Interrupting Measles Transmission in China – Progress and Challenges

8th Annual Meeting of the Partners for Measles Advocacy

Washington, D.C.

Sep 2008

Outline

Status of measles elimination Epidemiology Strategies

International support Challenges Plan of action

Status of Measles Elimination -- Epidemiology

Measles Incidence, China 1950-2007

0

2

4

6

8

10

12

14

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

年份

/10

报告

发病

率（

万）

YearSource: National Notifiable Disease Reporting System (NNDRS)

Before vaccineBefore vaccineLiquid vaccine used （ 1965 ）

Liquid vaccine used （ 1965 ）

EPI Conduct（ 1978 ）EPI Conduct（ 1978 ） Lyophilized V

accine 2 doses （ 1986 ）

Lyophilized Vaccine 2 doses （ 1986 ）

Accelerate measles control（ 1998 ）

Accelerate measles control（ 1998 ）

Measles Elimination Plan （ 2006 ）Measles Elimination Plan （ 2006 ）

0

200

400

600

800

1000

1200

1400

1600

1800

50

52

54

56

58

60

62

64

66

68

70

72

74

76

78

80

82

84

86

88

90

92

94

96

98

00

02

04

Inci

den

ce

(p

er

100

,000

)

Inci

de

nce

(p

er

10

0,0

00

)

Pre-vaccine era

Liquid vaccine introduced (1965)

Accelerated measles control (1998)

Source： NNDRS

2007

2004

2006

2005

（（ Incidence per 100,000Incidence per 100,000 ））

Geographic Distribution of Measles Incidence, China 2004-2007

Measles Incidence by Province, 2007

Source： NNDRS

0

5

10

15

20

25Gu

angd

ong

Sich

uan

Chon

gqin

gYu

nnan

Beij

ing

Tian

jin

Xinj

iang

Shan

xiZh

ejia

ngHe

nan

Neim

engg

uHu

nan

Jian

gsu

Heib

eiHu

bei

Shan

ghai

Fuji

anSh

anxi

Jian

gxi

Anhu

iGa

nsu

Shan

dong

Guiz

hou

Guan

gxi

Qian

ghai

Jili

nNi

ngxi

aLi

aoni

ngHe

ilon

gjia

ngXi

zang

Hain

an

Nati

onal

Inci

den

ce /1

00 0

00

0

10

20

30

40

50

60

70

80

0~ 5~ 10~ 15~ 20~ 25~ 30~ 35~ 40~ 45~ 50~ 55~ 60~ 65~ 70~

年龄组

(/10

)发

病率

万

2004200520062007

0

2040

6080

100120

140160

180

0~ 1~ 2~ 3~ 4~ 5~ 6~ 7~ 8~ 9~年龄组

(/10

)发

病率

万

2004

2005

2006

2007

Age-Specific Measles Incidence, China, 2004-2007

Source： NNDRS

Age group

Inci

denc

e /1

00

000

Inci

denc

e /1

00

000

0%

20%

40%

60%

80%

100%

15yrs- 61.2 48.5 26.1 15.9 23.7 16.0 17.8 26.0

1-14yrs 17.6 24.8 44.8 52.4 56.7 67.7 58.0 49.0

0- 21.2 26.7 29.1 31.7 19.7 16.3 24.2 25.0

Beijing Tianjin Guangdong Chongqing Yunnan Sichuan Xinjiang National

Age Distribution of Measles Cases -- Provinces with Highest Incidence (13-21/100,000) China, 2007

Status of Measles Elimination -- Strategies

Elimination Strategies and Implementation (1)

Strategies

1) Strengthen routine coverage 2 doses of measles-

containing vaccine (MCV)

MR at 8 months; MMR at 18-24 months

Goal: > 95% coverage

Implementation Immunization free of

charge

Immunization registry system

Coverage estimates: MCV1 = 94% MCV2 = 92%

Elimination Strategies and Implementation (2)

Strategies

2) SIAs 8m-14y in provinces

Incidence > 5/100,000 Incidence < 5/100,000, 7

0% cases aged < 14y 7y-14y in provinces

MCV1, MCV2 > 95% in 2y-7y

Follow up To be determined

Implementation

Completed: Catch up: 8 provinces Emergency wide age-range:

3 provinces

Planned 2008: Catch up: 10 provinces Follow up: 3 provinces

2007 Sichuan Sha’anxi Hebei

2006 Xizhang Qinghai

2005 Ningxia

2004 Xingjiang Guizhou

Completed Catch Up SIAs – China 2004-2007

Elimination Strategies and Implementation (3)

Strategy

3) Enforce school-entry immunization requirement Goal: > 95% 2-

dose MCV coverage

4) Outreach activities for special populations (migrants, high-risk adults)

Implementation Ongoing in all provinces

In process

Elimination Strategies and Implementation (4)

Strategy5) Strengthen surveillance

All outbreaks lab-confirmed

When incidence < 1/100,000,all cases investigated and > 80% laboratory-tested

National, provincial, prefecture labs reach WHO accreditation standard

6) Rapid outbreak response

Implementation Parallel surveillance systems

merged Reporting from township

level and above

60-100,000 suspected cases reported annually

50-60% suspected cases laboratory-tested

Ongoing in all provinces

International Support

• USD 902 million estimated for achieving measles elimination by 2012• Sustain current routine (USD 567 M--62%)• Strengthen routine (USD 207 M--22%)• SIAs (USD 128 M--14%)

• USD 20.8 million requested formally by China to international community (2006)• Initially for SIAs operational support to 8 priority

provinces

International Support Requested for Measles Elimination by China

• Guizhou measles control project 2003-2006• USD 3.5 million from USCDC to support SIAs,

surveillance, school entry and routine• USD 0.37 million from JICA to support

supplemental cold chain

• Guizhou and Sichuan measles elimination project 2007-2010 • USD 2.0 million from US CDC to support surveillance,

enforcement of school entry requirement and routine• USD 2.0 M from Measles Initiative for operational sup

port to SIAs.

