nadia teleb md, mph, dr.ph regional adviser, vaccine preventable diseases and immunization who/emro...
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Nadia Teleb MD, MPH, Dr.PHRegional Adviser, Vaccine Preventable Diseases and Immunization
WHO/EMRO
Measles control and elimination in the Eastern Mediterranean Region
Palestine
Bahrain
The Eastern Mediterranean Region
GAVI eligible: 7 countries, 56%
LMIC: 7 countries, 38.5%
HIC: 6 countries, 3% of LB
UMIC: 3 countries, 2.5%
Pop: 555 MillionLB: 16.4 Million
Outline
• Regional targets • Regional strategy• Progress in implementation of the regional
strategy• Progress towards achieving the target• Plans 2011-2012• Challenges and opportunities
Measles related targets in the EMR
Measles elimination from all countries
by 2010 (resolution EM/RC44/R.6, 1997)
Target date revised to 2015 (EPI managers’ meeting ,
July 2010)
Measles Mortality reduction target:
EMR adopts the global target
Regional Strategy to achieve measles control/elimination in the EMR
1. Achieving high population immunity: 1) Nationwide measles catch-up vaccination campaign, achieving
homogenous high coverage2) sustaining population immunity through high vaccination coverage
(≥95% coverage in all districts) with 2 doses of MCV; preferably during the second year of life: a. Routine MCV1; ANDb. Second dose: routine second dose and/or Periodic follow-up SIAs
which should continue until achieving the high routine coverage for MCV1 and MCV2
2. Strong case-based lab surveillance3. Case management
Progress in implementation of the regional strategy
1. Measles vaccination
Country MCV1 MCV2Type Age Type Age
Afghanistan M 9 m M 15-18 mBahrain MMR 12 m MMR 5yDjibouti M 9 m
Egypt MMR 12 m MMR 18 mIran MMR 12 m MMR 18 mIraq M 9 m MMR 15m, 4-6y
Jordan MMR 12 m MMR 15-18 mKuwait MMR 12 m MMR 2y, 12y
Lebanon MMR 12 m MMR 4-6 yLibya MMR 12 m MMR 15-18 m
Morocco M 9 mOman MMR 12 m MMR 15-18 m
Pakistan M 9m M 15-18 mPalestine M 9 m MMR 12m, 18 m
Rubella 12Y
Qatar MMR 12 m MMR 4-6 ySaudi Arabia M 9 m MMR 12m, 4-6 y
Somalia M 9 mSudan M 9 m
S. Sudan M 9MSyria MMR 12 m MMR 15-18 m
Tunisia MR
15 m12y
M 6 y
UAE MMR 12 m MMR 4-6 yYemen M 9 m M 15-18 mEMR MCV1 @ 9m: 7 countries/ MCV2 18 countries, / R in 15 countries/ MMR2: 14 Countries
MCV1/MCV2 Schedule/type of vaccine, EMR, 2011
Source: JRF 2010
Reported district coverage of MCV1, 2010Target 95% in all districts
Source: JRF 2010
Cove
rage
% Improving routine immunization:• RED approach in AFG, IRQ, PAK, SOM,
SUD, YEM• CHDs in Somalia• Acceleration campaigns in SUD, AFG• Vaccination week of the EMR
Palestine
Bahrain
Follow up campaigns
Response campaigns High routine coverage
Measles vaccination strategies in the EMR
2. Supplementary immunization activities (SIAs)
Catch-up campaigns implemented in all countries
Around 400 million people vaccinated 1994-2010 through SIAs
Measles SIAs in EMR 2010-2011
Country Activity Age Group Target Reached Coverage
Pakistan Flood response 9mo-13yrs 15,209,539 13,740,906 96%Somalia CHD 1st round 9-59mo 1,238,186 1,137,268 92%Sudan Follow up 9-59mo 2,187,679 2,076,757 97%Yemen Mop up 9mo-15yrs 603,043 455,517 76%Iraq Follow up 9-59mo 2794889 2,603,752 93%Iran Mop up 9mo-12yrs 118190 117,009 99%Kuwait Follow up 1-7 years 363329 272,829 75%EMR 22,514,855 20,404,038 91%
Afghanistan Follow up 9-59mo 137,408 84,591 62%
Pakistan Follow up 9-59mo 9,445,428 10,286,294 109%
Somalia CHDs/Mop up 6mo-15yrs 724,706 648,198 89%
Sudan Follow up 9-59mo 3,961,703 3,910,620 99%
Yemen Mop up 6mo-15yrs 177,702 146,001 82%
EMR 14,446,947 15,075,704 104%
Measles SIAs conducted 2011
Measles SIAs conducted 2010
Progress in implementation of the regional strategy
2. Measles surveillance
Palestine
Bahrain
Nation-wide Measles Case-based surveillance (19)
Moving to Nation-wide measles surveillance (1)
Measles Case-Based Surveillance in EMR, 2011
Sentinel sites measles surveillance (3)
Serology and virus detection/isolation capacity (11)
Measles Laboratory Network in the EMR, 2011
Palestine
Bahrain
Serology capacity only (6)
Regional Reference LaboratoriesSerology and virus detection/isolation and sequencing capacity (6)
Measles Virus Genotyped In the EMR Countries, 2007 to 2011
0
5
10
15
20
25
30
35
40
Afg Bah Djb Egy Ira Irq Jor Kuw Lib Mor Omn Pak Qat SAA Som Sud Syr Tun Yem
Countries
Nu
mb
er o
f S
amp
les
Gen
oty
ped
H1
D8
D5
D4
B3
No genotype data from 4 countries: PAL, LEB, S.SUD, UAE
Measles surveillance performance indicators in the EMR
2010 2009 2008 2007 2006 2005 Indicator
86% 72% 77% 80% 57% 75% %of countries ≥80% of suspected cases tested
100% 95% 91% 100% 68% 100% %of countries ≥80% cases with complete investigated
68% 73% 68% 70% 36% 50% %of countries with ≥80% specimen received at lab 7day of collection
91% 96% 96% 100% 89% 100% %of countries with ≥80% adequate specimens
