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Measles in EMR
7th Annual Meeting of Partners for Measles Advocacy
Washington, 2007
Regional progress in measles elimination
Key constraints
Indicators to monitor measles elimination in EMR
Outline
Routine infant immunization > 90% coverage MCV1 in all districts
Strategy for Measles Mortality Reduction and Elimination in EMRO
Second dose of measles vaccine either through a 2 dose schedule or follow-up SIAs
> 90% coverage in all districts
Catch-up vaccination susceptible cohorts
Case-based surveillance
Optimized case management
Trends in Measles Case Counts and MCV1 Coverage in EMR, 1995-2006*
0
25
50
75
100
125
150
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Year
Mea
sles
cas
es (
1000
s)
0
20
40
60
80
100MCV1 coverage (%)
* Preliminary, 2006
Geographic Distribution of Children not Receiving MCV1 in EMRO, 2005 (n=2.8 million)
41%
20%
13%6% 7%
5%
8%Pakistan
Sudan
Afghanistan
Yemen
Somalia
Iraq
Others
Palestine
Bahrain
Supplemental Immunization ActivitiesMeasles Campaigns in EMRO through 2005
Preschool and school age (15)School age (5)
Ongoing (2)
Tonga
Fash
oda
Panyijar
Rumbek-Cueibet
Kajo Keji
Budi
91.1%Torit
Akobo
Pochalla
Wuror
Waat
Aweil EastAweil North
Raja
Terekeka 101.3%
Ezo 105.4%
Juba
74.2%
Yirol
Tambura 103.4%
Tonj
Pibor
North Bor
MundriMaridi 87.3% Maruko Payam missed out
Magwi
Twic
Wau
Yambio
Yei
GogrialAweil South
South Bor
Kapoeta
64.2%
Awerial
Aweil West
Rubkoana
Guit
Koch
Mayom
Nyirol
Ayod
Diror
Latjor
Leer
Sobat
Renk
Ruweng
Old Fangak Atar
Measles Campaign Coverage in South SudanStatus by County (Jan 28, 2007)
Completed
Ongoing
Micro plans ready
Not yet micro-planned
Area of campaign
% of country targeted
Target pop No. children vaccinated
% coverage
2005
NW (6 districts) 5 160,563 137,581 85.7
NE (18 districts) 7 182,993 142,571 78.2
CS (5 districts) 3 102,976 80,495 78.2
2006
NWZ(14 dist) 15.4 542,104 387,787 71.5
CSZ (78 dist) 67.7 2,266,917 1,838,729 81
Catch-up Campaign in Somalia, 2005-06
Measles Vaccine Doses Administered in Catch-up Campaigns, 1999-2006 EMRO
0
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
45,000,000
1999
2000
2001
2002
2003
2004
2005
2006
Year
Do
ses
adm
inis
tere
d
Reduction in Measles Mortality in EMR, 1999-2005
0
20,000
40,000
60,000
80,000
100,000
120,000
1999 2000 2001 2002 2003 2004 2005
Year
Deaths
50% mortality reduction target
Planned Supplemental Measles Immunization; 2007-08 .
Catch-up campaigns
Follow-up campaigns
High-risk/mop-up campaigns
Recommended SIAs in EMR that are not Planned; 2007-08 .
Catch-up campaigns
Follow-up campaigns
High-risk/mop-up campaigns
Pakistan Catch-up Campaign • Phase 1
• Mar 2007 •1 district in 4 provinces (2.6M target)
• Phase 2• Jul 2007 • parts of NWFP, Baluchistan, Fana, AJK (8.2M)
• Phase 3• Aug 2007• Finish NWFP, Bal, AJK (5.3M)
•Phase 4• Nov 2007 (13.6M)• Sindh
• Phase 5• 1st Qtr ’08 (34.0M)• Punjab
• 19 countries with 2 dose schedule 12 at 12 –24 mos 7 at 4-6 yrs 16 use MMR
1 countries with periodic SIAs
2 countries with periodic SIAs and 2 dose schedule
2 countries with no second opportunity
Palestine
Bahrain
Routine second dose
1 dose schedule
1 dose + SIAs
Second Dose of Measles Immunization in EMRO, 2005
2 doses + SIAs
Palestine
Bahrain
Case based (17)
Case-based, needs to be improved (3)
Aggregate data (2)
Measles Surveillance in EMRO
No. countries reporting
Total susp cases
Total with lab test
No. lab- conf measles
No. epi-linked measles
No. clinical measles
Total measles
20 (90%) 19,950 7031 2259 935 9750 12,944
Status of Measles Reporting in EMRO, Jan-Dec, 2006*
* Provisional data, reporting not complete
Monthly Bulletin Case counts by country and
case classification
Key indicators
Mapping through EPIINFO
• Website
• Monitoring of susceptibility profiles
Feedback of Surveillance and Coverage Data
MeaslesImmunisation Status of Age Groups in Sud 2005
0%
20%
40%
60%
80%
100%
23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
Age in 2005Protected by 1st Dose Protected by 2nd DoseProtected in Campaigns Never Protected
Regional progress in measles elimination
Key constraints
Indicators to monitor measles elimination in EMR
Outline
Lack of national support for elimination
Competing priorities
Insecurity Resource mobilization for non-GAVI countries
Egypt, Morocco, Syria
Failure of keep-up strategies
Limited use of surveillance data
Key Constraints in Regional Elimination
Measles Case Counts and Vaccination Coverage, 1988-2005, Saudi Arabia
Co
vera
ge
0
5000
10000
15000
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
Year
Measle
s c
ases
0
10
20
30
40
50
60
70
80
90
100
Catch-up campaigns12-18 yrs 6-13 yrs
Age Distribution of Measles Cases in Saudi Arabia, Jan-Dec 2006
19%
33%
12%
14%
7%
15%
n=6975% vaccinated
< 1 yr
1 to 4 yrs
10 to 14 yrs
5 to 9 yrs
15-20 yrs
> 20 yrs
Age Distribution and Vaccination Status of Measles Cases in Selected EMR Countries, Jan-Dec 2006
18%
26%
21%
17%
4%
14%
Qatar (n=108)54% vaccinated
2%22%
31%
25%
15%
5%
Egypt n=99896% vaccinated
11%
20%
37%
19%
5%
8%
Syria (n=462)48% vaccinated
10%
42%
23%
5%
5%
15%
Lebanon (n=843)20% vaccinated
< 1 yr
1 to 4 yrs
10 to 14 yrs
5 to 9 yrs
15-20 yrs
> 20 yrs
Geographic Distribution of Measles Cases, Jan-Dec ‘06
Regional progress in measles elimination
Key constraints
Indicators to monitor measles elimination
Outline
Completeness of reportingIndicator: > 80% of districts reporting on a monthly
basis
Sensitivity of reporting systemIndicator: At least 2 suspect cases (excluding lab and
epi-confirmed measles and rubella) per 100,000 population at the national level.