International Support Obtained/Committed for Measles Elimination China (1)

Measles Olympics training workshop, Atlanta 2007

Measles Initiative Support to China’s Earthquake Affected Zone Reducing the incidence of measles in Chongqing

from 5/100,000 (2007) to < 0.5/100,000.

International Support Obtained/Committed for Measles Elimination China (2)

Challenges

• Persistent high incidence

• Infants

• Adults

• Achieving high-coverage SIAs

• Limited vaccine supply

• Inadequate funding for operational costs

• Maintaining gains of catch up SIAs

• Expense of follow up SIAs

• Strengthening routine to reduce need for follow up SIAs

• Measuring MCV1 and MCV2 coverage accurately

• Reaching floating population

Challenges

Measles Cases by Month -- Xinjiang 2004-May, 2008

0

1000

2000

3000

4000

5000

6000

1 2 3 4 5 6 7 8 91011121 2 3 4 5 6 7 8 91011121 2 3 4 5 6 7 8 91011121 2 3 4 5 6 7 8 91011121 2 3 4 5

2004 2005 2006 2007 2008

Month

Case

num

ber

SIAs

Age-Specific Measles Incidence -- Xinjiang, 2007-May,2008

0

200

400

600

800

1000

1200

1400

1600

1800

0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 15- 20- 25- 30- 35- 40- 45- 50-

Age

Inci

denc

e /1

00 0

00

2007 2008, May

Covered by SIAs 2004

Interpretation

Xinjiang data encapsulate national challenges Pre-school--aged children (Major issue)

Failure to reach children through routine Late implementation of follow up SIAs

School-aged children Some missed in 2004 catch up Incomplete implementation of school entry

requirement

Cases among adults

Plan of Action

• Strengthening routine immunization• Expansion of EPI to 14 vaccines

• Cold chain renewal

• Training

• Immunization registry

• Measles SIAs• Assuring funding

• Seeking international support for operational costs

• Increasing vaccine production capacity

Plan of Action (1)

SIAs Planned in 13 Provinces-- supported by central funds in calendar year of 2008

Catch up (10 provinces) Target: 8m-14y

Follow up (3 provinces) Target: 8m-6y

National fund covers vaccine and syringe, part of vaccinator’s subsidy

Shortage of funds for operational costs in western provinces

* Note: Number of SIAs conducted may be limited due to vaccine shortage

• Strengthening measles surveillance

• Single, merged measles surveillance system

• Enhancing outbreak investigation capacity

• Pilot projects for enhanced surveillance among adults

and infants

• Strengthening school entry requirement

• Ensuring >95% coverage for two doses MCV

• Considering development of standardized

approaches to implementation

Plan of Action (2)

Conclusions

Achieving nationwide measles elimination by 2012 remains challenging

Low-incidence measles persists after apparently high-quality SIAs

Rigorous implementation of all strategies is required

Strong international partnerships and resources are needed to achieve elimination

We acknowledge the support from Measles Initiative and US CDC for measles elimination activities in China, and welcome a new infusion of funds for upcoming SIAs from international partners

Thank you!

Back up Slides

H1a

Anhui07-1 Anhui07-3

Shandong07-43 Guangdong06-5

Neimeng07-5 Hunan07-9

Guangdong06-21 Guangdong06-29

Henan07-14 Shandong07-21 Hunan07-2

Hunan06-5 Jiangxi07-1

Guangdong06-2 Jiangsu06-6

Tianjin06-8 Shandong06-19 Neimeng07-6

Hunan06-1 Sichuan07-6

Hebei06-30 Shandong06-10

Sichuan07-4 Hebei06-28 Hunan06-3 Neimeng07-3

Shanxi06-3 Shanxi06-4

Shanxi06-5 Jilin06-2

Hunan06-2 Shanxi06-25

Tianjin06-14 Tianjin06-16

Jiangsu07-4 Henan07-3

Hebei06-29 Henan07-48

Shanxi06-27 Henan07-18

Henan07-37 Jiangsu06-7

Neimeng07-4 Guangdong06-30

Shandong06-20 Hunan07-6

Jiangsu07-14 Jiangsu07-12

Shandong07-41 Shandong07-32

Shandong07-39 Jilin06-1

China9463 Chin9427

Chin9435 Chin9372/H1 Chin9312 Chin9334

Chin9442 Chin9458

Chin9475 Chin94-1/H2

Edmonston-wt/54/A Chin9353

Shanghai-191/China-vaccine Shandong07-3

0.01

H1c

H1b

Gene type of Measles virus strain is H1a