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Programmatic Feasibility of Measles Elimination

World Health Organization Eastern Mediterranean Region

June 2010

Acronyms: EMR Eastern Mediterranean Region of the World Health Organization

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EMRO Eastern Mediterranean Regional Office of the World Health Organization

EPI Expanded Programme on Immunization GAVI Global Alliance for Vaccines and Immunizations GIVS Global Immunization Vision and Strategy IgM Immunoglobulin M MCV Measles Containing Vaccine NCC National Certification Committee (for polio) NVC National Validation Committee (for measles) PEI Polio Eradication Initiative RC Regional Commission RCC Regional Certification Committee (for polio) RD Regional Director RTAG Regional Technical Advisory Group RVC Regional Validation Commission (for measles) SIAs Supplementary Immunization Activities UNICEF United Nations Children’s Fund VPI Vaccine Preventable Diseases & Immunizations WHO World Health Organization

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Table of Contents: A. Introduction

1. Regional overview B. Strategies

1. Regional strategies 2. Partnerships 3. Additional disease control strategies needed for eradication

C. Measles Epidemiology in the Eastern Mediterranean Region 1. Regional

D. Costs of Measles Mortality Reduction and Elimination 1. Methods 2. Future costs

E. Time Taken 1. Coverage/Overview 2. Surveillance 3. Laboratory 4. Surveillance and laboratory cost (2011-2015)

F. Progress Towards Current Goal

1. Overview/MCV coverage 2. Country data 3. Enabling factors 4. Challenges

G. The Certification/Validation Process

1. Plan of Action 2. Principle Objectives of the Documentation and Verification Process 3. Definitions of Regional Measles Elimination 4. Country Elimination Indicators 5. Basic Principles 6. Verification Process 7. Timeline

H. Measles Control/Elimination in the Context of Health Systems Strengthening

I. Programmatic Feasibility

J. Future Strategies

K. References

L. Annexes

1. Country Data

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. A. Introduction: 1. Regional overview The Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) is composed of 22 Member States1. Countries in the region fall into 3 economic categories: high, middle, and low income. Regionally and throughout this report these categories will be referred to as Gulf Cooperation Council (GCC) (high-income), middle-income, and Global Alliance for Vaccines and Immunizations (GAVI) eligible (low-income), respectively. In general, GAVI eligible countries (Afghanistan, Djibouti, Pakistan, Somalia, Sudan, and Yemen) are provided more support (financial and programmatic) than Middle-income countries (Egypt, Jordan, Palestine, Syria, Morocco, Tunisia, Lebanon, Iraq, Iran, and Libya) that receive technical assistance and minimal financial support. GCC countries (Oman, Bahrain, Saudi Arabia, Kuwait, UAE, and Qatar) usually do not receive financial support from the Eastern Mediterranean Regional Office (EMRO) of WHO. During the Forty-first Session of the Regional Committee for the EMR held in 1997, the Regional Committee passed a resolution to eliminate measles by the year 2010 (Resolution number: EM/RC44/R.6 ). B. Strategies: 1. Regional Strategies To reach this goal, in 1999, EMRO developed a 5 year-plan based on WHO-UNICEF joint strategy for measles elimination which included a four-pronged strategy: 1) achieve and maintain ≥90% vaccination coverage of children with the first dose of measles-containing vaccine (MCV1) in every district of each country through routine immunization services, 2) achieve ≥90% vaccination coverage with the second dose of measles-containing vaccine (MCV2) in every district either through a routine 2-dose vaccination schedule or through supplementary immunization activities (SIAs), 3) establish case-based surveillance with investigation and laboratory testing of all suspected cases of measles, and 4) provide optimal clinical-case management, including supplementation of vitamin A. In 2005, the vaccination coverage targets in the EMR for MCV1 and MCV2 were changed to 95% for those countries moving toward elimination of measles. 2. Partnerships The EMR measles elimination initiative is conducted in concert with many international and regional organizations and governmental agencies. EMRO partners with these agencies and organizations in providing funding and technical assistance to Member States. These partners 1 Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, UAE, and Yemen.

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include UNICEF, the Measles Initiative (MI), the Centers for Disease Control and Prevention (CDC), the Bill and Melinda Gates Foundation, and the Lions Club. 3. Approached activities to implement strategies To achieve elimination of measles in the EMR, a number of strategies will need to be enhanced and/or developed. In general, current strategies will need to be fully implemented, namely, achieving 95% population coverage with both MCV1 and MCV2 and conducting case-based measles surveillance in every EMR Member State. Additional strategies may include: conducting follow-up campaigns in every Member State every 3-4 years until MCV1 and MCV2 reach >95% nationwide and in all districts. is achieved; targeting and reaching displaced populations (refugees, internally displaced persons (IDPs), and migrant workers) with MCV1 and MCV2 in both developed and conflict affected Member States; enhancing routine immunization programs in low performing countries; and increasing the coordination/communication between Member States and EMRO to improve surveillance and technical support. C. Measles Epidemiology in the Eastern Mediterranean Region 1. Regional

a. Before the elimination goal – Pre-1997 Prior to 1997, the 22 Member States had introduced MCV1 into their routine immunization programs and 12 had introduced MCV2. Between 1980 and 1997 MCV1 coverage increased from approximately 25% to 80%. During this period, the number of cases dramatically decreased from approximately 391,624 in 1980 to 33,085 in 1997 (EMRO Surveillance data).

b. After the elimination goal – Post 1997 After 1997, the estimated regional MCV1 coverage increased slowly from 80% in 1997 to 84% in 2009 (Figure 1). However, as of 2009, only 19 countries2 have MCV2 as a routine part of their EPI program.

Figure 1: Annual distribution of measles cases and MCV1 coverage in EMR, 1995-2009

2 Djibouti, Somalia, Sudan did not have MCV2 in 2009

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c. Measles related mortality and measles cases Estimated measles mortality has decreased from 104,000 in 1999 to 10,000 in 20073, reaching the Global Immunization and Vision Strategy (GIVS Goal three years before the year target of 2010 (Figure 2).

