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Progress towards Measles Elimination China, 2012
Li QUANLE Bureau of Disease Prevention and Control Ministry of Health, China Washington DC, 18–19 September 2012
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Outline Status of Measles Elimination in China
Brief history Epidemiology Virus detection and identification Performance of the surveillance National Plan of Actions Challenges Towards Measles Elimination Progress of Rubella Control Conclusions and Recommendations
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Measles cases by month of rash onset Western Pacific Region, 2008–2012
Year % of cases from China in WPRO 2008 89% 2009 79% 2010 77% 2011 47% 2012 Jan to Jun 54% 1 dot = 1 case Source: measles database from WHO HQ website This epidemic curve indicates the number of all confirmed measles cases reported monthly from all the countries and areas in our region since 2008. The bars are stacked by country, with yellow representing China, red for Japan, green for Philippines and blue for Viet Nam. At regional level, the number of cases reduced by 86% from 2008 to 2011 (for information only: from nearly 146,000 in 2008 to 21,000 in 2011). The number of cases further declined by 69% in the first six months of China has largely contributed to this achievement. 75% of the Region’s population live in China. the proportion of cases from China has been decreasing from 90% in 2008 to 54% in the first six months. Source: National measles and rubella surveillance reports
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Reported Measles Incidence and Immunization Coverage in China
Each of last 3 years was a record low incidence rate. Between year 2003~2009, provincial SIAs in 27 provinces Sep 2010, nation-wide SIA
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Confirmed Measles Cases by Month of Onset in China: 2007-2012(Aug)
Proportion of lab-confirmed case is increasing each year Nation wide selective SIAs, during “4.25 vaccination information campaign week”, SIAs in more than 400 counties with relatively high epidemic intensity Source: Measles Surveillance System(MSS)
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Lab-confirmed and Epi-linked measles cases by county, 2011-2012(Aug)
Jan-Aug, 2012 Note: Dots are placed at random within the county, and might not reflect the exact location of the case within the county. Source: National Notifiable Disease Reporting System (NNDRS)
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China Lab-Net for measles surveillance activities
1 National & WPRO reference lab Genotyping for measles isolates Quality control and accreditation for provincial lab Technical support for provincial lab Measles virus isolation and identification (PCR, ICA, PCR-RFLP, RT-PCR) Quality control and accreditation for prefecture lab Technical support for prefecture lab 31 Provincial labs China measles labnet has 3 dif levels. Each level has their own responsibility and play dif roles. Most of the serology diagnosis for suspected measles cases were done by prefecture labs. Of course they have the responsibility for the specimens collection. National lab and provincial labs also have the responsibility to do the quality control and technical support for their own lower level labs. 331 Prefecture labs Serology diagnosis for suspected measles cases Collection of specimens
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Genotyping results of Measles Virus in 2012*
*:Jan-June, 2012 179 isolates from 16 prov: 172 H1a 1 A-VL 6 D9 D A-VL Unpub data 8
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changing epidemiology of measles in china
Programmatic Efforts and High Quality Surveillance Produce Results changing epidemiology of measles in china
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China has Made Substantial Investments in Measles Vaccination Using Supplemental Immunization Activities Sept , Nation-wide SIA was conducted following the SIAs conducted in 27 provinces during 2003~2009 Winter 2011, unselective SIAs were conducted in >400 high risk counties, rest counties conducted selective SIAs Early 2012, around the World Vaccination Week,A month period of National wide selective SIAs has been conducted for children who missed MCV
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China Has Improved the Quality of Measles Surveillance: 2009 to 2012(Jul)
Discarded measles rate is annualized * per 100,000 population Quality of measles surveillance performance is getting better in resent 3 years, but still some gaps meet with target criteria.
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Fewer, Smaller, and Shorter Outbreaks Since 2009: Strong Evidence of Progress
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Different Epidemic Patterns among Different provinces, 2012(Jan-Aug)
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Challenges towards Measles Elimination What ?
Difficult to achieve and maintain high levels of population immunity Difficult to conduct high quality of case-based measles surveillance Difficult to ensure high quality laboratory performance Difficult to rapidly respond to outbreaks and manage measles cases Nosocomial infection may play an important role in transmission Case Importation from Neighbouring countries (e.g. Burma) Rubella control and monitoring is still at the primary stage
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Challenges towards Measles Elimination Why ?
Unbalanced development of economy and health services In the east, high density of the population and floating population ( need more frequent and higher coverage of routine vaccinations). In the west, low density of the population and hard to reached remote mountainous areas (first dose of MVC given usually are not timely). Capacities and facilities for public health service do not meet the needs Insufficient financial support Shortage of workface Immunity gaps in adults High incidence of infant cases due to Nosocomial infection Quality of surveillance hard to early detect immunity gaps Shortage of equipment and reagents Insufficient communication between EPI and Lab in some provinces Outbreak response was not always timely and standardized
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Registration Waiting Pre-check Observation
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Only For Her
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Nosocomial infection
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Outbreak with 23 Cases Occurred in Myanmar-China Border
国境线 国境口岸 国境通道 边民滞留点 陇川县城 150(0) 164(0) 136(1) 80(2) 350(0) 110(0) 250(0) 78(0) 20 / 1717 in New Refugees camp
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Myanmar Border Outbreak; Distribution of Measles Cases by Time(N=23)
Emergency vaccination Primary Case (onset in Myanmar) Laboratory Confirm Cases Epi-Link cases Case Number Date of Onset
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Myanmar Border Measles Cases
All 23 cases of measles occurred in people from Myanmar - there was no spread of measles to Chinese citizens China’s program response includes Emergency vaccination of Myanmar individuals in the area Intensifying surveillance for measles Information sharing with Myanmar Considerations for a cross-border meeting to plan enhanced vaccination activities in the area
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Ongoing Actions for Measles Elimination
MOH issued “Notification on further enhance EPI service” in July 2012, Re-emphasized EPI is the most important public health service, Made several important supportive policy. Nation Verification Commission (NVC) for Measles Elimination has been designated by MOH. National guideline on measles outbreak response, containing active search, risk assessment. emergence vaccination, etc, is going to be issued. Updating measles surveillance system,.
