At the Intersection of Health, Health Care and Policy Cite this article as: Robin Biellik, Iria Davidkin, Susanna Esposito, Andrey Lobanov, Mira Kojouharova, Günter Pfaff, José Ignacio Santos, John Simpson, Myriam Ben Mamou, Robb Butler, Sergei Deshevoi, Shahin Huseynov, Dragan Jankovic and Abigail Shefer Slow Progress In Finalizing Measles And Rubella Elimination In The European Region Health Affairs, 35, no.2 (2016):322-326 doi: 10.1377/hlthaff.2015.1055
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2016 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Eliminating Measles
10.1377/hlthaff.2015.1055 HEALTH AFFAIRS 35, NO. 2 (2016): 322–326 ©2016 Project HOPE— The People-to-People Health Foundation, Inc.
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By Robin Biellik, Iria Davidkin, Susanna Esposito, Andrey Lobanov, Mira Kojouharova, Günter Pfaff, José Ignacio Santos, John Simpson, Myriam Ben Mamou, Robb Butler, Sergei Deshevoi, Shahin Huseynov, Dragan Jankovic, and Abigail Shefer
DATAWATC H
Slow Progress In Finalizing Measles And Rubella Elimination In The European Region All countries in the World Health Organization European Region committed to eliminating endemic transmission of measles and rubella by 2015, and disease incidence has decreased dramatically. However, there was little progress between 2012 and 2013, and the goal will likely not be achieved on time. Genuine political commitment, increased technical capacity, and greater public awareness are urgently needed, especially in Western Europe. Robin Biellik (rbiellik@gmail .com) is a retired World Health Organization (WHO) epidemiologist living in Geneva, Switzerland. Iria Davidkin is a retired senior researcher in the Viral Infections Unit, National Institute for Health and Welfare, in Helsinki, Finland. Susanna Esposito is head of the Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, in Milan, Italy. Andrey Lobanov is a retired WHO medical officer living in Moscow, the Russian Federation.
I
n May 2012 the World Health Assembly, the decision-making body of the World Health Organization (WHO), adopted the Global Vaccine Action Plan for the 2011–20 Decade of Vaccines. The plan emphasizes reaching a set of regional and global immunization targets, including eliminating measles in four of the six WHO regions and eliminating rubella in two regions by 2015, and eliminating both diseases in five regions by 2020.1 To put the plan into action, the WHO Regional Office for Europe launched the European Vaccine Action Plan, with all fifty-three member
states2 making commitments to eliminate the endemic transmission of measles and rubella by 2015.3 The reported incidence of measles and rubella in the WHO European Region has declined dramatically over the past two decades. In the presence of improving disease surveillance, the annual average number of reported measles cases fell from more than 200,000 in the period 1990–99 to fewer than 30,000 in 2010–14 (Exhibit 1). Despite this, significant measles outbreaks occurred in 2013 and 2014 in Azerbaijan, Bosnia and Herzegovina, Georgia, Germany, Italy, Latvia, the Netherlands,
Exhibit 1 Reported Vaccination Coverage And Reported Cases Of Measles And Rubella Among Member States Of The World Health Organization European Region, 1980–2014
Mira Kojouharova is deputy head of the National Center for Infectious and Parasitic Diseases, Ministry of Health, in Sofia, Bulgaria. Günter Pfaff is head of the Department of Epidemiology and Health Reporting in the Baden-Württemberg State Health Office, in Stuttgart, Germany. José Ignacio Santos is a professor in the Faculty of Medicine, Universidad Nacional Autónoma de México, in Mexico City.
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SOURCE Authors’ analysis of data reported annually to the World Health Organization and United Nations Children’s Fund. NOTES Measles and rubella cases (bars) relate to the left-hand y axis. Measles- and rubella-containing vaccine, first dose (MRCV1), and measles- and rubella-containing vaccine, second dose (MRCV 2; lines), relate to the right-hand y axis. Data were incompletely reported in the earlier period.
