Measles is one of the most infectious viruses known to us and a major childhood killer while rubella/ congenital rubella syndrome (CRS) causes irreversible birth defects. Both, measles, and rubella can be prevented and eliminated with vaccination.
Eliminating measles is estimated to prevent at least 1.1 million cases of measles every year in the South-East Asia Region. For every case of measles prevented, approximately 2 weeks of disability-adjusted life years (DALYs) will be averted.
Rubella elimination is estimated to prevent 52, 118 cases of congenital rubella syndrome (CRS) annually in the Region.
In 2014, the WHO South-East Asia Region was a major contributor to global measles deaths reporting 40% of the total 114 900 deaths which reduced to 8% by 2021. This significant reduction in cases and deaths was backed by sustained efforts and unstinted political will at the highest levels.
Despite the remarkable progress, a decline in vaccine coverage, interruptions, and delays in immunization and surveillance activities due to COVID-19 pandemic has left the Region susceptible to large outbreaks, and off track for the 2023 target of measles and rubella elimination.
“We must sustain the gains against measles and rubella and other vaccine-preventable diseases by closing immunity gaps with tailored approaches for the highest impact such as catch-up campaigns. At the same time we must accelerate implementation of key elimination strategies,” said Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region.
Tracking progress against measles and rubella elimination
In 2013, Member countries of the WHO South-East Asia Region adopted the goal to eliminate measles and control rubella by 2020. To add impetus, Regional Director, Dr Poonam Khetrapal Singh in consultation with Member countries in 2014, identified measles elimination and rubella control by 2020 as a Flagship Priority.
Concerted efforts followed and measles cases declined sharply by 75%, measles deaths reduced by an estimated 72% between 2013 and 2021. An estimated 242 million cases of measles and more than 4.76 million deaths due to measles were averted during the period. Similarly, rubella cases declined by 80% between 2013 and 2021. Between 2017 and 2019, five countries in the WHO South-East Asia Region- Bhutan, DPR Korea, Maldives, Sri Lanka, and Timor-Leste eliminated measles while Maldives and Sri Lanka eliminated rubella in 2020.
Independent national verification committees were set up to monitor progress and verify measles elimination and rubella control. The Regional Director established a Regional Verification Commission (RVC) for measles elimination and rubella /CRS control to monitor progress and verify the elimination of measles and rubella.
In 2019, Member countries revised the goal to eliminate both measles and rubella by 2023. The recommended strategy to achieve elimination focused on five key objectives, first, achieving and maintaining high population immunity with at least 95% vaccination coverage with two doses of measles and rubella-containing vaccines in each district of each country. Second, develop and sustain a sensitive and timely case-based surveillance system for measles and rubella. Third, develop and maintain proficient measles and rubella laboratory network. Fourth, ensure adequate outbreak preparedness and respond rapidly to measles and rubella outbreaks. And fifth, strengthen support and collaborations with other public health initiatives to achieve the above strategic objectives.
In view of the focused and accelerated efforts, coverage with the first dose of the measles-containing vaccine (MCV1) in the Region increased from 85% in 2013 to an all-time high of 94% in 2019. The coverage of the second dose of the measles-containing vaccine (MCV2) increased from 59% in 2013 to 83%% in 2019. The coverage of the rubella-containing vaccine (RCV1) increased sharply from 12% in 2013 to an estimated 93% in 2019.
In the last decade, between 2013 to 2020, approximately 243 million children were vaccinated with MCV1, 19.7 million with MCV2, and 11.6 million children with RCV1 in the Region during routine immunization activities.
All countries in the Region conducted a supplementary immunization activity (SIA) with measles and/or rubella-containing vaccine between 2013 to 2022 to close the immunity gaps for measles and rubella in various age groups. More than 653 million children were vaccinated in these SIAs.
Surveillance for acute fever and rash was initiated in all countries along with enhancing sensitivity for measles and rubella surveillance. By 2021 at least one proficient national laboratory was established in each country to support measles and rubella case-based surveillance. The measles and rubella laboratory network expanded from 23 laboratories in 2013 to 58 in 2021.
The accelerated efforts resulted in five countries achieving measles elimination and two rubella elimination.
Key enablers guiding progress toward elimination goal
Historical success with the elimination of vaccine-preventable diseases: The Region’s victories over smallpox, polio, and maternal and neonatal tetanus and increases in routine immunization coverage laid the foundation for establishing a goal of elimination of measles and rubella. The available infrastructure and capacity were fine-tuned for efficient implementation of the regional strategy.
Political and programmatic commitment: The Region, through its various regional committee resolutions, expressed ownership and the highest level of political commitment to achieve the goal of measles and rubella elimination in the context where there was no global goal to guide the program. Declaring measles and rubella elimination as a flagship underscored the commitment to protect the population across the region and gave additional impetus.
Partnerships and collaborations: Much of the success of the immunization story in the South-East Asia Region has been due to the power of partnerships.
These partnerships brought an amazing range of stakeholders together. Thousands of people across the Region and the globe – medical doctors, health workers, laboratory technicians, officials working in regulatory agencies, policy-makers in health ministries, local partners, and international agencies – worked tirelessly, often in difficult terrain and circumstances, with a common purpose, to get vaccines where needed, and save lives.
Local partnerships have been key to the transformation in the Region’s immunization landscape in the past decade. The immunization task force or the immunization coordination committees created at all levels of administration in large countries were utilized as an oversight mechanism for measles and rubella elimination at each level. At the sub-national level, large countries ensured cross-border collaborations created for previous elimination programs to enhance the implementation of the strategies.
