Status of Measles and Rubella Elimination – Regions and Global

Closing immunity gaps in older children and adults towards measles and rubella elimination: lessons

learned and challenges

10 May 2016, Peter Strebel, WHO, IVB/EPI

AFR – measles elimination by 2020

AMR – measles elimination by 2000 rubella by 2010

EMR – measles elimination by 2015

EUR – measles and rubella elimination by 2015

SEAR – measles elimination by 2020, rubella/CRS

control by 2020

WPR – measles elimination by 2012, rubella

elimination (target date still to be determined)

All 6 WHO Regions have measles elimination goals

2000

2010

2015

2015

2020

2012

TDB

2020

2015

Global Vaccine Action Plan (GVAP) goals:

Measles elimination in 4 WHO regions by 2015 and 5 by 2020Rubella elimination in 2 WHO regions by 2015 and 5 by 2020 2

Region of the Americas free of rubella

3

The Report CardGlobal Vaccine Action Plan mid-point targets

– DTP3: All countries >90% national coverage, and >80% in every district by end 2015

– Polio: transmission stopped by end 2014

– Maternal and neonatal tetanus: eliminated by 2015

– Measles: eliminated in 4 regions by end-2015

– Rubella: eliminated in 2 regions by end-2015

– Introduction of under-utilized vaccines: At least 90 low or middle income countries to have introduced one or more such vaccines by 2015 4

Measles

0

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90

100

0

0.5

1

1.5

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MC

V C

ove

rage

* (%

)

No

. of

rep

ort

ed

cas

es

Mill

ion

s

Number of cases MCV1 Coverage* MCV2 Coverage*

94% Reduction in reported measles casesAnnual reported cases and MCV1* and MCV2** coverage, 1980-2014

6

* MCV1 coverage: coverage with first dose of measles-containing vaccine as estimated by WHO and UNICEF. **MCV2 estimates is only available from 2000 when global data collection started, however some countries have introduced the vaccine earlier.

Campaigns

Source: WHO/IVB database, 2015194 WHO Member States. Updated on 15 July 2015

21 countries introduced MCV2

since 2007

0 2,100 4,2001,050 Kilometers

72 Countries have low MCV1 coverage WHO/UNICEF Estimates of MCV1 Coverage, 2014

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 2015. All rights reserved

<50% (4 countries or 2%)

50-79% (33 countries or 17%)

80-89% (35 countries or 18%)

90-94% (46 countries or 24%)

Not available

Not applicable

>=95% (76 countries or 39%)

7

74 (37%) countries have <90% coverage with 1st dose of measles containing vaccines, 2014

5 WHO Regions still endemic for measlesReported Measles Incidence Rate*, Feb 2015 to Jan 2016 (12M period)

*Rate per 1'000'000 population

Data source: surveillance DEF file

Data in HQ as of 7 March 2016

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.

<1 (89 countries or 46%)

≥1 - <5 (34 countries or 18%)

≥5 - <10 (15 countries or 8%)

≥10 - <50 (28 countries or 14%)

≥50 (16 countries or 8%)

No data reported

to WHO HQ

(12 countries or 6%)

Not applicable

Rubella

Over half the world's children are not vaccinated against rubella

3 4 4 4 5 5 5 5 6 7 8 9 9 10 10 12 12 1316 18

22 23 23 24 25 24 26 26

39 39 41 41 42 44 46

0

20

40

60

80

1001980

1981

1982

1983

198

41985

1986

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1989

1990

1991

1992

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1994

1995

1996

199

71998

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22003

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2010

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2012

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2014

RC

V c

ov

era

ge (

%)

Global AFR AMR EMR EUR SEAR WPR

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.

*MCV1 was used as a proxy in the Member

States that have introduced Rubella vaccine.

Rubella containing vaccine coverage* by WHO region,1980-2014

By 2015, 18 countries

introduced RCV since 2012

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

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.

Introduced to date (148 countries or 76.3%)

Planned introductions in 2016 (11 countries or 5.7%)

Not Available, Not Introduced/No Plans

(35 countries or 18%)Not applicable

Estimates of the median incidence of CRS per 100,000

live births by country in 2010.

Vynnycky E, Adams EJ, Cutts FT, Reef SE, Navar AM, 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.0149160http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0149160

Regions Estimated numbers of CRS

cases*

2010

AFR 38,712

AMR <1

EMR 5,294

EURO 98

SEAR 49,229

WPR 8,889

GLOBAL 105,391

Progress by Region

The Americas (PAHO)Achievements:

• Proof of concept for measles and rubella elimination

• Declared as free of rubella and CRS

• On track for verification of measles elimination in 2016

Challenges:

• Maintaining elimination and ongoing importations

• Outbreak in Brazil – Pernambuco and Ceará States (19 March

2013 – 6 July 2015)– Transmission interrupted

• Outbreaks in the US– 648 confirmed cases in 2014– 189 cases in 2015– Intensive response efforts with large

financial costs

W. Pacific Region

Achievements:

• High MCV1, MCV2 and MCV-SIA coverage

• All countries have introduced RCV

• TAG recommends a 2020 rubella elimination goal

• Lowest measles incidence in 2012

Challenges:

• Resurgence in China and Philippines

• Large-scale measles outbreaks following importation in Viet Nam, Papua New Guinea, Solomon Islands and Mongolia

