MEASLES MORTALITY REDUCTION IN INDIA

Status and Future Plans

Presentation structure
Status of routine immunization and polio

eradication Implementation of national measles strategic plan Expansion of AFP surveillance to include measles surveillance Coordinated assistance from partners

Basic Demographics and Population Density, India

Total Population Density by State 35 States

Table 1: Demography1 Total Population Population Growth Rate2 Live Births Birth Rate
Number of persons per sq. km

2005

Percent of Total Population

Infant Mortality Rate 2 Children < 1 Year Children < 5 Years Children < 15 Years
1 2 3

1,028,610,328 1.51% 27,552,928 2.7 26.7 / Per 1000 population 68 / Per 1000 live births 25,793,927 2.5 123,974,000 12.1 3 35.3 363,373,000

Source: SEAR Annual EPI Reporting Form, 2005. Core Indicators, 2005 (Health Situation in WHO SEAR and WPR).

413,417,000 was used to calculate Non-Polio AFP rates in 2005.

Updated: July 2006

Evaluated Coverage for MCV 1: National Family Health Survey

NFHS-II(1998-99)
Missing or Excluded 0% to 30% 30% to 50% 50% to 70% 70% to 80% 80% to 90% 90% and above

NFHS-III(2005-06)
All India Measles Coverage NFHS-III : 58.8% NFHS-II : 50.7% NFHS-I : 42.2%

Source: NFHS Survey

District-wise evaluated MCV 1 coverage:

DLHS -2002-04

14% of districts coverage below 30% 24% of districts coverage between 30-50% 28% of districts coverage above 80%

Missing or Excluded 0% to 30% 30% to 50% 50% to 70%

70% to 80%
80% to 90% 90% and above

Source: DLHS(2002-04) Survey

Reported/surveyed annual measles vaccination coverage and cases India, 1974-2005

Reported measles cases
300,000

vaccination coverage (%)

Reported

100% 90%

250,000

80% 70% 60%

200,000

150,000

50%

Surveyed
100,000

40% 30% 20% 10%

50,000

0 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 '00 '01 '02 '03 '04 '05

0%

Year
Reported cases
Source: India MOH/UNICEF

Reported coverage

Unicef CES

NFHS

Key activities to improve routine immunization coverage

Development and implementation of multi year plan

for Immunization Enhanced budget and support through national rural health mission (NRHM) Immunization weeks in 2005 and 2006 in states with low coverage Monitoring of routine immunization clinics in low performing states by government and partners Introduced routine immunization monitoring system (RIMS)

Percentage Coverage (Measles) of Annual Target achieved during last three Immunization Weeks (2006-07)
100.00 90.00 80.00

Coverage of Annula Target(%)

70.00 60.00 50.00 40.00 30.00 20.00 12.35 10.00 NA 0.00 7.08 NA NA NA NA NA NA NA 25.59 18.62 15.23 15.83 35.70 30.38 59.52

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Current status of Polio eradication

Consistent progress from 2002 through 2005, falling

cases, reduced geographic distribution of disease Outbreak in 2006 a temporary setback GOI mobilizing to finish as soon as possible

Substantial financial commitment Use of mOPV1 Accelerated rounds to rapidly immunize youngest children Capitalize on immunity resulting from recent outbreak

Polio cases, India

2000 1750 1500 1250 1000 750 500 265 250 0 1998 1999 2000 2001 2002 2003 2004 2005 2006* 268 225 134 66 672 1126 1934 1600

Year
* data as on 16th February 2007

Measles Surveillance in 2005

Passive surveillance

Aggregate data Under reporting(52454 cases & 55 deaths in 2005)

States with low coverage reports least number of cases

Little useful epidemiological data Measles is included in integrated disease surveillance program (IDSP) Outbreaks Investigations carried out by various national, state, academic institutions No standard guidelines Limited efforts to consolidate information and initiate action

Key actions for measles control since 2005

GoI initiated a consultative process with WHO,

UNICEF, IAP, ICMR, NTAGI Strategic plan for Measles Control was endorsed National measles surveillance and outbreak investigation guidelines were published National polio surveillance project was assigned to assist and integrate measles surveillance with AFP surveillance

State by state approach Integrated reporting from AFP surveillance sites Track and investigation of measles outbreaks

Laboratory network expanded One per each state starting measles surveillance Two laboratories were accredited and other two due in 2007

Integrated AFP and measles surveillance assisted by NPSP - 2007

Commenced in 2005 & 2006

Planned to initiate by March 2007 Planned to initiate by Sept 2007 By September will cover 9 sates and 40% of the population

Clinically confirmed measles cases 2006 through weekly routine reporting: by blocks Variation of incidence even among Southern states
Tamil Nadu Annual incidence 2.8 per 100,000 population Karnataka Annual incidence 10.2 per 100,000 population Andhra Pradesh
Initiated in September 2006

