≥ 1/100 000 discarded measles cases % of suspected cases with adequate investigation % of suspected cases with adequate blood specimens Proportion of clinically confirmed measles cases Laboratory Indicators NML accredited? % specimens with results within 7 days of receipt % of outbreaks with specimens for virus detection Yes > 90% > 80% ≥ 2 per 100 000 > 80% > 80% > 80% ≤ 10%

2009

2010

2011

2012*

Target

2007

* Data as of March 2012

Immunity Profile Routine immunization coverage (last five years) • Administrative reports of MCV1, MCV2 • Surveys SIA coverage (since 1995) • Year, target age group, geographic scope, # immunized, coverage See next page for suggested template

Other immunity profile data • Seroprevalence surveys • Magnitude and duration of outbreaks, percent imported cases • Reproductive numbers based on models using above data Provide additional slides

6

28/02/2013

Immunity Profile, Country X, 2007-2011 2008 Category Target 2007 2009 2010 2011

National admin coverage - MCV1 MCV2 No. and % districts with > 90% MCV1 coverage Survey coverage - MCV1 MCV2 SIA target age % of country targeted (national=100%) SIA coverage (No., %)

Other data

Sustainability • • • • Is there a school entry requirement for measles immunization status? Is measles elimination reflected in costed multi-year plans? Does it have a budget? Total current and future NIP Budget, % committed by government and donors, shortfall Total current and future Measles Budget, % committed by government and donors, shortfall

7

28/02/2013

Challenges to Achieving and Sustaining Measles Elimination, Country X What are the challenges for • • achieving and sustaining adequate population immunity achieving and maintaining adequate surveillance to detect and classify imported, import-related and endemic transmission – Epidemiologic surveillance – Laboratory/virologic surveillance outbreak preparedness and response Other issues?

• •

Current & Proposed Measles Elimination Plans, 2012-2013 Country X • • • • Immunity profile Sensitivity and representativeness of epidemiologic and virologic surveillance and discern endemic from import-related transmission Prepare for and respond to outbreaks Verify measles elimination

See next page for suggested template; suggest to write current plans in black proposed plans in red

8

28/02/2013

Current & Proposed Measles Elimination Plans, Country X Immunity Profile Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

Current & Proposed Measles Elimination Plans, Country X Epidemiologic and Lab Surveillance Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

9

28/02/2013

Current & Proposed Measles Elimination Plans, Country X Outbreak Preparedness & Response Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

Current & Proposed Measles Elimination Plans, Country X Verification Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

10

28/02/2013

Current & Proposed Measles Elimination Plans, Country X Other Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

Summary • Summary of Measles situation (extent of endemic measles virus transmission) Major challenges to achieve and sustain measles elimination Major current and additional actions needed in 2012-2013 to address challenges

• •

11

ANNEX 5 CONSOLIDATED INFORMATION FROM COUNTRY PRESENTATIONS COUNTRY KOREA EPID. SURVEILLANCE AND VIRUS CHARACTERISTICS Dramatic decline in cases In 2011 43 cases: 58% under 4 yrs after 2001 SIA of age, 88% unvaccinated. Small outbreaks 2007, 2010, 73% cases have adequate 2011 investigation Only one imported case Laboratory indicators reached the 2012 target every year 35,000 cases reported in 2001; 11,000 cases 2008, especially high school and university: 78 cases 2012 In 2011, among 322 lab-confirmed cases, 32 cases imported and 13 import-related. For children under 15 years, most cases zero or 1 dose. Around 70% of measles are laboratory confirmed. MEASLES INCIDENCE POPULATION IMMUNITY Over 99% coverage administrative and survey since 2007 PROGRAMME SUSTAINABILITY Major challenges Immunization timeliness Importation of underimmunized population (foreign immigrants)

JAPAN

In 2010 MCV 1 for age one was 95.6%, Immunization coverage of other ages gradually increasing: 92.2% for MCV2 at age 56

Japan will update National Measles Elimination Plan (for next 5 years): will include improving immunization rate by promoting routine vaccination and time limited catch-up vaccination No endemic cases since 2009; sporadic imported cases found in 2011 and 2012. Major challenge to sustainability is the immunity status of illegal, immigrants and non-resident workers

MACAO

Between 2008 and 2012 Cases 8m to 40 years all zero dose only 6 cases, 4 imported and The surveillance performance has 2 import-related. achieved high standards since 2008.

Since 1998, MCV1 and 2 coverage around 90%

1

COUNTRY

MEASLES INCIDENCE

EPID. SURVEILLANCE AND VIRUS CHARACTERISTICS

POPULATION IMMUNITY 98% to 99% coverage for MMR 2 doses since 2006

PROGRAMME SUSTAINABILITY Adequate investigation and specimen collection are the major challenges; Hong Kong has an immunization multiyear plan which includes measles elimination. Immunization plan fully govt funded, school entrance checks to be introduced DOH has plans to improve surveillance and coverage. Availability of trained manpower at National & provincial level will be a major determinant for success

HONG KONG 71 cases in 2008, 13 in 2011 3 zero dose children < 5 yrs in of which 6 related to 2011, 84% adequate investigation; importation; 4 in 2012 97% adequate blood specimens; 46% clinically confirmed

BRUNEI

2 to 4 cases per year since 2008, zero cases in 2012 to date 1998 epidemic; lasted until late 2002 ~ 30,000 children with 292 reported deaths from hospitals. More than 50% cases were < 9 months and more than 50% deaths were < 4 months. No laboratory confirmed outbreaks detected since 2004 Only 7 cases since 2008, zero cases 2012 to date

Very high level of surveillance MCV1 and MCV2 indicators; 1 zero dose case in 2011 coverage over 90% since 2007 Decline in all surveillance indicators between 2008 and 2011 Routine Measles Coverage at 9 months around 60% over last five years Around 50% of children receive measles dose >12 months and not included in coverage reporting

PAPUA NEW GUINEA

FIJI

Only 5% of suspected cases with adequate investigation (small numbers for small pop)

MCV1 coverage around 70% to 80% since 2009, MCV2 higher in 2011

Measles elimination in multiyear plan. Hard-to reach communities a challenge.

2

COUNTRY

MEASLES INCIDENCE

EPID. SURVEILLANCE AND VIRUS CHARACTERISTICS Many countries not reporting AFR, very few have blood specimen analysis. Surveillance will depend upon Pacific region wide Hospital Based Active Surveillance (HBAS) system. Increasing proportion of adult measles in some eastern provinces High proportion of infant and children measles in some western provinces 60 to 70% of infant cases are zero dose. In 2012 50% of cases are under 8 months and 50% 8 to 11months.

POPULATION IMMUNITY MCV coverage varies from 52% to 99%.

PROGRAMME SUSTAINABILITY Some countries planning SIAs to protect increasing susceptible populations

PACIFIC ISLAND COUNTRIES AND AREAS (21) CHINA

Only 1 outbreak with more than 5 cases per thousand (in 2003).

Decline from 131,000 cases in 2008 to around 10,000 cases 2011. Measles virus transmission still not interrupted in all provinces after 2012 SIA

MCV1 coverage 94%

Challenges to sustainability: achieving adequate population immunity poor routine immunization in Western and poor areas High cost of immunization services Increasing proportion of infant cases Immunity gap in adults Large number and high mobility of migrants Achieving adequate surveillance to detect transmission Outbreak preparedness and response Political advocacy not yet reached at the level achieved for polio eradication(State

3

COUNTRY

MEASLES INCIDENCE

EPID. SURVEILLANCE AND VIRUS CHARACTERISTICS Under-reporting at 2nd level, only 50% cases had adequate case investigation, but >80% has blood specimens. Most cases are under 1 year and zero dose or 1 dose

POPULATION IMMUNITY MCV1 coverage 79%, MCV2 coverage 28%

PHILIPPINES Big outbreaks 2003, 2010, 2011

PROGRAMME SUSTAINABILITY Council) A new comprehensive multiyear plan will include defaulter tracing for 2nd dose; preschool screening for measles vaccination; outbreak preparedness and response; capacity building for surveillance and lab personnel To achieve elimination will need to improve routine MCV coverage. Conduct regular mop-up at 3 doses MCV: Measles at 6 months MMR at 12 months MR at 7 year old Challenges: Population immunity in high risk areas is not high Surveillance still need improvement in timeliness and completeness MR campaign for children 9m - 14 yrs

MALAYSIA

Outbreak 2011-2012; 1378 lab and epi-linked in 2011;

Most cases <7 years old; overwhelmingly under 2 years and zero dose; 56% investigated within 48 hours; 80% adequate blood specimens

65% of districts have MCV1 coverage >90%; 50% of districts have low MCV1 coverage

VIET NAM

Outbreaks 2006, 2009 (over 7,000 cases), 2010 SIA late 2010 resulted in decline in 2011; zero cases 2012 to date

Many cases in older age groups (mostly unvaccinated). Most cases <4 years; most zero dose cases <2 years. Adequate investigation rates have been low, but now improving from around 50%

Over 90% districts report 90% or more MCV1 coverage

4

COUNTRY

MEASLES INCIDENCE

EPID. SURVEILLANCE AND VIRUS CHARACTERISTICS Most cases 1 to 9 years old; cases 1 to 4 years often have already received one or more doses of measles vaccine. A shift in cases to older age cohorts, especially among 10 to 14 year old children, most unvaccinated. Adequate investigation rates need improvement. Most cases 1 to 4 years and zero dose; high proportion of clinically confirmed cases; <50% of cases with adequate blood specimens

POPULATION IMMUNITY 53% of districts report MCV1 coverage 90% or more. Routine 2nd dose at 18 months introduced 2012.