• Revising Regional Strategies and Plan of Action for the years 2016-2020

15

European RegionAchievements:

• High coverage with 2 doses of MCVs

• Interrupted endemic transmission of measles (22 MS) and rubella (23 MS)

Challenges:

• Low commitment to elimination in some member states

• Unimmunized and susceptible population: adolescent and adults, migrants, religious groups

• Mass immunization campaigns are not accepted in many countries

• Suboptimal vaccine demand

• Disruption caused by polio in Ukraine and influx of refugees into Europe

16

Achievements:

• In 2013, established a measles elimination goal by 2020

• MCV1 at 84% (India at 83%)

• India planning to introduce RCV 12016-2018 – 408 million children

• India started reporting monthly case data

Challenges:

• Need to increase routine immunization and strengthen surveillance (India and Indonesia)

• Outbreaks in some high coverage countries (Sri Lanka, Thailand)

• MR vaccine supplies

S.E. Asian Region

17

E. Mediterranean Region

Achievements:

• High level of control achieved in 6 countries, 3 of them are ready to verify elimination

Challenges:

• Persistent low coverage in some countries (Somalia, Iraq)

• Many member states affected by civil unrest

• New strategies needed to deliver vaccination services in civil war settings

• Problem of measles cases <1 year and among adults

18

African Region

Achievements:• 12 countries near elimination* and an

additional 14 on track for the 2020 goal• 19 countries with MCV2• 7 countries with RCV

Challenges:• Weak and fragile health systems in many

countries• Disruption caused by Ebola• Need for periodic SIAs in most countries

to reach children missed by routine immunization

• Measles outbreaks with age shift to older age groups

*Algeria, Burkina, Cap Verde, Rwanda, Eritrea, Gambia, Ghana, Mauritius, Senegal, Seychelles, Sao Tome, Zimbabwe

19

Monitoring Progress through Regional Verification of Measles and Rubella Elimination, 2014–2015

WHO Region

Regional Verification

Commissions

Established

Elimination Achieved

No. of countries % of countries

Americas YesMeasles: 34Rubella: 35

97%100%

Europe YesMeasles: 22

Rubella: 23

41%

43%

Western Pacific Yes Measles: 6 22%

Eastern No - -

South-East Asia No - -

Africa No - -

2015 Assessment Report of GVAP-- on measles and rubella goals

Recommendation:

Global, regional and national development partners support countries in securing the required resources and in implementing their measles and rubella elimination or control strategies and plans.

The recommendations of the mid-term review of the global measles and rubella strategic plan to be conducted in 2016, once endorsed by SAGE, should be taken into account in refining plans and for monitoring and enhancing quality of plan implementation.

21

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Younger thanage at MCV1

Age at MCV1to 4 years

5-14 years 15-23 years 24 years orolder

Vaccination status unknown

2 or more doses

1 dose

0 doses

22

The problem is failure to vaccinateAge and Vaccination Status of Confirmed* Measles Cases, 2010-2014 (n=356,632)

*Lab-confirmed or epi-linked.

Perc

ent

of

con

firm

ed c

ase

s

13%

41%

25%

11% 10%

2/3 of cases are age-eligible children who

received <2 doses

Changing Epidemiology of Measles leading to policy questions

Improving control: Near elimination:

23

? ?

15%

20%

13%

9% 10%

33%

0%

5%

10%

15%

20%

25%

30%

35%

<1 1-4 5-9 10-14 15-19 ≥20

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

29%

26%

17%

5% 4%

14%

6%

0%

5%

10%

15%

20%

25%

30%

35%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

9%

13%

7% 6%

11%

33%

21%

0%

5%

10%

15%

20%

25%

30%

35%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

9%

17%

12%

26%

16%

10% 9%

0%

5%

10%

15%

20%

25%

30%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

6%

12%10%

12%

15%

20%

25%

0%

5%

10%

15%

20%

25%

30%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Percentage of reported measles cases by age group

January-June 2013

WHO European Region (n=20 533)Turkey (n=6533) Georgia (n=5783)

Germany (n=1097)United Kingdom (n=1750)

Challenge of reaching susceptibles over a widening age range

Summary• The Americas has eliminated rubella and is on track for measles

• Other 5 Regions are still endemic for measles and rubella:

– High level control of measles but progress has slowed

– Coverage with RCV increasing but low in SE Asia and Africa

• SAGE has called for a midterm review

– Failure to implement strategies, not failure of strategies

• Changing epidemiology of measles leading to new challenges

• Challenge of vaccination in increasingly older age groups

• New opportunities to accelerate progress: MR introduction in India, new Gavi funding, victory of polio, and measles in the Americas

Acknowledgements• Country and regional programmes • Partners:

Immunity Gap among Infants <9mSAGE October 2015

Available evidence supports use of MCV before 9 months of age & recommends that infants from 6 months receive MCV*:• during a measles outbreak• during SIAs in settings where risk of

measles among infants remains high • for internally displaced populations

and refugees, in conflict zones; • individual children at high risk of

contracting measles (e.g. contacts of known measles cases )

• infants travelling to countries experiencing measles outbreaks

• infants known to be HIV-positive

*M, MR or MMR vaccines can be given

27

Source: Leuridan, E., et al., Early waning of maternal measles antibodies in era of measles elimination: longitudinal study. BMJ, 2010. 340: p. c1626.

3m