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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail. Measles Control -- South-East Asia Region, 1990-1997In 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. References
* 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 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 1. Reported measles morbidity and reported routine measles vaccination
coverage among children aged <=1 year, by country - South-East Asia Region,
1990-1997
=======================================================================================================
Morbidity
------------------------------------------------
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
revision.
+ 1996 data; 1997 data were not available.
& Based on 1996 survey data (2); data for 1997 not available.
=======================================================================================================
Return to top. Figure 1  Return to top. Table 2 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
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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