Figure 2. Estimated measles deaths in Eastern Mediterranean Countries, 2000 - 2007

Since the setting of the elimination goal, measles cases decreased from approximately 89,478 in 1998 (WHO/HQ data) to 15869 in 2009 (Measles data reported to EMRO). Of these cases, 40% were female and 60% were male. Most of the cases (44%) were aged between 1 and 4 years.

d. Vaccination status of cases 2009

During 2009, 44% of total cases reported to EMRO were of unknown vaccination status, 40% of measles cases with known vaccination status were unvaccinated, 41% were vaccinated with one dose of MCV and 19% with two doses.

e. Genotypes of cases

The predominant genotype in the EMR is D4 (Table 1). Additional genotypes isolated during 2007, 2008 and 2009 include B3, D5, and D8.

Table 1. Measles Genotypes detected in the EMR, 2007-2009 Country Genotype Associated with Endemic

Transmission Genotype Associated with Importation

Afghanistan D4 Bahrain D4 D4, D8 Djibouti B3 Egypt D4 Iran D4 H1

3 Variations between mortality and case data are due to different data sources used to determine the number of cases (surveillance data) and mortality (WHO modeling estimates).

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Iraq D4 Jordan D4 Kuwait B3, D5, D8 Lebanon *B3 (ND) Libya B3 Morocco C2 interrupted, B2, D7, D8 D4 Oman D8, D5 B3, D4 Pakistan D4 Palestine ND Qatar D4

Saudi Arabia ND

Somalia *B3 (ND)

Sudan B3, D4

Syria D4

Tunisia B3 B3

United Arab Emirates ND

Yemen B3

* Measles virus genotype was identified from cases imported to USA but not done in EMR LabNet

f. Geographic distribution of confirmed measles cases

Approximately 80% of cases identified during 2009 were found in 4 countries (Afghanistan, Iraq, Morocco, and Somalia) (Table 2). Since 2003, Iraq have been experiencing decreased security and social disruption that limited immunization services, decreased experienced immunization staff, displaced large segments of the population, and eroded immunization/health care infrastructure. Ultimately this led to low routine immunization coverage and an outbreak of measles during 2008-2009.

Table 2: Geographic Distribution of Confirmed Measles Cases, EMR, 2008 and 2009

Country 2008 2009

Afghanistan 1188 2871 Kingdom of Bahrain 2 3

Djibouti 8 20 Egypt 771 252

Iran (Islamic Republic of) 139 291 Iraq 5048 8763

Jordan 0 0 Kuwait 780 129

Lebanon 41 29 Libyan Arab Jamahiriya 8 656

Morocco 1820 592 Oman 15 18

Pakistan Palestine

53 0

451 5

Qatar 112 43 Saudi Arabia 318 80

Somalia 1129 1360 Sudan 97 68

Syrian Arab Republic 10 36

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Tunisia 0 26 United Arab Emirates 40 54

Yemen 53 127 Total 11632 15869

D. Costs of Measles Mortality reduction and Elimination 1. Methods The methods used to complete the financial projections section of the assessment include:

• Calculating the cost of one MMR dose per child for high, medium, and low income countries (GCC, middle income, and GAVI eligible, respectively)4

• Completing projections of coverage rates for MCV1, MCV2, and SIAs per country through 2015 • Calculating the total cost per year per country (from 2011-2015) based on MCV1 and MVC2

coverage projections, SIA coverage projections (when/where applicable), wastage rate for routine and SIA immunization strategies, inflation rate, estimated living children per cohort (UNPD estimates), and the cost of MMR per child (as listed above)

Assumptions for this model include: • The estimated target for future SIAs include children 9 – 59 months • Costs for vaccine are: GAVI - $0.40, based on EMRO data; middle income - $2.00,

based on Egypt data; GCC = $5.00, based on Bahrain data. • Vaccine given is MMR for all doses including SIAs • Improvement and/or maintenance of MCV1 and MCV2 coverage is estimated • The module includes operational cost for SIA that we estimated in the region to be 20%

of the total cost • Laboratory or surveillance costs • Technical assistance costs

2. Future Costs

Cost projections are through 2015. 2011-2015 projections are included because it is believed that 2015 is a more realistic target for measles elimination in the region. The below estimates do not currently include S. Sudan due to insufficient data on birth cohort estimates (Tables 3, 4 and 5). For Somalia, we only included the cost of the CHDs. Table 3 presents the cost of MCV1, MCV2 and SIA per year for the whole Region. The total cost for the period 2011-2015 is estimated to 364,478,966 USD. Table 3: Cost (in USD) of MCV1, MCV2 and SIA by Year, 2011 – 2015Year

MCV1 MCV2 SIA Total

2011 24,781,658.23 21,490,907.47 12,944,788.95 59,217,354.65 2012 25,465,184.77 24,746,151.35 14,499,085.83 64,710,421.95 2013 26,840,667.28 25,542,530.81 5,711,594.84 58,094,792.93 2014 28,328,468.29 27,934,458.94 12,313,008.68 68,575,935.91 2015 29,630,551.67 26,371,930.96 17,976,891.48 73,979,374.11

4 Because of a low response rate to the country level survey, an additional survey of 3 countries was conducted (Jordan, Egypt, Oman) requesting costs of measles elimination for as many years as possible. These data were used, along with GAVI eligible country financial reports, to calculate a cost per child for each of the 3 financial categories of the Region (GCC, GAVI eligible, and middle income).

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Total 135,046,530.2 126,085,979.53 63,445,369.78 324,577,879.55 Table 4 shows the cost of the same activities by GAVI, Middle Income and GCC countries. Table 4. Cost (in USD) of MCV1, MCV2 and SIA by Income Category, 2011-2015

MCV1 MCV2 SIA Total (%) GAVI 14,765,945.41 14,304,187.71 59,029,963.41 88,100,096.53 Middle Income 76,060,374.94 73,493,580.80 12,982,521.57 162,536,477.31 GCC 37,664,323.57 35,271,989.2 1,004,992.90 73,941,305.71 Total 128,490,643.92

123,069,757.71

73,017,477.88

324,577,879.55

Table 5 presents the cost of MCV1, MCV2 and SIA by country, EMR, 2011-2015 Table 5: Cost (in USD) of MCV1, MCV2, and SIA by Country, 2011 – 2015

Country MCV1 MCV2 SIA Total Afghanistan 2,138,071.145 2,061,010.8 2,921,629.375 7,120,711.364

