Programmatic Feasibility of Measles Elimination in South East Asia Region

Programmatic Feasibility of Elimination in South East Asia Region A. Introduction: In 2005, World Health Assembly resolution WHA58.15 endorsed the Global Immunization Vision and Strategies (GIVS) that included a global goal for measles mortality reduction: by 2010 or earlier, mortality due to measles will be reduced by 90% compared to the 2000 level. In 2007, the South-East Asia Region (SEAR) Technical Consultative Group for Polio Eradication and Control of Vaccine Preventable Diseases (TCG) endorsed the revised Regional Strategic Plan for Mortality Reduction for 2007-2010, which included this goal. The regional consultation on measles, held in SEARO in August 2009, agreed that measles elimination was technically, biologically and programmatically feasible. The report of the regional measles consultation is attached as Annex 1. Setting a regional goal to eliminate measles by 2020 was proposed by the consultation to the sixty-second session of the Regional Committee in Kathmandu in September 2009. The Regional Committee decided that setting a regional measles elimination goal would be considered at its sixty-third session in 2010. The Regional Committee adopted a resolution South-East Asia regional efforts on measles elimination requesting several actions including a report to the Sixty-third session of the Regional Committee on the status of global measles elimination goals and outcome of activities in the South-East Asia Region. The resolution of the regional committee is attached as annex 2. The findings, conclusions and recommendations of the regional measles consultation and contents of the regional committee resolution have been incorporated to the relevant sections of this report. B. Strategies: The key strategies to achieve the regional mortality reduction goal are: a. Improving and sustaining routine immunization coverage; b. Providing a second dose of measles vaccine through catch-up immunization campaigns and routine second dose/follow up immunization campaigns; c. Improving measles surveillance, including tracking and investigation of suspected measles outbreaks; and d. Improving case management including administration of vitamin A To support the efforts of member countries in measles mortality reduction, the South-East Asia partnership (SEAM) was brought together at the beginning of 2004. The partners of the global measles initiative 1 were the key partners of the SEAM. The partnership successfully mobilized resources for many supplementary immunization activities and surveillance activities. The key contributions from partners of the measles initiative and other donors are summarized in Table 1. 1 American Red Cross, United Nations Foundation, U.S. Centers for Disease Control and Prevention, UNICEF and World Health Organization 1

Table1: Technical and financial support from partners to measles mortality reduction in SEAR. Partner/ Donor Type of Support offered (Technical/ Financial) Details of support Financial Resources committed USD* in Period support ARC Financial Financial support for Tsunami 78.4 million 2005-2009 and affected countries (Bangladesh, technical India, Indonesia, Maldives, and Myanmar) for measles catch-up campaigns and surveillance UNF Financial and technical Coordinated the funding support from initiative (ARC and IFFIM). Funding support for measles catch-up campaign in DPR Korea 8 million 2004-2009 and follow up campaign in Bangladesh. CDC/ Atlanta Technical and Technical support through WHO and UNICEF for surveillance including 15.2 million 2002-2009 Financial CFR studies in Nepal and Bangladesh and SIA planning and monitoring. Annual funding support to WHO for key positions and priority activities in surveillance and SIA. Funding support to measles catch-up campaign in Sri Lanka (2003 and 2004), Nepal (2004-05), and first phase of catch-up campaign Bangladesh (2005). CIDA Financial Financial support for WHO 2002-2004 IFRC Technical and Financial Technical support to measles SIAs through participation of volunteers in countries and financial support to JICA GAVI/ IFFIM Republic of Korea UNICEF Technical and Financial them Technical and financial support to catch-up campaign in Bhutan and first phase of catch-up campaign in Bangladesh Financial Provided funds to WHO and UNICEF for measles surveillance. and measles catch-up campaigns and follow up campaigns in Bangladesh, India, Indonesia, Myanmar and Timor-Leste. Financial Funding for measles catch-up campaigns in DPR Korea Technical and Financial Technical assistance to member states in policy development, SIA planning and implementation (with main focus for cold chain, logistics and communications). Procuring c bundled vaccine from funds receiving from the partners of the measles initiative. Supported Myanmar catch-up campaign 2002-2004 USD 1.2 million @ 2005-2006 33.02 million 2007-2009 1.03 million 2007 Approximately 5 million# 2001-2009 WHO Technical Regional policy development and Approximately 2001-2009 of 2

