national strategic plan for measles elimination and rubella/crs control ...€¦ · 1 national...

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NATIONAL STRATEGIC PLAN FOR

MEASLES ELIMINATION AND

RUBELLA/CRS CONTROL

2015 -2020

1st draft 18th June, 2014

2nd draft 24th August 2014

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Contents

1. Country profile ............................................................................................................................... 4

2. National Health Systems ............................................................................................................. 5

3. Epidemiology of Measles and Rubella ...................................................................................... 7

4. Support from International Collaborating partners ................................................................ 10

5. Feasibility of Measles elimination and Rubella/CRS control ............................................... 10

Operational feasibility .................................................................................................................... 10

1. Contextual ........................................................................................................................... 10

2. General health system ....................................................................................................... 10

4. Research institutions ......................................................................................................... 11

6. Guiding Principles ...................................................................................................................... 12

7. Key Assumptions ........................................................................................................................ 12

Strategic Plan, Vision, Mission, Goal and Objectives ............................................................ 13

1. Vision: ......................................................................................................................................... 13

2. Mission: ...................................................................................................................................... 13

3. Goal: ............................................................................................................................................ 13

4. Outcome Objectives: ............................................................................................................... 13

5. Broad key strategies and main activities: ......................................................................... 13

5.1 Achieve and maintain two doses of measles and rubella vaccination coverage

at >95%. .......................................................................................................................................... 14

5.1.1 Micro-stratification and targeted immunization intervention for low MR

vaccine coverage ..................................................................................................................... 14

5.1.2 Accelerate immunization intervention to reach out children who are not

vaccinated .................................................................................................................................. 15

5.1.3 Sustain routine high MR vaccine coverage ...................................................... 15

5.1.4 Operational research on vaccine coverage and management .................... 16

5.2 Intensify surveillance and investigation of Measles and Rubella/CRS ............. 16

5.2.1 Scale up existing MR and CRS surveillance system ............................................ 17

5.2.2 Institute active case detection, investigation and immunization response ... 17

5.2.3 Strengthen AEFI surveillance ............................................................................... 18

5.2.4 Improve data management, reporting and feedback system ....................... 18

5.2.5 Strengthen capacity to investigate outbreak and response ......................... 19

5.3 Provide quality assured laboratory diagnosis and case management ............. 19

5.3.1 Maintain accreditation of national measles and rubella laboratory ................. 19

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5.3.2 Maintain institutional linkage with regional reference laboratory .................... 20

5.3.3 Strengthen local laboratory network on sample collection and shipment ..... 20

5.3.4 Ensure prompt case management ............................................................................ 21

5.3.5 Genotyping of Measles and Rubella virus ............................................................... 21

5.4. Intensify advocacy and risk communication for measles elimination and

Rubella/CRS control .................................................................................................................... 22

5.4.1 Develop communication plan and intervention tools .......................................... 22

5.4.2 Engage community participation in vaccination advocacy ................................ 23

5.4.3 Sensitise and advocate local government and policy makers .......................... 24

5.4.4 Dissemination of communication materials through mass media and

appropriate information technology. .................................................................................. 24

5.5 Enhance institutional capacity and Monitoring & Evaluation .............................. 24

5.5.1 Strengthen programme capacity ............................................................................... 24

5.5.2 Strengthen vaccine inventory management ........................................................... 25

5.5.3 Strengthen regulatory system .............................................................................. 25

5.5.4 Improve cold chain management and logistic ................................................. 26

5.5.5 Strengthen M & E ..................................................................................................... 27

5.6 Strengthen governance and collaboration with international organizations to

achieve regional and global elimination targets and indicators .................................... 27

5.6.1 Garnering political support and resource mobilization ................................. 27

5.6.2 Institution of appropriate governing structure ................................................. 28

5.6.3 Align and collaborate with various stakeholders and international

organization to support elimination target ........................................................................ 29

Annex I: Monitoring Indicators .......................................................................................................... 29

Annex II: Estimated Costing Matrix ................................................................................................. 34

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1. Country profile

Bhutan is located in the eastern Himalaya with a total area of 38, 394 km2 and

shares a common border with China to the north and India to the west, south and

east. Administratively the country is divided into three regions, twenty "Dzongkhag"

(District) and 205 Gewogs (Blocks). Gewog and Thromde (municipality area) is the

lowest administrative block. The country has mainly three geographical climatic

features with subtropical hot and humid conditions in the southern belt, cool

temperate climate in the central and snow capped mountains with cold alpine climate

in the north. Since the country is located in the heart of Himalaya, it has difficult

geographical terrain which has not only developed unique socio-cultural diversities

but also presents different health condition and often inaccessibility especially

remote localities.

The Population and Housing Census conducted in 2005 enumerated a population of

672,450 with 37,443 as floating population. The population is estimated to have

grown to 720 679 in 2012 with about 70% people living in rural areas. Life

expectancy has increased from 66 years in 1999 to 68 years in 2012 and the

population growth rate has stabilized to around 1.3 % from 3.1% in 1994 as per 2012

National Health Survey. Bhutan is also on track to achieve most of the MDG targets

by 2015 however malnutrition in children, infant mortality rate, under five mortality

rate are some of the challenges to achieve the targets. Bhutan has created a series

of Five Year Plans detailing its economic and development strategies since the

1960s. Bhutan has seen rapid economic and social development particularly in the

last decade. The Gross Domestic Product (GDP) in 2012 was about US $ 1779.6

million. The economy is mainly based on agriculture, but also depends on forestry,

tourism and hydroelectric power. The developmental activities are more significant in

the western Bhutan, especially in Thimphu and Phuntsholing. This has resulted in

the population movements towards these economic zones especially from the

Eastern Bhutan with about 63% net in-migration to Thimphu as per the 2005

Population and Housing Census.

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2. National Health Systems

Bhutanese people have free health care services from primary to tertiary level health

care as the right enshrined in the Constitution of the country, which states, " the

State shall provide free access to basic public health services in both modern

and traditional medicine" and “the state shall endeavour to provide security in

the event of sickness and disability or lack of adequate means of livelihood for

reasons beyond one’s control”.

The Bhutan health policy statement states that Bhutan shall continue to pursue the

comprehensive approach of Primary Health Care, provide universal access with

emphasis on disease prevention, health promotion, community participation and

intersectoral collaboration and with health services provided with integration of

modern and tradition health care systems that responds equitably, appropriately and

efficiently to the needs of all Bhutanese citizens.

