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Towards Measles Elimination in the Western Pacific Region Progress & Priorities. Global Measles and Rubella Management Meeting Geneva, 15-17 March 2011. Dr. David Sniadack and Dr. Wang Xiaojun Western Pacific Regional Office, WHO. Presentation Outline. Progress towards measles elimination

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towards measles elimination in the western pacific region progress priorities

Towards Measles Elimination in the Western Pacific RegionProgress & Priorities

Global Measles and Rubella Management Meeting

Geneva, 15-17 March 2011

Dr. David Sniadack and Dr. Wang Xiaojun

Western Pacific Regional Office, WHO

presentation outline
Presentation Outline
  • Progress towards measles elimination
  • Updates on rubella control
  • Priority activities in 2011-2012
  • Unmet funding needs
regional committee resolution 2010 wpr rc61 r7
Urged member states

to commit the human and financial resources

to develop and implement work plans

to regularly report surveillance data to WPRO

to establish independent national verification process following the establishment of standardized regional verification mechanisms by WPRO

to accelerate control of rubella and the prevention of congenital rubella syndrome

Requested the RD

to establish regional verification mechanism

to strengthen technical cooperation with Member States to achieve regional immunization goals

to seek additional resources to achieve regional goals utilizing frequent ICC meetings and other mechanisms

to report progress periodically to the Regional committee

Regional Committee Resolution, 2010 WPR/RC61.R7

Reaffirmed the 2012 measles elimination goal


Reported Measles Cases and MCV1 Coverage

Western Pacific Region 1980 – 2010

Source: WPRO surveillance database

WHO/UNICEF JRFs ,1980-2010


Measles Incidence*Western Pacific Region 2010

* per million population


< 1.0 (22)

1.0 – 9.9 (6)

10.0 – 49.9 (5)

50.0 – 99.9 (2)

Data pending (1)

Source: WPRO surveillance database, 2010

initiatives to improve routine measles coverage western pacific region 2010 2011
Initiatives to Improve Routine Measles Coverage,Western Pacific Region, 2010-2011
  • District approach: tackling low performing districts
    • Region: Capacity building through an inter-country workshop
    • China: Yellow-card warning mechanism (Guangxi, Guizhou)
  • Service delivery: responding to under-served populations
    • LAO PDR: planned increase in frequency of outreach services (4 to 6 times)
    • Philippines: Reaching Every Barangay strategy (REB) and urban poor project
    • Cambodia: Reaching Every Community Strategy (REC)

A chain is only as strong as its weakest link


Measles SIAs in 2010-2011

Western Pacific Region

SIA in China

5 provinces:8m-14y

3 provinces: 8m-6y

23 provinces: 8m-4y


102.3 million

LAO (9-59m)

3.0 million

PHL (9-95m)

18 million


CAM (9-59m)

1.5 million

2010 (CHN, VTN, PNG, TUV, FSM*)

VTN (9-71m)

7.0 million

FSM (12m-83m,Chuuk)


2011 (CAM, PHL, LAO)

PNG (6-35m)

0.5 million

TUV (12-71m)




Measles Incidence

10.0 – 49.9 (4)

50.0 – 99.9 (2)


Completeness and Timeliness of Country Reporting to WPRO

Western Pacific Region 2007-2010

  • Source: WPR surveillance database

Indicators of Progress Towards Measles Elimination

Western Pacific Region 2007-2010

Source: WPRO surveillance database


Measles and Rubella Lab Network

+331 prefectural labs

382 laboratories


3 RRLs

16 National (13 fully functional)

31 provincial

+ 331 prefectural



At/near (25)

Likely (6)

Hopefully (6)

Probability of Measles Elimination by country, Western Pacific Region

88.4% of

the regional


4.1% of the regional population

7.5% of the regional population


Measles Cases by Month

Viet Nam 2008– 2010

Measles Cases by Age

Viet Nam Oct 2008 – 2010

Source: Surveillance data


Laboratory Confirmed and Epi-Linked Measles Cases, by Month, Viet Nam 2010 – 2011*