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the Russian Federation, Turkey, Ukraine, and the United Kingdom. The average annual number of reported rubella cases fell from more than 300,000 in 2000–09 to fewer than 20,000 in 2010–14 (Exhibit 1). Rubella outbreaks in Poland and Romania accounted for the majority of the recently reported cases. Continuing the trend observed in recent years, approximately one-third of reported measles cases occurred in individuals ages twenty and older. However, there are substantial differences across member states in the age distribution of reported cases. Most recent outbreaks of measles and rubella have occurred among the general population, but some have been concentrated in groups recognized as inadequately vaccinated, such as Roma communities and certain religious groups. In some countries a substantial number of measles and rubella cases have been reported among health care workers. The proportion of the population that is vaccinated (that is, the “vaccination coverage,” expressed in percentage) in the European region as a whole remains high, with first-dose measles vaccination coverage at approximately 94 percent.4 In addition, wide-scale supplementary immunization activities5 have been conducted, primarily in Eastern Europe and the Newly Independent States (the countries in the former Soviet Union, except for the three Baltic States), with twenty-four reported since 2000. Despite these efforts, most of the measles cases reported in 2014 occurred among unvaccinated or incompletely vaccinated individuals, including many older people with unknown vaccination status. In 2013, following a global technical consultation on the feasibility of global measles eradication,6 the WHO developed and published technical guidance on the regional process for verifying measles and rubella elimination.7 This guidance was modeled on the process for certifying poliomyelitis eradication. Additional information on the regional process is included in online Appendix Exhibit 1.8 The member states were required to provide evidence of the status of endemic measles and rubella transmission in a standardized format.9 A standardized annual reporting form was used to assist each national verification committee in compiling and documenting evidence along the following five principal lines: the epidemiology of measles, rubella, and congenital rubella syndrome (CRS); the performance of measles, rubella, and CRS surveillance; the molecular epidemiology of measles and rubella viruses; population immunity; and the sustainability of the national immunization program. The verification process requires that all evidence examined and presented by the national
verification committees be based on WHOrecommended quantified performance indicators and markers and be independent, objective, and free of conflicts of interest.
Study Data And Methods In July 2013 the national verification committees submitted data and evidence on the status of measles and rubella elimination in their respective countries during the period 2010–12. Background data included the evolution of the national immunization schedule and historical data on vaccines and vaccination strategies adopted since the establishment of the national immunization program. In 2013 and 2014, members of the Regional Verification Commission for Measles and Rubella Elimination (RVC) of the WHO Regional Office for Europe classified the member states in accordance with the WHO’s definition of elimination—namely, “the absence of endemic measles or rubella cases in a defined geographical area for a period of at least 12 months, in the presence of a well-performing surveillance system”—based on the five lines of evidence contained in each country’s reports.7 The year 2012 was selected as the first year for evidence for elimination. Member states that demonstrated interruption of measles or rubella transmission in 2012, 2013, and 2014 would qualify as having achieved elimination. Of course, the situation remains dynamic, and measles or rubella transmission may be reestablished, in which case a member state may lose its elimination status. An algorithm was developed to standardize conclusions based on the evidence submitted (Exhibit 2). In some instances, RVC members were unable to decide whether disease transmission remained endemic or interrupted. Reasons included inadequate surveillance systems; absent, incomplete, or conflicting surveillance data; low sensitivity of surveillance data; and inadequate or incomplete evidence of population immunity. In these cases, an “inconclusive” decision was recorded. Final results were sent to each member state along with recommendations, where appropriate, on actions to improve reporting in future.
John Simpson is interim director of the Division of Emergency Preparedness, Resilience, and Response, Public Health England, in Salisbury. Myriam Ben Mamou is coordinator of the Measles and Rubella Laboratory, Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe, in Copenhagen, Denmark. Robb Butler is program manager in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Sergei Deshevoi is a medical officer in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Shahin Huseynov is a technical officer in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Dragan Jankovic is a technical officer in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Abigail Shefer is a medical officer in the Global Immunization Division at the Centers for Disease Control and Prevention, in Atlanta, Georgia. At the time of this work, she was a technical officer in the Division of Communicable Diseases, Health Security, and Environment, in the WHO Regional Office for Europe.
Study Results As part of the regional verification process, fortynine member states submitted reports covering 2010–12, and forty-six countries submitted annual reports for 2013. By November 2014 seven countries had not yet provided annual reports for 2013, and three of them also had not yet F eb ru a ry 2 0 16
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Exhibit 2 Algorithm To Standardize Conclusions Based On The Presentation Of Evidence On The Status Of Measles Or Rubella Elimination
SOURCE Authors’ analysis. NOTE RVC is the European Regional Verification Commission for Measles and Rubella Elimination.
established national verification committees. Italy and Ukraine subsequently submitted annual reports for 2013, which were reviewed in 2015. Based on the reports submitted, the RVC concluded that as of the end 2013, twenty-two countries had interrupted endemic measles transmission, but seven of these remained at high risk of reestablishing endemic transmission, mainly because of significant immunity gaps in the population (Exhibit 3).10 For additional details, see Appendix Exhibit 2.8 Endemic rubella transmission was interrupted in twenty-three countries, with seven at risk of reestablishing endemic transmission (Exhibit 4). For additional details, see Appendix Exhibit 3.8 Measles transmission was considered endemExhibit 3 Measles Elimination Status Among Member States Of The World Health Organization European Region, December 31, 2013
SOURCE Authors’ analysis.
