Measles Elimination and Rubella Control

India marching towards the goal

Dr Satyabrata RoutrayMeasles Rubella Focal Person, WHO-India

• Moving fast from mortality reduction to elimination

• MCV 1 and MCV 2 status in the country

• Lab-based Measles-Rubella Surveillance

• CRS Surveillance plan

• M-R vaccine introduction plans

• M-R campaign challenges in India

• Way forward

Outline of the presentation…

Country Profile• 36 states / Union Territories

– 668 Districts

– 6,007 Blocks

• 1.2 billion population – 26 million birth cohort

– 30 million pregnant women

• Inter state variation– Uttar Pradesh pop 199.5

million, birth cohort 5.5 million (largest state)

– Lakshadweep pop 0.064 million, birth cohort below 1 thousand (smallest -UT)

SEAR Measles Elimination Goal - 2020

SEAR countries resolve to eliminate Measles and control Rubella/CRS by the end of – 2020 .

Reduction in Estimated Measles Deaths by WHO Regions and in India, (2000 to 2012)

100

90

80

70

60

50

40

30

20

10

0AMR EUR AFR EMR SEAR SEAR

Ex IndiaIndia WPR Global

% R

ed

uc

tio

n

78%84%

88%

52%

2015 reduction goal (95%)

57%

Source: WER: Progress in Global Control and Regional Elimination of Measles, 2000–2012. (Feb 7, 2014)

64%100%

71%63%

Global targets by 2015:• Measles vaccination coverage ≥ 90% national and ≥ 80% district• Measles reported incidence <5 cases per million

aa

A&N ISLANDSaa

A&N ISLANDS

89%

2013 2014*

83%

> = 90%

80% to 90%

70% to 80%

60% to 70%

< 60%

Measles vaccine -1st dose reported coverage, HMIS

N : As per Need assessed by GoI

*Data as on 26 Jul 2014 State wide efforts to enhance MCV 1 by strengthening RI

14 States with <80% MCV1 Introduced, 2nd dose through SIA

21 States with >80% MCV1 introduced, 2nd dose through RI

* NTAGI : National Technical Advisory Group on Immunization

2nd dose Measles vaccine introduction - India

Following recommendations of NTAGI*, 2nd dose Measles vaccine introduced in - 2010

a

MCV-2 through measles SIAs conducted in 3 phases

PhaseMCUP

durationNo. of State

No. of District

EstimatedTarget

Population(9 m - 10 yrs)

Children vaccinated

% Coverage

Phase 1 2010-11 13 45 13,845,686 12,076,836 87.2

Phase 2 2011-12 14 153 40,167,580 36,134,669 90.0

Phase 3 2012-13 5 169 85,476,898 70,615,482 82.6

Total 14 367 139,490,164 118,826,987 85.2

Source: Based on target population available with GoI

Target population:

~ 139 million children 9 months – 10 years of age

367 districts in 14 states

Country Measles catch up campaign Guidelines

59%

38%

3%

Social mobilisation

Operational

Others

Social mobilisation includes

•Parents did not know of campaigns

•Did not know about place/date

•Did not give importance

•Fear of injection & AEFI

Operational

• No vaccine/logistics

• No vaccinator

•Site too far, long queue

Others

•Family travelling, sick child,

•Gone to School etc.

N - Total No of Unvaccinated children verified through RCA monitoring

(N = 352,824)

Measles Campaign Monitoring - IndiaReasons for unvaccinated children by RCA

RCA Data as of 21st November 2013

a

a

A&N ISLANDSa

a

A&N ISLANDS

47%

2013 2014*

62%

> = 80%

60% to 80%

40% to 60%

20% to 40%

< 20%

MCV 2 coverage in RI (including MMR), HMIS

N : As per Need assessed by GoI

*Data as on 26 Jul 2014 Country wide efforts ongoing to boost MCV 2 in RI

Laboratory supported, AFP based surveillance for

measles and rubella initiated across India

Functioning (28 states \ UTs)

Currently covering ~96% of the country’s population

In process (8 states \ UTs)

Measles Surveillance Status – August 2014

A

State.shp

1

2

3

State.shp

600 0 600 1200 Miles

Measles Survillance Plan 2013

9 - National laboratories

2 - Reference laboratories

2 - Proposed laboratories

1941

3122

7131 7070

4228

8984

10308

3314

7835

10059

238 247372

2855

4454

779

1130 1186

2734

4146

0

2000

4000

6000

8000

10000

12000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

No

. o

f cases

Measles cases Rubella cases

Measles & Rubella Cases by Year, selected states, 2005-2014

Source: WHO-India, NPSP

(2 states)No. of States (3 states) (6 states) (6 states) (7 states) (8 states) (11 states) (12 states) (15 states) (28 states)

* data as on 12 August, 2014

Measles cases reported & MCV1 coverage, India

0%

10%

20%

30%

40%

50%

60%

70%

80%

0

50,000

100,000

150,000

200,000

250,000

300,000

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

Reported Measles cases MCV1

Reported measles cases in JRF Reported MCV1 coverage in JRF

Measles SIA 2010 2011 2012 2013

Children covered ~ 4 million ~ 19 million ~ 34 million ~ 62 million

Measles vaccination campaign & it’s impact

Measles 2nd Dose- through campaign- through RI

~ 119 million children covered in measles catch-up campaigns

*Data as on 6th February 2014

0

1000

2000

3000

4000

5000

2010 2011 2012 2013

.

