Progress Toward Measles Elimination -- Eastern Mediterranean Region, 1980-1998

In 1997, the 23 member countries of the World Health Organization (WHO) Eastern Mediterranean Region (EMR)* resolved to eliminate measles from the region by 2010. Countries in the region have been divided into two groups according to the status of poliomyelitis eradication and the epidemiology of measles. The criteria used to classify the countries are 1) absence of indigenous transmission of polio for at least 3 years and 2) reliable surveillance for acute flaccid paralysis (AFP). Group 1 countries (Afghanistan, Djibouti, Egypt, Iraq, Libya, Pakistan, Somalia, Sudan, and Yemen) are countries where polio is endemic or was recently endemic and are implementing activities to reduce measles morbidity and mortality. Group 2 countries (Bahrain, Cyprus, Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Palestine National Authority and Palestinian populations served by United Nations Relief and Works Agency [UNRWA], Qatar, Saudi Arabia, Syria, Tunisia, and United Arab Emirates [UAE]) are polio-free and are implementing strategies to eliminate measles following the recommendations of EMR (1). The measles elimination strategies are 1) achieving and maintaining routine measles vaccination coverage at greater than or equal to 95% among children aged 1 year; 2) conducting a one-time mass vaccination campaign (catch-up campaign**) to interrupt indigenous transmission of measles; 3) conducting periodic national follow-up campaigns***; and 4) strengthening measles surveillance and laboratory confirmation of cases. This report presents preliminary data from the 14 countries of group 2 and indicates that substantial progress toward measles elimination has been made, especially in countries fully implementing the recommended strategies.

Routine Vaccination Coverage

In 1998, among the 14 countries in group 2, all except Morocco had a two-dose schedule for measles vaccination (Table 1). Reported coverage with at least one dose of measles vaccine among children aged 1 year was 96% (range: 86%-100%).

To achieve and maintain routine measles vaccine coverage of greater than or equal to 95%, the following strategies were implemented in some group 2 countries: 1) identification and tracking of children who have defaulted on a scheduled vaccination (e.g., home visits), 2) intensive education of the community and health-care providers, and 3) supervision and feedback to vaccination providers. Seven countries (Bahrain, Iran, Jordan, Kuwait, Oman, Syria, and Tunisia) have started monthly reporting of coverage at the district level.

Supplemental Vaccination Coverage

Since 1994, Bahrain, Jordan, Kuwait, Oman, Qatar, Saudi Arabia, Syria, Tunisia, and UAE have conducted catch-up campaigns (Table 2). A total of 13 million children in group 2 countries have been vaccinated in nationwide supplementary mass campaigns conducted during 1994-1999. In Kuwait, a second catch-up campaign was conducted in November 1998 targeting children aged 6-11 years. Timing of follow-up campaigns in the remaining countries that have conducted catch-up campaigns will be based on monitoring the number of susceptible children.

Lebanon, Morocco, and Palestine will implement measles vaccination campaigns in 2000 for children aged 1-14 years, 10 months-19 years, and 5-14 years, respectively. Iran and Cyprus have no plans to conduct supplemental activities.

The campaigns have been planned, conducted, and funded by the ministries of health of the respective countries. In all campaigns, the ministries of health emphasized the use of safe injection practices including disposal of used syringes.

Reported Incidence of Measles

Before the introduction of vaccination, approximately 200,000 measles cases were reported each year from group 2 countries (except Palestine). When measles vaccination was introduced during the early 1980s, the number of cases decreased. From 1983 to 1987, measles vaccine coverage increased from 30% to 70%; the reported number of measles cases decreased from 184,000 in 1980 to 61,000 in 1985 (Figure 1).

From 1980 to 1998, the reported incidence of measles decreased 93%, from 197.8 per 100,000 to 14.4 per 100,000. During the same period, the population of group 2 countries increased from 98 million to an estimated 158 million persons, of which an estimated 39% were aged less than 15 years.

The interepidemic interval increased during the 1990s with outbreaks in 1992 and 1993 resulting in 39,000 and 28,000 reported cases, respectively. In 1996, the number of measles cases reported in group 2 countries decreased to a record low of 8000 cases. In 1998, the number of cases increased to 23,000. Four countries (Iran, Morocco, Saudi Arabia, and Syria) that had not implemented catch-up campaigns reported 91% of total cases in 1998. During 1996-1998, the age distribution of 13,225 persons with measles reported to WHO by 10 countries (29% of total cases reported) was 1535 (12%) among children aged 1 year, 3244 (25%) among children aged 1-4 years, and 8446 (64%) among persons aged greater than or equal to 5 years.

Enhanced Surveillance

In 1998, case surveillance with laboratory investigations of all suspected measles cases began in Bahrain, Kuwait, Oman, and Tunisia. Collection of information about measles vaccination status began in Cyprus, Iran, Kuwait, Oman, Syria, and Palestinian populations served by UNRWA. In these countries, 5281 (63%) of 8311 reported measles cases occurred among children who had received one dose of measles vaccine. During 1998-1999, 1735 serum specimens were tested from persons with suspected measles (representing 9% of total reported cases) reported by Iran, Oman, Syria, and Tunisia to EMR. Of these, 865 (50%) were measles IgM positive. In Tunisia, from January through June 1999, 251 suspected measles cases were reported; of the 212 with negative measles IgM results, 133 (63%) were IgM positive for rubella.

Laboratory training workshops were conducted in Tunisia for EMR countries in 1997 and 1998. A regional measles laboratory network will be established to support the measles elimination program in EMR (2).