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ic in thirteen countries (Exhibit 3), and nine of these were considered to also have endemic rubella transmission (Exhibit 4). In addition, the RVC was unable to verify interruption of measles transmission in nine countries or of rubella transmission in twelve countries, because of inadequate surveillance data or low sensitivity of surveillance. Some improvement was noted in data timeliness and quality in the reports submitted in 2013 and 2014. However, there was little change when the final classification of measles and rubella elimination status among the member states in 2012 was compared to the classification in 2013.
Discussion The WHO Regional Office for Europe has launched a number of technical and advocacy initiatives designed to increase member states’ political commitment to and technical capacity for achieving the goal of eliminating measles and rubella by the end of 2015.11–14 Nevertheless, in view of the trends observed at the country level in the period 2010–13, that goal was unlikely to have been met. At the end of 2014 measles was subject to obligatory notification to national ministries of health in all member states; rubella and congenital rubella syndrome were notifiable in most but not all member states. There were occasional discrepancies between the number of measles and rubella cases reported routinely to the WHO Regional Office for Europe, those reported annually to the WHO and the United Nations Children’s Fund headquarters, and those reported to the RVC. These data should be consistent. In addition, the quality and timeliness of responses to measles and rubella outbreaks vary widely throughout the region. In most countries, outbreaks are investigated promptly, but in some cases, no response is implemented. Measles surveillance is well established in most member states, but several countries do not report the complete epidemiological and laboratory data required for detailed analysis. Rubella surveillance is mainly passive and simply a by-product of measles surveillance in many countries (that is, sera from suspected cases that test negative for measles are then tested for rubella). Some countries test pregnant women for rubella immunity to identify those who are at risk of rubella infection and whose newborns would thus be at risk of congenital rubella syndrome. This surveillance is the least developed in the region, and case definitions vary slightly among countries. Many member states do not routinely monitor WHO-recommended indicators of measles and
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rubella surveillance and laboratory performance. Furthermore, surveillance sensitivity is inadequate in many countries. This is one of the major reasons why the RVC classified many annual reports as inconclusive. Forty-eight of the fifty-three member states have at least one WHOaccredited national reference laboratory in which measles and rubella serology and virology are performed. Some countries also have proficiency-tested laboratories at the subnational level. The extent to which testing is also performed in hospital and private laboratories that are outside the laboratory network and not proficiency tested varies. All member states have a two-dose routine vaccination schedule for measles- and rubellacontaining vaccines, and most use the measlesmumps-rubella (MMR) vaccine. Vaccination coverage is generally higher with the first dose than with the second. Coverage is generally lower in Western European member states than in Eastern European ones and the Newly Independent States. Parental refusal to vaccinate children is a complex and growing problem, especially in Western Europe. Coverage may vary widely within countries, especially where autonomous state or regional authorities may selectively classify measles and rubella vaccination as mandatory or simply recommended. Some member states, primarily those in Eastern Europe and the Newly Independent States, have implemented the WHO-recommended strategy of using supplementary immunization activities to increase the population immunity profile. Some countries routinely target highrisk population groups with low coverage, such as health care workers; immigrants; displaced persons; and groups facing geographic, economic, ethnic, linguistic, religious, philosophical, cultural, or other barriers to vaccine receipt. Most member states maintain national or subnational electronic databases or immunization registries. However, a few have no established systems and can only estimate coverage through periodic surveys or by monitoring vaccine sales. Data from serological surveys of measles and rubella immunity are available in a few countries but are often unrepresentative or of unknown quality. Most member states provided information on the sustainability of their national immunizaPreliminary brief results of the research reported in this article were presented
Exhibit 4 Rubella Elimination Status Among Member States Of The World Health Organization European Region, December 31, 2013
SOURCE Authors’ analysis.
tion programs, and in 2013 about half had a national plan in place for measles and rubella elimination. Most countries established standard operating procedures related to measles and rubella prevention and control at each program level and showed evidence both of vaccine demand forecasting and stock management and of secure government funding for vaccine procurement. Some reported occasional interruptions in the procurement, supply, and availability of measles and rubella vaccines.
