The National Verification Committee (NVC) and Its Important Recommendations For 2013

Transcription

1 Status of Measles and Rubella Elimination Update for the year 2013 Germany

2 This update is to be submitted to the WHO Regional Office by 31 July Please upload an electronic version of the update and a copy of page 5 signed by the NVC members to the RVC SharePoint: How to upload the report: 1. Make a copy of your report and any supporting documents and supplementary data in original (MS Word) format. PLEASE DO NOT CONVERT THIS FILE IN PDF FORMAT! 2. Login at using the password provided by WHO secretariat to NVC chairperson and EPI manager 3. Click on Country Annual Status Reports 4. Select and click on your country folder 5. Click on Upload 6. Click on Browse or Upload Multiple Files to select a single or multiple files from your PC or MAC to upload 7. Select your file(s) and click on OK 8. Double check that the files are uploaded under the Country Annual Status Reports/Your country name Should you have any problems with access to the RVC SharePoint or uploading the report, please contact WHO secretariat by (eurorvc@euro.who.int). This update report consists of three sections: Section 1: The National Verification Committee (NVC) Section 2: Country measles and rubella profile Section 3: Update of general programme activities by components Abbreviations: MCV RCV NVC RVC measles-containing vaccine rubella containing vaccine national verification committee Regional verification commission 2

3 Definitions Disease elimination: the absence of endemic measles or rubella cases in a defined geographical area for a period of at least 12 months, in the presence of a well-performing surveillance system. Regional elimination can be declared after 36 or more months of the absence of endemic measles or rubella in all Member States. Disease eradication: worldwide interruption of measles or rubella transmission in the presence of a verified, well-performing surveillance system. Endemic case: a laboratory-confirmed or epidemiologically linked case of measles or rubella resulting from endemic transmission of measles or rubella virus. Endemic transmission: continuous transmission of indigenous or imported measles or rubella virus that persists for a period of 12 months or more in a defined geographical area. Re-establishment of endemic transmission: a situation in which epidemiological and laboratory evidence indicate the presence of a chain of transmission of a measles or rubella virus variant that continues uninterrupted for a period of 12 months or more in a defined geographical area where disease was previously eliminated. Classification of cases: Suspected measles case: a case with signs and symptoms consistent with measles clinical criteria: fever and maculopapular rash and cough or coryza (runny nose) or conjunctivitis (red eyes). Suspected rubella case: a case with signs and symptoms consistent with rubella clinical criteria: maculopapular rash and cervical, suboccipital or post-auricular adenopathy, or arthralgia/arthritis. Laboratory-confirmed measles case: a suspected case that meets the laboratory criteria for measles case confirmation. Laboratory-confirmed rubella case: a suspected case that meets the laboratory criteria for rubella surveillance case confirmation. Epidemiologically linked measles case: a suspected case that has not been adequately tested by laboratory and that was in contact with a laboratory-confirmed measles case 7 18 days before the onset of rash. Epidemiologically linked rubella case: a suspected case that has not been adequately tested by laboratory and that was in contact with a laboratory-confirmed rubella case days prior to onset of the disease. 3

4 Clinically compatible measles case: a suspected case that has not been adequately tested by laboratory and has not been epidemiologically linked to a confirmed measles case. Clinically compatible rubella case: a suspected case that has not been adequately tested by laboratory and has not been epidemiologically linked to a confirmed rubella case. Discarded case: a suspected case that was investigated and discarded, either through negative results of adequate laboratory testing for measles and rubella or by an epidemiological link to a laboratory-confirmed case of another disease; in addition, IgM-positive cases in recent vaccine recipients can be discarded if they meet all of the following criteria: history of vaccination with relevant vaccine 7 days to 6 weeks prior to specimen collection; onset of rash 7 14 days after vaccination; no evidence of virus transmission revealed by active search in community; no history of travel to areas in which the virus is known to be circulating. Imported case: a case exposed outside the country during the 7-18 days (measles) or days (rubella) prior to rash onset as supported by epidemiological and/or virological evidence. Import-related case: a locally-acquired measles or rubella infection occurring as part of a chain of transmission originating in an imported case, as supported by epidemiological and/or virological evidence. (Note: if transmission of import-related cases persists for 12 months or more, cases are no longer considered as import-related but as endemic). 4

