1. Monitoring progress towards the coverage and disease incidence targets GLOBAL MEASLES AND RUBELLA MANAGEMENT MEETING 15-17 March 2011 Geneva, Switzerland Marta Gacic-Dobo, EPI WHO HQ

2. Monitoring progress | May 14, 2015 2 |2 | Outline WHA 2010 targets for measles control - current status Monthly and annual measles data collection Indicators to monitor progress towards measles elimination

3. Monitoring progress | May 14, 2015 3 |3 | WHA 2010 targets for measles control to be achieved by 2015 Exceed 90% coverage with the first dose of measles- containing vaccine nationally and exceed 80% vaccination coverage in every district or equivalent administrative unit Reduce annual measles incidence to less than five cases per million and maintain that level Reduce measles mortality by 95% or more in comparison with 2000 estimates.

4. Monitoring progress | May 14, 2015 4 |4 | Immunization coverage with measles containing vaccines in infants, 2009 80-89% (29 countries or 15%) 50-79% (45 countries or 23%) >=90% (115 countries or 60%) <50% (4 countries or 2%) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2010. All rights reserved Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 193 WHO Member States. Date of slide: 21 July 2010

5. Monitoring progress | May 14, 2015 5 |5 | Countries with 90% national and 80% measles coverage in all districts, 2009 No or data reported to WHO (147 countries 75%, 33 countries don't report district level data but national coverage is over 90%) Yes (48 countries 25%)

6. Monitoring progress | May 14, 2015 6 |6 | Countries with % of districts achieving at least 80% MCV coverage, 2009 100 % districts (54 countries or 28%) 80-99 % districts (32 countries or 17%) 50-79 % districts (30 countries or 16%) No data (44 countries or 23%); MCV estimated coverage for 2009 33 countries > 90%; 11 countries< 90% 0-49 % districts (33 countries or 17%)

7. Monitoring progress | May 14, 2015 7 |7 | Reported measles incidence by WHO regions, 2000- 2009 Source: WHO/IVB database. Data for 2009. Date of Slide 08 December 2010 Decline in SEAR in 2009 is partially due to missing data for India

8. Monitoring progress | May 14, 2015 8 |8 | <5 (124 countries 64%) >5 (63 countries 32% ) No data reported to WHO (6 countries 4%) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2011. All rights reserved Source: WHO/IVB database. Data for 2009. Reported Measles Incidence Rate, 2009 Target <5 per 1 Million Population

9. Monitoring progress | May 14, 2015 9 |9 | <1 (97 countries 50% ) 5 - <50 (39 countries 20% ) 1 - <5 (27 countries 14% ) 50 - <100 (12 countries 6%) >=100 (12 countries 6%) No data (6 countries 4%) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2010. All rights reserved Source: WHO/IVB database. Data for 2009. Date of Slide 8 December 2010 Reported Measles Incidence Rate (per million), 2009

10. Monitoring progress | May 14, 2015 10 | Comparison of annual and monthly data collection Measles incidence data is collected through 2 parallel system –Annual immunization data collection (JRF) Number of reported cases (clinically, epidemiologically, and laboratory-confirmed cases) and laboratory confirmed cases Immunization schedule and vaccine presentation Immunization coverage for 1 st and 2 nd dose by routine services an supplementary immunization activities (data for 2010 available in July 2011) –Monthly data collection Number of suspected, lab confirmed epi linked and clinically confirmed cases by district and by month of onset Monthly reporting (data with date of onset in March available in HQ earliest in May) Data consolidated and disseminated by email and by the web http://www.who.int/immunization_monitoring/diseases/measles_monthlydata/en/index.ht ml http://www.who.int/immunization_monitoring/diseases/measles_monthlydata/en/index.ht ml

11. Monitoring progress | May 14, 2015 11 | Number of Reported Measles Cases by WHO Regions, 2010 Countries not reporting in last 12 months: AFR (6% of pop):Cape Verde, Comoros, Equatorial Guinea, Mauritius, Sao Tome and Principe, Seychelles and South Africa. AMR: (<1% of pop): Costa Rica and Uruguay. Canada and USA do not report suspected cases). EUR (<5% of pop): Kazakhstan, Monaco and San Marino. SEAR (67% of pop): India. WPR (84% of pop): China only reports suspected cases. Data source: surveillance DEF file Data in HQ as of 9 February 2011

12. Monitoring progress | May 14, 2015 12 | Comparison of reported measles cases and number of member states reporting from annual and monthly system, 2005-2009

13. Monitoring progress | May 14, 2015 13 | Comparison of reported measles cases and number of member states reporting from both annual and monthly system, 2005-2009 Burkina Faso JRF=54118, monthly=816 Iraq JRF=30328, monthly=8763 Bangladesh JRF=718 monthly=15107 (42 lab confirmed)

