Global Measles and Rubella Management Meeting
Geneva, 15-17 March 2011
Towards Measles Elimination
in the Western Pacific Region
Progress & Priorities
Dr. David Sniadack and Dr. Wang Xiaojun
Western Pacific Regional Office, WHO
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Presentation Outline
•
•
•
•
Progress towards measles elimination
Updates on rubella control
Priority activities in 2011-2012
Unmet funding needs
Regional Committee Resolution, 2010
WPR/RC61.R7
Reaffirmed the 2012 measles elimination goal
Urged member states
– to commit the human and
financial resources
– to develop and implement work
plans
– to regularly report surveillance
data to WPRO
– to establish independent national
verification process following the
establishment of standardized
regional verification mechanisms
by WPRO
– to accelerate control of rubella
and the prevention of congenital
rubella syndrome
Requested the RD
– to establish regional verification
mechanism
– to strengthen technical
cooperation with Member States
to achieve regional immunization
goals
– to seek additional resources to
achieve regional goals utilizing
frequent ICC meetings and other
mechanisms
– to report progress periodically to
the Regional committee
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Reported Measles Cases and MCV1 Coverage
Western Pacific Region 1980 – 2010
1400000
100
90
1200000
80
number of cases
Number of cases
100000
800000
600000
92% reduction
106,172
97,577
60
80000
60000
48,113
40000
20000
29,844
23,113
23,756
15,031
50
50,227
29,975
21,345
21,247
3,742 3,662
0
400000
year
14,494
8,836
8,914
95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10
200000
40
30
20
10
0
year
70
coverage (%)
120000
1000000
0
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10
Measles Accelerated
EPI
Measles Control
Measles Elimination
Control
WPR cases w/o CHN
China cases
WHO estimates
Source: WPRO surveillance database
WHO/UNICEF JRFs ,1980-2010
Measles Incidence*
Western Pacific Region 2010
* per million population
LEGEND
< 1.0 (22)
1.0 – 9.9 (6)
10.0 – 49.9 (5)
50.0 – 99.9 (2)
Data pending (1)
Source: WPRO surveillance database, 2010
Initiatives to Improve Routine Measles Coverage,
Western Pacific Region, 2010-2011
• District approach: tackling low performing districts
– Region: Capacity building through an inter-country workshop
– China: Yellow-card warning mechanism (Guangxi, Guizhou)
• Service delivery: responding to under-served populations
– LAO PDR: planned increase in frequency of outreach services (4 to 6 times)
– Philippines: Reaching Every Barangay strategy (REB) and urban poor project
– Cambodia: Reaching Every Community Strategy (REC)
A chain is only as strong as its weakest link
SIA in China
5 provinces:8m-14y
3 provinces: 8m-6y
23 provinces: 8m-4y
CHN
102.3 million
LAO (9-59m)
3.0 million
CAM (9-59m)
1.5 million
Measles SIAs in 2010-2011
Western Pacific Region
PHL (9-95m)
18 million
LEGEND
2010 (CHN, VTN, PNG, TUV, FSM*)
FSM (12m-83m,Chuuk)
6762
VTN (9-71m)
7.0 million
PNG (6-35m)
0.5 million
2011 (CAM, PHL, LAO)
TUV (12-71m)
1095
2010
2009
Measles Incidence
10.0 – 49.9 (4)
50.0 – 99.9 (2)
Completeness and Timeliness of Country Reporting to WPRO
Western Pacific Region 2007-2010
100%
94%
85%
81%
79%
80%
61%
60%
51%
47%
40%
19%
20%
0%
2007
2008
2009
Completeness
2010
2007
2008
2009
2010
Timeliness
•Source: WPR surveillance database
Indicators of Progress Towards Measles Elimination
Western Pacific Region 2007-2010
Category
Target
2007
2008
2009
2010
73.7
81.6
34.0
30.3
Incidence (per million population)