Measles Cases, by Province

Viet Nam 2010-11*

December 2010

January 2011

Dec 2011– Jan 2011

Jan-Nov 2010

* Data from surveillance reports through March 2011


Confirmed Measles Cases, by Week of Rash Onset,

2009-January 2011

Philippines 2010

1 dot = 1 case

Lab Confirmed and Epi-linked Measles Cases,

by Age, 2010


< 1

1 – 1.9

≥ 2

Lab-Confirmed Measles Cases, by Age Group and Vaccination Status, Cambodia 2010

Laboratory Confirmed Measles Cases and Discarded Rates, Cambodia 2010

1 dot = 1 lab case

Discarded rate (per 100,000)

rubella control in wpr
Rubella Control in WPR

Regional Plan for Control of Rubella and Prevention of Congenital

Rubella Syndrome in the Western Pacific Region, 2010-2015

Goal: To achieve and maintain control of rubella and prevention of CRS in the WPR

  • Rubella: ≤ 10 / 1 million population, excluding imported cases
  • CRS: ≤ 10 / 1 million Live births, excluding imported cases

July 2010

Nov 2010


WPR: 41 per million population

Rubella Incidence

Western Pacific Region 2009

LEGEND (per million population

< 1.0 (21)

1.0 – 9.9 (8)

10.0 – 19.9 (3)

20.0-99.9 (4)

Data source: JRFs

History of RCV Use in WPR

Protecting F & M ≥ 20 yrs (16)

Protecting F ≥20 yrs (5)


Protecting F & M ≥ 15 yrs (4)

Recent introduction of RCV (5)

RCV to be introduced (6)


rubella cases by sex and age group 2008 2010
Rubella Cases by Sex and Age Group2008-2010

Viet Nam

Females: 60% CBA


89% <20y

Data source: WPRO surveillance and laboratory database

priority activities of measles elimination western pacific region 2011 2012
Priority Activities of Measles Elimination Western Pacific Region, 2011-2012

Funding not secured

Closing immunity gaps, focusing on priority countries

  • Conducting quality SIAs, incorporating MR when feasible
      • 2011: CAM (Feb-Mar, MV, ? Oct), PHL (Apr, MR), LAO (Nov, MR)
      • 2012: PNG and several Pacific island countries
  • Improving routine MCV1 and MCV2 coverage
    • Introduction of MCV2 (CAM > 80% since 2008)
    • Exploring practical approaches to identifying under-served population groups/communities and improving their access to immunization services
      • Link to needed solution to address quality gaps in previous SIAs (vaccination of children 5-14 years old in CAM)
  • Identify and implement appropriate approach to and strategies for immunizing adults
    • Key constraints: funding, vaccine production capacity (MV or MR)
  • Epidemiologic analysis of adult measles cases in Beijing, China in collaboration with US CDC and WHO

Priority Activities of Measles Elimination Western Pacific Region, 2011-2012

Continue to improve surveillance, maintain accredited lab network, and provide more support to priority counties

  • Regional Level
    • Publish Measles and Rubella Bulletin monthly (planned in April 2011)
    • Frequent data analysis of countries
    • Update/revise field measles guidelines, incorporating rubella
    • Accreditation of all RRLs and NMLs in2011
  • Country level
    • Capacity building at country level: surveillance workshops
      • CAM, LAO, PNG, VTN
    • Country visits, followed by extensive follow-up actions

Priority Activities of Measles Elimination Western Pacific Region, 2011-2012

Initiate preparation for verification of measles elimination

  • Establish regional verification committee for measles elimination
  • Develop guidelines on verification of measles elimination for the region
  • Organize 1st regional verification commission meeting (September 2011)
  • Assist countries in initiating preparation upon country requests

Priority Activities of accelerating Rubella Control & CRS Prevention, Western Pacific Region, 2011-2012

