1. MEASLES MORTALITY REDUCTION IN INDIA Status and Future Plans

2. Presentation structure Status of routine immunization and polio eradication Implementation of national measles strategic plan Expansion of AFP surveillance to include measles surveillance Coordinated assistance from partners

3. Basic Demographics and Population Density, India Number of persons per sq. km Total Population Density by State Updated: July 2006 35 States

4. NFHS-III(2005-06)NFHS-II(1998-99) Source: NFHS Survey Evaluated Coverage for MCV 1: National Family Health Survey Missing or Excluded 0% to 30% 30% to 50% 50% to 70% 70% to 80% 80% to 90% 90% and above All India Measles Coverage NFHS-III : 58.8% NFHS-II : 50.7% NFHS-I : 42.2%

5. District-wise evaluated MCV 1 coverage: DLHS -2002-04 Source: DLHS(2002-04) Survey Missing or Excluded 0% to 30% 30% to 50% 50% to 70% 70% to 80% 80% to 90% 90% and above 14% of districts coverage below 30% 24% of districts coverage between 30-50% 28% of districts coverage above 80%

7. Key activities to improve routine immunization coverage Development and implementation of multi year plan for Immunization Enhanced budget and support through national rural health mission (NRHM) Immunization weeks in 2005 and 2006 in states with low coverage Monitoring of routine immunization clinics in low performing states by government and partners Introduced routine immunization monitoring system (RIMS)

8. Percentage Coverage (Measles) of Annual Target achieved during last three Immunization Weeks (2006-07)

9. Current status of Polio eradication Consistent progress from 2002 through 2005, falling cases, reduced geographic distribution of disease Outbreak in 2006 a temporary setback GOI mobilizing to finish as soon as possible Substantial financial commitment Use of mOPV1 Accelerated rounds to rapidly immunize youngest children Capitalize on immunity resulting from recent outbreak

10. Polio cases, India Year * data as on 16th February 2007

11. Measles Surveillance in 2005 Passive surveillance Aggregate data Under reporting(52454 cases & 55 deaths in 2005) States with low coverage reports least number of cases Little useful epidemiological data Measles is included in integrated disease surveillance program (IDSP) Outbreaks Investigations carried out by various national, state, academic institutions No standard guidelines Limited efforts to consolidate information and initiate action

12. Key actions for measles control since 2005 GoI initiated a consultative process with WHO, UNICEF, IAP, ICMR, NTAGI Strategic plan for Measles Control was endorsed National measles surveillance and outbreak investigation guidelines were published National polio surveillance project was assigned to assist and integrate measles surveillance with AFP surveillance State by state approach Integrated reporting from AFP surveillance sites Track and investigation of measles outbreaks Laboratory network expanded One per each state starting measles surveillance Two laboratories were accredited and other two due in 2007

13. Commenced in 2005 & 2006 Planned to initiate by March 2007 Planned to initiate by Sept 2007 By September will cover 9 sates and 40% of the population Integrated AFP and measles surveillance assisted by NPSP - 2007

14. Clinically confirmed measles cases 2006 through weekly routine reporting: by blocks Variation of incidence even among Southern states * data as on 15 th February, 2007 Tamil Nadu Annual incidence 2.8 per 100,000 population Karnataka Annual incidence 10.2 per 100,000 population Andhra Pradesh Initiated in September 2006

15. Suspected measles outbreaks investigated, 2006 Possibly Karnataka has not tracked some of the outbreaks Tamil NaduKarnatakaAndhra Pradesh Measles outbreaks confirmed (Total cases) 29 (1098) 33 (1045) 13 (290) Measles outbreaks negative 2 20 Rubella outbreaks confirmed (Total cases) 0 2 (109) 0 Mixed outbreaks confirmed (Total cases) 0 1 (28) 0 * data as on 15 th February, 2007 Tamil NaduKarnatakaAndhra Pradesh

16. Serologically confirmed measles outbreaks Percentage of measles cases by age groups, 2006* 89% of cases in Karnataka are under 10 years Total cases- 290Total cases- 1073 Total cases- 1012 * data as on 15 th February, 2007 Andhra PradeshKarnatakaTamil Nadu

17. Serologically confirmed measles outbreaks Vaccination status of measles cases (1-4 years), 2006 Low incidence, nearly 90% vaccinated cases and very low case fatality indicates Tamilnadu may not be a priority state for a catch-up campaign. N=89 Andhra Pradesh Vaccinated Not Vaccinated Unknown * data as on 15 th February, 2007 N=407 Karnataka N=339 Tamil Nadu

18. India Technical Advisory Group for Measles Control Formed to advise national government on measles control Terms of reference and composition recently endorsed by the Ministry of Health Director General, Indian Council of Medical Research will be the chairperson of this 22 member group Wide expertise and representation - national, state, medical associations, WHO, UNICEF and international experts, etc. Government would call the first meeting in second quarter of 2007

19. Coordinated partner assistance Draft concept paper has been prepared by WHO and circulated to partners of measles initiative Key areas for collaboration Advocacy Data for decision-making Implementation Fund raising

20. Key activities for partner assistance: (Advocacy and data for decision making) Ensure adequate staffing to provide measles technical and managerial support. Technical support to review available data on measles using the Measles Strategic Planning (MSP) Tool and prepare a situational analysis on measles Important background document for the first meeting of the India technical advisory group for measles Conduct survey of community perceptions towards measles and measles vaccination. By UNICEF community mobilizers and WHO/NPSP field volunteers Conduct measles case fatality rate studies in selected states

21. Key issues for consideration and support of partners: (Implementation) Through the GoI, explore potential readiness and suitability of any States to conduct a SIA in 2007/2008 Currently available USD 16.7 million from IFFIm for about 29 million children If national wide 9 months to -15Y campaigns planned, would need to target around 350 million children and would need around USD 200 million. Need to prioritize states according to low routine, reported incidence and age distribution of cases Building consensus in India expert advisory group regarding early implementing states.

22. Key Area for assistance: Fund Raising WHO/UNICEF to further explore with NORAD about highlighting measles activities Measles initiative to look for other potential donors interested in India

23. Challenges Government’s heavy involvement in finishing polio at the best opportunity Huge target populations for SIAs necessitating enormous amount of resources Funds for surveillance Anti vaccination lobbies against polio and Hepatitis B

24. Summary Government of India has started implementing measles control strategies So far focus has been for routine immunization strengthening and surveillance Government wants to introduce second opportunity based on surveillance State wise approach SIAs need very good planning Coordinated support from partners will be critical

25. Thank you

26. Monthly reported number of clinically confirmed measles cases reported, 2006-2007* Similar seasonality in states in south India Tamil NaduKarnataka

27. Estimated Paralytic Polio Cases/year, India OPV introduced in RI NIDs/SNIDs started NIDs/SNIDs strengthened

28. Unicef CES (1998-2005) India (Measles ) Source: Unicef CES Survey All India (country level) data for 2001 not available