The State of Measles and Rubella in the WHO European Region Mark Muscat Vaccine-preventable Diseases and Immunization Rome, Italy, 16-17 June 2016
All six WHO Regions have measles elimination goals 2
Annual reported cases, and MCV1* & MCV2** coverage, 1980-2014 94% reduction in reported measles cases * MCV1 coverage: coverage with first dose of measles-containing vaccine as estimated by WHO and UNICEF. **MCV2 estimates are only available from 2000 when global data collection started; however, some countries have introduced the vaccine earlier. Source: WHO/IVB database, 2015 3
WHO/UNICEF Estimates of MCV1 coverage, 2014 74 countries have low MCV1 coverage 4
Measles case distribution by month and WHO regions, 2009-2016 AFR SEAR AMR EMR EUR WPR 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 Jan 2009 Apr Jul Oct Jan 2010 Apr Jul Oct Jan 2011 Apr Jul Oct Jan 2012 Apr Jul Oct Jan 2013 Apr Jul Oct Jan 2014 Apr Jul Oct Jan 2015 Apr Jul Oct Jan 2016 Apr This is surveillance data, hence for the last month, the data may be incomplete. Note: India started submitting monthly measles data from 2014 onwards. Source: surveillance DEF file Data in HQ as of 9 May 2016 5
Reported measles incidence rate* - April 2015 to March 2016 (12 month period) 5 WHO Regions still endemic for measles <1 (91 countries or 47%) 1 - <5 (32 countries or 16%) 5 - <10 (32 countries or 16%) 10 - <50 (27 countries or 14%) 50 (13 countries or 7%) No data reported (11 countries or 6%) to WHO HQ Not applicable *Rate per 1 000 000 population 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 2016. All rights reserved. Source: surveillance DEF file Data in HQ as of 9 May 2016 6
Rubella-containing vaccine coverage by WHO region,1980-2014 Over half the world's children are not vaccinated against rubella Source: WHO/UNICEF coverage estimates 2014 revision. July 2015 Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 16 July 2015. 7
Countries with rubella vaccine in the national immunization programme and planned introductions in 2016 Data source: WHO/IVB Database, as of 12 April 2016 Map production Immunization Vaccines and Biologicals (IVB), World Health Organization 8
Estimates of the median incidence of congenital rubella syndrome per 100,000 live births by country, 2016 Vynnycky E, et al. (2016) Using Seroprevalence and Immunisation Coverage Data to Estimate the Global Burden of Congenital Rubella Syndrome, 1996-2010: A Systematic Review. PLoS ONE 11(3): e0149160. doi:10.1371/journal.pone.0149160 9
WHO European Region 10
Number of measles cases and coverage with measles-containing vaccine, WHO European Region, 1980-2014 Number of cases Immunization coverage (%) Data source: WHO/UNICEF JRF and CISID (as of 10 February 2014) 11
Measles in the WHO European Region, 1993, and 2007-2015* 341982 Bulgaria 21 664 France 14 966 Ukraine 12 744 Georgia 7868 Russian Kyrgyzstan 17 779 Federation 3264 98% REDUCTION 7075 9168 7892 30604 33268 26786 32174 17782 30 762 *Data extracted 04 June 2016 12
Top 10 countries with measles cases, WHO European Region, 2015* Kyrgyzstan Bosnia and Herzegovina Germany Kazakhstan Russian Federation Georgia 640 430 2383 2340 4583 17779 88% of cases in the Region in 4 countries (n=27 085) France 373 Serbia 368 Turkey 342 Austria 306 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000 11 countries reported zero cases *Data extracted 04 June 2016 13
Highest incidence countries for measles per million inhabitants WHO European Region, 2015* 10countries Highest incidence of >10 per million inhabitants Kyrgyzstan Bosnia and Herzegovina 1203 Kazakhstan 133 Georgia 108 Croatia 51 Serbia 42 Austria 36 Germany 30 Montenegro 24 Lithuania 18 WHO European Region 34 Armenia 11 2993 *Data extracted 04 June 2016 14
Monthly distribution of measles cases, WHO European Region, 2015* Number of reported measles cases 7000 6000 5000 4000 3000 2000 1000 Other Kazakhstan Germany Bosnia and Herzegovina Kyrgyzstan 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec *Data extracted 04 June 2016 15
Age distribution and vaccination status of measles cases, 2015* Age known in 10 630 cases (35%) Number of reported measles cases 5 000 4 500 4 000 3 500 3 000 2 500 2 000 1 500 1 000 500 0 Unknown number of doses Vaccinated 2 doses Vaccinated 1 dose Unvaccinated <1 1 4 5 9 10 14 15 19 20 Age group (years) *Data extracted 04 June 2016 16
