Global Measles and Rubella Management Meeting

Progress and Challenges in Bangladesh

15-17 March, 2011Geneva, WHO HQ

Dr Serguei Diorditsa

SYLHET

RAJSHAHI

KHULNA

DHAKA

CHITTAGONG

BARISAL

Measles control plan (2004-2010)

and next goals in Bangladesh

0

5000

10000

15000

20000

25000

30000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2016

Nu

mb

er o

f d

eath

s

60

65

70

75

80

85

90

95

100

Co

vera

ge

Measles death ( revised WHO 2010 estimates) MCV1 Coverage

Measles catch-up campaignimmunized: >35 million

Measles follow-up campaignimmunized: >18 million

plus OPV, vit A ,albendazole

Measles control plan 2004-2010

In 2011-2016, cMYP elimination targetIncluding 2nd dose MCV2 introduction

cMYP 2011-2016

Source: Child deaths due to measles 2000-2009 by WHO estimation, 10 Feb 2011

85%

Trends of measles cases and valid measles coverage by one year of age (1990-2010)

Measles catch-up campaignimmunized: >35 million

Measles follow-up campaignimmunized: >18 million

Dots are randomly placed within district boundary

Spot Map of Outbreaks Reported

in Bangladesh

2005 2006 2007 2008 2009 2010

Measles catch-up campaignimmunized: >35 million

Measles follow-up campaignimmunized: >18 million

Year 2005 2006 2007 2008 2009 2010

# of measles outbreaks ( lab) and ( mixed)

203 51 5 1 2 0

# of rubella outbreaks 87 26 102 59 145 193

Age Distribution of Lab Confirmed

Measles Outbreak Cases, Bangladesh, 2003-2010*

14%

14%

13%

13%

17%

23%

38%

43%

35%

31%

45%

50%

35%

30%

34%

37%

26%

13%

10%

8%

11%

12%

6%

10%

4%

4%

6%

7%

6%

4%

2003

2004

2005

2006

2007

2008

2009

2010

<1 year 1-4 years 5-9 years 10-14 years >=15 years Unknown

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

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

2003 2004 2005 2006 2007 2008 2009 2010

Nu

mb

er

of

Ca

se

s

Routne(suspected) Lab Measles and Mixed Rubella

Measles Cases in Bangladesh by Year 2003-2010

Changes in definition of outbreak:2003: 50 cases per ward2005:10 cases per ward2008: 3 cases per ward

Outbreak surveillance Case based surveillance

Measles catch-up campaignimmunized: >35 million

Measles follow-up campaignimmunized: >18 million

Measles surveillance indicators

SL Indicators 2009 2010

1Annual national incidence of non measles suspected measles cases (Target more than 2 per 100,000 population)

9.8 9.6

2Percentage of districts annually reporting at least 2 non measles suspected measles case per 100,000 population (Target at least 80% districts)

45% 58%

3 Annual number of reported rubella cases 13,464 13,125

4Percentage of reported suspected measles outbreaks fully investigated (Target 100%)

100% 100%

5 Completeness of monthly VPD surveillance reports (Target 90%) 91% 90%

6 Timeliness of monthly VPD surveillance reports (Target 80%) 84% 84%

7Percentage of suspected measles cases tested in a proficient laboratory, excluding from the denominator any cases that are epidemiologically linked to a laboratory confirmed case (Target 80%)

75% 81%

8 Percentage samples with laboratory results within 14 days (Target 80%) 52% 56%

Virus isolation status

Year No. of urine

Sample collected

Sample tested in regional

lab

Measles Rubella Negative Pending

2008 8 5 0 0 5 0

2009 27 16 0 3 13 11

2010 59 0 59

Non-measles suspected cases

reporting rate

2009 2010

58% (37/64) districts achieved rate ≥2.00 in 2010

2009 2010

No Case 4 0

<1.00 28 23

1.00 - 1.99 3 4

≥ 2.00 29 37

Number of DistrictsNon Measles Rate

per 100,000 populationLegend

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

2005 2010

<70% 27 1

70-79% 23 11

≥80% 14 52

LegendCoverage

MCV1Number of Districts

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

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

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 resourcesPositive•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

NegativeStaff members de-motivated from late arrival of funding EPI staff feel overloaded with added worksShortage of technical staff The campaigns did not attract a sufficient number of volunteers in some areas as their refreshment fund were not enough

Budget for integrated VPD surveillance and measles activities in 2011-2013

( in million USD)

2011 2012 2013

planned available gap planned available gap planned available

gap

MCV 2 vaccine

Bangladesh will apply to GAVI for MCV2 cost support

MR vaccine Bangladesh consider the cost of MR vaccine to be born from new Health Sector Programme for 2011-2016

MCV2 Introduction-Training & supervision

1,22 0 1,22

surveillance 2,5 2,0 0,5 2,3 1.0 1.3 2.3 1,0 1.3

Total gap 0.5 Total gap 1.52 Total gap

1.3

Total Gap for 2011-2013 3,32 million USD

Thank You

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

Budget for integrated (AFP/Measles/Other VPDs) surveillance and measles control/

elimination activities 2011-2016

Activities Fund required yearly 2011-2016

Fund required one time 2012

Fund available Funding gap

2011-2016

Funding gap one time

Annual Surveillance operational cost

2.5 million 1.5 million x2 l (in 2011-2012)

9,5 million

MCV2 Government will apply for GAVI support for vaccine

MCV2 Introduction-Training & supervision

1.22 million

0 1.22 million

Logistics –printings and others for MCV2

Cost is under consideration for next health sector program 2011-2016

MR vaccine Vaccine Cost is under consideration for next health sector program 2011-2016

Measles SIA No plan developed

Total 2011-2016 12.5 million 1.22 million

3 million 9,5 million 1.22 million

Total Gap 10,72 million

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