MEASLES ELIMINATION

DR.SIVA .P.M

CONTENTS

• HISTORY

• GLOBAL INITIATIVES FOR MEASLES ELIMINATION

• INITIATIVES IN INDIA

• CONCLUSION

History• One of the earliest written descriptions of measles as a disease

was provided by an Arab physician in the 9th century who

described differences between measles and smallpox in his

medical notes.

• A Scottish physician, Francis Home, demonstrated in 1757 that

Measles was caused by an infectious agent present in the blood

of patients. In 1954 the virus that causes measles was isolated

in Boston, Massachusetts, by John F. Enders and Thomas C. Peebles.

• Measles

• Caused by a RNA virus

• Paramyxo virus

• Only one antigenic type

• Remain active in room temp for at least

• 24hrs

• Reservoir/ source – human

• Transmission – respiratory route

Contd….

• Temporal pattern – peak in late winter

• and spring

• Communicability – 4days before and 4

days after rash onset

• Incubation period – 10-12 days

(7-18 d range)

SEPIO Meet, 18-20 May 2011 Bose, WHO

6

Measles complicationsCorneal scarring causing blindnessVitamin A deficiency

(Common)Encephalitis

Older children, adults

≈ 0.1% of cases

Chronic disability

Pneumonia &Diarrhea (Common)

Diarrhea common in developing countries

Pneumonia ~ 5-10% of cases, usually bacterial

desquamation

Global burden

• According to 2010 data's

• 1,39,300 deaths globally due to measles

• Nearly 380 deaths/day

• 15 deaths/hr

• Of these most of the deaths belongs to

children < 5 years

• >95% deaths occurs in low income countries with

weak infrastructures

• Comparing data's with 2000

• In the year 2000 there are 5,35,000 deaths due to

measles compared to 1,39,300 in 2010

• There is 74% reduction in deaths compared to 2000

• 85% estimated MCV coverage in 2010 compared to

2000 with only 72%

• 65% countries reached >= 90% MCV coverage in 2010

MR initiative April 2012

• It’s a collaborative effort of

• WHO

• UNICEF

• AMERICAN RED CROSS

• UNITED STATES CENTERS FOR DISEASE

CONTROL AND PREVENTION

• UNITED NATIONS FOUNDATION TO

CONTROL MEASLES AND RUBELLA

Vision

Achieve and maintain a world without measles, rubella

and CRS

Goals

By end 2015

• Reduce global measles mortality by at least 95%

compared with 2000 estimates

• Achieve regional measles and rubella / CRS

elimination goals

By end 2020

Achieve measles and rubella elimination in at least 5 WHO

regions

Milestones

By end 2015

Reduce annual incidence to < 5cases/mill and maintain that

level

Achieve at least 90% coverage with the first routine dose of

MCV nationally

• And exceed 80% vaccination coverage in

every district

• Achieve at least 95% coverage with M,MR,or

MMR during SIAs in every district

• Establish a target date for the global

eradication of measles

• By end 2020

• Sustain the achievement of the 2015 goals

• Achieve at least 95% coverage with both the

first and second routine doses of measles

vaccine in each districts and nationally

Strategy to eliminate measles

• The strategy of 2012 – 2020 builds on

experiences in AMERICAS and in countries in

other WHO regions that successfully

eliminated indigenous transmission of

measles…

• There are five components in this strategy :

Components

• 1. Achieve and maintain high levels of population

immunity by providing high vaccination coverage

with 2 doses of measles vaccine

2. Monitor disease using effective surveillance and

evaluate programmatic efforts to ensure progress.

• 3. Develop and maintain outbreak preparedness ,

respond rapidly to outbreaks and manage cases

• 4. Communicate and engage to build public

confidence and demand for immunization.

