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MEASLES - NEPAL, 2000-2006

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In 2002, the United Nations General Assembly Special Session on 

Children set a goal to reduce global measles deaths by half (compared 

with 1999) by 2005 (1). Nepal, a southeast Asian country with an 

estimated population of 27 million, adopted the measles mortality 

reduction strategies of the World Health Organization (WHO) (2) in 

2003, with a goal of reducing measles deaths by half (compared with 

2003) by 2005. The strategies consisted of strengthening routine 

childhood immunization programs, providing a 2nd opportunity for 

measles vaccination through supplementary immunization activities 

(SIAs), improving surveillance, and improving measles case 

management. This report describes routine immunization activities in 

Nepal, the implementation of measles SIAs, and measles surveillance 

data for the period 2000-2006. The findings demonstrate a substantial 

decrease in reported measles incidence. Assuming a reduction in 

measles deaths that paralleled the decrease in incidence, the 

findings also suggest progress toward the goal of measles mortality reduction.



Background and Routine Vaccination

------------------------------------------

Nepal is divided into 75 districts in 5 regions. The Expanded 

Programme on Immunization (EPI) was initiated in 1979 in Nepal in 3 

districts; by 1988, the program had been expanded to all 75 districts 

(3). The program aims to achieve and maintain coverage of >90 percent 

fully immunized children nationwide by 2010 (4) and targets children 

aged >9 months with measles vaccine. According to WHO/UNICEF 

estimates, measles vaccination coverage among children aged <1 year 

increased from 58 percent in 1988 to 71 percent in 2000; coverage 

further increased from 75 percent in 2003 to 85 percent in 2006 (5). 

Despite high national coverage in 2006, 6 of 75 districts 

(representing 4 percent of the population aged <5 years) were unable 

to reach >70 percent coverage because of lack of security resulting 

from civil unrest, limited access to certain areas, or lack of human resources.



Surveillance

-------------

Measles in Nepal is reported as part of the Health Management 

Information System (HMIS), which covers all 4102 government health 

facilities in Nepal. However, HMIS does not provide detailed 

geographic and age group data, and reports often are incomplete and 

not timely; moreover, HMIS reports only clinically suspected measles 

and does not report laboratory testing. Information on 

measles-related deaths is not reported systematically. In March 2003, 

the government of Nepal and WHO initiated a more comprehensive 

measles surveillance system to supplement HMIS with more detailed 

information on cases in clusters of suspected measles. The new 

measles surveillance system, which includes field investigations and 

laboratory testing of blood specimens, is supported by surveillance 

medical officers (SMOs), who have conducted health facility visits 

for active acute flaccid paralysis (AFP) surveillance since 1998. 

This integrated surveillance network provides timely and detailed 

data on AFP, Japanese encephalitis, and measles cases though weekly 

reports from 413 major health-care centers and hospitals throughout 

all 75 districts of the country (i.e., approximately 10 percent of 

all government health facilities), including all inpatient 

facilities. In addition, SMOs conduct weekly visits to 84 active 

surveillance sites within this network.



If 5 or more cases of suspected measles are detected during a 2-week 

period from one geographic area, an outbreak investigation is 

undertaken in which epidemiologic information is collected on all 

suspected measles cases in the area, and blood samples are drawn for 

at least 5 cases for laboratory confirmation of measles (i.e., via 

identification of immunoglobulin M [IgM] measles antibodies). An 

outbreak is considered a confirmed measles outbreak if at least one 

case is laboratory confirmed in a person who had not received measles 

vaccination one month before. All untested suspected cases in a 

laboratory-confirmed outbreak are considered epidemiologically 

confirmed. Since January 2004, all samples that test negative for 

measles IgM have been tested for rubella IgM. With rubella IgM 

testing, similar criteria allow an outbreak to be considered a 

confirmed rubella outbreak or a confirmed mixed measles and rubella 

outbreak. Approximately 90 percent of cases associated with confirmed 

measles outbreaks in 2003 were in children aged <15 years; this 

finding supported the decision to conduct a "catch-up" SIA targeting 

children aged 9 months-15 years.