The health care is delivered through three tiered system namely; the primary,

secondary and tertiary providing preventive, promotive and curative services as

shown in figure (1) below.

Tertiary ( National and Regional

Level)

• National referral Hospital (1)

• Regionnal Referral Hospital (2)

Secondary ( District Level)

• District level Hospital (32)

• District Health Office (20)

Primary ( Block and community

level)

• Basic Health Units (192)

• Out breach clinics (550)

Figure 1: Pyramid of Health care delivery system

To provide deliver health care services, health infrastructure are spread across the

country including the remote places (figure 2).

across the country, most people have reasonable access to health services with only

4.6% of Bhutanese population living at a distance of more than 3 hours from the

nearest health facility and 81.5 % of the population seeking help from the health

professionals as the first line of treatment (National Health Survey 2012).

The current health workforce working in the above heath facilities consists of 194

doctors, 736 nurses, 578 basic health unit workers, 807 technical categories and 98

traditional health workers.

Figure 2: Map of Health infrastructure

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country including the remote places (figure 2). With wide coverage of health







Figure 2: Map of Health infrastructure


With wide coverage of health facilities







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Table 1: The main indicators as per the National Health Survey 2012

Indicators Year

1984 1994 2000 2012

Crude rate of natural increase 2.6 3.1 2.5 1.2

Total fertility rate (Births per

women)

- 5.6 4.7 2.3

Crude death rate 39.1 39.9 34.1 17.9

Infant Mortality rate/1000 live births 102.8 70.7 60.5 30.0

Under-five mortality rate 162.4 96.9 84.0 37.3

Maternal Mortality Ratio/100000 live

births

777 380 255 86

3. Epidemiology of Measles and Rubella

Measles vaccination program in Bhutan was started in 1979 along with BCG, DPT &

OPV. Measles vaccine was given as single dose at 9 months of age through routine

immunization services. During early phase of immunization programme, measles

vaccination coverage was found very low in most districts ranging from 24%- 83%.

With the implementation of EPI acceleration plan in 1988, measles vaccination

coverage increased to 89% in 1991 as per the first EPI survey report. In 2006,

Bhutan introduced rubella vaccine as combined MR vaccine.

To rapidly reduce measles morbidity and mortality, Bhutan has conducted three

nationwide measles vaccination catch up campaign using monovalent measles

vaccine in 1995 and 2001 and MR vaccine in 2006 coinciding with introduction of

rubella vaccination. Further in 2006, second dose of measles vaccine was

introduced with combined MR vaccine at 24 months. The second EPI coverage

survey conducted in 2002 reported measles vaccine increased to 92%. Since then,

the measles coverage was sustained at more than 90% which was authenticated by

EPI coverage survey conducted 2008 which reported measles rubella vaccine

coverage at 95% (Figure 3). Further, the recent National Health Survey conducted in

2012 reported first measles rubella vaccine dose (MR1) coverage at 97%.

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Figure 3: MR vaccine coverage and cases from 1998 - 2013

With consistent maintenance of high MR vaccine coverage, measles and rubella

cases have declined to very minimal cases. As per the WHO measles elimination

target of measles incidence {<1 measles case confirmed by laboratory or

epidemiological linkage (excluding clinically compatible and imported cases) per

1000 000 population} Bhutan has already achieved the target. The last laboratory

confirmed measles case reported was in 2012 however rubella is still detected but in

single digit only. In 2013, laboratory confirmed rubella cases were six cases only.

The last case of measles death reported was in 1986, and CRS case was reported in

2009.

The most affected age group by measles is among children under 5 years old (figure

4) However, there was measles outbreak in 2010 in the army barrack which suggest

that there could certain elderly population who have not received vaccination.

Although vaccination history are rarely documented in the case investigation form

but available information revealed that most case did not received MR vaccination

and few are possibly sero-conversion failure cases. With introduction of MR2 dose in

2006, measles case among age group 1-5 years has declined. .

04

13

610 4

2

20

91 0

65

22

53

9

3 2

23

7 36

71% 76% 76% 78% 78%

88% 89% 93% 90%95% 99% 94.7%95% 95% 95% 97%

85% 88% 89% 89%

0

10

20

30

40

50

60

70

0

20

40

60

80

100

120

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

mb

er

of

case

s

Va

ccie

n C

ov

era

ge

(%

)

Year

Lab confirmed measles cases Lab confirmed rubella cases MR1 MR2

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Figure 4: Age break down of measles cases from 2006-2013

Simialrly, common affected age group by rubella is among children under 5 years but

cases are prevalent among 6-10 years of age (figure 5) which is observed during

early phase of rubella vacciantion introducution and this will decline over the years.

Figure 5: Age break down of rubella cases from 2006-2013

Bhutan has maintained measles rubella vaccine coverage more than 90% for more

than eight years and already achieved the regional target of measles morbidity and

mortality reduction in 2007. As one of the SEARO member state to adopt measles

0

2

4

6

8

10

12

14

16

<1 yr 1-5 yrs 6-10 yrs 11-15 yrs 16-25 yrs >26yrs

Nu

mb

er

of

case

s

Age group

2006 2007 2008 2009 2010 2011 2012 2013

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

<1 yr 1-5 yrs 6-10 yrs 11-15 yrs 16-25 yrs >26yrs

Nu

mb

er

of

case

s

Age group

2006 2007 2008 2009 2010 2011 2012 2013

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elimination prior to region target by 2020, Bhutan has already embarked in the pre-

elimination stage and target to eliminate measles in the country by 2016.

4. Support from International Collaborating partners

The success of VPDP was mainly due to the support from the national and

international collaborating partners. The main international collaborating partners are

WHO, UNICEF and JICA which provided both fund and technical support.

5. Feasibility of Measles elimination and Rubella/CRS control

After the introduction of immunization programme in 1979, Bhutan has come a long

way to achieve and sustain measles and rubella vaccine coverage >95% with no

measles cases reported since 2013 and no deaths since 1986. The last CRS cases

reported is in 2009 and 3 rubella lab confirmed cases reported in 2013. Furthermore,

the socio-economic status of the people has improved dramatically from one of the

poorest nation to a low middle income country along with improvements in all the

health, education and socio-economic indicators. External review of Vaccine

Preventable Disease Programme conducted by WHO in 2012 also found measles

elimination feasible in Bhutan.

