REGIONAL COMMITTEE Sixty-second Session Kathmandu, Nepal 7–10 September 2009
Provisional Agenda item 9 SEA/RC62/8 21 July 2009
MEASLES The global goal for measles control is reducing measles mortality by 90% in 2010 in comparison to 2000. Nevertheless, the Americas (2002), the Eastern Mediterranean (2010), Europe (2012) and the Western Pacific regions (2012) of WHO have set their respective measles elimination goals. The African Region has set a pre-elimination goal of reducing measles mortality by 98% in 2012 compared to 2000 estimates. In the South-East Asia (SEA) Region, which has a measles morality reduction goal, four Member States are implementing measles elimination strategies and all Member States except India have reached an advanced stage of measles mortality reduction. With the success in the Americas and progress in three regions with an elimination goal, there is interest in exploring the feasibility of setting a global measles elimination goal. Accordingly, the 125th session of the WHO Executive Board directed the WHO Secretariat to submit a report on the “feasibility of global elimination of measles” to the 126th session of the Executive Board in January 2010. The Regional Office will also organize a regional consultation from 25-27 August 2009 to consider the feasibility of a regional measles elimination goal. This paper presents an update on the progress in achieving the goal of measles mortality reduction in the SEA Region. The important considerations in establishing a measles elimination goal include achieving high and sustainable routine immunization coverage; a highly sensitive surveillance system; availability of funding; adequate vaccine supply of assured quality; and application of lessons learnt from polio eradication. The High-Level Preparatory (HLP) Meeting for the Regional Committee reviewed this paper, asked the Secretariat to update it in light of the discussions, and recommended the inclusion of “measles” on the agenda of the Sixty-second Session of the Regional Committee to be held in September 2009. The outcome of the regional measles consultation (August 2009) will be attached as an annex to this document. The HLP meeting also proposed a draft resolution for the consideration by the Regional Committee. The paper is now submitted to the Sixty-second Session of the Regional Committee for its consideration, and for its decision regarding the resolution proposed by the HLP meeting.
SEA/RC62/8
Feasibility of setting a measles elimination goal in the South-East Asia Region 1. In 2003, the World Health Assembly through resolution WHA56.20 endorsed the goal of reducing measles mortality by 50% by 2005 relative to 1999 estimates. Although Member States in the South-East Asia (SEA) Region had been implementing measles control activities since 2000, the resolution provided them with impetus to accelerate the implementation of intensified measles control strategies. 2. In line with the resolution, in 2003, the SEAR Technical Consultative Group for Polio Eradication and Control of Vaccine Preventable Diseases (TCG) endorsed the Regional Strategic Plan for Measles Mortality Reduction for 2003-2005. The plan provided a framework for countries to contribute to the global measles goal. The key strategies were: (1) (2) (3) (4) 3. Improving and sustaining routine immunization coverage; providing a second dose of measles vaccine through catch-up immunization campaigns and routine second dose/follow-up immunization campaigns; improving measles surveillance by including tracking, and investigating suspected measles outbreaks and laboratory confirmation of outbreaks; and improving case management including administration of vitamin A.
With a 60% global mortality reduction by 2005, this goal was achieved1.
4. In 2005, the World Health Assembly resolution WHA58.15 endorsed the Global Immunization Vision and Strategies (GIVS) goal, that by 2010 or earlier, mortality due to measles will be reduced by 90% compared to the 2000 level. 5. In 2007, taking into account the regional progress in measles control, the Regional Measles Strategic Plan 2007-2010 was revised to incorporate the 90% measles mortality reduction goal. 6. According to the implementation status of this plan, the Region can be categorized into: •
Member States implementing elimination strategies: Bhutan, DPR Korea, Maldives and Sri Lanka have successfully implemented all WHO-recommended strategies and have surpassed the 90% measles mortality reduction goal. Member States at an advanced stage of measles mortality reduction: Bangladesh, Indonesia, Myanmar, Nepal, and Timor-Leste have successfully implemented strategies for measles mortality reduction and have achieved or are close to achieving the 90% measles mortality reduction goal. Member States with delayed or partial implementation of measles mortality reduction strategies: India has developed a strategic plan for measles mortality reduction. However, full implementation has been delayed and India has not conducted a catch-
•
•
1
Wolfson, L.J., Strebel, P.M., et al.; Has the 2005 measles mortality reduction goal been achieved? A natural history modeling study. Lancet 2007, 369: 191-200.