Impact of Elimination Activities

Since 1990, Oman achieved high routine measles vaccination coverage (greater than or equal to 95%) because of a defaulter system that traces birth registrations, frequent and regular supervision, and outreach visit information. Coverage in the catch-up campaign in 1994 was 93%, and after the campaign, measles incidence decreased to extremely low levels; five cases were confirmed in 1998 (Figure 2). Oman also has implemented case-based surveillance with laboratory confirmation. Kuwait implemented catch-up campaigns in two phases, the first in 1994 and the second in 1998. Cases decreased from 462 in 1994 to a record low 12 cases in 1995, but increased to 90 cases in 1998.

Reported by: Ministries of health of Bahrain, Cyprus, Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Palestine National Authority and Palestinian populations served by United Nations Relief and Works Agency, Qatar, Saudi Arabia, Syria, Tunisia, and United Arab Emirates, World Health Organization, Eastern Mediterranean Region, Alexandria, Egypt. Vaccines and other Biologicals Dept, World Health Organization, Geneva, Switzerland. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases; Epidemiology and Surveillance Div; Vaccine Preventable Disease Eradication Div, National Immunization Program; and an EIS Officer, CDC.

Editorial Note:

Eradication of polio is the highest vaccination priority in the EMR, and measles elimination activities are being phased in on the basis of the status of polio eradication in the country. In the nine countries where polio is endemic or was recently endemic, measles remains a major cause of morbidity and mortality. Only those countries that have evidence of interruption of indigenous transmission of polio for at least 3 years, based on high quality AFP surveillance****, have started measles elimination activities. Because of the proximity of countries where polio is endemic, complete and timely surveillance for AFP cases should continue until global eradication is achieved.

The 14 countries that have started measles elimination activities have had high routine measles vaccination coverage since 1994. This has reduced reported measles-associated morbidity by greater than 90%, compared with the early 1980s. During 1997 and 1998, the number of measles cases increased to approximately 20,000 each year; however, most cases occurred in Iran, Morocco, Saudi Arabia, and Syria before implementation of supplemental vaccination activities.

Bahrain, Jordan, Saudi Arabia, Syria, Tunisia, and UAE reported high coverage in their catch-up campaigns. Because these campaigns were implemented during 1998 and 1999, annual surveillance data might not yet demonstrate their impact on elimination of measles.

Oman is a model of implementation of the EMR measles elimination strategy. As a result of high coverage with the first dose, introduction of a routine second dose in 1994, and a well-executed catch-up campaign in 1994, measles incidence has been reduced to a low level suggestive of interruption of indigenous transmission of measles virus.

Detailed epidemiologic investigation of all suspected cases with laboratory confirmation and virus isolation from all chains of measles transmission is required to determine interruption of indigenous transmission of measles and evaluate the impact of EMR elimination activities. Monitoring of timeliness and completeness of reporting and other surveillance indicators at district levels should be a priority among these countries (1).

Priority program activities for the 14 countries in the EMR now targeting measles elimination are 1) to maintain high routine vaccination coverage (greater than or equal to 95%) with the first dose of measles vaccine; 2) to achieve high coverage (greater than 90%) in catch-up campaigns in Lebanon, Morocco, and Palestine; 3) to either achieve and maintain high coverage with a routine second dose of measles vaccine or implement timely follow-up campaigns in those countries that have conducted catch-up campaigns; and 4) to strengthen case-based measles surveillance and establish a regional measles laboratory network to support laboratory diagnosis of suspected measles cases and virus isolation from all chains of measles transmission. To achieve high routine coverage, countries should monitor and report coverage at the smallest administrative level on a regular basis. Supervision and feedback are necessary to ensure corrective measures in areas with low coverage. Monitoring of age-specific susceptibility based on vaccine coverage is necessary to plan supplemental vaccination activities. To achieve and maintain the regional goal of measles elimination by 2010, high level political commitment and substantial resources will be required to implement the strategies in countries now targeting elimination and gradually expand elimination activities to the rest of the region as polio eradication is completed.

References

1. World Health Organization. Eradication and elimination of diseases with specific reference to measles and tuberculosis. Alexandria, Egypt: World Health Organization, Eastern Mediterranean Region October 1997:19-25.
2. World Health Organization. Annual report of the Regional Director. Alexandria, Egypt: World Health Organization, Eastern Mediterranean Region 1998:115-22.

* Member countries are Djibouti, Egypt, Libya, Morocco, Somalia, Sudan, and Tunisia in northern and eastern Africa; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen in the Arab Gulf states; Iraq, Jordan, Lebanon, Syria, and the Palestinian National Authority in the Middle East; Afghanistan, Iran, and Pakistan in Asia; and Cyprus.

** A one-time, nationwide vaccination campaign targeting all children, usually aged 9 months-15 years, regardless of history of measles vaccination or disease.

*** Subsequent nationwide vaccination campaigns conducted every 2-5 years targeting all children born after the catch-up campaign, usually aged 9 months-4 years.

**** Nonpolio AFP rate greater than or equal to 1 per 100,000 children aged less than 15 years.

TABLE 1. Measles vaccination schedule, reported routine one-dose measles vaccination coverage among children aged 1 year, and reported measles incidence,* by country -- World Health Organization, Eastern Mediterranean Region, 1998

TABLE 2. Dates of catch-up campaign,* type of vaccine, target age group, and vaccination coverage during measles vaccination campaigns, by country -- World Health Organization, Eastern Mediterranean Region, 1994-1999

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