measles elimination and rubella control india marching...
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Measles Elimination and Rubella Control
India marching towards the goal
Dr Satyabrata RoutrayMeasles Rubella Focal Person, WHO-India
• Moving fast from mortality reduction to elimination
• MCV 1 and MCV 2 status in the country
• Lab-based Measles-Rubella Surveillance
• CRS Surveillance plan
• M-R vaccine introduction plans
• M-R campaign challenges in India
• Way forward
Outline of the presentation…
Country Profile• 36 states / Union Territories
– 668 Districts
– 6,007 Blocks
• 1.2 billion population – 26 million birth cohort
– 30 million pregnant women
• Inter state variation– Uttar Pradesh pop 199.5
million, birth cohort 5.5 million (largest state)
– Lakshadweep pop 0.064 million, birth cohort below 1 thousand (smallest -UT)
SEAR Measles Elimination Goal - 2020
SEAR countries resolve to eliminate Measles and control Rubella/CRS by the end of – 2020 .
Reduction in Estimated Measles Deaths by WHO Regions and in India, (2000 to 2012)
100
90
80
70
60
50
40
30
20
10
0AMR EUR AFR EMR SEAR SEAR
Ex IndiaIndia WPR Global
% R
ed
uc
tio
n
78%84%
88%
52%
2015 reduction goal (95%)
57%
Source: WER: Progress in Global Control and Regional Elimination of Measles, 2000–2012. (Feb 7, 2014)
64%100%
71%63%
Global targets by 2015:• Measles vaccination coverage ≥ 90% national and ≥ 80% district• Measles reported incidence <5 cases per million
aa
A&N ISLANDSaa
A&N ISLANDS
89%
2013 2014*
83%
> = 90%
80% to 90%
70% to 80%
60% to 70%
< 60%
Measles vaccine -1st dose reported coverage, HMIS
N : As per Need assessed by GoI
*Data as on 26 Jul 2014 State wide efforts to enhance MCV 1 by strengthening RI
14 States with <80% MCV1 Introduced, 2nd dose through SIA
21 States with >80% MCV1 introduced, 2nd dose through RI
* NTAGI : National Technical Advisory Group on Immunization
2nd dose Measles vaccine introduction - India
Following recommendations of NTAGI*, 2nd dose Measles vaccine introduced in - 2010
a
MCV-2 through measles SIAs conducted in 3 phases
PhaseMCUP
durationNo. of State
No. of District
EstimatedTarget
Population(9 m - 10 yrs)
Children vaccinated
% Coverage
Phase 1 2010-11 13 45 13,845,686 12,076,836 87.2
Phase 2 2011-12 14 153 40,167,580 36,134,669 90.0
Phase 3 2012-13 5 169 85,476,898 70,615,482 82.6
Total 14 367 139,490,164 118,826,987 85.2
Source: Based on target population available with GoI
Target population:
~ 139 million children 9 months – 10 years of age
367 districts in 14 states
59%
38%
3%
Social mobilisation
Operational
Others
Social mobilisation includes
•Parents did not know of campaigns
•Did not know about place/date
•Did not give importance
•Fear of injection & AEFI
Operational
• No vaccine/logistics
• No vaccinator
•Site too far, long queue
Others
•Family travelling, sick child,
•Gone to School etc.
N - Total No of Unvaccinated children verified through RCA monitoring
(N = 352,824)
Measles Campaign Monitoring - IndiaReasons for unvaccinated children by RCA
RCA Data as of 21st November 2013
a
a
A&N ISLANDSa
a
A&N ISLANDS
47%
2013 2014*
62%
> = 80%
60% to 80%
40% to 60%
20% to 40%
< 20%
MCV 2 coverage in RI (including MMR), HMIS
N : As per Need assessed by GoI
*Data as on 26 Jul 2014 Country wide efforts ongoing to boost MCV 2 in RI
Laboratory supported, AFP based surveillance for
measles and rubella initiated across India
Functioning (28 states \ UTs)
Currently covering ~96% of the country’s population
In process (8 states \ UTs)
Measles Surveillance Status – August 2014
A
State.shp
1
2
3
State.shp
600 0 600 1200 Miles
Measles Survillance Plan 2013
9 - National laboratories
2 - Reference laboratories
2 - Proposed laboratories
1941
3122
7131 7070
4228
8984
10308
3314
7835
10059
238 247372
2855
4454
779
1130 1186
2734
4146
0
2000
4000
6000
8000
10000
12000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
No
. o
f cases
Measles cases Rubella cases
Measles & Rubella Cases by Year, selected states, 2005-2014
Source: WHO-India, NPSP
(2 states)No. of States (3 states) (6 states) (6 states) (7 states) (8 states) (11 states) (12 states) (15 states) (28 states)
* data as on 12 August, 2014
Measles cases reported & MCV1 coverage, India
0%
10%
20%
30%
40%
50%
60%
70%
80%
0
50,000
100,000
150,000
200,000
250,000
300,000
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
Reported Measles cases MCV1
Reported measles cases in JRF Reported MCV1 coverage in JRF
Measles SIA 2010 2011 2012 2013
Children covered ~ 4 million ~ 19 million ~ 34 million ~ 62 million
Measles vaccination campaign & it’s impact
Measles 2nd Dose- through campaign- through RI
~ 119 million children covered in measles catch-up campaigns
*Data as on 6th February 2014
0
1000
2000
3000
4000
5000
2010 2011 2012 2013
.