and Financial coordination with other partners. Technical assistance to member states in policy development, surveillance and SIA planning and implementation (with main focus in micro planning, training and monitoring through the surveillance medical officers network established for polio eradication) 2.5 million# *Funds from the measles initiative were channelled through UNF. All funds received from ARC and IFFIM came through UNF. CDC/Atlanta provided funds to measles initiative as well as directly to WHO and UNICEF @ JICA channelled the funds through UNICEF # These amounts are funds WHO and UNICEF provided from the organizational funds. The funds that WHO and UNICEF received from other partners of the measles initiative and used for measles control activities are reflected against ARC, UNF and CDC/Atlanta. The regional consultation of measles concluded that current strategies for measles mortality reduction should work for measles elimination in the region. However the intensity of the implementation should be at higher level to reach desired immunization and surveillance standards. The regional consultation observed that: Strong political commitment and full country ownership is required for measles elimination. To achieve elimination, immunization programmes must be capable of attaining and maintaining population immunity >93-95% against measles. The programme target is >95% coverage with two doses of measles vaccine in all districts. This can be achieved through a combination of routine services and/or mass campaigns. According to the projected estimates routine immunization services should be scaled up to vaccinate an additional 7.8 million infants per year, amounting to 78 million for the period 2010-2020. In addition, approximately 321 million children need to be reached through MCV2, and over 680 million children through SIAs. Even countries that provide MCV2 through routine immunization would require periodic SIAs to vaccinate accumulated susceptible children. In states Bihar and Uttara Pradesh in India, the existing infrastructure, capacity, micro plans and momentum conducting regular polio campaigns, could be beneficial to planning measles SIAs. If clear dates and targets are set, measles SIAs can be done with polio campaigns. The focus of SIAs in India needs to initially be on the high priority states (<80% coverage). In states where MCV2 is provided through routine immunization, SIAs could be scheduled in line with the target year of elimination to stop transmission of measles. A high quality surveillance system that meets surveillance performance indicators needs to be ensured. Laboratory strengthening is an essential component of measles elimination strategies. There is a need for close collaboration and linking of laboratory and surveillance data. The surveillance systems must be strengthened to monitor the progress towards the achievement of this goal. The surveillance system must provide the needed sensitivity and specificity to ensure the detection of measles virus. Adequate resources (equipment, staff, training and supervision) need to be provided to ensure safe injection practices and waste disposal. 3

A comprehensive analysis of the costs required to scale-up routine immunization to >=95% in every district is needed to complete the cost analysis for measles elimination. A system for monitoring and responding to Adverse Events Following Immunization (AEFI) should be put in place. This system is required for vaccine delivered through either routine or SIAs. There is a possibility of decreased external funding as measles mortality reduction/elimination progresses and hence there is need for domestic funding to sustain activities. The experience with polio eradication in the Region has highlighted the need to expect that difficulties will arise and that that the process of measles elimination may be long and complex. With these in mind, measles elimination efforts in the Region should plan for the following: Ongoing research to better understand measles virus and disease in the highest risk settings and refinement of control tools and strategies. Thorough assessment of the resources required (financial, human, and materials). Building a diverse and strong partnership to sustain efforts. As far as possible, upfront funding commitments from large governments and major donors to ensure sufficient supplies and human resources. An advocacy and communication strategy that is tailored to key audiences (general public, politicians, technical experts etc.). C. Epidemiology in the Region: In 2003, the World Health Assembly (WHA) through resolution WHA56.20 endorsed the goal of reducing measles mortality by 50% by 2005 relative to 1999 estimates. In line with the resolution, in 2003, the SEAR Technical Consultative Group for Polio Eradication and Control of Vaccine Preventable Diseases (TCG) endorsed the Regional Strategic Plan for Mortality Reduction for 2003-2005. In 2007, taking into account the regional progress in measles control, the SEAR Technical Consultative Group for Polio Eradication and Control of Vaccine Preventable Diseases (TCG) endorsed the revised Regional Strategic Plan for Mortality Reduction for 2007-2010, with a goal of reducing the estimated number of measles deaths by 90% in 2010 relative to 2000 estimates. Table 2 provides reported measles incidence Rate per 100,000 population and reported number of and Rubella. Each country in the region strengthened measles surveillance in different years. Sudden increase of measles incidence could be observed in the following year in several member states. Once catchup campaigns were conducted reduction of incidence could be noticed. The incidence rates given in the table is based on the number of cases reported in WHO/UNICEF annual joint reporting forms (JRF). They are mostly clinically confirmed cases. Since rubella virus is circulating in the region most of these cases reported in JRF could be rubella cases. Hence marked reduction of incidence could not be observed in most countries based on JRF data. The reported number of serologically confirmed outbreaks is a better indicator of impact of measles SIAs in the member states of the region. 4