PROGRAMME SUSTAINABILITY Strong national commitment, but plan relies on external support; High risk strategy to reach every community is linked to measles 2nd routine dose introduction.

CAMBODIA

Large outbreaks 2008, 2009 SIAs 2011; zero cases 2012 to date

LAO PDR

Large outbreak in 2007; <200 cases per year 20082011; 7 cases to date in 2012.

National MCV1 coverage 69% in 2011; 15% of districts with >90% MCV1 coverage; MCV2 not yet introduced.

High dependency on external funding: govt contribution 15%; Currently low level of endemic measles virus shared with the border areas of Cambodia, China, Thailand and Vietnam; may require periodic SIAs to maintain adequate immunity in the population Surveillance needs improvement by greater attention to reporting all suspect AFR and collecting samples from as many cases as

5

COUNTRY

MEASLES INCIDENCE

EPID. SURVEILLANCE AND VIRUS CHARACTERISTICS Mongolia meets WHO targets for measles surveillance except of district reporting indicator: Country has no reported lab-confirmed measles cases for past two years

POPULATION IMMUNITY National coverage MCV1 and MCV2: 98%; 95% of districts with >90% reported coverage

MONGOLIA

Last outbreak 2002: 1205 cases; zero cases since 2010

PROGRAMME SUSTAINABILITY possible Additional actions need in 2012-2013: Strengthen lab capacity especially for molecular testing (PCR); Expand RED strategy

6

ANNEX 6 Guidelines for the Regional Measles Consultation (18–20 April 2012) 1. Objective: To evaluate the current status of measles elimination, identify the challenges to achieve elimination and plan the priority activities needed to achieve and sustain the goal. 2. Expected outcome after the meeting The Regional Verification Commission (RVC) will be fully briefed on measles elimination status in the region and regional and national measles elimination plans will be updated, with incorporation of suggestions/inputs from RVC members and others. 3. Actions required before, during and after the consultation I. Before the consultation The country or areas is requested to prepare a (1) 15-minute presentation, and (2) draft action plan. Templates for both are attached. The Powerpoint presentation should include 1) measles elimination status using the five components of verification as a framework; 2) challenges to achieving and/or sustaining measles elimination 3) current and proposed additional plans/activities to eliminate measles The action plan (in Excel) should include key activities, timelines, and budget and funding status/needs. Countries and areas are requested to submit their draft presentations and action plans to WPRO by April 12. II. During the meeting Each country will present its measles elimination status, challenges, and current and proposed plans to the RVC. Plenary discussion and feedback will follow each country presentation. After the country presentations, group work will be conducted among groups of similar countries to further stimulate new thinking and ideas, with national representatives making additional revisions/edits to the action plans. Each country will be requested to report what additional changes they may have made to their action plans.

The country participants will then advise their MOH counterparts on Thursday night/Friday morning and, during the Friday afternoon session, the MOH officials will be asked to support the proposed plans or advise what modifications or further changes may be needed. III. After the meeting The country action plan should be finalized by 15 May 2012, after in-country consultation, and shared with WPRO so that an updated regional action plan may be prepared and shared with Member States and partners.

ANNEX 7

Action Plan in 2012-2013 for Achieving and Sustaining Measles Elimination Country/Area: Objectives: 1. Improve immunity profile against measles 2. Strengthen epidemiologic and virologic surveillance 3. Outbreak preparedness and response 4. Verification Planned Activates in 2012-2013 SI Activity Title Activity description Improving immunity profile 1 2 3 4 5 6 7 8 9 10 Strengthening epidemiologic and virologic surveillance 1 2 3 4 5 6 7 8 9 10 3. Outbreak preparedness and response 1 2 3 4 5 6 7 8 9 10 Expected outcome Timeframe Monitoring indicators Estimated budget Funding and Gaps Need for external Government Partners Funding Gap TA

Instruction - Indicate current plans in black; proposed plans in red

ANNEX 7 Country/Area: Objectives: 1. Improve immunity profile against measles 2. Strengthen epidemiologic and virologic surveillance 3. Outbreak preparedness and response 4. Verification Planned Activates in 2012-2013 SI Activity Title 4. Verification 1 2 3 4 5 6 7 8 9 10 5. Other 1 2 3 4 5 6 7 8 9 10 Activity description Expected outcome Timeframe Monitoring indicators Estimated budget Funding and Gaps Need for external Government Partners Funding Gap TA

Instruction - Indicate current plans in black; proposed plans in red

China

Current & Proposed Measles Elimination Plans, China, Immunity Profile Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

Strengthen routine Routine immunity service, to improve 2-dose MCV coverage and timely vaccination rate Non-selective SIAs (risk areas, 426 counties selected) and selective SIAs in other areas Non-selective SIAs in Dec 2011 – Jan 2012, and selective SIAs during winter 2011 and spring 2012

Combined with “4.25” Mar-Apr, 2012 vaccination month to carry out National selective SIAs

1

Current & Proposed Measles Elimination Plans, China Epidemiologic and Lab Surveillance Sl. Activity Finish classification of suspected case in 2 days lab result available Provincial/prefecture/county level evaluate progress on measles elimination in 2011 Take full advantage of single case “early-warning” signal Qualified county-level CDCs and hospital serum test lab (if necessary) Establish “fever and rash” symptom surveillance system locally and gradually Strengthen rubella surveillance and control

Timeframe Budget 2011Before Apr 2012 201120112011-

Funding Amount Govt Partners Shortfall

Current & Proposed Measles Elimination Plans, China Outbreak Preparedness & Response Sl. Activity Apply outbreak response criteria into single confirmed measles case investigation and disposal Issue national outbreak response guideline, containing active search, risk assessment, emergence vaccination, etc.

Timeframe 2011.6-

Budget

Funding Amount Govt Partners Shortfall

2012-

2

Current & Proposed Measles Elimination Plans, China Verification Sl. Activity Developing proposals for verification (in progress) Establishing National Verification Committee

Timeframe 2012-

Budget

Funding Amount Govt Partners Shortfall

2012-

Cambodia

3

Immunity Profile SI 1

Activity Title High Risk Community Strategy MR Vaccine Introduction Annual Measles Elimination Workshops Cold Chain replacement to maintain high MCV1/2 coverage Measles Elimination preparedness external assessment Advocacy efforts

Timeframe 20122012-2013 20122012-2013 20122012-2013 20122012-2013

Estimated budget (USD) 800,000 9,000,000 40,000 50,000

Funding and Gaps Funding Government Partners Gap 100,000 50,000 20,000 600,000 700,000 250,000 20,000 50,000

2

3

4

5

2013 20122012-2013

20,000 40,000

20,000 40,000

20,000 40,000

6

Epi & lab surveillance Activity Title Measles/rubella surveillance Timeframe Estimated Funding and Gaps budget Funding Govern Part (USD)

ment

ners

Gap

1

20122012-2013 80,000

25,000 15,000 80,000

55,000 35,000 80,000

2

National Measles Laboratory 20122012-2013 50,000 Support Measles surveillance training [regional] 20122012-13 80,000

3

4

Outbreak preparedness & response SI Activity Title Estimated Funding and Gaps Budget Timeframe (USD) Governm Partners Funding ent Gap 20122012-2013 100,000 100,000

1

Measles outbreak response

Verification Activities Estimated_ Budget Timeframe (USD) Funding and Gaps GoV Partners Funding Gap 20,000

SI

Activity Title

1

National Measles Verification 20122012-2013 Committee

20,000

5

Lao PDR

Current & Proposed Measles Elimination Plans, Lao PDR Immunity Profile Funding Amount Sl. Activity Timeframe Budget Govt Partners Shortfall

1 2 3 4 5

Achieve MCV coverage>90% natl. & >80% of all districts Identify districts with <90%, make POA to improve coverage Replace MV with MR

2012-2015

$17M

$3.8M

$9.7M

$3.5M

2012-2013

$60,000

$60,000

2012-2013

$400,000 $1M

$400,000 $1M

Conduct periodic SIA 2013-2015

Introduce MCV2

2015

$300,000

GAVI?

$300,000

6

Current & Proposed Measles Elimination Plans, Lao PDR Epidemiologic and Lab Surveillance Funding Amount Govt Partners Shortfall

Sl.

