Measles in EMR 7 th Annual Meeting of Partners for Measles Advocacy Washington, 2007

l Regional progress in measles elimination l Key constraints l Indicators to monitor measles elimination in EMR Outline

l Routine infant immunization l > 90% coverage MCV1 in all districts Strategy for Measles Mortality Reduction and Elimination in EMRO l Second dose of measles vaccine either through a 2 dose schedule or follow-up SIAs l > 90% coverage in all districts l Catch-up vaccination l susceptible cohorts l Case-based surveillance l Optimized case management

Trends in Measles Case Counts and MCV1 Coverage in EMR, * * Preliminary, 2006

Geographic Distribution of Children not Receiving MCV1 in EMRO, 2005 (n=2.8 million)

Palestine Bahrain Supplemental Immunization Activities Measles Campaigns in EMRO through 2005 Preschool and school age (15) School age (5) Ongoing (2)

Tonga Fashoda Panyijar Rumbek-Cueibet Kajo Keji Budi 91.1% Torit Akobo Pochalla Wuror Waat Aweil East Aweil North Raja Terekeka 101.3% Ezo 105.4% Juba 74.2% Yirol Tambura 103.4% Tonj Pibor North Bor Mundri Maridi 87.3% Maruko Payam missed out Magwi Twic Wau Yambio Yei Gogrial Aweil South South Bor Kapoeta 64.2% Awerial Aweil West Rubkoana Guit Koch Mayom Nyirol Ayod Diror Latjor Leer Sobat Renk Ruweng Old Fangak Atar Measles Campaign Coverage in South Sudan Status by County (Jan 28, 2007) Completed Ongoing Micro plans ready Not yet micro-planned

Area of campaign % of country targeted Target popNo. children vaccinated % coverage 2005 NW (6 districts) 5 160,563137, NE (18 districts) 7 182,993142, CS (5 districts) 3 102,97680, NWZ(14 dist) ,104387, CSZ (78 dist)67.72,266,9171,838,72981 Catch-up Campaign in Somalia,

Measles Vaccine Doses Administered in Catch-up Campaigns, EMRO

Reduction in Measles Mortality in EMR, % mortality reduction target

Planned Supplemental Measles Immunization; Catch-up campaigns Follow-up campaigns High-risk/mop-up campaigns

Recommended SIAs in EMR that are not Planned; Catch-up campaigns Follow-up campaigns High-risk/mop-up campaigns

Pakistan Catch-up Campaign Phase 1 Mar district in 4 provinces (2.6M target) Phase 2 Jul 2007 parts of NWFP, Baluchistan, Fana, AJK (8.2M) Phase 3 Aug 2007 Finish NWFP, Bal, AJK (5.3M) Phase 4 Nov 2007 (13.6M) Sindh Phase 5 1 st Qtr ’08 (34.0M) Punjab

19 countries with 2 dose schedule  12 at 12 –24 mos  7 at 4-6 yrs  16 use MMR  1 countries with periodic SIAs  2 countries with periodic SIAs and 2 dose schedule  2 countries with no second opportunity Palestine Bahrain Routine second dose 1 dose schedule 1 dose + SIAs Second Dose of Measles Immunization in EMRO, doses + SIAs

Palestine Bahrain Case based (17) Case-based, needs to be improved (3) Aggregate data (2) Measles Surveillance in EMRO

No. countries reporting Total susp cases Total with lab test No. lab- conf measles No. epi- linked measles No. clinical measles Total measles 20 (90%)19, ,944 Status of Measles Reporting in EMRO, Jan-Dec, 2006* * Provisional data, reporting not complete

l Monthly Bulletin l Case counts by country and case classification l Key indicators l Mapping through EPIINFO Website Monitoring of susceptibility profiles Feedback of Surveillance and Coverage Data

l Regional progress in measles elimination l Key constraints l Indicators to monitor measles elimination in EMR Outline

l Lack of national support for elimination l Competing priorities l Insecurity l Resource mobilization for non-GAVI countries l Egypt, Morocco, Syria l Failure of keep-up strategies l Limited use of surveillance data Key Constraints in Regional Elimination

Measles Case Counts and Vaccination Coverage, , Saudi Arabia Coverage Catch-up campaigns yrs 6-13 yrs

