Accelerating Progress towards Measles and Rubella Elimination Eastern Mediterranean Region 1 21 June 2016 Geneva, Switzerland

Regional Measles and Rubella Goals Measles elimination from all countries of the EMR by 2020 – Resolution EM/RC44/R.6 – 1997 (elimination by 2010) – Revised by Resolution EM/RC58/R.5 – 2011 (elimination by 2015) – Revised target EMVAP to achieve elimination by 2020 No regional target for rubella/CRS elimination – Thirteen countries have developed national targets for rubella/CRS elimination – RTAG recommended establishing regional target for rubella elimination by

Measles and rubella reported cases and MCV1/MCV2 coverage in EMR

Comparison of EMR MCV1 coverage WHO UNICEF estimates, and number of countries reaching MCV1 coverage ≥90% 2000 – 2014 (N=21) 4 EMR MCV1 coverage No. Countries MCV1 ≥90%

Reported coverage of MCV1 and MCV2 by country 2015 (JRF data) 5 MCV1/MCV2 coverage

MCV1 coverage by WHO UNICEF estimates in EMR countries 6 Number of Countries

Measles SIA coverage by country % Coverage

SIAs in EMR Country Vaccin e Target Age Dates Admi n Cov Survey Cov Survey Notes Other intervent Afghanistan Measles 9m-59m %92% Djibouti Measles 9m-14yMay 1591%NAOPV Djibouti Measles 15y-25yrNov %NA Egypt MR 9-119mNov %98% Cluster coverage survey Iraq MR 9m-59mSept %Vit A Pakistan Measles 6-119m2014/ %85% Sindh only OPV Somalia Measles 9-119m2015/201690%90-93%RCAVit A Syria MMR/M R 6-59m Apr 2015/ Apr % /84% Yemen MR 9-15y201585% Sudan Measles 9m-15yMay % 8

Local funding for measles SIAs in EMR 2015 A total of million USD raised locally by these countries in 2015 Country Total Budget Amount Raised Locally Locally- raised amt $ / child Afghanistan6 m USD$250,000$0.04 Egypt26.8 m USD25.4 m USD$1 Pakistan49.6 m USD17 m USD$0.28 Syria6.4 m USD5.6 m USD$3.50 9

Palestine Bahrain MCV2 introduced in Routine prior to 2015 No MCV2 introduction plans currently MCV2 introduction into routine EPI in EMR

Palestine Bahrain Rubella introduced Rubella containing vaccine introduction in EMR Rubella introduced prior 2011 Rubella introduction date after 2016 or not yet set 4 countries may introduce RCV by end of 2020

Category Target 2016* Baseline 2006 Incidence (% countries < 5 per million population) 100% 18(82%)8(36%) 6(27%)10(45%)9(41%)6(27%) Incidence of confirmed measles/ million population < High Quality Surveillance National reporting of discarded measles cases (goal: ≥2 per 100,000) 80%4(18%) 13 (59%) 14 (64%) 11(50%)22% % of 2 nd level admin units reporting ≥ 2/ discarded measles cases 80% 10(48%) 7 (33%) 4 (19%) 7( 7 (33%) % of suspected cases with adequate blood specimens 80%20 (91%)19(86%) 20(91%) 12(55%) High Population Immunity % countries with MCV1 >90% 100% 12(55%) % countries with MCV1 >80% in all dist 100% 12(55%)8(36%)11(50%)10(45%) % SIAs with all districts >95% Indicators of Progress Towards Measles (and Rubella) Elimination EMR Region * ¹ Data as of May 2016

Measles Incidence by country EMR 2015 (Confirmed measles cases/million, target < 1/million)

Distribution of confirmed measles cases by age and vaccination status EMR Number of confirmed measles cases

Distribution of confirmed measles cases in outbreaks in Egypt and Sudan 2015 Egypt 2015 confirmed cases = 5431Sudan 2015 confirmed cases =