Activity

Timeframe

Budget

1 2 3 4 5 6 7

AFR investigations Laboratory staff Laboratory equip& supplies Clinicians sensitization Transport of lab samples CRS retrospective study Establish CRS surveillance

2012-2013 2012-2013 2012-2013 2012-2013 2012-2013 2012 2012-2015

$ 150,000 $250,000 $80,000 $100,000 $40,000 $10,000 $ 50,000

$100,000 $50,000 $200,000 $50,000 $80,000 $40,000 $40,000 $10,000 $50,000 $60,000

Current & Proposed Measles Elimination Plans, Lao PDR Outbreak Preparedness & Response

Sl.

Activity

Timeframe

Budget

Funding Amount Govt Partners Shortfall

1

Make new OR guidelines including immunization and surveillance response

2012

$10,000

$10,000

2

Conduct Outbreak Response Activities

2012-2015

$200,000

$200,000

7

Current & Proposed Measles Elimination Plans, Lao PDR Verification Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

1

Establish a Natl. 2012 Measles Verification Committee Make a Natl. 2012 Measles Elimination POA Conduct NVC meetings Write annual report Attend regional meetings Site visits to Provinces 2012-2015 2012-2015 2012-2015 2012-2015

$5,000

$5,000

2

$5,000

$5,000

3 4 5 6

$8,000 $500 $10,000 $10,000 $10,000

$8,000 $500

$10,000

Viet Nam

8

Current & Proposed Measles Elimination Plans, Viet Nam Immunity Profile Funding Amount

Activity Maintain high coverage for MCV1 and MCV2 through routine EPI SIA in HRAs MR campaign for children 9m - 14 yrs

Timeframe

Funding Amount Govt Partners

2012+

x

x

2012 - 13 2013 - 14

x x

WHO GAVI

Current & Proposed Measles Elimination Plans, Viet Nam Epidemiologic and Lab Surveillance Activity Revising guideline for integration of rubella surveillance Develop and printing Poster on surveillance Training for EPI staff and health worker in hospital Monitoring and supportive supervision Timeframe Funding Amount Govt Partners Shortfall

2012 2012 2012 - 13 2012+

x x x x WHO WHO WHO x

9

Current & Proposed Measles Elimination Plans, Viet Nam Outbreak Preparedness & Response Funding Amount Govt Partners Shortfall

Activity

Timeframe

500,000 doses vaccine stockpile Vaccination respond to measles outbreak.

2012+

x

2012+

x

WHO

x

Fiji

10

Current & Proposed Measles Elimination Plans, FIJI Immunity Profile Sl. Activity Routine Immunisation High risk group immunisation Reach every community EVM Training & Fieldwork Cold chain supervisory visits Social Mobilisation Evaluate coverage -FDHS Timeframe Annually Annually Monthly subnational May-June 2012 Quarterly Ongoing August-Nov 2012 Budget USD 30,000 5,000 20,000 20,000 15000 20000 Total DHS Is 0.7M Funding Amount Govt 100% 100% 40% 20% 20% 60% 80% 80% 100% 100% Partners Shortfall

Current & Proposed Measles Elimination Plans, Epidemiologic and Lab Surveillance Sl. Activity HBAS Syndromic Surveillance Timeframe Monthly Weekly Budget USD 7000 1000 10000 10,000 0 100% 25% 75% 100% Funding Amount Govt Partners 100% Shortfall

Case Investigation Weekly Refresher Training 4 per year -2012 -subnational

11

Current & Proposed Measles Elimination Plans, FIJI Outbreak Preparedness & Response Sl. Activity Finalization of Measles Outbreak Plan Risk Vulnerability Assessments Timeframe Immediate [in next 3 months] Every quarter Budget USD 1000 Funding Amount Govt 50% Partners 50% Shortfall

2000 10000

100% 0 100%

Refresher Training August 2012 of HCW [outbreak]

Current & Proposed Measles Elimination Plans, FIJI Verification Sl. Activity Set up Fiji NVC Field Visits by NVC Meetings by NVC Timeframe 3 months As Needed ( at least 1 / Qtr) Quarterly 0 3000 500 100% 100% Budget (USD) Funding Amount Govt Partners Shortfall

12

Papua New Guinea

Measles Elimination in current cMYP…1 • Measles Elimination Strategies incorporated and costed as part of cMYP 2011-15 • Indicators & Targets outlined for immunization activities and surveillance indicators • Outlines possible future activities as Measles Second Dose and SIAs in 2014 • Costing done for measles elimination activities (service delivery, advocacy & communication, vaccine & logistics, surveillance and programme management) as part of cMYP

13

Measles Elimination in current cMYP…2 • Total national EPI cost: ~ 33.2 m in 2013 to 42.7 m in 2015; majority to be funded by GoPNG; ~ 5 million short fall to be supported by partners • Support by partners in PNG in SIA 2012: Operational cost by AusAID, technical assistance and Vitamin A & Albendazole tablet by WHO and 40% of Measles Vaccine & TT cards by UNICEF • Systemic approach with strengthening routine immunization is the essence of cMYP

Proposed activities towards Measles Elimination…1 • Increasing Immunization coverage (2012-15): – District microplanning for routine immunization with emphasis on RED-REC initiative – Supportive supervision on implementation of district plan for improving routine immunization including measles coverage – On-site on-job training for all the priority districts as part of supportive supervision – Conduct data quality assessment to improving data management at district level – Conduct high-quality MCV SIAs (ensuring all districts to achieve >95% coverage) based on 2012 SIA GoPNG supports entire cost of routine immunization; RED initiative supported by WHO and AusAID; Financial short-fall of ~ 2.0 M USD if SIA planned in 2014; Technical support requested from WHO/UNICEF

14

Proposed activities towards Measles Elimination…2 • Strengthening Surveillance (2012-15): – Strengthen District capacity in reporting all suspected measles cases with collection of serum specimens – Supervisory visits to poor performing districts by Provincial and National Surveillance Officers along with CPHL team – Strengthen PHO's capacity in provision of technical support to the district manager in detecting, investigating and reporting suspected measles cases – Quarterly Feedback to districts on Surveillance indicators by Province and bi-annual feedback by the national level

• Strengthen capacity of provincial and districts managers to respond to suspected outbreaks GoPNG supports personnel costs of CPHL; Logistics support for lab and Technical support requested from WHO

Proposed activities towards Measles Elimination…3 • Verification of Measles Elimination (2012-15): – Establish Measles Elimination Committee at National level – Organize Annual National Measles Elimination Consultation Meeting with Provinces and international partners to review the progress & develop annual national and provincial plans – Conduct risk assessment of districts to identify priority districts in each year in line with low-performing district initiative – Wide consultation on strengthening measles elimination activity with Child Health Advisory Committee – Develop annual plans based on recommendations of National Measles Elimination Committee and Child Health Advisory Committee GoPNG is committed to regional goal of measles elimination; Planned activities have been costed in cMYP 2011-15; Other activities will be supported; Technical support requested from WHO

15

Japan

National Measles Elimination Plan (Dec 2007) The Plan includes recommendations for immunization strategies, case- based measles surveillance, and monitoring to ensure elimination of measles by 2012. Contents 1. The aim of National Measles Elimination Plan 2. Epidemiological investigation 3. The prevention of the occurrence of measles Catch-up immunization 4. Offering medical treatment 5. Promotion of research and development 6. International cooperation 7. Evaluation and promotion system

16

• Updating National Measles Elimination Plan (for next 5 years) • Improving Immunization rate by promoting routine vaccination and time limited Catchup vaccination • Promoting Routine Use of RT-PCR – When should we do Catch-up vaccination?

Next steps for 2012-2013 in Japan

Republic of Korea

17

Current & Proposed Measles Elimination Plans, Republic of Korea Area Immunity profile Activity Routine vaccination through NIP School entry requirement for 2nd MMR Continue to inform physicians to report every suspicious case surveillance Outbreak preparedness & response Reduce the time requirement for reporting Maintain high specimen collection rate Intensive investigation for source of infection Identify Pocket of population hospitalization of a suspected case

Malaysia

18

Measles Elimination Plans: Immunity Profile Sl. 1 2 Activity Timeframe Budget Funding Amount Govt MOH MOH Partners Shortfall

Improve routine ongoing MCV1 vaccination Risk assessment at district level - Review cards and registration book Targeted mop-up (SIA) Supervision Public awareness Q1 & Q2 2012

3 4 5

ongoing ongoing Q3 2012 and ongoing

MOH MOH MOH

Measles Elimination Plans: Epidemiologic and Lab Surveillance Funding Amount Govt MOH Partners Shortfall

Sl. 1

Activity

Timeframe

Budget

Sensitive and On-going timely case-based surveillance Review of cases Lab accreditation

2 3

MOH MOH WHO

19

Measles Elimination Plans: Outbreak Preparedness & Response Sl. 1 Activity Redistribute GL on Measles Surv Manual Training health and hospital staff Sharing reports Advertorial Availability of VTM Timeframe Ongoing Budget Funding Amount Govt MOH Partners Shortfall

2 3 4 5

Ongoing Ongoing Regular Ongoing

MOH MOH MOH MOH MPA MPA

Measles Elimination Plans: Verification Sl. 1 Activity Established Nat Verification Committee Timeframe 2011 - ongoing Budget Funding Amount Govt MOH Partners MPA Shortfall

