measles elimination orig
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MEASLES ELIMINATION
DR.SIVA .P.M
CONTENTS
• HISTORY
• GLOBAL INITIATIVES FOR MEASLES ELIMINATION
• INITIATIVES IN INDIA
• CONCLUSION
History• One of the earliest written descriptions of measles as a disease
was provided by an Arab physician in the 9th century who
described differences between measles and smallpox in his
medical notes.
• A Scottish physician, Francis Home, demonstrated in 1757 that
Measles was caused by an infectious agent present in the blood
of patients. In 1954 the virus that causes measles was isolated
in Boston, Massachusetts, by John F. Enders and Thomas C. Peebles.
• Measles
• Caused by a RNA virus
• Paramyxo virus
• Only one antigenic type
• Remain active in room temp for at least
• 24hrs
• Reservoir/ source – human
• Transmission – respiratory route
Contd….
• Temporal pattern – peak in late winter
• and spring
• Communicability – 4days before and 4
days after rash onset
• Incubation period – 10-12 days
(7-18 d range)
SEPIO Meet, 18-20 May 2011 Bose, WHO
6
Measles complicationsCorneal scarring causing blindnessVitamin A deficiency
(Common)Encephalitis
Older children, adults
≈ 0.1% of cases
Chronic disability
Pneumonia &Diarrhea (Common)
Diarrhea common in developing countries
Pneumonia ~ 5-10% of cases, usually bacterial
desquamation
Global burden
• According to 2010 data's
• 1,39,300 deaths globally due to measles
• Nearly 380 deaths/day
• 15 deaths/hr
• Of these most of the deaths belongs to
children < 5 years
• >95% deaths occurs in low income countries with
weak infrastructures
• Comparing data's with 2000
• In the year 2000 there are 5,35,000 deaths due to
measles compared to 1,39,300 in 2010
• There is 74% reduction in deaths compared to 2000
• 85% estimated MCV coverage in 2010 compared to
2000 with only 72%
• 65% countries reached >= 90% MCV coverage in 2010
MR initiative April 2012
• It’s a collaborative effort of
• WHO
• UNICEF
• AMERICAN RED CROSS
• UNITED STATES CENTERS FOR DISEASE
CONTROL AND PREVENTION
• UNITED NATIONS FOUNDATION TO
CONTROL MEASLES AND RUBELLA
Vision
Achieve and maintain a world without measles, rubella
and CRS
Goals
By end 2015
• Reduce global measles mortality by at least 95%
compared with 2000 estimates
• Achieve regional measles and rubella / CRS
elimination goals
By end 2020
Achieve measles and rubella elimination in at least 5 WHO
regions
Milestones
By end 2015
Reduce annual incidence to < 5cases/mill and maintain that
level
Achieve at least 90% coverage with the first routine dose of
MCV nationally
• And exceed 80% vaccination coverage in
every district
• Achieve at least 95% coverage with M,MR,or
MMR during SIAs in every district
• Establish a target date for the global
eradication of measles
• By end 2020
• Sustain the achievement of the 2015 goals
• Achieve at least 95% coverage with both the
first and second routine doses of measles
vaccine in each districts and nationally
Strategy to eliminate measles
• The strategy of 2012 – 2020 builds on
experiences in AMERICAS and in countries in
other WHO regions that successfully
eliminated indigenous transmission of
measles…
• There are five components in this strategy :
Components
• 1. Achieve and maintain high levels of population
immunity by providing high vaccination coverage
with 2 doses of measles vaccine
2. Monitor disease using effective surveillance and
evaluate programmatic efforts to ensure progress.
• 3. Develop and maintain outbreak preparedness ,
respond rapidly to outbreaks and manage cases
• 4. Communicate and engage to build public
confidence and demand for immunization.