* data as on 15th February, 2007

Suspected measles outbreaks investigated, 2006 Possibly Karnataka has not tracked some of the outbreaks
Tamil Nadu Karnataka Andhra Pradesh

Tamil Nadu Measles outbreaks confirmed (Total cases) Measles outbreaks negative Rubella outbreaks confirmed (Total cases) Mixed outbreaks confirmed (Total cases) 15th February, 2007

Karnataka

Andhra Pradesh

29 (1098) 2 0 0

33 (1045) 2 2 (109) 1 (28)

13 (290) 0 0 0

* data as on

Serologically confirmed measles outbreaks Percentage of measles cases by age groups, 2006* 89% of cases in Karnataka are under 10 years
Tamil Nadu
50
50

Karnataka
50

Andhra Pradesh
49

40

40 33

42
40

38

40

31
30 30

30

20

20

20

14
10

15 4

8 5

10

9 2

10

2
1-4 years 5-9 years 10-15 years > 15 years

0 < 1 year 1-4 years 5-9 years 10-15 years > 15 years

0 < 1 year 1-4 years 5-9 years 10-15 years > 15 years

0 < 1 year

Total cases- 1012

Total cases- 1073

Total cases- 290

* data as on 15th February, 2007

Serologically confirmed measles outbreaks Vaccination status of measles cases (1-4 years), 2006
Low incidence, nearly 90% vaccinated cases and very low case fatality indicates Tamilnadu may not be a priority state for a catch-up campaign.
Tamil Nadu
9% 4%
17%

Karnataka

Andhra Pradesh

25%

29%

22% 61%

87%

46%

N=339 Vaccinated

N=407 Not Vaccinated

N=89 Unknown

* data as on 15th February, 2007

India Technical Advisory Group for Measles Control

Formed to advise national government on measles

control Terms of reference and composition recently endorsed by the Ministry of Health Director General, Indian Council of Medical Research will be the chairperson of this 22 member group Wide expertise and representation - national, state, medical associations, WHO, UNICEF and international experts, etc. Government would call the first meeting in second quarter of 2007

Coordinated partner assistance

Draft concept paper has been prepared by

WHO and circulated to partners of measles initiative

Key areas for collaboration

Advocacy Data for decision-making Implementation Fund raising

Key activities for partner assistance: (Advocacy and data for decision making)
Ensure adequate staffing to provide measles

technical and managerial support. Technical support to review available data on measles using the Measles Strategic Planning (MSP) Tool and prepare a situational analysis on measles

Important background document for the first meeting of the India technical advisory group for measles

Conduct survey of community perceptions towards

measles and measles vaccination.

By UNICEF community mobilizers and WHO/NPSP field volunteers

Conduct measles case fatality rate studies in

selected states

Key issues for consideration and support of partners: (Implementation)

Through the GoI, explore potential readiness

and suitability of any States to conduct a SIA in 2007/2008

Currently available USD 16.7 million from IFFIm for about 29 million children If national wide 9 months to -15Y campaigns planned, would need to target around 350 million children and would need around USD 200 million.

Need to prioritize states according to low routine, reported incidence and age distribution of cases Building consensus in India expert advisory group regarding early implementing states.

Key Area for assistance: Fund Raising

WHO/UNICEF to further explore with NORAD

about highlighting measles activities

Measles initiative to look for other potential

donors interested in India

Challenges
Governments heavy involvement in finishing

polio at the best opportunity Huge target populations for SIAs necessitating enormous amount of resources Funds for surveillance Anti vaccination lobbies against polio and Hepatitis B

Summary
Government of India has started

implementing measles control strategies So far focus has been for routine immunization strengthening and surveillance Government wants to introduce second opportunity based on surveillance

State wise approach SIAs need very good planning

Coordinated support from partners will be

critical

Thank you

Monthly reported number of clinically confirmed measles cases reported, 2006-2007* Similar seasonality in states in south India
Tamil Nadu
1350 1200 1050 900 750 600 450 300 150 0 55 289 207 130 21 20 41 73 62 72 87 145
150 0
Jan06 Feb06 Mar06 Apr06 May06 Jun- Jul-06 Aug06 06 Sep06 Oct06 Nov06 Dec06 Jan07

Karnataka

1350 1335 1200 1050 900 750 660 872 865

507

600 450 404 336 300 301 144 139 421

493

446

299

258

111

Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan05 05 06 06 06 06 06 06 06 06 06 06 06 06 07

Measles cases

Measles cases

Estimated Paralytic Polio Cases/year, India

200,000
NIDs/SNIDs NIDs/SNIDs strengthened OPV introduced started in RI

150,000

100,000

50,000

Before 1978

1994

1998

2002

2006

Unicef CES (1998-2005) India (Measles )

100 90 80 70 60 55.2 50 40 30 20 10 0 1998 1999 2000 NA 2001 50.2 55.6

68.1

% coverage

2005

1998

1999

2000

2001

2005

Source: Unicef CES Survey

All India (country level) data for 2001 not available