Measles Vaccination Campaign, 2004-2005

-----------------------------------------------

Nepal public health authorities conducted a nationwide measles SIA in 

3 phases during September 2004-April 2005, targeting an estimated 9.4 

million children aged 9 months-15 years. Oral poliovirus vaccine also 

was administered to all children aged <5 years. The overall reported 

measles vaccination coverage was 105 percent of the population 

target; in one district, the coverage was as low as 64 percent. The 

population targets were obtained from administrative lists.



Measles Incidence

--------------------

In 2003, a total of 67 suspected measles outbreaks were investigated 

using the integrated system; in 2004, a total of 196 outbreaks were 

investigated. Nearly 70 percent of these outbreaks were confirmed 

measles outbreaks (data presented in a table in the original text). 

After the start of the SIAs, the number of suspected measles 

outbreaks detected decreased to 46 in 2005 and to 31 in 2006. In 

2005, only one (2 percent) of the 46 investigated outbreaks was a 

laboratory-confirmed measles outbreak, whereas 36 (78 percent) were 

laboratory-confirmed rubella outbreaks. Similarly, in 2006, 2 (6 

percent) of 31 outbreaks were laboratory-confirmed measles outbreaks, 

and 24 (77 percent) were laboratory-confirmed rubella outbreaks. 

During 2005 and 2006, 3 mixed measles and rubella outbreaks were 

number of measles cases associated with outbreaks decreased from 

approximately 1000 in 2003 to approximately 50 in 2006. During 2005 

and 2006, a total of 1119 suspected measles cases that were not part 

of any recognized outbreak were reported to SMOs. Serum specimens 

were collected for 84 of these cases; 3 (4 percent) were laboratory 

confirmed as measles cases.



The average annual number of measles cases reported through HMIS 

during the 4 years (2000-2003) before the start of the SIA was 10 

425. After the SIA, the number of reported cases decreased to 3931 in 

2005 and to 1935 in 2006, decreases of 62 percent and 81 percent, 

respectively, from the 2000-2003 average (data presented in a table 

and a figure in the original text).



Health and Population; P Bangdel, MSc, UNICEF Country Office, 

Kathmandu; T Sedai, MA, B Lamichhane, MBBS, MPH, J Partridge, PhD, 

World Health Organization Country Office, Kathmandu, Nepal. J 

Liyanage, MBBS, MPH, World Health Organization Regional Office for 

Southeast Asia, New Delhi, India. P Strebel, MBChB, A Dabbagh, PhD, 

Dept of Immunization, Vaccines, and Biologicals, World Health 

Organization, Geneva, Switzerland. O Mach, MD, V Dietz, MD, Global 

Immunization Div, National Center for Immunization and Respiratory 

Diseases, CDC]



MMWR Editorial Note

-------------------------

Because information on measles-related deaths is not routinely 

collected in Nepal, no direct measurement of reduction in deaths 

associated with improved measles control is possible. However, 

reports from other countries have assumed that a reduction in measles 

deaths occurred in the same proportion as a reduction in reported 

measles cases (6,7). A concomitant decrease in suspected cases and 

measles deaths has been observed in other countries that monitored 

measles deaths before and after SIAs (8,9). By making this same 

assumption for Nepal, the findings in this report suggest that, by 

the end of 2005, Nepal had achieved its goal of reducing measles 

mortality by at least 50 percent from 2003 levels. The reduction in 

measles incidence in Nepal during 2003-2006 indicated by HMIS data 

might underestimate the actual relative reduction in measles deaths 

because, compared with pre-SIA years, a more pronounced decrease 

occurred in the number of confirmed outbreaks and in the proportion 

of confirmed measles cases in outbreaks during post-SIA years. In 

addition, treatment of measles patients** has been emphasized since 2003.



to set its measles program objective toward elimination. In the 

Ministry of Health and Population's Multi-Year Plan of Action for 

immunization, the measles elimination phase will begin in 2010 (4). 