Conclusion Despite progress in some countries, the goal of measles and rubella elimination in the WHO European Region by the target date of 2015 was unlikely to have been met.15 This is an unexpected outcome in a region where sufficient resources are available. Unless and until progress toward genuine political commitment, increased technical capacity, and universal public awareness of the benefits of measles and rubella elimination (especially in Western Europe) is urgently accelerated, this important public health initiative will remain unfulfilled. ▪
in a poster at the thirty-third annual meeting of the European Society for
Paediatric Infectious Diseases, Leipzig, Germany, May 2015.
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NOTES 1 World Health Organization. Draft global vaccine action plan: report by the Secretariat [Internet]. Geneva: WHO; 2012 May 11 [cited 2015 Dec 10]. Available from: http:// apps.who.int/gb/ebwha/pdf_files/ WHA65/A65_22-en.pdf 2 Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Monaco, Montenegro, the Netherlands, Norway, Poland, Portugal, the Republic of Moldova, Romania, the Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, the United Kingdom, and Uzbekistan. 3 World Health Organization Regional Office for Europe. European Vaccine Action Plan: 2015–2020 [Internet]. Copenhagen: WHO; 2014 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0007/255679/WHO_ EVAP_UK_v30_WEBx.pdf 4 World Health Organization. WHO vaccine-preventable diseases: monitoring system. 2015 global summary [Internet]. Geneva: WHO; [last updated 2015 Sep 8; cited 2015 Dec 10]. Available from: http://apps.who.int/ immunization_monitoring/global summary 5 Supplementary immunization activities (SIAs) generally are carried out using two target age ranges: An initial nationwide catch-up SIA targets all children ages nine months to fourteen years, and periodic followup SIAs target all children born since
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the last SIA. 6 World Health Organization. Proceedings of the Global Technical Consultation to assess the feasibility of measles eradication, 28–30 July 2010. J Infect Dis. 2011;204 (Suppl 1):S4–13. 7 Framework for verifying elimination of measles and rubella. Wkly Epidemiol Rec [serial on the Internet]. 2013;88(9):89–99. Available from: http://www.who.int/wer/2013/ wer8809/en/ 8 To access the Appendix, click on the Appendix link in the box to the right of the article online. 9 The required evidence includes certification of the following: endemic measles and rubella cases have not occurred for three consecutive years; the disease surveillance system is sufficiently sensitive, specific, timely, and complete to detect cases if they had occurred; and the absence of endemic cases is supported by genotyping evidence. 10 World Health Organization Regional Office for Europe. Third meeting of the European Regional Verification Commission for Measles and Rubella Elimination (RVC): 10–12 November 2014, Copenhagen, Denmark [Internet]. Copenhagen: WHO; c 2015 [cited 2015 Dec 10]. Available from: http://www.euro.who.int/__ data/assets/pdf_file/0011/275519/ 3rd-Meeting-European-RVCMeasles-Rubella-Elimination.pdf? ua=1 11 World Health Organization Regional Office for Europe. Measles and rubella elimination 2015: package for accelerated action: 2013–2015 [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http://www.euro.who.int/__ data/assets/pdf_file/0020/215480/ PACKAGE-FOR-ACCELERATEDACTION-20132015.pdf
12 World Health Organization Regional Office for Europe. The guide to tailoring immunization programmes (TIP): increasing coverage of infant and child vaccination in the WHO European Region [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0003/187347/The-Guideto-Tailoring-ImmunizationProgrammes-TIP.pdf 13 World Health Organization Regional Office for Europe. Guidelines for measles and rubella outbreak investigation and response in the WHO European Region [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0003/217164/Outbreak Guidelines-updated.pdf 14 World Health Organization Regional Office for Europe. Vaccine safety events: managing the communications response: a guide for Ministry of Health EPI managers and health promotion units [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0007/187171/VaccineSafety-Events-managing-thecommunications-response-final.pdf 15 World Health Organization Regional Office for Europe. Extraordinary meeting of the European Technical Advisory Group of Experts on Immunization (ETAGE): 30 January 2015, Copenhagen, Denmark [Internet]. Copenhagen: WHO; c 2015 [cited 2015 Dec 10]. Available from: http://www.euro.who.int/__ data/assets/pdf_file/0005/274640/ Extraordinary-meeting-EuropeanTechnical-Advisory-Group-ExpertsImmunization-ETAGE-en.pdf?ua=1