Appropriate articulation of strategies and directives: The development of evidence-based strategies remained a key component in the process. ‘The Strategic plan for measles elimination and rubella and congenital rubella syndrome control in the South-East Asia Region, 2014-2020’ and a costed 'Strategic plan for measles and rubella elimination in WHO South-East Asia Region: 2020–2024’ provided the strategic framework to the program and identified five key areas of focus for program implementation viz-immunization, surveillance, laboratory support, outbreak response and creating an enabling environment through advocacy, enhanced program oversight and better program governance. The first strategy focused more on developing the systems and the processes and the second on innovative approaches to accelerating progress.
Technical leadership: The Regional and National Immunization Technical Advisory Groups provided overall technical leadership to the immunization program while the Regional Verification Commission for measles and rubella elimination (SEA-RVCV), established in 2016, monitored the implementation of norms and standards in the elimination of measles and rubella.
A review of the annual progress report submitted by the National Verification Committees resulted in laying out the standard criteria in the “Framework for Verification of Measles and Rubella Elimination” developed by WHO in 2016 and revised in 2020 in consultation with experts and Member countries. The corresponding National Verification Committees in the countries worked with respective governments to provide technical leadership and monitor progress towards the goal of measles and rubella elimination.
The measles, rubella, and congenital rubella syndrome surveillance guide was also developed in 2017 and updated in 2022 to support Member countries develop implementation of elimination standard surveillance for measles and rubella.
Monitoring, evaluation, and course corrections: Since 2014, a weekly bulletin on measles and rubella laboratory and surveillance performance based on the weekly surveillance reports of countries was regularly disseminated to programme managers of Member countries, partners, stakeholders, and experts. Similarly, fact sheets for each country and Region were prepared annually to provide a visual aid to monitor data trends and immunity profiles to enable countries plan supplementary immunization activities to close immunity gaps. Quarterly measles and rubella bulletin was published regularly since 2019.
Programmatic risk assessment for measles and rubella transmission was regularly conducted in all the countries on an annual basis since 2017 and reviewed regularly jointly by the national immunization programs and national verification committees to prioritize geographical areas and develop further strategies to mitigate the risk of measles and rubella transmission as well as to close the immunity gaps through vaccination activities.
Generating, translating, and disseminating valuable knowledge: The lessons learned from countries in the Region on accelerating progress toward measles elimination and rubella control were disseminated widely. In addition, documenting and disseminating the lessons learned on measles and rubella elimination among countries that have achieved the goal, as well as those facing significant challenges, were disseminated through various publications.
Research and development: Several research studies to guide strategic interventions in the measles and rubella programme were implemented during the period. These included costing of measles and rubella elimination in the WHO South-East Asia Region; serosurveys to assess the population immunity profile against measles and rubella in India, and Nepal and research and development of rapid diagnostic test kit for measles and rubella.
Challenges, opportunities, and the way forward
The COVID-19 pandemic significantly impacted routine immunization coverage, including meases and rubella-containing vaccines. Coverage of the first dose of the Measles-Containing Vaccine (MCV1) declined from 94% in 2019 to 86% in 2021 and coverage of the second dose (MCV2) declined from 83% in 2019 to 78% in 2021. Coverage of the Rubella-Containing Vaccine (RCV) declined from 93% in 2019 to 86% in 2021.
(A 15-month girl receives measles-rubella vaccine at Patan Hospital, Lalitpur, Nepal) Photo credit: © WHO
Striving to cover immunization gaps countries organized catchup campaigns. An outbreak readiness assessment was conducted to identify areas that needed to be strengthened. WHO worked to support countries in their efforts to close the immunity gaps and ensure a high level of preparedness for outbreak response.
With continued efforts during COVID-19 pandemic, Bhutan, DPR Korea, Maldives, Sri Lanka, and Timor-Leste sustained their measles elimination status while Maldives and Sri Lanka sustained rubella elimination.
In 2022 an independent review commissioned assessed the progress and the situation and cautioned that the Region was off track to achieving the 2023 target for measles and rubella elimination. It recommended that the target be reassessed in consultation with global and regional experts, partners, and member countries.
The challenges to achieve measles and rubella elimination are enhancing routine immunization coverage to 95% or more coverage with two doses of a measles-rubella-containing vaccine in all districts of all countries and strengthening measles and rubella surveillance which remained limited in endemic countries. Insufficient funds and local commitment towards key strategies also pose major hindrances to achieving elimination of measles and rubella. Consistent implementation of key elimination strategies continued to be a major challenge.
While outbreaks of measles serve as a tracer of the gaps in immunization coverage and primary health care, these gaps need to be urgently addressed while strengthening the capacity for outbreak investigations to identify causes and inform corrective actions.
Measles and rubella activities including surveillance and case management must be fully embedded as key components of primary health care systems to achieve universal health coverage in line with the Region’s new Strategy for PHC. Use of life course approach for catch-up measles and rubella vaccination to catalyse efforts to mainstream catch-up vaccination and reduce the need for supplementary immunization activity to fill gaps in coverage. More efficient and effective approaches tailored to local challenges need to be adopted
The elimination of measles and rubella is feasible in the WHO South-East Asia Region which has demonstrated its strong will and real progress toward this goal. WHO remains committed to providing high-quality technical assistance to Member countries to support these efforts.
Now more than ever, we must collectively work to sustain the hard-fought gains, accelerate progress and innovate new ideas to ensure each child gets lasting protection from vaccine-preventable diseases allowing them to live happier and healthier lives.