Confirmed measles cases (confirmed by lab, epidemiologic
linkage or clinically)
High Quality Surveillance
National reporting of discarded measles cases
> 2 per
100 000
2.5
1.6
2.8
2.5
% of 2nd administrative levels reporting ≥ 1/100 000
discarded measles cases
> 80%
31%
27%
43%
35%
% of suspected cases with adequate investigation
> 80%
27%
47%
36%
35%
% of suspected cases with adequate blood specimens
> 80%
65%
62%
72%
67%
Proportion of clinically confirmed measles cases
<10%
83%
48%
25%
52%
National MCV1 coverage
> 95%
92%
93%
96%
NA
National MCV2 coverage
> 95%
86%
88%
94%
NA
High Population Immunity
Source: WPRO surveillance database
Measles and Rubella Lab Network
+331 prefectural labs
382 laboratories
1 GSL
3 RRLs
16 National (13 fully functional)
31 provincial
+ 331 prefectural
Probability of Measles Elimination
by country, Western Pacific Region
88.4% of
the regional
population
4.1% of the regional population
7.5% of the regional population
LEGEND
At/near (25)
Likely (6)
Hopefully (6)
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
1600
1400
Measles Cases by Month
Viet Nam 2008– 2010
number of measles cases
1200
1000
800
600
400
2010(N = 1151)
Jan
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
May
Mar
Jan
Feb
Dec
Oct
2009(N = 3797)
Nov
Sep
Jul
Aug
Jun
Apr
May
Mar
Jan
Feb
Dec
Oct
2008(N = 1144)
Nov
Sep
Jul
Aug
Jun
Apr
May
Jan
Feb
0
Mar
200
2011(N
= 3)
Year and Month
1400
1200
1000
Number of cases
Measles Cases by Age
Viet Nam Oct 2008 – 2010
800
600
400
200
0
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39<=40
age in years
Source: Surveillance data
Laboratory Confirmed and Epi-Linked
Measles Cases, by Month, Viet Nam
2010 – 2011*
Measles Cases, by Province
Viet Nam 2010-11*
200
180
Number of Cases
160
north
140
central
highland
south
December 2010
120
100
80
60
40
20
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
January 2011
Jan-Nov 2010
* Data from surveillance reports through March 2011
Dec 2011– Jan 2011
Confirmed Measles Cases, by Week of Rash Onset,
2009-January 2011
Philippines 2010
1 dot = 1 case
Lab Confirmed and Epi-linked Measles Cases,
by Age, 2010
650
600
575
550
500
450
Number of Cases
400
350
314
300
236
250
200
131
150
109 119 108
100
87
44 46 45 43
50
30 26
46 42 42
21 19
8
27 21
16 19
11 15 14 16 12 17
41
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 ≥30
age in years
Lab-Confirmed Measles Cases, by Age Group
and Vaccination Status, Cambodia 2010
Laboratory Confirmed Measles Cases
and Discarded Rates, Cambodia 2010
45
40
35
30
number of cases
25
20
15
10
1 dot = 1 lab case
5
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 3940+
age in years
Discarded rate (per 100,000)
<1
1 – 1.9
≥2
Rubella Control in WPR
Regional Plan for Control of Rubella and Prevention of Congenital
Rubella Syndrome in the Western Pacific Region, 2010-2015
Goal: To achieve and maintain control of rubella and prevention of CRS in the WPR
–
Rubella: ≤ 10 / 1 million population, excluding imported cases
–
CRS: ≤ 10 / 1 million Live births, excluding imported cases
July 2010
Nov 2010
WPR: 41 per million
population
Rubella Incidence
Western Pacific Region 2009
LEGEND (per million population
< 1.0 (21)
1.0 – 9.9 (8)
10.0 – 19.9 (3)
20.0-99.9 (4)
Data source: JRFs
History of RCV Use in WPR
Protecting F & M ≥ 20 yrs (16)
Protecting F ≥20 yrs (5)
CAM, LAO, VTN
Protecting F & M ≥ 15 yrs (4)
Recent introduction of RCV (5)
RCV to be introduced (6)
PNG, SOL, VAN
Data source: WPRO surveillance and laboratory database
2009 (N= 1049)
89% <20y
Philippines
>=45yr
40-44yr
35-39yr
30-34yr
25-29yr
