Measles, Rubella and CRS EliminationRegion of the Americas

Engaging Government and Civil Society to Achieve the Elimination

12th Annual Meeting of the Measles and Rubella InitiativeWashington, 10-11 September 2013

Dr. Carlos Castillo SolórzanoMs. Katri Kontio

Dr. Carolina Danovaro

Presentation Outline Outline

• Progress to achieve regional measles, rubella and congenital rubella syndrome (CRS) elimination goals

• Engaging government and civil societyto achieve and maintain the elimination

• Challenges for maintaining the Regional elimination

• Next steps

1994

19951997 Sucre

Agreement in Bolivia

1999

2001

2002

2003 1th IEC* meeting

2007

2009

2012

2013

1994: Resolution to eliminate measles by 2000

2007: Resolution on documentation and verification process

2013: 4th IEC* meeting

Milestones: Measles, Rubella and CRS Elimination in the Region of the Americas

First Ladiesas Ambassadors for

the measles elimination

First mass campaigns

against rubella

2003: Resolution to eliminate rubella by 2010

2009: LAST ENDEMIC

RUBELLA AND CRS CASES

2002: LAST ENDEMIC

MEASLES CASE

2012: Resolution to maintain the elimination

Largest measles outbreaks: Canada and

Ecuador 2011-2012

* IEC=International Expert Committee for the documentation and verification process

0

50,000

100,000

150,000

200,000

250,000

300,000

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13

0

20

40

60

80

100

Measles cases Rubella cases Coverage Measles Coverage MMR

MeaslesCatch-up campaigns

* MMR in children 1 year of age by vaccine introduction

Measles Follow-up campaigns

% V

accin

ation

co

verag

eC

on

firm

ed c

ase

s

Rubella speed-upcampaigns

Source: country reports to FCH-IM/PAHO

Last case of endemic measles

Last case of endemic rubella

* Data as of September 4, 2013

Measles Vaccination Coverage among Children <1 Year of Age* and Reported Measles and Rubella Cases, the Americas, 1980-2013*

Catch-up(<15yr)

Follow-up(1-4 yr)

Speed-up(adol/adult)

140 million 80 million 260 million

Source: Country reports to PAHO/WHO*Data as of September 9, 2013

Final reports and amendmentsFinal reports

Draft report/On-going activities

• All National Commissions have submitted the reports.

• Final and amendment reports due to December 2013.

Where are We Now with the Regional Verification Process?

IEC field visits2013PER (Feb)*ECU (Jul)*NIC (Aug)CARIBBEAN (Nov)BRA (Nov)

2014GUTVENPARURU

Fourth Annual International Expert Committee (IEC) Meeting, May 2013

Main recommendations for Member States:•Provide a plan for sustainability of program and strengthening of regular immunization program.•Implement the 2012 Resolution (CSP 28.R14):

To provide evidence (critical analysis of data) that supports that endemic measles and rubella virus transmission has been interrupted, and

To maintain elimination.

July 2013 – PAHO’s Technical Advisory Group (TAG) endorsed the IEC recommendations

7

Engaging Government and Civil Society to Achieve

Elimination in the Americas

Source: Ministries of Health, Departments of Statistics and Epidemiology.

Technical Feasibility for Measles and Rubella Elimination

USA:•Measles

(1997)•Rubella (2001)

Cuba:•Measles (1993)•Rubella (2004)

English Speaking Caribbean:•Measles (1991)•Rubella (2001)

Costa Rica:•Measles (1999)•Rubella (2001)

Served as strong evidence for the operational feasibility ofmeasles elimination and

rubella/CRS control among the Member States of the Region

Lessons from Implementation of Rubella Campaigns Served as a Model for Other Countries to Eliminate Rubella and CRS

Caribbean countries carried out vaccination campaign against MR during 1998-2001

•Persons aged 20--39 years

Nationwide Campaign for Vaccination of Women Against Rubella, Chile, 1999•Non-pregnant women 10-29 years

Nationwide Campaign for Vaccination of Adults Against Rubella and Measles

Costa Rica, 2001•Persons aged 15--39 years

119

104 10195

116

0

20

40

60

80

100

120

15 a 19 20 a 24 25 a 29 30 a 34 35 a 39

Edad

% c

ob

ertu

ra

Post partum MR coverage (March 2002)= 98%

Strong Political Decision

− Pan American Sanitary Conference, 1994To set a goal to eliminate measles from the Region by 2000

−Pan American Sanitary Conference, 2003To eliminate rubella and congenital rubella syndrome from their countries by 2010

