Progress in the Elimination of Measles, Rubella and Congenital Rubella Syndrome in the Americas XV DbI Conference Sao Paulo, September 27th, 2011 Dr. Salvador Garcia-Jimenez Immunization Unit PAHO-WHO

Thrombocytopenic purpura and neonatal hepatitis Congenital Rubella Syndrome

Congenital deafness: hearing loss Ocular blindness: congenital cataracts Neurological disorders: severe mental impairment Congenital heart disease Intrauterine growth retardation, hepatosplenomegaly, and / or blood disorders Pneumonitis Most common manifestations

HELEN KELLER: Blindness separates us from things, but deafness separates us from people.

Deafblindness banishes those who suffer from a world of loneliness and isolation of human solidarity which only can rescue them. Blessed are those who, with his humanism make bearable the exile. Salvador Garcia-Ximenez

PAHO David Salisbury, TAG, 1997 (Technical Advisory Group on Vaccine Preventable Diseases) 20,000 WHO Cutts & Vynnycky Jour.Int. Epid. 1999;28: ,000 (4,500-36,000) CRS cases expected per year in the Americas without the control actions

Adult rubella vaccination results in the Americas Caribbean - English Speaking millions of men and women Chile millions of women Costa Rica millions of men and women Brasil millions of women Honduras millions of men and women El Salvador millions of men and women Ecuador millions of men and women Paraguay millions of men and women

Tracking campaigns Rubella elimination in The Americas Routine Coverage(%) Confirmed Cases Accelerated campaigns 43 of 44 countries of the Americas introduced the MMR vaccine in routine services. Source: Report to PAHO country. * Data as of September / C Final Transmisión Last case Rub. 2B SE 5/2009 1G Final Transmisión

All countries of the Americas are firmly committed to measles, rubella and congenital rubella syndrome elimination as part of a Regional strategy. Number of people vaccinated in the region by each strategy: Catch-up (<15yr) Follow-up (1-4 yr) Speed-up (adol/adult) 140 million60 million250 million

Estimated vaccination coverage with measles- rubella vaccine by WHO region, After 2015: 90%

Strengthened surveillance Outbreak control Measles Elimination Reported Measles and Rubella Cases, the Americas, *Data until EW 52/2010. Source: EPI tables ( ) and country reports to PAHO/WHO (since 2004) & 2006 Directing Council Rubella Resolutions Calls Member States to: (g) “ eliminate rubella and congenital rubella syndrome from their countries by the year 2010” 44 th DC, September 2003 (a) “implement policies and operational strategies to meet the rubella and CRS elimination target by 2010” 47th DC, September 2006 Starting in 2001, in a horizon of 15 years, it has been estimated that the initiative to eliminate rubella and CRS will save $ 3 Billion and will prevent more than 112,500 cases of CRS in Latin America and the Caribbean

Rubella cases: 135,947 The Americas, 1998 Impact of Rubella Elimination Strategies, the Americas, 1998– dot = 1 case Source: Country reports to PAHO. * Data until EW 52/2010 Import-associated Rubella cases: 15** -7 CAN, 1 FGU and 7 USA 25 months without confirmed endemic rubella cases Close monitoring of… Seasonality Virus excretion from confirmed CRS cases Last endemic rubella cases EW 5/2009

French Guinea =1 United States 2010 = = 4 1 dot = 1 case TOTAL 2010 = 17cases 2011 = 4 cases Reported cases of rubella in the Americas, Source: Country Reports to PAHO / WHO Note: The cases were imported, associated with importation or unknown. Canada 2010 = 7

Recent cases of Measles/Rubella and CRS Measles: Venezuela / 16 November, 2002 Measles/Rubella/CRS: Brasil/ 26 August, 2009 Rubella Argentina/ February,2009 > 8 years without endemic measles transmission > 2 years without endemic rubella transmission Source: Country Reports PAHO/WHO

Updated estimate of the CRS disease burden, global * † in 1996 and 2008 Regions NumberRangeNumberRange Africa31, 1336, ,01742,4409, ,228 Americas9,7012, , East Mediterranean 9,2653, ,2875, ,384 European9,5095,742-13, ,949 Southeast Asia50,6373, ,43252,6433, ,274 Western Pacific10,0983,495-17,83910,6413,741-18,618 GLOBAL120,342252,45-285,089111,88816, ,754 *unpublished, Adams E, Vynnycky E †All member states

Use of rubella vaccine by WHO Region, 1996 vs Region1996 No. of countries (%) 2010 No. of countries (%) AFR2 (4%)3 (7%) AMR21 (60%)35 (100%) EMR9 (43%)15 (71%) EUR39 (74%)53 (100%) SEAR2 (20%)4 (36%) WPR10 (37%)21 (78%) Global83 (43%)131 (68%) Source: WHO

Goals for the control of rubella by WHO Region, 2011 AMR- Rubella Elimination 2010 EUR-Rubella Elimination 2015 EMR-National CRS Prevention WPR- Accelerated Rubella Control and CRS Prevention Source: WHO

Challenges for the maintenance of the elimination of measles, rubella and CRS in the Americas (1) Risk of importation of the virus from other regions Prevention and rapid response to outbreaks Prevent or limit secondary cases of imports (in some countries) Reaching the subject through the second chance / campaigns tracking high quality

Alerts to prevent / limit imports of measles and rubella in the Americas in 2011 Given the numerous upcoming athletic and cultural celebrations that will be held in various countries in the Americas, PAHO/WHO particularly recommends that all people planning to travel internationally should be vaccinated against measles, rubella, poliomyelitis, and other vaccine- preventable diseases regardless of the reason for travel, country of origin, or geographic area of destination. COPA MUNDIAL FIFA SUB de Julio 20 de Agosto COPA MUNDIAL FIFA SUB de Junio – 10 de Julio COPA MUNDIAL FEMENINA DE LA FIFA 26 de Junio 17 de Julio Deafblind International World Conference Sao Paulo 26 – 01 Oct 2011

D6 last ftransmisión D9 last transmisión Genotype D4 D5 D6 D8 D9 B3 H1 Unknown / other Measles Elimination in the Americas, Imports caused limited outbreaks Genotypes did not continue the transmission Source: Report from country to the Global Measles and Rubella Laboratory.

Reasons for non-vaccination: United States, 2011 * Born before 1957 (3%). Born outside the United States (1%). Medical contraindications (1%). Intentionally delayed vaccination (1%). Age were not vaccinated. Personal or religious reasons (53%). * Data: Up to Sept 24, 2011 Source: CDC Report to PAHO / WHO.

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