Measles and Rubella
in WHO Region of
Europe:
Regional Update
Dr. Abigail Shefer
Technical Officer
Accelerated Disease Control and Elimination
Vaccine-preventable Diseases and Immunization
WHO Region of Europe
• 53 member states
• 12 time zones
• 4 official languages
• Measles & Rubella/Polio
elimination/eradication goals
Elimination Goals
http://www.euro.who.int/__data/assets/pdf_file/0003/88086/RC55_eres07.pdf
Events in the WHO European Region, 1980–2013
100
90
600000
Vaccination coverage
Number of reported measles cases
80
500000
Lowest number of
measles cases recorded:
6936
400000
70
60
50
Elimination goal
reset to 2015
300000
200000
All 53 Member
States have
2-dose MCV
schedule
Accelerated
package of
action
40
30
20
100000
10
0
0
% coverage with measles-containing vaccine (MCV1)
700000
Measles in the WHO European Region,
1993–2013*
341 982
Lowest measles
cases recorded
98%
REDUCTION
1993
Bulgaria,
22 004
France,
14 949
37
073
30 625
Ukraine,
12 744
Turkey,*
6 547
25 022 20 601 *
6 936
2007
2008
2009
2010
2011
2012
2013*
* Provisional data for January–June 2013.
Rubella in the WHO European Region,
2000 and 2011–2013*
621 039
2000
98%
Ukraine,
3 667
REDUCTION
9 672
2011
Romania,
20 812
Poland,*
35 740
30 509 36 097*
2012
2013*
* Provisional data for January–July 2013.
Percentage of reported measles cases by age group
January-June 2013
30%
25%
20%
29%
26%
25%
20%
17%
14%
15%
10%
5%
5%
15%
9%
10%
10%
10-14 15-19
Age group (years)
30%
25%
21%
20%
15%
10%
13%
9%
11%
7%
6%
5%
5-9 10-14 15-19 20-29 ≥30
Age group (years)
<1
30%
(n=1750)
1-4
5-9 10-14 15-19 20-29 ≥30
Age group (years)
Germany (n=1097)
26%
0%
5-9
1-4
United Kingdom
30%
5%
1-4
Georgia (n=5783)33%
0%
13%
<1
6%
4%
0%
<1
15%
35%
≥20
25%
20%
17%
15%
10%
16%
12%
10%
9%
9%
5%
% of reported measles cases
20%
30%
Turkey (n=6533)
% of reported measles cases
33%
% of reported measles cases
% of reported measles cases
35%
% of reported measles cases
WHO European Region (n=20 533)
35%
25%
25%
20%
20%
15%
15%
12%
10%
10%
12%
6%
5%
0%
0%
<1
1-4
5-9 10-14 15-19 20-29 ≥30
Age group (years)
<1
1-4
5-9 10-14 15-19 20-29 ≥30
Age group (years)
Progress towards goal
 All Member States use 2 doses of measles containing vaccine
 All Member States adopted rubella immunization programme
 Regional immunization coverage levels remained high
 Supplementary immunization activities (2005-2012)
>>> 44.6 million doses with measles-containing vaccines
 67 national and subnational laboratories are fully accredited
 Surveillance tools for evidence-based decision making are available
e.g. immunization registries, genotyping data, seroprevalence
studies, vaccine supply
Challenges to Achieving Goals
Suboptimal
coverage and
immunity gaps at
subnational level
Lack of national
case-based
surveillance for
measles and
rubella*
Political, public, and
health professional
complacency
Continued
outbreaks and lack
of comprehensive
response
Resources for low
and middle income
countries to address
gaps in coverage
* In 2012, 13 Member States lacked national case based surveillance for Measles and 29 for Rubella
Root causes
Awareness and
risk/benefit perceptions
at all levels
• Public
• Health Professional
• Government
Health care systems
in transition
• Funding, organization,
and availability of
services
Advocacy and communication by WHO and
national health authorities
Target audiences
•Parents, health care providers, underimmunized teenagers
and adults, immunization programme managers
•Diverse national, regional, and local cultures
•Range of views on immunization: supportive, hesitant, antivaccination, complacent, uninformed
Objectives
•Educate about vaccine-preventable diseases and vaccines
•Change immunization behaviour
•Maintain or restore confidence in existing vaccines