Table 2: Reported Incidence Rate per 100,000 population and reported number of and Rubella, SEAR, 2000-2009 Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Incidence Rate 3.70 3.13 2.66 3.06 7.24 18.64 4.37 2.03 1.81 0.49 Bangladesh - - - - 90 120 34 0 1 1 Rubella - - - - 87 26 102 59 1 Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Incidence Rate 20.26 35.58 3.77 0.00 0.40 1.46 0.00 1.67 1.04 0.88 - - - - 9 10 0 Rubella - - - - 41 0 0 Incidence Rate 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.94 0.34 0.00 - - - - 0 87 0 Rubella - - - - 2 0 0 Incidence Rate 3.82 5.01 3.84 4.40 5.01 5.10 5.46 3.59 4.68 NR - - - - 101 Rubella - - - - 24 Incidence Rate 22.59 10.07 9.21 11.44 13.48 7.23 9.21 8.62 6.73 8.61 - - - - 58 78 35 24 22 Rubella - - - - 3 18 12 15 45 Incidence Rate 6.87 0.00 342.83 26.73 12.78 474.90 15.72 6.56 0.00 1.91 - - - - 1 0 0 Rubella - - - - 0 0 0 Incidence Rate 1.81 0.00 1.41 1.56 2.35 0.55 1.30 1.88 0.56 0.36 - - - - 18 9 22 25 9 11 Rubella - - - - 1 0 0 0 2 Incidence Rate 39.96 45.09 27.94 53.78 49.25 20.02 11.06 5.39 7.79 0.69 - - - - 148 1 2 2 6 2 Rubella - - - - 36 24 10 27 57 Incidence Rate 88.88 1.65 0.74 0.34 0.18 0.02 0.00 0.21 0.16 0.10 - - - - 0 0 Rubella - - - - 2 2 Incidence Rate 6.69 11.89 16.31 7.25 6.20 5.35 5.63 6.22 11.10 NR - - - - 98 4 18 Rubella - - - - 9 2 Incidence Rate 0.00 0.00 0.00 0.00 4.83 21.99 9.15 0.00 0.00 NR - - - - 0 0 Rubella - - - - 0 0 Incidence Rate 7.98 6.19 5.22 5.90 6.89 6.64 5.68 4.35 4.74 4.14 - - - - 256 296 140 159 141 36 Rubella - - - - 0 177 72 124 127 107 Source: Population: 2000-2001-United Nations Population Division, Department of Economic and Social Affairs, World Population Prospects the 2002 revision; 2002 onwards - WHO/SEARO Annual EPI Reporting Form (AERF); Cases: WHO/UNICEF JRF /Rubella : SEAR/IVD Annual EPI Reporting Form NR=No Report 5

Table 3: Percentage age distribution of measles cases from confirmed measles outbreaks before and after measles supplementary immunization activities, SEAR Country Year < 1 yr 1-4 Before SIA 5-9 10-14 = >15 Total cases Year < 1 yr 1-4 After SIA Bangladesh 2005 13.5 35.8 34.1 10.8 5.8 10146 2007 0.0 0.0 0.0 0.0 0.0 0 Bhutan 2005 11.1 0.0 0.0 0.0 88.9 9 2007 50.0 50.0 0.0 0.0 0.0 10 2006- DPR Korea 07 2.9 5.3 17.9 21.5 52.4 3657 2008 0.0 0.0 0.0 0.0 0.0 0 Indonesia 2005 9.1 38.4 23.1 2.2 0.5 3262 2008 9.0 45.8 40.0 4.6 0.7 725 Maldives 2005 4.0 7.7 8.6 25.4 54.3 1395 2006 0.0 0.0 0.0 0.0 0.0 0 Myanmar 2001 7.2 47.2 40.1 7.2 1 1629 2008 2.9 17.1 26.5 34.9 18.5 275 Nepal 2005 0.0 32.0 44.0 12.0 12.0 25 2006 4.4 28.9 33.3 24.4 8.9 45 Sri Lanka 2000 7.7 5.3 16.3 16 54.8 6392 2005 0.0 0.0 0.0 0.0 0.0 0 Timor-Leste 2004 14.6 82.9 2.4 0.0 0.0 41 2004 14.6 82.9 2.4 0.0 0.0 41 Source: SEAR/IVD Annual EPI Reporting (AERF) except Sri Lanka 2000, Myanmar 2001, DPRK 2006-07 Country reports 5-9 10-14 = >15 Total cases The outbreak investigation data before conducting measles catch-up campaigns has shown a broad age distribution. Majority of cases aged <10 years in countries where routine MCV1 coverage was moderate or low over the years. In countries where routine MCV1 coverage was high (Bhutan, DPR Korea, Maldives and Sri Lanka) majority of cases occurred in those aged >10 years. When reviewing the reported measles incidence, number of serologically confirmed outbreaks and age distribution of cases, it is evident that there had been dramatic change in measles epidemiology in countries that have conducted high quality measles catch-up campaigns to cover the susceptible populations. In Bangladesh, Bhutan, DPR Korea, Maldives, Nepal, Sri Lanka and Timor-Leste measles incidence is very low, outbreaks were not reported recently and cases occur mainly among the children who did not get second opportunity (born after the catch up campaign and did not get second routine dose). However, measles surveillance data in Indonesia does not indicate a marked impact of the phased national measles catch up campaign. Extensive review of measles data by provinces was conducted and it was found that the status of implementation of all three immunization strategies (routine immunization at 9 months, school entry immunization and SIAs) varied from province to province. Similarly sensitively of the surveillance system in the provinces is also varied. Nevertheless measles control is good in 20 provinces out of 33 provinces in the country. In another nine provinces there were gaps in some districts and in four provinces there were several gaps in implementation of measles control strategies. Since Myanmar conducted catch-up campaign targeting children 9 months-5 6