20-24yr
15-19yr
10-14yr
5-9yr
1-4yr
<1yr
>=45yr
40-44yr
35-39yr
30-34yr
25-29yr
20-24yr
15-19yr
10-14yr
5-9yr
1-4yr
<1yr
>=45yr
40-44yr
250
200
150
women
0
2008(N= 270)
2009(N= 568)
<1yr
1-4yr
5-9yr
10-14yr
15-19yr
20-24yr
25-29yr
30-34yr
35-39yr
40-44yr
>=45yr
2008 (N= 690)
35-39yr
30-34yr
25-29yr
20-24yr
15-19yr
women
<1yr
1-4yr
5-9yr
10-14yr
15-19yr
20-24yr
25-29yr
30-34yr
35-39yr
40-44yr
>=45yr
5-9yr
10-14yr
400
<1yr
1-4yr
5-9yr
10-14yr
15-19yr
20-24yr
25-29yr
30-34yr
35-39yr
40-44yr
>=45yr
Number of cases
<1yr
0
1-4yr
Number of cases
Rubella Cases by Sex and Age Group
2008-2010
500
450
men
350
300
Viet Nam
Females: 60% CBA
100
50
2010 (N= 1758)
400
350
300
men
250
200
150
100
50
2010(N= 884)
Priority Activities of Measles Elimination
Western Pacific Region, 2011-2012
Closing immunity gaps, focusing on priority countries
•
•
•
•
Conducting quality SIAs, incorporating MR when feasible
⁻ 2011: CAM (Feb-Mar, MV, ? Oct), PHL (Apr, MR), LAO (Nov, MR)
⁻ 2012: PNG and several Pacific island countries
Improving routine MCV1 and MCV2 coverage
– Introduction of MCV2 (CAM > 80% since 2008)
– Exploring practical approaches to identifying under-served population
groups/communities and improving their access to immunization
services
⁻ Link to needed solution to address quality gaps in previous SIAs
(vaccination of children 5-14 years old in CAM)
Identify and implement appropriate approach to and strategies for
immunizing adults
– Key constraints: funding, vaccine production capacity (MV or MR)
Epidemiologic analysis of adult measles cases in Beijing, China in
collaboration with US CDC and WHO
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Priority Activities of Measles Elimination
Western Pacific Region, 2011-2012
Continue to improve surveillance, maintain accredited lab network, and
provide more support to priority counties
• Regional Level
– Publish Measles and Rubella Bulletin monthly (planned in April 2011)
– Frequent data analysis of countries
– Update/revise field measles guidelines, incorporating rubella
– Accreditation of all RRLs and NMLs in 2011
• Country level
– Capacity building at country level: surveillance workshops
• CAM, LAO, PNG, VTN
– Country visits, followed by extensive follow-up actions
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Priority Activities of Measles Elimination
Western Pacific Region, 2011-2012
Initiate preparation for verification of measles elimination
• Establish regional verification committee for measles elimination
• Develop guidelines on verification of measles elimination for the
region
• Organize 1st regional verification commission meeting (September
2011)
• Assist countries in initiating preparation upon country requests
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Priority Activities of accelerating Rubella Control & CRS
Prevention, Western Pacific Region, 2011-2012
• Encourage introduction of RCV in Member States
– With > 80% MCV coverage: CAM (GAVI support), VTN
– With a need for frequent SIAs: LAO, PNG, SOL, VAN
• Establish CRS sentinel surveillance (CHN, VTN)
• Studies on disease burden of CRS (LAO, PHL, VTN)
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Unmet Funding Need in Priority Countries*
Western Pacific Region, 2011
Activity
Surveillance
Lab network
SIAs
Others
Total
Total costs
$784,000
$500,000
$9,376,000
CRS, Verification, TA
$4,000,000
Allocataion
Funding request to
Fund allocated by Gaps in WPRO funding allocation as
WPRO
WPRO
Amount
Proportion
$338,000
$193,000
$145,000
43%
$496,000
$256,000
$240,000
48%
$3,669,000
$1,688,000