Age Distribution of Measles Cases in Saudi Arabia, Jan-Dec 2006 n=697 5% vaccinated < 1 yr 1 to 4 yrs 10 to 14 yrs 5 to 9 yrs yrs > 20 yrs

Age Distribution and Vaccination Status of Measles Cases in Selected EMR Countries, Jan-Dec 2006 Qatar (n=108) 54% vaccinated Egypt n=998 96% vaccinated Syria (n=462) 48% vaccinated Lebanon (n=843) 20% vaccinated < 1 yr 1 to 4 yrs 10 to 14 yrs 5 to 9 yrs yrs > 20 yrs

Geographic Distribution of Measles Cases, Jan-Dec ‘06

l Regional progress in measles elimination l Key constraints l Indicators to monitor measles elimination Outline

Completeness of reporting Indicator: > 80% of districts reporting on a monthly basis Sensitivity of reporting system Indicator: At least 2 suspect cases (excluding lab and epi-confirmed measles and rubella) per 100,000 population at the national level. Adequacy of laboratory testing Indicator: > 80% of suspect measles cases are tested for measles IgM antibody, excluding cases epidemiologically linked to a laboratory confirmed case from the denominator Indicators for Measles Elimination Recommendations from EMR-TAG, 2006

Adequacy of epidemiologic investigation* Indicator: > 80% of suspect measles cases have an adequate epidemiologic investigation*. Adequacy of laboratory testing Indicator: > 80% of measles virus outbreaks and chains of transmission chains (outbreaks) have sufficient* samples for viral isolation * An adequate investigation includes at a minimum the suspect cases with all of the following data elements; date of rash onset, specimen collection, date of specimen collection, vaccination status, date of last vaccination, age, and district) Indicators for Measles Elimination Recommendations from EMR-TAG, 2006

Palestine Bahrain Reporting on a timely basis (n=16) Delayed reporting (n=4) Completeness of Reporting to Regional Office, Countries Reporting on a Monthly Basis, 2006 Inconsistent/not reporting (2 countries)

Suspect Cases + per 100,000 in EMR, Jan-Dec-2006* + Suspect cases – lab and epi confirmed cases * Adjusted for annualized rate Proposed regional target 2/100,000

Palestine Bahrain > 80% of suspect cases (10 countries) Serologic Testing of Suspect Cases (Jan-Dec ’06, EMR) Indicator: > 80% of suspect cases with testing 50-80% (3 countries) < 50% (7 countries) Not reporting (2 countries)

Palestine Bahrain > 80% (6 countries) Adequacy of Epidemiologic Investigation, Jan-Dec ’06 EMR Indicator: >80% of measles case reports with complete investigation 50-80% (5 countries) < 50% (6 countries) Not reporting (5 countries)

 Measles incidence of < 1 confirmed case per million per year, excluding cases confirmed as imported.  All districts with > 90% vaccination coverage for the first dose of measles vaccine and 95% coverage national coverage for the second dose.  90% of outbreaks are < 10 cases in size  Epidemiologic and laboratory data indicate that measles viruses are imported. Recommended Criteria for Measles Elimination EMR-TAG, 2006

Measles Cases per Million in EMR, Jan-Dec-2006* * provisional

Palestine Bahrain MCV1 > 90% in all districts (7 countries) MCV1 > 80% in all districts (2 countries) MCV1 Coverage* Indicator: > 90% coverage in all districts MCV1 > 50% in all districts (4 countries) MCV1 < 50% in some districts (8 countries) * Based on 2005 JRF, data is unavailable for Lebanon

Considerable progress in mortality reduction Pak campaign will reduce further Few countries are close to elimination Several countries with large outbreaks Failure of “keep-up” strategies SIAs are playing an important role to achieve elimination Summary

Surveillance is improving Impact on program activities Countries have accepted agreed upon indicators RTAG will address issue of “certification” Summary

Advocacy Raising awareness of national health authorities Development of country-level TAGs Certification process? Surveillance Revisit regional reporting format Outbreak surveillance Source of infection Genotyping Achieving high population-based immunity Better monitoring of routine EPI data Achieving and monitoring high MCV2 coverage Monitoring susceptibility profiles at sub-national levels Priority Activities

EMR MCV Coverage and Percent of Games Won-Chicago Cubs,