years from 2002-2004 measles outbreaks continued to occur among children above 5 years. However after the follow up campaign in 2007 the incidence substantially reduced. Table 4: Percentage age distribution of measles cases from confirmed measles outbreaks in 2009 in countries that have conducted measles supplementary immunization activities, SEAR Country < 1 yr 1-4 5-9 10-14 = >15 Total cases Bangladesh 22.9 50 12.5 10.4 4.2 48 Bhutan 0 0 0 0 0 0 DPR Korea 0 0 0 0 0 0 Indonesia 6.9 33.5 20 3.6 2.2 963 Maldives 16.7 0 0 33.3 50 6 Myanmar 8.5 24.6 16.1 41.5 9.3 118 Nepal 10.5 36.8 26.3 15.8 10.5 19 Sri Lanka 0 0 0 0 0 0 Timor- Leste 0 0 0 0 0 0 Source: SEAR/IVD Annual EPI Reporting (AERF) In India and Thailand where measles catch-up campaigns have not yet been conducted percentage age distribution of cases remained unchanged over the years. India is conducting outbreak investigation focused surveillance in seven states. Majority of the cases are under 10 years of age. Thailand has been providing a second dose through routine services since 1997. Despite that measles outbreaks occur among adult populations who live or work in institutions. Table 5: Percentage age distribution of measles cases from confirmed measles outbreaks in countries that have not et conducted measles supplementary immunization activities, SEAR < 1 yr 1-4 5-9 10-14 = >15 Country Year Year India 2006 8.4 35.7 41.0 11.6 3.3 2764 2008 7.7 37.3 39.8 11.5 3.7 6364 Thailand 2001 5.9 46.7 20.2 17.2 10.0 781 2008 0.0 0.0 21% 79% 612 Source: SEAR/IVD Annual EPI Reporting (AERF, Thailand 2008 Country reports Total cases < 1 yr 1-4 5-9 10-14 = >15 Total cases Table 6 below presents the reported number of death from the member states of the region. Mortality reported from routine surveillance and outbreak investigations remains low. In 2004 and 2005 with improved surveillance in several countries reported number of deaths increased. Subsequent to full implementation of measles control strategies reported number of deaths has been reduced to very low number in all countries except India and Indonesia. 7

Table 6: Reported number of measles deaths, SEAR 2000-2009 Country 2001 2002 2003 2004 2005 2006 2007 2008 2009 Bangladesh 4 22 17 48 38 2 17 8 Bhutan 0 0 0 0 0 0 0 0 4 DPR Korea India* 0 0 0 0 0 2 33 22 Indonesia 5 1 44 22 11 8 9 44 Maldives 0 0 0 0 0 0 0 0 0 Myanmar 34 0 12 7 1 4 9 3 0 Nepal 0 0 18 63 6 0 4 9 0 Sri Lanka 0 0 0 0 0 0 0 0 0 Thailand 3 4 1 0 0 1 2 2 0 Timor- Leste NA 0 0 0 9 0 0 0 0 SEAR 37 13 54 131 86 56 58 62 56 Source: SEAR/IVD Annual EPI Reporting (AERF) 2000-2004 and Monthly and VPD reporting Form, 2005-2009. *Source India: AERF 2001-2009 Figure 1: Laboratory Confirmed and Rubella by District Nepal, Bangladesh, Myanmar and Indonesia, 2009 D. Costs of Mortality reduction, and Elimination Estimating the cost for routine measles immunization was difficult. As measles surveillance is integrated to national surveillance systems of many countries, it is difficult to estimate the cost of measles surveillance. Table 7 provides information 8

about government contributions through national health expenditure for measles controls and additional funds provided by donors for measles SIAs and surveillance in each country. Table 7: Government contribution and Partner support to measles mortality reduction in SEAR 2002-2010 Country Government contribution Partners support in USD Bundled Operational Surveillance Technical Vaccine for costs for cost assistance SIAs SIAs Total Bangladesh Bundled vaccine and operational costs for MCV1, Human resources and infrastructure for surveillance including the national laboratory, USD 3 million for bundled vaccine in follow up campaign, USD 2.3 million for operational costs for catch-up and follow- up campaigns 12,098,044 3,500,000 4,000,000 803,510 20,401,554 Bhutan Bundled vaccine and operational costs for MCV1 and MCV2, Human resources and infrastructure for surveillance including the national laboratory, USD 0.2 million for bundled vaccine in three SIAs, USD 0.6 million for operational costs for SIAs 350,000 200,000 550,000 DPR Korea Operational costs for MCV1 and MCV2, Human resources and infrastructure for surveillance including the national laboratory, all operational costs for catchup campaign 5,388,187 100,000 5,488,187 India Bundled vaccine and operational costs for MCV1, Human resources and infrastructure for surveillance at all levels and state laboratories, 11,656,675 1,520,313 13,176,988 Indonesia Bundled vaccine and operational costs for MCV1 and MCV2, Human resources and infrastructure for surveillance including laboratories, part of the operational costs for measles catch-up campaign 16,057,242 18,862,432 2,228,887 938,609 38,087,170 Maldives Bundled vaccine and operational costs for MCV1 and MCV2, Human resources and infrastructure for surveillance including the national laboratory, part of the operational costs for (USD 0.076 million) for measles catch-up campaign 110,000 175,000 285,000 Myanmar Operational costs formcv1, Human resources and infrastructure for surveillance at all levels including the laboratory, part of the operational costs for measles catch-up and follow-up campaigns 4,900,000 3,400,000 839,001 9,139,001 Nepal Bundled vaccine and operational costs for MCV1, Human resources and infrastructure for surveillance including the national laboratory, part of the operational costs for catch-up campaign 3,659,954 5,100,000 2,144,221 10,904,175 Sri Lanka Bundled vaccine and operational costs for the MCV1 and MCV2, Human resources and infrastructure for surveillance and the national laboratory, all operational costs for catch-up campaign 2,100,000 2,100,000 Thailand Timor- Lester Bundled vaccine and operational costs for MCV1 and MCV2, Human resources and infrastructure for surveillance and the national laboratory, 0 Bundled vaccine and operational costs for MCV1, Human resources and infrastructure for surveillance and national laboratory, part of the 150,000 372,000 60,000 170,000 752,000 9

