2. Learning Objectives
By the end of this lecture you will know:-
Difference between Control, Elimination & Eradication
Why we need to eliminate Measles !
Factors favouring the elimination & Challenges
Current strategies
3. Basic concepts
Control : Reduction of incidence & prevalence to a locally
acceptable level.
Elimination : Eradication from a large Geographic region or
political jurisdiction.
Eradication : Termination of all transmission by extermination
of agent through Surveillance & containment.
4. Measles (Rubeola)
An acute highly infectious viral disease of childhood
Caused by RNA virus of family Paramyxovirus
Fever with Cough, coryza or conjunctivitis (3Cs) followed by a
typical RASH
Koplik’s spots
Transmission by person‐to‐person via aerosolised droplets.
Complications
6. Why Measles ?
Global: 122000 Deaths in 2012 (330/day).
Disproportionate burden in developing countries.
India: 56000 Deaths 2011 or 156/day.
MDG 4, one indicator is (%) infants received primary dose.
Very severe in malnourished children (400 times).
Epidemic during winter & early spring.
7. Factors favoring Elimination
1) Virus: Only one antigenic type & cannot survive outside body
2) Reservoir : Human case
3) Source of infection: Aerosolised droplets
4) Transmission: Person to person
5) Communicability: 4 days before to 4 days after rash
6) Isolation: 1 week from rash
7) Secondary Attack Rate : Rare
8) Vaccine: Gives lifelong immunity but with TWO doses
8. Challenges for Elimination
Weak Immunization system
Highly infectious nature
Inaccessible population
Refusal by some population
Changing Epidemiology of Measles
Catch–up to > 130 Million children
Gaps in Human & Financial resources at multiple levels
9. Rationale for 2nd Dose
Effectiveness 85% at 9 months & 95% at >12 months
DLHS-3 (2007-08) Measles 1st dose 69.6%.
Actual protection at 9 months to only 60%
(70% Coverage × 85% Efficacy = 60%).
40% remained susceptible to measles.
2nd opportunity ≥ 1 year will give double benefits.
10. Measles control - Strategies
Mortality
Reduction
Elimination
1st dose coverage >90% >95%
2nd Opportunity >90% >95%
Surveillance
Aggregate or case-
based
Case-based
Case Management
Vitamin A Supportive
Rx
Vitamin A Supportive
Rx
Targets for 2015
Routine MCV1 >90% National, >80% every district
Incidence < 5 case / million
Mortality reduction by >95 % (from 2000 level)
11. What has been done....
2nd dose Measles introduced in India 2010 under UIP
21 states MCV 1 coverage > 80% by RIA
14 states MCV1 < 80% coverage targeted all children 9mt-10yr
by SIA then introduced in RIA after 6 months
Phase I: 2010-11, Phase II:2011-12 & Phase III:2012-13
Mission Indradhanush (All under 5 by 2020 for 7 VPD)
12. Global Activities
1980 WHO & UNICEF: Accelerated measles mortality reduction
strategy
2 dose of MCV to all through RI & SIA and improve surveillance
63rd WHA 2010 set targets for 2015
1. Achieve at least 90% measles vaccination coverage nationally
and 80% coverage in all districts.
2. Reduce measles cases to <5 per million.
3. Reduce measles mortality by 95% compared to 2000 levels.
Global Measles & Rubella strategic plan 2012 – 2020
Close the Immunization Gap, 6 targets for 2015
Editor's Notes
Blooms taxonomy
Elimination : Eradication from a large Geographic region or political jurisdiction.
E.g. Measles from the Americas & Europe (WHO Regions)
Absence of endemic measles for > 12 months in presence of adequate surveillance
Sustained incidence < 1/100,0000 population
Polio from SEARO in February 2014
Eradication : Termination of all transmission by extermination of agent through surveillance & containment.
Absolute process, An all or none phenomenon.
It implies that disease will no longer occur in a population.
Smallpox in 1980
Polio, Measles, Diphtheria and Guinea worm expected.
An acute highly infectious viral disease of childhood
Caused by RNA virus of family Paramyxovirus
Clinically: Fever with Cough, coryza or conjunctivitis (3Cs) followed by a typical RASH
Koplik’s spots in the mouth.
Transmission by person‐to‐person via aerosolised droplets.
Incubation period 14 days from rash (range 7–18 days).
Complications are fatal
Leading cause of <5 mortality by VPD (Vaccine preventable Dis)
Children (>6mt-3yr) developing & >5 yr in developed country
60 % unvaccinated in just 6 countries
India has 6.4 million (2013)
Weak Immunization system (CES 2009 74.1% for Measles)
Highly infectious nature
Inaccessible population
Refusal by some population
Changing Epidemiology of Measles (Adolescent to adult)
Need to provide Catch–up to > 130 Million children
Gaps in Human & Financial resources at multiple levels
Effectiveness 85% at 9 months & 95% at >12 months
DLHS-3 survey (2007-08) coverage of 1st dose of measles stands at 69.6%.
Actual protection at 9 months was offered to only 60% (70% Coverage × 85% Efficacy = 60%).
40% remained susceptible to measles.
2nd opportunity given ≥ 1 year along with simultaneous increase in 1st dose coverage is an effective way
NTAGI : National Technical Advisory Group on Immunization M-R vaccine introduction plan in India
Nation wide M-R campaigns to be conducted
M-R vaccine to replace both MCV1, and MCV 2 at 9-12 months and 16-24 months respectively
Rubella vaccine introduction likely 1stquarter -2015
1980 WHO & UNICEF: Accelerated measles mortality reduction strategy
2 dose of MCV to all through RI & SIA and improve surveillance
63rd WHA 2010 set targets for 2015
Achieve at least 90% measles vaccination coverage nationally and 80% coverage in all districts.
Reduce measles cases to <5 per million.
Reduce measles mortality by 95% compared to 2000 levels.
Global Measles & Rubella strategic plan 2012 - 2020
Strong routine immunization of > 90%. Reaching Every District (RED) strategy,
Provide 2nd opportunity for immunization. One time only “catch-up” campaign “Follow-up” campaigns every 3-4 years or “Routine second dose”
Surveillance
Improved case management (Vitamin A – antibiotics – supportive treatment-Timely referral
Health, Education and WCD
Social Mobilization (IEC/IPC/BCC)
Injection safety, waste management , AEFI management established
Laboratory based measles-rubella surveillance system established across country on AFP surveillance network
Strong routine immunization of > 90%. Reaching Every District (RED) strategy,
Provide 2nd opportunity for immunization. One time only “catch-up” campaign “Follow-up” campaigns every 3-4 years or “Routine second dose”
Surveillance
Improved case management (Vitamin A – antibiotics – supportive treatment-Timely referral
Health, Education and WCD
Social Mobilization (IEC/IPC/BCC)
Injection safety, waste management , AEFI management established
Laboratory based measles-rubella surveillance system established across country on AFP surveillance network