Measles and RubellaGlobal Update

SAGEOctober 2018

l Alya Dabbagh, PhD

l WHO HQ, IVB/EPI

Overview

lGlobal update

lRegional update

lSummary

2

Measles and Rubella Targets

Global: World Health Assembly, 2010Milestones by 2015:1. MCV1 coverage ≥ 90% national & ≥ 80% in

every district2. Measles reported incidence <5 cases/million3. Measles mortality reduction of 95% vs. 2000

Regional elimination (GVAP, 2012):By 2015:– Elimination of measles in 4 WHO Regions – Elimination of rubella in 2 WHO Regions

By 2020:– Elimination of measles & rubella in 5 WHO Regions

3

Global Update

Measles Global Annual Reported Cases and MCV1* and MCV2** Coverage, 1980-2017

*MCV1 coverage: first dose of measles-containing vaccine as estimated by WHO and UNICEF.**MCV2 coverage estimates are only available from 2000 when global data collection started, however some countries introduced MCV2 earlier. Source: WHO/IVB database & WHO/UNICEF coverage estimates 2017 revision, July 2018. 194 Member States. Date of slide: 20 August 2018

85%

67%

173,330

5

0 2,100 4,2001,050 Kilometers

Global Milestone #1: MCV1 coverage ≥ 90% national & ≥ 80% in every district

Immunization coverage with 1st dose of MCV in infants, 2017

<50% (8 countries or 4%)50-79% (27 countries or 14%)80-89% (41 countries or 21%)90-94% (40 countries or 21%)

Not available

Not applicable

>=95% (78 countries or 40%)

Source: WHO/UNICEF coverage estimates 2017 revision, July 2018. Map production: Immunization Vaccines and Biologicals, (IVB). World Health Organization. 194 WHO Member States. Date of slide: 15 July 2018

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2018. All rights reserved

• 118 (61%) countries have >90% coverage with 1st dose of MCV

• 44 (23%) with MCV1 coverage ≥ 90% national and ≥ 80% in every district

6

98 106 110 112 117 122 125 128 130 134 136 138 144 148 154 160 164 167

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Number of countries introduced 2nd dose of measles MCV2 coverage

Number of countries having introduced 2nd dose of measles containing vaccine (MCV2) and global MCV2 coverage,

2000-2017

Source: WHO/UNICEF coverage estimates 2017 revision, July 2018, and WHO database, as at 06 July 2018.Immunization Vaccines and Biologicals, (IVB), World Health Organization.194 WHO Member States. Date of slide: 15 July 2018.

27 countries not yet introduced MCV2

7

Countries with rubella vaccine in the national immunization programme and planned introductions in 2018

Data source: WHO/IVB Database, as of 15 May 2018Map production Immunization Vaccines and Biologicals (IVB),World Health Organization

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2018. All rights reserved.

Introduced* to date (167 countries or 86%)Planned introductions in 2018 (2 countries or 1%)Not Available, Not Introduced/No Plans for 2018

(25 countries or 13%)Not applicable

* Includes partial introduction

Ø Global RCV coverage , 2017= 52%

Ø 25 countries lack RCV

0 2,400 4,8001,200Kil

8

Global Milestone #2: Measles Incidence <5 cases/million

2010: 60% countries <5 cases/million2017: 61% of countries <5 cases/million

9

Global Milestone #395% Reduction in Measles Deaths

20.4 million deaths prevented from 2000-2016 by measles vaccination

No. o

f mea

sles d

eath

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Year

Measles deaths

down 84%!

10

Regional Update

Reported Measles Cases by Region2014-2017

Source: WHO/UNICEF Joint Reporting Form

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Num

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easl

es c

ases

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iona

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e pe

r 1,0

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Measlesoutbreaksintheposteliminationera.TheAmericas,2003-2018*(incidenceratepermillion)

Regional verification of

measles elimination

N= 6,989 (6.9)

Source: SysVPD (ISIS) and country reports sent to PAHO/WHO. *Data as of epidemiological week 40-2018

13

Sources: Ministry of Health of Venezuela. *Data as of epidemiological week 32 –2018. Pan American Health Organization