Operational feasibility

1. Contextual

� Political and social stability in the country - favourable

� Effective government with clear geographical demarcations and division of

responsibilities - favourable

� Good, collaborative relations with countries from where carriers could be

imported–favourable

2. General health system

� Governance

o Politically and technically strong leadership; political stability -

favourable

o Culture of relying on evidence and reliable HIS data - favourable

� Health services

o Geographically, economically and culturally accessible - favourable

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� Human resources for health

o Sufficient, educated, trainable, motivated, properly remunerated, stable -

favourable

3. Vaccine Preventable Disease Programme (VPDP)

� Technical and administrative capacity and leadership – favourable with

additional technical expert provided

� Able to mobilize financial resources – favourable since UNICEF and JICA

is also providing fund other than WHO. Also Health Trust fund is

operational for traditional vaccine.

� Enough fiscal space (can be authorized to expand budget as required) -

favourable

� Excellent Laboratory service to diagnose measles and rubella or strategy for

achieving that – favourable, Infectious Diseases Serology Laboratory

under the Public health Laboratory is WHO accreditated National

Measles Laboratory.

� Excellent surveillance or strategy for achieving that – favourable, needs

further improvement

� Good epidemiological support – Not favourable. Need capacity building

� Good management of preventive and curative services including supply chain

and human resources - favourable

� Good capacity in communication and advocacy – favourable with some

improvement

� Good information technology support including case mapping to stratify the

problem. - favourable, needs further improvement

4. Research institutions

a. Good research capacity for public health problems in the country -

Needs further improvement

b. Capacity for genotyping measles and rubella - Needs to be

established

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6. Guiding Principles

Achievement of Measles elimination and rubella/CRS control targets set in the

strategic plan will be guided by the following broad principles:

� Forge National ownership of Measles elimination through

establishment a Measles Elimination Commission to garner political

support, resources and provide oversight and accountability

� The Vaccine Preventable Disease Program, CDD, DoPH shall

coordinate the consultative planning, implementation, research,

monitoring and evaluation of Measles and rubella/CRS elimination

and control activities.

� Build strong mechanisms for partnerships with line Ministries and

agencies for effective implementation of this plan.

� Strengthen decentralized measles elimination and rubella/CRS

control with district health taking the onus of elimination and control

activities.

� Collaborate with neighboring countries, international organizations

and agencies.

� Utilize modern technology for surveillance, disease notification,

conduct research and epidemiology analysis to generate evidences

to guide measles elimination and rubella/CRS control strategies and

interventions.

7. Key Assumptions

The following key assumptions are important to achieve measles elimination and

rubella/CRS control within the time frame of this National Strategic Plan and sustain

beyond:

� Continued political commitment by leadership at all levels to support

the national strategic plan and provide adequate financial and

human resources

� Continued international support both in technical and financial

aspects

� Further improvement in the socio-economic developments of the

people of Bhutan

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Strategic Plan, Vision, Mission, Goal and Objectives

1. Vision:

Bhutan free of indigenous Measles, Rubella and zero CRS

2. Mission:

Achieving elimination of measles and control of rubella through intensification of

immunization and surveillance system including laboratory capacity and strengthen

institutional collaboration to prevent reintroduction of measles and reduction of

rubella and CRS.

3. Goal:

To achieve zero indigenous Measles by 2016 and WHO certification by 2020, and

reduction of rubella and CRS until it is no longer public health problem.

4. Outcome Objectives:

1. To achieve measles elimination by 2016

2. To achieve and maintain two doses of measles and rubella vaccination

coverage at >95% from 2016 onwards

3. To achieve rubella/CRS control as no longer public health problem by 2016.

4. To further strengthen institutional capacity including surveillance and

laboratory to sustain measles elimination and rubella/CRS control.

To support the above objectives, the following strategies will be implemented and if

necessary will be reviewed every two years:

5. Broad key strategies and main activities:

The main strategies include achieving two doses of measles and rubella

vaccination coverage more than 95% through micro-stratification particularly MR2

and intensify surveillance and investigation of every measles, and rubella/CRS

case by use of web-based mobile networks for real time reporting. The

surveillance will be backed by quality assured laboratory and effective case

management at the health facility by the health worker. The governance

structures to provide elimination oversight will be instituted at all levels and

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monitoring, evaluation and supervision will be strengthened. Advocacy and risk

communication on measles elimination and rubella/CRS control will be

strengthened to sensitize and maximize community participation in measles

elimination and rubella/CRS control activities. Further, research capacity will be

strengthened to keep measles on the agenda beyond the elimination phase. The

specific strategies and activities for each strategy are described here below.

5.1 Achieve and maintain two doses of measles and rubella vaccination

coverage at >95%.

The studies have shown that the average sero-conversion rate with measles

vaccination at 9 months was found to be 85%. Thus, approximately 15% of

vaccinated children would remain susceptible to measles and rubella infection in

spite of receiving one dose of MR vaccine. However, sero-conversion rate improves

to >95% when the vaccine is given after one year of age, but the first dose has to be

given earlier to protect infants. Therefore, 2nd dose of MR has been recommended

at 24 months to cover those sero-conversion failure cases and achieve high

measles and rubella vaccine coverage.

In Bhutan, MR1 coverage is above 95% but MR2 coverage is still below 90%.

Therefore, to improve MR2 coverage, micro stratification and targeted immunization

will be conducted at district level.

5.1.1 Micro-stratification and targeted immunization intervention for low

MR vaccine coverage

Micro planning and stratification will be focussed in districts with low coverage of MR

vaccination such as Haa, Gasa, Tashiyangtse and Pemagatsel. Micro stratification

will be conducted for every gewog (Block) of those districts through active

engagement of the village health workers/ community leaders. This will ensure that

the unreached population is reached through targeted intervention. Mop up

campaigns will also be conducted at the gewogs level especially the unreached

population consisting of migrant population and road side workers. The adequate

vaccine and logistic supply to the Basic Health Units and outreach clinics will be

assured by district health office and programme.

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Key Activities:

1. Identification of low MR vaccine coverage areas/chiwog/gewog in district that

has coverage <90%.

2. Development of a micro plan action in consultation with the DHO’s

3. Forecasting MR vaccines requirement and distribution plan

4. Conduct MR catch up campaigns for micro-stratified low coverage areas

5. Sensitize the Village Health Workers for communication and social

mobilization

5.1.2 Accelerate immunization intervention to reach out children who are

not vaccinated

There are pockets in the country where the immunization services are still not

reached to the children residing in the urban areas and peri urban areas such as

population residing in the temporary settlements, road site settlements, monastic

institutions, etc. To reach out those children, day care and early Child Care

Development (ECCD) centres will be visited by heath workers as most of the

children are admitted in these centres as early as 2 years of age. This visit will

enable to verify the MR vaccination status among the children in the centres. Those

children found unvaccinated will be vaccinated.