SEA/RC62/8 Page 2
up campaign. Thailand has achieved high-level coverage for routine first and second doses of the measles vaccine, but has not conducted a catch-up campaign yet. 7. Consequent to the implementation of the recommended strategies, measles routine immunization coverage in the Region increased from 61% in 2000 to 73% in 2007. The weighted average coverage of all Member States other than India increased from 77% to 85%. From 2000-2008 all Member States except India and Thailand have conducted measles catchup campaigns and immunized 120 million people, mainly children. WHO has estimated that between 2000 and 2007 the annual number of measles deaths in the SEA Region reduced by 42% (from 235 000 to 136 000). However, achievement by the Region of the 90% measles mortality reduction goal depends on India accelerating the implementation of its measles mortality reduction strategic plan. 8. Although there is no global goal for measles elimination, the WHO Region of the Americas achieved regional measles elimination in 2002. The Eastern Mediterranean Region (2010), the European Region (2010) and the Western Pacific Region (2012) have a measles elimination goal. Measles elimination is technically feasible because the causative organism has only a human host, there is an effective intervention available (measles vaccine with high efficacy), and sensitive and specific diagnostic tools are available. The strategies for measles elimination are the same as for sustainable measles mortality reduction. For elimination, however, the strategies have to be implemented with higher intensity to reach higher targets in routine immunization coverage, providing a second dose and surveillance to ensure population immunity to stop the transmission of measles virus. 9. With the success in the Americas and progress in three regions with an elimination goal, there is interest in exploring the feasibility of setting a global measles elimination goal. Accordingly, the 125th session of the WHO Executive Board directed the WHO Secretariat to submit a report on the “feasibility of global elimination of measles” to the 126th session of the Executive Board to be held in January 2010. 10. The recently concluded High-Level Preparatory (HLP) Meeting for the Regional Committee reviewed the measles situation in the Region and made the following observations: •
For sustainable measles mortality reduction, routine immunization coverage needs to be increased above 90% nationally and above 80% in all districts. Nevertheless, an initial catch-up campaign and periodic follow-up campaigns for susceptible children can keep measles mortality at a lower level until routine immunization is improved. For measles elimination, immunization coverage for both doses of measles vaccine needs to be more than 95% in all districts. The second dose is usually provided through a nationwide catch-up campaign followed by either a routine second dose or through periodic follow-up campaigns. High-quality surveillance is important for pursuing the elimination goal. There is a need for WHO technical support in this area, including an expanded role in measles surveillance for WHO-supported surveillance networks. Activities for measles elimination need to be identified, funding requirements estimated and political commitment obtained, prior to setting an elimination target.
•
•
•
SEA/RC62/8 Page 3
•
Before setting a regional elimination goal a thorough understanding of the regional situation, the estimated costs and sustainability issues need to be understood by Member States. In this regard, the regional consultation on measles planned for 25-27 August 2009 is very important. It should be attended by both technical and policy-level officials from Member States. It should provide appropriate evidence and information for the Regional Committee’s deliberations and guidance on the feasibility of setting a regional measles elimination goal, and for Executive Board members from the Region to enable proactive participation in the discussion on measles at the 126th session of the Executive Board in January 2010.