Phase I Phase IIMeasles catch-up campaign
Phase III
Cases fro
m c
onfirm
ed m
easle
s o
utb
reaks
Measles cases from three 3 states (Gujarat,
Madhya Pradesh and Rajasthan) with
surveillance pre and post Measles vaccination
campaigns
Serologically confirmed# Measles outbreaks, India(Andhra Pradesh, Arunachal Pradesh, Assam, Bihar, Chhattisgarh, D&D Haveli, Daman & Diu, Gujarat, Haryana Jharkhand, Karnataka, Kerala,
Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Odisha, Pondicherry, Rajasthan, Sikkim, Tamil Nadu, Telangana, Tripura,
Uttar Pradesh, Uttarakhand and West Bengal)@
Measles outbreaks confirmed
2013*
208 outbreaks, (15 states)
No Surveillance
310 outbreaks, (28 states)
2014*
*data as on 12th August, 2014 , Source – WHO NPSP
# Outbreak confirmation for Measles: ≥ 2 cases IgM positive for rubella, @ Surveillance started from January 2013 in Maharashtra & Odisha and from October 2013 in UP, Surveillance started in Chhattisgarh and Uttarakhand
in January 2014, Manipur and Mizoram in March 2014, Arunachal Pradesh and Meghalaya in April 2014, Pondicherry, Sikkim and Tripura in May 2014,
Nagaland in June 2014,Telangana carved out of Andhra Pradesh in 2014, D&N Haveli and Daman & Diu in July 2014
Serologically confirmed# Rubella outbreaks, India(Andhra Pradesh, Arunachal Pradesh, Assam, Bihar, Chhattisgarh, D&D Haveli, Daman & Diu, Gujarat, Haryana Jharkhand, Karnataka, Kerala,
Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Odisha, Pondicherry, Rajasthan, Sikkim, Tamil Nadu, Telangana, Tripura,
Uttar Pradesh, Uttarakhand and West Bengal)@
Rubella outbreaks confirmed
# Outbreak confirmation for Rubella: ≥ 2 cases IgM positive for rubella, @ Surveillance started from January 2013 in Maharashtra & Odisha and from October 2013 in UP, Surveillance started in Chhattisgarh and Uttarakhand in
January 2014, Manipur and Mizoram in March 2014, Arunachal Pradesh and Meghalaya in April 2014, Pondicherry, Sikkim and Tripura in May 2014,
Nagaland in June 2014,Telangana carved out of Andhra Pradesh in 2014, D&N Haveli and Daman & Diu in July 2014
* data as on 12th August, 2014 , Source – WHO NPSP
2013*
71 outbreaks, (15 states) 87 outbreaks, (28 states)
2014*
No Surveillance
Rubella / CRS surveillance
• Current laboratory based measles-rubella surveillance generates information on rubella epidemiology in the country
• Projected estimate suggest high CRS burden in the country as there is no rubella antigen in the national immunization schedule at present
• Sentinel CRS surveillance system under active discussion in the MOH with all partners , likely to be initiated soon
M-R vaccine introduction plan in India NTAGI Recommendations:
• Wide age range (9 months-15 years), Nation wide M-R campaigns to be conducted
• M-R vaccine to replace both MCV1, and MCV 2 at 9-12 months and 16-24 months respectively
• Rubella vaccine introduction likely 1st quarter - 2015
Political commitment for Rubella vaccine:
• ‘Prime Minister’has already announced four new vaccines including Rubella in routine Immunization
MR campaign in India – challenges
• Country target (9 months-15 years ) - 450 million
• Vaccine availability and management will be a big challenge
• SIAs will be phased across states and staggered, 2-3 years
• Quality training, micro planning & monitoring will be the key to success for high coverage with safety
• Health, Education and WCD (women and child development department ) will play vital roles in campaign
• Social Mobilization (IEC/IPC/BCC) will get priority and focus
• Injection safety, waste management , AEFI management established , based on lessons from last MCV-2 campaigns
Way forward• Country intensifying efforts to enhance both MCV 1 and
MCV 2 in routine immunization
• Laboratory based measles-rubella surveillance system established across country on AFP surveillance network
• CRS surveillance efforts being initiated
• Country set to conduct a wide age range M-R campaigns covering all States & Union territories with political will
• Following MR campaigns, M-R vaccine will replace both MCV1 and MCV 2 in routine immunization
• MR surveillance will transition to case based after SIAs
• future campaigns with M-R will be determined based on surveillance data generated
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