Assessment of the MR vaccination status for the population inhabiting in temporary

settlements such as road side camps will also be conducted and provide vaccination

if found unvaccinated. Based on assessment, catch up campaigns among

unprivileged population and monk will be conducted in collaboration with the relevant

stakeholders.

Key Activities:

1. Periodic assessment (quarterly/annually) of immunization coverage status

among day care centres establishment, the population residing in the

temporary settlements and monastic institutions

2. Provide vaccination to the unvaccinated children and population

5.1.3 Sustain routine high MR vaccine coverage

To achieve measles elimination and Rubella/CRS control by 2016 and sustain

onwards, Programme has to continue MR immunization and maintain high coverage

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>95% nationally and 90% at the district level. In order to sustain high MR coverage,

adequate quality vaccine supply will be maintained in all health facilities. Regular Out

Reach Clinics (ORC) session will be conducted to maintain high coverage. Further,

the vaccine inventory management system will be strengthened through the

development of web based reporting at the district level to facilitate in vaccine

procurement and remobilization and cold chain inventory.

Key Activities:

• Procurement of MR vaccines and cold chain equipment

• Develop web based reporting system and training of health workers on web

based reporting

• Training of health workers on immunization techniques and cold chain

equipment preventive maintenance.

• Periodic monitoring (quarterly/Annually) and supervision from central to the

districts and district to BHUs

• Observation of Global Immunization Weeks and World Mothers Day to

sensitize the mothers on the importance of vaccination.

5.1.4 Operational research on vaccine coverage and management

In order to achieve measles elimination status by 2016, need based operational

research has to be planned and conducted to understand the local context and

generate strategic information to facilitate and promote evidence based planning and

decision making.

Key Activities:

• Conduct measles coverage survey

• Conduct study on MR immunity among general population

• Conduct study on effectiveness of Vaccine Vial Monitor (VVM)

• Conduct study on Vaccine wastage and utilization and Effective Vaccine

Management (EVM)

5.2 Intensify surveillance and investigation of Measles and Rubella/CRS

Good surveillance system with data management is critical for achieving measles

elimination and rubella.CRS control. Monitoring progress towards achieving

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elimination can only be accomplished in the presence of a surveillance system that

meets measles elimination and rubella/CRS control targets defined by WHO.

Integrated epidemiological and laboratory-based surveillance is also required to

provide the necessary sensitivity and specificity to ensure that measles and rubella

virus is detected.

5.2.1 Scale up existing MR and CRS surveillance system

The existing Measles, Rubella and CRS surveillance system is a passive

surveillance system. As a preparatory step towards measles elimination and

rubella/CRS control, the existing surveillance system will be scaled up to an active

surveillance where every measles, rubella and CRS cases will be reported

immediately and investigated within 24-48 hours. Case based surveillance has been

instituted but it is not implemented at the moment because clinicians and health care

workers are not aware and trained on it. Clinicians and health workers will also be

trained on case based surveillance and investigation. As part of active case finding,

VHW will be involved in detecting and referring fever with rashes and signs of CRS

Key Activities:

• Revise Measles and Rubella CRS surveillance guideline and develop

appropriate training modules for health workers

• Training of health workers on revised MR and CRS surveillance

guideline

• Training on basic field epidemiology on surveillance and cased

investigation.

5.2.2 Institute active case detection, investigation and immunization

response

To stop the measles and rubella transmission, the confirmed measles and rubella

cases will be followed up immediately by active contact tracing and investigation.

This is also enabling to eliminate potential source in the community and susceptible

population. All contact of the cases will be thoroughly investigated and reported.

Based on investigation findings, health workers will provide appropriate intervention

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including immunization if required. All suspected CRS case should be investigated,

managed/referred and reported.

Key Activities:

• Inclusion of contact tracing in the revised surveillance guideline

• Training of health workers on contact tracing based on revised MR and

CRS surveillance guideline

• Management and referral protocol for CRS developed and

disseminated

5.2.3 Strengthen Adverse Events Following Immunization (AEFI)

surveillance

Country has AEFI surveillance in place for routine vaccine including measles and

rubella vaccine. However, there is lack of proper reporting, documentation and data

management at the moment. Also the existing AEFI surveillance does not include

the reporting of minor AEFI’s. Therefore, existing AEFI guideline will be revised and

health workers will be trained to strengthen AEFI surveillance.

Key Activities:

• Revise AEFI surveillance guideline

• Training of health workers on revised AEFI guideline

5.2.4 Improve data management, reporting and feedback system

Measles, rubella and CRS are notifiable diseases and all notifiable diseases are

reported through web based. However, the existing case based reporting is done by

using conventional technology like faxing, telephone and email where health centers

has access to internet facility. Also, there is no software program developed to

manage data in the programme. This has been the main constraint in getting

information collected from the field for quick response and also managing reliable

data. To address this problem, VPDP in collaboration with the Public Health

Laboratory will develop web based reporting for case based investigation reporting.

At the moment, there is no feedback mechanism instituted for sharing information

collected from the field. Therefore, programme will improve data management and

institute mandatory regular feedback mechanism. This information should be shared

to relevant stakeholders (WHO and UNICEF).

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Key Activities:

• Develop web based system for reporting and data management

• Develop feedback format and mechanism

• Training of programme personnel on data analysis

• Prepare annual reports

• Printing of annual report

5.2.5 Strengthen capacity to investigate outbreak and response

The rapid response team (RRT) is instituted at district and national level for

investigation and response of any disease outbreaks. The same RRT will be used for

measles and rubella outbreak investigation and containment. The rapid response

team capacity will be built in measles and rubella outbreak investigation including

their knowledge in field epidemiology.

Key Activities:

• Develop out break preparedness and response plan

• Training of RRT on basic field epidemiology and measles and rubella

outbreak investigation and response

5.3 Provide quality assured laboratory diagnosis and case management

Laboratory plays critical role in confirming measles or rubella as clinical signs and

symptoms are generalized and difficult to diagnose clinically. Bhutan has started

measles and rubella serology in the Public Health Laboratory in 2003 and

accreditated as national measles and rubella laboratory in the country in 2008 by

WHO. As measles and rubella cases are rarely detected in the country, clinician

and health worker may lose their competency and knowledge on measles and

rubella case detection and management. Therefore, period refresher training on n

measles and rubella case detection and management will be conducted to

maintain zero mortality.

