Global Measles and Rubella Management Meeting
Progress and Challenges in Bangladesh
15-17 March, 2011Geneva, WHO HQ
Dr Serguei Diorditsa
SYLHET
RAJSHAHI
KHULNA
DHAKA
CHITTAGONG
BARISAL
Measles control plan (2004-2010)
and next goals in Bangladesh
0
5000
10000
15000
20000
25000
30000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2016
Nu
mb
er o
f d
eath
s
60
65
70
75
80
85
90
95
100
Co
vera
ge
Measles death ( revised WHO 2010 estimates) MCV1 Coverage
Measles catch-up campaignimmunized: >35 million
Measles follow-up campaignimmunized: >18 million
plus OPV, vit A ,albendazole
Measles control plan 2004-2010
In 2011-2016, cMYP elimination targetIncluding 2nd dose MCV2 introduction
cMYP 2011-2016
Source: Child deaths due to measles 2000-2009 by WHO estimation, 10 Feb 2011
85%
Trends of measles cases and valid measles coverage by one year of age (1990-2010)
Measles catch-up campaignimmunized: >35 million
Measles follow-up campaignimmunized: >18 million
Dots are randomly placed within district boundary
Spot Map of Outbreaks Reported
in Bangladesh
2005 2006 2007 2008 2009 2010
Measles catch-up campaignimmunized: >35 million
Measles follow-up campaignimmunized: >18 million
Year 2005 2006 2007 2008 2009 2010
# of measles outbreaks ( lab) and ( mixed)
203 51 5 1 2 0
# of rubella outbreaks 87 26 102 59 145 193
Age Distribution of Lab Confirmed
Measles Outbreak Cases, Bangladesh, 2003-2010*
14%
14%
13%
13%
17%
23%
38%
43%
35%
31%
45%
50%
35%
30%
34%
37%
26%
13%
10%
8%
11%
12%
6%
10%
4%
4%
6%
7%
6%
4%
2003
2004
2005
2006
2007
2008
2009
2010
<1 year 1-4 years 5-9 years 10-14 years >=15 years Unknown
No Laboratory Confirmed Measles Outbreak detected in 2007
N=523 (12)
N=5,248 (68)
N=9,378 (120)
N=2,095 (34)
N=132 (1)
N=48 (1)
No Laboratory Confirmed Measles Outbreak detected in 2010
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
2003 2004 2005 2006 2007 2008 2009 2010
Nu
mb
er
of
Ca
se
s
Routne(suspected) Lab Measles and Mixed Rubella
Measles Cases in Bangladesh by Year 2003-2010
Changes in definition of outbreak:2003: 50 cases per ward2005:10 cases per ward2008: 3 cases per ward
Outbreak surveillance Case based surveillance
Measles catch-up campaignimmunized: >35 million
Measles follow-up campaignimmunized: >18 million
Measles surveillance indicators
SL Indicators 2009 2010
1Annual national incidence of non measles suspected measles cases (Target more than 2 per 100,000 population)
9.8 9.6
2Percentage of districts annually reporting at least 2 non measles suspected measles case per 100,000 population (Target at least 80% districts)
45% 58%
3 Annual number of reported rubella cases 13,464 13,125
4Percentage of reported suspected measles outbreaks fully investigated (Target 100%)
100% 100%
5 Completeness of monthly VPD surveillance reports (Target 90%) 91% 90%
6 Timeliness of monthly VPD surveillance reports (Target 80%) 84% 84%
7Percentage of suspected measles cases tested in a proficient laboratory, excluding from the denominator any cases that are epidemiologically linked to a laboratory confirmed case (Target 80%)
75% 81%
8 Percentage samples with laboratory results within 14 days (Target 80%) 52% 56%
Virus isolation status
Year No. of urine
Sample collected
Sample tested in regional
lab
Measles Rubella Negative Pending
2008 8 5 0 0 5 0
2009 27 16 0 3 13 11
2010 59 0 59
Non-measles suspected cases
reporting rate
2009 2010
58% (37/64) districts achieved rate ≥2.00 in 2010
2009 2010
No Case 4 0
<1.00 28 23
1.00 - 1.99 3 4
≥ 2.00 29 37
Number of DistrictsNon Measles Rate
per 100,000 populationLegend
Measles vaccination valid coverage by
12 months of age, 2005 and 2010
Source: CES 2005 and 2010
2005 2010
81% (52/64) districts achieved ≥80% coverage in 2010
2005 2010
<70% 27 1
70-79% 23 11
≥80% 14 52
LegendCoverage
MCV1Number of Districts
Challenge to improve Surveillance indicators
Measles case based surveillance -Integrated with AFP and other VPD
Challenge: financial sustainability and transition of VPD network parallel to health systems
140 facilities included for weekly active surveillance for AFP, NT and Measles- at the same time they are reporting 6 EPI diseases on weekly basis
All 471 Upazila Health Complexes (UHCs) included in weekly passive reporting
156 additional facilities conduct weekly passive reporting VPD surveillance supported by WHO funded
network of 42 SMOs
ICDDRB study on Impact of Measles Activities on
Routine Immunization Services and Health Systems in Bangladesh
T. Koehlmoos et al. The Journal of Infectious Diseases ( in press)
Conclusion:
