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Global Measles and Rubella Management Meeting Progress and Challenges in Bangladesh 15 -17 March, Global Measles and Rubella Management Meeting Progress and Challenges in Bangladesh 15 -17 March, 2011 Geneva, WHO HQ Dr Serguei Diorditsa 1

Measles control plan (2004 -2010) and next goals in Bangladesh Measles control plan 2004 Measles control plan (2004 -2010) and next goals in Bangladesh Measles control plan 2004 -2010 Measles catch-up campaign immunized: >35 million c. MYP 2011 -2016 85% Measles follow-up campaign immunized: >18 million plus OPV, vit A , albendazole In 2011 -2016, c. MYP elimination target Including 2 nd dose MCV 2 introduction 2 Source: Child deaths due to measles 2000 -2009 by WHO estimation, 10 Feb 2011

Trends of measles cases and valid measles coverage by one year of age (1990 Trends of measles cases and valid measles coverage by one year of age (1990 -2010) Measles follow-up campaign immunized: >18 million Measles catch-up campaign immunized: >35 million 3

Spot Map of Outbreaks Reported in Bangladesh Measles catch-up campaign immunized: >35 million 2005 Spot Map of Outbreaks Reported in Bangladesh Measles catch-up campaign immunized: >35 million 2005 Measles follow-up campaign immunized: >18 million 2006 2007 2008 2009 2010 Dots are randomly placed within district boundary Year # of measles outbreaks ( lab) and ( mixed) # of rubella outbreaks 2005 2006 2007 2008 2009 2010 203 51 5 1 2 0 87 26 102 59 145 193 4

Age Distribution of Lab Confirmed Measles Outbreak Cases, Bangladesh, 2003 -2010* No Laboratory Confirmed Age Distribution of Lab Confirmed Measles Outbreak Cases, Bangladesh, 2003 -2010* No Laboratory Confirmed Measles Outbreak detected in 2010 N=48 (1) N=132 (1) No Laboratory Confirmed Measles Outbreak detected in 2007 N=2, 095 (34) N=9, 378 (120) N=5, 248 (68) N=523 (12) 5

Measles Cases in Bangladesh by Year 2003 -2010 Outbreak surveillance Case based surveillance Measles Measles Cases in Bangladesh by Year 2003 -2010 Outbreak surveillance Case based surveillance Measles catch-up campaign immunized: >35 million Measles follow-up campaign immunized: >18 million Changes in definition of outbreak: 2003: 50 cases per ward 2005: 10 cases per ward 2008: 3 cases per ward 7

Measles surveillance indicators 8 Measles surveillance indicators 8

Virus isolation status Year No. of urine Sample collected Sample tested in regional lab 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 9

Non-measles suspected cases reporting rate 58% (37/64) districts achieved rate ≥ 2. 00 in Non-measles suspected cases reporting rate 58% (37/64) districts achieved rate ≥ 2. 00 in 2010 2009 2010 10

Measles vaccination valid coverage by 12 months of age, 2005 and 2010 81% (52/64) Measles vaccination valid coverage by 12 months of age, 2005 and 2010 81% (52/64) districts achieved ≥ 80% coverage in 2010 2005 2010 11 Source: CES 2005 and 2010

Challenge to improve Surveillance indicators Measles case based surveillance -Integrated with AFP and other 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 12

ICDDRB study on Impact of Measles Activities on Routine Immunization Services and Health Systems 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 13

ICDDRB study (cont’d) Examples of impacts Impact on Financing Impact on human resources Positive ICDDRB study (cont’d) Examples of impacts Impact on Financing Impact on human resources Positive • 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 • Helped to develop skills in fundraising 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 Negative Staff members de-motivated from late arrival of funding EPI staff feel overloaded with added works Shortage of technical staff The campaigns did not attract a sufficient number of volunteers in some areas as their refreshment fund were not enough 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 14

Budget for integrated VPD surveillance and measles activities in 2011 -2013 ( in million Budget for integrated VPD surveillance and measles activities in 2011 -2013 ( in million USD) 2011 planned 2012 available gap planned 2013 available gap planned available gap MCV 2 vaccine Bangladesh will apply to GAVI for MCV 2 cost support MR vaccine Bangladesh consider the cost of MR vaccine to be born from new Health Sector Programme for 2011 -2016 MCV 2 Introduction -Training & supervision surveillance 1, 22 2, 5 2, 0 0, 5 Total gap 0. 5 Total Gap for 2011 -2013 0 1, 22 2, 3 1. 0 1. 3 Total gap 1. 52 2. 3 1, 0 1. 3 Total gap 1. 3 3, 32 million USD 15

Thank You 16 Thank You 16

2011 Plans and budget • Measles initiative co-financed activities of WHO surveillance network in 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 18

Budget for integrated (AFP/Measles/Other VPDs) surveillance and measles control/ elimination activities 2011 -2016 Activities Budget for integrated (AFP/Measles/Other VPDs) surveillance and measles control/ elimination activities 2011 -2016 Activities Fund required yearly 20112016 Annual Surveillance operational cost 2. 5 million MCV 2 Government will apply for GAVI support for vaccine MCV 2 Introduction. Training & supervision Fund required one time 2012 Funding gap 2011 -2016 1. 5 million x 2 l (in 2011 -2012) 1. 22 million Fund available 9, 5 million 0 Funding gap one time 1. 22 million Logistics –printings and others for MCV 2 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 Total Gap 1. 22 million 3 million 9, 5 million 1. 22 million 19 10, 72 million

Advocacy Plans and Opportunities • Advocate to include measles elimination activities in the new Advocacy Plans and Opportunities • Advocate to include measles elimination activities in the new national health sector development plan for 20112016 including: ü Funds for surveillance activities ü Create national position of district immunization and surveillance medical officers (DISMO) ü 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 20