1. Global Measles and Rubella Management Meeting Progress and Challenges in Bangladesh 15-17 March, 2011 Geneva, WHO HQ Dr Serguei Diorditsa

2. Measles control plan (2004-2010) and next goals in Bangladesh Measles catch-up campaign immunized: >35 million Measles follow-up campaign immunized: >18 million plus OPV, vit A,albendazole Measles control plan 2004-2010 In 2011-2016, cMYP elimination target Including 2 nd dose MCV2 introduction cMYP 2011-2016 Source: Child deaths due to measles 2000-2009 by WHO estimation, 10 Feb 2011 85%

3. Trends of measles cases and valid measles coverage by one year of age (1990-2010) Measles catch-up campaign immunized: >35 million Measles follow-up campaign immunized: >18 million

4. Dots are randomly placed within district boundary Spot Map of Outbreaks Reported in Bangladesh 2005 2006 2007 2008 2009 2010 Measles catch-up campaign immunized: >35 million Measles follow-up campaign immunized: >18 million Year200520062007200820092010 # of measles outbreaks ( lab) and ( mixed) 203515120 # of rubella outbreaks872610259145193

5. Age Distribution of Lab Confirmed Measles Outbreak Cases, Bangladesh, 2003-2010* No Laboratory Confirmed Measles Outbreak detected in 2007 N=523 (12) N=5,248 (68) N=9,378 (120) N=2,095 (34) N=132 (1) N=48 (1) No Laboratory Confirmed Measles Outbreak detected in 2010

6. Vaccination Status of Lab Confirmed Outbreak Cases, Bangladesh, 2003-2010 No Laboratory Confirmed Measles Outbreak detected in 2007 No Laboratory Confirmed Measles Outbreak detected in 2010

7. Measles Cases in Bangladesh by Year 2003-2010 Changes in definition of outbreak: 2003: 50 cases per ward 2005:10 cases per ward 2008: 3 cases per ward Outbreak surveillance Case based surveillance Measles catch-up campaign immunized: >35 million Measles follow-up campaign immunized: >18 million

8. Measles surveillance indicators

9. Virus isolation status YearNo. of urine Sample collected Sample tested in regional lab MeaslesRubellaNegativePending 2008850050 20092716031311 2010590

10. Non-measles suspected cases reporting rate 2009 2010 58% (37/64) districts achieved rate ≥2.00 in 2010

11. Measles vaccination valid coverage by 12 months of age, 2005 and 2010 Source: CES 2005 and 2010 2005 2010 81% (52/64) districts achieved ≥80% coverage in 2010

12. Challenge to improve Surveillance indicators Measles case based surveillance -Integrated with AFP and other VPD Challenge: financial sustainability and transition of VPD network parallel to health systems 140 facilities included for weekly active surveillance for AFP, NT and Measles- at the same time they are reporting 6 EPI diseases on weekly basis All 471 Upazila Health Complexes (UHCs) included in weekly passive reporting 156 additional facilities conduct weekly passive reporting VPD surveillance supported by WHO funded network of 42 SMOs

13. ICDDRB study on Impact of Measles Activities on Routine Immunization Services and Health Systems in Bangladesh T. Koehlmoos et al. The Journal of Infectious Diseases ( in press) Conclusion: Measles elimination activities had enormous positive impacts on immunization programme and health systems of Bangladesh Effective integration of the immunization programme with health systems, high level political commitment and effective inter-agency collaboration contributed the campaigns successful Examples of impacts: Governance Strengthened inter-ministerial coordination and collaboration Effective collaboration between MOHFW and development partners Increased involvement of other sectors in immunization programme ICC becomes more active Raised awareness among political leaders Improved accountability of staff members of the EPI programme Planning and management Improved skills of staff to develop strategies in EPI planning at national to local level Improved skills to management of mass campaigns Identifying and mapping of target and hard-to-reach population for other EPI outreach activities Stimulate interdepartmental & inter-sectoral planning Better long term planning of financing EPI service delivery Injection safety Management & surveillance of AEFI Increased awareness among community members due to huge publicity Delivery of add-on’s interventions (vitamin A, deworming, OPV) Increased EPI centres and clinic visits of people after campaigns resulted to do less motivational works

14. ICDDRB study (cont’d) Examples of impacts Impact on Logistics New equipments were kept as fixed assets for routine immunization Training and technical assistance to the local staff increased their skills and confidence to maintain cold chain Impact on Financing Helped to develop skills in fund- raising from local and international partners Funding or in-kind support for campaigns release money for other EPI activities Motivated government & other funders to invest more money in EP Impact on human resources Positive Increased stock of EPI workforce/volunteers Contributed development of inter-personal communication among the staff members of different sectors Created opportunity for staff members involved from other department of MOHFW to learn more about EPI Negative Staff members de-motivated from late arrival of funding EPI staff feel overloaded with added works Shortage of technical staff The campaigns did not attract a sufficient number of volunteers in some areas as their refreshment fund were not enough

15. Budget for integrated VPD surveillance and measles activities in 2011-2013 ( in million USD) 201120122013 plannedavailablegapplannedavailablegapplannedavailabl e gap MCV 2 vaccine Bangladesh will apply to GAVI for MCV2 cost support MR vaccineBangladesh consider the cost of MR vaccine to be born from new Health Sector Programme for 2011-2016 MCV2 Introduction -Training & supervision 1,220 surveillance2,52,00,52,31.01.32.31,01.3 Total gap0.5Total gap1.52Total gap 1.3 Total Gap for 2011-20133,32 million USD

16. Thank You

17. WHO estimates on measles death in Bangladesh 2000-2009 Measles catch-up campaign immunized: >35 million Measles follow-up campaign immunized: >18 million Measles control plan 2004-2010 In 2011-2016, cMYP elimination target Including 2 nd dose MCV2 introduction cMYP 2011-2016 Source: Child deaths due to measles 2000-2009 by WHO estimation, 10 Feb 2011

18. 2011 Plans and budget Measles initiative co-financed activities of WHO surveillance network in 2007-2010 No funds for specific measles surveillance strengthening activities in 2011. In 2011 WHO SMOs network will continue support the current level of measles in integration with AFP surveillance. No donor’s commitment to support surveillance network after 2012

19. Budget for integrated (AFP/Measles/Other VPDs) surveillance and measles control/ elimination activities 2011-2016 ActivitiesFund required yearly 2011- 2016 Fund required one time 2012 Fund availableFunding gap 2011-2016 Funding gap one time Annual Surveillance operational cost 2.5 million1.5 million x2 l (in 2011-2012) 9,5 million MCV2Government will apply for GAVI support for vaccine MCV2 Introduction- Training & supervision 1.22 million 0 Logistics –printings and others for MCV2 Cost is under consideration for next health sector program 2011-2016 MR vaccineVaccine Cost is under consideration for next health sector program 2011-2016 Measles SIA No plan developed Total 2011-201612.5 million1.22 million 3 million9,5 million1.22 million Total Gap10,72 million

20. Advocacy Plans and Opportunities Advocate to include measles elimination activities in the new national health sector development plan for 2011- 2016 including : Funds for surveillance activities Create national position of district immunization and surveillance medical officers (DISMO) Introduce MR vaccine and allocate cost in the health sector plan EPI will apply for GAVI support on MCV-2 introduction Advocate for donors support of WHO surveillance network to maintain current activities and during the transition to DISMOs