progress towards sustainable measles mortality reduction south-east asia region jayantha liyanage...

IMMUNIZATION AND VACCINE DEVELOPMENTIVD

Progress towards Sustainable Measles Mortality Reduction

South-East Asia Region


Jayantha LiyanageMedical Officer- EPI

Immunization and Vaccine Development WHO/SEARO


Presentation structure

•Progress towards the regional goal

•Summary of achievements and main challenges

•Plans for 2007-08


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 1st dose of measles vaccine

• Polio endemic

However there is reasonable human resources for

EPI in most countries at most levels


Regional Strategic Plan 2006-2009

Goal By 2009 reduce the number of estimated

measles deaths by 90% in comparison to 2000Specific objectives• 1st 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


WHO/UNICEF estimates for MCV1 coverage 2001-05Regional coverage increased from 59% in 1999 to 65% in

2005

0

20

40

60

80

100

BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS*

MC

V1

Co

vera

ge

(%)

2001 2002 2003 2004 2005

Source: WHO/UNICEF estimates

IMMUNIZATION AND VACCINE DEVELOPMENTIVDUpdated 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

Polio Measles

Bangladesh SMO (43) 1 1

Bhutan Govt. - 1

DPR Korea Govt. 1 1

India SMO (307) 8 3

Indonesia SO (37) 3 4

Maldives Govt. - 1

Myanmar SMO (20) 1 1

Nepal SMO (10) - 1

Sri Lanka Govt. 1 1

Thailand Govt. 1 1

Timor-Leste Govt. - 1

Total 421 16 16

Country

Number of Surveillance

Medical Officers (SMO) and

Coordinators

Number of Laboratories


Reported incidence rates of clinically confirmed measles cases in selected countries 2000-05

0

10

20

30

40

50

60

2000 2001 2002 2003 2004 2005 2006

Year

Inci

den

ce r

ate

per

100

,000

po

pu

lati

on

Bangladesh India Indonesia Myanmar

Nepal Thailand Timor-Leste

Data as of 19 Feb 2007

Source: WHO/UNICEF JRF 2000-2004; Monthly Reporting Form, 2005-2006


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


Measles and Rubella Serology (IgM) Results in 2006 All laboratories report data monthly

Data as of 31 Dec 2006

# % # % # %Bangladesh Dhaka 448 448 198 44.2 164 36.6 74 16.5 82 7-Jan-07Bhutan Thimphu 67 62 2 3.2 9 14.5 50 80.6 0 10-Jan-07DPR Korea Pyongyang 14 14 0 0.0 0 0.0 14 100.0 0 11-Dec-06

Chennai 366 350 273 78.0 14 4.0 48 13.7 70 8-Jan-07Bangalore 169 169 141 83.4 1 0.6 23 13.6 34 2-Jan-07Coonoor 0 0 0 0.0 0 0.0 0 0.0 0 10-Nov-06

366 519 414 79.8 15 2.9 71 13.7 104Bandung 215 215 168 78.1 24 11.2 22 10.2 32 2-Jan-07Jakarta 151 151 123 81.5 16 10.6 12 7.9 21 3-Jan-07Surabaya 394 294 214 72.8 14 4.8 65 22.1 47 5-Jan-07Yogyakarta 101 101 11 10.9 61 60.4 30 29.7 18 9-Nov-06

861 761 516 67.8 115 15.1 129 17.0 118Maldives Male' 17 17 0 0.0 9 52.9 8 47.1 0 12-Jun-06Myanmar Yangon 254 254 203 79.9 0 0.0 35 13.8 19 11-Dec-06Nepal Kathmandu 214 214 7 3.3 106 49.5 75 35.0 31 10-Jan-07Sri Lanka Colombo 73 73 0 0.0 2 2.7 69 94.5 1 8-Jan-07Thailand Bangkok 3 481 481 196 40.7 24 5.0 192 39.9 4 9-Jan-07Timor-Leste Dilli NR NR NR NR NR NR NR NR NR NR

2795 2781 1534 55.2 444 16.0 717 23.9 277Source: Reported by SEAR Measles Laboratory Network

1 Samples from fever & rash cases are first tested for measles; negative samples are then tested for rubella.2 Percentages may not add to 100%; Equivocal results not included and some samples are in process with results pending.3 Includes samples not tested for measles first but tested for rubella only. NR=No Report

Measles Rubella

Date of Last Report

Received in SEARO

Number of Serum Samples

Received1

Number Tested for Measles &

Rubella

Total

India

Indonesia

Number of Outbreaks

Investigated, If Known

Country Laboratories

Positive Results 2 Number of Samples Negative for Measles

and Rubella 2

Indonesia Total from four labs

India Total from three labs


Number of suspected measles Outbreaks Investigated SEAR, 2003-2006

0

50

100

150

200

250

300

2003 2004 2005 2006

Source: SEAR EPI Annual Reporting Form, 2003-2005; Monthly Reporting Form, 2006 (Feb 2007)