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2016 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Eliminating Measles
10.1377/hlthaff.2015.1055 HEALTH AFFAIRS 35, NO. 2 (2016): 322–326 ©2016 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
&
Rubella
By Robin Biellik, Iria Davidkin, Susanna Esposito, Andrey Lobanov, Mira Kojouharova, Günter Pfaff, José Ignacio Santos, John Simpson, Myriam Ben Mamou, Robb Butler, Sergei Deshevoi, Shahin Huseynov, Dragan Jankovic, and Abigail Shefer
DATAWATC H
Slow Progress In Finalizing Measles And Rubella Elimination In The European Region All countries in the World Health Organization European Region committed to eliminating endemic transmission of measles and rubella by 2015, and disease incidence has decreased dramatically. However, there was little progress between 2012 and 2013, and the goal will likely not be achieved on time. Genuine political commitment, increased technical capacity, and greater public awareness are urgently needed, especially in Western Europe. Robin Biellik (rbiellik@gmail .com) is a retired World Health Organization (WHO) epidemiologist living in Geneva, Switzerland. Iria Davidkin is a retired senior researcher in the Viral Infections Unit, National Institute for Health and Welfare, in Helsinki, Finland. Susanna Esposito is head of the Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, in Milan, Italy. Andrey Lobanov is a retired WHO medical officer living in Moscow, the Russian Federation.
I
n May 2012 the World Health Assembly, the decision-making body of the World Health Organization (WHO), adopted the Global Vaccine Action Plan for the 2011–20 Decade of Vaccines. The plan emphasizes reaching a set of regional and global immunization targets, including eliminating measles in four of the six WHO regions and eliminating rubella in two regions by 2015, and eliminating both diseases in five regions by 2020.1 To put the plan into action, the WHO Regional Office for Europe launched the European Vaccine Action Plan, with all fifty-three member
states2 making commitments to eliminate the endemic transmission of measles and rubella by 2015.3 The reported incidence of measles and rubella in the WHO European Region has declined dramatically over the past two decades. In the presence of improving disease surveillance, the annual average number of reported measles cases fell from more than 200,000 in the period 1990–99 to fewer than 30,000 in 2010–14 (Exhibit 1). Despite this, significant measles outbreaks occurred in 2013 and 2014 in Azerbaijan, Bosnia and Herzegovina, Georgia, Germany, Italy, Latvia, the Netherlands,
Exhibit 1 Reported Vaccination Coverage And Reported Cases Of Measles And Rubella Among Member States Of The World Health Organization European Region, 1980–2014
Mira Kojouharova is deputy head of the National Center for Infectious and Parasitic Diseases, Ministry of Health, in Sofia, Bulgaria. Günter Pfaff is head of the Department of Epidemiology and Health Reporting in the Baden-Württemberg State Health Office, in Stuttgart, Germany. José Ignacio Santos is a professor in the Faculty of Medicine, Universidad Nacional Autónoma de México, in Mexico City.
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SOURCE Authors’ analysis of data reported annually to the World Health Organization and United Nations Children’s Fund. NOTES Measles and rubella cases (bars) relate to the left-hand y axis. Measles- and rubella-containing vaccine, first dose (MRCV1), and measles- and rubella-containing vaccine, second dose (MRCV 2; lines), relate to the right-hand y axis. Data were incompletely reported in the earlier period.
