Update on Progress and Challenges in Achieving Measles and Rubella Targets SAGE Meeting 6 November 2013 P. Strebel, WHO/IVB/EPI
Overview Global progress Regional updates Summary 2
Measles and Rubella Targets Global targets by 2015: Measles mortality reduction of 95% vs. 2000 Measles reported incidence <5 cases per million Measles vaccination coverage 90% national and 80% district Regional targets: Measles Elimination goals: 2000 AMRO 2012 WPRO 2015 EURO, EMRO 2020 AFRO, SEARO Rubella Elimination goals: 2010 AMRO, 2015 EURO Global Vaccine Action Plan (GVAP): 2020 Measles and rubella elimination in 5 WHO regions 3
Global MCV1 coverage has levelled off at 84% 1 st Dose measles vaccine coverage by WHO region, 1980-2012 80 60 40 20 0 MCV1 Coverage* (%) 100 16 19 20 37 42 48 47 54 63 68 73 69 69 70 72 73 73 71 72 72 73 73 72 74 77 76 81 81 83 84 84 84 84 Global AFR SEAR EMR AMR EUR WPR Source: WHO/UNICEF coverage estimates 2012 revision. July 2013; Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 17 July 2013 4
MCV2 in Routine and Measles SIAs, 2012-2013 MCV2 in routine 2012: in 146 of 194 countries (75%) 2013: Kenya, Rwanda, Sao Tome, Zambia 2014/5: Burkina Faso, Senegal, Malawi, Mozambique, Papua New Guinea, Sierra Leone Measles, MR SIAs 2012: 112 million reached in 32 countries 2013 (as of October): 64 million reached in 10 countries Problems: Low coverage in some countries Administrative coverage often misleading (survey estimates lower)* *Source: W. Gong, BMGF, unpublished literature review, 2013 5
Global RCV coverage has reached 43% Number of countries using RCV and global coverage with RCV1 number of countries 200 150 100 50 0 New Introductions: 2013: Cambodia, Ghana, Rwanda, Senegal, 2014 (planned): Bangladesh, Vietnam, Burkina Faso, United Republic of Tanzania 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 100 80 60 40 20 0 % coverage Number of countries introduced Rubella Rubella 1 coverage Source: WHO/UNICEF coverage estimates 2012 revision. July 2013 Immunization Vaccines and Biologicals, (IVB), World Health Organization
77% Reduction in Global Measles Incidence, 2000-2012 1,000.0 Measles incidence per million populagon (log scale) 100.0 10.0 1.0 0.1 2015 Goal Projected 10- yr trend Trend to reach goal GOAL GLOBAL needed AFR EMR EUR SEAR WPR AMR 7
Reduction in estimated measles deaths, 1985-2012 1000s 1,200 1,000 800 600 89% drop from 985-2012 78% drop from 2000-2012 400 200 0 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 Source: WHO/IVB provisional estimates, 21 October 2013 8
9 Regional Updates
The Americas Measles vaccination coverage among children <1 year of age* and reported measles and rubella cases, 1970-2012 300,000 Measles Catch-up campaigns 100 Confirmed cases 250,000 200,000 150,000 100,000 50,000 Measles Follow-up campaigns Last endemic measles case Rubella speed-up campaigns Last endemic rubella case 80 60 40 20 Routine infant vaccination coverage (%) 0 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 0 Measles cases Rubella cases M coverage MR coverage *MR in children aged 1 year as countries introduced measles-rubella containing vaccines Source: Country reports to FCH-IM/PAHO.
Reported measles importagons by genotype The Americas, 2012 genotype D8 genotype D4 genotype B3 genotype D9 Source: Country reports to PAHO/WHO (as of EW 3/2013) and the Global Measles Laboratory at the US Centers for Disease Control (CDC)
Western Pacific Region Measles Cases by Month and Country, 2008- August 2013 30 000 Number of measles cases 25 000 20 000 15 000 10 000 5 000 0 Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul 2008 2009 2010 2011 2012 2013 China Japan Philippines Viet Nam Others Source: Measles and Rubella monthly country reports to WHO by 20 September 2013
China Measles cases by age group and vaccination status, January - May 2013 Source: National surveillance report as of May 2013 数据截至 2013 年 5 月
European Region Measles Case Distribution by Month & Country, 2008-2013 8000 7000 6000 5000 4000 3000 2000 1000 0 Belgium Bulgaria Switzerland Germany Spain France UK Italy Romania Russia Turkey Ukraine Georgia other Data source: surveillance DEF file Data in HQ as of 5 Aug 2013
Percentage of reported measles cases by age group January-June 2013 % of reported measles cases 35% 30% 25% 20% 15% 10% 5% 0% WHO European Region (n=20 533) 33% 20% 15% 13% 9% 10% <1 1-4 5-9 10-14 15-19 20 Age group (years) % of reported measles cases % of reported measles cases 35% 30% 25% 20% 15% 10% 5% 0% 30% 25% 20% 15% 10% 5% 0% Turkey (n=6533) 29% 26% 17% 14% 5% 6% 4% <1 1-4 5-9 10-14 15-19 20-29 30 Age group (years) United Kingdom (n=1750) 26% 17% 16% 12% 9% 10% 9% <1 1-4 5-9 10-14 15-19 20-29 30 Age group (years) % of reported measles cases % of reported measles cases 35% 30% 25% 20% 15% 10% 5% 0% 30% 25% 20% 15% 10% 5% 0% Georgia (n=5783) 33% 21% 13% 11% 9% 7% 6% <1 1-4 5-9 10-14 15-19 20-29 30 Age group (years) Germany (n=1097) 25% 20% 15% 12% 10% 12% 6% <1 1-4 5-9 10-14 15-19 20-29 30 Age group (years)