operational costs for catch-up campaign It is anticipated that key donors mentioned in the table 1 above would continue support for measles elimination in the region. Once region set goal with time line all potential donors will be contacted both at national and regional levels. A conservative estimate of the total expected cost of measles elimination in SEAR for the period 2010-2020, based on the projected schedule of SIAs and MCV2 introduction is presented in Table 8, and current experience with best surveillance practices in the Region, would be as follows: Routine MCV2: $186.44 million (India would account for 64%) SIAs: $527.71 million (India would account for 72%) Field surveillance: US$150 million Additionally, experience in other WHO regions suggests that scaling up routine immunization to achieve and sustain >95% coverage could require up to 2-3 times the cost of the introduction of routine MCV2 and the SIAs, though the major portion of this cost would probably be borne by the national immunization programme with potential support from donors and partners. This would require more comprehensive costing analyses in the future. Changes in SIA and MCV2 schedule and cost assumptions will alter the cost estimates. It should be noted that the estimates presented most likely represent lower bounds on actual costs. Bangladesh, Bhutan, DPR Korea, Myanmar, Nepal and Timor-Leste are moderately reliant on donor support. The remaining countries including the large countries are essentially self-financing. Of the estimated 714 million USD needed for SIAs and introduction of routine MCV2 to achieve measles elimination in the Region, 82% is required in countries that are financially self-reliant. Hence, elimination of measles from SEAR will be largely based on political and financial commitment by Member States within the Region. Nevertheless, mobilizing external donor funding for the additional funds required to support SIAs in highly dependent and moderately dependent countries (130 million USD over 10 years) should be a priority. Table 8: Estimated costs for measles elimination by 2020 in SEAR Member States Cost of adding 2nd Additional Supplementar Total dose of costs for y excluding measles supporting immunization Target year scaling up vaccine in laboratory activities for measles of Routine the national based (SIA) Costs** elimination Immunizat immunizatio surveillanc # ion (USD n schedule e* (USD (USD millions) (USD millions) millions) millions) 1 4 5 6 7 8 9 Member State Bangladesh 2015 24.89 12.30 34.51 71.70 Bhutan 2015 0.00 0.25 0.14 0.14 Cost of scaling up routine immunization to achieve programme targets (USD millions) Based on experience in 10

DPR Korea Achieved but requires documentation @ TBD other regions assumed to India 2020 119.26 113.35 380.33 612.94 be 2 to 3 Indonesia 2015 22.98 11.20 56.79 90.97 times SIA Maldives 2015 0.00 0.25 0.24 0.24 costs Myanmar 2015 14.97 2.65 40.53 58.15 Nepal 2015 4.07 4.95 10.63 19.65 Sri Lanka 2012 0.00 0.5 0.89 0.89 Thailand 2015 0.00 1.0 2.62 2.62 Timor Leste 2020 0.28 0.25 1.04 1.32 TOTAL 186.45 146.70 527.72 858.62 1,000-1,500 *Shared Costs with polio and other VPD surveillance **: India SIA costs include large-scale, catch-up campaigns. #: SIA Unit cost per vaccinee: Bundled Vaccine costs range from USD 0.30-0.36 (UNICEF Supply Division, Copenhagen); Operational costs range from USD 0.09 to 1.71 (Country experience). @ As notified through e-mail dated 1 September 2009. Achieving and sustaining immunization and surveillance standards will be challenging particularly for some of the large countries of the Region and will require substantial investment of financial and human resources. Because the international funding available from the Initiative for mortality reduction is substantially reduced for the next biennium, the cost implications need to be carefully considered and attempts need to be made to mobilize resources within countries. Recently India has decided to fund measles catch-up campaigns in 14 states that has less than 80% MCV1 coverage and introduction of MCV2 in all other states through national resources. Bangladesh provided 75% of the cost of measles followup campaign in 2010. Meanwhile Indonesia despite providing more than 80% of the funds required for measles follow up campaign in 10 provinces in 2010, find difficulties in mobilizing external resources for a funding gap of USD 1.2 million E. Progress Towards the Current Goal: The regional strategic plan 2007-2010 has identified four specific objectives for four strategies mentioned in the section B of this document. Detailed data on country progress is available in the attached SEAR measles rubella fact sheet (Annex 3). Objective1: Achieve at least 90% national Containing Vaccine (MCV1) coverage and at least 80% MCV1 coverage in all districts in member countries by 2010 routine immunization coverage in the Region increased from 61% in 2000 to 75% 2 in 2008 (table 9). However about 10 million children born in 2008 did not receive measles vaccine. In 2007 Bhutan, DPR Korea, Maldives, and Sri Lanka achieved more than 90% coverage with routine measles vaccination nationally and 80% coverage in all districts. Thailand achieved national coverage of more than 90% but district-level data are not available. Bangladesh, Indonesia, and Myanmar had a 2 http://www.who.int/immunization_monitoring/en/globalsummary/wucoveragecountrylist.cfm. 11