2

Verify vaccination ongoing coverage at the field Record search for cases ongoing

MOH

3

MOH

MMA

20

Philippines

Sustainability • Nationwide routine implementation of 2-dose MCV – mMV at 9mos ; MMR at 12-15 months – Catch up, defaulter tracing so that all children have received 2 doses of MCV by 24 months of age. Nationwide Preschool and School-based screening and vaccination Intensify monitoring/supportive supervision using standard monitoring tool: ( 3As + 3Fs) Dedicated GOP - EPI budget for the procurement of vaccines and other injection supplies – USD179M Proposed EPI Budget 2012-2016 submitted to DBM • USD 20M Procurement of MCV – USD 1.8M VPD Surveillance – USD 1.3M Laboratory Surveillance

• •

•

21

Sustainability • • Creation of National Verification Committee for Measles Elimination Development of the National Measles Outbreak Preparedness and Response Guidelines Develop the comprehensive multiyear plan Capability Building for Surveillance and Laboratory Personnel – VPD Comprehensive Surveillance Training – Alternative Method for Laboratory Confirmation (e.g.DBS)

• •

Viet Nam

22

Current & Proposed Measles Elimination Plans, Viet Nam Immunity Profile Funding Amount

Activity Maintain high coverage for MCV1 and MCV2 through routine EPI SIA in HRAs MR campaign for children 9m - 14 yrs

Timeframe

Funding Amount Govt Partners

2012+

x

x

2012 - 13 2013 - 14

x x

WHO GAVI

Current & Proposed Measles Elimination Plans, Viet Nam Epidemiologic and Lab Surveillance Activity Revising guideline for integration of rubella surveillance Develop and printing Poster on surveillance Training for EPI staff and health worker in hospital Monitoring and supportive supervision Timeframe Funding Amount Govt Partners Shortfall

2012 2012 2012 - 13 2012+

x x x x WHO WHO WHO x

23

Current & Proposed Measles Elimination Plans, Viet Nam Outbreak Preparedness & Response Funding Amount Govt Partners Shortfall

Activity

Timeframe

500,000 doses vaccine stockpile Vaccination respond to measles outbreak.

2012+

x

2012+

x

WHO

x

Hong Kong (China)

24

Action Plan for Measles Elimination, HKSAR Immunity Profile Sl. Activity Description Expected outcome

1

Maintain high Continue MMR vaccination High levels of population immunity programme immunisation against measles coverage and sero-immunity against measles.

Action Plan for Measles Elimination, HKSAR Epidemiologic and Lab Surveillance Sl. Activity Description Expected outcome Thorough epidemiologic To fully investigate all suspected Higher number of investigation on all measles cases including collection of cases with suspected measles cases demographic, epidemiologic adequate information and encourage collection investigation of specimen for laboratory testing. Blood specimen collection To collect blood specimens for all More cases with for laboratory testing reported measles cases adequate blood specimens and less clinically confirmed cases Facilitate virologic testing To collect specimens for virological Higher number of isolation and genotyping for all IgM confirmed cases positive cases. with known genotype. Enhanced measles To enhance surveillance by detecting Increased surveillance for fever and measles IgM in suspected cases sensitivity in rash cases with fever and rash detection of measles cases

1

2

3

4

25

Action Plan for Measles Elimination, HKSAR Epidemiologic and Lab Surveillance Sl. 5 Serosurveys 6 Laboratory accreditation

Activity Strain characterization

Description Genotyping from direct specimens or virus isolates

Expected outcome Inform on circulating strains to determine likely source (imported or endemic/ourbreak) Inform on population immunity level in contribution to monitoring vaccination programme Maintain ongoing status of accreditation

Annual population serological surveys

7

Accreditation by WHO as National and Regional Laboratory

Action Plan for Measles Elimination, HKSAR Outbreak Preparedness & Response Sl. Activity Description Expected outcome

1

Mop-up MMR vaccination

To provide mop-up immunisation during case/ outbreak investigation to those individuals not fully immunised

Smaller outbreak size

26

Action Plan for Measles Elimination, HKSAR Verification Sl. Activity Description Expected outcome

1

National Verification With guidelines from WPRO, Establishment Committee to invite local experts in of NVC establishment related fields and establish a NVC to overlook the progress on measles elimination

Macao (China)

27

Sl.

Activity

Timeframe

Budget Govt

Funding Amount Partners Shortfall

1

Request all HCWs The end in pediatric of June department to vaccinate the MCV. University entry The end requirement for of June measles immunization status, especially for the nonresident students.

MOP$1 100% 0,000

2

--

--

Sl.

Activity

Timeframe

Budget Govt

Funding Amount Partners Shortfall

1

To promote the The end MOP$5 100% guideline of of August 0,000 notification of measles to clinical doctor To develop the capacity of virus detection in laboratory The end MOP$3 100% of August 00,000

2

28

Sl.

Activity

Timeframe

Budget Govt

Funding Amount Partners Shortfall

1 Stock of MCV

--

--

100%

2 To establish the The end -outbreak of preparedness October and response plan

Sl.

Activity

Timeframe

Budget Govt

Funding Amount Partners Shortfall

1

Survey of immunization coverage of measles vaccine in children at 2y and P1 Serological study of Measles immunity status in Macao resident

The end of October

MOP$2 100% 0,000

2

The end of Novemb er

MOP$2 100% 00,000

29

Brunei Darussalam

Current & Proposed Measles Elimination Plans Immunity Profile Brunei Darussalam Funding Amount Sl. Activity Timeframe Budget Govt Partners Shortfall

1

School entry Immunisation check at Year 1. Subnational and National coverage of MMR1 and MMR2

2012-2013

Included Fully in the Funded budget of MOH

-----

-----

2

Current

30

Current & Proposed Measles Elimination Plans, Epidemiologic and Lab Surveillance Brunei Darussalam Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

1

Strengthening of 2012-2014 suspected measles surveillance (timely notification, adequate investigation, adequate blood sample) Genotyping of lab confirmed cases (KIV) 2012-2014

Included Fully ------in the Funded Annual MOH budget

-------

2

Current & Proposed Measles Elimination Plans, Outbreak Preparedness & Response Brunei Darussalam Sl. Activity Timeframe Budget Funding Amount Govt Partners Shortfall

1

Active case search in 20 nearby households for suspected measles past 60 days. And investigate the cases identified. Assessment of immunization status of children aged 14 year in 20 nearby households where the case resides.

Current

Included Fully -----in the Funded Annual budget of MOH

-----

2

31

Current & Proposed Measles Elimination Plans, Verification Brunei Darussalam Sl. Activity Timeframe Budget Funding Amount Govt Partners Short fall

1

The HBMISS study conducted to check measles IgG in Year 4 student nationwide.

2011-2012

National Development Plan

Fully Funded

-----

-----

Mongolia

32

Current Measles Elimination Plans Existing plans and budget to achieve and sustain measles elimination Goal: To eliminate measles in Mongolia Objective 1. To reach population immunity level at least 95% Objective 2. To strengthen case-based surveillance for measles Expected results to reach at least 95% coverage for full doses of MCV to involve fully the target population into catch-up and SIAs to introduce integrated network on vaccination coverage to conduct measles sero-survey every two years to introduce surveillance for rash and fever in all level to meet WHO target on measles surveillance performance to confirm every measles case by laboratory to have lab capacity to determine measles importation through genotyping of measles isolates. Total budget: 392,000 USD US$ 70,000 by GoM US$ 322,000 by donors (WHO, UNICEF and GAVI HSS) Health Minister’s order # 57 dated Feb 16, 2012 on National Measles Strategy

Planning Update to Eliminate Measles • Additional activities to improve immunity profile – Expand RED strategy, US$500,000 for 2013-2014

• Additional activities to improve sensitivity and representativeness of epidemiologic and virologic surveillance and discern endemic from import-related transmission – Strengthen lab capacity especially for molecular testing (PCR), 2013-2015

