Global Measles and Rubella
Management Meeting
Progress and Challenges
in Bangladesh
RAJSHAHI
SYLHET
15-17 March, 2011
Geneva, WHO HQ
DHAKA
CHITTAGONG
KHULNA
BARISAL
Dr Serguei Diorditsa
Measles control plan (2004-2010)
and next goals in Bangladesh
30000
Measles control plan 2004-2010
cMYP 2011-2016
100
95
25000
Measles catch-up campaign
immunized: >35 million
90
85%
85
15000
80
Measles follow-up campaign
immunized: >18 million
plus OPV, vit A ,albendazole
10000
In 2011-2016, cMYP
elimination target
Including 2nd dose
MCV2 introduction
75
70
5000
65
0
60
2002
2003
2004
2005
2006
2007
2008
2009
Measles death ( revised WHO 2010 estimates)
Source: Child deaths due to measles 2000-2009 by WHO estimation, 10 Feb 2011
2010
MCV1 Coverage
2016
Coverage
Number of deaths
20000
Trends of measles cases and valid measles
coverage by one year of age (1990-2010)
Measles follow-up campaign
30000
immunized: >18 million
100
25000
90
81
78
71
70
67
65
69
67
62
59
60
54
59
65
64
61
69
20000
71
15000
Measles catch-up campaign
immunized: >35 million
61
10000
53
Measles Case from JRF
MCV1 Coverage (CES)
10
20
09
20
08
20
07
20
06
20
05
20
04
20
03
02
20
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
19
19
19
19
93
0
92
40
91
5000
90
50
Number of cases
80
Percentage
83
81
85
Spot Map of Outbreaks Reported
in Bangladesh
Measles catch-up campaign
immunized: >35 million
2005
Measles follow-up campaign
immunized: >18 million
2006
2007
2008
2009
2010
Dots are randomly placed within district boundary
Year
# of measles outbreaks
( lab) and ( mixed)
# of rubella outbreaks
2005
2006
2007
2008
2009
2010
203
51
5
1
2
0
87
26
102
59
145
193
Age Distribution of Lab Confirmed
Measles Outbreak Cases, Bangladesh,
2003-2010*
2010
No Laboratory Confirmed Measles Outbreak detected in 2010
23%
2009
2008
2007
50%
17%
13%
45%
10%
26%
6%
4%
6%
N=48 (1)
N=132 (1)
No Laboratory Confirmed Measles Outbreak detected in 2007
2006
13%
2005
13%
2004
14%
2003
14%
31%
37%
35%
34%
43%
30%
38%
<1 year
1-4 years
35%
5-9 years
10-14 years
>=15 years
12%
7%
N=2,095 (34)
11%
6%
N=9,378 (120)
8%
10%
Unknown
4%
4%
N=5,248 (68)
N=523 (12)
Measles Cases in Bangladesh by Year
2003-2010
20,000
18,000
Outbreak
surveillance
Case based surveillance
Measles catch-up campaign
immunized: >35 million
16,000
Number of Cases
14,000
12,000
Measles follow-up campaign
immunized: >18 million
10,000
8,000
6,000
4,000
2,000
0
2003
2004
2005
Routne(suspected)
Changes in definition of outbreak:
2003: 50 cases per ward
2005:10 cases per ward
2008: 3 cases per ward
2006
2007
2008
Lab Measles and Mixed
2009
Rubella
2010
Measles surveillance indicators
SL Indicators
1
Annual national incidence of non measles suspected measles cases (Target more
than 2 per 100,000 population)
2
Percentage of districts annually reporting at least 2 non measles suspected measles
case per 100,000 population (Target at least 80% districts)
3 Annual number of reported rubella cases
4
Percentage of reported suspected measles outbreaks fully investigated (Target
100%)
2009
2010
9.8
9.6
45%
58%
13,464 13,125
100%
100%
5 Completeness of monthly VPD surveillance reports (Target 90%)
91%
90%
6 Timeliness of monthly VPD surveillance reports (Target 80%)
84%
84%
Percentage of suspected measles cases tested in a proficient laboratory, excluding
7 from the denominator any cases that are epidemiologically linked to a laboratory
confirmed case (Target 80%)
75%
81%
8 Percentage samples with laboratory results within 14 days (Target 80%)
52%
56%
Virus isolation status
Year
No. of
urine
Sample
collected
2008
8
2009
2010
Sample
tested in
regional
lab
Measles
Rubella
Negative
Pending
5
0
0
5
0
27
16
0
3
13
11
59
0
59
Non-measles suspected cases
reporting rate
58% (37/64) districts achieved rate ≥2.00 in 2010
2009
2010
Non Measles Rate
Number of Districts
per 100,000
2009
2010
Legend
population
No Case
4
0
<1.00
28
23
1.00 - 1.99
3
4
≥ 2.00
29
37
Measles vaccination valid coverage by
12 months of age, 2005 and 2010
81% (52/64) districts achieved ≥80% coverage in 2010
2005
2010
Legend
Source: CES 2005 and 2010
Coverage
MCV1
Number of Districts
2005
2010
<70%
27
1
70-79%
23
11
≥80%
14
52
Challenge to improve Surveillance
indicators
Measles case based surveillance -Integrated with AFP and other VPD
Challenge: financial sustainability and transition of VPD
network parallel to health systems
140 facilities included for weekly
active surveillance for AFP, NT and
Measles- at the same time they are
reporting 6 EPI diseases on weekly
basis
All 471 Upazila Health Complexes
(UHCs) included in weekly passive
reporting
156 additional facilities conduct
weekly passive reporting
VPD surveillance supported by WHO funded
network of 42 SMOs
ICDDRB study on Impact of Measles Activities on