Measles incidence by country EMR Jan-Mar 2016 (Confirmed measles cases/million, target < 1/million) 16 * Djibouti and Libya did not submit report

Age distribution of confirmed measles cases in countries of EMR Jan-Mar 2016 Number of confirmed measles cases

Rubella incidence by country EMR Jan-Mar 2016 (Confirmed rubella cases/million, target < 1/million) 18 * Djibouti and Libya did not submit report

Age distribution of confirmed rubella cases in countries of EMR Jan-Mar 2016 Number of confirmed rubella cases

Routine strengthening activities in EMR Stand alone activities to increase MCV1 coverage – Implementation of RED approach: Afghanistan, Iraq, Pakistan, Somalia, Sudan and Yemen – Acceleration activities: CHDs in Somalia, catch-up activities in Syria and surrounding countries, integrated interventions in Yemen,.. – Programme strengthening: EPI reviews, EVM assessment and improvement plan, improving data quality Activities as part of ongoing measles activities (SIAs or MSD introduction) – Human resource capacity building – Improving reporting system and data quality – Improving microplanning capacity Meetings/Communication – Country implementation of Immunization Week – Inter-country meeting on Measles/Rubella elimination, Amman, November-December 2015

Regional and National Verification RVC in process of being established National verification committee: – Established in 8 countries: Afghanistan, Bahrain, Iran, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria – Other countries in process of establishing

Challenges to achieving regional goals Security situation: deteriorating in the EMR over a prolonged period – Inaccessibility of population – Unclear or multiple lines of authority – Delayed implementation of planned activities Funding scarcity: for follow-up SIAs and surveillance – Delayed implementation of the follow up SIAs – Slow progress in improving surveillance sensitivity Competing priorities: – Emergency relief in conflict countries – Polio eradication 22

Programme Plans

Priorities for 2017 Increase MCV1 / MCV2 coverage and ensure uniformity of coverage within the country Expand measles case based surveillance to all countries and increase the overall quality of surveillance in all countries Improve quality of SIA with better planning and intra campaign monitoring Establish CRS surveillance Verification of measles elimination in Bahrain, Palestine, and Oman

SIA plans and budget 25 CountryVaccine Target Age Dates Geographic Extent Other intervent Funding source If Gavi, JA dates PakistanMeasles9-59m2018NationalVit A/OPVGAVI17/7/16 AfghanistanMeasles9m-14y2018NationalVit A/OPVGAVI SudanMR9m-14y2018NationalVit AGAVI SomaliaMeasles9-59m2017NationalVit A/OPVGAVI DjiboutiMeasles9-59m2018NationalVit A/OPVGAVI IraqMeasles9-59m2018NationalOPV SyriaMeasles9-59m2018NationalVit A/OPV JordanMeasles9-59m2018SubnationalOPV LebanonMeasles9-59m2018SubnationalOPV YemenMR9-59m2018SubnationalOPVGAVI7/8/16

GAVI application and introduction plans for MR CountryVaccine Year of Intro (or Measles SIA) MCV1 coverage (2012) Year of planned GAVI application Budget estimate SudanMR201885%2017$12,000,000 AfghanistanMR201859%2017$15,000,000 26

measles and rubella/CRS surveillance plans and budget Regional training for MR surveillance guidelines in elimination phase – early 2017 MR/VPD surveillance review – 4 countries of EMR in 2017 Establish CRS surveillance – Sudan, Pakistan, Afghanistan, Yemen 27

Technical Assistance needs 2017 TA needs for SIA planning – Afghanistan and Sudan TA needs for surveillance – Establishing CRS surveillance in Sudan, Afghanistan, Pakistan and Yemen TA needs for GAVI applications – Application for MR introduction Afghanistan and Sudan 28

Resource gaps Financial resources to support the strengthening and maintenance of MR case based surveillance Financial resources to maintain high quality lab surveillance Financial resources for follow up MR campaigns in non GAVI countries, especially those with acute/chronic armed conflict 29

Thank you 30