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Measles Control -- South-East Asia Region, 1990-1997

In 1989, the World Health Assembly resolved to reduce measles morbidity and mortality by 90% and 95%, respectively, by 1995, compared with the number of cases during the prevaccine era. In 1990, the World Summit for Children adopted a goal to vaccinate 90% of children against measles by 2000. Although these goals have not been met, progress has been achieved toward global measles control, including in the South-East Asia Region (SEAR) member countries* of the World Health Organization (WHO). By the end of 1997, estimated worldwide measles morbidity and death were reduced by 74% and 85%, respectively, and by 70% and 88%, respectively, in SEAR (1). In February 1999, representatives of the United Nations Children's Fund (UNICEF), WHO, and CDC met and recommended a regional plan of action for measles control. This report summarizes the progress in measles control in SEAR during 1990-1997 and summarizes the plans for future activities in the region.

Routine Vaccination

Except for Thailand and the Democratic People's Republic of Korea (DPR Korea), the routine vaccination schedule in SEAR countries includes a single dose of measles vaccine administered at age 9 months. In Thailand, an additional dose is recommended at school entry; in DPR Korea, the first measles vaccine dose is given at age 12 months, a second dose at age 7 years, and a third at age 17 years. In SEAR, reported vaccination coverage among children aged less than or equal to 1 year with a single dose of measles vaccine increased from less than 10% in 1985 to greater than 80% in 1990 (Figure 1). Since 1990, routine measles vaccination coverage** remained stable at approximately 85%. In 1997, nine of the 10 member countries reported routine measles vaccination coverage of greater than 80% (Table 1).

Supplemental Vaccination

Nationwide supplemental measles vaccination campaigns were conducted in Bhutan (1995) among children aged less than 15 years, and in Maldives (1995-1997) among children aged 5-14 years. Subnational supplemental mass vaccination campaigns have been conducted in the region targeting high-risk*** areas, including Bangladesh flood areas (1998), DPR Korea border areas (1995), urban centers in India (1995-1999) and in Myanmar (1995 and 1997), and in three high-risk districts in Nepal (1995). Limited information is available about the impact of these campaigns.

Measles Incidence

During 1990-1997 in SEAR, the number of reported measles cases and reported measles incidence decreased by 48% and 53%, respectively (Table 1). Indonesia, Myanmar, and Sri Lanka reported a substantial decrease in measles incidence rates, and Bangladesh and Nepal reported large increases. In Bangladesh, the 445% increase in measles incidence in 1997 compared with 1990 primarily resulted from an expanded national reporting system; the 5070% increase in measles incidence in Nepal in 1997 compared with 1990 reflected multiple outbreaks in addition to improved case identification and reporting. DPR Korea and Maldives reported no measles cases in 1990 and 1997.

Data on age distribution of persons with measles were available from routine reports from Indonesia, Sri Lanka, and Thailand, and from outbreak investigations in Bhutan, Maldives, and Myanmar (Table 2). In Myanmar, 70% of the cases reported from 11 townships during 1998-1999 occurred among children aged less than 5 years. In countries with higher vaccination coverage (Bhutan, Indonesia, Maldives, Sri Lanka, and Thailand), greater than 50% of cases occurred among children aged greater than or equal to 5 years.

Plan of Action

The main objective of measles control activities in SEAR through 2003 is to reduce measles morbidity and death by 90% and 95%, respectively, compared with the prevaccine era. No goal for regional elimination of measles has been established. Member countries are divided into two groups based on their measles control level and poliomyelitis eradication status.

Group 1 countries (Bangladesh, DPR Korea, India, Myanmar, and Nepal) have limited measles control, and polio is endemic or recently was endemic. These countries should focus on reducing measles mortality by increasing routine vaccination coverage to greater than 90%, improving case management, and conducting supplemental vaccination as an extraordinary activity in areas that have been unreachable by routine vaccination services. Planning and implementing supplemental measles vaccination should not divert resources from polio eradication activities. Health-care providers should be trained in management of measles cases and its complications. In addition, vitamin A supplementation, an important component of measles treatment and prevention, should be given at every measles vaccination contact. Measles surveillance should be improved by complete and timely data reporting, including number of cases, age distribution, vaccination status, and location.