5 Section 1: The National Verification Committee (NVC) 1.1 Members of the National Verification Committee Name NVC Status Position Signature 1 Prof. Dr. Oliver Razum Chairperson University of Bielefeld, Faculty of Health Sciences. Dean, Chair of Epidemiology and International Public Health 2 Secretary Remark: The executive secretariat is hosted by the Robert Koch-Institute. Involved persons are not members of the NVC 3 PD Dr. Cornelia Betsch Member University of Erfurt, Department for Psychology 4 Prof. Dr. Heidemarie Holzmann Member Medical University of Vienna, Austria. Department for Applied Medical Virology 5 Prof. Dr. Bijan Kouros Member Stuttgart 6 Dr. Martin Terhardt Member Paediatrician in private practice, Ratingen 7 Prof. Dr. Dr. Sabine Wicker Member, Deputy chair University Hospital Frankfurt. Head of Occupational Health Service Add row 5 Delete last row

6 1.2 General information on the activities of the national verification committee Below, please provide a brief summary of the NVC activities in the year under review and current year to-date, including key issues addressed from the meetings and list any concerns that have arisen, including concerns from the NVC about the national programme, challenges in organizing and/or holding regular NVC meetings Activity Date (Month/Year) Highlights Challenges 1 Constitutional Meeting of the National Verification Committee Preparation of the Committee s Standard Operation Procedure for the development of its annual reports (SOP) Creating algorithms for quality assessment of the surveillance system - Identifying missing data according to the WHO framework and finding surrogates 3 First annual report of the committee Publication of the report on RKI website in February According to data of the National Reference Laboratory an endemic transmission of measles in Germany was rarely observed on national level since After recurrent importation of measles sustained transmission chains were shorter than 12 months. - According to surveillance data identification of transmission chains and imported cases is extremely difficult. - Assessment of the rubella elimination status is only possible to a limited extent. The data is not

7 representative for the entire country and does not allow for nationwide conclusions. 4 Report of the National Verification Committee to MOH on status of MRelimination according to SOP 5 Publication of the WHO report on the website of the Robert Koch Institute Regional differences in immunisation coverages of 4-7 old children Inadequate levels of immunity especially in adolescents and young adults - Reasons for not been immunised are manifold, data on hard-to-reachpopulation groups are lacking - Only little data on immunity and attitude towards MRvaccination of healthcare-workers - No national or regional immunisation campaign, seldom e.g. in schools on local level. - No linkage of surveillance data and data of the National Reference Laboratory - No data on discarded cases Add row Delete last row 7