33

1 ANNEX 9

DRAFT- April 2012

Guidelines on Verification of Measles Elimination in the Western Pacific Region

WHO Regional Office of the Western Pacific Manila, Philippines

April 2012

2 Executive Summary The Western Pacific Region has made substantial progress towards measles elimination since establishing the goal in 2003. Concerted efforts around the Region have reduced measles incidence to less than 12 cases per million of population in 2011 and 4.3 (annualized) during the first quarter of 2012. As many as 32 countries and areas may have eliminated measles, and 26 are likely to be ready for verification. At its 2010 meeting, the Regional Committee reaffirmed the 2012 measles elimination goal, urged the Regional Director to establish a regional verification mechanism and requested Member States to establish an independent national verification process for measles elimination following the establishment of a regional verification mechanism. Establishing verification processes and criteria will acknowledge countries and areas that have eliminated measles and provide guidance for those that have not yet achieved elimination. These guidelines are based on shared experiences and consultation with other WHO Regions, a consultation among Member States on verification of measles elimination in the Western Pacific Region held in Manila in June 2010 and a consultation among Regional verification Commission Members with Member States in Apruil 2012. Definitions of measles elimination and other essential concepts are provided, and core principles enumerated. The core principles include the independence of the verification process led by the Regional Verification Commission (RVC) and National Verification Committees (NVCs) at Regional and national levels, respectively, and that the RVC will have the discretion to apply alternative evidence for elimination in place of recommended evidence and indicators for countries unable to provide data to assess standard indicators. Two criteria and four verification components are presented that will form the basis of verification. The two criteria include absence of endemic measles virus transmission for three years in the presence of high quality surveillance for both national and regional elimination and absence of endemic genotype(s). The four components of evidence include incidence, epidemiologic and virologic characteristics, epidemiologic surveillance and laboratory performance, population immunity, and sustainability of measles elimination in the context of national immunization programme sustainability. Specific indicators are suggested under each component. The structure and membership of the RVC and NVCs are described, as well as standard mechanisms for verification through a description of RVC and NVC functions and terms of reference. These include normative, advisory and verification functions and for the chair, management functions. An advocacy function is also included in the RVC and NVC terms of reference. Finally, post-verification needs are described. These include the need to maintain high levels of population immunity, verification-standard epidemiologic and virologic surveillance, and preparedness plans for outbreak response. NVCs will coordinate the submission of annual reports to the RVC so that the RVC may verify both progress toward measles elimination and its ongoing achievement.

3

Contents Definitions 1. Overview of measles elimination in the Western Pacific Region 1.1. Introduction 1.2. Strategies to eliminate measles 1.3. Progress toward regional measles elimination 2. Core principles for verification of measles elimination 3. Standard verification criteria, components and indicators 3.1. Verification criteria 3.2. Components and indicators of elimination 3.2.1. Evolution of incidence, epidemiologic and virologic characteristics 3.2.2. Epidemiologic surveillance and laboratory performance 3.2.3. High population immunity 3.2.4. Sustainability of measles elimination in the context of NIP sustainability 4. Structure of verification bodies 4.1. RVC and NVC structure 4.2. RVC and NVC membership and appointment 4.3. Secretariat support 5. Mechanism of verification 5.1. RVC functions and terms of reference 5.2. NVC functions and terms of reference 5.3. Advocacy functions for RVC & NVCs 6. Post-verification needs

4 Definitions1 1. Measles eradication 2: worldwide interruption of measles transmission in the presence of a surveillance system that has been verified to be performing well. 2. Measles elimination: the absence of endemic measles transmission in a defined geographical area (e.g. region) for ≥ 36 months in the presence of a well performing surveillance system. 3. Endemic measles transmission: the existence of continuous transmission of indigenous or imported measles virus that persists for ≥ 12 months in any defined geographical area. 4. Re-establishment of endemic transmission: occurs when epidemiological and laboratory evidence indicates the presence of a chain of transmission of a virus strain3 that continues uninterrupted for ≥ 12 months in a defined geographical area where measles had previously been eliminated. 5. Measles outbreak in countries with an elimination goal: 4 when ≥ 2 confirmed cases are temporally related (with dates of rash onset occurring between 7 and 21 days apart) and are epidemiologically or virologically linked, or both. 6. A clinical measles case: any case with fever and maculopapular rash (i.e. nonvesicular) and any of the following: cough, coryza (i.e. runny nose) or conjunctivitis (i.e. red eyes). 7. A laboratory-confirmed measles case: a case that meets the clinical definition for measles and has been confirmed by a laboratory. 5 8. An epidemiologically linked confirmed measles case: a clinical case of measles that has not been confirmed by a laboratory but that is geographically and temporally related (with dates of rash onset occurring between 7 and 21 days apart) to a laboratory-confirmed case or (in the event of an outbreak) to another epidemiologically confirmed measles case. 9. A clinically compatible measles case: a case that meets the clinical case definition for measles but for which no adequate blood specimen was taken and which has not been linked epidemiologically to another case positive for measles immunoglobulin M (IgM) or another laboratory-confirmed communicable disease. 10. A discarded measles case: a case that meets the clinical case definition for measles and that has been investigated and discarded as a non-measles case using (a) laboratory testing in a proficient laboratory 6 or (b) epidemiological linkage to an outbreak that has been confirmed by a laboratory not to be measles. 11. A vaccine-associated measles case: a suspected case that meets all 5 of the following criteria: (i) the patient had a rash illness, with or without fever, but did not have cough or other respiratory symptoms related to the rash; (ii) the rash began 7–14 days after vaccination with a measles-containing vaccine; (iii) the blood specimen, which was positive for measles IgM, was collected 8–56 days 1 2

World Health Organization. Monitoring progress towards measles elimination, Wkly Epidemiol Rec 2010; 85:490–4. A proposal to use the term “eradication“ at regional and country levels was proposed by participants at the Ernst Strüngmann Forum on Disease Eradication in the context of Global Health in the 21st Century, held in Frankfurt, Germany, in August 2010. 3 A virus strain comprises viruses with N gene (450) sequences that are at least 99.7% identical (1 nt change). 4 This definition may vary across countries 5 Manual for the laboratory diagnosis of measles and rubella virus infection, 2nd ed. Geneva, World Health Organization, 2007 (WHO/IVB/07.01). (Also available at http://whqlibdoc.who.int/hq/2007/WHO_IVB_07.01_eng.pdf.) 6 A proficient laboratory is a WHO network laboratory that uses a validated assay and has passed the annual WHO proficiency test or one that follows national standards and successfully participates in an approved external qualityassurance programme

5 after vaccination; (iv) thorough field investigation did not identify any secondary cases; and (v) field and laboratory investigations failed to identify other causes. 12. An endemic measles case: a case of measles confirmed by laboratory testing or epidemiological linkage resulting from endemic transmission of measles virus. 13. An imported case of measles: a case with virological or epidemiological evidence, or both, of exposure outside the region or country during the 7–21 days prior to rash onset. 14. An import-related measles case: a locally acquired infection occurring as part of a chain of transmission originated by an imported case as supported by epidemiological or virological evidence, or both. (Note: if transmission of measles cases related to importation persists for ≥ 12 months, cases are no longer considered to be import-related, they are considered to be endemic.)

6 1. Overview of measles elimination in the Western Pacific Region 1.1 Introduction In 2003, the Western Pacific Regional Committee (RC) resolved to eliminate measles and control hepatitis B, and to use activities for achieving these to also strengthen routine immunization (WPR/RC54.R3) . In 2005, the RC established 2012 as the target year for measles elimination (WPR/RC56.R8). In 2010, the RC reaffirmed the 2012 goal, urged the Regional Director to establish a regional verification mechanism and requested Member States to establish an independent national verification process for measles elimination following the establishment by the WHO Regional Office for the Western Pacific of standardized regional verification mechanisms. Establishing verification processes and criteria will acknowledge countries and areas that have eliminated measles and provide guidance for those that have not yet achieved elimination. 1.2 Strategies The key strategies for measles elimination include (1) achieving high (≥ 95%) vaccination coverage with two doses of measles containing vaccine (MCV) administered either through routine or supplementary immunization activities, (2) develop and sustain sensitive and timely case-based measles surveillance, and (3) develop and maintain access to an accredited measles laboratory network to confirm or discard suspected measles cases and detect measles virus for genotyping and molecular analysis. 1.3 Progress toward measles elimination The Western Pacific Region has made substantial progress towards measles elimination since establishing the goal in 2003. Concerted efforts around the Region have reduced measles incidence to 11.6 cases per million population in 2011 and 4 cases per million (annualized) in the first quarter of 2012. Epidemiologic and virologic surveillance data suggest that endemic measles virus transmission already may have been eliminated in as many as 31 countries and areas. Most countries and areas that were once highly endemic for measles are reporting very few cases in 2012 through April, and many of these may be imported or import-related (Figure 1) Figure 1: Confirmed Measles Cases, by Month of Onset and Country, Western Pacific Region 2007—2012* 35,000

National SIAs conducted 30,000 CAM PHL LAO PNG

National SIAs conducted JPN PNG CHN VTN CAM PHL CAM LAO

25,000

Number of cases

20,000

15,000

10,000

5,000

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2007 2008 2009 2010 2011 2012

CHN

JPN

PHL

VTN

others

World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization * Source: WPRO measles-rubella monthly country reports as of April 2012

7 Reported MCV1 coverage has trended upward since 2003, reaching 96.5% in 2010. Thirty two countries and areas have introduced a routine MCV2 dose, with reported coverage of 91%. Supplementary immunization activities (SIAs) have been used to ensure uniformly high MCV coverage targeting children of wide age range. Over 300 million children have been vaccinated against measles during large scale SIAs from 2003 – 2011. All countries and areas of the Western Pacific Region conduct case-based, laboratory supported surveillance for measles. Intensive efforts to improve casebased surveillance in the region began in 2007. From 2007 to 2011, completeness of monthly reporting to WHO Regional Office of the Western Pacific has consistently increased from 51% to 95%, and timeliness of monthly reporting from 19% to 89%. Among 32 countries and areas reporting suspected cases to the Regional Office, 2.8 suspected measles cases per 100 000 of population were discarded as non-measles (target ≥ 2.0), and adequate blood specimens were collected from 74% of suspected measles cases (target ≥ 80%), suggesting that regionally, surveillance is sensitive in identifying and appropriately classifying suspected measles cases. However, not all countries have achieved surveillance indicator targets. Among 14 countries and areas submitting sufficient data to calculate the indicators (21 pacific island countries are considered as one epidemiologic block), 9 (64%) achieved the target discarded measles rate and 9 (64%) achieved the target adequate specimen collection rate. The Western Pacific Region measles and rubella laboratory network (LabNet) has grown to include a total of 383 laboratories, including one WHO global specialized laboratory (GSL), three WHO regional reference laboratories (RRLs) in Australia, China, and Hong Kong, 17 fully functional national measles-rubella laboratories (NMLs) including the GSL and RRLs, and, and in China, 31 provincial and 331 prefecture laboratories. In 2011, the LabNet tested specimens from 23 557 suspected measles and rubella cases.

