MEASLES MORTALITY REDUCTION IN INDIA

Status and Future Plans

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

Basic Demographics and Population Density, India

Number of persons per sq. km

Total Population Density by State

Updated: July 2006

Table 1: Demography1 2005Percent of Total

PopulationTotal Population 1,028,610,328

Population Growth Rate2 1.51%Live Births 27,552,928 2.7

Birth Rate

Infant Mortality Rate 2

Children < 1 Year 25,793,927 2.5

Children < 5 Years 123,974,000 12.1

Children < 15 Years 363,373,000 3 35.3

26.7 / Per 1000 population

68 / Per 1000 live births

1Source: SEAR Annual EPI Reporting Form, 2005.

3 413,417,000 was used to calculate Non-Polio AFP rates in 2005.

2 Core Indicators, 2005 (Health Situation in WHO SEAR and WPR).

35 States

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%

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%

Reported/surveyed annual measles vaccination coverage and cases

India, 1974-2005

0

50,000

100,000

150,000

200,000

250,000

300,000

74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 '00 '01 '02 '03 '04 '05

Year

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Reported cases Reported coverage Unicef CES NFHS

Source: India MOH/UNICEF

Reported measles cases vaccination coverage (%)

Reported

Surveyed

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)

59.52

25.59

35.70

12.35

30.38

7.08

18.62

NA NA NA NA NA NA

15.23

NA NA

15.83

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

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Rajas

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Uttara

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Uttar P

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Orissa

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States (reported data of IW1,IW2,IW3)

Co

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of

An

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et(%

)Percentage Coverage (Measles) of Annual Target

achieved during last three Immunization Weeks (2006-07)

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

Polio cases, India

Year

* data as on 16th February 2007

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

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

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

Clinically confirmed measles cases 2006 through weekly routine reporting: by blocks

Variation of incidence even among Southern states

* data as on 15th February, 2007

Tamil NaduAnnual incidence2.8 per 100,000 population

KarnatakaAnnual incidence10.2 per 100,000 population

Andhra Pradesh

Initiated in September 2006

Suspected measles outbreaks investigated, 2006Possibly Karnataka has not tracked some of the outbreaks

Tamil Nadu Karnataka Andhra Pradesh

Measles outbreaks confirmed

(Total cases)

29

(1098)

33

(1045)

13

(290)

Measles outbreaks negative 2 2 0

Rubella outbreaks confirmed

(Total cases)0

2

(109)0

Mixed outbreaks confirmed

(Total cases)0

1

(28)0

* data as on 15th February, 2007

Tamil Nadu Karnataka Andhra Pradesh

Serologically confirmed measles outbreaksPercentage 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 15th February, 2007

Andhra PradeshKarnatakaTamil Nadu

Serologically confirmed measles outbreaksVaccination 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 15th February, 2007

N=407

Karnataka

N=339

Tamil Nadu

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

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

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

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.

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

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

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

Thank you

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

Tamil Nadu Karnataka

Estimated Paralytic Polio Cases/year, India

OPV introduced

in RI

NIDs/SNIDsstarted

NIDs/SNIDs strengthened

Unicef CES (1998-2005)India (Measles )

Source: Unicef CES Survey All India (country level) data for 2001 not available

55.2

50.2

55.6

68.1

NA0

10

20

30

40

50

60

70

80

90

100

1998 1999 2000 2001 2005

% c

ove

rag

e

1998 1999 2000 2001 2005