8 1.3 Status of measles and rubella elimination in 2013 Please summarize the information from the national immunization and surveillance systems suggesting the evidence-based rationale for the status of measles and rubella virus circulation in the country. Tick the boxes below as deemed appropriate and provide your rationale in the spaces below. If you can t make a conclusion, please leave the boxes unchecked and explain in the text box below. Measles: Endemic Re-established endemic transmission Interrupted endemic transmission In 2013, the predominant Genotype diagnosed in Germany was D8-Frankfurt/Main. This genotype has been detected continuously for 42 weeks in Germany and led to an annual incidence higher than 1 case / 1 Mio inhabitants. Since this Genotype has sporadically been detected also in 2014, data are compatible with sustained transmission chains -partly longer than 12 months. Previous to 2013, an endemic transmission of measles virus has not been observed at national level in Germany since According to the available data, Germany has missed the elimination goal for measles in Outbreaks occurred especially in Bavaria, Berlin-Brandenburg and North Rhine-Westphalia because of a high proportion of susceptibles in the general population as well as in particular population groups. However MCV vaccination coverages in 4 to 7 years old children have increased from 91.4% (MCV1) and 25.9% (MCV2) in 2001 to 96.7% and 92.4% in 2012, respectively. Data show as well that children are often vaccinated too late according to recommendations of the Standing Committee on Vaccination (MCV2 not later than with 23 months). Over the past years the age distribution of measles cases shifted in Germany towards adolescents and younger adults with over 70% being over 10 years of age in No national supplemental immunization activities with MCV/RCV have been conducted in 2013 or are planned in the near future. However a variety of measures and activities were conducted or are planned at local or regional level. Communication activities of the Federal Institute of Health Education have been intensified over the past years. The main challenge that remains in Germany is to close immunization gaps especially in adolescents and young adults. Remark I (s. 3.1.e): In 2013, a total of 218 outbreaks (containing 869 cases) has been reported from 13 of the 16 states, with 185 outbreaks including <5 cases and 33 with 5 cases. Of the 218 outbreaks 89 were notified from the federal state Bavaria and 71 from Berlin (73% of all outbreaks). In 9 outbreaks more than one federal state were affected (nationwide). In 17 of 33 outbreaks (52%) a genotype has been detected. In section 3.1. only outbreaks with 5 or more cases are described. Remark II (s. 3.2.): Definition of Timeliness: Percentage of measles and rubella routine reports submitted within 3 days to national level, divided by the number of all submitted reports in the reporting year. The prescribed time limit has changed with legislation in March Precise daily calculations are possible with an update of the electronic surveillance system in autumn Due to the recent changes, data are unfortunately still of limited quality. Appropriate data are expected to be provided in the 2014 report. Notification of discarded cases is not mandatory in Germany. A surrogat assessment of the number of discarded cases might be 8

9 possible with data of a nationwide laboratory sentinel to be established in Virusdetection: defined as outbreaks with laboratory-confirmed virusdetection (PCR or Genotyping) of at least one included case. Remark III (s. 3.3.b): Genotype reporting started in September 2012 with an up-dated version of the German electronic surveillance notification program. Implementation is ongoing due to different program providers. In 2013, for 135 out of 143 cases with genotyping local public health authorities used free-text commentaries to report genotypes. After linkage of the database of the National Reference Laboratory MMR and the database of the surveillance department, genotyping results were available for 231 cases (s. annex 1). Remark IV (s. 3.4.c): Data of Rubella: Endemic Re-established endemic transmission Interrupted endemic transmission None of the three categories offered here matched the situation of Germany. Assessment of the nationwide status of rubella elimination according to WHO indicators was still not possible for Germany before 2013 since mandatory case-based rubella surveillance has been established in March As it took a while to implement the mandatory surveillance, data was of limited quality for the first months after introduction and do not allow for nationwide conclusions for the year Therefore it was decided by the Robert Koch Institute to start official reporting of rubella cases with January Nationwide case-based notification of rubella will form the basis for the assessments of the rubella elimination status starting in

10 Section 2: Country measles and rubella profile 2.1 Update on strategies and procedures: Please indicate in the table below any changes of measles and rubella elimination programme in your country in 2013: Area of work Measles Rubella CRS Strategies Routine immunization schedule Surveillance and reporting Other Establishment of a MMR-Working Group of the German Standing Committee on Vaccination to further improve and simplify MMRrecommendations Preparation of a nationwide laboratory sentinel to assess discarded cases in National meeting of the MOH with representatives of the federal states and RKI to discuss - progress and challenges towards elimination and necessary further steps and developments - discussion of the recommendations of the National Verification Committee - an update of the German Interventional Programme Measles, Mumps and Rubella Legislation of a national case-based notification requirement for rubella and CRS cases as well as for mumps, pertussis and varicella National meeting of the MOH with representatives of the federal states and RKI to discuss - progress and challenges towards elimination and necessary further steps and developments - discussion of the recommendations of the National Verification Committee - an update of the German Interventional Programme Measles, Mumps and Rubella 10

