Interrupting Measles Transmission in China – Progress and Challenges

1. Interrupting Measles Transmission in China – Progress and Challenges 8th Annual Meeting of the Partners for Measles Advocacy Washington, D.C. Sep 2008

2. Outline • Status of measles elimination • Epidemiology • Strategies • International support • Challenges • Plan of action

3. Status of Measles Elimination -- Epidemiology

4. Measles Elimination Plan（2006） Liquid vaccine introduced (1965) Liquid vaccine used（1965） 1800 Before vaccine Pre-vaccine era Incidence (per 100,000) 1600 1400 1200 Incidence (per 100,000) 1000 EPI Conduct（1978） 800 Lyophilized Vaccine2 doses（1986） Accelerate measles control （1998） Accelerated measles control (1998) 600 400 200 0 94 96 98 00 02 04 66 68 70 72 74 76 78 80 82 84 86 88 50 52 54 56 58 60 62 64 90 92 Measles Incidence, China 1950-2007 Year Source: National Notifiable Disease Reporting System (NNDRS)

5. 2005 2004 2006 2007 Geographic Distribution of Measles Incidence, China 2004-2007 （Incidence per 100,000） Source：NNDRS

6. Measles Incidence by Province, 2007 Source：NNDRS

7. Incidence /100 000 Incidence /100 000 Age group Age-Specific Measles Incidence, China, 2004-2007 Source：NNDRS

8. Age Distribution of Measles Cases -- Provinces with Highest Incidence (13-21/100,000) China, 2007

9. Status of Measles Elimination -- Strategies

10. Strategies 1) Strengthen routine coverage 2 doses of measles-containing vaccine (MCV) MR at 8 months; MMRat 18-24 months Goal: > 95% coverage Implementation Immunization free of charge Immunization registry system Coverage estimates: MCV1 = 94% MCV2 = 92% Elimination Strategies and Implementation (1)

11. Strategies 2) SIAs 8m-14y in provinces Incidence > 5/100,000 Incidence < 5/100,000, 70% cases aged < 14y 7y-14y in provinces MCV1, MCV2 > 95% in 2y-7y Follow up To be determined Implementation Completed: Catch up: 8 provinces Emergency wide age-range: 3 provinces Planned 2008: Catch up: 10 provinces Follow up: 3 provinces Elimination Strategies and Implementation (2)

12. Completed Catch Up SIAs – China 2004-2007 • Sichuan Sha’anxi • Hebei 2006 Xizhang Qinghai 2005 Ningxia • Xingjiang Guizhou

13. Strategy 3) Enforce school-entry immunization requirement Goal: > 95% 2-dose MCV coverage 4) Outreach activities for special populations (migrants, high-risk adults) Implementation Ongoing in all provinces In process Elimination Strategies and Implementation (3)

14. Strategy 5) Strengthen surveillance All outbreaks lab-confirmed When incidence < 1/100,000,all cases investigated and > 80% laboratory-tested National, provincial, prefecture labs reach WHO accreditation standard 6) Rapid outbreak response Implementation Parallel surveillance systems merged Reporting from township level and above 60-100,000 suspected cases reported annually 50-60% suspected cases laboratory-tested Ongoing in all provinces Elimination Strategies and Implementation (4)

15. International Support

16. International Support Requested for Measles Elimination by China • USD 902 million estimated for achieving measles elimination by 2012 • Sustain current routine (USD 567 M--62%) • Strengthen routine (USD 207 M--22%) • SIAs (USD 128 M--14%) • USD 20.8 million requested formally by China to international community (2006) • Initially for SIAs operational support to 8 priority provinces

17. International Support Obtained/Committed for Measles Elimination China (1) • Guizhou measles control project 2003-2006 • USD 3.5 million from USCDC to support SIAs, surveillance, school entry and routine • USD 0.37 million from JICA to support supplemental cold chain • Guizhou and Sichuan measles elimination project 2007-2010 • USD 2.0 million from US CDC to support surveillance, enforcement of school entry requirement and routine • USD 2.0 M from Measles Initiative for operational support to SIAs.

