1. MEASLES ELIMINATION

2. CONTENTS
• HISTORY
• GLOBAL INITIATIVES FOR MEASLES ELIMINATION
• INITIATIVES IN INDIA
• CONCLUSION

3. 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.

4. • 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

5. 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)

6. Measles complications
Corneal scarring
causing blindness
Vitamin 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 SEPIO Meet, 18-20 May 2011 Bose, WHO 6

7. 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

9. • 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

10. 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

11. 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

12. 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

13. • 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

14. • 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

18. 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 :

19. 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

20. • 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

21. 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

22. 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

23. • 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

24. • 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

25. • 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

26. • 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

27. • 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

28. 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

29. • Mortality reduction setting
• Each confirmed outbreak requires a thorough
risk assessment to guide the decisions and
planning of outbreak response immunization.

30. 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

31. 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

32. • 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.
•

33. 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

34. 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

35. Global Context: Worldwide measles vaccination
delivery strategies, mid-2010
India
MCV1 & MCV2, no SIAs (40 member states or 21%)
MCV1, MCV2 & one-time catch-up (36 member states or 19%)
MCV1, MCV2 & regular SIAs (57 member states or 28%)
MCV1 & regular SIAs (59 member states or 31%)

36. UPDATE ON ACCELERATED
MEASLES CONTROL

37. 2nd Dose of Measles vaccine:
State specific delivery strategies
SIA: MCV1 <80%
RI: MCV1 > 80%
MCV1: Coverage of Measles containing vaccine
per DLHS-3; CES-06 for Nagaland

38. 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

40. MCV2 introduction through Supplementary
Immunization Activity (SIA) in Phases
Phase 1
 Initiated in November 2010;
 45 districts from 13 states
o 9 district from Chhattisgarh
o 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

41. Reasons for un-vaccinated children:
RCA surveys results
Parents didn't know about the
1 11 0 campaign IEC/IPC
9 (43.7%)
20 Parents didn't know about place
9 or date of the place or date of
the campaign
Fear of injection Un-aware of
10 need
(43.9%)
16
Fear of AEFI
11 Operational Gap
(3.7%)
20 3 Parents didn't give importance
N=unvaccinated children; 30,200
Note: Figures are % of total responses provided

42. 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

43. 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

44. Measles SIA plan, India
Phase 1, 45 districts covered
Phase 2 A (144 districts)
Phase 2 B (81 districts)
Phase 3 (91 districts)
Total target- 135 million children
Districts- 361

46. Planned phases of measles catch-up campaigns
Phase 1 Phase 2A Phase 2B Phase 3 Total
Dates Q4 2010 – Q3 – Q4 Q1 2012 Q4 2012
Q2 2011 2011
No. districts 45 144 81 91 361
Target population 14.0 41.5 33.4 47.0 135.0
(9m-10yrs)
millions
Children 12.0
vaccinated
(millions)

47. Expansion of measles outbreak surveillance
• Reporting of clinical
measles cases linked
with AFP weekly
reporting in these states
• One state level lab
2006 strengthened in each
2007
state testing for measles
2009
and rubella IgM
2010
2011

48. Serologically confirmed measles outbreaks:
Age and vaccination status of measles cases*, 2011
Total cases = 9,221
4000
3800
3600
3400
 61 % no or unknown
3200
3000
2800
2600
vaccination status
2400
2200  86 % < 10 yrs of age
2000
1800
1600
1400
1200
1000
800
600
400
200
0
< 1 year 1-4 years 5-9 years 10-14 years >= 15 years
Vaccinated Not Vaccinated Unknown
* Serologically and epidemiologically confirmed cases
** Data from 8 states (Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh,
* data as on 15th Jun, 2011 Rajasthan, Tamilnadu and West Bengal

49. Serologically confirmed# measles, rubella and mixed
outbreaks
(Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu and West Bengal)
#
2011* 2010
Widespread measles virus
transmission indicating gaps in RI
129 outbreaks 219 outbreaks
109 Measles outbreaks confirmed 198
10 Rubella outbreaks confirmed 16
10 Mixed outbreaks confirmed 5
* data as on 15th Jun, 2011 # Outbreak confirmation for Measles: 2011 ≥ 2 cases IgM positive for measles and rubella

50. 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

51. Thank you!
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