5.3.1 Maintain accreditation of national measles and rubella laboratory

Laboratory testing to confirm a clinically suspected measles and rubella is an

essential part of the surveillance system including contact tracing. Therefore,

confirmation by quality assured laboratory testing is one of the requirement for

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achieving measles elimination targets and indicators. The existing national measles

and rubella laboratory under the Public Health Laboratory is an accreditated

laboratory for measles and rubella testing and will continue to renew and maintain

accreditation status.

Key Activities:

• Participate in IEQAS programme for proficiency testing.

• Referral of 20% of samples tested to regional measles and rubella

reference laboratory for across checking.

• Invitation of WHO experts annually for onsite assessment of national

measles and rubella laboratory for renewal of accreditation status.

• Training of laboratory personnel.

5.3.2 Maintain institutional linkage with regional reference laboratory

Laboratory based surveillance and studies will be conducted to supplement

information generated through routine surveillance system. This would require

information sharing, technical support and collaboration with WHO regional

reference laboratory and also among national measles and rubella laboratory from

other members’ state in the region. There is already established regional measles

and rubella laboratory network and Bhutan will continue to participate to maintain

existing linkages and collaboration.

Key Activities:

• Supply of quality measles and rubella test kits through WHO procurement

• Supply of controls and reagents from regional reference laboratory

• Technical assistance from regional reference laboratory

• Referrals of samples to regional reference laboratory

5.3.3 Strengthen local laboratory network on sample collection and

shipment

As per the global Measles elimination strategies and indicators, country need to

achieve samples testing more than 80% from total suspected cases reported by

national accreditated measles and rubella laboratory. Also from total confirm

measles and rubella samples, more than 80% of samples need to perform

genotyping. To achieve those laboratory indicators, samples from every suspected

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case must be collected and shipped to national Measles and Rubella Laboratory.

However, problems of samples collection and shipment still exist in the districts

especially samples collection for genotyping. To overcome sample collection and

logistic problems, local laboratory network will be strengthened and laboratory

people will be trained on samples collection and shipment to the national reference

laboratory with support from VPDP.

Key Activities:

• Development of SOP for sample collection and shipment

• Training of laboratory persons on sample collection and shipment

• Established shipment mechanism from districts to national reference

laboratory

5.3.4 Ensure prompt case management

Measles and rubella cases are rapidly declining in the country and as a result there

is risk for clinicians and health workers to miss the diagnosis of measles and rubella

including case management. This may create knowledge gap in case detection and

management if there is measles and rubella outbreak. Therefore, clinicians and

health workers will be trained periodically (Annually/bi-annually) on case definition,

symptomatic management for all suspected Measles and Rubella cases, Vitamin A

supplementation, and hospitalization of all complicated cases of fever and rash. The

clinicians and health workers also will be trained on early referral and management

of all CRS cases.

Key Activities:

• Include case management in the revised surveillance guideline

• Training of clinicians and health workers on revised MR surveillance

guideline

5.3.5 Genotyping of Measles and Rubella virus

Currently, country does not have indigenous measles and rubella genotype baseline.

However, as country gears up for Measles elimination by 2016, and rubella

elimination in near future, initiating and establishing measles genotyping capacity in

the country is critical to ascertain the indigenous measles and rubella genotypes.

This genotype information will be useful to track measles imported cases and

22

moreover, genotype information will be very essential to monitor the transmission

dynamic in the region. The measles and rubella genotype information will also be

used for planning appropriate interventions at the national and regional level. The

capacity for PCR and genotyping will be built in the Public Health Laboratory with

support from WHO and regional Measles and Rubella reference Laboratory.

Key Activities:

• Procurement of laboratory equipments

• Procurement of reagents and consumables

• Ex-country training of laboratory personnel in PCR and genotyping

• Institutional linkages with WHO regional Measles and rubella reference

laboratory on genotyping.

• Collaborative study with reference laboratory on Measles and Rubella

genotyping

5.4. Intensify advocacy and risk communication for measles elimination

and Rubella/CRS control

Successful measles elimination and rubella/CRS control will depend on good

advocacy and risk communication strategies to reach out policy makers, local

leaders and community on importance of measles elimination and rubella/CRS

control. Advocacy and risk communication has been successfully conducted in

past during catch up campaigns. However, over the years, advocacy and

communication has been neglected. Therefore, advocacy and risk

communication will be intensified during measles elimination stage including

rubella/CRS control.

5.4.1 Develop communication plan and intervention tools

Communication plan and other intervention tools for measles elimination and

rubella/CRS control will be developed as deemed appropriate. Information

Education and Communication materials will be developed and disseminated

through various forms of information technology to reach various section of the

population. Sensitization activities will be carried among the targeted population. M

health application will be utilized and adopted for tracking of missed out children.

Key Activities:

23

• Technical support and consultative meeting for the development of the

communication plan for measles elimination and Rubella CRS control

• Development of communication materials (broadcast & print)

• Pre test of the communication action plan

• Printing of communication plan and communication materials

• Training of Health workers on implementation of communication action

plan including BCC, Risk and outbreak communication

5.4.2 Engage community participation in vaccination advocacy

Community participation is one of the key successful factors for the overall

achievement of the high immunization program. They (community health workers,

leaders and members) will act as a bridge between the health system and the

community. Ministry of Health would pursue this through active engagement of the

community leaders, community members and village health workers. This will be

implemented in close collaboration with the Village Health Workers Program and the

district health offices. Wherever necessary exposure visit and study visit will be

planned for the village health workers and other community leaders to learn the best

practices in other high coverage districts and where there is good community

participation.

Key Activities:

• Continue and enhance engagement of VHWs during the vaccination program

• Sensitize and orient the village health workers, NFE instructors and

community leaders on Routine Immunization Schedule

• Exposure visit of VHWs/community leaders to other districts with high

community participation/performance to learn and share best practices

• Training of VHWs on line listing of children eligible for immunization and

tracing dropouts

• Training of VHWs on detection/referral of fever with rash and CRS

• Training of VHWs on AEFI

24

5.4.3 Sensitise and advocate local government and policy makers

Conduct sensitization workshops to the local government and policy makers to

garner their support especially in terms of resource mobilization and political will.

Key activities:

• Review meeting on MR coverage status update with the key policy makers

5.4.4 Dissemination of communication materials through mass media

and appropriate information technology.

Information Technology and other innovative means such as use of mobile

applications will be adopted wherever possible to disseminate the IEC materials to

general and targeted population.

