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

1. Measles, Rubella and CRS EliminationRegion of the AmericasEngaging Government and Civil Society to Achieve the Elimination 12th Annual Meeting of the Measles and Rubella InitiativeWashington, 10-11 September 2013 Dr. Carlos Castillo Solórzano Ms. Katri Kontio Dr. Carolina Danovaro

2. Presentation 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

3. Milestones: Measles, Rubella and CRS Elimination in the Region of the Americas 1994: Resolution to eliminate measles by 2000 2013: 4th IEC* meeting 2007: Resolution on documentation and verification process 2012 1999 1994 2002 2007 19951997 1th IEC* meeting 2001 2003 2009 2013 Sucre Agreement in Bolivia 2012: Resolution to maintain the elimination 2003: Resolution to eliminate rubella by 2010 2002: LAST ENDEMIC MEASLES CASE First mass campaigns against rubella 2009: LAST ENDEMIC RUBELLA AND CRS CASES First Ladiesas Ambassadors forthe measles elimination Largest measles outbreaks: Canada and Ecuador 2011-2012 * IEC=International Expert Committee for the documentation and verification process

4. MeaslesVaccination Coverage among Children <1 Year of Age* and Reported Measles and Rubella Cases, the Americas, 1980-2013* Measles Catch-up campaigns Rubella speed-up campaigns Measles Follow-up campaigns Confirmed cases % Vaccination coverage Last case of endemic measles Last case of endemic rubella * MMR in children 1 year of age by vaccine introduction Source: country reports to FCH-IM/PAHO * Data as of September 4, 2013

5. Where are We Now with the Regional Verification Process? IEC field visits2013PER (Feb)*ECU (Jul)* NIC (Aug) CARIBBEAN (Nov) BRA (Nov) 2014GUT VEN PAR URU • All National Commissions have submitted the reports. • Final and amendment reports due to December 2013. Final reports and amendments Final reports Draft report/On-going activities Source: Country reports to PAHO/WHO *Data as of September 9, 2013

6. 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

8. Technical Feasibility for Measles and Rubella Elimination • English Speaking Caribbean: • Measles (1991) • Rubella (2001) • USA: • Measles (1997) • Rubella (2001) • Cuba: • Measles (1993) • Rubella (2004) • 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 Source: Ministries of Health, Departments of Statistics and Epidemiology.

9. 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 Post partum MR coverage (March 2002) = 98%

10. Strong Political Decision • Pan American Sanitary Conference, 1994To set a goal to eliminate measles from the Region by 2000 • Pan American Sanitary Conference, 2003 To eliminate rubella and congenital rubella syndrome from their countries by 2010

11. 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

12. 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 Initiatives for Supporting Achievements of the Regional Elimination Goals: Social Mobilization

14. 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

15. High Level Advocacy with Government and Civil Society

16. State Dignitaries as Vaccination Leaders • Political priority • Financial resources (budgetary and extra-budgetary) • Active participation in public events

17. National and Sub-National Level Financial Contributions Example, Paraguay, 2007 Source: country reports to FCH-IM/PAHO

18. 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

19. Scientific Societies and Medical Associations Independent observers that contributes in creating confidence and trust in vaccines among the public

20. Church: Partners of Cooperation and Enablers

21. National Communication Plans During the Elimination Phase • Political support • Investments • Early planning and production of material

22. Example of Communications and Social Mobilization: Brazilian National Vaccination Campaign to Eliminate Rubella and CRS • 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

24. 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.

25. Project of Technical Cooperation among Countries (TCC): Vaccination against Measles and Rubella in Border Areas of Argentina and Brazil Participating Countries: (~ 20,000 vaccinated) Guyana Paraguay Peru Suriname Uruguay Venezuela Argentina Bolivia Brazil Chile Colombia French Guiana 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).

26. Challenges for Maintaining the Region Free of Endemic Measles and Rubella: Post-elimination Era

27. Interruption of Measles & Rubella/CRS Endemic Transmission in the Americas DOCUMENTATION AND VERIFICATION ACCELERATED CONTROL ELIMINATION CONTROL 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

28. Towards Regional Certification: The Last Inch? 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

29. 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

30. 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

31. Program Plans (2014) • 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

32. Thank you!¡gracias!