11 2.2 Progress towards measles and rubella elimination Vaccination coverage* Remarks Measles containing vaccine, 1 st dose 96.6% 96.7% not yet available Measles containing vaccine, 2 nd dose 92.1% 92.4% not yet available Rubella containing vaccine, 1 st dose 96.3% 96.4% not yet available Rubella containing vaccine, 2 nd dose 91.8% 92.2% not yet available nationwide school entrance examination, children 4-7 years old nationwide school entrance examination, children 4-7 years old nationwide school entrance examination, children 4-7 years old nationwide school entrance examination, children 4-7 years old Incidence Remarks Measles incidence per 1 million population Rubella incidence per 1 million population na na na see comment on page 9 Number of CRS cases * Based on official national reports. The numerator is total measles cases, including laboratory-confirmed, epidemiologically linked, and clinically compatible cases, but excluding imported cases. The numerator is total rubella cases, including laboratory-confirmed, epidemiologically linked, and clinically compatible cases, but excluding imported cases 11

12 Section 3: Update of general programme activities 3.1 Epidemiology of measles and rubella in 2013 a. Number of suspected cases investigated for measles and rubella Total suspected cases Classified as measles Classified as rubella Discarded (non-measles, non-rubella) Pending classification Measles no data no data no data no data no data Rubella no data no data no data no data no data Other rash and fever diseases no data no data no data no data no data Total no data no data no data no data no data b. Number of measles, rubella and CRS cases, by case confirmation and origin of infection Measles Laboratoryconfirmed Epidemiologically linked Clinically compatible Total Imported Import-related Endemic Unknown ,706 Total ,713 Rubella Laboratoryconfirmed Epidemiologically linked Clinically compatible Total Imported not applicable na na na Import-related na na na na Endemic na na na na Unknown na na na na Total ** na na na na Do not include imported cases in this total ** Do not include imported cases in this total 12

13 < 1 year 1-4 years 5-9 years years years years 30 + Unknown Total < 1 year 1-4 years 5-9 years years years years 30 + Unknown Total CRS Laboratoryconfirmed Epidemiologically linked Clinically compatible Total Imported Import-related Endemic Unknown Total c. Age and vaccination status of laboratory-confirmed, epidemiologically-linked and clinically compatible cases of measles and rubella (excluding imported cases). Measles 0 doses ,307 1 dose or more doses Unknown Total ,771 Rubella 0 doses na na na na na na na na na 1 dose na na na na na na na na na 2 or more doses na na na na na na na na na Unknown na na na na na na na na na Total na na na na na na na na na Do not include imported cases in this total 13

14 d. Please complete the following tables for each territory at 1 st subnational administrative: Number of measles cases: Administrative territory Baden- Würrtemberg Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Bavaria Berlin Brandenburg Bremen Hamburg Hesse Mecklenburg- West Pomerania Lower Saxony North Rhine- Westphalia Rhineland- Palatinate

15 Saarland Saxony Saxony-Anhalt Schleswig- Holstein Thuringia TOTAL ,771 Add row Delete last row Number of rubella cases: Administrative territory Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total not applicable Add row Delete last row 15

16 e. Outbreaks in 2013 Measles: Outbreak ID Name of the 1st admin. level(s) (subnational) Date of onset of the first case Date of onset of the last case or ongoing Total number of cases in 2013 Genotype (s) and MeaNS ID Origin of the outbreak (Imported/ importrelated/ unknown) Outbreak report form attached to the report (Yes/No) 1 Bavaria unknown unknown no 2 Bavaria D8 unknown no 3 Bavaria unknown unknown no 4 Bavaria unknown unknown no 5 Bavaria unknown unknown no 6 Bavaria unknown unknown no 7 Bavaria unknown unknown no 8 Bavaria unknown unknown no 9 Bavaria unknown unknown no 10 Bavaria D8 unknown no 11 Berlin D8 unknown no 12 Berlin D8 unknown no 13 Brb D8 unknown no 14 Brb D8 unknown no 15 Bremen unknown unknown no 16 LS D8-F/M unknown no 17 nationwid e 18 nationwid e 19 nationwid e D8-F/M unknown no D8 unknown no D8 unknown no 20 nationwid D8 unknown no