• 5. Perform the research and development needed
to support cost-effective operations and improve
vaccination and diagnostic tools
1.Achieve and maintain high levels of population immunity
• Coverage >=95%
• Unvaccinated children old enough to receive MCV1 (9 or 12
months)
• Strengthening routine immunization
• 2nd dose via RI 1 month after 1rst dose ( 15 to 18months gen) or
at school entry
• Catch up and follow up
2.Monitor disease using effective surveillance and evaluate to ensure progress
• Effective surveillance needed to provide information :
• 1. To set priorities
• 2. Plan activities
• 3. Allocate resources
• 4. Implement prevention programmes
• 5. Respond to outbreaks
• 6. Evaluate control measures
• WHO developed standards based on
• 1. Case based surveillance with laboratory
confirmation
• 2. In depth outbreak investigations
• 3. Identification of viral genotypes from every
outbreak
• Measles elimination :
the absence of endemic measles cases for a period of
12 months or more, in the presence of adequate surveillance
• INDICATORS :
1. VACCINATION COVERAGE
• Vaccination coverage indicator : vaccine coverage of both 1rst routine
measles dose (MCV1) and 2nd dose of Measles vaccination (routine or
SIAs)
• Vaccination coverage target : achieving and maintaining at least 95%
coverage with both MCV1 and the 2nd dose of measles vaccination in all
districts and nationally
• 2.OUTBREAK SIZE:
• Outbreak size indicator: monitoring of outbreak size
of all outbreaks including outbreaks in closed setting
and outbreaks where interventions have taken place
to stop the outbreak
• Outbreak size target : at least 80% of outbreaks
should have less than 10 confirmed measles cases
• 3. INCIDENCE:
• Incidence indicator: measles incidence /mill/year
• Incidence target: measles incidence of less than 1
confirmed measles case per million population per
year excluding cases confirmed as imported
• 4. ENDEMIC MEASLES VIRUS STRAIN(s):
• Endemic measles indicator : the number of
endemic measles virus strains
• Endemic measles target : zero cases of measles
caused by an endemic strain for at least
12months
3.Develop and maintain outbreak preparedness and respond rapidly
• In elimination setting :
• Single case outbreak rapid investigation and
response
• In emergency setting:
• Urgent coordinated SIAs include
vit A supplementation prevent outbreaks and
child mortality
• Mortality reduction setting
• Each confirmed outbreak requires a thorough
risk assessment to guide the decisions and
planning of outbreak response immunization.
4.Communicate and engage to build public confidence
• Community awareness regarding
• 1. Immunization rights
• 2. Benefits
• 3. Safety
• 4. Available services
• Will promote public acceptance and participation
5.Perform research and development
• CDC in may 2011 highlighted critical research
areas necessary to achieve measles eradication:
• 1. Measles epidemiology
• 2. Assessing vaccine efficacy and effectiveness
• 3. Needle free vaccine delivery methods
• 4. Improved methods for laboratory testing for
measles
• 5. New immunization strategies
• 6. Improved methods to monitor and evaluate vaccination
programmes
• 7. Development of effective advocacy tools to use with
decision makers
• 8. Improved messages and strategies to communicate with
potential beneficiaries and their families
• 9. Economic analyses of different strategic options and
mathematical modeling.