86% 95% 81% 90% 58% 75% %of countries with ≥80% results reported within 7 days
42% 52% 52% 42% 22% Zero% %of countries that achieved the reporting rate ≥2 /100,000 population at national level
27% 9% 9% 9% 4% Zero% %of countries that achieved the reporting rate ≥1 /100,000 population at all sub-national level
Palestine
Bahrain
Measles vaccination strategies in the EMR
2. Supplementary immunization activities (SIAs)
Rubella & CRS Surveillance system situation in EMR
Rubella testing and CRS system (9 countries)
Rubella testing only (12countries)
None (2countries)
Geographic distribution of rubella cases in the EMR countries by district and final diagnosis between July 2010 and June 2011
The source of data in this slide is country measles surveillance DEFs received on monthly basis from countries
Progress towards achieving the target
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
Measles mortality reduction in the EMR 2000-2008
93%
90%
Estim
ated
mea
sles
dea
ths
Bah
rain
Djib
outi
Jord
an
Pal
estin
e
Tun
isia
Egy
pt
Syr
ia
Om
an
Leba
non
Pak
ista
n
Iran
Iraq
Liby
a
Kuw
ait
Sud
an
Yem
en
Sau
di A
rabi
a
Mor
occo
UA
E
Qat
ar
Som
alia
Afg
hani
stan
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
0.00 0.00 0.00 0.00 0.00 0.18 0.45 0.954.93
5.757.62
8.759.64
10.44
15.1715.52
15.8416.12
16.16
59.79
66.59
76.87
Measles minimum incidence rate per million population in the EMR 2010
Ca
ses/
mill
ion
Progress in Measles elimination in the EMR88% reduction in reported cases between 1998 to 20108 countries close to elimination in 2010
Source: Country reports Inadequate surveillance
Geographic distribution of measles cases in the EMR countries by district and final diagnosis between July 2010 and June 2011
Source : Official countries’reports
Progress In Eastern Mediterranean Region • Achieving the target:
– Measles mortality reduction target achieved 3 years ahead• Sustainability is threatened
– Measles Elimination target goal by 2010 was not reached• 8 countries are close to elimination• Target date postponed to 2015
• Measles case-based surveillance in 20 countries, expanding in 3 countries
• Regional guidelines for elimination validation developed, field tested and officialised
• Regional Validation Commission was formulated • National validation committee established in 5 countries, others are in
the process
Future plans• Supporting improving population immunity
– Continue strengthening routine immunization: RED approach, CHDs
– Introduction of MCV2 in Sudan Nov. 2011– Timely follow up SIAs
• Strengthening Measles surveillance:– Case based surveillance in Somalia and S. Sudan– Improving surveillance indicators to reach
requirements of validation indicators – Preparing for validation of elimination in the
ready countries
Country Activity Age Group TargetRemaining
gap
AfghanistanFollow up 9-59mo 441,932 $89,906
Pakistan Follow up 9-59mo 214,098 $214,098
Somalia CHD/Mop up 6mo-15yrs 900,329 $859,951
S. Sudan Follow up 6-59mo 658,486 $290,000
Yemen Mop up 6-59mo 271,000 $250,000Total EMR 2,485,845 $1,703,955
CountryTarget age
group
Target number of children
Funds needed
AfghanistanFollow up 6-59 months 5,001,074 6,824,918N Sudan Follow up 9-59 months 2,500,000 2,715,000S. Sudan Follow up 6-59 months 972,292 2,228,016Somalia CHD/Mop up 9 - 59 mo 3,037,180 10,594,181Pakistan Follow up 9-59 months 8,817,181 5,490,458Yemen Follow up 9-59 months 3,900,484 4,355,765Total EMR 24,228,211 $32,208,338
SIAs planned for 2011 and required funds
SIAs planned for 2012 and required funds
Planned SIAs for 2011 and funding requirement
Challenges
• Funding: specially for the follow-up campaigns – FU campaigns needed in 7 countries– Target:> 95 million for 2011-2015
• National managerial Capacity:– Inadequate number and qualification of staff – Devolution in Pakistan
• Competing priorities:– Polio eradication– Other EPI issues: NVI,..
• Pockets of susceptible populations/groups – Hard to reach populations in low income
countries– Pockets in countries with big expatriate
population
• Security situation: rapidly deteriorating in the EMR– Delayed implementation of planned activities
– Financial support from international partners
– Interest of the countries
– Renewing commitment: EPI technical paper submitted to RC October 2011
– Polio infrastructures
Opportunities
Summary
Remarkable progress in measles mortality reduction,
Measles elimination was not achieved in time, More efforts are needed with the current
political turmoil and security situation in some countries
Bridging funding gaps to support LIC countries is challenging
Acknowledgements
• Partners of the Measles initiative• CDC Atlanta• EMR RRLs in Tunisia and Oman• VIDRL Australia• EMR EPI staff, lab network• WHO/HQ
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