• 5. Perform the research and development needed

to support cost-effective operations and improve

vaccination and diagnostic tools

1.Achieve and maintain high levels of population immunity

• Coverage >=95%

• Unvaccinated children old enough to receive MCV1 (9 or 12

months)

• Strengthening routine immunization

• 2nd dose via RI 1 month after 1rst dose ( 15 to 18months gen) or

at school entry

• Catch up and follow up

2.Monitor disease using effective surveillance and evaluate to ensure progress

• Effective surveillance needed to provide information :

• 1. To set priorities

• 2. Plan activities

• 3. Allocate resources

• 4. Implement prevention programmes

• 5. Respond to outbreaks

• 6. Evaluate control measures

• WHO developed standards based on

• 1. Case based surveillance with laboratory

confirmation

• 2. In depth outbreak investigations

• 3. Identification of viral genotypes from every

outbreak

• Measles elimination :

the absence of endemic measles cases for a period of

12 months or more, in the presence of adequate surveillance

• INDICATORS :

1. VACCINATION COVERAGE

• Vaccination coverage indicator : vaccine coverage of both 1rst routine

measles dose (MCV1) and 2nd dose of Measles vaccination (routine or

SIAs)

• Vaccination coverage target : achieving and maintaining at least 95%

coverage with both MCV1 and the 2nd dose of measles vaccination in all

districts and nationally

• 2.OUTBREAK SIZE:

• Outbreak size indicator: monitoring of outbreak size

of all outbreaks including outbreaks in closed setting

and outbreaks where interventions have taken place

to stop the outbreak

• Outbreak size target : at least 80% of outbreaks

should have less than 10 confirmed measles cases

• 3. INCIDENCE:

• Incidence indicator: measles incidence /mill/year

• Incidence target: measles incidence of less than 1

confirmed measles case per million population per

year excluding cases confirmed as imported

• 4. ENDEMIC MEASLES VIRUS STRAIN(s):

• Endemic measles indicator : the number of

endemic measles virus strains

• Endemic measles target : zero cases of measles

caused by an endemic strain for at least

12months

3.Develop and maintain outbreak preparedness and respond rapidly

• In elimination setting :

• Single case outbreak rapid investigation and

response

• In emergency setting:

• Urgent coordinated SIAs include

vit A supplementation prevent outbreaks and

child mortality

• Mortality reduction setting

• Each confirmed outbreak requires a thorough

risk assessment to guide the decisions and

planning of outbreak response immunization.

4.Communicate and engage to build public confidence

• Community awareness regarding

• 1. Immunization rights

• 2. Benefits

• 3. Safety

• 4. Available services

• Will promote public acceptance and participation

5.Perform research and development

• CDC in may 2011 highlighted critical research

areas necessary to achieve measles eradication:

• 1. Measles epidemiology

• 2. Assessing vaccine efficacy and effectiveness

• 3. Needle free vaccine delivery methods

• 4. Improved methods for laboratory testing for

measles

• 5. New immunization strategies

• 6. Improved methods to monitor and evaluate vaccination

programmes

• 7. Development of effective advocacy tools to use with

decision makers

• 8. Improved messages and strategies to communicate with

potential beneficiaries and their families

• 9. Economic analyses of different strategic options and

mathematical modeling.

•

INITIATIVES IN INDIA

• Accelerated measles control strategy

• Update on accelerated measles control

– Mcv-2 in routine services

– Catch-up campaigns

– Laboratory supported measles surveillance

• Linkages with RI

Principles of accelerated measles control strategies in India

1. Improve and sustain routine immunization coverage (MCV-

1)

2. Provide a second opportunity for measles immunization to all

eligible children (MCV-2)

3. Sensitive, laboratory supported measles outbreak

surveillance for case/outbreak confirmation

4. Fully investigate all detected measles outbreaks and ensure

appropriate case management

Global Context: Worldwide measles vaccination delivery strategies, mid-2010

MCV1 & MCV2, no SIAs (40 member states or 21%)

MCV1 & regular SIAs (59 member states or 31%)

MCV1, MCV2 & one-time catch-up (36 member states or 19%)

MCV1, MCV2 & regular SIAs (57 member states or 28%)