Key Activities:

• Airing of TV/Radio spots and jingles on media

5.5 Enhance institutional capacity and Monitoring & Evaluation

Although Bhutan has reduced the reported measles cases to zero and rubella/CRS

case to very minimal level, it is important that the country has the institutions and the

technical capacity including strong M&E in place to successfully eliminate measles

and control rubella/CRS. Therefore, following enabling strategies will be adopted.

5.5.1 Strengthen programme capacity

For the success of program implementation, various management skills, like project

planning and implementing, monitoring and supervision are important. This is more

critical during the elimination and control phase, which demands the strengthening of

program capacity. To strengthen the program capacity, additional program personnel

with vaccinology and/or public health background will be recruited. The existing

program personnel and relevant officials will also be trained on vaccinology, new

vaccines introduction, surveillance, vaccine pharmacovigilance and programme

management.

Key Activities:

• Recruitment of one additional program personnel with expertise in

vaccinology/Public health

25

• Train program personnel and relevant officials on vaccinology

• Training of program and relevant officials on vaccine pharmacovigilance

• Training of program and relevant officials on surveillance & AEFI

• Training of program personnel on program management

• Training on new vaccine evaluation and introduction for program and relevant

officials (can be more specific by adding no. of people at each level)

5.5.2 Strengthen vaccine inventory management

Proper vaccine inventory management system is important to reduce wastage and

enhance proper forecasting of vaccine and cold chain requirement. Vaccines are

supplied to the national program using UNICEF Procurement Services. Domestic

vaccine supply chain has four levels. National store distributes vaccines to all

regional stores. From the Regional stores, vaccines are distributed to district

hospitals and from district hospital to the BHUs. Stock registers are updated when

they get new vaccines as well as when vaccines are distributed to other health

centres. Central and Regional cold stores are using Vaccine Supply and Stock

Management (VSSM) tool for vaccine inventory management. However, capacity of

the Central and Regional EPI in-charges on the use of this electronic tool needs to

be strengthened and expanded up to the district level. Timely recording, reporting

and updating vaccine stock at all levels are weak and also needs strengthen.

Key activities:

• Develop web based vaccine inventory management system/VSSM

• Training of EPI in charges and EPI/MCH in charges on web based vaccine

inventory management system

• Training of new EPI technicians on vaccine management

5.5.3 Strengthen regulatory system

Ensure all the vaccines supplied and used in Bhutan are WHO prequalified and

registered with DRA in line with the DRA regulation and Medicine Act of Kingdom of

Bhutan, 2003. The DRA capacity on registration of new vaccines needs to be

strengthened and improve abridged registration for WHO prequalified vaccines.

Key activities:

26

• Training on new vaccines registration for the DRA/Program and

relevant oficials

• Procurement of temperature monitoring devices

• Refreshers training of drug inspectors on regulatory activities for

vaccines and cold chain requirement

• Quality testing of vaccines

5.5.4 Improve cold chain management and logistic

National Cold Store has a cold room where vaccines are stored after the vaccines

arrive in the country. The vaccines are transported from the airport to the Central

Cold store and from Central Cold store to Regional cold stores by refrigerated vans.

ILR and refrigerators are also used to store the vaccines and make ice packs at

central, regional, district and BHU levels. Cold boxes are used usually during power

failure for short duration. Vaccine carriers are used to transport the vaccines to the

ORCs. Temperature monitoring devices are used to monitor the temperature of the

cold chain equipment including transportation. Trained EPI technicians are available

in the Central and Regional Cold stores to carry out maintenance and repair works of

refrigerators whenever there is breakdown of cold chain equipment. Most of the cold

chain equipment used in the country is WHO prequalified except some refrigerators.

Currently, two regional cold stores have no cold room facilities which need to be

provided. The existing refrigerated vans are old and have frequent breakdown which

hampers the transportation of vaccines to the regional stores and then to the

districts. The commercial domestic refrigerators are being used in some of the health

facilities which were objected by DRA and WHO during evaluation as the

temperature maintenance are not uniform which may lead to cold chain failure.

Therefore, these refrigerators need to be replaced by WHO prequalified refrigerators.

Key activities:

• Procurement of Walk-in cooler in two regional cold stores

• Procurement of refrigerated vans

• Procurement of WHO prequalified refrigerators

• Procurement of cold boxes and vaccine carrier

• (Try to be more specific and add Nos.)

27

5.5.5 Strengthen M & E

Monitoring and supportive supervision is being done by Central Program and

districts using standard check lists on the routine immunization activities. However,

the frequency of supervisory visits is not adequate due to human resource constraint

at the central and district levels. Effective Vaccine Management Assessment needs

to be conducted every two years. Possibility of impact assessment after training

needs to be explored. The internal and external validation of measles elimination and

rubella/CRS control status needs to be conducted.

Key Activities:

• Conduct quarterly monitoring and supportive supervision from central

to districts

• Conduct quarterly monitoring and supportive supervision from districts

to BHUs

• Conduct Effective Vaccine Management Assessment

• Conduct internal validation of Measles elimination status

5.6 Strengthen governance and collaboration with international

organizations to achieve regional and global elimination targets and

indicators

Political commitment and good governance has proven to be corner stone for

success disease elimination in number of countries who have eliminated or

control public health diseases. Further, strong supports from international

agencies or donors are critical for technical and funding support.

5.6.1 Garnering political support and resource mobilization

The VPDP, DoPH under the Ministry of Health has immensely benefited from the

political will and support for the implementation of its activities. The political support

is required more than ever, as the program moves into the measles elimination and

rubella/CRS control. The international donors are phasing out their support and there

is a challenge in mobilization of adequate resources. There is need to explore the

mobilization of funding support from RGoB/BHTF or facilitate resource mobilization

for this activities. Therefore, this strategy focuses on garnering political support and

instituting governance for Measles elimination.

28

Key activity:

• Sensitization of policy makers on measles elimination and rubella/CRS

control and resource mobilization and requirements

• Conduct periodic update on the status of measles elimination and

rubella/CRS control

5.6.2 Institution of appropriate governing structure

A commission needs to be constituted for oversight, policy directives and other

necessary tasks for measles elimination and rubella/CRS control. The members of

the commission will be sensitized on the importance of measles elimination and

rubella/CRS control and their roles and responsibilities. The existing NCIP will be

designated as a technical advisory committee and support measles elimination and

rubella/CRS control. Both the commission and the NCIP will hold periodic meetings

to review and to guide the program implementation towards measles elimination and

rubella/CRS control targets.