$1,981,000
54%
$188,000
$30,000
$158,000
84%
$4,691,000
$2,167,000
$2,524,000
54%
Unmet need
$3,500,000
Fund (USD)
$3,000,000
$2,500,000
$2,000,000
$1,500,000
$1,000,000
$500,000
$0
Surveillance
Lab Network
SIAs
Others
Activity
* Priority countries/areas for funding support: CHN, CAM, LAO, MOG, PHL, PNG, VTN, PICs
Thank You
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Additional slides
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Korea
Mongolia
D8, 1 D4, 1
D11, 1 B3, 1
D9, 1
A, 1
B3, 1
B3 from Libya
H1, 1
H1, 1
D9 from Thailand,
B3 from France
Hong Kong
China
H1, 5
H1, 38
D9, 1
A, 4
B3, 1 D9 from Philippines,
B3 from South Africa
D9, 1
Viet Nam
H1, 232
A, 1
Japan
D5, 1
D8, 1
Macao
H1, 2 D9, 2
G3, 2
Philippines
H1, 22
Lao PDR
H1, 2
D9, 9
D9, 6
Cambodia
H1, 1
G3, 1
D9, 2
D9, 3
H1 from Vietnam
Malaysia
Singapore
D8, 1
G3, 3
H1, 2
B3, 1
A, 3
H1, 12
D4, 9
D9, 8
D9, 1
D8, 18
Australia
H1, 1B3, 1
New Zealand
D4, 2
D8, 6
Genotypic distribution of Measles
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
virus in WPR 2009-2010
Reported MCV1 and MCV2 Coverage
by Country/Area, Western Pacific Region 2009
MCV1
MCV2
100
95
90
85
Coverage (%)
80
16
Non-Pacific Island Countries
75
70
65
60
55
50
45
40
BRU
CHN
VTN
HOK
MAA
SIN
KOR
MOG
JPN
AUS
CAM
MAC
NEZ
PHL
LAO
PNG
Country
MCV1
100
MCV2
95
90
85
Coverage (%)
80
75
70
65
20
Pacific Island Countries
60
55
50
45
40
NIU
TOK
TON
NRU
FRP
NEC
WAF*
TUV
CNMI
MIC
AMS*
KIR
GUM*
VAN
MSI
COK
BLA
FIJ
SOL
SMA
Country
* For five countries with 2009 dataWorld
not available,
coverage data
were used,
including
AMS (2008),
WAF
(2007), GUMProgramme
(MCV1 in 2005,on
MCV2
in 2008)
Healthhistoric
Organization
• Western
Pacific
Regional
Office
• Expanded
Immunization
Source: WHO/UNICEF JRFs, 2009
Reported Measles Cases, China 2009 – 2011*
16,000
14,000
Measles SIA
number of cases
12,000
10,000
8,000
6,000
Decrease from
previous year
4,000
2,000
44%
44% 65%
2009 (N= 59950 )
2010 (N= 44597 )
Feb
Nov
Dec
Jan
Aug
Sep
Oct
Jun
Jul
Mar
Apr
May
Jan
Feb
Oct
Nov
Dec
Jul
Aug
Sep
May
Jun
Feb
Mar
Apr
Jan
0
2011
(N=
1799 )
World
Health2011
Organization • Western Pacific Regional Office • Expanded Programme on Immunization
*Surveillance report through
February
0 5
10 15 20 25 30 35 40 45 50
Trends in Age Distribution and Geographic Spread of Measles
Viet Nam October 2008-2010
ON D J FMAM J J A S ON D J FMA M J J AS OND OND J FMAM J J A S OND J FMA M J J AS ON D OND J FMAM J J A SON D J FMA M J J A S ON D ON D J FMAM J J A S OND J FMAM J J A S ON D
north
Oct-Dec08
central
Jan-Jun09
highland
Jul-Dec09
south
Jan-Dec10
Confirmed Measles Cases, by Month of Rash Onset,
Philippines 2003 – January 2011
1600
D3
D9
1400
1200
number of cases
1000
800
National SIA, Feb and Mar 04
(9m-7yr)
National SIA, Oct -Dec 07
(9m-4yr)
600
400
D9. G3
200
0
J FMA M J J A S ON D J FM AM J J A S O ND J FMAM J J A S OND J FMA M J J A S ON D J FM AM J J A S O ND J F MAM J J A S OND J FMA M J J A S ON D J FM AM J J A S O ND J F
2003
2004
2005
2006
Year and Month
2007
2008
2009
2010
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
'11
Laboratory Confirmed Measles Cases
Philippines 2010 - January 2011
Oct 2010
Nov2010
Dec 2010
Jan2011
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Measles Cases, by Month of Rash Onset and Method of
Confirmation, Cambodia 2003 – 2011*
400
Clinically Confirmed
Lab confirmed
350
Number of cases
300
Phased National Dec 2000May 2004
(9m - 14yrs)
- Change to AFR
- Incentives
250
National SIA ,
Feb - Apr 07
(9m - 59m)
200
150
100
50
0