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the Russian Federation, Turkey, Ukraine, and the United Kingdom. The average annual number of reported rubella cases fell from more than 300,000 in 2000–09 to fewer than 20,000 in 2010–14 (Exhibit 1). Rubella outbreaks in Poland and Romania accounted for the majority of the recently reported cases. Continuing the trend observed in recent years, approximately one-third of reported measles cases occurred in individuals ages twenty and older. However, there are substantial differences across member states in the age distribution of reported cases. Most recent outbreaks of measles and rubella have occurred among the general population, but some have been concentrated in groups recognized as inadequately vaccinated, such as Roma communities and certain religious groups. In some countries a substantial number of measles and rubella cases have been reported among health care workers. The proportion of the population that is vaccinated (that is, the “vaccination coverage,” expressed in percentage) in the European region as a whole remains high, with first-dose measles vaccination coverage at approximately 94 percent.4 In addition, wide-scale supplementary immunization activities5 have been conducted, primarily in Eastern Europe and the Newly Independent States (the countries in the former Soviet Union, except for the three Baltic States), with twenty-four reported since 2000. Despite these efforts, most of the measles cases reported in 2014 occurred among unvaccinated or incompletely vaccinated individuals, including many older people with unknown vaccination status. In 2013, following a global technical consultation on the feasibility of global measles eradication,6 the WHO developed and published technical guidance on the regional process for verifying measles and rubella elimination.7 This guidance was modeled on the process for certifying poliomyelitis eradication. Additional information on the regional process is included in online Appendix Exhibit 1.8 The member states were required to provide evidence of the status of endemic measles and rubella transmission in a standardized format.9 A standardized annual reporting form was used to assist each national verification committee in compiling and documenting evidence along the following five principal lines: the epidemiology of measles, rubella, and congenital rubella syndrome (CRS); the performance of measles, rubella, and CRS surveillance; the molecular epidemiology of measles and rubella viruses; population immunity; and the sustainability of the national immunization program. The verification process requires that all evidence examined and presented by the national
verification committees be based on WHOrecommended quantified performance indicators and markers and be independent, objective, and free of conflicts of interest.
Study Data And Methods In July 2013 the national verification committees submitted data and evidence on the status of measles and rubella elimination in their respective countries during the period 2010–12. Background data included the evolution of the national immunization schedule and historical data on vaccines and vaccination strategies adopted since the establishment of the national immunization program. In 2013 and 2014, members of the Regional Verification Commission for Measles and Rubella Elimination (RVC) of the WHO Regional Office for Europe classified the member states in accordance with the WHO’s definition of elimination—namely, “the absence of endemic measles or rubella cases in a defined geographical area for a period of at least 12 months, in the presence of a well-performing surveillance system”—based on the five lines of evidence contained in each country’s reports.7 The year 2012 was selected as the first year for evidence for elimination. Member states that demonstrated interruption of measles or rubella transmission in 2012, 2013, and 2014 would qualify as having achieved elimination. Of course, the situation remains dynamic, and measles or rubella transmission may be reestablished, in which case a member state may lose its elimination status. An algorithm was developed to standardize conclusions based on the evidence submitted (Exhibit 2). In some instances, RVC members were unable to decide whether disease transmission remained endemic or interrupted. Reasons included inadequate surveillance systems; absent, incomplete, or conflicting surveillance data; low sensitivity of surveillance data; and inadequate or incomplete evidence of population immunity. In these cases, an “inconclusive” decision was recorded. Final results were sent to each member state along with recommendations, where appropriate, on actions to improve reporting in future.
John Simpson is interim director of the Division of Emergency Preparedness, Resilience, and Response, Public Health England, in Salisbury. Myriam Ben Mamou is coordinator of the Measles and Rubella Laboratory, Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe, in Copenhagen, Denmark. Robb Butler is program manager in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Sergei Deshevoi is a medical officer in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Shahin Huseynov is a technical officer in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Dragan Jankovic is a technical officer in the Division of Communicable Diseases, Health Security, and Environment, WHO Regional Office for Europe. Abigail Shefer is a medical officer in the Global Immunization Division at the Centers for Disease Control and Prevention, in Atlanta, Georgia. At the time of this work, she was a technical officer in the Division of Communicable Diseases, Health Security, and Environment, in the WHO Regional Office for Europe.
Study Results As part of the regional verification process, fortynine member states submitted reports covering 2010–12, and forty-six countries submitted annual reports for 2013. By November 2014 seven countries had not yet provided annual reports for 2013, and three of them also had not yet F eb ru a ry 2 0 16
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Exhibit 2 Algorithm To Standardize Conclusions Based On The Presentation Of Evidence On The Status Of Measles Or Rubella Elimination
SOURCE Authors’ analysis. NOTE RVC is the European Regional Verification Commission for Measles and Rubella Elimination.
established national verification committees. Italy and Ukraine subsequently submitted annual reports for 2013, which were reviewed in 2015. Based on the reports submitted, the RVC concluded that as of the end 2013, twenty-two countries had interrupted endemic measles transmission, but seven of these remained at high risk of reestablishing endemic transmission, mainly because of significant immunity gaps in the population (Exhibit 3).10 For additional details, see Appendix Exhibit 2.8 Endemic rubella transmission was interrupted in twenty-three countries, with seven at risk of reestablishing endemic transmission (Exhibit 4). For additional details, see Appendix Exhibit 3.8 Measles transmission was considered endemExhibit 3 Measles Elimination Status Among Member States Of The World Health Organization European Region, December 31, 2013
SOURCE Authors’ analysis.