Reported Measles cases by Epidemiological Weeks, Venezuela 2018

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Measles case distribution (WPR), 2014-2018

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Viet NamSingaporeRepublic of KoreaPhilippinesPapua New GuineaOthers

MongoliaMalaysiaJapanChinaAustralia

Notes: Based on data received 2018-07 - Data Source: IVB Database

15

Measles case distribution (EUR), 2014-2018

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UkraineSerbiaRussian FederationRomaniaOthersKyrgyzstan

ItalyGermanyGeorgiaFranceBosnia and Herzegovina

Notes: Based on data received 2018-07 - Data Source: IVB Database16

Scorecard on Verification of Elimination, Sept. 2018

WHO Region(no. countries)

Regional Verification

Commissions Established

Elimination Achieved

No. of countries % of countries

Americas (n=35) Yes Measles: 34Rubella: 35

97%100%

Europe (n=53) Yes Measles: 37Rubella: 37

70%70%

Western Pacific (n=27) Yes Measles: 6Rubella: 2

22%7%

Eastern Mediterranean (21) Yes - -

South-East Asia (n=11) Yes Measles: 4 36%

Africa (n=47) Yes - -

TOTAL Measles: 81 (42%)Rubella: 74 (38%)

EUR: 6 additional countries interrupted measles transmission for >12 m but <36 m.5 additional countries interrupted rubella transmission for >12 m but <36 m.

17

Key Regional Achievementsl One Region achieved and sustained rubella elimination (AMR). Rubella elimination verified in an

additional 39 member states.

l Three regions with all countries having introduced RCV (AMR/EUR/WPR).

l India and Indonesia introducing rubella vaccine in 2017-2018 (>470 million targeted through SIAs). Six countries in SEA verified as having controlled rubella

l 12 AFR countries near measles elimination* and an additional 14 on track for the 2020 goal.

l 7 EMR countries are close to measles elimination with 4 (Bahrain, Jordan, Oman & Palestine) reporting interruption of transmission for more than 36 months (pending verification)

l High coverage with 2 doses of MCVs (AMR/EUR/WPR).

l RVC established in all 6 Regions. With three regions verifying rubella elimination (AMR/EUR/WPR).

*Algeria, Burkina, Cape Verde, Rwanda, Eritrea, Gambia, Ghana, Mauritius, Senegal, Seychelles, Sao Tome, Zimbabwe

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Key Regional Challenges (1)

l Gaps in population immunity due to:

– Weak and fragile health systems in many countries (AFR/EMR)

– Vaccine demand and hesitancy (EUR; SEAR)

– Civil unrest, famine, active conflict, socio-economic/political crisis (EMR/PAHO)

– Declining maternal antibody levels

l Susceptible distributed across increasingly wide age groups, making eventual elimination

more expensive & more technically difficult (EUR/EMR/SEAR/WPR).

l Outbreaks affecting adolescent and adults, healthcare workers, migrants, indigenous and

religious groups (EUR/PAHO/WPR/SEAR)

l Infants <1 year old affected by measles (EUR/EMR/SEAR/WPR/PAHO)

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Key Regional Challenges (2)

l Maintaining elimination in the face of ongoing importations both within and between regions (PAHO/EUR)

l No target for rubella /CRS elimination (AFR/EMR/SEAR)

l No target date for rubella elimination (WPR)

l Low political commitment to elimination in some member states

l Inadequate resources to fully implement recommended strategies:– Inadequate resources for wide age-range campaigns to address population

immunity gaps– Steadily declining resources through M&R Initiative– MICs left out– Lack of resources for surveillance (AFR/EMR/SEAR)– Polio transition (AFR/EMR/SEAR)

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Summary• Substantial progress in measles control/elimination since 2000

– Global number of cases and estimated deaths significantly reduced– Lowest ever measles incidence in WPR in 2017

• Concerns– Compared to 2016, resurgence of measles in 4 of the 6 Regions– Regional measles elimination can be achieved but sustainability

remains a challange– 2015 global milestones and 3 regional targets were not met

• The recent trends highlight the fragility of gains made in measles elimination– Urgent need to step up efforts towards achieving and sustaining the global and regional

goals.– Without strong and equitable routine systems, elimination, when achieved, is not likely to

be sustained.

