Nadia Teleb MD, MPH, Dr.PHRegional Adviser, Vaccine Preventable Diseases and Immunization

WHO/EMRO

Measles control and elimination in the Eastern Mediterranean Region

Palestine

Bahrain

The Eastern Mediterranean Region

GAVI eligible: 7 countries, 56% LMIC: 7 countries, 38.5%

HIC: 6 countries, 3% of LBUMIC: 3 countries, 2.5%

Pop: 555 MillionLB: 16.4 Million

Outline

• Regional targets • Regional strategy• Progress in implementation of the regional

strategy• Progress towards achieving the target• Plans 2011-2012• Challenges and opportunities

Measles related targets in the EMR

Measles elimination from all countries by 2010 (resolution EM/RC44/R.6, 1997)

Target date revised to 2015 (EPI managers’ meeting ,

July 2010)

Measles Mortality reduction target:EMR adopts the global target

Regional Strategy to achieve measles control/elimination in the EMR

1. Achieving high population immunity: 1) Nationwide measles catch-up vaccination campaign, achieving

homogenous high coverage2) sustaining population immunity through high vaccination coverage (≥95%

coverage in all districts) with 2 doses of MCV; preferably during the second year of life: a. Routine MCV1; ANDb. Second dose: routine second dose and/or Periodic follow-up SIAs which

should continue until achieving the high routine coverage for MCV1 and MCV2

2. Strong case-based lab surveillance3. Case management

Progress in implementation of the regional strategy

1. Measles vaccination

Country MCV1 MCV2Type Age Type Age

Afghanistan M 9 m M 15-18 mBahrain MMR 12 m MMR 5yDjibouti M 9 m

Egypt MMR 12 m MMR 18 mIran MMR 12 m MMR 18 mIraq M 9 m MMR 15m, 4-6y

Jordan MMR 12 m MMR 15-18 mKuwait MMR 12 m MMR 2y, 12y

Lebanon MMR 12 m MMR 4-6 yLibya MMR 12 m MMR 15-18 m

Morocco M 9 mOman MMR 12 m MMR 15-18 m

Pakistan M 9m M 15-18 mPalestine M 9 m MMR 12m, 18 m

Rubella 12Y

Qatar MMR 12 m MMR 4-6 ySaudi Arabia M 9 m MMR 12m, 4-6 y

Somalia M 9 mSudan M 9 m

S. Sudan M 9MSyria MMR 12 m MMR 15-18 m

Tunisia MR

15 m12y

M 6 y

UAE MMR 12 m MMR 4-6 yYemen M 9 m M 15-18 mEMR MCV1 @ 9m: 7 countries/ MCV2 18 countries, / R in 15 countries/ MMR2: 14 Countries

MCV1/MCV2 Schedule/type of vaccine, EMR, 2011

Source: JRF 2010

Reported district coverage of MCV1, 2010Target 95% in all districts

Source: JRF 2010

Cove

rage

% Improving routine immunization:• RED approach in AFG, IRQ, PAK, SOM,

SUD, YEM• CHDs in Somalia• Acceleration campaigns in SUD, AFG• Vaccination week of the EMR

Palestine

Bahrain

Follow up campaigns Response campaigns High routine coverage

Measles vaccination strategies in the EMR

2. Supplementary immunization activities (SIAs)

Catch-up campaigns implemented in all countries

Around 400 million people vaccinated 1994-2010 through SIAs

Measles SIAs in EMR 2010-2011

Country Activity Age Group Target Reached Coverage

Pakistan Flood response 9mo-13yrs 15,209,539 13,740,906 96%Somalia CHD 1st round 9-59mo 1,238,186 1,137,268 92%Sudan Follow up 9-59mo 2,187,679 2,076,757 97%Yemen Mop up 9mo-15yrs 603,043 455,517 76%Iraq Follow up 9-59mo 2794889 2,603,752 93%Iran Mop up 9mo-12yrs 118190 117,009 99%Kuwait Follow up 1-7 years 363329 272,829 75%EMR 22,514,855 20,404,038 91%

Afghanistan Follow up 9-59mo 137,408 84,591 62%

Pakistan Follow up 9-59mo 9,445,428 10,286,294 109%

Somalia CHDs/Mop up 6mo-15yrs 724,706 648,198 89%

Sudan Follow up 9-59mo 3,961,703 3,910,620 99%

Yemen Mop up 6mo-15yrs 177,702 146,001 82%EMR 14,446,947 15,075,704 104%

Measles SIAs conducted 2011

Measles SIAs conducted 2010

Progress in implementation of the regional strategy

2. Measles surveillance

Palestine

Bahrain

Nation-wide Measles Case-based surveillance (19)

Moving to Nation-wide measles surveillance (1)

Measles Case-Based Surveillance in EMR, 2011

Sentinel sites measles surveillance (3)

Serology and virus detection/isolation capacity (11)

Measles Laboratory Network in the EMR, 2011

Palestine

Bahrain

Serology capacity only (6)

Regional Reference LaboratoriesSerology and virus detection/isolation and sequencing capacity (6)