The capacity of the NCIP members will be developed on advance vaccinology,

newer vaccines, AEFI and causality assessment to enable them to carry out their

functions effectively and recommend appropriate corrective interventions.

Key Activities:

• Develop ToR for elimination commission/committee

• Formation of the Commission

• Sensitization of commission members

• Designate NCIP as technical advisory committee for measles

elimination and rubella/CRS control

• Conduct periodic commission and NCIP meetings and as and when

necessary.

• Ex country training for NCIP members on advance vaccinology, AEFI

and causality assessment.

29

5.6.3 Align and collaborate with various stakeholders and international

organization to support elimination target

To successfully achieve measles elimination and rubella/CRS control, and to sustain,

there is a need to garner new partnership involving other organizations, ministries

and agencies. Their involvement will be crucial during measles elimination and

rubella/CRS control phase. Under the guidance of VPDP, MoH, the new partners

need to incorporate measles elimination and rubella/CRS control activities in their

work plans. The possible line agencies are Ministry of Education, Ministry of Home

and Cultural Affairs, DRA, NGOs and Thromdes. These stakeholders will be

sensitized on the importance of measles elimination and rubella/CRS control and the

strategic plans will be shared with them.

The commission will liaise with international development partners to align the

elimination and control activities for certification within the global perspective. The

involvement of development partners like WHO, UNICEF, GAVI, JICA and so on is

essential for further enhancing technical and financial support. The strategy and the

control plan will be shared with these partners. This document will be updated as

when new updates are available at the international level and they will advice the

government on the new elimination strategies and situation as and when emerged at

the international fora.

Key activities:

• Sensitize and share measles elimination and control strategic plan to

relevant stakeholders including international organizations for support

• Conduct coordination and consultative meeting with development

partners

• Review and adapt global and regional measles elimination and

rubella/CRS control initiatives as and when emerged at the

international fora.

Annex I: Monitoring Indicators

30

Objective/Strategy Description of

indicator

Indicator

Definition Base

line

(2014)

Target

(%)

(2016)

1. Achieve and maintain >95% two doses of measles and rubella vaccination coverage.

1.1 Micro-stratification and targeted immunization intervention for low MR vaccine coverage

Immunization

coverage

MCV1 & MCV2

coverage at the

national level

95

The numerator is the number of

infants who received MCV1 &

MCV2 and the denominator is the

surviving birth cohort multiplied by

100

Immunization

coverage

MCV1 & MCV2

coverage at the

District level

90

1.2 Accelerate immunization intervention to reach out children who are not vaccinated

1.3 Sustain routine high MR vaccine coverage

1.4 Operational research on vaccine coverage and management

2. Intensify surveillance and investigation of measles and Rubella/CRS

2.1 Scale up existing MR and

CRS surveillance system

Adequacy of

investigation

Proportion of all

suspected measles

and rubella cases

that have had an

adequate

investigation initiated

within 48 hours of

notification

≥ 90


suspected cases of measles or rubella

for which an adequate investigation

was initiated within 48 hours of

notification and the denominator is the

total number of suspected measles and

rubella cases, multiplied by 100

2.2 Strengthen case based

surveillance system for measles,

rubella and CRS

Timeliness of

reporting

Proportion of

surveillance units

reporting to the

national level on time

100


surveillance units reporting on time and

the denominator is the total number of

surveillance units in the country

multiplied by 100 [Remember each

reporting unit will report 52 times a

year]

2.3 Institute active case

detection, investigation and

immunization response

Disease Incidence

Annual incidence of

confirmed measles

and rubella cases

Absence of

measles

and rubella

indigenous

cases

The numerator is the confirmed

number of measles or rubella cases for

the year and the denominator is the

population in which the cases occurred

multiplied by 1,000,000. When

numerator is zero, the target incidence

would be zero. 2.4 Strengthen AEFI

surveillance

2.5 Improve data management,

reporting system and feedback

31

2.6 Strengthen capacity to

investigate outbreak and

response

Outbreak

investigation

Percentage of

suspected measles

outbreaks fully

investigated

≥ 90


confirmed outbreaks that meet the fully

investigated outbreak criteria and the

denominator is the total number of

suspected outbreaks multiplied by 100

Percentage of

suspected outbreaks

tested for virus

detection

≥ 90


confirmed outbreaks tested for virus

detection and the denominator is the

total number of suspected outbreaks

multiplied by 100

Reporting rate of

discarded non-

measles non-rubella

cases

A national reported

discarded rate of

non-measles, non-

rubella per 100,000

population

≥ 2

The numerator is the number of non-

measles non-rubella discarded cases

and the denominator is the total

population of the country multiplied by

100,000

3. Provide quality assured laboratory diagnosis and case management

3.1 Maintain accreditation of

national measles and rubella

laboratory

Proportion of

suspected cases

with adequate

specimens for

detecting acute

measles or rubella

infection collected

and tested in a

proficient laboratory

≥ 90


suspected cases from whom adequate

specimens for detecting measles or

rubella were collected and tested and

the denominator is the total number of

suspected measles or rubella cases

multiplied by 100 [Epi linked cases

should be removed from the

denominator]

3.,2 Maintain institutional linkage

with regional reference

laboratory

Timeliness of

specimen transport

Proportion of

specimens received

at the laboratory

within 5 days of

collection

≥ 80

The numerator is the total number of

specimens received in the laboratory

within 5 days of collection and the


specimens received by the laboratory

multiplied by 100

3.3 Strengthen local laboratory

network on sample collection

and shipment

Timeliness of

reporting laboratory

results

Proportion of results

reported by the

laboratory within 4

days of receiving the

specimen

100

The numerator is the total number of

specimens for which laboratory results

were available within 4 days of

receiving the specimen and the


specimen received for testing multiplied

by 100

3.4 Ensure prompt case

management

3.5 Genotyping of Measles and

Rubella virus

4. Intensification of communication for measles elimination and Rubella/CRS control

32

4.1 Develop communication plan

and intervention tools

4.2 Engage community

participation in vaccination

advocacy

4.4 Dissemination of

communication materials

through media and appropriate

information technology.