• Measles elimination activities had enormous positive impacts on immunization programme and health systems of Bangladesh
• Effective integration of the immunization programme with health systems, high level political commitment and effective inter-agency collaboration contributed the campaigns successful
Examples of impacts:Governance•Strengthened inter-ministerial coordination and collaboration•Effective collaboration between MOHFW and development partners•Increased involvement of other sectors in immunization programme•ICC becomes more active•Raised awareness among political leaders•Improved accountability of staff members of the EPI programme
Planning and management•Improved skills of staff to develop strategies in EPI planning at national to local level •Improved skills to management of mass campaigns•Identifying and mapping of target and hard-to-reach population for other EPI outreach activities•Stimulate interdepartmental & inter-sectoral planning•Better long term planning of financing
EPI service delivery •Injection safety •Management & surveillance of AEFI
•Increased awareness among community members due to huge publicity •Delivery of add-on’s interventions (vitamin A, deworming, OPV)•Increased EPI centres and clinic visits of people after campaigns resulted to do less motivational works
ICDDRB study (cont’d)
Examples of impacts
Impact on Logistics
•New equipments were kept as fixed assets for routine immunization •Training and technical assistance to the local staff increased their skills and confidence to maintain cold chain
Impact on Financing
•Helped to develop skills in fund-raising from local and international partners•Funding or in-kind support for campaigns release money for other EPI activities•Motivated government & other funders to invest more money in EP
Impact on human resourcesPositive•Increased stock of EPI workforce/volunteers•Contributed development of inter-personal communication among the staff members of different sectors •Created opportunity for staff members involved from other department of MOHFW to learn more about EPI
NegativeStaff members de-motivated from late arrival of funding EPI staff feel overloaded with added worksShortage of technical staff The campaigns did not attract a sufficient number of volunteers in some areas as their refreshment fund were not enough
Budget for integrated VPD surveillance and measles activities in 2011-2013
( in million USD)
2011 2012 2013
planned available gap planned available gap planned available
gap
MCV 2 vaccine
Bangladesh will apply to GAVI for MCV2 cost support
MR vaccine Bangladesh consider the cost of MR vaccine to be born from new Health Sector Programme for 2011-2016
MCV2 Introduction-Training & supervision
1,22 0 1,22
surveillance 2,5 2,0 0,5 2,3 1.0 1.3 2.3 1,0 1.3
Total gap 0.5 Total gap 1.52 Total gap
1.3
Total Gap for 2011-2013 3,32 million USD
Thank You
2011 Plans and budget
• Measles initiative co-financed activities of WHO surveillance network in 2007-2010
• No funds for specific measles surveillance strengthening activities in 2011.
• In 2011 WHO SMOs network will continue support the current level of measles in integration with AFP surveillance.
• No donor’s commitment to support surveillance network after 2012
Budget for integrated (AFP/Measles/Other VPDs) surveillance and measles control/
elimination activities 2011-2016
Activities Fund required yearly 2011-2016
Fund required one time 2012
Fund available Funding gap
2011-2016
Funding gap one time
Annual Surveillance operational cost
2.5 million 1.5 million x2 l (in 2011-2012)
9,5 million
MCV2 Government will apply for GAVI support for vaccine
MCV2 Introduction-Training & supervision
1.22 million
0 1.22 million
Logistics –printings and others for MCV2
Cost is under consideration for next health sector program 2011-2016
MR vaccine Vaccine Cost is under consideration for next health sector program 2011-2016
Measles SIA No plan developed
Total 2011-2016 12.5 million 1.22 million
3 million 9,5 million 1.22 million
Total Gap 10,72 million
Advocacy Plans and Opportunities
• Advocate to include measles elimination activities in the new national health sector development plan for 2011-
2016 including: Funds for surveillance activities Create national position of district immunization and surveillance medical
officers (DISMO) Introduce MR vaccine and allocate cost in the health sector plan
• EPI will apply for GAVI support on MCV-2 introduction• Advocate for donors support of WHO surveillance
network to maintain current activities and during the transition to DISMOs