World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Towards Measles Elimination in the Western Pacific Region Progress & Priorities Global Measles and Rubella Management Meeting Geneva, March 2011 Dr. David Sniadack and Dr. Wang Xiaojun Western Pacific Regional Office, WHO

Presentation Outline Progress towards measles elimination Updates on rubella control Priority activities in Unmet funding needs

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 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 Regional Committee Resolution, 2010 WPR/RC61.R7 Reaffirmed the 2012 measles elimination goal

Source: WPRO surveillance database WHO/UNICEF JRFs, Reported Measles Cases and MCV1 Coverage Western Pacific Region 1980 – 2010

Measles Incidence* Western Pacific Region 2010 < 1.0 (22) 1.0 – 9.9 (6) 50.0 – 99.9 (2) LEGEND 10.0 – 49.9 (5) Source: WPRO surveillance database, 2010 * per million population Data pending (1)

Initiatives to Improve Routine Measles Coverage, Western Pacific Region, 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

2010 (CHN, VTN, PNG, TUV, FSM*) 2011 (CAM, PHL, LAO) LEGEND 50.0 – 99.9 (2) 10.0 – 49.9 (4) 2009 Measles Incidence CHN million FSM (12m-83m,Chuuk) 6762 PHL (9-95m) 18 million CAM (9-59m) 1.5 million LAO (9-59m) 3.0 million VTN (9-71m) 7.0 million PNG (6-35m) 0.5 million TUV (12-71m) 1095 Measles SIAs in Western Pacific Region 2010 SIA in China 5 provinces:8m-14y 3 provinces: 8m-6y 23 provinces: 8m-4y

Source: WPR surveillance database Completeness and Timeliness of Country Reporting to WPRO Western Pacific Region

CategoryTarget 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 % of 2 nd administrative levels reporting ≥ 1/ 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% High Population Immunity National MCV1 coverage> 95%92%93%96%NA National MCV2 coverage> 95%86%88%94%NA Indicators of Progress Towards Measles Elimination Western Pacific Region Source: WPRO surveillance database

+331 prefectural labs 1 GSL 3 RRLs 16 National (13 fully functional) 31 provincial prefectural 382 laboratories Measles and Rubella Lab Network

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization At/near (25) Likely (6) LEGEND Hopefully (6) 4.1% of the regional population 7.5% of the regional population 88.4% of the regional population Probability of Measles Elimination by country, Western Pacific Region

Measles Cases by Month Viet Nam 2008– 2010 Source: Surveillance data Measles Cases by Age Viet Nam Oct 2008 – 2010

Measles Cases, by Province Viet Nam * * Data from surveillance reports through March 2011 Jan-Nov 2010 Dec 2011– Jan 2011 December 2010 January 2011 Laboratory Confirmed and Epi-Linked Measles Cases, by Month, Viet Nam 2010 – 2011*

Philippines dot = 1 case Lab Confirmed and Epi-linked Measles Cases, by Age, 2010 Confirmed Measles Cases, by Week of Rash Onset, 2009-January 2011

Lab-Confirmed Measles Cases, by Age Group and Vaccination Status, Cambodia dot = 1 lab case < 1 1 – 1.9 ≥ 2 Discarded rate (per 100,000) Laboratory Confirmed Measles Cases and Discarded Rates, Cambodia 2010

Rubella Control in WPR 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 Regional Plan for Control of Rubella and Prevention of Congenital Rubella Syndrome in the Western Pacific Region, July 2010 Nov 2010

< 1.0 (21) 1.0 – 9.9 (8) 10.0 – 19.9 (3) LEGEND (per million population (4) Rubella Incidence Western Pacific Region 2009 Protecting F & M ≥ 20 yrs (16) Protecting F ≥20 yrs (5) Protecting F & M ≥ 15 yrs (4) Recent introduction of RCV (5) RCV to be introduced (6) CAM, LAO, VTN PNG, SOL, VAN History of RCV Use in WPR Data source: JRFs WPR: 41 per million population

Rubella Cases by Sex and Age Group Data source: WPRO surveillance and laboratory database Viet Nam Females: 60% CBA Philippines 89% <20y

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Priority Activities of Measles Elimination Western Pacific Region, 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 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 Priority Activities of Measles Elimination Western Pacific Region,

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 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 1 st regional verification commission meeting (September 2011) Assist countries in initiating preparation upon country requests Priority Activities of Measles Elimination Western Pacific Region,

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 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) Priority Activities of accelerating Rubella Control & CRS Prevention, Western Pacific Region,

Unmet Funding Need in Priority Countries* Western Pacific Region, 2011 * Priority countries/areas for funding support: CHN, CAM, LAO, MOG, PHL, PNG, VTN, PICs

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 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 Genotypic distribution of Measles virus in WPR Australia New Zealand Japan D9 from Philippines, B3 from South Africa Hong Kong D9 from Thailand, B3 from France B3 from Libya Korea Mongolia H1, 1 Philippines Macao H1, 2 D9, 2 Viet Nam Singapore Lao PDR Malaysia H1 from Vietnam Cambodia

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Reported MCV1 and MCV2 Coverage by Country/Area, Western Pacific Region 2009 * For five countries with 2009 data not available, historic coverage data were used, including AMS (2008), WAF (2007), GUM (MCV1 in 2005, MCV2 in 2008) Source: WHO/UNICEF JRFs, Non-Pacific Island Countries 20 Pacific Island Countries

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Reported Measles Cases, China 2009 – 2011* *Surveillance report through February 2011 Measles SIA Decrease from previous year 44% 65% 44%

Oct-Dec08 Jan-Jun09Jul-Dec09Jan-Dec10 Trends in Age Distribution and Geographic Spread of Measles Viet Nam October

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Rash Onset, Philippines 2003 – January 2011 D3 D9. G3 D9

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Laboratory Confirmed Measles Cases Philippines January 2011 Oct 2010Nov2010Dec 2010Jan2011

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* * Data reported as of March 2011 Clinically Confirmed Lab confirmed

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Reported Rubella Cases and RCV Coverage Western Pacific Region Data source: WHO/UNICEF Joint Reporting Forms, and measles rubella surveillance data Incidence (2009): 41 per million population With disease data from China Reported coverage Coverage estimate with China data

World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 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 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 Challenges of Measles Elimination - Immunity Gaps

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 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 N = 457