•
11. The HLP meeting recommended that “measles” be included as an item on the agenda of the Sixty-second Session of the Regional Committee to be held in September 2009, and that an updated working paper be submitted. The summary recommendations of the regional measles consultation will be attached as an annex to the working paper. 12. The important considerations in establishing a measles elimination goal include the following: (1) Definition of elimination and eradication: At its April 2009 meeting, WHO’s Strategic Advisory Group of Experts concluded that measles eradication is defined as the worldwide interruption of measles transmission and that the simultaneous elimination of measles in all WHO regions would equate to global eradication. The Region of the Americas has defined regional elimination as a situation where endemic transmission of measles cannot occur and sustained transmission does not occur for more than 12 months following the occurrence of an imported case. High and sustainable immunization coverage: Programmes aiming to achieve elimination should target reaching and sustaining >95% coverage with two doses of measles vaccine in all districts of the country. This can be accomplished through a combination of routine delivery and/or mass vaccination campaigns. For most countries this will involve improving coverage with the first dose through routine services, conducting a one-time measles nationwide catch-up campaign to cover all susceptible individuals and conducting periodic follow-up campaigns. When MCV1 coverage reaches >80% coverage for at least three years, a routine MCV2 dose can be added. Follow-up supplementary immunization campaigns should be continued until routine immunization coverage for both doses can be maintained at > 95%. A highly sensitive surveillance system: The surveillance system must be strengthened so that (i) high sensitivity is achieved at national level to detect at least two nonmeasles suspected measles cases per 100 000 population; (ii) more than 80% districts of the country are able to detect at least one non-measles suspected measles case per 100 000 population per year; (iii) 80% suspected measles cases are tested in a WHOaccredited laboratory for measles IgM; and (iv) virus isolation is achieved in 80% transmission chains (outbreaks). Availability of funding: Achieving and sustaining immunization and surveillance standards will be a huge challenge in some of the large countries of the Region and will require substantial investment of financial and human resources. Because the international funding available from the Measles Initiative for mortality reduction is
(2)
(3)
(4)
SEA/RC62/8 Page 4
substantially reduced for the next biennium, the cost implications need to be carefully considered. (5) Vaccine supply of assured quality: A regional elimination goal would require a cohort of 274 million children in India alone aged less than ten years to be immunized against measles through a catch-up campaign. In addition, large countries like Thailand need to conduct measles catch-up campaigns for susceptible children. India, Indonesia, Bangladesh, Myanmar and Nepal need to conduct periodic follow-up campaigns every three to four years for children born after the previous campaign. This would create challenges of supplying vaccine of assured quality and programmatic issues related to injection safety, adverse events after immunization (AEFI) and waste management. Lessons learnt from polio eradication: There are important lessons to be learned from polio eradication such as the importance of government ownership of the programme, the need to work within and strengthen the primary health care approach, the critical importance of a strong routine immunization system and high routine immunization coverage, the investments needed, both financial and technical, and the contribution of the polio eradication infrastructure to the successes achieved in measles mortality reduction, etc. Competing priorities: Polio eradication is an unfinished business in the SEA Region, and the continued demands on technical and financial resources are substantial and will continue to be so until the job is finished. Most of these resources will be needed in India, which also has the largest estimated burden of measles mortality in the Region. Member States are also faced with other health priorities that compete for resources, such as tuberculosis, malaria, HIV/AIDS and other emerging infections. Political will and support from society: In order to set an elimination goal for the Region, political and societal support will be needed, together with the technical/epidemiological expertise necessary to document it.
(6)
(7)
(8)
13. The challenges identified above are not overwhelming; nor should the persistent nature of some of the challenges preclude the Member States from pursuing measles elimination, and the Region from considering a measles elimination goal. The progress in mortality reduction made in the Region so far demonstrates that setting a goal of measles elimination in the SEA Region is technically feasible. The Region of the Americas has demonstrated this by achieving regional measles elimination. The Eastern Mediterranean Region adopted a regional measles elimination goal despite having endemic polio in two of its Member States. Although external funding for measles control has declined recently, establishing a regional elimination goal could revive global interest and generate increased levels of funding. There is also the potential for fostering commitment at country level; this could result in internal funding as well. Financial support from GAVI to several recipient countries in the Region also provides them with an opportunity to strengthen their routine immunization systems in parallel, which is the foundation of a successful measles elimination programme. 14. The Regional Committee is invited to consider the working paper and pass the proposed resolution on the next steps towards adopting a regional measles elimination goal.
SEA/RC62/8 Page 5
Annex Table 1: Reported number of measles cases in the South-East Asia Region (1990-2008) Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor Leste SEA Region 1990 1 705 173 – 89 612 92 105 0 7 900 182 4 004 29 244 – 224 925 2000 5 098 418 – 22 236 47 788 20 861 9 397 16 527 4 074 – 106 419 2001 4 414 756 – 37 969 21 595 0 1 639 10 849 309 7 319 – 84 850 – 51 780 19 534 926 736 6 749 139 10 241 0 93 616 2002 3 484 27 – 44 004 24 457 77 830 13 344 65 4 565 94 91 503 2003 4 067 0 2004 9 743 3 0 51 546 29 171 37 1 274 12 074 35 4 165 41 108 089 2005 25 935 11 0 52 454 15 853 1 395 302 5 023 3 3 328 203 104 507 2006 6 192 2 0 60 751 20 422 47 735 2 838 0 3 499 90 94 576 2007 2 924 11 3 550 36 900 19 456 20 1 088 1 415 44 3 893 0 69 301 2008 2 660 7 82 48 181 15 266 0 333 2 089 33 7 016 0 75 667
Source: WHO/UNICEF JRF.
