Measles, Rubella and CRS Elimination

Region of the Americas

Engaging Government and Civil Society

to Achieve the Elimination

12th Annual Meeting of the Measles and Rubella Initiative

Washington, 10-11 September 2013
Dr. Carlos Castillo Solórzano
Ms. Katri Kontio
Dr. Carolina Danovaro
 Presentation Outline
• Progress to achieve regional measles, rubella and
congenital rubella syndrome (CRS) elimination
goals
• Engaging government and civil society
to achieve and maintain the elimination
• Challenges for maintaining the Regional elimination
• Next steps
 Milestones: Measles, Rubella and CRS Elimination
in the Region of the Americas

1994: Resolution to eliminate measles by 2000 2012: Resolution to maintain the elimination

2003: Resolution to eliminate rubella by 2010

2007: Resolution on 2013: 4th IEC*

documentation and meeting
2002: LAST verification process
ENDEMIC
MEASLES CASE

1994 1999 2002 2007 2012

1th IEC*
1995 2001 2003 meeting 2009 2013
First mass Sucre
1997 campaigns Agreement 2009: LAST
against rubella in Bolivia ENDEMIC
First Ladies
RUBELLA AND
as Ambassadors for
CRS CASES
the measles elimination
Largest measles
outbreaks: Canada and
Ecuador 2011-2012

* IEC=International Expert Committee for the documentation and verification process

 Measles Vaccination Coverage among Children <1 Year of Age* and
Reported Measles and Rubella Cases, the Americas, 1980-2013*
Measles
300,000 Catch-up campaigns 100

250,000
Rubella speed-up 80
campaigns
200,000

% Vaccination coverage
Confirmed cases

Measles Follow-up campaigns 60

150,000

40
Last case of
100,000
Last case of
endemic
endemic
measles
rubella
20
50,000

0 0
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13

Measles cases Rubella cases Coverage Measles Coverage MMR

* MMR in children 1 year of age by vaccine introduction

Catch-up Follow-up Speed-up

(<15yr) (1-4 yr) (adol/adult)
Source: country reports to FCH-IM/PAHO
* Data as of September 4, 2013 140 million 80 million 260 million
 Where are We Now with the Regional
Verification Process?
IEC field visits
2013
PER (Feb)*
ECU (Jul)*
NIC (Aug)
CARIBBEAN (Nov)
BRA (Nov)
• All National
Commissions
have submitted
the reports.

Final reports and

amendments
Final reports

2014
Draft report/On- GUT
• Final and
going activities amendment VEN
reports due to PAR
December 2013. URU
Source: Country reports to PAHO/WHO
*Data as of September 9, 2013
Fourth Annual International Expert Committee (IEC)
Meeting, May 2013
Main recommendations
for Member States:
•Provide a plan for
sustainability of program and
strengthening of regular
immunization program.
•Implement the 2012
Resolution (CSP 28.R14):
 To provide evidence
(critical analysis of data)
that supports that endemic
measles and rubella virus
transmission has been
interrupted, and
 To maintain elimination.

July 2013 – PAHO’s Technical Advisory Group (TAG)

endorsed the IEC recommendations
 Engaging Government and Civil
Society to Achieve
Elimination in the Americas

6
 Technical Feasibility
for Measles and Rubella Elimination
USA: English Speaking Caribbean:
•Measles •Measles (1991)
(1997) •Rubella (2001)
•Rubella
(2001)
Cuba:
•Measles (1993)
•Rubella (2004)

Costa Rica:
•Measles
(1999)
•Rubella
Served as strong evidence for the
(2001)
operational feasibility of
measles elimination and
rubella/CRS control among the
Member States of the Region

Source: Ministries of Health, Departments of Statistics and Epidemiology.

 Lessons from Implementation of Rubella Campaigns Served
as a Model for Other Countries to Eliminate Rubella and CRS
Caribbean countries carried out vaccination
campaign against MR during 1998-2001
•Persons aged 20--39 years

Nationwide Campaign for Vaccination of

Women Against Rubella, Chile, 1999
•Non-pregnant women 10-29 years

Nationwide Campaign for Vaccination of

Adults Against Rubella and Measles
120
119

104
116 Costa Rica, 2001
•Persons aged 15--39 years
101
100 95

80
% cobertura

60 Post partum
40
MR coverage
20
(March 2002)
= 98%
0
15 a 19 20 a 24 25 a 29 30 a 34 35 a 39

Edad
 Strong Political Decision

− Pan American Sanitary

Conference, 1994
To set a goal to eliminate
measles from the Region by
2000

−Pan American Sanitary

Conference, 2003
To eliminate rubella and
congenital rubella syndrome
from their countries by 2010
 1990s: Early Advocates
for the Regional Measles Elimination Goal

The support of the First

Ladies was critical to
provide greater
dissemination of the
measles eradication
initiative at the national
and international level
 Establishments of National and
International Expert Committees

President of Costa Rica,

Oscar Árias Sánchez,
signed an executive
decree creating a
national expert
commission to verify the
elimination of measles,
rubella and CRS in the
country, 2008
National and Sub-national Initiatives
for Supporting Achievements of the
Regional Elimination Goals:
Social Mobilization

12
 High Level Advocacy with Government and
Civil Society
With key
decision makers Multisectorial and
and opinion participatory
leaders

Lobby Advocacy

• Based on the leadership

and spokesman with
technical expertise
• Flexible/adaptive to the
reality of each country
• Take advantage of
windows of opportunity
• Pro-Active
• Planned with measurable objectives (SMART)
• Multi level (National, sub- national and local)
• Use of collaborative networks and
• Key persons to diffuse information
• Actively seeking for collaborative partners
 High Level Advocacy
with Government and Civil Society
Pediatric
Societies,
Schools of
Medicines
Private Community
Sector Organization

Church/
Lobby Advocacy Elimination
Media Religious
campaign
inst.