national coverage of more than 80%. Coverage in Nepal was 79% and Timor-Leste was 73%. The coverage in India increased from 54% in 2000 to 70% in 2008. Table 9: MCV1 coverage in the SEAR (2000-2009) Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009* Bangladesh 76 77 75 76 81 88 83 89 89 88 Bhutan 76 78 78 88 87 93 90 95 99 98 DPR Korea 78 92 98 95 95 96 96 99 98 NA India 54 55 56 59 61 64 70 70 70 NR Indonesia 72 70 72 74 76 78 80 80 83 82 Maldives 99 98 97 96 97 97 97 97 97 98 Myanmar 84 73 77 76 78 72 78 81 82 87 Nepal 71 71 71 75 73 74 85 81 79 75 Sri Lanka 99 99 99 99 96 99 99 98 98 97 Thailand 94 94 94 96 96 96 96 96 98 NR Timor Leste ND ND 56 55 55 48 64 63 73 73 SEAR 61 61 62 65 67 70 74 75 75 Source - 1990-2008: WHO/UNICEF Coverage Estimates *2009: Country Official Estimates NR=Not Reported NA=Not available in the report ND= No Data Objective 2: Conduct case-based measles surveillance within an integrated vaccine preventable disease surveillance system in countries that have conducted measles catch-up campaigns After completion of measles catch-up campaigns Bangladesh, Bhutan, DPR Korea, Maldives, Myanmar, Nepal and Sri Lanka have started case based surveillance. Indonesia is doing a phased implementation In Bangladesh, India, Indonesia, Myanmar and Nepal, the polio surveillance networks supported by WHO also assist in measles/rubella surveillance. Regional measles/ rubella laboratory network has 20 laboratories of which 18 are accredited. Objective 3: Achieve full investigation and appropriate clinical case management of all suspected measles outbreaks by all member countries by 2009 There were no suspected measles outbreaks in DPR Korea, Bhutan and Maldives and Timor Leste in 2009. In 2009 Bangladesh, Myanmar, and Sri Lanka have fully investigated all suspected measles outbreaks reported. Outbreak investigations were completed in Indonesia (47%), Thailand (54%) and Nepal (97%). There were no confirmed measles outbreaks in Sri Lanka. Confirmed measles outbreaks were in Bangladesh (1), Indonesia (22), Myanmar (11), Nepal (2) and Thailand (13). India investigated 165 suspected measles outbreaks in seven states where measles surveillance has been strengthened and 62 were confirmed as measles. Objective 4: Provide a second opportunity for measles immunization to eligible children in all member States by 2010. Between 2002-2007 all countries in the region except India and Thailand have conducted a nation wide measles catch-up campaign to provide a second opportunity for susceptible age groups (table 10). Susceptible age groups were identified through 12

analysis of outbreak investigation data Bangladesh, Myanmar, Nepal and Timor-Leste have conducted follow up campaignsat the appropriate time to prevent accumulation of suseptibles to measles.. Indonesia is conducting follow up campaigns in phases. In the Region, 140 million children received measles vaccination in these campaigns from 2000-2010. In addition to conducting catch-up campaigns Bhutan, DPR Korea, Maldives and Sri Lanka are providing second opportunity through routine immunization in all districts(table 11).. Thailand is providing second opportunity as a routine second dose since 1997., However, MCV 2 coverage has not been validated as MCV2. Hence there could be reporting errors except in DPR Korea, Maldives, Sri Lanka and Thailand. Table 10: supplementary Immunization campaigns conducted in countries of the South-East Asia Region (2000-2010) Country Year Type Bangladesh Target age group Target Coverage Vaccinated Percentage Coverage 2005-2006 Catch Up 9M- 10 Y 35680911 36012154 100.9 2010 Follow Up 9m 5 18085685 18085685 100 Bhutan 2006 Catch Up 9M-15 Y & 15-44Y (F) 338040 332041 98.2 DPR Korea 2007 Catch Up 6 M-45 Y 16123376 16109432 99.9 Indonesia 2000-2007 Catch Up 6M - 15 Y 42712567 40316089 94.4 2009 Crash program Maldives 2005/2006 Catch Up Myanmar Nepal 9M-5 Y 2124275 1954333 92 6-25 Y & 25-34Y (F) 144997 123642 85.3 2002-2004 Catch Up 9m 5 Y 5670597 4910950 86.6 2007 Follow Up 9 M - 5 Y 6056000 5706351 94.2 2004-2005 Catch Up 9M - 15 Y 9423867 9839723 104.4 2008 Follow Up 9M 5 Y 3903515 3634277 93.1 Sri Lanka 2003-2004 Catch Up Timor- Leste 10-14 Y and 16 to 20 Y 3878173 3259281 84 2003-2004 Catch Up 9M - 15 y 519005 285126 54.9 2009 Follow Up 9-59 M 166872 126823 76 SEA 2000-2010 144827880 140,695,907 97.1 Region Source: WHO/UNICEF joint reporting forms Table 11: MCV 2 coverage in the SEAR (2004-2009) Country 2004 2005 2006 2007 2008 2009 Bhutan 72 DPR Korea 98 98 Indonesia 85 91 85 78 NR Maldives 82 85 56 96 Myanmar 65 Sri Lanka 95 99 98 97 97 97 Thailand* 95 95 94 94 91 P Source: WHO/UNICEF JRF, 2004-2009 P - Thailand 2009 JRF are pending NR=No report 13