Routine Immunization Services and Health Systems
in Bangladesh
T. Koehlmoos et al. The Journal of Infectious Diseases ( in press)
Conclusion:
•
Measles elimination activities had enormous positive impacts on immunization programme and health
systems of Bangladesh
•
Effective integration of the immunization programme with health systems, high level political commitment
and effective inter-agency collaboration contributed the campaigns successful
Examples of impacts:
Governance
•Strengthened inter-ministerial
coordination and collaboration
•Effective collaboration between
MOHFW and development
partners
•Increased involvement of other
sectors in immunization
programme
•ICC becomes more active
•Raised awareness among
political leaders
•Improved accountability of staff
members of the EPI programme
Planning and management
•Improved skills of staff to
develop strategies in EPI
planning at national to local
level
•Improved skills to management
of mass campaigns
•Identifying and mapping of
target and hard-to-reach
population for other EPI
outreach activities
•Stimulate interdepartmental &
inter-sectoral planning
•Better long term planning of
financing
EPI service delivery
•Injection safety
•Management &
surveillance of AEFI
•Increased awareness among
community members due to
huge publicity
•Delivery of add-on’s
interventions (vitamin A,
deworming, OPV)
•Increased EPI centres and
clinic visits of people after
campaigns resulted to do less
motivational works
ICDDRB study (cont’d)
Examples of impacts
Impact on Financing
Impact on human resources
Positive
•Increased stock of EPI workforce/volunteers
•Contributed development of inter-personal
communication among the staff members of
different sectors
•Created opportunity for staff members involved
from other department of MOHFW to learn more
about EPI
•Helped to develop skills in fundraising from local and international
partners
•Funding or in-kind support for
campaigns release money for other
EPI activities
•Motivated government & other
funders to invest more money in EP
Negative
Staff members de-motivated from late arrival of
funding
EPI staff feel overloaded with added works
Shortage of technical staff
The campaigns did not attract a sufficient number of
volunteers in some areas as their refreshment fund
were not enough
Impact on Logistics
•New equipments were kept as fixed
assets for routine immunization
•Training and technical assistance to
the local staff increased their skills
and confidence to maintain cold chain
Budget for integrated VPD surveillance and
measles activities in 2011-2013
( in million USD)
2011
planned
2012
available
gap
planned
2013
available
gap
planned
availabl
e
gap
MCV 2
vaccine
Bangladesh will apply to GAVI for MCV2 cost support
MR vaccine
Bangladesh consider the cost of MR vaccine to be born from new Health Sector Programme
for 2011-2016
MCV2
Introduction
-Training &
supervision
surveillance
2,5
2,0
0,5
Total gap
0.5
Total Gap for 2011-2013
1,22
0
1,22
2,3
1.0
1.3
Total gap
1.52
3,32 million USD
2.3
1,0
1.3
Total
gap
1.3
Thank You
2011 Plans and budget
• Measles initiative co-financed activities of WHO
surveillance network in 2007-2010
• No funds for specific measles surveillance strengthening
activities in 2011.
• In 2011 WHO SMOs network will continue support the
current level of measles in integration with AFP
surveillance.
• No donor’s commitment to support surveillance network
after 2012
Budget for integrated (AFP/Measles/Other
VPDs) surveillance and measles control/
elimination activities 2011-2016
Activities
Fund
required
yearly 20112016
Annual Surveillance
operational cost
2.5 million
MCV2
Government will apply for GAVI support for vaccine
MCV2 IntroductionTraining & supervision
Fund
required
one time
2012
1.22
million
Fund available
Funding
gap
2011-2016
1.5 million x2 l
(in 2011-2012)
9,5 million
0
Funding
gap one
time
1.22
million
Logistics –printings and
others for MCV2
Cost is under consideration for next health sector program 2011-2016
MR vaccine
Vaccine Cost is under consideration for next health sector program
2011-2016
Measles SIA
No plan developed
Total 2011-2016
12.5 million
Total Gap
1.22
million
3 million
9,5 million
1.22
million
10,72 million
Advocacy Plans and Opportunities
• Advocate to include measles elimination activities in the
new national health sector development plan for 20112016 including:
 Funds for surveillance activities
 Create national position of district immunization and surveillance medical
officers (DISMO)
 Introduce MR vaccine and allocate cost in the health sector plan
• EPI will apply for GAVI support on MCV-2 introduction
• Advocate for donors support of WHO surveillance
network to maintain current activities and during the
transition to DISMOs