Immunization

Measles and Rubella elimination

WHO/V Gupta Smith

In September 2013, during the Sixty-Sixth Regional Committee in New Delhi, all countries of WHO’s South-East Asia Region committed to eliminate measles and control rubella/congenital rubella syndrome (CRS) by 2020. A Regional Strategic Plan for Measles Elimination and Rubella/Congenital Rubella Syndrome Control was subsequently developed which covered a period from 2014-2020. The recommended strategies include:

1. Immunization: ≥95% coverage with two doses of measles and rubella containing vaccine (MRCV) in each district through routine and/or supplementary immunization activities (SIAs)
2. Surveillance: developing and sustaining a sensitive and timely case-based measles surveillance system that meets recommended performance indicators
3. Laboratory: developing and maintaining an accredited measles laboratory network
4. Linkages: Linkages to other public health programs to achieve above three goals.

In April 2017, Bhutan and Maldives were verified to have eliminated endemic measles.

Measles is a highly contagious viral disease, which affects mostly children. It is transmitted via droplets from the nose, mouth or throat of infected persons. Initial symptoms, which usually appear 10–12 days after infection, include high fever, runny nose, bloodshot eyes, and tiny white spots on the inside of the mouth. Several days later, a rash develops, starting on the face and upper neck and gradually spreading downwards.

Rubella is an acute, usually mild exanthematous fever affecting susceptible children and young adults worldwide. Its public health importance is due mainly to the teratogenic potential of the virus.

There is no specific treatment for both measles and rubella, most people recover within 2–3 weeks. However, particularly in malnourished children and people with reduced immunity, measles can cause serious complications, including blindness, encephalitis, severe diarrhoea, ear infection and pneumonia. Measles and rubella can be prevented by immunization.

Strategy: Achieve and maintain at least 95% vaccination coverage with two doses of measles and rubella containing vaccines within each district of each country in the Region, through routine and/or supplementary immunization.

Progress: As of end 2016, children in all eleven countries have access to 2 doses of measles containing vaccine (MCV) and eight countries have access to rubella-containing vaccine with DPR Korea, India and Indonesia in the process of introducing rubella-containing vaccine in routine immunization. In 2016, regional coverage with MCV1 was 87% and coverage of MCV2 was 63%. MCV1 is given at 9 months and MCV2 at 15-30 months in the Region (Refer to EPI fact sheets for RI schedules).

All countries have conducted a supplementary immunization activities (SIA) using measles and rubella containing vaccine to close the immunity gap due to sub-optimal coverage in routine immunization. An estimated 219.85 million additional children have been reached through SIA with measles containing vaccine between 2013 and 2017, 98% of the targeted for the period.

Strategy: To develop and sustain a sensitive and timely case-based measles and rubella surveillance system and CRS surveillance in each country in the Region that fulfills recommended surveillance performance indicators.

Progress: In 2013, measles surveillance with laboratory confirmation of suspected cases was implemented in all countries in the Region. Bangladesh, Nepal, and Myanmar reported case-based measles surveillance data monthly to the WHO South-East Asia Regional Office, while other countries in the region reported aggregate measles surveillance data monthly. Five countries (Bangladesh, India, Indonesia, Myanmar and Nepal) used the WHO-supported network of surveillance medical officers initially established for polio eradication to conduct measles surveillance. By 2017, all countries have initiated laboratory supported case-based surveillance for measles and rubella with India and Indonesia still expanding the surveillance across the country. The sensitivity of surveillance is measured using a proxy indicator of non-measles no-rubella cases of fever and rash rate of 2 or more per 100,000 population. While the sensitivity remains low in the entire Region at 0.73 per 100 000, five countries have already achieved the target of >2 non-measles non-rubella cases per 100,000 population and others are working to achieve the rate.

SEAR MR LabNet map

Strategy: Develop and maintain an accredited measles and rubella laboratory network that supports every country or area in the country for measles elimination and rubella/CRS control.

Progress: Measles-rubella surveillance in the Region is backed up by a WHO-accredited network of measles-rubella laboratories with at least one proficient laboratory in each of the countries, and supported by a Regional Reference Laboratory within the National Institute of Health, Thailand.

SEAR MR Laboratory Network was established by 2003 as integral part of the WHO Global MR Laboratory Network, and is currently comprised of 40 laboratories with at least one proficient laboratory in each of the country in the Region. Four additional laboratories (three in Indonesia and one in Nepal) have been proposed to join the network in 2018. To ensure that each laboratory is recognized as “proficient”, an onsite accreditation review of laboratory practices is conducted annually.

Strategy: Strengthen support and linkages to achieve the three objectives.

Progress: Several activities along the following four areas have been conducted.
• Advocacy, social mobilization & communication
• Outbreak preparedness and response
• Measles in emergency setting
• Research and development

A Regional Verification Commission (RVC) and National Verification Committees on measles elimination and rubella control have been formed to support countries in reviewing progress towards measles elimination and rubella/CRS control.

The government of India adopted the goal of Measles Elimination and Rubella and Congenital Rubella Syndrome Control† by 2020. To accelerate progress towards measles elimination and rubella/CRS control by 2020, India intensified approaches to close the population immunity gap for measles and rubella through strengthening of routine immunization as well as through supplementary immunization activities (SIA). In this regard, India is in the process of vaccinating children aged 9 months to below 15 years of age with measles and rubella containing vaccine (MRCV) in eight phases with a target to vaccinate more than 400 million children by first quarter of 2019. Two of these eight phases were completed by January 2018 in 13 states of India. Remaining phases are ongoing.

Country Achievements

BHUTAN

Banished from Bhutan: The story of how a small mountain kingdom eliminated measles

WHO Bhutan/S Bahadur

MALDIVES

A Killer Nailed: An island nation's triumph over measles

baby vaccinated maldives
WHO/Maldives