India plans to introduce a routine second dose in 17 states with evaluated routine immunization coverage of more than 80%. In addition, India plans to conduct measles catch up campaign in 14 high priority states. The first phase of the campaign will be conducted in 40 districts in these states in last quarter of 2010. It is planned to complete the campaigns in reaming districts in 2-3 phases by 2012. Thailand is planning to conduct a measles catch-up campaign in provinces which are prone to measles outbreaks, as well as in adolescents and young adult populations with the focus on institutions (i.e. universities, the military, factories, etc). Planning for measles campaigns provided an opportunity to improve routine immunization services through conducting training for middle-level managers and basic health workers, establishing an AEFI monitoring system, addressing the gaps in the cold chain and developing a system to dispose the waste accumulated during vaccination sessions. Based on these achievement by 2009 all countries in the Region, except India, have reached or exceeded the 2010 goal of a 90% reduction in measles mortality. The achievement was mainly due to successful supplementary immunization activities. However according to WHO/HQ estimates the measles mortality in the region has been reduced by 46% in 2008 compare to 2000 estimates. The South-East Asia Region will not achieve the regional measles mortality reduction goal by 2010. Based on the plans presented by India, the earliest date for achievement of this goal is end 2012 assuming full implementation in all high-burden states by this date. F. Enabling Factors: Political commitment and national health systems of member sates were key factors contributed for measles mortality reduction, especially for the catch-up campaigns. Communities accepted the catch-up campaigns as well as outbreaks investigations and involved in mobilization of families to receive vaccination. Polio eradication infrastructure in five priority countries for polio eradication in the region (Bangladesh, India, Indonesia, Myanmar and Nepal) made a enormous contribution in measles surveillance and SIAs. The role of polio laboratories was expanded to include measles laboratory surveillance. G. Challenges: There were few challenges during implementation of measles mortality reduction strategies. The strategies used to overcome them are summarised in table 12 Table 12: Challenges encountered during implementation of measles control Challenges encountered Strategies used to overcome challenges Explained the opportunities to improve the quality of routine immunization Some countries were reluctant to services through SIAs. conduct supplementary immunization Routine immunization sessions were anticipating that routine immunization conducted according to the planned will be disturbed schedule during the measles SIAs 14

Vaccine storage capacity was not adequate at national and sub national levels for SIA. Especially if integrated with OPV Almost all countries needed external funding support for measles SIAs and some countries needed funds for surveillance Policy makers of some countries were worried about Adverse Events following measles immunization during SIAs. Inadequate data to show measles disease burden and decide the immunization strategies Hired temporary cold space at national level. Vaccine was sent to sub national level in phases Establishment of the south East Asia partnership on the lines of measles initiative, that mobilized the resources for measles control activities Shared the AEFI data of the countries that have already conducted SIAs. Convinced the importance of training to avoid programme errors. AEFI management kits were made availably to manage anaphylaxis and a referral system was established for severe AEFI AFP surveillance networks were expanded to include measles surveillance with focus to tack and investigate outbreaks. This provided reasonable amount of background information. There are challenges in sustaining funds for this H. Control/Elimination in the Context of Health Systems Strengthening: Planning for measles campaigns provided an opportunity to improve routine immunization services through conducting training for middle-level managers and basic health workers, establishing an AEFI monitoring system, addressing the gaps in the cold chain and developing a system to dispose the waste accumulated during vaccination sessions. High level of measles control in the countries has revealed previously unrecognized high prevalence of rubella and appropriate immunization strategies for rubella were initiated. Successful expansion of AFP surveillance to measles surveillance have encouraged to integrate other vaccine preventable disease surveillance. SIAs were integrated to OPV, Vitamin A, TT, antihelminthic drugs as per the needs of the countries. Furthermore, polio eradication initiatives, implementation of RED strategies, GAVI ISS and HSS resources have supported measles control activities. I. Programmatic Feasibility: All countries in the region, except India, have reached or exceeded the 2010 goal of 90% reduction of measles mortality in comparison to 2000 estimates. However South-East Asia Region will not achieve the regional measles mortality reduction goal by 2010. Achievement of the global and regional goal to reduce measles deaths by 90% depends on India, in particular the full implementation of recommended strategies in the 10 states with high burden and low coverage. Based on the provisional plans presented, the earliest date for achievement of this goal is end 2012 assuming full implementation in all high-burden states by this date. The critical 15