Bahrain 283,531.8205 291,153.7 0 574,685.5455 Djibouti 146,851.83 19,097.0 38,797.4 204,746.3323 Egypt 17,263,797.33 17,223,013.1 0 34,486,810.43Iran 13,448,993.25 13,448,993.2 0 26,897,986.51 Iraq 8,718,514.298 5,737,853.3 10,083,595.41 24,539,963.02

Jordan 144,049.8 1,374,044.3 378,028.4 1,896,122.5 Kuwait 1,213,777.505 1,211,626.7 0 2,425,404.21

Lebanon 615,444.07 633,284.5 572,937.76 1,821,666.33 Libya 1,272,442.0 1,283,887.8 0 2,555,339.80

Morocco 27,583,267.29 26,761,092.10 1,947,960 56,292,319.3 Oman 1,561,241.6 1,537,914.4 0 3,099,156.048

Pakistan 8,674,812.636 8,582,700.609 7,865,419.136 25,122,932.39 Palestine 570,000 570,000 0 1,140,000

Qatar 321,638.9 320,889.0 83,821.1 726,349.0 Saudi Arabia Somalia

32,497,843.84 30,187,406.94 45,000,000.00

62,685,250.78 45,000,000.00

S. Sudan Sudan 2,059,496.4 1,923,986.5 184,8312.9 5,831,795.8 Syria 4,934,169.6 4,945,126.0 0 9,879,295.6

Tunisia 1,509,697.3 1,516,286.5 0 3,025,983.8 UAE 1,786,289.9 1,722,998.5 921,171.8 4,430,460.3

Yemen 1,746,713.4 1,717,392.8 1,355,804.6 4,819,910.92 Total 128,490,643.9 123,069,757.75 73,017,477.88 324,577,879.54

E. Time Taken

1. Coverage/Overview

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The goal for measles elimination was set in 1997. At that time MCV1 coverage was 79% in the EMR and measles mortality was over 100,000 per year. Limited reliable data is available on MCV2 coverage and surveillance indicators prior to 1997. As of 2009, MCV1 coverage is reported to be 84% for the region. Measles mortality is estimated to have been reduced to 10,000 deaths as of 2007 and as of 2008 only 11,629 cases were reported to EMRO. However, in 2009, an epidemic year, 16874 cases were reported. In 2009, 15 countries reported MCV1 coverage above 95% and 11 countries reported MCV2 coverage above 95% (Figure3). Figure 3: MCV1 & MCV2 Coverage by Country, 2009

2. Surveillance

As of 2009, nationwide case based surveillance is being conducted in the entire region with the exception of Morocco, Pakistan, Somalia, and Southern part of Sudan. Efforts are underway to implement case based surveillance in these countries. Reporting from countries conducting case-based surveillance occurs monthly to EMRO.

Key indicators being analyzed include the non-measles suspected measles case detection rate, percent of suspected cases with a blood specimen collected, adequacy of investigation of suspected measles cases, and collection of specimens for viral detection. Some measles surveillance indicators are currently not being monitored due to insufficient data including: percent of confirmed cases with infection source identified, percent of outbreaks with samples collected for virus detection, and percent of suspected cases investigated within 48 hours of notification. It was noted that countries should start including the date of notification and the source of infection in the measles case based database submitted to EMRO on a monthly basis. Table 6 shows the quality indicators by country for the year 2009. Table 6: Selected Measles Surveillance Quality Indicators, 200

Conid

Reporting rate

/100000

%of confirmed

cases with Identified source of infection

% of measles

with complete

inv

% of measles

tested

% of specimens

received at the lab

within 7days

% of adequate

specimens

% of specimens

reported to EPI within 7days

Afghanistan 1.84 62.8% 7.0% 71% 93.35% 97% 100%

Bahrain 8.40 50.0% 100.0% 100.00% 100.00% 100.00% 100%

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Djibouti 1.40 0.0% 58.8% 100.00% 97.06% 100.00% 97.06%

Iran 1.54 0.0% 52.8% 88% 99.44% 100.00% 100%

Iraq 2.65 0.0% 79.0% 100.00% 60.24% 100.00% 100%

Jordan 1.50 77.8% 100.00% 83% 100.00% 94%

Egypt 0.58 0.0% 99.3% 100.00% 83% 95% 95%

Kuwait 20.47 0.0% 0.0% 98% 96% 100.00% 100.00%

Lebanon 0.9 0.0% 57.6% 58% 49% 100.00%

Libya 3.08 0.0% 99.6% 100.00% 95% 100.00% 100.00%

Morocco 0.07 0.0% 96.0% 4% 100.00% 100.00% 90.00%

Oman 16.17 0.0% 87.9% 99% 82% 99.09% 100.00%

Pakistan 0.20 0.0% 58.2% 79% 90% 97% 96%

Palestine 3.03 60.4% 96% 94% 100.00% 100.00%

Qatar 5.50 0.0% 55.2% 40% 91.-% 100.00% 98%

Saudi Arabia 0.71 0.0% 2.5% 100% 34% 100.00% 100%

Somalia 0.47 0.0% 0.4% 4% 100.00% 100.00% 88%

Sudan 1.74 0.0% 99.1% 96.66% 66% 100.00% 100%

Syria 1.62 0.0% 95.8% 96.96% 96% 97% 100.00%

Tunisia 4.56 0.0% 85.3% 100% 74% 100.00% 100.00%

UAE 1.53 0.0% 68.3% 93.06% 90% 100.00% 99%

Yemen 2.96 0.0% 61.4% 95% 70% 99.61% 95% 3. Laboratory

Considerable resources have been used to establish measles and rubella laboratory capacity (serologic testing for IgM-class antibodies). All countries have a national laboratory for measles and there are two Regional Reference Laboratories (Tunisia and Oman) which support Member States for measles isolation validation and virus genotyping. Figure 4 shows the capacity of EMR LabNet Work. Figure 4: Measles/Rubella Laboratory Network in the EMR, 2009

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Standard laboratory procedures have been established and are followed. Laboratories are functioning at a high level of proficiency and meet performance indicators and timeliness of reporting criteria on measles case-based surveillance with laboratory confirmation reported in the monthly measles bulletinHigh quality of the testing achieving more than 90% concordance results with external quality control performed by the two Regional Reference Laboratories. Currently all countries are participating in the Global measles and rubella proficiency testing program. Of the 21 countries who participated in the proficiency testing program in 2008, scored 99% in Measles and 99.5% in Rubella. Laboratory accreditation reviews were undertaken in between 2005 to 2009 for 21 countries. Results showed that 20 of the 21 countries were fully accredited, and one country Djibouti did not pass accreditation requirement and received work plan to implement and to be reviewed early 2010, Somalia is on schedule for accreditation before the end of 2010.

