Measles and Rubella Elimination

The Sixty-sixth meeting of the Regional Committee for South East Asia, in 2013, adopted the regional goal of measles elimination and rubella control by 2020. To provide impetus to the progress towards this goal, in 2014 the Regional Director announced Measles Elimination and Rubella Control by 2020 as one of the Flagship Priorities for the Region. During the Seventy-Second Session of the Regional Committee for WHO South-East Asia Region the goal of ‘measles elimination and rubella/CRS control by 2020’ was revised to ‘measles and rubella elimination by 2023’.

It is estimated that there has been 98% reduction in mortality due to measles in the Region by 2020 compared to 2000  and the estimated number of measles cases reduction by 82% for the same period.

As of December  2021, five countries have been verified and have sustained measles elimination - Bhutan, DPR Korea, Maldives, Sri Lanka, Timor-Leste.  In addition Maldives and Sri Lanka have sustained their rubella elimination status in 2021.

All eleven Member countries in the Region have adopted “Acute Fever and maculopapular rash“ surveillance and good progress has been made to enhance the sensitivity of surveillance  with non-measles non-rubella discard rate of 1.46 per 100 000 population.

COVID-19 pandemic had a significant impact on measles and rubella elimination efforts. All eleven Member countries in the Region are administering two-doses of measles containing vaccine (MCV) and at least one dose of rubella containing vaccine (RCV) in Routine Immunization. The coverage of first dose of measles containing vaccine across the Region has shown a significant decline from 94% in 2019 to 88% in 2020 and the coverage for second dose of measles containing vaccine declined from 83% in 2019 to 78% in 2020. Similarly, the coverage of rubella containing vaccine declined from 93% in 2019 to 87% in 2020. 

Independent review commissioned to assess progress towards measles and rubella elimination by 2023 has cautioned that the Region is off track to achieve the 2023 milestones and for a need to revise the dates in consultation with global and regional experts , partners and Member States.

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.

Measles elimination is estimated to prevent at least 1.1 million cases of measles every year in the Region and for every case of measles prevented approximately 2 weeks of disability adjusted life years (DALYs) will be averted. By 2023, approximately 1.1 million deaths due to measles also can be averted through a combination of various strategies during 2020-2023, at an average cost of USD 1,373 per death averted.

Rubella elimination is estimated to prevent 52 118 cases of congenital rubella syndrome (CRS) annually in the Region. The cost of a CRS case management (treatment and disability support) has been estimated to be US$ 4 200 for low-income countries, US$ 57 000 per case in middle-income countries and US$ 140 000 over a lifetime in high-income countries. The loss of DALYs for every CRS case averted will be between 27 years in low- and middle-income countries to 18 years in high-income countries.

A Regional Strategic Plan for measles and rubella elimination in the WHO South-East Asia Region (2020-2024) was adopted by Seventy-Second Session of the Regional Committee for WHO South-East Asia Region the with the following strategic objectives.

• Strategic Objective 1 (SO1): Achieve and maintain high population immunity with at least 95% vaccination coverage with two doses of measles and rubella containing vaccines in each district of each country.
• Strategic Objective 2 (SO2): Develop and sustain a sensitive and timely case-based surveillance system for measles and rubella.
• Strategic Objective 3 (SO3): Develop and maintain a proficient measles and rubella laboratory network.
• Strategic Objective 4 (SO4): Ensure adequate outbreak preparedness and respond rapidly to measles and rubella outbreaks
• Strategic Objective 5 (SO5): Strengthen support and linkages to achieve the above strategic objectives.

CHALLENGES

1. Impact of COVID-19 pandemic on the flagship area of measles and rubella elimination and response actions. The decline in coverage of measles vaccination is likely to result in increased mortality and morbidity due to measles. Similarly, surveillance for vaccine-preventable diseases was affected by the pandemic due to various reasons but gradually reviving. Around 38 553 suspected measles cases were reported in 2021  compared to 31 091 cases in 2020, and  68 929 cases in 2019. The pandemic also delayed the implementation of mass vaccination campaigns for measles and rubella in the Region, and delayed various monitoring and evaluation activities.
2. Significant challenges to achieve measles and rubella elimination in the Region remain irrespective of the pandemic, the greatest of which is to improve routine immunization to 95% or more coverage with two doses of a measles-rubella containing vaccine in all districts of all countries. A significant number of children in the Region do not receive the first dose of a measles containing vaccine through the routine immunization programme annually. Sensitivity of the surveillance for measles and rubella remains sub-optimal in endemic countries resulting under reporting and underestimation of the disease burden.
3. An additional funding requirement of US$ 0.19 per capita per year will have to be committed, in addition to the current funding level, jointly by national governments and partners to optimally implement strategies to achieve measles and rubella elimination goal by 2023.¹
4. Ensuring optimal implementation of key elimination strategies at accelerated pace remains a huge challenge, more so now with the COVID-19 pandemic and COVID-19 recovery phase that is likely to last for a couple of years to come.

LOOKING FORWARD

High level consultation to revise the target date for measles and rubella elimination

Independent review commissioned to assess progress towards measles and rubella elimination by 2023 has cautioned that the Region is off track to achieve the 2023 milestones and for a need to revise the dates in consultation with global and regional experts , partners and Member States. The SEA Regional Immunization Technical Advisory Group, the SEA Regional Verification Commission for Measles and Rubella Elimination and  respective Member States will be consulted over the period of next 12-18 months with an aim of presenting the findings to the Regional Committee on possible revision of the dates for measles and rubella elimination target .

Recovery from impact of  COVID-19 pandemic: Countries in the WHO South-East Asia Region have developed strategic, operational and policy guidelines for reviving immunization and surveillance activities following the COVID-19 pandemic and indicators are gradually showing upwards trend.  It is critical to continue to regularly identify gaps in performance at national and sub-national levels following the COVID-19 pandemic and to develop tailored strategies to plug these gaps.

Continued Technical Assistance: The current way forward is to provide high quality technical assistance to Member States to support accelerated implementation of the recommendations made by the 12^th meeting of the Immunization Technical Advisory Group,  the 6^rd meeting of the Regional Verification Commission for measles and rubella and form the Independent Regional Review of measles and rubella program to ensure a full and timely implementation of these recommendations to achieve measles and rubella elimination by 2023.