8 2. Core principles for verification of measles elimination 2.1 Attainment of measles elimination should be verified independently for individual countries and areas, and eventually for the Region, following standard procedures and criteria. 2.2 Pacific island countries and areas, with a total population of 3.1 million, will be verified as an epidemiologic block, as done for certification of polio-free status in the Pacific sub-region. 2.3 The regional verification commission (RVC) will determine whether individual countries, the Pacific subregion, and the Region as a whole have eliminated endemic measles virus transmission. 2.4 National verification committees (NVCs) will be established to collect relevant evidence of national elimination and submit corresponding documentation to the RVC on an annual basis to report progress toward or achievement of measles elimination. National secretariats may be formed to assist the NVC in collecting data and preparing documentation. 2.5 For large countries, NVCs may also verify measles elimination for each 2nd level administrative unit, applying the same general criteria and processes as applied for the country. 2.6 National and Regional elimination will require an absence of endemic measles cases for at least 36 months. This is to ensure that re-established endemic transmission has not occurred. 2.7 Documentation will address two major criteria, supported by indicators within four components. 2.8 The RVC will may apply complimentary or alternative evidence as it deems appropriate to make a final determination of verification. Countries unable to provide data satisfying one or more component indicators indicators may still be verified as having eliminated measles as long as the RVC is satisfied that available evidence is sufficient to justify verification 2.9 The verification process may involve field assessments by RVC or NVC members if additional information or validation of documentation is required.

9

3

Standard verification criteria, components and indicators

Verification of elimination will address two criteria supported by indicators within four components, as noted above. This section describes the criteria, components and component indicators. 3.1 Verification criteria 3.1.1 3.1.2 No endemic measles virus infection for 3 years nationally and for the Region, in presence of high quality surveillance Genotype analysis indicates absence of endemic measles virus

3.2 Components and component indicators 3.2.1 Evolution of incidence, epidemiologic and virologic characteristics The country or area should be able to describe the incidence and epidemiology of measles within its borders over time, leading to a logical outcome of absence of endemic measles virus transmission. Ideally, the time period would begin prior to the year of measles vaccine introduction and conclude the year in which verification of elimination is being considered. The last five years should be particularly highlighted. 3.2.1.1 Incidence In describing incidence of measles it is necessary to classify confirmed measles by source of infection and by method of confirmation. Source of infection may be endemic, imported, import-related, or unknown. Method of confirmation may be by laboratory, epidemiologic linkage, or clinical criteria (Table 1). Definitions of these terms were listed at the beginning of the Guidelines. Table 1. Source and method of measles case confirmation* CONFIRMED Method confirmed→ Source of infection ↓ Endemic Unknown Imported Import-related Laboratory Clinically Epidemiologic Compatible Linkage B D F H I J K L

A C E G

Every confirmed or clinically compatible case of measles may be represented in one of the cells in Table 1. When measles surveillance performs well, i.e., adequate case investigations with contact tracing are routinely performed and adequate specimens are routinely collected, the numbers of clinically compatible cases populating cells I, J, K and L, depicted in brown, should be small. Measles elimination status will be determined ultimately by the absence of endemic cases corresponding to cells A and B, depicted in red. However, as cases of unknown source may also result from

10 endemic transmission, cases populating cells C and D, depicted in yellow, may be considered as possibly endemic. Imported and import-related cases are likely to continue to varying degrees after endemic measles virus has been eliminated, depending on migration patterns into and out of the country or area. Hence, cells E, F, G and H corresponding to these sources of infection and depicted in green, would be expected to be populated by a variable number of cases. A large number of confirmed cases of unknown origin (i.e., cells C and D), raise questions regarding the quality of surveillance and the ability of a country to confidently determine the absence of endemic measles virus transmission. Indicator: Proportion of confirmed and clinically compatible cases of known source of infection (Target: ≥ 80%) 3.2.1.2 Epidemiologic and virologic characteristics Descriptive epidemiologic characteristics of measles cases corresponding to time, place and person are important indicators of measles elimination. Demonstrating changes in spatial and personal characteristics of measles cases (e.g., age distribution, vaccination status) over time may be suggestive of achievement of measles elimination. Genotype and genetic characteristics also are important to verify the absence of endemic measles virus transmission. Genotypes known to be endemic in the Western Pacific Region in 2011 included at a minimum D9 (Philippines, Cambodia, Malaysia) and H1 (China, Viet Nam, Lao People's Democratic Republic). However, other genotypes including D4 and D8 are frequently imported from the European and South East Asia Region, respectively. Virologic surveillance and genetic sequencing, together with good epidemiologic investigations, are important to help differentiate endemic from imported and import-related cases and to determine if and when endemic transmission may be re-established. Epidemic curves of confirmed cases (regardless of source) are a simple way to show the evolution of measles incidence. Epidemic curve features consistent with progress leading to elimination normally include increasing intervals between clusters/outbreaks, decreasing numbers of cases in clusters/outbreaks, decreasing duration of clusters/outbreaks, increases in percentage of sporadic cases and a loss of seasonality. If many clinically confirmed cases are reported, it is often helpful to stack bars by method of confirmation. Spot maps may be prepared indicating index cases separately from secondary, tertiary and subsequent generations of cases, as well as indicating source. Consistent decreases in geographic spread of measles virus over consecutive time intervals can help confirm progress towards and eventual achievement of measles elimination. Tables and bar charts indicating age distribution and vaccination status of cases over time may also suggest progress toward elimination. As countries and areas near elimination, an increasing percentage of cases are likely to occur at the extremes of age (infants and adults) and the percentage of cases that were previously vaccinated (usually with a single MCV dose) is likely to increase. Indicator: Wide range and multiple years of epidemiologic and virologic analysis in support of achievement of elimination of endemic measles virus 3.3 Epidemiologic surveillance and laboratory performance In the setting of elimination, surveillance for measles must be sufficiently sensitive to detect any suspected measles cases and have adequate capacity for timely and

11 proper case investigation and laboratory analysis. The credibility of elimination depends on epidemiologic and laboratory surveillance quality. Standard indicators of surveillance performance have been described1 and include (1) national and subnational reporting rates of at least 2 discarded measles cases per 100 000 population; (2) adequate specimen collection from at least 80% of suspected measles cases; (3) adequate specimens for virus detection from at least 80% of lab-confirmed outbreaks and 4) adequate investigations of at least 80% of suspected cases. The measles laboratory network in the Western Pacific Region consists of 383 laboratories including one global specialized laboratory, three regional reference laboratories (RRLs) 17 national measles laboratories (NMLs) and, in China, 31 provincial and 331 prefectural laboratories. The WHO Regional Office of the Western Pacific conducts accreditation of RRls, NMLs, and the 31 Chinese provincial laboratories; almost all network laboratories were accredited as of March 2012. The network is critical for serologic (ELISA) testing for anti-measles and anti-rubella IgM, and also for virologic surveillance of virus detected from cases. WHO accredits network laboratories using well-established criteria. 3.3.1 3.3.1.1 3.3.1.2 Indicators and suggested targets for epidemiologic surveillance quality Percent of suspected cases with adequate investigation9 (target: ≥ 80% of suspected cases) Percent of suspected cases with adequate specimen collection10 (target: ≥ 80% of suspected cases, excluding epidemiologically linked cases) Discarded measles rate at national level (target: ≥ 2 per 100 000 population) Discarded measles rate at subnational level (target: ≥ 2 per 100 000 population for ≥ 80% of 2nd level administrative units) Specimens for genotypic analysis11 are available from cases associated with outbreaks (or "chains of transmission") (target: ≥ 80% of outbreaks or chains of transmission). Additional evidence For countries without systems in place to to collect the data required to calculate the four indicators above, additional evidence may be submitted to demonstrate measles surveillance sensitivity and quality For countries where substantial numbers of measles cases present to the private sector, additional evidence should be submitted to

3.3.1.3 3.3.1.4

3.3.1.5

3.3.1.6 3.3.1.6.1

3.3.1.6.2

An adequate investigation includes at a minimum collection of all of the following data from each suspected case of measles: name or identifiers, place of residence, place of infection (at least to district level), age (or date of birth), sex, date of rash onset, date of specimen collection, vaccination status, date of last vaccination, date of notification and date of investigation (excluding cases that are either confirmed as measles by epidemiological linkage or discarded as non-measles by being epidemiologically linked to another laboratory-confirmed case of communicable disease or by epidemiological linkage to a case negative for measles IgM), and travel history 10 Adequate specimens for serology are those collected within 28 days after rash onset that consist of ≥ 0.5 ml serum of ≥ 3 fully filled circles of dried blood on a filter-paper, or oral fluid. For oral fluid samples, the sponge-collection device should be rubbed for about 1 minute along the gum until the device is thoroughly wet; epidemiologically linked cases should be excluded from the denominator 11 When possible, samples should be collected from 5–10 cases early in the outbreak and every 2–3 months thereafter if transmission continues. For virus isolation, adequate throat or urine samples are those collected within 5 days after rash onset. For virus detection using molecular techniques, adequate throat samples are those collected ≤14 days after rash onset, and adequate oral fluid samples are those collected ≤21 days after rash onset.