All countries have moved to measles case-base surveillance with laboratory confirmation, 18 of these countries are implementing nationwide, and four countries, Morocco, Pakistan, Somalia and [Southern part of Sudan are performing in identified sentinel sites. Thus the serological testing had increased, approximately 23587 serum samples were tested in the EMR Lab Net for measles IgM in 2009 compared to 6684 samples in 2006, an increase of 28% (Figure 5). This Figure Shows the reported number of suspected measles cases, number tested and number laboratory confirmed by year. Countries reporting measles cases to the Region has scaled up since 2005. Some of countries have experienced measles outbreaks in 2007 (Egypt, Kuwait, Saudi Arabia and Syria), 2008 (Egypt and Iraq) and 2009 (Iraq, Afghanistan, Iran and Yemen).

Figure 5: Total Number of Measles Suspected Cases Lab Tested, 2005 – 2009

4. Surveillance and laboratory cost (2011-2015)

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The total cost of surveillance and laboratory activities for the Region is presented in Table 7. Table 7. Estimates based data from countries and support provided to GAVI countries, EMRO, 2011-2015

Activities Cost 2011 2012 2013 2014 2015

Surveillance cost Laboratory activities

7,856,222.5 7,767,831.4 7,683,649.0 7,603,476.0 7,527,120 3,638,616.5 3,465,349.6 3,300,333.0 2,200,000.0 1,220,000

Temporary staff cost 3,026,200.0 3,177,510.0 3,336,385.5 3,839,589.5 4,031,561.4 Total 14,521,039.014,410,691.014,320,367.5013,643,065.512,778,681

EMRO is currently providing financial support to GAVI countries that is estimated to approximately 1,300,000 USD annually. F. Progress toward the Current Goal 1. Overview/MCV coverage While implementation of the measles elimination strategy has varied by country because of financial, security, and managerial constraints; all countries have exhibited strong commitment and determination to achieve measles elimination. Estimated measles mortality decreased from over 100,000 during 1997 to 10,000 deaths during 2007 (Figure 1), representing a 90% reduction in measles mortality. This mortality reduction is indicative of high immunization coverage with MCV1 Regionally. MCV1 coverage has increased from 80% coverage during 1997 to 84% during 2009. Some countries (Jordan, Syria, Iran, Bahrain, Oman, Libya, Palestine, and Tunisia) are at elimination phase, others seem near to reaching elimination, and a group of countries are still experiencing high burden of disease (Table 8). Table 8. Reported measles cases, measles incidence per million, routine measles vaccination, coverage and measles immunization schedule, WHO Eastern Mediterranean Region, 1997 and 2009 Country 1997 2009 Covera

ge MCV1 1997

Schedule of immunization Dose1 Dose 2

Coverage MCV1 2009 Dose1 Dose 2

Reported cases (incidence) 2009

Elimination 2012 Bahrain 94 MMR (12mo) MMR(4-6y) 99 99 3 (3) Egypt 92 MMR(12mo) MMR (15-18 mo) 98 96 252 () Iran 95 MMR(12mo) MMR (15-18 mo) 97 96 291 (3.99) Jordan 95 MMR(12mo) MMR (15-18 mo) 95 90 0 (0) Oman 98 MMR (12mo) MMR (15-18 mo) 97 98 18 (6.00) Palestin 96 MCV(12mo) MMR (15-18 mo) 98 96 5 (1.25) Saudi Arabia 92 MMR(12mo) MMR (4-6 y) 95 98 80 (3.20)

Syria 93 MMR(12mo) MMR (15-18 mo) 98 97 36 (1.7) Tunisia 92 MCV (12mo) MCV (4-6 y) 98 99 26 (2.6)

Elimination by 2013 Kuwait 95 MMR(12mo) MMR (4-6 y) 99 97 129 (43) Lebanon 89 MMR(12mo) MMR (4-6 y) 93 88 29 (7.25)

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Libya 91 MMR(12mo) MMR (15-18 mo) 98 97 656 (109.3) Morocco 92 MCV(9mo) MMR (4-6 y) 95 592 (19.1) Qatar 87 MMR(12mo) MMR (4-6 y) 97 98 43 (43) UAE 95 MMR(12mo) MMR (4-6 y) 92 89 54 (13.5)

Elimination by 2015 Afghanistan 48 MCV(9mo) MCV (15-18 mo) 76 39 2871 (106.3) Djibouti 31 MCV (9mo) - - 70 - 20 (20) Iraq 85 MCV (9mo) MMR (15-18 mo) 96 102 8763 (282) Pakistan 52 MCV(12mo) MCV (18 mo)

80 ? 461* (2.55)

Somalia 25 MCV (9 mo) - - 59 - 1360 (151)

Sudan 58 MCV (9mo) - 80 - 68 (1.66) Yemen 46 MCV(9mo) MCV(15-18mo) 69 44 127 (5.77) Since the establishment of the elimination goal in 1997, EMRO recommends that Member States provide two routine measles doses, preferably in the second year of life. As of 2009 only Afghanistan, Egypt, Iran, Iraq, Jordan, Libya, Oman, Palestine, Syria, and Yemen are meeting this recommendation – to various levels of success. Seven countries have a two dose schedule with the first dose at nine months. Three countries have a one dose schedule. AllEMR countries that currently offer a second routine dose at school entry provide a booster DPT dose at 18 months and it would be feasible to offer a measles dose at 18 months as well. In addition to routine immunization programs, following the establishment of the elimination goal in 1997, Member States began conducting catch-up campaigns for their unimmunized populations. Since this time, catch-up campaigns have been completed in every member state excep. In addition to catch-up campaigns, many countries have conducted targeted measles SIAs to control outbreaks or bridge the immunity gap among some high risk groups. 2. Country Data See annex 1 for country level data on progress to date, 5 year plan, enabling factors, challenges, when likely to achieve goal, improvements needed, and competing public health priorities. 3. Enabling Factors Countries that have achieved success with MCV1 and MCV2 vaccine implementation and coverage site strong country level political commitment and support from EMRO as reasons for successful immunization programs. Countries that have had less stable political commitment but that have made some progress toward measles elimination site EMRO and GAVI support as the reasons for the gains achieved. However, there are countries with stable political commitment but didn’t approach elimination. 4. Challenges Primary challenges to the achievement of measles elimination among GAVI countries include:

• security issues that limit access to routine immunization services and quality immunization campaigns

• poor political commitment which inhibits strong routine immunization programs • Lack of funds to support measles elimination efforts, particularly conducing follow-up

measles campaigns

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Among middle income and GCC countries, challenges include:

• Eliminating the immunity gap among high risk groups (refugees/migrants) • Reducing the risk of importations through increasing routine coverage mainly among

some high risk groups (migrant workers). G. The Certification/Validation Process 1. Plan of action During the first EMR Measles Elimination Technical Consultative Meeting, held during 16—18 September 2008 in Cairo, Egypt, the decision was taken to begin the process of validating the elimination of measles in the EMR. This decision authorized the development of measles validation guidelines that establish the concepts, criteria, methodologies, and data elements necessary to document the interruption of endemic measles virus transmission in EMR countries and to create a standardized verification process. Additionally, at the RTAG meeting for measles in November 2008, the recommendation was given to EMRO to include the documentation of rubella and CRS in the measles elimination validation guidelines and subsequent validation documentation. Therefore, countries applying for measles elimination validation should include documentation toward rubella and CRS elimination. However, it is not necessary to have eliminated rubella and CRS before applying for measles elimination validation. 2. Principle Objectives of the Documentation and Verification Process The objectives of this verification process are to:

• Document epidemiological evidence of the absence of endemic measles cases.

• Evaluate quality of surveillance system to detect and rapidly respond to measles and

rubella virus circulation and laboratory capacity to provide serological diagnosis and molecular epidemiological information about circulating viruses.

• Verify the absence of endemic measles virus strains (through viral detection) in all

countries of the EMR.

• Determine level of population immunity (>95%) required to prevent the reestablishment of endemic measles and rubella virus circulation.

• Determine if the information is complete, valid, representative, and consistent.

3. Measures of Progress towards Measles Elimination and Markers Suggestive of Having Achieved Elimination In the context of countries with an elimination goal, monitoring progress towards the achievement of this goal can only be accomplished in the presence of a well-performing surveillance system. The surveillance system (both epidemiology and laboratory together) must provide the needed sensitivity and specificity to ensure the detection of measles virus. The

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performance indicators and targets highlighted in Section A below should be monitored by countries with elimination goals to assess the quality of the surveillance system. In addition, two measures, one of process, the other of outcome, are recommended to monitor progress towards measles elimination and to assist in determining whether elimination has been achieved. It is recommended that the practicality and usefulness of the proposed measures be evaluated on an ongoing basis and modified as required. a. Surveillance Performance Indicators for Countries with Elimination Goal: Reporting Rate:

• At national level, a rate of at least 2 non-measles suspected measles cases5 per 100, 000 population should be considered a minimum. These cases must have been investigated and discarded as non-measles cases using laboratory testing in a proficient laboratory6 or epidemiological-linkage to another laboratory-confirmed disease or epidemiological-linkage to an IgM negative case.

• In addition, at least 1 non-measles suspected measles case should be reported annually per 100,000 populations in at least 80% of the administrative units at the province level or its administrative equivalent or at an administrative level that has a population of at least 100,000.

Laboratory Confirmation. Specimens adequate7 for detecting acute measles infection should be collected from at least 80% of suspected measles cases and tested in a proficient laboratory. Any suspected cases that are not tested by the laboratory and are epidemiologically linked to a laboratory-confirmed case of measles or other communicable disease should be excluded from the denominator Viral Detection. Samples8 adequate for virus detection should be collected from at least 80% of laboratory-confirmed outbreaks (a chain of transmission may not be an outbreak and we should collect specimen for viral detection) and tested in an accredited laboratory. The numerator is the number of outbreaks with adequate samples submitted for viral detection and the denominator is the number of outbreaks identified.

Adequacy of Investigation. At least 80% of all reported suspected measles cases should have had an adequate investigation initiated within 48 hours of notification. The numerator is

5 A case in an individual meeting the case definition for suspected measles: rash, fever and any of the following – cough, coryza and/or conjunctivitis – and not vaccinated against measles in the 6 weeks prior to serum collection. I would not include measles vaccine related cases in the case definition. 6 A proficient laboratory is a WHO network laboratory that uses a validated assay and has passed the annual WHO proficiency test. 7 Adequate specimens are: Serum; minimum of 0.5 ml, Dried blood sample; at least 3 fully filled circles on filter paper collection device, Oral fluid; sponge collection device should be rubbed along the gum until the device is thoroughly wet. This usually takes one minute. Adequate samples are those collected within 28 days after rash onset. 8 Where possible, samples should be collected from 5–10 cases early in the outbreak and every 2-3 months thereafter if transmission continues. For virus isolation, adequate throat or urine samples are those collected within 5 days after rash onset. For virus detection using molecular techniques, adequate throat samples are those collected up to 14 days after rash onset, and adequate oral fluid samples are those collected up to 21 days after rash onset.

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the number of suspected measles cases for which an adequate9 investigation was initiated within 48 hours of notification, and the denominator is the total number of suspected measles cases.

b. Measures for Monitoring Progress towards Measles Elimination:

To monitor progress towards elimination, it is essential to monitor the population immunity profile and incidence of confirmed measles cases. One indirect measure of population immunity is vaccination coverage. The incidence of confirmed measles cases per million total population should be monitored to assess progress towards reaching elimination. Incidence monitoring is reliable only when there is a well-performing surveillance system (See Section A) as indicated by meeting the surveillance performance indicators above) and when adequate case investigations are carried out.