European Region Rubella Cases by Month & Country, 2008- August 2013 12000 10000 8000 Rest of WHO Europe Italy Ukraine Bosnia and Herzegovina Bulgaria Georgia Russian Federation Romania Poland 6000 Romania: 55 CRS cases 4000 2000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2010 2011 2012 2013 *Monthly reported cases to the CISID, WHO Europe
Eastern Mediterranean Region Reported measles cases and MCV1 coverage, 1980-2012 500000 450000 400000 350000 300000 250000 200000 150000 100000 50000 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 100 90 80 70 60 50 40 30 20 10 0 Measles cases Measles coverage (WHO- UNICEF esymate) 17 hwp://www.emro.who.int/enyty/vpi/
Eastern Mediterranean Region Measles Cases by Month and Country, 2008-2013 4000 3500 12,347 23,451 11,183 3000 2500 2000 1500 6,459 4,983 13,348 1000 500 0 Afghanistan Iraq Morocco Pakistan Sudan South Sudan Somalia Yemen Lebanon other Data source: monthly measles surveillance DEF file Data in HQ as of 5 Aug 2013
South East Asian Region 120,000 106,419 111,986 100 No. of cases 100,000 80,000 60,000 84,850 81,954 94,700 88,964 98,099 73,545 72,541 84,244 54,228 69,546 46,945 80 60 40 % Coverage 40,000 20,000 20-2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0 Measles cases MCV coverage Reported Measles Cases 1 and MCV1 Coverage 2, SEAR, 2000 2012 1 WHO/UNICEF JRF 2 WHO/UNICEF estimates, 2013
India: Measles 2 nd dose introducyon and impact of SIAs on Measles outbreaks 14 states with MCV1 <80%: through SIAs; 21 states with MCV1 80%: through rougne RJS GR MP Phase 1 (45 districts covered) Phase 2 (153 districts) Phase 3 (169 districts) MCV2 through routine (17 states) No. and size of measles outbreaks has decreased a`er SIAs in states in phases 1,2 & 3* No. of outbreak- related cases 4000 3500 3000 2500 2000 1500 1000 500 0 Pre (2010) Post (2013) Cases Outbreaks 90 80 70 60 50 40 30 20 10 0 No. of reported outbreaks * Outbreaks and cases of Gujarat (GR), Madhya Pradesh (MP) and Rajasthan (RJS) states that had laboratory supported Measles surveillance for year 2010 and 2013 Source: Based on target populayon available with Government of India Data as on 30/09/2013 20
MCV1 Coverage for SEAR countries, 2008-2012 95%
African Region Measles case reports & MCV1 coverage, 1980-2012 Measles case reports 1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 Measles case reports MCV1 coverage estimates 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 year Catch up SIAs Follow up SIAs 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% WHO- UNICEF MCV1 coverage estimates
DemocraGc Republic of Congo (DRC) Weekly trends of measles reporyng by province, 2010 2013 Age distribugon 65% <5 years
Nigeria Suspected and Confirmed Measles Cases, Weeks 1-17, 2013 Age distribugon 80% <5 years Confirmed (n=20258) Suspected (n=22742) Source: Measles case based database as of 26 Apr 2013
Summary Assessment by the SAGE Working Group on Measles and Rubella 25
Major global challenge weak immunization systems Rest of the world, 6.38 India, 6.37 21 million infants missed MCV1 in 2012 2/3 live in India Nigeria Iraq, 0.31 Afghanistan, 0.31 United States of America, 0.34 Philippines, 0.35 DemocraYc Republic of the Congo, 0.68 Pakistan, 0.73 Indonesia, 0.92 Ethiopia, 1.00 Nigeria, 3.76 Ethiopia Indonesia Pakistan DRC 21 million infants not immunized (MCV1), 2012
Key Challenges by WHO Region Americas risk of importations W. Pacific completing measles elimination in China Europe competing priorities, susceptible adults E. Med security limiting access SE Asia heterogeneous coverage in large countries (e.g. India, Indonesia) Africa weak immunization & health systems 27
Global Scorecard Indicator 2015 Target 2012 Comment MCV1 coverage 90% 84% No progress since 2009 Measles incidence (per million) <5 /million 33.3 Rate of decrease too slow Measles mortality reduction 95% 78% (provisional) Rate of decrease too slow
Regional Scorecard WHO Region AMR Elimination Target 2000 measles 2010 rubella MCV1 coverage 2012 Measles/Rubella incidence (/million) 94% 0.2 0.015 Comment On track WPR 2012 measles 97% 5.9 On track EUR 2015 measles 2015 rubella 94% 31.0 32.8 Off track EMR 2015 measles 83% 59.2 Off track SEAR 2020 measles 78% 25.3 New target AFR 2020 measles 73% 123.5 Off track
Draft Recommendations SAGE commends countries and Regions for progress being made. However, based on current performance, the global 2015 measles control targets as well as elimination targets in EUR, EMR and AFR will not be met on time 4 Regions still need to establish rubella elimination targets. SAGE urges the AFR, EMR, EUR and SEAR to work towards establishing rubella elimination targets The GVAP coverage targets of 90% nationally and 80% in every district are insufficient to achieve measles elimination. This coverage target should be raised to 95% at both national and district level 30
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Questions for SAGE Does SAGE agree with the assessments of the working group? Does SAGE endorse the 3 draft recommendations? What additional strategies, tactics, and/or innovations are needed to get back on track, or remain on track? 32