NGOs Donors

Education
System
State Dignitaries as Vaccination Leaders

• Political priority

• Financial resources
(budgetary and extra-
budgetary)

• Active participation in
public events
 National and Sub-National Level
Financial Contributions

Total Cost US$ 8,600,000

42% Local resource mobilization

PAHO/WHO
57%
Ministry of Health and
Social Services

1%
Example, Paraguay, 2007

Source: country reports to FCH-IM/PAHO

 Joint and Collaborative Action:
Strategic alliances and Partners in the Field
Participate in implementation of
vaccination program and plans:
the micro-macro-programming,
financing and operations
Scientific Societies and Medical Associations
Independent observers that contributes in creating
confidence and trust in vaccines among the public
 Church:
Partners of Cooperation and
Enablers
National Communication Plans During the
Elimination Phase
Holistic
Interaction with
Multiple
voices with
• Political
approach: journalist/press uniform support
multimedia messages
• Investments
• Early
planning and
production of
material
Campaign Resource pack
Events and
and
planning by communication
public
stages demonstrations
materials

Famous Created
Vaccination people and demand for
Audience
segmentation
safety
workshops opinion vaccination
leaders services
 Example of Communications and Social
Mobilization: Brazilian National Vaccination
Campaign to Eliminate Rubella and CRS

• Situation analysis showed that

94% of those surveyed would
receive vaccine to help
eliminate rubella. As a result,
the communication strategy
focused on disease elimination.
• The slogan was (Vaccination
has become a family program)
• Television and radio spots
reminded audiences that Brazil
had eliminated polio and now
the country was eliminating
rubella.
21
Regional and Sub-regional Initiatives
to Achive the Elimination Goals:

Pan Americanism and Solidarity

22
 The Sucre Agreement (2002):
Strategy to Prevent the Regionalization of the
Measles Outbreak
Decision to
coordinate a
simultaneous
vaccination week
initiatives
in the Andean sub-
region.
Project of Technical Cooperation among Countries (TCC):
Vaccination against Measles and Rubella in Border Areas
of Argentina and Brazil
Participating Countries:
(~ 20,000 vaccinated)
Argentina Guyana
Bolivia Paraguay
Brazil Peru
Chile Suriname
Colombia Uruguay
French Guiana Venezuela

This TCC is powerful communication

mechanism between the two subregional
integration systems of South America:
the Andean Community of Nations (CAN)
and the Southern Common Market
(MERCOSUR).
 Challenges for Maintaining
the Region Free of Endemic
Measles and Rubella:

Post-elimination Era

25
Interruption of Measles & Rubella/CRS
Endemic Transmission in the Americas

ACCELERATED DOCUMENTATION
CONTROL ELIMINATION AND
CONTROL VERIFICATION

MEASLES: 27th Pan American

Venezuela / NOV 16, 2002
Sanitary Conference,
DC, 2007:
To document endemic
CRS: measles, rubella and
Brazil/ AUG 26, 2009
congenital rubella
elimination in the
Region
RUBELLA
Argentina/ FEB, 2009
 Towards Regional Certification:
The Last Inch?
Continued Dedication to Measles & Rubella
Elimination from the Western Hemisphere

28th Pan American Sanitary Conference, DC, 2012:

To maintain the regional elimination in the Americas
•Continuing measles and rubella virus transmission anywhere in the world
will continue to pose a risk to the Region of the Americas and cause possible
virus importations and outbreak

•Challenges in immunization programs, such as weak surveillance and

heterogeneous coverage, that put at risk the elimination of measles and
rubella
 A Continuing Struggle for the Americas for Maintaining
Elimination Achievement: Main Challenges (1)

• Risk of introduction of endemic transmission due to virus importations

• Heterogeneous vaccination coverage

− Outbreak occur among unvaccinated population groups

• High cost of containing outbreaks in the post-elimination ere

− Small outbreaks with high cost per case; large-scale or/and sustained
outbreaks (e.g. Canada in 2011 (n=803 cases, cost estimate $9,5
million)

• Weak surveillance system to detect sporadic imported cases of

measles and rubella in some countries
 A Continuing Struggle for the Americas for Maintaining
Elimination Achievement: Main Challenges (2)

• High volume of international tourism and

international events and mass gatherings
Need to keep in mind large international events to be held
in the Region such as the World Cup and the 2016
Olympics

• Resource mobilization for the elimination of

SR in the context of low incidence

• Maintaining immunization within the

political and social agenda at the country
and Regional level
 Program Plans (2014)

•Provision of technical support for countries in

implementation of the plan of action for maintaining
the elimination of measles, rubella and CRS in the
Americas

•Publish technical guidelines & operational

research

•Documentation and Verification Process

Thank you!
¡gracias!