•
INITIATIVES IN INDIA
• Accelerated measles control strategy
• Update on accelerated measles control
– Mcv-2 in routine services
– Catch-up campaigns
– Laboratory supported measles surveillance
• Linkages with RI
Principles of accelerated measles control strategies in India
1. Improve and sustain routine immunization coverage (MCV-
1)
2. Provide a second opportunity for measles immunization to all
eligible children (MCV-2)
3. Sensitive, laboratory supported measles outbreak
surveillance for case/outbreak confirmation
4. Fully investigate all detected measles outbreaks and ensure
appropriate case management
Global Context: Worldwide measles vaccination delivery strategies, mid-2010
MCV1 & MCV2, no SIAs (40 member states or 21%)
MCV1 & regular SIAs (59 member states or 31%)
MCV1, MCV2 & one-time catch-up (36 member states or 19%)
MCV1, MCV2 & regular SIAs (57 member states or 28%)
India
UPDATE ON ACCELERATED MEASLES CONTROL
SIA: MCV1 <80%
RI: MCV1 > 80%
2nd Dose of Measles vaccine: State specific delivery strategies
MCV1: Coverage of Measles containing vaccine per DLHS-3; CES-06 for Nagaland
2nd Dose of Measles in RI
• 17 states (MCV1>80%)
introduced measles 2nd dose
in their routine immunization
program
• 45 districts, who completed
measles campaign in phase -1
are in process of introducing
2nd dose in their RI program
MCV2 introduction through Supplementary Immunization Activity (SIA) in Phases
Initiated in November 2010; 45 districts from 13 states
o 9 district from Chhattisgarho 5 districts from each of the 6
states (Bihar, Jharkhand, Rajasthan, Madhya Pradesh, Gujarat & Haryana)
o 1 district from each of the 6 North-East states
Approximately 14 million target children 9 months – 10 yrs
Phase 1
Un-aware of need
(43.9%)
Reasons for un-vaccinated children: RCA surveys results
20
10
11
320
16
9
1 110
9
Parents didn't know about the
campaign
Parents didn't know about place
or date of the place or date of
the campaign
Fear of injection
Fear of AEFI
Parents didn't give importance
IEC/IPC(43.7%)
Operational Gap
(3.7%)
N=unvaccinated children; 30,200Note: Figures are % of total responses provided
Enhanced AEFI surveillance during the Measles catch-up campaigns
304 minor AEFIs and 40 serious AEFIs reported
All serious AEFIs reported and correctly managed
NO DEATHS – VACCINE OR PROGRAMME RELATED
Lesson learnt from 1st Phase:Areas for improvement
• Coordination and planning:
– Better coordination of the three primary department of health, education and
ICDS
– Clear timelines of availability of logistics
• Communication and advocacy:
– IEC ,BCC and interpersonal communication
– IAP, IMA and private doctors sensitization
– Private school principals orientation
• Vaccination in urban areas
• Injection waste management
• Supervision at all levels
Measles SIA plan, India
Phase 2 A (144 districts)
Phase 1, 45 districts covered
Phase 2 B (81 districts)
Phase 3 (91 districts)
Total target- 135 million childrenDistricts- 361
Planned phases of measles catch-up campaigns
Phase 1 Phase 2A
Phase 2B Phase 3 Total
Dates Q4 2010 – Q2 2011
Q3 – Q4 2011
Q1 2012 Q4 2012
No. districts 45 144 81 91 361
Target population (9m-10yrs)
millions
14.0 41.5 33.4 47.0 135.0
Children vaccinated (millions)
12.0
Expansion of measles outbreak surveillance
• Reporting of clinical
measles cases linked with
AFP weekly reporting in
these states
• One state level lab
strengthened in each state
testing for measles and
rubella IgM
2006
2007
2010
2009
2011
0200400600800
1000120014001600180020002200240026002800300032003400360038004000
< 1 year 1-4 years 5-9 years 10-14 years >= 15 years
Total cases = 9,221
Vaccinated Not Vaccinated Unknown
* Serologically and epidemiologically confirmed cases
** Data from 8 states (Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamilnadu and West Bengal* data as on 15th Jun, 2011
61 % no or unknown vaccination status
86 % < 10 yrs of age
Serologically confirmed measles outbreaks: Age and vaccination status of measles cases*, 2011
Serologically confirmed# measles, rubella and mixed outbreaks
(Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu and West
Bengal)
129 outbreaks
Measles outbreaks confirmed
Rubella outbreaks confirmed
Mixed outbreaks confirmed
1091010
2011*
# Outbreak confirmation for Measles: 2011 ≥ 2 cases IgM positive for measles and rubella
* data as on 15th Jun, 2011
2010#
198 16 5
219 outbreaks
Widespread measles virus transmission indicating gaps
in RI
RI – Measles synergies
• Measles catch-up campaigns has helped, RI
– By augmenting AEFI surveillance (reporting & management)
– By improving injection safety practices on a large scale
– By enforcing waste management practices (as per national guidelines)
– By optimizing cold-chain space & efficient vaccine stock management
practice at various levels (state/district/block)
– Encouraging fixed-day , fixed-site session based approach
• RI-measles synergy study is being done in jharkhand
• Year 2012 declared year of intensification of RI
– Operational plan under development
54
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