India

UPDATE ON ACCELERATED MEASLES CONTROL

SIA: MCV1 <80%

RI: MCV1 > 80%

2nd Dose of Measles vaccine: State specific delivery strategies

MCV1: Coverage of Measles containing vaccine per DLHS-3; CES-06 for Nagaland

2nd Dose of Measles in RI

• 17 states (MCV1>80%)

introduced measles 2nd dose

in their routine immunization

program

• 45 districts, who completed

measles campaign in phase -1

are in process of introducing

2nd dose in their RI program

MCV2 introduction through Supplementary Immunization Activity (SIA) in Phases

Initiated in November 2010; 45 districts from 13 states

o 9 district from Chhattisgarho 5 districts from each of the 6

states (Bihar, Jharkhand, Rajasthan, Madhya Pradesh, Gujarat & Haryana)

o 1 district from each of the 6 North-East states

Approximately 14 million target children 9 months – 10 yrs

Phase 1

Un-aware of need

(43.9%)

Reasons for un-vaccinated children: RCA surveys results

20

10

11

320

16

9

1 110

9

Parents didn't know about the

campaign

Parents didn't know about place

or date of the place or date of

the campaign

Fear of injection

Fear of AEFI

Parents didn't give importance

IEC/IPC(43.7%)

Operational Gap

(3.7%)

N=unvaccinated children; 30,200Note: Figures are % of total responses provided

Enhanced AEFI surveillance during the Measles catch-up campaigns

304 minor AEFIs and 40 serious AEFIs reported

All serious AEFIs reported and correctly managed

NO DEATHS – VACCINE OR PROGRAMME RELATED

Lesson learnt from 1st Phase:Areas for improvement

• Coordination and planning:

– Better coordination of the three primary department of health, education and

ICDS

– Clear timelines of availability of logistics

• Communication and advocacy:

– IEC ,BCC and interpersonal communication

– IAP, IMA and private doctors sensitization

– Private school principals orientation

• Vaccination in urban areas

• Injection waste management

• Supervision at all levels

Measles SIA plan, India

Phase 2 A (144 districts)

Phase 1, 45 districts covered

Phase 2 B (81 districts)

Phase 3 (91 districts)

Total target- 135 million childrenDistricts- 361

Planned phases of measles catch-up campaigns

Phase 1 Phase 2A

Phase 2B Phase 3 Total

Dates Q4 2010 – Q2 2011

Q3 – Q4 2011

Q1 2012 Q4 2012

No. districts 45 144 81 91 361

Target population (9m-10yrs)

millions

14.0 41.5 33.4 47.0 135.0

Children vaccinated (millions)

12.0

Expansion of measles outbreak surveillance

• Reporting of clinical

measles cases linked with

AFP weekly reporting in

these states

• One state level lab

strengthened in each state

testing for measles and

rubella IgM

2006

2007

2010

2009

2011

0200400600800

1000120014001600180020002200240026002800300032003400360038004000

< 1 year 1-4 years 5-9 years 10-14 years >= 15 years

Total cases = 9,221

Vaccinated Not Vaccinated Unknown

* Serologically and epidemiologically confirmed cases

** Data from 8 states (Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamilnadu and West Bengal* data as on 15th Jun, 2011

61 % no or unknown vaccination status

86 % < 10 yrs of age

Serologically confirmed measles outbreaks: Age and vaccination status of measles cases*, 2011

Serologically confirmed# measles, rubella and mixed outbreaks

(Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu and West

Bengal)

129 outbreaks

Measles outbreaks confirmed

Rubella outbreaks confirmed

Mixed outbreaks confirmed

1091010

2011*

# Outbreak confirmation for Measles: 2011 ≥ 2 cases IgM positive for measles and rubella

* data as on 15th Jun, 2011

2010#

198 16 5

219 outbreaks

Widespread measles virus transmission indicating gaps

in RI

RI – Measles synergies

• Measles catch-up campaigns has helped, RI

– By augmenting AEFI surveillance (reporting & management)

– By improving injection safety practices on a large scale

– By enforcing waste management practices (as per national guidelines)

– By optimizing cold-chain space & efficient vaccine stock management

practice at various levels (state/district/block)

– Encouraging fixed-day , fixed-site session based approach

• RI-measles synergy study is being done in jharkhand

• Year 2012 declared year of intensification of RI

– Operational plan under development

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