Countries should conduct adequate investigations of ALL suspected measles outbreaks that include contact tracing and active case finding, and should determine the size, duration, and origin of all outbreaks. As countries approach elimination, the size and duration of the outbreaks will diminish and the majority of outbreaks should be import-related in origin. These measures are useful for providing general guidance and may not apply to small and/or isolated populations such as forest, mountain or island communities. The two measures below will be monitored at the global level and are accompanied by markers that suggest elimination has been achieved. Regions and countries may include additional measures and markers as appropriate for the Region. Verification of elimination by region will require further analysis of the measures below (for example, an assessment of the reliability of coverage data in each country) and use of additional data elements such as an analysis of the origin and viral genotypes of all confirmed cases in each country.

Vaccination coverage:

Vaccination coverage among individuals born since vaccine was introduced in each country should be routinely monitored to permit the assessment of the population immunity profile. Indicator: Vaccination coverage of both first routine measles dose (MCV1) and second dose (MCV2), whether delivered through routine or SIA strategy, among appropriate age-groups. Marker: Achieving and maintaining at least 95% coverage annually with both MCV1 and MCV2 in all districts or their administrative equivalent and at national level.

Incidence:

9 An adequate investigation includes at a minimum collection of all of the following data elements from each suspected measles case; name or identifiers, age (or date of birth), sex, date of rash onset, date of specimen collection, vaccination status, date of last vaccination, date of notification and date of investigation, travel history, and district. In addition, the investigation should include contact tracing and additional case finding. Cases that do not require specimen collection (e.g. have been epidemiologically linked to a laboratory confirmed case) are considered as adequately investigated if they have all the above information except the date of specimen collection.

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Measles incidence per million total population should be monitored to assess progress towards elimination. The objective is to demonstrate that there are no cases of endemic measles. To achieve this, the source of all confirmed measles cases should be determined and classified as one of the following: endemic, imported, import-related or of unknown source. In addition, all measles cases should be classified as either laboratory confirmed, confirmed by epidemiological linkage to a laboratory confirmed case, or clinically confirmed (see table). Confirmation status/Source

Laboratory confirmed (a)

Confirmed by Epidemiological linkage (b)

Clinically confirmed (c)

Endemic Imported Import-related

Unknown Two incidence measures should be monitored:

• Incidence per million total population of ALL confirmed (laboratory , epi-linked and clinically confirmed) measles cases regardless of the source (endemic, imported, import- related or unknown) (sum of columns a +b+c in the table above). The objective is to demonstrate that there are no cases of endemic measles.

• Incidence per million total population of measles cases which are either laboratory confirmed or confirmed by epidemiological linkage regardless of the source (endemic, imported, import- related or unknown). This incidence measure should exclude any clinically confirmed cases (sum of columns a +b in the table above)

Marker10:

Achieving a measles incidence of zero endemic measles cases

4. Definitions:

• Endemic measles transmission: the existence of continuous transmission of indigenous or imported measles virus that persists for a period of 12 months or more in any defined geographical area.

• Measles outbreak in countries with an elimination goal11. When two or more

confirmed cases are temporally-related (with 7-21 days between dates of rash onset), and are epidemiologically and/or virologically linked.

10 The often used incidence target of <1 per million total population has been removed as it was shown to be confusing and is not indicative of having achieved elimination.

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• Measles imported case is a case exposed outside the region/country during the 7 to 21

days prior to rash onset as supported by epidemiological and/or virological evidence.

• Measles import-related case is a locally-acquired infection occurring as part of a chain of transmission originated by an imported case as supported by epidemiologic and/or virological evidence.

• Elimination: The absence of endemic measles cases for a period of at least twelve

months or more, in the presence of a well-performing surveillance system.

• Re-establishment of Endemic Transmission. Re-establishment of endemic measles transmission is a situation in which epidemiological and laboratory evidence indicates the presence of a chain of transmission of a virus genotype that continues uninterrupted for a period of twelve months or more in a defined geographical area.

• An epidemiologically linked measles case. A suspected measles case which cannot be

laboratory confirmed itself (some countries report cases that are both laboratory confirmed and epi –linked. We do recommend to not test epi-linked cases)but was geographically and temporally related (with 7-21 days between dates of rash onset) to a laboratory-confirmed measles case.

5. Basic Principales

• The area for documenting the interruption of endemic transmission is regional. • At the national and regional level, an independent Regional Validation Commission

(RVC) will be formed to verify the attainment of the goal. • At the national level, a National Validation Committee (NVC) will be established in each

country. This committee might include members of the polio validation committee, if one has been formed.

• The EMR Secretariat will provide a standard plan of action to ensure uniformity in the

criteria that will be used to verify elimination. • Each country will prepare a plan of action for documentation and a realistic timetable for

the implementation for attaining the goal. • Documentation will be based mainly on the achievement and sustainability of: 1)

elevated measles vaccination coverage, 2) quality and timeliness of measles, rubella, CRS and virologic surveillance, and 3) the satisfactory evolution of national immunization programs to maintain measles/rubella elimination.

• Once the elimination goal is met, countries should commit to sustaining elimination

strategies to maintain the interruption of endemic transmission, the timely detection of

11 This definition may vary in some countries or regions.

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importations, and effective response measures to prevent the reestablishment of endemic transmission.

6. Verification Process

Countries will be requested to submit their measles elimination validation report to the RVC following nationwide measles elimination. This report will be reviewed by the RVC and either accepted and granted measles elimination verification or be returned with a request for more information and/or feedback for the NVC and national EPI program on areas in need of improvement before report resubmission. Once a country report is granted elimination status, an annual update will be required to maintain elimination validation.

7. Timeline In 2008, the first draft of the measles validation guidelines was developed and field tested in

five countries: Jordan, Syria, Iran in 2008 and Oman and Bahrain in 2009. A timetable and a plan of action for the documentation process will be set to monitor, country-by- country, completion of the Regional goal. Table 10. Timetable for the validation of measles elimination in EMRO

Year

Activity 2010 2011 2012 2013 2014

Presentation of the Plan of Action to the Technical Advisory Group of Vaccine-preventable Diseases at the Inter-country Measles Meeting

Formation of the Regional Validation Commission

Establishment of the National Committee in the countries of EMR.