Measles Virus Genotyped In the EMR Countries, 2007 to 2011

0

5

10

15

20

25

30

35

40

Afg Bah Djb Egy Ira Irq Jor Kuw Lib Mor Omn Pak Qat SAA Som Sud Syr Tun Yem

Countries

Num

ber o

f Sam

ples

Gen

otyp

ed

H1D8D5D4B3

No genotype data from 4 countries: PAL, LEB, S.SUD, UAE

Measles surveillance performance indicators in the EMR

2010 2009 2008 2007 2006 2005 Indicator

86% 72% 77% 80% 57% 75% %of countries ≥80% of suspected cases tested

100% 95% 91% 100% 68% 100% %of countries ≥80% cases with complete investigated

68% 73% 68% 70% 36% 50% %of countries with ≥80% specimen received at lab 7day of collection

91% 96% 96% 100% 89% 100% %of countries with ≥80% adequate specimens

86% 95% 81% 90% 58% 75% %of countries with ≥80% results reported within 7 days

42% 52% 52% 42% 22% Zero% %of countries that achieved the reporting rate ≥2 /100,000 population at national level

27% 9% 9% 9% 4% Zero% %of countries that achieved the reporting rate ≥1 /100,000 population at all sub-national level

Palestine

Bahrain

Measles vaccination strategies in the EMR2. Supplementary immunization activities (SIAs)

Rubella & CRS Surveillance system situation in EMR

Rubella testing and CRS system (9 countries) Rubella testing only (12countries) None (2countries)

Geographic distribution of rubella cases in the EMR countries by district and final diagnosis between July 2010 and June 2011

The source of data in this slide is country measles surveillance DEFs received on monthly basis from countries

Progress towards achieving the target

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Measles mortality reduction in the EMR 2000-2008

93%

90%

Estim

ated

mea

sles d

eath

s

Bah

rain

Djib

outi

Jord

an

Pal

estin

e

Tuni

sia

Egy

pt

Syr

ia

Om

an

Leba

non

Pak

ista

n

Iran

Iraq

Liby

a

Kuw

ait

Sud

an

Yem

en

Sau

di A

rabi

a

Mor

occo

UA

E

Qat

ar

Som

alia

Afg

hani

stan

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

0.00 0.00 0.00 0.00 0.00 0.18 0.45 0.954.935.75

7.62 8.759.6410.44

15.1715.52

15.8416.12

16.16

59.7966.59

76.87

Measles minimum incidence rate per million population in the EMR 2010

Cas

es/m

illio

n Progress in Measles elimination in the EMR

88% reduction in reported cases between 1998 to 20108 countries close to elimination in 2010

Source: Country reports Inadequate surveillance

Geographic distribution of measles cases in the EMR countries by district and final diagnosis between July 2010 and June 2011

Source : Official countries’reports

Progress In Eastern Mediterranean Region • Achieving the target:

– Measles mortality reduction target achieved 3 years ahead• Sustainability is threatened

– Measles Elimination target goal by 2010 was not reached• 8 countries are close to elimination• Target date postponed to 2015

• Measles case-based surveillance in 20 countries, expanding in 3 countries

• Regional guidelines for elimination validation developed, field tested and officialised

• Regional Validation Commission was formulated • National validation committee established in 5 countries, others are in

the process

Future plans• Supporting improving population immunity

– Continue strengthening routine immunization: RED approach, CHDs

– Introduction of MCV2 in Sudan Nov. 2011– Timely follow up SIAs

• Strengthening Measles surveillance:– Case based surveillance in Somalia and S. Sudan– Improving surveillance indicators to reach

requirements of validation indicators – Preparing for validation of elimination in the

ready countries

Country Activity Age Group Target Remaining gap

AfghanistanFollow up 9-59mo 441,932 $89,906Pakistan Follow up 9-59mo 214,098 $214,098Somalia CHD/Mop up 6mo-15yrs 900,329 $859,951S. Sudan Follow up 6-59mo 658,486 $290,000Yemen Mop up 6-59mo 271,000 $250,000Total EMR 2,485,845 $1,703,955

Country Target age group

Target number of children

Funds needed

AfghanistanFollow up 6-59 months 5,001,074 6,824,918N Sudan Follow up 9-59 months 2,500,000 2,715,000S. Sudan Follow up 6-59 months 972,292 2,228,016Somalia CHD/Mop up 9 - 59 mo 3,037,180 10,594,181Pakistan Follow up 9-59 months 8,817,181 5,490,458Yemen Follow up 9-59 months 3,900,484 4,355,765Total EMR 24,228,211 $32,208,338

SIAs planned for 2011 and required funds

SIAs planned for 2012 and required funds

Planned SIAs for 2011 and funding requirement

Challenges

• Funding: specially for the follow-up campaigns – FU campaigns needed in 7 countries– Target:> 95 million for 2011-2015

• National managerial Capacity:– Inadequate number and qualification of staff – Devolution in Pakistan

• Competing priorities:– Polio eradication– Other EPI issues: NVI,..

• Pockets of susceptible populations/groups – Hard to reach populations in low income

countries– Pockets in countries with big expatriate

population• Security situation: rapidly deteriorating in the

EMR– Delayed implementation of planned activities

– Financial support from international partners

– Interest of the countries

– Renewing commitment: EPI technical paper submitted to RC October 2011

– Polio infrastructures

Opportunities

Summary

Remarkable progress in measles mortality reduction,

Measles elimination was not achieved in time, More efforts are needed with the current

political turmoil and security situation in some countries

Bridging funding gaps to support LIC countries is challenging

Acknowledgements

• Partners of the Measles initiative• CDC Atlanta• EMR RRLs in Tunisia and Oman• VIDRL Australia• EMR EPI staff, lab network• WHO/HQ