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New Policy to Enhance EPI Services Was Issued by Ministry of Health on July 2012
Strengthen leadership and optimize coordination at all levels Make immunization a top priority as a basic public health service Assure that key leaders are fully responsible for immunization Improve access to vaccines and information about vaccination Assure sufficient location of sites for timely immunization to reach all children Have well-trained staff and pleasant environments for immunization services Improve efficiency through the use of immunization information systems Assure adequate subsidy for immunizing doctors and establish an immunization program working fund for operational expenses Payment for vaccine administration should not be less than 5 RMB per dose; more for rural areas Support an immunization working fund with at least 1 RMB per person in the jurisdiction Strengthen EPI performance through evaluation and incentives Strengthen program performance evaluation Reward programs for good performance
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Incidence of Rubella in China 2004 -2011
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Geographic distribution of rubella incidence, 2006~2011
2006年 2007年 2008年 2009年 2010年 2011年 Higher incidence appears to be in some western and coastal eastern provinces
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MOH-WHO Intensify Rubella and CRS Surveillance
Goals: Improving awareness of rubella and CRS prevalence and disease burden and for future establish rubella and CRS surveillance in China Contents: Establish surveillance for detecting rubella and CRS cases. Follow-up of pregnant women with suspected rubella and investigate suspected CRS cases. Strengthen communication with birth defects surveillance system. Carry out outbreak investigation and research on rubella vaccine efficiency. Pilot sites: Heilongjiang, Shandong and Hubei Province
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Conclusion China has made substantial and rapid progress towards the elimination of measles. China remains committed to the elimination of indigenous measles virus in all provinces. Accelerate rubella control still has long way ahead.
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Recommendations for Next Step
Revision of “Management of Vaccination Regulations” Update China’s 5-year action plan to eliminate measles Technical and programmatic strategies Political and financial commitment Further strengthen routine immunization Especially in western provinces Start preparation of verification processes Pilot in three provinces and then all provinces Conduct research according the new epidemiologic status Young infants, adults, Nosocomial infection etc. Work with international organizations and other partners Both financial and technical support needed Strengthen international cooperation, summarize and share the experiences of other countries in order to eliminate measles Considering the size and density of China’s population and the complicated patterns of measles, as a large developing country, China urgently needs more support from WHO
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Thank you
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Extra slides
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Reported Measles Incidence and Case Numbers 1950~2011
Nation wide SIA 2 dose,0.2ml, 8m,7y 发病率线图和发病数柱图,并详细标注MCV常规免疫程序变迁,尤其是增加剂次的省,要详细标注 2 dose,0.5ml, 8m MR 18m,MMR/M 1965: Liquid vaccine 1978: EPI Implemented 1986: Lyophilized Vaccine 1998: Accelerate measles control 2006: Measles Elimination Plan
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Measles Incidence Rate, Western Pacific Region
WPR 27.0/million WPR 81.6/million 2008 2010 < 1 per million population 1.0–4.9 per million population 5.0–9.9 per million population Legend: 10.0–49.9 per million population >50 per million population WPR 5.7/million 1. In the region, measles incidence decreased from 81.6 per million population in 2008, to 27.0 in 2010, then further down to an annualized incidence of 5.7 per million population in 2012 based on cases reported in Jan-June 2012. 2. From those three maps, we can see decreasing incidence in most countries, from red or pink, then to yellow or green, or remains low incidence. 3. Decline of measles incidence in China largely contributed to the dramatic reduction of regional measles incidence. 2012 Source: National measles and rubella surveillance reports 1 Annualized measles incidence
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Lab-confirmed and Epi-linked measles cases by year of age and vaccination status, China 2011, 2012(Jan-Aug)
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Genotyping results of MeV in 2012*
*Jan-June, 2012 Total 179 isolates: 172H1a 1A-VL 6D9 H1a Unpub data
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Genotyping Results of MeV in 2011
Total 294 isolates from 25 Prov 288 H1a 3 A-VL 3 D11 A-VL For virus surveillance, in 2011, D A-VL Unpub data 36
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Genotyping results of MeV in 2011
288 H1a 3 A-VL 3 D11 H1a 3 D11 were found in the neibouring area with Myanmar, Unpub data 37
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Lab-confirmed and Epi-linked measles cases by month of age, 2011 and 2012(Jan-Aug)
病例数 Case number 病例数 Case number 57.32% 42.68% 56.55% 43.45% 2011 Jan-Aug, 2012 Half of <1 year-old cases belonged to 0~7 months infants 8~11 months cases mainly had 0-dose measles vaccination histories (timely vaccination)
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Measles Incidence by Province and Proportion of Case Number by Age-group, 2011
by Age-group and province Low coverage of age 1~14i years is still a major problem in the western areas , esp. areas with high incidence Some coastal and eastern provinces have relatively more adults and infants cases
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Myanmar – China Border C M Hospitalized, 15% Out patient, 18%
Attend school, 23% SIAs in 2008, 30% SIAs in 2010, 29% SIAs in 2012, 29% 缅 中 C M M
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Vaccination status in Burma side
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Incidence of Rubella, 53/10万 17/10万 9/10万
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Lab-confirmed and Clinical Rubella cases by county, 2012(Jan-Aug)
Dots are placed at random within the county, and might not reflect the exact location of the case within the county. Source: National Notifiable Disease Reporting System (NNDRS)
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