1990s: Early Advocates for the Regional Measles Elimination Goal

The support of the First Ladies was critical to

provide greater dissemination of the measles eradication

initiative at the national and international level

Establishments of National and International Expert Committees

President of Costa Rica,

Oscar Árias Sánchez,

signed an executive

decree creating a

national expert

commission to verify the

elimination of measles,

rubella and CRS in the

country, 2008

13

National and Sub-national Initiativesfor Supporting Achievements of the

Regional Elimination Goals: Social Mobilization

High Level Advocacy with Government and Civil Society

With key decision makers and opinion leaders

Multisectorial and participatory

• Based on the leadership and spokesman with technical expertise

• Flexible/adaptive to the reality of each country

• Take advantage of windows of opportunity

• Pro-Active• Planned with measurable objectives (SMART)• Multi level (National, sub- national and local)• Use of collaborative networks and • Key persons to diffuse information• Actively seeking for collaborative partners

High Level Advocacy with Government and Civil Society

State Dignitaries as Vaccination Leaders

• Political priority

• Financial resources (budgetary and extra-budgetary)

• Active participation in public events

National and Sub-National Level Financial Contributions

Example, Paraguay, 2007

Source: country reports to FCH-IM/PAHO

Joint and Collaborative Action: Strategic alliances and Partners in the Field

Participate in implementation of vaccination program and plans: the micro-macro-programming,

financing and operations

Scientific Societies and Medical Associations

Independent observers that contributes in creating confidence and trust in vaccines among the public

Church: Partners of Cooperation and

Enablers

National Communication Plans During the Elimination Phase

• Political support

• Investments• Early

planning and production of material

Example of Communications and Social Mobilization: Brazilian National Vaccination

Campaign to Eliminate Rubella and CRS

22

• Situation analysis showed that 94% of those surveyed would receive vaccine to help eliminate rubella. As a result, the communication strategy focused on disease elimination.

• The slogan was (Vaccination has become a family program)

• Television and radio spots reminded audiences that Brazil had eliminated polio and now the country was eliminating rubella.

23

Regional and Sub-regional Initiatives to Achive the Elimination Goals:

Pan Americanism and Solidarity

The Sucre Agreement (2002): Strategy to Prevent the Regionalization of the

Measles Outbreak Decision to coordinate a simultaneous vaccination week initiativesin the Andean sub-region.

Project of Technical Cooperation among Countries (TCC): Vaccination against Measles and Rubella in Border Areas

of Argentina and Brazil

Participating Countries: (~ 20,000 vaccinated)

This TCC is powerful communication mechanism between the two subregional

integration systems of South America: the Andean Community of Nations (CAN)

and the Southern Common Market (MERCOSUR).

Argentina BoliviaBrazilChile ColombiaFrench Guiana

GuyanaParaguay Peru SurinameUruguayVenezuela

26

Challenges for Maintaining the Region Free of Endemic

Measles and Rubella:

Post-elimination Era

Interruption of Measles & Rubella/CRS Endemic Transmission in the Americas

CONTROL ACCELERATED CONTROL

ELIMINATIONDOCUMENTATIONANDVERIFICATION

27th Pan American Sanitary

Conference, DC, 2007:

To document endemic measles,

rubella and congenital rubella elimination in the

Region

MEASLES:Venezuela / NOV 16,

2002

CRS:Brazil/ AUG 26, 2009

RUBELLAArgentina/ FEB, 2009

Continued Dedication to Measles & Rubella Elimination from the Western Hemisphere

28th Pan American Sanitary Conference, DC, 2012:To maintain the regional elimination in the Americas

•Continuing measles and rubella virus transmission anywhere in the world will continue to pose a risk to the Region of the Americas and cause possible virus importations and outbreak

•Challenges in immunization programs, such as weak surveillance and heterogeneous coverage, that put at risk the elimination of measles and rubella

Towards Regional Certification: The Last Inch?

A Continuing Struggle for the Americas for Maintaining Elimination Achievement: Main Challenges (1)

• Risk of introduction of endemic transmission due to virus importations

• Heterogeneous vaccination coverage − Outbreak occur among unvaccinated population groups

• High cost of containing outbreaks in the post-elimination ere− Small outbreaks with high cost per case; large-scale or/and sustained

outbreaks (e.g. Canada in 2011 (n=803 cases, cost estimate $9,5 million)

• Weak surveillance system to detect sporadic imported cases of measles and rubella in some countries

A Continuing Struggle for the Americas for Maintaining Elimination Achievement: Main Challenges (2)

•High volume of international tourism and international events and mass gatheringsNeed to keep in mind large international events to be held in the Region such as the World Cup and the 2016 Olympics

•Resource mobilization for the elimination of SR in the context of low incidence

•Maintaining immunization within the political and social agenda at the country and Regional level

•Provision of technical support for countries in implementation of the plan of action for maintaining the elimination of measles, rubella and CRS in the Americas

•Publish technical guidelines & operational research

•Documentation and Verification Process

Program Plans (2014)

Thank you!Thank you!¡gracias!¡gracias!