23rd Webinar Summary Report on “Status of Vaccine Preventable Disease in South Asia and Feasibility of Elimination of MR”, 15th November 2022

Sandip Parajuli

 

 

Brief Background:

The master of ceremony Dr. Animesh Kunwar started the proceedings of the webinar by introducing the speaker Dr. Sudhir Khanal and the moderator Dr. Bedana Pokhrel.

Dr. Sudhir Khanal is a public health physician with more than twenty years of work experience at global level. At present he is positioned as Technical Officer for Measles at the WHO Regional Office for South East Asia. He is coordinating and collaborating with Global and Regional partners and Ministries of health of eleven countries in WHO SEARO to develop national strategy and action plan for elimination of Measles and Rubella through health system strengthening.

Dr. Bedana Pokhrel, the moderator of the program is a recent graduate of Community Medicine from BPKIHS. She completed Master Training of Trainers (MTOT) for international classification of diseases 11th revision, the global standard for diagnostic health information held at BPKIHS. She has actively participated as a resource person in the training course in service provider training on PACKAGE OF ESSENTIAL NON-COMMUNICABLE DISEASE (PEN) conducted at BPKIHS, Dharan, and also on-site training at Gaighat, Udaypur.

Dr. Sudhir Khanal started his presentation with describing the vaccine preventable diseases and the need for vaccination. He highlighted the status of vaccine preventable disease in South Asia, the set backs that the region suffered from the pandemic, the graphical representations of eleven countries positioning from their target and the feasibility of elimination of MR and the key challenges that we need to overcome.

The webinar lasted for 1 hour and 32 mins. On behalf of the Nepalese Society of Community Medicine (NESCOM), a certificate of appreciation was presented following the insightful presentation by Dr. Sudhir Khanal. The webinar ended with the concluding remarks by Dr. Prajjwal Pyakurel along with the announcement that the upcoming NESCOM webinar series which will now be supervised by Dr. Surya Parajuli.

Objectives of the webinar:

  1. To understand the status of vaccine preventable disease in South Asia
  2. To impart knowledge of the plans implemented by SEAR countries in meeting the target
  3. To know the feasibility of elimination of Measles and Rubella
  4. To address the key challenges that we face in thus context.

Key points discussed during the webinar:

  1. Vaccination is the most cost-effective public health intervention after hand-washing. For every 1 USD invested in measles vaccination there is a return of 76.5 USD. It is estimated that vaccines will help keep an estimated 24 million people from falling into poverty by 2030. Immunization will have positive impact to 14 of 17 SDGs. The Global Immunization Program guided by Immunization Agenda 2030 envisions a world where everyone, everywhere, at every age fully benefits from vaccines for good health and well-being.
  2. Immunization Agenda 2030 has been adapted to the region as regional vaccine action plan 2030 with three impact goals. Goals include pursuing vaccine preventable disease elimination and control goals (achieving measles and rubella elimination, sustaining polio-free status, maintaining MNT elimination, achieving hepatitis B control in 11 South East Asia countries namely Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste), reducing overall mortality and morbidity from vaccine preventable diseases for all across the life course and leaving no one behind by increasing equitable access and use of new and existing vaccines. There are 7 strategic priorities and 33 key areas of focus.
  3. DTP3 coverage is the precursor of the immunization program and the strength of past immunization program was measured with DTP3 coverage which is given at first year of infancy. We are gradually moving to MCV2 which is given at second year. All time high DTP3 coverage was achieved in 2019 by SEA region which surpassed the Global coverage.
  4. Surveillance for priority Vaccine Preventable Diseases in SEAR includes Polio, Measles, Congenital Rubella Syndrome, Neonatal tetanus, Diptheria, Pertusis, Japanese Encephalitis, Rotavirus, Invasive Bacterial Disease and Typhoid. Non-measles and non-rubella discarded rates is viewed as an indicator of sensitivity of surveillance.
  5. Measles and rubella elimination is a regional flagship priority in the SEA Region.
  6. Region certified polio-free status on 27 March 2014 is maintained despite the COVID-19 pandemic.
  7. Bangladesh, Bhutan, Nepal, Thailand verified for control of hepatitis B through immunization
  8. Maternal and neonatal tetanus elimination has been sustained in the South-East Asia Region since 2016. Countries will need to do post-validation assessment exercise every 3-5 years.
  9. Ten out of eleven countries in SEA Region are providing COVID vaccination. DPR Korea is the only country not on the list. Out of 15 emergency use authorized vaccine, 12 vaccines are available in the region. 3.2 billion doses of COVID vaccines have been administered throughout the region where 73.3% received one dose, 66.3% completed primary series and 19.2% received one booster dose. 10 countries achieved 40% completed primary series.
  10. Globally regional verification commissions have established measles elimination to be 39% and rubella elimination to be 46%. There has been backsliding like in Mongolia where reestablished transmission of measles happened during the covid pandemic.
  11. As of June 2022, an estimated 91% reduction in mortality due to measles has occurred in 2020 in the Region compared with 2003. Two essential criteria and five lines of evidences are needed for verification of measles and rubella elimination in the Region.

The essential criteria includes:

  1. Documentation of interruption of endemic measles or rubella transmission, for a period of at least 36 months from the last known endemic case
  2. Presence of high-quality, laboratory-supported surveillance system

The Five lines of evidence required for verification of measles/rubella elimination includes:

  1. Detailed description of the current and past epidemiology of measles, rubella, CRS
  2. Analysis of molecular epidemiology to document viral transmission patterns and the duration of the circulation of viruses of specific lineages
  3. Quality of surveillance and monitoring systems for measles, rubella & CRS
  4. Population immunity presented as birth cohort analysis, including evidence on adults and underserved, migrant and refugee groups
  5. Accountability framework of the programme
  6. Seventy second session of the WHO Regional Committee for South-East Asia endorsed SEA/RC72/R3 on “measles and rubella elimination by 2023”. A Regional costed strategic plan covering the period 2020-2024 has been developed which has five key strategic objective areas: Immunization, Surveillance, Laboratory, Outbreak preparedness and response and Linkages
  7. Age distribution of confirmed measles and rubella cases shows approximately 90% of cases in children under 15 years of age. Reported cases of measles despite 2 doses of MCV were investigated. It was found that most of them were due to recording errors and other times it was due to vaccine failure.

Policy brief:

  1. There is little data on circulating measles genotypes (target is to have genotype information for more than 80% chains of transmissions). Strengthening of virus genetic data need joint efforts of field surveillance and laboratory testing
  2. The under-five susceptibility population has reached closer to one full birth cohort in the Region making it vulnerable to imminent outbreak and the utmost need to prepare for that.
  3. Outbreak response readiness status in SEAR using ten indicators showed that countries in the region are far away from preparedness and there lies the call for action.

Points to be discussed in the Executive committee:

  1. Policy regarding vaccination for older age groups (beyond 2 years) during routine sessions must be implemented
  2. Accountability mechanism at subnational level and re prioritization of MR activities post pandemic recovery period
  3. Inclusion of non-government sectors
  4. MR lab network need to penetrate private sector
  5. Molecular epidemiology needed more than ever as of open border that Nepal shares with India

Conclusion:

Measles and Rubella elimination is feasible using the existing tools however the efforts need to be supplemented with sufficient resources and political commitment. Both immunization and surveillance activities have been impacted by the COVID-19 pandemic and has pushed back the progress by at least 5-8 years. There is a need to have in depth review of MR activities and develop tailored mitigation plans at national and subnational level to accelerate progress.