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ic in thirteen countries (Exhibit 3), and nine of these were considered to also have endemic rubella transmission (Exhibit 4). In addition, the RVC was unable to verify interruption of measles transmission in nine countries or of rubella transmission in twelve countries, because of inadequate surveillance data or low sensitivity of surveillance. Some improvement was noted in data timeliness and quality in the reports submitted in 2013 and 2014. However, there was little change when the final classification of measles and rubella elimination status among the member states in 2012 was compared to the classification in 2013.
Discussion The WHO Regional Office for Europe has launched a number of technical and advocacy initiatives designed to increase member states’ political commitment to and technical capacity for achieving the goal of eliminating measles and rubella by the end of 2015.11–14 Nevertheless, in view of the trends observed at the country level in the period 2010–13, that goal was unlikely to have been met. At the end of 2014 measles was subject to obligatory notification to national ministries of health in all member states; rubella and congenital rubella syndrome were notifiable in most but not all member states. There were occasional discrepancies between the number of measles and rubella cases reported routinely to the WHO Regional Office for Europe, those reported annually to the WHO and the United Nations Children’s Fund headquarters, and those reported to the RVC. These data should be consistent. In addition, the quality and timeliness of responses to measles and rubella outbreaks vary widely throughout the region. In most countries, outbreaks are investigated promptly, but in some cases, no response is implemented. Measles surveillance is well established in most member states, but several countries do not report the complete epidemiological and laboratory data required for detailed analysis. Rubella surveillance is mainly passive and simply a by-product of measles surveillance in many countries (that is, sera from suspected cases that test negative for measles are then tested for rubella). Some countries test pregnant women for rubella immunity to identify those who are at risk of rubella infection and whose newborns would thus be at risk of congenital rubella syndrome. This surveillance is the least developed in the region, and case definitions vary slightly among countries. Many member states do not routinely monitor WHO-recommended indicators of measles and
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rubella surveillance and laboratory performance. Furthermore, surveillance sensitivity is inadequate in many countries. This is one of the major reasons why the RVC classified many annual reports as inconclusive. Forty-eight of the fifty-three member states have at least one WHOaccredited national reference laboratory in which measles and rubella serology and virology are performed. Some countries also have proficiency-tested laboratories at the subnational level. The extent to which testing is also performed in hospital and private laboratories that are outside the laboratory network and not proficiency tested varies. All member states have a two-dose routine vaccination schedule for measles- and rubellacontaining vaccines, and most use the measlesmumps-rubella (MMR) vaccine. Vaccination coverage is generally higher with the first dose than with the second. Coverage is generally lower in Western European member states than in Eastern European ones and the Newly Independent States. Parental refusal to vaccinate children is a complex and growing problem, especially in Western Europe. Coverage may vary widely within countries, especially where autonomous state or regional authorities may selectively classify measles and rubella vaccination as mandatory or simply recommended. Some member states, primarily those in Eastern Europe and the Newly Independent States, have implemented the WHO-recommended strategy of using supplementary immunization activities to increase the population immunity profile. Some countries routinely target highrisk population groups with low coverage, such as health care workers; immigrants; displaced persons; and groups facing geographic, economic, ethnic, linguistic, religious, philosophical, cultural, or other barriers to vaccine receipt. Most member states maintain national or subnational electronic databases or immunization registries. However, a few have no established systems and can only estimate coverage through periodic surveys or by monitoring vaccine sales. Data from serological surveys of measles and rubella immunity are available in a few countries but are often unrepresentative or of unknown quality. Most member states provided information on the sustainability of their national immunizaPreliminary brief results of the research reported in this article were presented
Exhibit 4 Rubella Elimination Status Among Member States Of The World Health Organization European Region, December 31, 2013
SOURCE Authors’ analysis.
tion programs, and in 2013 about half had a national plan in place for measles and rubella elimination. Most countries established standard operating procedures related to measles and rubella prevention and control at each program level and showed evidence both of vaccine demand forecasting and stock management and of secure government funding for vaccine procurement. Some reported occasional interruptions in the procurement, supply, and availability of measles and rubella vaccines.