•Introduce and create demand for new vaccines
•Inform on vaccine-related events, disease outbreaks
•Interact – to influence as well as understand public’s views
and motivations
Accelerated package of action for the elimination
of measles and rubella in the WHO European Region
COMMUNICATIONS,
INFORMATION AND
ADVOCACY
OUTBREAK
PREVENTION AND
RESPONSE
3
4
SURVEILLANCE
2
STRENGTHENING
OF VACCINATION
AND IMMUNIZATION
SYSTEMS
1
http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/vaccines-andimmunization/publications/2013/measles-and-rubella-elimination-2015.-package-for-accelerated-action-2013-2015
5
RESOURCE
MOBILIZATION AND
PARTNERSHIPS
6
VERIFICATION OF
MEASLES AND
RUBELLA
ELIMINATION
1. Strengthening of Vaccination and Immunization Systems
 National programmes
 Training of coordinators/mid level management on RED/Immunizations (1-2 subregional/yr)
 Training and follow-up missions to improve vaccine management (1-2 MS/yr)
 Assessment and follow-up missions on implementation on national regulatory
authority improvement plans (4 missions total/yr)
 Training to improve immunization information systems (2 sub-regional/yr)
 National immunization technical advisory groups (NITAGs)
 Impact assessment of existing NITAGs and dissemination of results (by 2014)
 Promotion of NITAG establishment in 18 MS still lacking (visits to 2-4 MS/annum)
 Publication of guidance and best practice document (by June 2014)
 Guide to tailoring immunization programs (TIP) – see next slide
Guide to Tailoring Immunization Programmes (TIP)
 Innovative Guide to assist Member States in tailoring
vaccination responses to unique needs of most vulnerable
populations
– Diagnose problems and define subpopulations through quantitative and
qualitative methods
– Deliver targeted campaigns and services
– Increase demand for vaccination
 Launched in April 2013
 Status – Implementation in at least 2 Member States per year
– In use 4 Member States by end 2013
 Evaluation and resource requirements – Qualitative through
online surveys, key informant interviews, focus groups
http://www.euro.who.int/__data/assets/pdf_file/0003/187347/The-Guide-to-Tailoring-Immunization-Programmes-TIP.pdf
2. Surveillance
 Case-based surveillance
 Technical assistance plan to achieve case-based rubella reporting (2-4 MS/yr)
 Technical assistance plan to develop monthly CRS reporting (6-8 MS/end 2014)
 Implementation of MRSM* to improve surveillance reporting (4-6 MS/2013-15)
 Lab and epi data integration
 MS: Implementation of pilot to integrate lab/epi data (2-4 MS/by end 2014)
 Regional: MRLDMS* to integrate lab/epi data (by end 2013)
 Vaccine safety
 Publication of manual on vaccine safety risk management (2014); sub-regional
trainings (3/ yr); training package for CME accreditation (mid 2014)
* MRSM = Measles Rubella Surveillance Module; MRLDMS = MR Laboratory Data Management System
3. Outbreak response and preparedness
 Regional Guidelines for Outbreak Response (2013)
 Publication Sept 2013
 Verification process for MR elimination
 Change to include requirement for submission of national outbreak response
plans for review as part of annual status reporting (2014)
 Coordination of response to outbreaks in Region
 Measles outbreak in Caucasus and Turkey started in 2012
 Sub-regional meeting attended by AZR, GEO, ARM (July 2013, Tblisi, GA)
 Consensus to conduct catch-up or SIAs – plans under development
4. Communication and advocacy, 2013
•Tools for HCWs and imm. programme managers – talking with parents
about vaccines, TIP, managing response to vaccine safety events, etc.
•Tools for parents – decision-making guides, smartphone immunizationreminder app
•In-country communication capacity building – 3 sub-regional training
programmes, national comms reviews, establishment of vaccine comm.