Major components of the elimination strategy include high routine 

immunization coverage (>90 percent in >80 percent of districts), 

provision of a 2nd opportunity for measles vaccination through 

routine vaccination or SIAs, and case-based surveillance with 

laboratory confirmation.



The integration of measles surveillance and AFP surveillance since 

2003 has made use of the extensive surveillance infrastructure in 

Nepal, which was developed for AFP surveillance and, since 2004, has 

included investigation and laboratory testing of suspected 

encephalitis cases for Japanese B encephalitis. WHO formally 

accredited the Nepal national measles reference laboratory in 2006. 

The 1st steps toward further strengthening surveillance began in 

January 2007; a case-based measles surveillance system, in which all 

suspected measles cases are investigated and laboratory tested for 

IgM, was started in 12 active surveillance sites in the Kathmandu 

Valley and in 2 active surveillance sites in the Far West Development 

Region. In addition to continuing outbreak investigations, this 

case-based surveillance system will expand to include the entire 

country by 2010 and will use measles virus genotyping to determine 

the origin of virus isolates; however, data on measles-related 

mortality are not available through this system.



Additional measures to increase routine vaccination coverage, 

particularly in remote areas and those with low coverage, will be 

critical for preventing outbreaks and moving toward the goal of 

measles elimination. Despite advances in delivering routine 

vaccination, the proportion of children susceptible to measles 

started to increase after the 2004-2005 SIA, increasing the 

likelihood of measles outbreaks. A nationwide follow-up measles 

vaccination campaign targeting children aged 9 months to 4 years 11 

months is planned for 2008. Given the difficulties with access to 

certain areas of Nepal, providing a 2nd measles vaccination 

opportunity through routine vaccination is not likely to reach high 

coverage levels with both doses. Because SIAs have been effective 

throughout Nepal, including in areas that are difficult to access, 

repeated SIAs likely will be the long-term strategy for regularly 

providing a 2nd measles vaccination opportunity.



Nepal has achieved a substantial reduction in reported measles 

incidence and in the number of confirmed measles outbreaks. This 

experience provides useful lessons for other countries in southeast 

Asia as they progress toward measles mortality reduction.



References

-----------

(1) United Nations General Assembly Special Session on Children. A 

Special Session on Children; 2002. Resolution S-27/2. Available at 



(2) World Health Organization, UNICEF. Measles mortality reduction 



(3) Suvedi BK. Twenty-five years of immunization program in Nepal. 



(4) Nepal Ministry of Health and Population. Multi-year plan of 

and Population; 2006.



(5) World Health Organization, UNICEF. WHO/UNICEF review of national 

immunization coverage, 1980-2006. Available at



(6) Otten M, Kezaala R, Fall A, et al. Public-health impact of 

accelerated measles control in the WHO African Region 2000-03. Lancet 



[7] CDC. Measles mortality reduction---West Africa, 1996-2002. MMWR 



(8) Biellik R, Madema S, Taole A, et al. First five years of measles 





[N.B. Footnotes, Table and Figure do not appear in this transcript]



--



[Striking progress has been made in reduction of measles virus 

infection in Nepal in the years from 2004 to the present. (The figure 

in the original text illustrates this vividly). The revised aim of 

achieving complete elimination of measles by a program commencing in 

2010 will be an ambitious task in such a challenging geographical situation.



A map of Nepal an be accessed at 



diseases with a focus on current outbreaks.  The above summary of 

measles activities in Nepal is being posted as an exception.  At the 

present time, there is an international initiative to reduce the 

morbidity and mortality due to measles (see 

2010 compared to 2000 estimates".  There is a strong likelihood that 

following the achievement of the goal of eradication of polio, and 

the demonstrated successes of the measles initiative (as demonstrated 

in the above report from Nepal), that the activities of the measles 

initiative will be transformed into a worldwide initiative to 

eliminate (and perhaps eradicate) measles.  The above report on the 

measles situation in Nepal is an excellent analysis of the 

challenges, and how they can be overcome, making a goal of measles 

elimination a viable target. - Mod.MPP]



1997

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Measles - Nepal 19970518.1007]

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