Phase I Phase IIMeasles catch-up campaign

Phase III

Cases fro

m c

onfirm

ed m

easle

s o

utb

reaks

Measles cases from three 3 states (Gujarat,

Madhya Pradesh and Rajasthan) with

surveillance pre and post Measles vaccination

campaigns

Serologically confirmed# Measles outbreaks, India(Andhra Pradesh, Arunachal Pradesh, Assam, Bihar, Chhattisgarh, D&D Haveli, Daman & Diu, Gujarat, Haryana Jharkhand, Karnataka, Kerala,

Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Odisha, Pondicherry, Rajasthan, Sikkim, Tamil Nadu, Telangana, Tripura,

Uttar Pradesh, Uttarakhand and West Bengal)@

Measles outbreaks confirmed

2013*

208 outbreaks, (15 states)

No Surveillance

310 outbreaks, (28 states)

2014*

*data as on 12th August, 2014 , Source – WHO NPSP

# Outbreak confirmation for Measles: ≥ 2 cases IgM positive for rubella, @ Surveillance started from January 2013 in Maharashtra & Odisha and from October 2013 in UP, Surveillance started in Chhattisgarh and Uttarakhand

in January 2014, Manipur and Mizoram in March 2014, Arunachal Pradesh and Meghalaya in April 2014, Pondicherry, Sikkim and Tripura in May 2014,

Nagaland in June 2014,Telangana carved out of Andhra Pradesh in 2014, D&N Haveli and Daman & Diu in July 2014

Serologically confirmed# Rubella outbreaks, India(Andhra Pradesh, Arunachal Pradesh, Assam, Bihar, Chhattisgarh, D&D Haveli, Daman & Diu, Gujarat, Haryana Jharkhand, Karnataka, Kerala,

Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Odisha, Pondicherry, Rajasthan, Sikkim, Tamil Nadu, Telangana, Tripura,

Uttar Pradesh, Uttarakhand and West Bengal)@

Rubella outbreaks confirmed

# Outbreak confirmation for Rubella: ≥ 2 cases IgM positive for rubella, @ Surveillance started from January 2013 in Maharashtra & Odisha and from October 2013 in UP, Surveillance started in Chhattisgarh and Uttarakhand in

January 2014, Manipur and Mizoram in March 2014, Arunachal Pradesh and Meghalaya in April 2014, Pondicherry, Sikkim and Tripura in May 2014,

Nagaland in June 2014,Telangana carved out of Andhra Pradesh in 2014, D&N Haveli and Daman & Diu in July 2014

* data as on 12th August, 2014 , Source – WHO NPSP

2013*

71 outbreaks, (15 states) 87 outbreaks, (28 states)

2014*

No Surveillance

Rubella / CRS surveillance

• Current laboratory based measles-rubella surveillance generates information on rubella epidemiology in the country

• Projected estimate suggest high CRS burden in the country as there is no rubella antigen in the national immunization schedule at present

• Sentinel CRS surveillance system under active discussion in the MOH with all partners , likely to be initiated soon

M-R vaccine introduction plan in India NTAGI Recommendations:

• Wide age range (9 months-15 years), Nation wide M-R campaigns to be conducted

• M-R vaccine to replace both MCV1, and MCV 2 at 9-12 months and 16-24 months respectively

• Rubella vaccine introduction likely 1st quarter - 2015

Political commitment for Rubella vaccine:

• ‘Prime Minister’has already announced four new vaccines including Rubella in routine Immunization

MR campaign in India – challenges

• Country target (9 months-15 years ) - 450 million

• Vaccine availability and management will be a big challenge

• SIAs will be phased across states and staggered, 2-3 years

• Quality training, micro planning & monitoring will be the key to success for high coverage with safety

• Health, Education and WCD (women and child development department ) will play vital roles in campaign

• Social Mobilization (IEC/IPC/BCC) will get priority and focus

• Injection safety, waste management , AEFI management established , based on lessons from last MCV-2 campaigns

Way forward• Country intensifying efforts to enhance both MCV 1 and

MCV 2 in routine immunization

• Laboratory based measles-rubella surveillance system established across country on AFP surveillance network

• CRS surveillance efforts being initiated

• Country set to conduct a wide age range M-R campaigns covering all States & Union territories with political will

• Following MR campaigns, M-R vaccine will replace both MCV1 and MCV 2 in routine immunization

• MR surveillance will transition to case based after SIAs

• future campaigns with M-R will be determined based on surveillance data generated

Thank you

Polio is gone !

Measles - Rubella next !