Progress towards Sustainable Measles Mortality Reduction South-East Asia Region Jayantha Liyanage Medical Officer- EPI Immunization and Vaccine Development WHO/SEARO

Presentation structure Progress towards the regional goal Summary of achievements and main challenges Plans for

South-East Asia Region 11 diverse countries 1.6 billion; 25% of world’s population Massive immunization burden >500 million children aged <15 years 35 % (11 million infants) un-immunized with 1 st dose of measles vaccine Polio endemic However there is reasonable human resources for EPI in most countries at most levels

Regional Strategic Plan Goal By 2009 reduce the number of estimated measles deaths by 90% in comparison to 2000 Specific objectives 1 st dose measles coverage >90%, nationally and in >80% of districts by 2009 Fully investigate all detected/reported measles outbreaks Case based measles surveillance within integrated surveillance systems in countries that completed catch-up campaigns Provide a second opportunity for measles immunization

WHO/UNICEF estimates for MCV1 coverage Regional coverage increased from 59% in 1999 to 65% in 2005 Source: WHO/UNICEF estimates

Updated Sep 2006 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 All rights reserved Continue to use the surveillance staff in five priority countries in measles surveillance and SIAs

Reported incidence rates of clinically confirmed measles cases in selected countries Data as of 19 Feb 2007 Source: WHO/UNICEF JRF ; Monthly Reporting Form,

Status of SEAR measles laboratory network 16 National Measles laboratories – Expansion in India continues 1 Regional reference laboratory – NIH Bangkok GSL for SEAR - CDC Atlanta Labs perform IgM ELISA confirm Measles / rubella Virus isolation in Vero SLAM - 6 labs in the region. Isolates referred to RRL / GSL - CDC for genotyping 2006 Proficiency testing – 14 laboratories participated – 13 laboratories passed Data management software - MLIS developed

Measles and Rubella Serology (IgM) Results in 2006 All laboratories report data monthly Data as of 31 Dec 2006

Number of suspected measles Outbreaks Investigated SEAR, Source: SEAR EPI Annual Reporting Form, ; Monthly Reporting Form, 2006 (Feb 2007) Number of Outbreaks Investigated Data as of 19 Feb 2007

Vaccine Preventable Diseases reported to SEARO out of 11 countries are reporting monthly Data as of 19 Feb 2007 Source: Monthly Reports from Countries

Age distribution of measles outbreaks Target age group for SIA was based on country age distribution of cases CountryYear*Number of cases** Age (yrs) distribution of cases (%)Target Age group for SIA ≤ ≥15 Bangladesh M-10Y DPR Korea M-45Y Indonesia M-12Y Myanmar M-10 Y Nepal M-15 Y Maldives Y Sri Lanka20006, Y Source: Annual EPI Reporting Form *Most recent year of outbreak in country **Country Report *** only the cases with age known considered Updated as of 19 Feb 2007

Second Opportunity for Measles Immunization, SEAR, 2007 Data as of: Feb 2007 Measles 2 nd Opportunity through Routine Immunization Catch-up Campaigns completed Measles 2 nd Opportunity through Catch-up/Follow up Campaigns 4 Countries providing MR/MMR Catch-up/Follow-up Campaigns planned in 2007

Number of children vaccinated during measles SIA and planned SIAs in SEAR Planned 120 million would be vaccinated by August 2007

Strengthening of measles surveillance and Impact of measles catch-up campaign Bangladesh, Source : Monthly VPD MDB submitted to SEARO Clinically confirmed cases Measles Catch-up Campaign Data as of 19 Feb 2007

Cases reported from serologically confirmed suspected Measles Outbreaks Bangladesh, Source : Monthly VPD XLS Data as of 19 Feb 2007 Measles Catch-up Campaign After the SIA Few measles outbreaks. Rubella outbreaks continue to be detected

Strengthening of Measles surveillance and impact of measles catch-up campaign, Nepal, Data as of 19 Feb 2007 Source: Monthly VPD MDB Measles Catch-up Campaign Phase1Phase2Phase3 Types of outbreaks Number of outbreaks Total outbreaks reported Serologically confirmed Measles Serologically confirmed Rubella Serologically confirmed Mixed 1120

Adding other interventions to measles SIAs CountryYearMeaslesRubellaOPVVit A Bed nets Sri Lanka2004 √√ Nepal2004/05 √ Under 5 Y Nationally Maldives2005 √√ Bhutan2006 √√ Indonesia 2005 √ Under 5 Y in 2 provinces 6-59 M In 2 provinces 2006 √ Under 5 Y in 9 provinces 6-59 M In 9 provinces Selected districts in 8 provinces

Summary of achievements Large countries emphasis on strengthening routine immunization and enhancing coverage Established integrated surveillance and regional lab network (16 labs) Major increase in reporting and outbreak investigations Catch up campaigns; above 95% coverage Notable examples: Nepal, Bangladesh, Bhutan, Indonesia Built strong partnerships: SEAM Identifying disease burden due to Rubella Integration of some public health interventions

Challenges/Issues Finishing polio – India and Bangladesh Funding for sustaining surveillance net works and SIAs in India Coordinate integration in large countries –Established programmes go alone e.g Vit A distribution in Nepal, Bangladesh and Myanmar –Logistic difficulties in delivering bed nets in time –Non availability of adequate stocks of OPV for large countries

Plans for India will be the focus Improving routine immunization to sustain gains of SIAs –c MYP –GAVI funded activities Surveillance –Initiate case based surveillance after SIA Nepal and Bangladesh in 2007 Indonesia and Myanmar in 2008 –India: Gradual expansion of measles surveillance to more states –Improving the monthly reporting to SEAR and commence monthly reporting to HQ WHO/UNICEF to ensure adequate technical support to the countries

SIA plan CountryTimeTarget areaAge group TargetIntegrated Interventions YEAR 2007 Indonesia FebruaryJava Island (catch-up) 6 M -12 y14,800,000Vit A, OPV AugustRemaining islands (Catch-up) 6 M -12 y5,400,000ITNs, Vit A, OPV MyanmarJan, Mach May National (Follow-up) 9 M -5 Y7,100,000 DPRKMarch - April National (Catch-up) 9 M-45Y16,200,000 Vit A Year 2008 Nepal *Q 4National (follow-up) 9-59 M3,700,000? Vit A, ?OPV Timor Leste * 2008National (Catch-up) 9 M-15 Y400,000? OPV India* * states (Catch-up) 9M-10 Y29,000,000? OPV * Subject to government confirmation

THANK YOU

Building on AFP Surveillance to Support Measles and Other VPD Surveillance, SEAR Updated September 2006 * Surveillance Officers partially supported by WHO ** Active surveillance also has passive surveillance components *** Countries submitting case-based also submit monthly aggregate

17 SEAR Measles laboratory Accreditation status 2006 CountryLaboratoryAccreditation status BangladeshDhakaAccredited BhutanThimpuProvisionally accredited DPRKPyonangPending IndiaBangaloreDue in 2007 ChennaiAccredited CoonoorAccredited HyderabadDue in 2007 IndonesiaBandungAccredited JakartaAccredited SurabayaAccredited YogyakartaAccredited MaldivesMaleNot accredited MyanmarYangoonAccredited NepalKathmanduProvisionally accredited ThailandBangkokAccredited Timor LesteDilliNot operational SrilankaColomboAccredited