18. International Support Obtained/Committed for Measles Elimination China (2) • Measles Olympics training workshop, Atlanta 2007 • Measles Initiative Support to China’s Earthquake Affected Zone • Reducing the incidence of measles in Chongqing from 5/100,000 (2007) to < 0.5/100,000.

19. Challenges

20. Challenges • Persistent high incidence • Infants • Adults • Achieving high-coverage SIAs • Limited vaccine supply • Inadequate funding for operational costs • Maintaining gains of catch up SIAs • Expense of follow up SIAs • Strengthening routine to reduce need for follow up SIAs • Measuring MCV1 and MCV2 coverage accurately • Reaching floating population

21. Measles Cases by Month -- Xinjiang 2004-May, 2008 SIAs

22. Age-Specific Measles Incidence -- Xinjiang, 2007-May,2008 Covered by SIAs 2004

23. Interpretation • Xinjiang data encapsulate national challenges • Pre-school--aged children (Major issue) • Failure to reach children through routine • Late implementation of followup SIAs • School-aged children • Some missed in 2004 catchup • Incomplete implementation of school entry requirement • Cases among adults

24. Plan of Action

25. Plan of Action (1) • Strengthening routine immunization • Expansion of EPI to 14 vaccines • Cold chain renewal • Training • Immunization registry • Measles SIAs • Assuring funding • Seeking international support for operational costs • Increasing vaccine production capacity

26. SIAs Planned in 13 Provinces-- supported by central funds in calendar year of 2008 • Catch up (10 provinces) • Target: 8m-14y • Follow up (3 provinces) • Target: 8m-6y • National fund covers vaccine and syringe, part of vaccinator’s subsidy • Shortage of funds for operational costs in western provinces * Note: Number of SIAs conducted may be limited due to vaccine shortage

27. Plan of Action (2) • Strengthening measles surveillance • Single, merged measles surveillance system • Enhancing outbreak investigation capacity • Pilot projects for enhanced surveillance among adults and infants • Strengthening school entry requirement • Ensuring >95% coverage for two doses MCV • Considering development of standardized approaches to implementation

28. Conclusions • Achieving nationwide measles elimination by 2012 remains challenging • Low-incidence measles persists after apparently high-quality SIAs • Rigorous implementation of all strategies is required • Strong international partnerships and resources are needed to achieve elimination

29. We acknowledge the support from Measles Initiative and US CDC for measles elimination activities in China, and welcome a new infusion of funds for upcoming SIAs from international partners Thank you!

31. Back up Slides

32. Anhui07-1 Anhui07-3 Shandong07-43 Guangdong06-5 Neimeng07-5 Hunan07-9 Guangdong06-21 Guangdong06-29 Henan07-14 Shandong07-21 Hunan07-2 Hunan06-5 Jiangxi07-1 Guangdong06-2 Jiangsu06-6 Tianjin06-8 Shandong06-19 Neimeng07-6 Hunan06-1 Sichuan07-6 Hebei06-30 Shandong06-10 Sichuan07-4 Hebei06-28 H1a Hunan06-3 Neimeng07-3 Shanxi06-3 Shanxi06-4 Shanxi06-5 Jilin06-2 Hunan06-2 Shanxi06-25 Tianjin06-14 Tianjin06-16 Jiangsu07-4 Henan07-3 Hebei06-29 Henan07-48 Shanxi06-27 Henan07-18 Henan07-37 Jiangsu06-7 Neimeng07-4 Guangdong06-30 Shandong06-20 Hunan07-6 Jiangsu07-14 Jiangsu07-12 Shandong07-41 Shandong07-32 Shandong07-39 Jilin06-1 China9463 Chin9427 Chin9435 Chin9372/H1 H1c Chin9312 Chin9334 Chin9442 H1b Chin9458 Chin9475 Chin94-1/H2 Edmonston-wt/54/A Chin9353 Shanghai-191/China-vaccine Shandong07-3 0.01 Gene type of Measles virus strain is H1a