Countries in Group 2 (Bhutan, Indonesia, Maldives, Sri Lanka, and Thailand) are in more advanced stages of measles control and have been free from polio for greater than 2 years. In these countries, measles outbreak prevention through enhanced surveillance, sustained high routine coverage (greater than 90%), and targeted supplemental vaccination should be emphasized. Epidemiologic investigation of all measles cases should be a priority, with laboratory confirmation whenever possible. The capacity for laboratory diagnosis is available in Indonesia, Sri Lanka, and Thailand. Measles surveillance should be linked with acute flaccid paralysis (AFP) surveillance by using the same field staff and reporting systems when AFP surveillance has reached accepted standards**** and no polio cases are being reported. This type of surveillance has been initiated in Indonesia, Myanmar, and Sri Lanka. Vaccination coverage data should be analyzed continually to detect an impending outbreak when nationwide supplemental vaccination campaigns may be required to reduce the pool of susceptible children.

Reported by: Regional Office for South-East Asia, New Delhi, India; Dept of Vaccines and Other Biologicals, World Health Organization, Geneva, Switzerland. United Nations Children's Fund Regional Office for South Asia, Kathmandu, Nepal. Vaccine Preventable Disease Eradication Div, National Immunization Program; and an EIS Officer, CDC.

Editorial Note:

Despite routine coverage of greater than 80% since 1990 in SEAR, measles is a major cause of morbidity and death among children aged less than 5 years (1). Basing calculations on the reported vaccination coverage and a vaccine efficacy of 85%, approximately 9 million (25%) children in SEAR are not protected through vaccination against measles at their first birthday.

Reported routine vaccination coverage rates in SEAR vary widely from year to year and, when compared with coverage survey results, usually overestimate the true coverage rate. For example, in Bangladesh in 1997, a nationwide survey conducted by the Ministry of Health among children aged 12-23 months documented measles coverage at 70% (3) whereas the coverage reported to WHO was 97% for the same year. In Indonesia in 1997, a nationwide survey conducted by the Ministry of Health estimated measles vaccination coverage among children aged 12-23 months at 71% compared with the reported coverage of 92% (4). In Nepal in 1998, a nationwide survey conducted by the Ministry of Health estimated measles vaccination coverage among children aged 12-23 months at 73% compared with reported coverage in 1997 of 88% (5). In DPR Korea in 1998, a nationwide survey conducted by UNICEF among children aged 12-23 months found measles vaccination coverage to be 34% compared with reported coverage of 100% in 1996 (6).

Achieving greater than 90% coverage through routine vaccination is a cornerstone of measles control in SEAR. Strategies for improving routine coverage include identifying populations without access to routine services, raising community awareness of the need for vaccination, reducing missed opportunities to vaccinate children whenever contact occurs within the health-care system, linking curative and preventive services, and providing outreach services. Assessing and mapping vaccination coverage at the district and subdistrict levels are needed to monitor program performance and to identify areas requiring additional resources. Measles surveillance needs to be strengthened because it is critical for documenting the changing epidemiology of measles and for evaluating the impact of vaccination activities in the region.

Polio remains endemic in at least four of the 10 SEAR countries (7), and achieving polio eradication by the end of 2000 remains the top vaccine-preventable disease priority (8). Careful phasing in of measles control is needed on both regional and national levels. Linking measles surveillance with AFP surveillance is a key strategy for accelerating measles control in countries with effective polio eradication programs. SEAR is in the early stages of coordinated efforts to control measles, and a sustained commitment with long-term national action plans is required to further reduce measles in the region.