Nu

mb

er o

f O

utb

rea

ks I

nve

stig

ated



Measles Routine

Number of cases

Number of outbreaks

Number of cases

NTDipth-theria

Pertussis RubellaEnceph-

alitis

Number of cases

of AEFI5

Date of last report

Number of reports

expected

% Complete-ness

% Timeli-ness

Bangladesh2 2283 51 3942 44 265 35 46 3389 0 2076 15-Feb-07 12 100 100

Bhutan 0 0 0 0 1 0 1 0 0 11 14-Feb-07 12 83 50

DPR Korea 0 0 0 0 0 0 260 63 0 0 21-Dec-06 12 75 33

India NR NR NR NR NR NR NR NR NR NR NR 12 0 0

Indonesia 20304 81 1472 113 146 2131 0 0 0 14-Feb-07 12 67 50

Maldives 43 0 0 0 0 0 0 0 0 13 13-Dec-06 12 83 67

Myanmar 301 23 459 4 45 2 0 0 0 6 19-Feb-07 12 100 92

Nepal2 411 3 629 0 15 0 0 0 1479 33 14-Feb-07 12 100 100

Sri Lanka 41 0 0 0 1 0 67 6 131 3972 09-Feb-07 12 33 17

Thailand 3121 6 501 1 3 2 96 414 255 74 19-Dec-06 12 100 50

Timor-Leste 24 0 0 0 1 1 22 0 0 0 15-Dec-06 12 50 25

Total 26528 7003 49 444 186 2623 3872 1865 6185

4 Includes routine and outbreak reporting. 5 Adverse Events Following Immunization. NR=No Report

2 In Bangladesh & Nepal, measles outbreaks may include rubella and mixed (measles and rubella) outbreaks. 3 Reporting to SEARO/IVD: Timeliness determined by the receipt of data on or before 15th of each month.

1During the ninth TCG Meeting 2003, SEAR member countries agreed to monthly VPD reporting to SEARO/IVD.

Measles Outbreak

Measles

Deaths4

Number of CasesTimeliness and Completeness of reports

received in SEARO, 2006

Vaccine Preventable Diseases reported to SEARO 2006

10 out of 11 countries are reporting monthly


Source: Monthly Reports from Countries


Age distribution of measles outbreaksTarget age group for SIA was based on country age

distribution of cases

Country Year*

Number

of cases*

*

Age (yrs) distribution of cases (%)

TargetAge

groupfor SIA

≤ 1 1-4 5-9 10-14 ≥15

Bangladesh

2005 10146 13.4 36.2

33.6 10.8 5.8 9 M-10Y

DPR Korea

2007 2257 4.3 5.3 12.3 30.5 47 6 M-45Y

Indonesia 2005 2393 12.4 52.3

31.5 3 0.7 6 M-12Y

Myanmar 2004 1639 7.1 45.8 39 7.1 1 9 M-10 Y

Nepal 2004 6050 5.4 36.6 38.7 14.5 4.5 9 M-15 Y

Maldives 2005 1395 4 7.7 8.6 25.4 54.3 6-25 Y

Sri Lanka 2000 6,392 7.7 5.3 16.3 16 54.8 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


Second Opportunity for Measles Immunization, SEAR, 2007

Data as of: Feb 2007

Measles 2nd Opportunity through

Routine Immunization

Catch-up Campaigns completed

Measles 2nd Opportunity through

Catch-up/Follow up Campaigns

4 Countries providing MR/MMR

Catch-up/Follow-up Campaigns planned in 2007


Number of children vaccinated during measles SIA 2000-06 and planned SIAs in 2007- SEAR

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

45,000,000

50,000,000

2000 2002 2003 2004 2005 2006 2007

Indonesia Myanmar Sri Lanka

Nepal Bangladesh Maldives

Bhutan DPR Korea Timor Leste

Planned120 million would be vaccinated by August 2007


0

1000

2000

3000

4000

5000

6000

7000

8000

2003 2004 2005 2006

Active Outbreak Passive

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



0

500

1000

1500

2000

2500

3000

3500

4000Ja

n

Feb Mar

Apr

May

Jun

Jul

Aug

Sep Oct

Nov

Dec Ja

n

Feb Mar

Apr

May

Jun

Jul

Aug

Sep Oct

Nov

Dec

2005 2006

Outbreak - Measles Outbreak - Mix (Measles & Rubella) Outbreak - Rubella

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

Source : Monthly VPD XLS



After the SIA•Few measles outbreaks.•Rubella outbreaks continue to be detected


Strengthening of Measles surveillance and impact of measles catch-up campaign, Nepal, 2003-2006