Adequacy of laboratory testingIndicator: > 80% of suspect measles cases are tested
for measles IgM antibody, excluding cases epidemiologically linked to a laboratory confirmed case from the denominator
Indicators for Measles Elimination Recommendations from EMR-TAG, 2006
Adequacy of epidemiologic investigation*Indicator: > 80% of suspect measles cases have an
adequate epidemiologic investigation*.
Adequacy of laboratory testingIndicator: > 80% of measles virus outbreaks and chains
of transmission chains (outbreaks) have sufficient* samples for viral isolation
*An adequate investigation includes at a minimum the suspect cases with all of the following data elements; date of rash onset, specimen collection, date of specimen collection, vaccination status, date of last vaccination, age, and district)
Indicators for Measles Elimination Recommendations from EMR-TAG, 2006
Palestine
Bahrain
Reporting on a timely basis (n=16)
Delayed reporting (n=4)
Completeness of Reporting to Regional Office, Countries Reporting on a Monthly Basis, 2006
Inconsistent/not reporting (2 countries)
Suspect Cases+ per 100,000 in EMR, Jan-Dec-2006*
0
5
10
15
20
25
Me
as
les
ca
se
s p
er
10
0,0
00
Ye
m
Om
a
Ba
h
Qa
t
Afg
So
m
Jo
r
Eg
y
Pa
l
Mo
r
Dji
Le
b
KS
A Ira
Irn
UA
E
Su
d
Lib
Sy
r
Tu
n
Ku
w
Pa
k
+ Suspect cases – lab and epi confirmed cases* Adjusted for annualized rate
Proposed regional target 2/100,000
Palestine
Bahrain
> 80% of suspect cases (10 countries)
Serologic Testing of Suspect Cases (Jan-Dec ’06, EMR) Indicator: > 80% of suspect cases with testing
50-80% (3 countries)
< 50% (7 countries)
Not reporting (2 countries)
Palestine
Bahrain
> 80% (6 countries)
Adequacy of Epidemiologic Investigation, Jan-Dec ’06 EMRIndicator: >80% of measles case reports with complete investigation
50-80% (5 countries)
< 50% (6 countries)
Not reporting (5 countries)
Measles incidence of < 1 confirmed case per million per year, excluding cases confirmed as imported.
All districts with > 90% vaccination coverage for the first dose of measles vaccine and 95% coverage national coverage for the second dose.
90% of outbreaks are < 10 cases in size
Epidemiologic and laboratory data indicate that measles viruses are imported.
Recommended Criteria for Measles Elimination EMR-TAG, 2006
Measles Cases per Million in EMR, Jan-Dec-2006*
0
50
100
150
200
250
Me
as
les
ca
se
s p
er
1,0
00
,00
0
Yem Leb Qat
Afg
Som D
jiM
or
KS
A
Syr
Bah
Egy
UA
E
Om
aS
ud Irq
Lib
Pal Irn
Jor
Tu
n
* provisional
Palestine
Bahrain
MCV1 > 90% in all districts (7 countries)
MCV1 > 80% in all districts (2 countries)
MCV1 Coverage* Indicator: > 90% coverage in all districts
MCV1 > 50% in all districts (4 countries)
MCV1 < 50% in some districts (8 countries)
* Based on 2005 JRF, data is unavailable for Lebanon
• Considerable progress in mortality reduction• Pak campaign will reduce further
• Few countries are close to elimination
• Several countries with large outbreaks• Failure of “keep-up” strategies
• SIAs are playing an important role to achieve elimination
Summary
• Surveillance is improving• Impact on program activities
• Countries have accepted agreed upon indicators
• RTAG will address issue of “certification”
Summary
• Advocacy• Raising awareness of national health authorities• Development of country-level TAGs • Certification process?
• Surveillance• Revisit regional reporting format
• Outbreak surveillance• Source of infection• Genotyping
• Achieving high population-based immunity• Better monitoring of routine EPI data• Achieving and monitoring high MCV2 coverage • Monitoring susceptibility profiles at sub-national levels
Priority Activities
EMR MCV Coverage and Percent of Games Won-Chicago Cubs, 1995-2006
0
25
50
75
100
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Year
Per
cen
t
CubsEMRO