  1. CDC. Progress toward global measles control and regional elimination, 1990-1998. MMWR 1998;47:1049-54.
  2. World Health Organization Regional Office for South East Asia. New Delhi, India. Thailand: Country Report, Ministry of Health, Thailand. Fifth Meeting of the South-East Asia Region Technical Consultative Group, Bangkok, 1998.
  3. Bangladesh: National Institute of Population Research and Training, Ministry of Health and Family Welfare. Mitra and Associates Demographic and Health Surveys, December 1997.
  4. Indonesia: Central Bureau of Statistics, State Ministry of Population, National Family Planning Co-ordinating Board, Ministry of Health, Demographic and Health Survey Macro International Demographic and Health Survey, 1997.
  5. Nepal: Family Health Division, Department of Health Services, Ministry of Health. Routine Immunisation and NID Coverage Survey Report, 1998.
  6. DPR Korea: UNICEF Country Office, Democratic People's Republic of Korea. Multiple Indicator Cluster Sample Survey, 1998.
  7. CDC. Progress toward poliomyelites eradication--South-East Asia Region, 1997-1998. MMWR 1999;48:230-2,239.
  8. Andrus JK, Banerjee K, Hull BP, Smith JC, Mochny I. Polio eradication in the World Health Organization South-East Asia Region by the year 2000: midway assessment of progress and future challenges. J Infect Dis 1997;175:S89-S96.

* Bangladesh, Bhutan, Democratic People's Republic of Korea (DPR Korea), India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand.

** Routine measles vaccination provides services in a periodic, repetitive, and predictable manner at fixed sites and through mobile services in areas where fixed services are not available.

*** Poor, densely populated areas (e.g., urban and periurban slums) with low routine vaccination coverage (less than 80%).

**** AFP rate of greater than or equal to 1 per 100,000 children aged less than 15 years, and two stool samples collected in greater than or equal to 80% of AFP cases.

Table 1

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TABLE 1. Reported measles morbidity and reported routine measles vaccination
coverage among children aged <=1 year, by country - South-East Asia Region,
                          No. reported                                       Reported vaccination
                             cases                  Incidence*                   coverage (%)
                       ------------------   --------------------------- -----------------------------
                                                             Percentage                    Percentage
Country                   1990       1997   1990   1997        change   1990    1997         change
Bangladesh               1,705     10,329    1.6    8.5          431%     82      97           15%
Bhutan                     173        169   10.5    9.1          -13%     79      84            5%
Democratic People's
  Republic of Korea          0          0    0.0    0.0             0     98     100+           2%
India                   82,716     61,004    9.7    6.4          -34%     91      81          -10%
Indonesia               92,105     15,313   50.4    7.5          -85%     86      92            6%
Maldives                     0          0    0.0    0.0             0     96      96             0
Myanmar                  7,900      1,035   19.1    2.2          -88%     68      88           20%
Nepal                      182     11,669    1.0   51.7        5,070%     68      88           20%
Sri Lanka                4,004        195   23.5    1.1          -95%     80      94           14%
Thailand                29,244     14,617   52.6   24.7          -53%     70      92&          22%

Total                  218,029    114,331   16.5    7.7          -53%     88      85           -3%
* Per 100,000 population, based on population data from United Nation's World Population Report,1996
+ 1996 data; 1997 data were not available.
& Based on 1996 survey data (2); data for 1997 not available.

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Figure 1

Figure 1
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Table 2

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TABLE 2. Measles cases in South East Asia Region reported by national ministries of
health to the World Health Organization (WHO) - South-East Asia Region, 1995-1998
                                                            Age (yrs) distribution of case-patients (%)
                                                   <1             1-4              5-9           10-14           >=15
   Data                                No.   ---------------  ------------   ---------------  ------------   ------------
  source      Country     Year       cases     No.      (%)     No.    (%)     No.      (%)     No.    (%)     No.    (%)
  Routine     Indonesia   1997      16,082   2,436     (15)   5,289   (33)   5,668     (35)*                 2,689   (17)
  reports     Sri Lanka   1997          64       7     (11)      14   (22)      43     (67)+
              Thailand    1997      15,122   5,212     (34)&                 4,877     (32)   3,422    (23)  1,611   (11)

 Outbreaks    Bhutan      1998          60       2     ( 3)      13   (22)      31     (52)      11    (18)      3   ( 5)
              Maldives    1995       3,070       0              215   ( 7)     215     ( 7)   1,781    (58)    859   (28)
              Myanmar     1998         319      15     ( 5)     208   (65)      56     (17)      18    ( 6)     22   ( 7)
* Aged 5-14 years.
+ Aged >=5 years.
& Aged <5 years.

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