9

12 demonstrate that cases identified by the private sector are captured by national surveillance systems 3.3.2 Indicators of laboratory performance 3.3.2.1 Measles network labs are WHO-accredited 12 for serologic and, if relevant, for virologic work (target: 100% of labs) 3.3.2.2 Proportion of laboratories (government and private) that conduct measles diagnostic testing that have adequate quality assurance mechanisms in place (target: 100% of laboratories) 3.3.2.3 Proportion of virus detection and genotyping results (where appropriate) that are completed within 2 months of receipt of specimen (target: ≥ 80% of specimens received) 3.3.2.4 Complementary evidence: completeness and timeliness of monthly reporting (including zero reporting) to the WHO Regional Office for specimens received for serologic and virologic testing (target: ≥ 80% of specimens received in the laboratory) 3.4 High population immunity Achieving and sustaining high levels of population immunity against measles in every district is a fundamental strategy to interrupt endemic measles virus transmission and prevent re-establishment of measles virus transmission when imported cases are introduced. Population immunity may be measured by annual administrative reports of routine vaccination coverage with first and second dose measles containing vaccine (MCV1 and MCV2) at the national and sub-national levels and SIA coverage as reported in the WHO and UNICEF Joint Reporting Form (JRF), as well as annual WHO-UNICEF estimates of national coverage that sometimes differ from reported coverage. Population-based surveys of routine and SIA coverage also can be useful and include WHO 30-cluster surveys, USAID-sponsored demographic and health surveys (DHS), and UNICEF-sponsored multiple indicator cluster surveys (MICS). However, limitations of population-based surveys may include lack of representativeness of all geographic areas (e.g., districts), strata of society and an inability to identify potentially large pockets of susceptible individuals. Sero-epidemiologic surveys are also useful, but suffer from the same potential limitations as coverage surveys and also potential limitations of sensitivity, specificity and predictive value of the laboratory tests for anti-measles Immunoglobulin G (IgG) as correlates of immunity. Finally, data from rapid coverage assessments (RCAs) may be an additional source of information to assess local level coverage. An indirect method for estimating population immunity relies on measles surveillance using the distribution of outbreak size as an indicator when population immunity is high: at least 80% of measles chains of transmission have < 10 cases. Additional data such as distribution of outbreak duration, number of generations of transmission, proportion of imported and import-related cases, and sero-epidemiologic survey data may feed into models that determine effective reproduction numbers (R).7,8 Experience with several Western Pacific Region countries including Viet Nam and the Philippines suggest that very high levels of protection may not be required among all adults to interrupt measles virus transmission if high coverage exists among children and adolescents, as young and school-age children appear to be a critical WHO measles laboratory accreditation criteria include (1) Annual proficiency test results ≥ 90%; (2) at least 90% concordance of NML with RRL confirmatory testing; (3) passing on-site inspection. 12

13 link in sustaining chains of measles virus transmission.14 Nevertheless, an accurate description of vaccine and natural immunity by individual birth cohort beginning the year when measles vaccine was first introduced into the country is useful to assess potential immunity gaps. Such a description should consider SIAs and changes in schedule in specific years. Special additional analysis may also be done for vulnerable population groups who potentially have less access to vaccination services, e.g. migrants, urban or rural poor, people in remote areas. 3.4.1 Indicators of population immunity 3.4.1.1 Administrative reports of MCV1 coverage, national and by district (target: ≥ 95% nationally and in every district) 3.4.1.2 Administrative reports of MCV2 coverage, national and by district (target: ≥ 95% nationally and in every district) 3.4.1.3 Administrative reports of SIA coverage, national and by district (target: ≥ 95% nationally and in every district) 3.4.1.4 Additional evidence: 3.4.1.4.1 Coverage and/or seroepidemiologic survey data (e.g., DHS, MICS, WHO 30 cluster surveys, etc.) 3.4.1.4.2 Descriptions of intensified efforts made to identify and reach high risk populations (migrants, remote, poor, ethnic minorities, etc.) through routine and supplementary immunization Sustainability of measles elimination (and the national immunization programme) (NIP) Verification of measles elimination should include an assessment of whether elimination can be sustained. The assessment aims to (1) highlight strengths and weaknesses of national immunization programmes that are linked to maintaining high routine and/or supplementary immunization coverage and high quality surveillance, and (2) encourage the preparation of costed preparedness plans for needed responses to potential outbreaks resulting from measles virus importations. Sources of information for national immunization programme (NIP) sustainability include JRF reports, comprehensive Multi-Year Plans (c-MYPs) for immunization, national EPI reviews, and other sources. This last verification component is indicative of measles elimination's role in strengthening routine immunization and surveillance systems, and ensuring equity in immunization service delivery. Such sustainability assessments may be incorporated into larger programme reviews and feasibility assessments of new immunizationrelated initiatives, and can also be used to strengthen health systems overall. 3.4.2 Indicators 3.4.2.1 Evidence of plans and financing for routine immunization and achieving and sustaining measles elimination including SIAs, surveillance and lab, while fostering cooperation with other relevant sectors 3.4.2.2 Documented evidence of monitoring and reviewing progress against the above plans 3.4.2.3 Documented programmatic risk assessment

Sniadack DH, Mendoza-Aldana J, Huyen, DTT, et al. Epidemiology of a measles epidemic in Vietnam, 20082010. JID 2011 (suppl 1): S476-S482.

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14 3.4.2.4 Budgeted importation and outbreak preparedness and response plans in place

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4

Structure of verification bodies

4.1 RVC and NVC structure The Regional Verification Commission (RVC) and National Verification Committees (NVCs) will work together to verify measles elimination in each country and area, and for the Pacific island countries and areas as a group (Figure 2). The RVC will be the only body authorized to verify measles elimination in countries and areas, and for the region as a whole. The NVC will determine when countries and areas are ready for verification, submit the necessary documentation to the RVC for its consideration, and coordinate the collection of relevant data that demonstrate measles elimination. Figure 2: Organizational Structure of RVC and NVC Regional Verification Commission

National Verification Committee

National Verification Committee

National Verification Committee

National Verification Committee

Sub-regional Verification Committee (forPacific)

4.2 RVC and NVC membership and appointment RVC and NVC members should be independent and objective, and therefore they should not be involved directly in the management and operations of their respective NIPs or epidemiologic and laboratory-based VPD surveillance. Members should be senior subject-matter experts with different areas of expertise such as epidemiology, pediatrics, public health practice, virology and molecular biology. RVC members and officers (chair, vice-chair, rapporteur) are appointed by and report to the Director of the WHO Regional Office of the Western Pacific and remain independent of the WPR Technical Advisory Group on Immunization and vaccine preventable diseases (TAG), although they may share information and reports with the TAG. RVC members will serve terms of two years, with the possibility of renewal. To avoid any potential or perceived conflicts of interest, each RVC member will complete and sign a declaration of interests form prior to each RVC Meeting. NVC members will be appointed by their respective Ministers of Health and report to the RVC. A minimum of five members should be represented on the NVC and as with the RVC, should ideally represent different areas of expertise including epidemiology, pediatrics, public health practice, virology and molecular biology. NVC members should also provide periodic written declaration of interests to prevent potential conflicts of interest. As the 21 Pacific island countries and areas are to be considered as one epidemiological block for the purpose of verification of measles elimination, a subregional verification committee (SRVC) will be formed in the same manner as for certification of polio-free status. SRVC members will be appointed by the Director of the WHO Regional Office of the Western Pacific and will serve in a similar way as an NVC for the Pacific with the same terms of reference (below).