  • Encourage introduction of RCV in Member States
    • With > 80% MCV coverage: CAM (GAVI support), VTN
    • With a need for frequent SIAs: LAO, PNG, SOL, VAN
  • Establish CRS sentinel surveillance (CHN, VTN)
  • Studies on disease burden of CRS (LAO, PHL, VTN)
unmet funding need in priority countries western pacific region 2011
Unmet Funding Need in Priority Countries*Western Pacific Region, 2011

* Priority countries/areas for funding support: CHN, CAM, LAO, MOG, PHL, PNG, VTN, PICs



B3 from Libya


H1, 1


D9 from Thailand, B3 from France

Hong Kong

D9 from Philippines, B3 from South Africa



H1, 2 D9, 2





H1 from Vietnam



New Zealand

Genotypic distribution of Measles virus in WPR 2009-2010

reported mcv1 and mcv2 coverage by country area western pacific region 2009
Reported MCV1 and MCV2 Coverage by Country/Area, Western Pacific Region 2009


Non-Pacific Island Countries


Pacific Island Countries

* For five countries with 2009 data not available, historic coverage data were used, including AMS (2008), WAF (2007), GUM (MCV1 in 2005, MCV2 in 2008)

Source: WHO/UNICEF JRFs, 2009


Reported Measles Cases, China 2009 – 2011*

Measles SIA

Decrease from previous year




*Surveillance report through February 2011


Trends in Age Distribution and Geographic Spread of Measles

Viet Nam October 2008-2010






Confirmed Measles Cases, by Month of Rash Onset,

Philippines 2003 – January 2011



D9. G3


Laboratory Confirmed Measles Cases

Philippines 2010 - January 2011

Oct 2010


Dec 2010



Measles Cases, by Month of Rash Onset and Method of Confirmation, Cambodia 2003 – 2011*

Clinically Confirmed

Lab confirmed

* Data reported as of March 2011


Reported Rubella Cases and RCV CoverageWestern Pacific Region 1993-2009

Incidence (2009): 41 per million population

Reported coverage

Coverage estimate with China data

With disease data from China

Data source: WHO/UNICEF Joint Reporting Forms, 1993-2009 and measles rubella surveillance data

challenges of measles elimination western pacific region
Challenges of Measles Elimination Western Pacific Region
  • High measles incidence in several countries
  • Evolving epidemiology
    • Shifting to infants and adults
    • Increased risk of measles transmission in densely populated urban areas
  • Importation and exportation
    • Importation: to Australia and New Zealand from several countries and Regions
    • Exportation: from Philippines to Australia, Canada, Japan, New Zealand and U.S.

Challenges of Measles Elimination - Immunity Gaps

  • Difficulty in ‘eliminating’ immunity gaps
    • Inadequate monitoring to identify low coverage areas/ populations
    • Inadequate systems and/or resources to increase responsiveness to under-served populations
    • Identifying and addressing quality gaps in previous SIAs
    • Identifying and implementing appropriate strategies to address measles in infants and adults
challenges of measles elimination surveillance
Challenges of Measles Elimination - Surveillance
  • Low sensitivity of surveillance at sub-national levels
  • Difficulty in timely obtaining accurate epidemiologic data
    • Delayed and incomplete case investigation data
    • Discrepancies between lab reports and national reports
  • Large proportion of clinically confirmed cases in some countries
  • Inadequate attention to collecting specimens for virus detection
challenges of measles elimination
Challenges of Measles Elimination
  • Funding gaps: Increasing needs and decreasing resources/sources
  • Competing priorities and stretched HRs
  • High level and broad political commitment
    • Interest and confidence in measles elimination
reasons for missed opportunities to rubella control
Reasons for Missed Opportunities to Rubella Control
  • Lack of evidence
    • Although rubella case are identified in greater numbers, CRS is under-reported and under-recognized in most developing countries in the region, resulting in less priority
  • Lack of motivation
    • Perception that control of rubella and prevention of CRS is an additional task: health officials are not motivated especially under pressure of eliminating measles by 2012
rubella cases by sex and age group western pacific region 2008 2010
Rubella Cases by Sex and Age GroupWestern Pacific Region 2008-2010

Data source: WPRO surveillance and laboratory database