J FM AM J J A S OND J FM AM J J A S OND J FMA M J J A S O ND J FMA M J J A S O ND J FMA M J J A S O ND J FMA M J J A S O ND J FMAM J J A S ON D J F MAM J J A S ON D J F
2003
2004
2005
2006
2007
2008
2009
2010
Year and Month
* Data reported as of March 2011
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
'11
Reported Rubella Cases and RCV Coverage
Western Pacific Region 1993-2009
140,000
Number of cases
Coverage (%)
127,305
Incidence (2009): 41 per million population
100
120,000
80
100,000
With disease data from China
Reported coverage
80,000
85,236
73,655
Coverage estimate with China data
60,000
40
42,947
40,000
27,124
20,000
4,006
3,496
5,770
3,540
6,738
965
3,911
7,854
6,866
4,564
60
28,713
20
5,076
0
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Data source: WHO/UNICEF Joint Reporting Forms, 1993-2009 and measles rubella surveillance data
Challenges of Measles Elimination
Western Pacific Region
• High measles incidence in several countries
• Evolving epidemiology
– Shifting to infants and adults
– Increased risk of measles transmission in densely populated urban
areas
• Importation and exportation
– Importation: to Australia and New Zealand from several
countries and Regions
– Exportation: from Philippines to Australia, Canada, Japan,
New Zealand and U.S.
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Challenges of Measles Elimination
- Immunity Gaps
• Difficulty in ‘eliminating’ immunity gaps
– Inadequate monitoring to identify low coverage areas/
populations
– Inadequate systems and/or resources to increase
responsiveness to under-served populations
– Identifying and addressing quality gaps in previous SIAs
– Identifying and implementing appropriate strategies to
address measles in infants and adults
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Challenges of Measles Elimination
- Surveillance
• Low sensitivity of surveillance at sub-national levels
• Difficulty in timely obtaining accurate epidemiologic data
– Delayed and incomplete case investigation data
– Discrepancies between lab reports and national reports
• Large proportion of clinically confirmed cases in some countries
• Inadequate attention to collecting specimens for virus detection
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Challenges of Measles Elimination
• Funding gaps: Increasing needs
and decreasing resources/sources
• Competing priorities and
stretched HRs
• High level and broad political
commitment
– Interest and confidence in measles
elimination
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Reasons for Missed Opportunities to Rubella Control
• Lack of evidence
– Although rubella case are identified in greater numbers, CRS is
under-reported and under-recognized in most developing
countries in the region, resulting in less priority
• Lack of motivation
– Perception that control of rubella and prevention of CRS is an
additional task: health officials are not motivated especially under
pressure of eliminating measles by 2012
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Confirmed Measles Cases, by Week of Rash Onset,
2009-January 2011
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Rubella Cases by Sex and Age Group
Western Pacific Region 2008-2010
Data source: WPRO surveillance and laboratory database
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
Laboratory Confirmed Measles Cases, by
Age, Cambodia 2010
45
40
35
30
number of cases
25
20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 3940+
age in years
N = 457
World Health Organization • Western Pacific Regional Office • Expanded Programme on Immunization