Table 2: Measles vaccination coverage during infancy in the South-East Asia Region (1990-2008) Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor Leste 1990 65 93 98 56 58 96 90 57 80 80 ND 2000 76 76 78 54 72 99 84 71 99 94 ND 2001 77 78 92 55 70 99 73 71 99 94 ND 2002 75 78 98 56 72 99 77 71 99 94 39 2003 76 88 95 59 72 96 76 75 99 96 55 2004 81 87 95 61 72 97 78 73 96 96 55 2005 88 93 96 64 72 97 72 74 99 96 48 2006 88 90 96 67 72 97 78 85 99 96 64 2007 88 95 99 67 72 97 80 81 98 96 63 2008* 85 99 98 102 80 97 82 79 98 98 73
Source: 1990-2007: WHO/UNICEF Coverage Estimates; *2008-Country Official Estimates N.B. - ND = No data
SEA/RC62/8 Page 6
Table 3: Measles supplementary immunization campaigns conducted in countries of the South-East Asia Region (2000-2008) Country Bangladesh Bhutan DPR Korea Indonesia Maldives Myanmar Nepal Sri Lanka Timor-Leste SEA Region Year 2005-2006 2006 2007 2000-2007 2005/2006 2002-2004 2007 2004-2005 2008 2003-2004 2003-2004 Type Catch Up Catch Up Catch Up Catch Up Catch Up Catch Up Follow Up Catch Up Follow Up Catch Up Catch Up 2000-2008 Target age group 9M- 10 Y 9M-15 Y & 15-44Y (F) 6 M-45 Y 6M - 15 Y 6-25 Y & 25-34Y (F) 9m - 5 Y 9M-5Y 9M - 15 Y 9M - 5 Y 10 - 14 Y and 16 to 20 Y 9M - 15 y Coverage Target 35 680 911 338 040 16 123 376 42 712 567 144 997 5 670 597 6 056 000 9 423 867 3 903 515 3 878 173 519 005 124 451 048 Vaccinated 36 012 154 332 041 16 109 432 40 316 089 123 642 4 910 950 5 706 351 9 839 723 3 634 277 3 259 281 285 126 120 529 066 Percentage Coverage 100.9 98.2 99.9 94.4 85.3 86.6 94.2 104.4 93.1 84.0 54.9 96.8
Fatal adverse events following measles immunization in the South-East Asia Region Bangladesh: In 2003 Bangladesh reported three deaths following measles immunization in a routine immunization clinic. On investigation it was found that these deaths had most likely occurred due to toxic shock syndrome that could have resulted following contamination of the reconstituted vaccine. Myanmar: In 2005 and 2006 there were nine fatal adverse events following all EPI vaccines in routine immunization clinics. However on investigation it was found that eight of these events were coincidental events. In one case, the cause of death was unknown. India: India had three clusters of fatal adverse events following measles immunization in routine immunization clinics of three states in 2008. In one cluster, where four deaths occurred, the cause of death was found to be due to toxic shock syndrome. The investigations in respect of the other two clusters detected no apparent cause of death. Discussion on adverse events following immunization (AEFI) episodes: In the case of all the episodes mentioned above, after excluding the coincidental events, it was found that it was the errors made by the EPI programme staff in the handling and use of vaccines that had mainly resulted in these episodes. The vaccine itself was not implicated. WHO monitors AEFI across the Region through monthly reports submitted by the Member States. WHO has also been invited by government(s) concerned to investigate most of these episodes. It remains committed to supporting governments in the strengthening of AEFI monitoring systems through the formation of AEFI committees and training the members of these committees on AEFI causality assessment. These clusters of deaths following measles vaccination have all occurred in the setting of routine vaccination. To date no fatal AEFIs have been recorded during measles Supplementary Immunization Activities (SIAs) in the Region. This highlights the importance of using measles SIAs as a means to retrain all EPI staff, especially vaccinators, in safe injection technique.