1. Progress towards Measles Elimination China, 2012
Li QUANLE
Bureau of Disease Prevention and Control
Ministry of Health, China
Washington DC,
18–19 September 2012

2. 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

3. 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

4. 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

5. 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)

6. 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)

7. China Lab-Net for measles surveillance activities1
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

8. 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

9. changing epidemiology of measles in china
Programmatic Efforts and High Quality Surveillance Produce Results
changing epidemiology of measles in china

10. 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

11. 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.

12. Fewer, Smaller, and Shorter Outbreaks Since 2009: Strong Evidence of Progress

13. Different Epidemic Patterns among Different provinces, 2012(Jan-Aug)

14. 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

15. 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

16. Registration
Waiting
Pre-check
Observation

17. Only For
Her

18. Nosocomial
infection

19. 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

20. 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

21. 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

22. 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,.

23. 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

25. Incidence of Rubella in China 2004 -2011

26. 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

27. 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

28. 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.

29. 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

30. Thank you

31. Extra slides

32. 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

33. 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

34. Lab-confirmed and Epi-linked measles cases by year of age and vaccination status, China 2011, 2012(Jan-Aug)

35. Genotyping results of MeV in 2012*
*Jan-June, 2012
Total 179 isolates:
172H1a
1A-VL
6D9
H1a
Unpub data

36. 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

37. 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

38. 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)

39. 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

40. 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

41. Vaccination status in Burma side

42. Incidence of Rubella,
53/10万
17/10万
9/10万

43. 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)