14. Monitoring progress | May 14, 2015 14 | Comparison of monthly and annual data by year and by % difference 2009200820072006 15%30%25% monthly data at least 10% higher than annual data 65%57%51%46%less than 10% difference between monthly and annual data 20%14%24%29%monthly data at least 10% lower than annual data

15. Monitoring progress | May 14, 2015 15 | Comparison of reported measles cases a from annual and monthly system by WHO regions,2008-2009

16. Monitoring progress | May 14, 2015 16 | Summary Data received from 179 member states (93%) monthly Annual and monthly reporting system seems to converge, however in case of large outbreaks monthly system fails to capture all cases. (Iraq, Burkina Faso in 2009) Monthly reporting system has 2 months lag at global level, therefore difficult to timely capture outbreaks

17. Monitoring progress | May 14, 2015 17 | Monitoring progress towards measles elimination Measures to monitoring progress towards measles elimination –Vaccination coverage –Incidence

18. Monitoring progress | May 14, 2015 18 | Surveillance performance indicators generate from HQ TargetIndicator Yes At the national level, a rate of ≥2 discarded measles cases/100 000 population per year should be considered a minimum. 1. reporting rate Potentially Yes In addition, ≥2 discarded measles case should be reported annually per 100 000 population in ≥80% of subnational administrative units (e.g. at the province level or its NoSpecimens adequate for detecting acute measles infection should be collected from ≥80% of suspected cases and tested in a proficient laboratory. 2. Laboratory confirmation NoViral detection: Samples adequate for detecting measles virus should be collected from ≥80% of laboratory-confirmed outbreaks and tested in an accredited laboratory 3. Viral detection No Adequacy of investigation: At a minimum, 80% of all suspected measles cases should have had an adequate investigation initiated within 48 hours of notification. 4. Adequacy of investigation

19. Monitoring progress | May 14, 2015 19 | Measures for monitoring progress towards measles elimination 1. Vaccination coverage Measure –Vaccination coverage of both the first routine dose of measles- containing vaccine (MCV1) and the second dose (MCV2), whether delivered through routine services or supplementary immunization activities among appropriate age groups. Target –Achieving and maintaining ≥95% coverage annually with both MCV1 and MCV2 in all districts, or their administrative equivalent, and nationally. Data available: –MCV1 from routine –MCV2 from routine –SIA coverage Data not available: –Combined coverage from SIA and routine for MCV1 and MCV2 % of districts reporting >=95% coverage is available but only for MCV1. - but not combined for both MCV1 and MCV2 also what about SIA?

20. Monitoring progress | May 14, 2015 20 | Measures for monitoring progress towards measles elimination Surveillance To enable meaningful comparisons across countries and regions, the following 2 measures of measles incidence have been proposed: –for countries and regions without an elimination goal or that have not yet implemented the immunization and surveillance activities needed for elimination, the incidence per 1 000 000 population of all measles cases (laboratory confirmed, epidemiologically linked and clinically compatible) regardless of source of infection; This measure of incidence approximates the actual measles burden when surveillance is not sufficiently advanced to confirm or discard measles cases on the basis of laboratory criteria or epidemiological linkage alone; –for countries and regions implementing the immunization and surveillance activities needed for elimination, the incidence per 1 000 000 population should be determined only for confirmed measles cases (i.e. either laboratory confirmed or confirmed by epidemiological linkage) that result from transmission within the country; this incidence measure excludes clinically compatible and imported cases Target: In areas where incidence is low the following target has been proposed as a measure of near elimination: an incidence of <1 measles case confirmed by laboratory or epidemiological linkage (excluding clinically compatible and imported cases) per 1 000 000 population; the numerator is total number of measles cases confirmed by laboratory or epidemiological linkage, excluding imported cases.

21. Monitoring progress | May 14, 2015 21 | Reported Measles Incidence Rate*, Jan 2010 to Dec 2010 *Rate per 100'000 population Data source: surveillance DEF file Data in HQ as of 9 February 2011 The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2011. All rights reserved. <0.1 (85 countries or 44%) ≥0.1 - <1 (43 countries or 22%) ≥1 - <5 (26 countries or 13%) ≥5 (23 countries or 12%) No data reported to WHO HQ (16 countries or 8%) NB: From January 2009 to December 2010, there have been 18,391 laboratory confirmed measles cases in South Africa. http://www.nicd.ac.za/

22. Monitoring progress | May 14, 2015 22 | Questions? Is it a need for 2 parallel systems (monthly and annual) –When to switch to the monthly system for measuring indicators? Is it a need for more detailed and/or more frequent information at HQ ? –Weekly reporting? –Case based reporting?

23. Thank You