interventions required to achieve and sustain the 90% measles mortality reduction goal in the Region are: I. Successful implementation of high quality catch-up SIAs in all high-burden states of India. II. Maintaining the gains in other countries through further improvements in routine immunization, timely high quality follow-up SIAs, introduction of routine MCV2 (where appropriate), and epidemiologic and laboratory surveillance that meets performance standards. III. Strong political and financial commitment by countries and partners to support these activities. In the regional measles consultation: All countries agreed on the technical feasibility of measles elimination. However, the programmatic feasibility and time line of achieving elimination varied. Eight countries (Bangladesh, Bhutan, Indonesia, Nepal, Thailand, Myanmar, Maldives and Sri Lanka) agreed that a goal for achieving measles elimination by 2015 would be feasible, whereas Timor-Leste agreed that this would be feasible by 2020. After debate and due consideration. India agreed that a target year of 2020 is feasible. India is preparing to offer MCV2 starting from 2010 either through routine immunization or through campaigns in order to achieve its revised 90% measles mortality goal by 2012 While most countries identified measles as a national priority, some acknowledged that there were other competing priorities. India, Indonesia and Timor-Leste would have the greatest challenges in reaching measles elimination. Although the regional consultation proposed a regional measles elimination goal by 2020 to the sixty-second session of the Regional Committee in September 2009, the Regional Committee decided to review the target year to reach measles elimination later. In summary, measles elimination target by 2020 and 95% mortality reduction by 2015 are feasible in the region subjected to the agreement of member states and endorsement of the regional committee. During the regional consultation, all countries indicated that an elimination goal would be met by high level political and societal support. Societal commitment for a measles elimination goal by 2020: Based on the experience of the Small Pox eradication, polio eradication initiative, Kala-azar elimination, malaria control, leprosy elimination and lymphatic filariasis elimination societal commitment for the disease elimination and eradication was good except for challenges in some sporadic resistance. However all these diseases have visible severe signs and symptoms. Still some communities may not have realise the complications due to measles. mortality reduction strategies were accelerated in the member states after a nation wide large measles outbreak or in an environment where several outbreaks are presented. That situation mobilized communities for supplementary immunization activities. When the measles incidence decreased it would be important to ensure societal commitment by appropriate advocacy and communication strategies. Some countries with very low levels of measles incidence (Sri Lanka, Thailand) foresaw that convincing parents and medical community alike will be major communication challenges 16

Financial Feasibility: The contribution from the countries to measles mortality reduction has been varied. All countries used the national health infrastructure and human resources in health to implement the strategies. Several countries provided almost all the operational costs for supplementary immunization activities. Most recently Bangladesh funded almost 75% of the total cost of the follow-up campaign. Except for Bangladesh follow up campaign in all other SIAs bundled vaccine cost was provided by development partners. India has indicated that total cost of the SIAs will be covered by the government. Almost all countries envisaged substantial operational and financial challenges to achieve the elimination goal. For most countries the costs associated with their EPI programme are funded from internal resources. However, adding the second dose of measles vaccine will require additional resources in EPI for those countries which have not done this. Substantial investments will have to be made in capacity building of human resources especially in countries with maturing immunization programmes (e.g. India, Timor-Leste). Most countries anticipated that high level political commitment will be available for measles elimination, despite competing priorities from continuing polio eradication activities and other infectious diseases.. Despite there is keen interest from most of the countries for measles elimination the proportion of estimated funds from the countries is currently not clear. It The cost estimates presented by the Member States based on the country reports to achieve elimination by 2020 are lower bounds of the costs. This area requires further review by Member States who observed that actual costing needs more time and the involvement of concerned national departments. Most of the member states in the region will require donor contributions to embark on measles elimination since they have several competing health priorities. Polio eradication and measles elimination Polio eradication is unlikely to be a pre-requisite for embarking on measles eradication. However there are important lessons to be learned from polio eradication. These include: The importance of government ownership of the programme. Strengthening routine immunization system to achieve high coverage. Achieving high SIA coverage. Financial and technical support. Using polio eradication infrastructure for measles mortality reduction efforts. Failure to reach the target has caused increasing programme fatigue and waning of donor support. A more cautious approach from the onset with a well calculated 17

timeline to guard against the unexpected delays will be important when a measles elimination goal is set. Ranking measles mortality reduction or elimination among the public health priorities in countries of the Region: The comments made by member states during regional measles consultation is given below: Country Bangladesh Bhutan Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Ranking of measles control (elimination/ mortality reduction) as a national health priority Child health and LCC is the priority programme among others 38 programmes of HNPSP EPI is the lead of CH & LCC control and Polio eradication are the priority activities of EPI Royal government accords high priority to child health and MDG s. Immunization is an integral part of primary healthcare package and measles mortality reduction would contribute towards the achievement of PHC goals UCI at all villages 2010, Sustain Polio free status, mortality reduction Elimination of Maternal and Neonatal Tetanus, Elimination of Health Master Plan 2006 2015 states goal of elimination by 2015. A regional elimination target would help increase commitment further. Rank Disease / Health condition 1. AIDS, 2Malaria,3. Tuberculosis,4. Diarrhoea / Dysentry,5. Cholera, 6. Avian Influenza,7 Dengue Hemorrhagic Fever,8. Vaccine Preventable Diseases, 9. P.E.M, 10. P.P.H & A.P.H EPI is Priority number one priority Program, Polio eradication, elimination, JE control, Sustaining tetanus elimination are priorities in EPI Very High is not in the top10 national health priority 18