21

Thank you!Thanks to:• MR SAGE WG members• MR Regional focal

points• SIG team

EXTRA SLIDES

Strengthening of RI Systems • RI is critical for achieving the elimination goals:

– > 95% coverage with 2 doses of MCV is needed – Central theme for M&R Initiative Strategic Plan (2012-2020) and ongoing activities– 2/3 of measles cases averted through RI (J. Inf Dis. 204, 2011)

• Studies demonstrate that properly planned SIAs can strengthening RI (E.g.,):– Improve micro-planning, training and supervision of HCW – Improvement of CC, waste management system & injection-safety standards– strengthened AEFI surveillance

• MCV2 in the 2YL offers an ideal opportunity by:– fixing an immunization/health check contact during 2YL (e.g. growth monitoring, booster

doses, Vit A)– catch-up vaccination for all missed vaccines

• Measles vaccination school entry checks can improve coverage of other VPDs.

• Measles Outbreaks as an indicators of weak RI:– Measles is highly infectious and seeks out susceptibles; disease is highly visible,– Outbreaks identifies gaps in RI programs and population groups missed by RI.

Challenge: Polio Transition

• 88% of estimated measles

deaths occur in these countries

• Most of the world’s rubella and

CRS cases (100,000)

• Polio field staff spend nearly

1/3 of their time working on RI

& MR.

• Critical for SIA quality and

surveillance

• Estimated $77 million (70%) of

annual needs for VPD/MR

surveillance are coming from

polio $$

• Over 2500 polio-funded staff

are supporting VPD/MR

surveillance

16 countries with largest polio assets

RISKS:• Polio virus transmission if re-introduced• Resurgence of measles and rubella

2017CAN=45USA=120ARG=3VEN=727Total=895

Distributionofconfirmedmeaslescasesbycountries.TheAmericas2017and2018*.

2017

2018*

2018Argentina= 11Antigua and Barbuda=1Brazil= 2,044Canada=25

Colombia=105; Ecuador=19; Guatemala=1Mexico= 5Peru= 36 USA=137Venezuela=4,605 (58 deaths) Total= 6,989

Sources: Surveillance country reports sent to the Immunization Unit of PAHO/WHO and Epidemiological Update of Measles*Data as of epidemiological week 40–2018. Report as 6 October 2018. Venezuela last updated until EW-32 2018.

active measles casesnon-active measles cases

l 1 confirmed case

Reported Measles Cases by Classification and Epidemiological Week.Venezuela EW-26, 2017 – EW-40, 2018

Source: Immunization Direction, Ministry of Popular Power for Health

n= 7068

Confirmed (5, 598)

• Clínic (3, 218)

• Laboratory (1,946)

• Epi Link (534)

2017 2018

n= 1451

Confirmed (727)

• Laboratory (507)

• Epi Link (220)

3 3 4 4 5 5 5 5 6 7 8 8 9 101012121315

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Global AFR AMR EMR EUR SEAR WPR

Rubella containing vaccine 1st Dose (RCV1) coverage* by WHO region, 1980-2017global coverage at 52% in 2017

Source: WHO/UNICEF coverage estimates 2017 revision, July 2018.Immunization Vaccines and Biologicals, (IVB), World Health Organization.194 WHO Member States. Date of slide: 15 July 2018.

*coverage estimates for the 1st dose of rubella containing vaccine are based on WHO and UNICEF estimates of coverage of measles containing vaccine.

0 2,100 4,2001,050 Kilometers

Immunization coverage with 2nd dose of measles containing vaccines by administered schedule, 2017

<50% (12 countries or 6%)50-79% (36 countries or 19%)80-89% (34 countries or 18%)90-94% (32 countries or 17%)

Not available/ Not introduced (27 countries or 14%)Not applicable

>=95% (50 countries or 26%)2nd dose of measles containing vaccines in schedule but no coverage data available (3 countries or 2%)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2018. All rights reserved

Source: WHO/UNICEF coverage estimates 2017 revision, July 2018. Map production: Immunization Vaccines and Biologicals, (IVB). World Health Organization. 194 WHO Member States. Date of slide: 15 July 2018