1. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization WHO Region for Western Pacific 10 th Annual Measles Initiative Meeting Update on Measles Elimination in the Western Pacific Region Washington, DC September 13, 2011 Dr David H. Sniadack, Medical Officer, EPI

2. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Urged member states –to commit human and financial resources –to develop and implement work plans –to regularly report surveillance data to WPRO –to establish independent national verification process following the establishment of standardized regional verification mechanisms by WPRO –to accelerate control of rubella and the prevention of congenital rubella syndrome Requested the RD –to establish regional verification mechanism –to strengthen technical cooperation with Member States to achieve regional immunization goals –to seek additional resources to achieve regional goals utilizing frequent ICC meetings and other mechanisms –to report progress periodically to the Regional committee Regional Committee Resolution, 2010 WPR/RC61.R7 Reaffirmed the 2012 measles elimination goal! Accelerate rubella control and CRS prevention!

3. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Reported Measles Cases and MCV1 Coverage Western Pacific Region 2000 – 2012 97%

4. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Measles Incidence* Western Pacific Region 2008 * per million population Source: WPRO measles-rubella monthly country reports and WHO-UNICEF Joint Reporting Form (data for 2008) < 1.0 (22) 1.0 – 4.9 (4) 20.0 – 29.9 (0) LEGEND: 10.0 – 19.9 (4) 5.0 – 9.9 (3) ≥ 50.0 (3) 40.0 – 49.9 (0) 30.0 – 39.9 (0) Incidence 82 per million (29 <10/mill)

5. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Percent of Districts at Different Levels of MCV1 Coverage in Five Priority Countries,* WPR 2007 – 2010 * KHM,LAO,MNG,PNG,VNM 74% 77% 78% (≥ 90%)

6. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 2007: 79% 2010: 93% Reported Routine Measles Vaccination Coverage, by Operational District, Cambodia 2007, 2010 <50% 50-79% ≥ 90% 80-89% 50-79%: 55% (n=42) <50%: 5% (n=4) ≥ 90%: 15% (n=11) 80-89%: 25% (n=19) <50% 1% (n= 1) 50-79%: 14% (n=11) ≥ 90% 44% (n=34) 80-89% 40% (n=31)

7. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 2007: 40% 2010: 64% Reported Routine Measles Vaccination Coverage, by District, Lao PDR 2007 and 2010 50-79% 35% (n=49) <50% 58% (n=81) ≥ 90% 4% (n= 6) 80-89% 3% (n= 4) <50% 23% (n=33) 50-79% 59% (n=84) ≥ 90% 10% (n=14) 80-89% 8% (n=12)

8. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization LEGEND 2010 (CHN, FSM, PNG, TUV, VNM) 2011 (KHM, LAO, PHL) CHN 102.3 million FSM (12m-8y, Chuuk) 6,800 (90%) PHL (9-95m) 18.5 million KHM 9-59 m: 1.5 million (100%) 5-9 y: 433,000 LAO (9m-19y) 3.0 million VNM (9-71m) 7.0 million (97%) PNG (6-35m) 500,000 TUV (12-71m) 1,100 (79%) Measles SIAs in 2010-2012, Western Pacific Region 5 provinces: 8m-14y 3 provinces: 8m-6y 23 provinces: 8m-4y 2012 (KIR, PNG, SMA, SOL, VAN) KIR (9-47m): 8,400 VAN (9-47m) 22,600 SOL (9-47m) 48,500 SMA (12-47m):11,500

9. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Measles Incidence* Western Pacific Region 2011 * per million population Source: WPRO measles-rubella monthly country reports, data through June 2011 < 1.0 (24) 1.0 – 4.9 (4) 20.0 – 29.9 (1) LEGEND: 10.0 – 19.9 (1) 5.0 – 9.9 (3) ≥ 50.0 (1) 40.0 – 49.9 (1) 30.0 – 39.9 (1) Incidence 16 per million (31 <10/mill)

10. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization CategoryTarget20072008200920102011² Incidence (per million population) Confirmed measles cases (confirmed by lab, epidemiologic linkage or clinically) 73.781.634.027.015.8 High Quality Surveillance National reporting of discarded measles cases > 2 per 100 000 2.5 1.62.81.72.9 % of districts reporting ≥ 1/100 000 discarded measles cases> 80% 31% 27%43%38%41% % of suspected cases with adequate investigation> 80% 27%47%36%76%67% % of suspected cases with adequate blood specimens> 80% 65% 62%72%71%78% Proportion of clinically confirmed measles cases<10% 83% 48%25%35%28% High Population Immunity National MCV1 coverage> 95% 92%93%96%97%NA National MCV2 coverage> 95% 86%88%94%91%NA Indicators of Progress Towards Measles Elimination Western Pacific Region 2007-2011¹ Source: WPRO surveillance database ¹ Data as of July 2011 ² Annualized numbers

11. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset China 2007 — 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011 75% decrease in 2011 cases National SIA

12. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset Japan 2008 — 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011 Rolling SIA for 13 & 18 year olds each year from 2008-12; Improving routine MVCV1 and MCV2 coverage

13. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset Philippines 2003 — 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011 SIA 9m - 7y SIA 9m - 7y SIA 9- 48 m

14. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset Viet Nam 2008 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 SIA

15. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Lab-confirmed & Epi-linked Measles Cases, by Province Viet Nam 2010 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 1 dot = 1 case 20102011

16. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset Malaysia 2008 — 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011 2004 SIA: 7-14 y; 93%

17. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by State Malaysia 2010 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 1 dot = 1 case 2010 2011 ≥ 2 1.0 - 1.9 < 1 Discarded measles per 100K population: No suspected measles cases

18. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Year of Age, Malaysia 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 Routine schedule: MCV1 at 12-24m; MCV2 at 7y

19. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset Australia 2007 — 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011 1998 SIA: 5-12 y; 75%

20. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Imported Measles Genotypes, by Territory, Australia 2011 France – D4 India Indonesia – D9 Singapore – D9 Thailand – D4, D8 India Indonesia – D9 Singapore – D9 Thailand – D4, D8 Singapore Cambodia – D8 England – D4 France India – D4, D8 Malaysia – D4 New Zealand – D4 Singapore – D9 Thailand – D8 Cambodia – D8 England – D4 France India – D4, D8 Malaysia – D4 New Zealand – D4 Singapore – D9 Thailand – D8 Bangladesh France – D4 Italy – D4 Philippines – D9 Bangladesh France – D4 Italy – D4 Philippines – D9 Indonesia – D9 Philippines Thailand Indonesia – D9 Philippines Thailand Kenya/Tanzania * Source: WPRO measles-rubella monthly country reports, data through July 2011

21. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Genotype Distribution of Measles Virus, WPR 2011 Australia New Zealand Philippines Singapore Malaysia China Korea Japan Hong Kong Macao D9 - 12 D8-1 D4 D8 D9 D11 G3 H1 B3 A UT * Data up to July 2011 D8-1 D9-1 D9-2 A-1 D9-18 G3-2 A-2 D9-4 D8-1 D4-1 D8-1 D9-11 D8-3 D4-9

22. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Data source: JRFs and surveillance data 15% of regional population Common rubella genotypes: 1E and 2B Rubella Incidence, Western Pacific Region, 2010 <= 10 (25) 11 – 25 (1) 26 – 49 (3) >= 50 (0) No data (7) LEGEND (per million population)

23. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization F & M ≥ 20 yrs protected (16) F ≥ 20 yrs protected (5) F & M ≥ 15 & < 20yrs protected (4) Recent introduction of RCV (5) RCV not yet introduced (6) LAO: introduction late 2011 KHM, VNM: under discussion PNG, SOL, VAN: considering Rubella Protection and Plans in the Western Pacific Region Data source: JRFs Legend

24. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Priority Activities for Measles Elimination & Rubella Control, Western Pacific Region, 2011-2012 Conducting quality SIAs, incorporating RCV when feasible ⁻ 2011: CHN (Xinjiang, others?), KHM (Oct/Nov), LAO (Nov) ⁻ 2012: PNG, 4 PICs – KIR, SOL, SMA, VAN; also ORI Improving routine MCV1, MCV2 and RCV coverage and schedules Strategies for immunizing adults (if needed) Strengthening surveillance –Sub-national sensitivity –Contact tracing; epidemiologic linkages –Measles virus detection Verification

25. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Measles Elimination Funding Needs (in thousands), Western Pacific Region 2011-2012 Funding currently available: US$ 1,717,000 Expected funding in 2012: US$ 570,000 Total 2011-12 funding: US$ 2,387,000 All funds are in US$ Total Need: $5,728,000 SHORTFALL: $3,341,000 KHMCHNLAOMNGPHLPNGVNMPICs*OthersWPROTotal SIAs 500600100 350 425 1,875 ORI 40048248126452271,877 Surveillance 75 60100 18020 535 Lab 45501916 4619661680311 Tech Asst 25 75 2550 80 200405 Verification 350 Rubella & CRS 601006010 20115 375 Total 680550862150822603883548805505,728 * PICs: KIR, SMA, SOL, VAN

26. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Thank You With malice toward none, with charity for all, with firmness in the right, as God gives us to see the right, let us strive on to finish the work we are in. - Abraham Lincoln 2 nd Inaugural Address March 4, 1865

27. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization 27 Geographic Distribution of Reported Measles Cases, by Province, China, January-June 2011 1 dot =2 cases

28. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset, Cambodia 2007 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 SIA

29. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Laboratory Confirmed Measles Cases, by Year of Age, Cambodia 2010 N = 457 SIA Target

30. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Laboratory Confirmed Measles Cases with Rash Onset from May-July, by Year of Age and Vaccination Status, Cambodia 2011* * Source: WPRO measles-rubella monthly laboratory reports N = 108 SIA Target

31. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Discarded Measles Rate and Measles IgM Positive Cases, by District and Age Group, Cambodia 2011* * Source: WPRO measles-rubella monthly surveillance reports, data through June 2011 ≥ 2 1.0 - 1.9 < 1 Discarded measles per 100K pop: No suspected measles cases ≥ 15yr 10 - 14yr 5 - 9yr 1 - 4yr < 1yr Age of MIgM pos cases 2011: May - July 2010

32. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Lab-Confirmed Measles Cases, by Operational District and Age Group, Cambodia May–July 2011* * Source: WPRO measles-rubella monthly surveillance reports, data through July 2011 ≥ 2 1.0 - 1.9 < 1 Annualized discarded measles per 100K pop: ≥ 15yr 10 - 14yr 5 - 9yr 1 - 4yr < 1yr Age of MIgM(+) cases

33. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset Lao PDR 2008 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 * Source: WPRO measles-rubella monthly country reports, data through July 2011

34. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Province Lao PDR 2010 — 2011* ≥ 2 1.0 - 1.9 < 1 Discarded measles per 100K population: No suspected measles cases * Source: WPRO measles-rubella monthly country reports, data through June 2011 1 dot = 1 case 20102011 * Source: WPRO measles-rubella monthly surveillance reports, data through July 2011

35. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Age Group & Vaccination Status Kuala Lumpur and Sabah (Malaysia) 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 Kuala LumpurSabah

36. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset Singapore 2007 — 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011

37. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Age Singapore 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011 Routine schedule: MCV1 at 12-24m; MCV2 at 6-7y

38. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Age Group & Vaccination Status Australia 2010 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011

39. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization ≥ 50 20.0 - 49.9 10.0 - 19.9 Measles incidence per 1M population: 5.0 – 9.9 1.0 – 4.9 < 1 1 dot = 1 case 2010 2011 Lab-confirmed & Epi-linked Measles Cases, by Province Australia 2010 & 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011

40. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Genotypes and Countries of Imported Measles Cases, Australia 2011* Thailand New Zealand Malaysia Italy India France England India Cambodia Singapore Philippines Indonesia Total: 10 Total: 8 Total genotypes in 2011: D4=19; D8=22; D9=30 * Source: WPRO measles-rubella monthly country reports, data through July 2011

41. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Month of Onset New Zealand 2007 — 2011* * Source: WPRO measles-rubella monthly country reports, data through July 2011

42. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization ≥ 50 20.0 - 49.9 10.0 - 19.9 Measles incidence per 1M population: 5.0 – 9.9 1.0 – 4.9 < 1 1 dot = 1 case 20102011 Confirmed Measles Cases, by Region New Zealand 2010 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011

43. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Confirmed Measles Cases, by Age Group & Vaccination Status, New Zealand 2010 — 2011* * Source: WPRO measles-rubella monthly country reports, data through June 2011

44. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Reported Rubella Cases, Western Pacific Region 1993-2010 Data source: WHO/UNICEF Joint Reporting Forms (1993-2010) and measles rubella surveillance data Reporting from China No. cases

45. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization LEGEND (per million population) Protecting F & M ≥ 20 yrs (16) Protecting F ≥ 20 yrs (5) Protecting F & M ≥ 15 & < 20yrs (4) Recent introduction of RCV (5) RCV not yet introduced (6) LAO: will introduce in late 2011 CAM, VTN: under discussion PNG, SOL, VAN: considering Protection from RCV in WPR <= 10 (25) 11 – 25 (1) 26 – 49 (3) >= 50 (0) No data (7) Data source: JRFs and surveillance data 15% of regional population Common rubella genotypes: 1E and 2B Rubella Incidence Western Pacific Region, 2010

46. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Susceptibility to Rubella, Vientiane, Lao PDR Study (2010): among 784 women of child bearing age (15-45 y): 36% were susceptible to rubella at 15-19 y; - 78% of these are infected by rubella during CBA years Age group (years) Source: MOH, Lao PDR %

47. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Updated WHO Position Purpose and Approaches for Rubella Vaccination The primary purpose is to prevent the occurrence of congenital rubella infection including CRS Countries should use the two dose measles vaccine strategy to use MR or MMR vaccine –Preferred approach: MR or MMR vaccine in a wide-age range campaign followed immediately with introduction of routine MR or MMR vaccine –Achieve and maintain ≥ 80% RCV immunization coverage delivered through routine services and/or regular SIAs Wkly Epid Rec, 15 July 2011, vol 86:301-316

48. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization PDA/ASD/PS/PH, thrombocytopenia, Cataract (bilateral) Petechia, Cataract, PDA CRS Cases Hospitalized in Two Children Hospitals, Viet Nam, April 2011 Cataract, Nystagmus, PDA, ASDPetechia, Cataract, PDA Credits: Dr. Kohei Toda, EPI Officer, WHO/Viet Nam LBW, hydrocephalus, PDA, CoA

49. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Source: WPRO surveillance database WHO/UNICEF JRFs,1980-2011 Reported Measles Cases and MCV1 Coverage Western Pacific Region 1980 – 2011* * Data as of June 2011 97%

50. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Measles Incidence* Western Pacific Region 2010 * per million population Source: WPRO measles-rubella monthly country reports < 1.0 (23) 1.0 – 4.9 (6) 20.0 – 29.9 (3) LEGEND: 10.0 – 19.9 (2) 5.0 – 9.9 (0) ≥ 50.0 (2) 40.0 – 49.9 (0) 30.0 – 39.9 (0) Incidence 27 per million (29 <10/mill)

51. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Measles Incidence* Western Pacific Region 2012 * per million population < 1.0 (27) 1.0 – 4.9 (5) 20.0 – 29.9 (0) LEGEND: 10.0 – 19.9 (0) 5.0 – 9.9 (4) ≥ 50.0 (0) 40.0 – 49.9 (0) 30.0 – 39.9 (0) Expected data Incidence 4 per million (36 <10/mill)

52. World Health Organization Western Pacific Regional Office Expanded Programme on Immunization Publish Measles and Rubella Bulletin monthly (as of May 2011) Regular data analysis of countries/areas and feedback Update/revise guidelines for measles and incorporate rubella control, outbreak response and verification Support surveillance capacity building at national and sub-national levels Accreditation of all RRLs and NMLs in 2011 Convene Regional Verification Commission Country visits to support immunization, surveillance, laboratory and verification (where appropriate) Resource mobilization Priority Activities of Measles Elimination Western Pacific Regional Office, 2011-2012