Age distribution of measles cases in the six selected countries in 2015 with data on age* % of % reported of of reported measles measles cases cases cases 40% 40% 40% 30% 30% 30% 10% 10% 10% 0% 0% 0% Turkey Turkey (n=342) Turkey (n=342) 31% 31% 29% 31% 29% 24% 29% 24% 24% 8% 8% 3% 4% 8% 3% 4% 2% 2% <1 <1 1 4 1 4 3% 4% 5 9 5 9 10 14 10 14 15 19 15 19 20 29 20 29 30 30 2% Age Age group group (years) (years) <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) % of of reported measles cases cases % of reported measles cases 40% 40% 40% Germany (n=2381)* Germany (n=2381)* Germany (n=2381)* 30% 30% 30% 16% 17% 16% 12% 13% 17% 14% 12% 13% 14% 16% 17% 10% 8% 8% 10% 12% 13% 14% 10% 8% 0% 0% <1 <1 1 4 1 4 5 9 5 9 10 14 10 14 15 19 15 19 20 29 20 29 30 30 0% Age Age group group (years) (years) <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) % of of reported measles cases cases % of reported measles cases Italy Italy (n=259)* (n=259)* Italy (n=259)* 40% 40% 40% 33% 33% 30% 33% 30% 30% 24% 24% 21% 21% 24% 21% 10% 8% 10% 8% 6% 8% 6% 8% 10% 1% 1% 8% 6% 8% 0% 0% <1 <1 1% 1 4 1 4 5 9 5 9 10 14 10 14 15 19 15 19 20 29 20 29 30 30 0% Age Age group group (years) (years) <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) % of % of reported measles cases 40% 30% 10% 10% 0% 0% 25% 25% Kazakhstan Ukraine Kazakhstan Ukraine (n=977) (n=2340) (n=977) (n=2340) 13% 13% 10% 10% 10% 10% 2% 3% 0% 2% 3% 0% <1 1 4 5 9 10 14 15 19 20 29 30 <1 1 4Age group 5 9 (years) 10 14 15 19 20 29 30 Age group (years) % of of reported measles cases cases % of reported measles cases 40% 40% 40% Bosnia and Serbia (n=304)(n=2238)* Bosnia Bosnia and Serbia Herzegovina and Serbia Herzegovina (n=304) (n=2238)* (n=2238)* 30% 30% 30% 21% 21% 15% 14% 16% 21% 15% 15% 12% 14% 16% 15% 15% 12% 14% 16% 15% 10% 7% 7% 12% 10% 10% 7% 0% 0% <1 <1 1 4 1 4 5 9 5 9 10 14 10 14 15 19 15 19 20 29 20 29 30 30 0% Age Age group group (years) (years) <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) % of of reported measles cases cases % of reported measles cases 40% 40% 40% 30% 30% 30% Russian Federation (n=639)* Russian Russian Federation Federation (n=639)* (n=639)* 34% 34% 34% 17% 17% 17% 9% 8% 10% 10% 9% 8% 7% 5% 7% 10% 9% 8% 5% 7% 5% 0% 0% <1 <1 1 4 1 4 5 9 5 9 10 14 10 14 15 19 15 19 20 29 20 29 30 30 0% Age Age group group (years) (years) <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) *Data extracted 04 June 2016. For 2345 cases from Bosnia and Herzegovina, 2 cases from Germany and 1 case from Russian Federation, the age group was unknown. 17
Measles outbreaks occurred in several susceptible populations Roma and Sinti communities Susceptible adults Unvaccinated adolescents Traveller communities Unvaccinated children Health care workers Orthodox protestant communities Followers of anthrposophy Ultra orthodox Jewish communities 18
Main public settings for measles outbreaks Health-care settings Proportion of measles among health care workers in selected countries, 2014 Laboratory confirmed measles outbreak cases in Latvia (n= 31) Other 58% HCW 42% Measles outbreak cases in Czech Republic (n=171) Bulgaria Croatia Czech Republic Denmark France Greece Latvia Italy Netherlands Spain Switzerland Other 60% HCW 40% Measles outbreak cases in Spain (n=120) Other 75% HCW 25% Further reading: WHO EpiBrief, 2014, 2:1 9 www.euro.who.int/ data/assets/pdf_file/0020/254234/epibrief_2_2014-rev3-with-data.pdf?ua=1 19
Main public settings for measles outbreaks Educational facilities Universities Anthroposophic Schools Schools Austria France Germany Ireland Italy Spain Switzerland UK Kindergardens Day care centres 20
Rubella in the WHO European Region, 2000 and 2011-2015* 621 039 Romania 4805 Romania 20 773 Poland 38 585 Poland 5899 Poland 2029 98% REDUCTION 9464 29618 39 554 6516 2368 *Data extracted 04 June 2016 21
Countries with rubella cases, WHO European Region, 2015* Poland Georgia Germany Italy Romania 100 91 37 18 2029 86% of cases in the Region in 1 country (n=2029) Russian Federation 14 Bosnia and Herzegovina 12 United Kingdom 10 Bulgaria 10 14 other countries 47 0 500 1000 1500 2000 2500 21 countries reported zero cases *Data extracted 04 June 2016 22
