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

2. Presentation structure Progress towards the regional goal Summary of achievements and main challenges Plans for 2007-08

3. 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

4. Regional Strategic Plan 2006-2009 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

5. WHO/UNICEF estimates for MCV1 coverage 2001-05 Regional coverage increased from 59% in 1999 to 65% in 2005 Source: WHO/UNICEF estimates

6. 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 2005. All rights reserved Continue to use the surveillance staff in five priority countries in measles surveillance and SIAs

7. Reported incidence rates of clinically confirmed measles cases in selected countries 2000-05 Data as of 19 Feb 2007 Source: WHO/UNICEF JRF 2000-2004; Monthly Reporting Form, 2005-2006

8. 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

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

10. Number of suspected measles Outbreaks Investigated SEAR, 2003-2006 Source: SEAR EPI Annual Reporting Form, 2003-2005; Monthly Reporting Form, 2006 (Feb 2007) Number of Outbreaks Investigated Data as of 19 Feb 2007

11. Vaccine Preventable Diseases reported to SEARO 2006 10 out of 11 countries are reporting monthly Data as of 19 Feb 2007 Source: Monthly Reports from Countries

12. 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 ≤ 11-45-910-14≥15 Bangladesh20051014613.436.233.610.85.8 9 M-10Y DPR Korea200722574.35.312.330.547 6 M-45Y Indonesia2005239312.452.331.530.7 6 M-12Y Myanmar 200416397.145.8397.119 M-10 Y Nepal 200460505.436.638.714.54.59 M-15 Y Maldives2005139547.78.625.454.3 6-25 Y Sri Lanka20006,3927.75.316.31654.8 10-20Y 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

13. 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

14. Number of children vaccinated during measles SIA 2000-06 and planned SIAs in 2007- SEAR Planned 120 million would be vaccinated by August 2007

15. Strengthening of measles surveillance and Impact of measles catch-up campaign Bangladesh, 2003-2006 Source : Monthly VPD MDB submitted to SEARO Clinically confirmed cases Measles Catch-up Campaign Data as of 19 Feb 2007

16. Cases reported from serologically confirmed suspected Measles Outbreaks Bangladesh, 2005-2006 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

17. Strengthening of Measles surveillance and impact of measles catch-up campaign, Nepal, 2003-2006 Data as of 19 Feb 2007 Source: Monthly VPD MDB Measles Catch-up Campaign Phase1Phase2Phase3 Types of outbreaks Number of outbreaks 200420052006 Total outbreaks reported 1953927 Serologically confirmed Measles 13713 Serologically confirmed Rubella 133624 Serologically confirmed Mixed 1120

18. 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

19. 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

20. 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

21. Plans for 2007-08 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

22. SIA plan 2007-08 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* * 20081-2 states (Catch-up) 9M-10 Y29,000,000? OPV * Subject to government confirmation

23. THANK YOU

24. Building on AFP Surveillance to Support Measles and Other VPD Surveillance, SEAR - 2007 Updated September 2006 * Surveillance Officers partially supported by WHO ** Active surveillance also has passive surveillance components *** Countries submitting case-based also submit monthly aggregate

25. 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