16 It should be noted that, particularly in countries and areas with small populations, it may be difficult to identify national experts without professional linkages to their respective NIPs, surveillance units or Ministries of Health. In such situations, the requirement for absolute independence of some NVC members may be waived on a case-by-case basis. However the RVC would need to be satisfied that the NVC is sufficiently objective when controversial issues such as data quality may arise. 4.3 Secretariat support to RVC and NVCs The WHO Regional Office of the Western Pacific will serve as the secretariat for the RVC. NVCs may establish their own Secretariats, such as the NIP and Vaccine Preventable Disease surveillance units, to provide necessary evidence of measles elimination. In the countries with WHO country offices, WHO staff may provide technical and operational support to both the Secretariats and NVCs. Countries and areas without WHO country offices are welcome to consult with the WHO Regional Office of the Western Pacific for assistance when necessary.

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5

Mechanism of verification

Authority to verify measles elimination will be vested solely in the RVC, which will assess progress toward, achievement of, and maintaining measles elimination in countries and areas of the Region annually leading ultimately to regional verification of measles elimination. The NVC will similarly assess measles elimination status within its borders, determine when a country or area is ready for verification, and assist their Ministries of Health prepare the necessary evidentiary documentation for submission to the RVC. The RVC will guide NVCs, and NVCs will guide NIPs and VPD surveillance units with respect to requirements to verify measles elimination. In this respect, the RVC and NVCs will serve as de facto advisory bodies on fulfilment of verification criteria and the components of verification. Insofar as the indicators within the components are directly related to WHO-recommended measles elimination strategies, the RVC and NVCs also will serve as de facto national advisory bodies for measles elimination. Guidance provided by RVC and NVC members should be consistent with recommendations from the Western Pacific Region Technical Advisory Group (TAG) on Immunization and VPDs. The TAG should be consulted in the event of discrepant technical opinions by the RVC. The RVC should be consulted in the event of discrepant technical opinions by any NVC. In addition to their normative, verification and advisory functions, RVCs and NVCs may also serve an advocacy role to promote measles elimination activities. 5.1 RVC functions and terms of reference 5.1.1 5.1.1.1 Normative function To review and establish criteria and procedures for documenting and verifying the achievement of measles elimination nationally and for the Region Advisory & verification functions - national To advise NVCs on verification criteria, requirements and procedures, including guidance on (1) collecting and analyzing data needed for verification, and (2) proper documentation. To review and analyze the annual reports submitted by national verification committees To conduct field visits when needed to monitor progress and verify evidence. To monitor progress and determine national verification status and recommend pathways of verification for delayed or provisionally approved countries and areas. To monitor progress toward accelerated rubella control and CRS prevention and, if established as a national or regional goal, rubella elimination. Verification function - regional To verify achievement of measles elimination for the region. To monitor progress toward accelerated rubella control and CRS prevention and, if established as a national or regional goal, rubella elimination.

5.1.2 5.1.2.1

5.1.2.2 5.1.2.3 5.1.2.4

5.1.2.5

5.1.3 5.1.3.1 5.1.3.2

18 In addition, the RVC Chair will serve a leadership and management function 5.1.4 5.1.4.1 5.1.4.2 5.1.4.3 5.1.4.4 Management function of RVC Chair To preside over RVC meetings to be held at least once a year To define internal operating procedures and RVC member responsibilities To supervise the documentation and verification process To prepare and submit annual meeting/verification reports to RD who will then share with Member States through appropriate channels

5.2 NVC functions and terms of reference 5.2.1 5.2.1.1 Advisory and assessment function To advise Ministry of Health (MOH) , the NIP and the VPD surveillance units on requirements for verification of measles elimination To compile and analyze information from the MOH to monitor progress toward measles elimination and assess if the country or area can verify elimination of endemic measles virus in accordance with established criteria and components To conduct field visits when needed to monitor progress, assess data quality and validate analyses and assessments To provide guidance and propose feasible alternatives if standard verification data are not sufficient or consistent To supervise and guide the annual verification documentation process at the country level, propose feasible alternatives if standard verification data are insufficient and endorse the government's annual verification report before submission to the RVC To monitor progress toward accelerated rubella control and CRS prevention and, if established as a national or regional goal, rubella elimination. To provide programmatic guidance consistent with verification criteria and components.

5.2.1.2

5.2.1.3 5.2.1.4 5.2.1.5

5.2.1.6

5.2.1.7

As with the RVC chair, the NVC Chair also will serve a leadership and management function 5.2.2 5.2.2.1 5.2.2.2 Management function of NVC Chair To define internal procedures and responsibilities of committee members in accordance with guidelines provided by the RVC To prepare an NVC plan of action (POA) including activities, timeline, expected outcomes, and human and financial resource requirements in collaboration with the NIP and MOH, and to present the POA to the RVC for approval To preside over NVC meetings to be held at least twice per year To attend RVC or other regional meetings when required

5.2.2.3 5.2.2.4

19 5.3 Advocacy function for both RVC and NVCs 5.3.1 To raise awareness of and commitment to measles elimination, targeting high ranking health officials, health professionals, partners and political leaders through multiple channels such as national health conferences, scientific seminars, media, personal contacts.

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6

Post-verification needs

After verification of measles elimination, countries and areas will need to sustain measles elimination and prevent re-establishment of endemic measles virus transmission by continuing the same strategies recommended to eliminate measles: (1) high population immunity against measles through supplementary and/or routine immunization; (2) high quality epidemiologic and virologic surveillance; (3) access to a WHO-accredited laboratory. Moreover, countries and areas should have budgeted preparedness plans in place in the event of import-related measles outbreaks. Annual assessments should be conducted by governments with NVC assistance, and annual reports submitted to the RVC. The RVC in turn will review annual country and area reports and field visits when necessary, and provide feedback and recommendations through to governments through NVCs.

21 Summary of Criteria, Components and Indicators for Verification of Measles Elimination Criteria: 1. No endemic measles virus infection for 3 years nationally and for the Region, in the presence of high quality surveillance 2. Genotype analysis indicates absence of endemic measles virus Components: 1. Measles incidence, epidemiologic and virologic characteristics (absence of endemic virus) 1.1. Proportion of confirmed and clinically compatible cases of known source of infection (Target: ≥ 80%) 1.2. Wide range and multiple years of epidemiologic and virologic analysis in support of achievement of elimination of endemic measles virus 2. Epidemiologic surveillance and laboratory performance 2.1. Epidemiologic surveillance performance 2.1.1. Percent of suspected cases with adequate investigation (target: ≥ 80% of suspected cases) 2.1.2. Percent of suspected cases with adequate specimen collection (target: ≥ 80% of suspected cases, excluding epidemiologically linked cases) 2.1.3. Discarded measles rate at national level (target: ≥ 2 per 100 000 population) 2.1.4. Discarded measles rate at subnational level (target: ≥ 2 per 100 000 population in ≥ 80% of 2nd level administrative units) 2.1.5. Specimens for genotypic analysis are available from cases associated with outbreaks (or "chains of transmission") (target: ≥ 80% of outbreaks or chains of transmission) 2.1.6. Additional evidence 2.1.6.1. For countries without systems in place to collect the data required to calculate the four indicators above, additional evidence may be submitted to demonstrate measles surveillance sensitivity and quality 2.1.6.2. For countries where substantial numbers of measles cases present to the private sector, additional evidence should be submitted to demonstrate that cases identified by the private sector are captured by national surveillance systems 2.2. Laboratory performance 2.2.1. Measles network labs are WHO-accredited 15 for serologic and, if relevant, for virologic work (target: 100% of labs) 2.2.2. Proportion of laboratories (government and private) that conduct measles diagnostic testing that have adequate quality assurance mechanisms in place (target: 100% of laboratories)

WHO measles laboratory accreditation criteria include (1) Annual proficiency test results ≥ 90%; (2) at least 90% concordance of NML with RRL confirmatory testing; (3) passing on-site inspection.

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22 2.2.3. Proportion of virus detection and genotyping results (where appropriate) that are completed within 2 months of receipt of specimen (target: ≥ 80% of specimens received) 2.2.4. Complementary evidence: completeness and timeliness of monthly reporting (including zero reporting) to the WHO Regional Office for specimens received for serologic and virologic testing (target: ≥ 80% of specimens received in the laboratory) 3. Population Immunity 3.1. Administrative reports of MCV1 coverage, national and by district (target: ≥ 95% nationally and in every district) 3.2. Administrative reports of MCV2 coverage, national and by district (target: ≥ 95% nationally and in every district) 3.3. Administrative reports of SIA coverage, national and by district (target: ≥ 95% nationally and in every district) 3.4. Additional evidence: 3.4.1. Coverage and/or seroepidemiologic survey data (e.g., DHS, MICS, WHO 30 cluster surveys, etc.) 3.4.2. Descriptions of intensified efforts made to identify and reach high risk populations (migrants, remote, poor, ethnic minorities, etc.) through routine and supplementary immunization 4. Sustainability of measles elimination in the context of a sustainable NIP 4.1. Evidence of plans and financing for routine immunization and achieving and sustaining measles elimination including SIAs, surveillance and lab, while fostering cooperation with other relevant sectors 4.2. Documented evidence of monitoring and reviewing progress against the above plans 4.3. Documented programmatic risk assessment 4.4. Budgeted importation and outbreak preparedness and response plans in place