Conclusion Despite progress in some countries, the goal of measles and rubella elimination in the WHO European Region by the target date of 2015 was unlikely to have been met.15 This is an unexpected outcome in a region where sufficient resources are available. Unless and until progress toward genuine political commitment, increased technical capacity, and universal public awareness of the benefits of measles and rubella elimination (especially in Western Europe) is urgently accelerated, this important public health initiative will remain unfulfilled. ▪
in a poster at the thirty-third annual meeting of the European Society for
Paediatric Infectious Diseases, Leipzig, Germany, May 2015.
F eb ru a ry 2 0 16
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Eliminating Measles
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NOTES 1 World Health Organization. Draft global vaccine action plan: report by the Secretariat [Internet]. Geneva: WHO; 2012 May 11 [cited 2015 Dec 10]. Available from: http:// apps.who.int/gb/ebwha/pdf_files/ WHA65/A65_22-en.pdf 2 Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Monaco, Montenegro, the Netherlands, Norway, Poland, Portugal, the Republic of Moldova, Romania, the Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, the United Kingdom, and Uzbekistan. 3 World Health Organization Regional Office for Europe. European Vaccine Action Plan: 2015–2020 [Internet]. Copenhagen: WHO; 2014 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0007/255679/WHO_ EVAP_UK_v30_WEBx.pdf 4 World Health Organization. WHO vaccine-preventable diseases: monitoring system. 2015 global summary [Internet]. Geneva: WHO; [last updated 2015 Sep 8; cited 2015 Dec 10]. Available from: http://apps.who.int/ immunization_monitoring/global summary 5 Supplementary immunization activities (SIAs) generally are carried out using two target age ranges: An initial nationwide catch-up SIA targets all children ages nine months to fourteen years, and periodic followup SIAs target all children born since
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the last SIA. 6 World Health Organization. Proceedings of the Global Technical Consultation to assess the feasibility of measles eradication, 28–30 July 2010. J Infect Dis. 2011;204 (Suppl 1):S4–13. 7 Framework for verifying elimination of measles and rubella. Wkly Epidemiol Rec [serial on the Internet]. 2013;88(9):89–99. Available from: http://www.who.int/wer/2013/ wer8809/en/ 8 To access the Appendix, click on the Appendix link in the box to the right of the article online. 9 The required evidence includes certification of the following: endemic measles and rubella cases have not occurred for three consecutive years; the disease surveillance system is sufficiently sensitive, specific, timely, and complete to detect cases if they had occurred; and the absence of endemic cases is supported by genotyping evidence. 10 World Health Organization Regional Office for Europe. Third meeting of the European Regional Verification Commission for Measles and Rubella Elimination (RVC): 10–12 November 2014, Copenhagen, Denmark [Internet]. Copenhagen: WHO; c 2015 [cited 2015 Dec 10]. Available from: http://www.euro.who.int/__ data/assets/pdf_file/0011/275519/ 3rd-Meeting-European-RVCMeasles-Rubella-Elimination.pdf? ua=1 11 World Health Organization Regional Office for Europe. Measles and rubella elimination 2015: package for accelerated action: 2013–2015 [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http://www.euro.who.int/__ data/assets/pdf_file/0020/215480/ PACKAGE-FOR-ACCELERATEDACTION-20132015.pdf
12 World Health Organization Regional Office for Europe. The guide to tailoring immunization programmes (TIP): increasing coverage of infant and child vaccination in the WHO European Region [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0003/187347/The-Guideto-Tailoring-ImmunizationProgrammes-TIP.pdf 13 World Health Organization Regional Office for Europe. Guidelines for measles and rubella outbreak investigation and response in the WHO European Region [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0003/217164/Outbreak Guidelines-updated.pdf 14 World Health Organization Regional Office for Europe. Vaccine safety events: managing the communications response: a guide for Ministry of Health EPI managers and health promotion units [Internet]. Copenhagen: WHO; c 2013 [cited 2015 Dec 10]. Available from: http:// www.euro.who.int/__data/assets/ pdf_file/0007/187171/VaccineSafety-Events-managing-thecommunications-response-final.pdf 15 World Health Organization Regional Office for Europe. Extraordinary meeting of the European Technical Advisory Group of Experts on Immunization (ETAGE): 30 January 2015, Copenhagen, Denmark [Internet]. Copenhagen: WHO; c 2015 [cited 2015 Dec 10]. Available from: http://www.euro.who.int/__ data/assets/pdf_file/0005/274640/ Extraordinary-meeting-EuropeanTechnical-Advisory-Group-ExpertsImmunization-ETAGE-en.pdf?ua=1
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