Monthly distribution of rubella cases, WHO European Region, 2015 350 Other Number of reported rubella cases 300 250 200 150 100 50 Italy Germany Georgia Poland 92% of cases in the Region (n=2259) 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec *Data extracted 04 June 2016 23
Diagnosis classification of reported rubella cases in top four countries, 2015 Number of reported rubella cases 30 25 20 15 10 5 Germany (n=91) Clincally compatible Epidemiologically linked Laboratory confirmed Number of reported rubella cases 16 14 12 10 8 6 4 2 Italy (n=37) Clincally compatible Epidemiologically linked Laboratory confirmed Number of reported rubella cases 0 800 700 600 500 400 300 200 100 <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) Poland (n=2029) Clincally compatible Epidemiologically linked Laboratory confirmed Number of reported rubella cases 0 70 60 50 40 30 20 10 <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) Georgia (n=100) Clincally compatible Epidemiologically linked Laboratory confirmed 0 <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) 0 <1 1 4 5 9 10 14 15 19 20 29 30 Age group (years) 24
the challenges 25
1. High vaccination coverage 2. Closing Immunity gaps Commitment 3. Highquality surveillance 4. Knowledge and training 26
Challenge 1 Reaching and maintaining high vaccination coverage Delayed vaccination Vaccine hesitants Lost to follow up Vaccine refusals Distrust in vaccines Previously not targeted for vaccination Distrust in health authorities Lack of access 27
Addressing the challenge Reaching and maintaining high vaccination coverage Strengthen immunization programmes Electronic vaccination registry Reminder and recall systems Champions and experts as advocates 28
Challenge 2 Closing immunity gaps Susceptible adults Unvaccinated adolescents Susceptible health care workers Low coverage communities 29
Addressing the challenge Supplementary immunization activities Tailoring Immunization Programmes Closing immunity gaps Pre school entry policies Health care workers policies Opportunity vaccination Pre travel vaccination 30
Challenge 3 Performing high-quality surveillance Inadequate reporting of suspected cases Sub optimal laboratory testing rate Insufficient genotyping and sequencing Distribution of rubella genotypes year 2015 Measles Lack of national operating procedures for epidemiological and laboratory investigations Rubella 31
Addressing the challenge Performing high-quality surveillance Reporting of suspected cases Epidemiological investigation Laboratory confirmation Genotyping and sequencing Establishing national operating procedures for epidemiological and laboratory investigation 32
Challenge 4 Knowledge and training Widespread misinformation and myths Lack of education and training on vaccines in medical curricula Vaccine side-effects are worse than the actual disease False contraindications Lack of information Lack of personal knowledge and disease awareness The MMR vaccine causes childhood disorders, including autism Sophistication of anti vaccine lobbying and media skills 33
Addressing the challenge Knowledge and training Web based information on diseases and benefits of vaccines Medical curricula Continued medical education Training in communication School based learning Health care workers to promote vaccines Champions and experts as advocates 34
Resource mobilization and partnerships 35
Verification of Measles and Rubella elimination Regional Verification Commission (RVC) established in 2012 4 th RVC meeting, November 2015 Evaluation of country Annual Status Updates and feedback to countries Meetings with National Verification Committees Modifications to verification process Updating of annual reporting form Messaging and communication 36
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Summary Progress has been made toward eliminating measles and rubella WHO European region off track for 2015 goal More action needed: Commitment Maintaining high vaccination coverage Closing immunity gaps High-quality surveillance Fostering partnerships 40
Acknowledgements Colleagues at Vaccine-preventable Diseases and Immunization Unit Myriam Ben Mamou Catharina De Kat-Reynen Dragan Jankovic Theodoros Kaloumenos Patrick O Connor Simarjit Singh 41