Data collection and analysis by the Ministry of Health in collaboration with the National Committees in countries at “phase of elimination”

Implementation of Follow-up Campaigns

Continuous monitoring of surveillance indicators

Visit of the Regional Validation Commission to countries

Review of Evidence by the Regional Validation Commission

H. Measles Control/Elimination in the Context of Health Systems Strengthening: Rubella control and measles elimination go hand in hand in EMRO. The use of rubella vaccine and the measles surveillance for rubella disease monitoring is expanding among EMR countries. A total of 16 (73%) countries report the use of rubella vaccine, 9 (41%) of the countries that have

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begun using rubella vaccine report vaccine coverage of more than 95% and 10 (45%) report having implemented CRS surveillance. However, EMRO did not develop a comprehensive strategy to eliminate/control rubella and CRS. A technical consultation is planned during the fourth quarter of 2009 to develop and implement such strategy. Additionally, child health days were used in Somalia to deliver a range of child survival interventions. This strategy included MCV and was well received by the local populations. Expanding this model to other countries to improve MCV coverage is a potential opportunity to reduce other childhood diseases while working towards measles elimination in the Region. I. Programmatic Feasibility: 1. Is the region (and individual countries of the region) likely to achieve (or maintain) its

measles goal by the region’s target year? • No, given the security and political commitment challenges faced by many countries in

the Region the goal will not be achieved by 2010. 2. When is the region likely to achieve this goal?

• With strong financial support and strategic interventions a reasonable target for measles elimination is 2015.

• See annex 1 for country specific estimates on when goal achievement is likely. 3. What needs to be in place to reach (or maintain) the regional goal by the target year?

• Continued financial support for GAVI eligible countries will need to be maintained (and potentially increased) and periodic financial support to middle income countries will be needed to encourage them to complete important SIAs.

• Technical support through EMRO will be vital to all countries to assist with technical planning for improving routine immunization and completing quality SIAs.

4. What of the following would be most feasible:

• An elimination target by 2015.

5. Are member states likely to make the necessary political commitments if an global eradication goal is set? • Most countries will support an elimination or eradication goal. Strategic communications

will need to take place to ensure that countries that have less stability will have the resources/ability to fully commit to the activities that will be needed to achieve such a goal.

6. Describe the societal comments for the countries in the region for a measles elimination goal

by 2015. For example, would measles eradication be perceived as a worthy goal by the society?) • Unknown but often measles is perceived to be more serious than other vaccine

preventable diseases. 7. Are member states likely to make the necessary and financial commitments? What

proportion of estimated funds needed is likely to be provided by the member states of the region? • GCC countries will continue to fund their programs • Some middle income countries (Iraq, Lebanon) may need some support to conduct

follow-up SIAs but will maintain funding for routine immunization

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• GAVI countries will continue to need full financial support for SIAs and some may also need support forroutine immunization.

8. For the region, is polio eradication a pre-requisite for embarking on measles eradication?

• Answer deferred at this time. 9. How does measles mortality reduction or elimination rank among the public health priorities

in each countries in the Region (for each country, rank the key public health priorities along with measles)

Unknown for each country. J. Future Strategies: Future strategies once measles elimination has been achieved have yet to be determined by EMRO. However, to complete measles elimination in the region we will continue with the Regional elimination strategy. Annex 1: Country Data Country: AfghanistanAdditional questions: Progress to date: Improvement in reaching children with difficulty to access because of

security issues. These children are mainly vaccinated through follow-up SIA

5 yr plan: Continue providing two doses of MCV through routine and improving coverage trough RED strategy and conducting SIA every three years and improving surveillance indicators

Enabling factors: Committed staff and good coordination between polio, EPI and measles staff. Financial support from international partners

Challenges: Security issues that make it difficult to sustain routine immunizations

Likely to achieve elimination by 2010?

No

When likely to achieve? 2015 What improvements need to occur to achieve?

Improving routine immunization to achieve a 96% coverage for both measles

Key public health priorities?

Reduced under 5 year child mortality

Anticipated laboratory needs/support to achieve elimination by 2015?

Regular continuous support for the functioning of the lab

Country: Bahrain Additional questions: Progress to date: Reaching measles elimination that just needs to be validated

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5 yr plan: Sustaining the measles high coverage and monitoring importantion through a high preferment measles surveillance system

Enabling factors: No funding issues for measles elimination activities Challenges: Importations through foreign workers Likely to achieve elimination by 2010?

Yes


none - just sustaining the gains




EMRO does not provide support to laboratory support to GCC countries

Country: Djibouti Additional questions: Progress to date: Conducting timely follow-up SIA and improving MCV1.

Improvement of surveillance by establishing a National Measles Laboratory and improving reporting system

5 yr plan: Improving MCV1 coverage to reach 80% and keep conducting follow-up SIA

Enabling factors: Around 85% of the population lives in Djibouti City that makes them easy to reach

Challenges: Have the high commitment and political engagement of the MOH to be more involved in improving routine immunizations


No


Improve routine immunization and surveillance




Funding support for consumables for the lab and kits for specimen collection

Country: Egypt Additional questions:

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Progress to date: Conducted high quality catch up campaign and reach high measles coverage through routine

5 yr plan: Sustaining high measles coverage through routine and keep improving measles reporting rate

Enabling factors: Commitment and political engagement Challenges: Shortage of funds to conduct some measles elimination activities Likely to achieve elimination by 2010?

No


Improving surveillance system




None

Country: Iran Additional questions: Progress to date: Reached high measles coverage through routine 5 yr plan: Sustaining high measles coverage through routine and keep

improving measles reporting rate Enabling factors: Commitment and political engagement Challenges: Bridging the immunity gap among high risk groups Likely to achieve elimination by 2010?

No


Measles immunity coverage among high risk groups




None

Country: Iraq Additional questions: Progress to date: Progress made but gains could not sustained because of the war 5 yr plan: Conducting a nationwide measles campaign and sustaining routine

(keep-up strategy) and surveillance

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Enabling factors: High commitment of the MOH to eliminate measles Challenges: Lack of security and lack of correlation between the coverage rates

reported and measles incidence rates Likely to achieve elimination by 2010?

No


Security




None

Country: Jordan Additional questions: Progress to date: Reached high measles coverage through routine 5 yr plan: Sustaining high measles coverage through routine and keep

improving measles surveillance system Enabling factors: MOH is committed to eliminate measles Challenges: Measles immunity gap among some high risk groups including

refugees from Iraq Likely to achieve elimination by 2010?