5. Enhance institutional capacity and Monitoring & Evaluation

5.1 Strengthen programme

capacity

5.2 Strengthen vaccine inventory

management

5.3 Strengthen regulatory

mechanism

5.4 Improve cold chain

management and logistic

5.5 Strengthen M & E

6. Strengthen governance and collaboration with international organizations to achieve regional and global elimination targets

6.1 Garnering political support

and resource mobilization

Sensitization of policy

makers on measles

elimination and

rubella/CRS control

6.2 Institution of appropriate

governing structure

Develop ToR for

elimination and

control commission

Formation of the

Commission

Sensitization of

commission member

Designate NCIP as

technical advisory

committee to support

measles elimination

and rubella/CRS

control

Conduct periodic

commission and

NCIP meetings and

as and when

necessary.

Ex country training

for NCIP members on

33

advance vaccinology,

AEFI and causality

assessment and

pharmacovigilance.

6.3 Align and collaborate with

various stakeholders and

international organization to

support elimination target

Sensitize and share

measles elimination

and control strategic

plan to relevant

stakeholders

Sensitize and share

measles elimination

and control strategic

plan to international

organizations for

support.

Review and adapt

global and regional

measles elimination

and rubella/CRS

control initiatives as

and when required.

34

Annex II: Estimated Costing Matrix

Objective/Strategy

Activities

Year Wise Estimated Cost

2015 2016 2017 2018 2019

Strategy objective 1:

Achieve and

maintain >95% two

doses of measles

and rubella

vaccination

coverage

Identification of low MR vaccine coverage areas/chiwog/gewog in district that has coverage <90%.

Development of a micro plan of action in consultation with the DHOs

Forecasting MR vaccines requirement and distribution plan

Conduct MR catch up campaigns for micro-stratified low coverage areas

Sensitize of the Village Health Workers for communication and social mobilization

Periodic assessment of immunization coverage status among day care centres establishment, the population residing in the temporary settlements and , monastic institutions

Provide vaccination to the unvaccinated children and population

Procurement of MR vaccines and cold chain equipments

Develop web based reporting system and training of health workers on web based reporting

Training of health workers on immunization techniques and cold chain equipment preventive maintenance

Periodic monitoring and supervision from central to the districts and district to BHUs

Revise Measles and Rubella/ CRS surveillance guideline and develop appropriate training modules for health workers

Training of health workers on revised MR and CRS surveillance guideline

Training on basic field epidemiology on surveillance and case investigation

Conduct measles coverage survey

Conduct study on MR immunity among general

35

population

Conduct study on effectiveness of Vaccine Vial Monitor (VVM)

Conduct study on Vaccine wastage and utilization and Effective Vaccine Management (EVM)


Intensify

surveillance and

investigation of

measles and

Rubella/CRS

Inclusion of contact tracing in the revised surveillance guideline

Training of health workers on contact tracing based on revised MR and CRS surveillance guideline

Revise AEFI surveillance guideline

Training of health workers on revised AEFI guideline

Develop web based system for reporting and data management

Develop feedback format and mechanisms

Training of programme personnel on data analysis

Prepare annual reports and Printing of annual report

Develop out break preparedness and response plan

Training of RRT on basic field epidemiology and measles and rubella outbreak investigation and response


Provide quality

assured laboratory

diagnosis and case

management

Participate in IEQAS programme for proficiency testing.

Referral of 20% of samples tested to regional measles and rubella reference laboratory for across checking.

Invitation of WHO experts annually for onsite assessment of national measles and rubella laboratory for renewal of accreditation status.

36

Supply of quality measles and rubella test kits through WHO procurement

Supply of controls and reagents from regional reference laboratory

Technical assistance from regional reference laboratory

Referrals of samples to regional reference laboratory

Development of SOP for sample collection and shipment

Training of laboratory persons on sample collection and shipment

Established shipment mechanism from districts to national reference laboratory

Include case management in the revised surveillance guideline

Training of clinicians and health workers on revised MR surveillance guideline

Procurement of laboratory equipments , Procurement of reagents and consumables

Ex-country training of laboratory personnel in PCR and genotyping

Institutional linkages with WHO regional Measles and rubella reference laboratory on genotyping.

Collaborative study with reference laboratory on Measles and Rubella genotyping


Intensification of

communication for

measles elimination

and Rubella/CRS

control

Technical support and consultative meeting for the development of the communication plan for measles elimination and Rubella CRS control

Development of communication materials (broadcast & print) and Pre test of the communication action plan

Printing of communication plan and communication materials

Training of Health workers on implementation of communication action plan including BCC, Risk and outbreak communication

Continue and enhance engagement of VHWs during the vaccination program

37

Sensitize and orient the village health workers, NFE instructors and community leaders on Routine Immunization Schedule

Exposure visit of VHWs/community leaders to other districts with high community participation/performance to learn and share best practices

Training of VHWs on line listing of children eligible for immunization and tracing dropouts

Airing of TV/Radio spots and jingles on media

Review meeting on MR coverage status update with the key policy makers


Enhance

institutional capacity

and Monitoring &

Evaluation

Recruitment of one additional program personnel with expertise in vaccinology/Public health

Train program personnel and relevant officials on vaccinology

Training of program and relevant officials on vaccine pharmacovigilance, surveillance & AEFI, program management, new vaccine evaluation and introduction

Develop web based vaccine inventory management system/VSSM

Training of EPI in charges and EPI/MCH in charges on web based vaccine inventory management system

Training of new EPI technicians on vaccine management

Training on new vaccines registration

Procurement of temperature monitoring devices

Refreshers training of drug inspectors on regulatory activities for vaccines and cold chain requirement

Quality testing of vaccines

Procurement of Walk-in cooler in two regional cold stores

Procurement of refrigerated vans

Procurement of WHO prequalified refrigerators,

38

cold boxes and vaccine carrier

Conduct quarterly monitoring and supportive supervision from central to districts

Conduct quarterly monitoring and supportive supervision from districts to BHUs

Conduct Effective Vaccine Management Assessment

Conduct internal validation of Measles elimination status


Strengthen

governance and

collaboration with

international

organizations to

achieve regional

and global

elimination targets

Sensitization of policy makers on measles elimination and rubella/CRS control and resource mobilization and requirements

Conduct periodic update on the status of measles elimination and rubella/CRS control.

Develop ToR for elimination commission/committee

Formation of the Commission and Sensitization of commission members

Designate NCIP as technical advisory committee for measles elimination and rubella/CRS control

Conduct periodic commission and NCIP meetings and as and when necessary.

Ex country training for NCIP members on advance vaccinology, AEFI and causality assessment.

Sensitize and share measles elimination and control strategic plan to relevant stakeholders including international organizations for support

Conduct coordination and consultative meeting with development partners

Review and adapt global and regional measles elimination and rubella/CRS control initiatives as and when emerged at the international fora.

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