Data as of 19 Feb 2007 Source: Monthly VPD MDB


Phase1 Phase2 Phase3

Types of outbreaks

Number of outbreaks

2004 2005 2006

Total outbreaks reported 195 39 27

Serologically confirmed Measles 137 1 3

Serologically confirmed Rubella 13 36 24Serologically confirmed Mixed 11 2 0

0

200

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600

800

1000

1200

1400

1600

1800

JAN

FE

BM

AR

AP

RM

AY

JUN

JUL

AU

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PO

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DE

CJA

NF

EB

MA

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PR

MA

Y

JUN

JUL

AU

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SE

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NO

V

DE

CJA

N

FE

BM

AR

AP

R

MA

YJU

NJU

L

AU

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OC

T

NO

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EC

JAN

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R

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YJU

N

JUL

AU

GS

EP

OC

TN

OV

DE

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2003 2004 2005 2006

Outbreak Routine


Adding other interventions to measles SIAs

Country Year Measles Rubella OPV Vit ABed nets

Sri Lanka 2004 √ √

Nepal 2004/05 √ Under 5 YNationally

Maldives 2005 √ √

Bhutan 2006 √ √

Indonesia2005

√

Under 5 Y in 2

provinces

6-59 M In 2

provinces

2006√

Under 5 Yin 9

provinces

6-59 M In 9

provinces

Selected districts in

8 provinces


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


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


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


SIA plan 2007-08Country Time Target area Age

groupTarget Integrated

Interventions

YEAR 2007

Indonesia February Java Island (catch-up)

6 M -12 y 14,800,000 Vit A, OPV

August Remaining islands

(Catch-up)

6 M -12 y 5,400,000 ITNs, Vit A, OPV

Myanmar Jan, Mach May

National (Follow-up)

9 M -5 Y 7,100,000

DPRK March -April

National(Catch-up)

9 M-45Y 16,200,000 Vit A

Year 2008

Nepal * Q 4 National(follow-up)

9-59 M 3,700,000 ? Vit A, ?OPV

TimorLeste *

2008 National(Catch-up)

9 M-15 Y 400,000 ? OPV

India** 2008 1-2 states(Catch-up)

9M-10 Y 29,000,000 ? OPV

* Subject to government confirmation


THANK YOU



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

Data Collection at National Level

Monthly Data Reporting to

SEARO***

Surveillance Integrated with AFP

Labs Reporting Monthly Serology Results

Bangladesh SMO (43) Active (VPD) Yes Case-Based Case-Based Yes 1

Bhutan Govt. Passive Yes Aggregate Aggregate Yes 1

DPR Korea Govt. Passive Yes Aggregate Aggregate Yes 1

India SMO (307) Passive No Aggregate NR No 3

Indonesia SO (37)*Passive (limited

active)Yes Aggregate Aggregate In-process 4

Maldives Govt. Passive Yes Aggregate Aggregate Yes 1

Myanmar SMO (20)* Active (VPD) Yes Case-Based Case-Based Yes 1

Nepal SMO (10) Active (VPD) Yes Case-Based Case-Based Yes 1

Sri Lanka Govt. Active Yes Case-Based Aggregate Yes 1

Thailand Govt. Passive Yes Aggregate Aggregate Yes 1

Timor-Leste Govt. Passive Yes Aggregate Aggregate Yes NR

Measles Surveillance

Country

Surveillance Medical Officers (SMO)

Surveillance Type**

Monthly VPD & AEFI

Reporting to SEARO


17 SEAR Measles laboratory Accreditation status 2006

Country Laboratory Accreditation status

Bangladesh Dhaka Accredited

Bhutan Thimpu Provisionally accredited

DPRK Pyonang Pending

India Bangalore Due in 2007

Chennai Accredited

Coonoor Accredited

Hyderabad Due in 2007

Indonesia Bandung Accredited

Jakarta Accredited

Surabaya Accredited

Yogyakarta Accredited

Maldives Male Not accredited

Myanmar Yangoon Accredited

Nepal Kathmandu Provisionally accredited

Thailand Bangkok Accredited

Timor Leste Dilli Not operational

Srilanka Colombo Accredited

progress towards sustainable measles mortality reduction south-east asia region jayantha liyanage...

Documents

measles surveillance

dose measles coverage

confirmed measles cases

monthly reporting form

regional coverage

sear epi annual reporting

annual epi reporting

surveillance staff