Yes





None

Country: Kuwait Additional questions: Progress to date: Reached high measles coverage through routine 5 yr plan: Validating the measles reported coverage rates and conduct localized

SIA among high risk groups (foreign workers). Improve surveillance system

Enabling factors: No funding issues to conduct measles elimination activities

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Challenges: Need to conduct high quality localized SIA to bridge the immunity gap among some high risk groups


No


Bridge the gap among high risk groups and improve surveillance system




None

Country: Lebanon Additional questions: Progress to date: Conducted catch-up campaign in 2008 and keep strenghtening

routine 5 yr plan: Develop an EPI policy to include private sector in order to have a

uniform strategy for routine immunization and strenghten measles surveillance

Enabling factors: New leadership in EPI Challenges: Involve private sector that cover around 50% of immunization

activities Likely to achieve elimination by 2010?

No


Strenghten routine immunization to achieve the 95% coverage rate for MCV1 and MCV2




None

Country: Libya Additional questions: Progress to date: Reached high measles coverage but still having outbreaks among

nationals and in areas with mobile population coming from Tchad 5 yr plan: Validate administrative measles coverage and continue localized SIA

among mobile population

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Enabling factors: No funding issues and high political commitments from the government

Challenges: Measles outbreaks still occuring despite high measles coverage Likely to achieve elimination by 2010?

Yes


Monitor and validate measles coverage and strenghten measles surveillance to be at the standards of of elimination




None

Country: Morocco Additional questions: Progress to date: Conducted the catch-up measles/rubella campaign in 2008. Will

implement nationwide measles surveillance system by the end of 2009

5 yr plan: Implement RED strategy in all country and strenghten measles surveillance system

Enabling factors: Well developped public health structure at provincial level that can implement efficient measles elimination activities

Challenges: Measles coverage are not high in all districts around the country, particularly in remote and difficult to reach montagnuous areas


No


Implementation of RED strategy all over the country




None

Country: Oman Additional questions: Progress to date: Reached a measles program up to the level that seems at the phase of

elimination

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5 yr plan: Sustain the routine measles high coverage and keep improving measles surveillance to be able to monitor and timely detect importations

Enabling factors: Very high political commitment to eliminate measles Challenges: The country has to deal with importantions from neighboring

countries (Yemen, Somalia) Likely to achieve elimination by 2010?

Yes





None

Country: Pakistan Additional questions: Progress to date: Conducted a high quality catch-up campaign in 2007-08 and started

implementing a nationwide measles case-based surveillance 5 yr plan: Improving routine measles vaccine coverage to reach 85-90% for

both doses and having a nationwide high quality measles case-based surveillance

Enabling factors: MOH at different levels are willing to work with EMRO to move up with the mealses elimination

Challenges: Barriers to routine immunization services because of lack of staff at national and provincial levels. Security issues in some areas of the country


No


Improve and sustain keep-up strategy (routine immunization services)




None

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Country: Qatar Additional questions: Progress to date: Reached high measles coverage at national and keep imporving

measles surveillance 5 yr plan: Improving routine measles coverage for both doses to reach 95% at

national level as well as at district level Enabling factors: No funding issues Challenges: Difficulty to access to some sub-population (foreign workers) that not

immunized against measles Likely to achieve elimination by 2010?

No


Bridge the immunity gap among high-risk sub-population




None

Country: South Sudan Additional questions: Progress to date: None 5 yr plan: Improving MCV1 coverage to reach 80% and keep conducting

follow-up SIA Enabling factors: Funds to support routine immunization by several international

partners and NGO Challenges: Polio is still the first priority VPD and lack of infrastructure and

qualified and motivated staff Likely to achieve elimination by 2010?

No


Security and buildinig capacity and infrastructre of public health system





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Country: Saudi Arabia Additional questions: Progress to date: Reached high measles coverage through routine 5 yr plan: Validating the measles reported coverage rates and conduct localized


Enabling factors: No funding issues to conduct measles elimination activities Challenges: Need to conduct high quality localized SIA to bridge the immunity

gap among some high risk groups Likely to achieve elimination by 2010?

No






None

Country: Somalia Additional questions: Progress to date: Conducting child health day including all childhood antigens with

measles vaccine. Improving measles case-based surveillance in some zones of the country (Somaliland, Puntland)

5 yr plan: Improving MCV1 coverage to reach 80% and keep conducting follow-up SIA

Enabling factors: Funds to support routine immunization by several international partners and NGO

Challenges: Security issues in some areas of the country (South and Central zones)


No


Security and buildinig capacity and infrastructre of public health system



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Country: Sudan Additional questions: Progress to date: Reached 80% for first routine measles dose for 3 years in a row and

planning to move MCV1 from 9 to 12 months in 2010 and introduction of MMR

5 yr plan: Sustaining high measles coverage through routine and keep improving measles surveillance system

Enabling factors: Commitment and political engagement of MOH Sudan to measles elimination

Challenges: Shortage of funds to conduct some measles elimination activities Likely to achieve elimination by 2010?

No


Sustaining high routine measles coverage and keep improving measles surveillance system




None

Country: Syria Additional questions: Progress to date: Reached high measles coverage through routine 5 yr plan: Sustaining high measles coverage through routine and keep



Yes




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None

Country: Tunisia Additional questions: Progress to date: Reached high measles coverage through routine 5 yr plan: Sustaining high measles coverage through routine and keep



Yes





None

Country: UAE Additional questions: Progress to date: Reached high measles coverage through routine 5 yr plan: Validating the measles reported coverage rates and conduct localized


Enabling factors: No funding issues to conduct measles elimination activities Challenges: Need to conduct high quality localized SIA to bridge the immunity

gap among some high risk groups Likely to achieve elimination by 2010?

No





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None

Country: Yemen Additional questions: Progress to date: Improvement of MCV1 coverage and measles surveillance system 5 yr plan: Keep improving both MCV1 and MCV2 and measles surveillance

with monitoring performance indicators Enabling factors: Continuous support from EMRO to implement measles elimination

activities Challenges: Security issues in some areas Likely to achieve elimination by 2010?

No





None

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