working group (first in Estonia, template for other MS), high-level measles
advocacy meeting, outbreak comms support in specific countries
•Internet – “Gold standard” website template on imm. and vaccinepreventable diseases for public health authorities
•Social media – smartphone apps, FaceBook, YouTube, Twitter, email,
blogs, peer-sharing on EIW campaign site (increasingly important –
governments at various stages of implementation and engagement with the
public)
•Public events – European Immunization Week (all 53 Member States
participating), campaigns to introduce new vaccines, catch-up campaigns
•Traditional media – high-profile M&R media interviews, op eds (Lancet)
5. Resource mobilization and partnerships
 Regional: Enhance cross border collaboration between Regions
for outbreak response
 Secure funding source for revitalization of MECACAR* platform (by June
2014)
 Organization of cross-border (European and Eastern Mediterranean regions)
coordination meeting (to be held by June 2014)
 Revitalize MECACAR
 Develop and endorse Joint MR Activity Plan
* MECACAR = Middle East and Caucasus and Central Asian Republics
6. Verification of measles and rubella elimination
National Verification Committees
37 established 16 pending
Framework for the verification process
► Importance of high quality
data
33 Annual Status Reports
(2010-2012)
► Necessary information
available at:
www.euro.who.int
MRI Support Needed
 Middle income countries (not GAVI eligible)
 Support for any kind of supplemental immunization activities
 Support for outbreak response
 Vaccine supply, with consideration of legal regulation in affected countries
(vaccines registered for use)
 Developing new strategies to address susceptible population
 Adults
 HCWs
 Migrant population (diversity of groups and characteristics)
 Developing MS capacities to implement new strategies
 Legal
 Advocacy and communication
 SOP for health system (institutions and HCW)
Supplementary slides
Measles and rubella incidence per million total population
and MCV1 Coverage, WHO European Region, 1999-2013
SIA conducted in selected Countries
* Monthly MR reporting to WHO European region until July 2013
Source: Source: WHO/UNICEF JRF and month MR reporting to WHO European region
Update : 05-Sep-2013
Confirmed measles cases by month,
WHO European Region, 2005-Jul 2013
Source: Monthly MR reporting to WHO
European region
Update: 05-Sep-2012
Countries with highest number of measles
cases in the WHO Europe, 2010 - 2013
Country
Bulgaria
France
Ukraine
Romania
Turkey
Italy
Georgia
United Kingdom
Spain
Germany
Total
% of all measles in
the WHO Europe
WHO Europe
2010
2011
2012
2013
21,664
5,019
42
187
15
864
22
397
285
805
155
14,966
1,313
4,178
105
5,187
64
1,083
3,507
1,600
1
859
12,744
7,247
698
691
30
1,903
1,210
168
15
190
1,959
1,041
6,983
106
6,451
1,811
105
1,385
21,835
21,034
16,058
12,653
7,801
6,848
6,567
5,194
5,107
3,958
29,300
32,158
25,551
20,046
107,055
95.95
87.28
90.28
88.36
90.44
30,537
36,845
28,301
22,688
118,371
Data as of 05 Sept 13; Source – CISID monthly measles and rubella surveillance, WHO Europe
Total
Countries with highest number of rubella
cases in the WHO Europe, 2010 - 2013
Country
2010
2011
2012
2013
Poland
4,197
4,290
6,259
35,740
Romania
354
4,805
20,772
84
Bosnia and Herzegovina 1,861
23
0
0
Russian Federation
1
2
1,003
0
Ukraine
0
0
942
9
Italy
43
105
246
0
Georgia
60
64
67
163
Bulgaria
40
40
19
5
United Kingdom of Great Britain
12 and Northern
6
Ireland
69
10
Spain
9
10
63
3
Total
6,577
9,345
29,440
36,014
% of all measles in
97.65
98.74
99.46
99.77
the WHO Europe
WHO Europe
6,735
9,464
29,601
36,098
Data as of 05 Sept 13; Source – CISID monthly measles and rubella surveillance, WHO Europe
Total
50,486
26,015
1,884
1,006
951
394
354
104
97
85
81,376
99.36
81,898
Proportion of measles cases by age groups,
WHO European Region 2010-2013
52.7%
(>95 000 Cases)
Data Source: Monthly MR reporting to WHO European Region
*Data as of 05 Sep 2013
Proportion of measles cases by age groups,
seven countries and the Region, 2010-2013
(>95 000 Cases)
Data Source: Monthly MR reporting to WHO European Region
*Data as of 05 Sep 2013
Immunization status as a percentage of measles cases,
by age group, WHO European Region 2010-2013*
(>95 000)
Data Source: Monthly MR reporting to WHO European Region
Data as of 05 Sep 2013
Case-based surveillance, European Region 2013
CASE- BASED
REPORTING
IS
CRITICAL
FOR ELIMINATION
Measles incidence Jan-Jun 2013 and major outbreaks in
the European Region
Measles outbreaks in 2013
Azerbaijan
Georgia
Germany
Netherlands
Romania
Turkey
Ukraine
United Kingdom
Rubella incidence in Jan-Jun 2013 and major outbreaks in the
European Region 2008-2013
Rubella outbreaks
(2008 – 2013)
Austria
Bosnia and Herzegovina
Georgia
Italy
Kyrgyzstan
Malta
Netherlands
Poland
Romania
Russian Federation
Ukraine
Sixty-third Regional Committee
16-18 September 2013, Izmir, Turkey