17 e 21 nationwid e 22 nationwid e 23 nationwid e 24 nationwid e unknown unknown no D8 unknown no D8 unknown no D8-F/M unknown no 25 NRW D8 unknown no 26 NRW unknown unknown no 27 NRW D8 unknown no 28 NRW unknown unknown no 29 SA D8-F/M unknown no 30 Saxony unknown unknown no 31 Saxony unknown unknown no 32 Saxony unknown unknown no 33 Saxony unknown unknown no Add row Delete last row Rubella : Outbreak ID Name of the 1st admin. level(s) (subnational) Date of onset of the first case Date of onset of the last case or ongoing Total number of cases in 2013 Genotype (s) and MeaNS ID Origin of the outbreak (Imported/ importrelated/ unknown) Outbreak report form attached to the report (Yes/No) not applicable Add row Delete last row 17

18 3.2 Performance of measles and rubella surveillance in 2013 Please indicate both numerator and denominator used for calculation of performance indicators, as described in attachment Annex 2. Measles Numerator Denominator Rate or percentage Remarks Timeliness of reporting no data no data no data Completeness of reporting 1,771 1, % Rate of laboratory investigations 1,037 1, % Rate of discarded cases no data no data no data Lab sentinel planned Representativeness of reporting discarded cases no data no data no data Viral detection % Origin of infection identified 65 1, % Timeliness of investigation no data no data no data Rubella Numerator Denominator Rate or percentage Remarks Timeliness of reporting not applicable Completeness of reporting Rate of laboratory investigations Rate of discarded cases Representativeness of reporting discarded cases Viral detection Origin of infection identified Timeliness of investigation 18

19 Alternative indicators, if used: Measles Numerator Denominator Rate or percentage Remarks Timeliness of notification not applicable not applicable not applicable not applicable Rate of cases tested negative for measles IgM not applicable not applicable not applicable not applicable Rubella Numerator Denominator Rate or percentage Remarks Timeliness of notification not applicable not applicable not applicable not applicable Rate of cases tested negative for rubella IgM not applicable not applicable not applicable not applicable 3.3 Laboratory performance and molecular epidemiology of measles and rubella viruses in 2013 Please present results from proficient laboratories only. These are laboratories that use a validated assay and pass the laboratory external quality assurance (EQA) test of the WHO Global Measles and Rubella Laboratory Network and/or of other reputable EQA programs. a. Please fill in the table below. Test Number of cases Pending Positive Negative Inconclusive tested Measles IgM no data no data Measles RT-PCR no data no data Measles virus isolation no data no data Measles genotyping no data no data Rubella IgM not applicable na na na na Rubella RT-PCR na na na na na Rubella virus isolation na na na na na Rubella genotyping na na na na na Women tested for rubella IgM during pregnancy as part of a screening protocol as well as any other results of general screenings of population should not be reported in this form 19

20 b. Cases tested positive with genotype information: Case ID 1st admin. Level (subnatio nal) Date of onset of rash MeaNS or RubeNS ID Genotype Origin, if known Tested in WHO accredited lab (Yes/No) Outbreak ID, if applicable S. Annex 1 Add row Delete last row 3.4 Population immunity against measles and rubella a. Please describe the methods by which routine immunization coverage is determined, including both numerator and denominator data. Please clearly indicate source of information of population statistics. 1st dose Description Source of data Comments Numerator 1) Number of children at 4-7 years of age presenting vaccination document and having received at least 1 dose of MCV/ RCV 2) Number of children at 24, 36 and 48 months of age and having received at least 1 dose of MCV/RCV 1) country-wide schoolentrance examinations 2) Cohort generated from analyses of country-wide health insurance claims data; 1) update annually 2) update annually as part of vaccination monitoring system (project financed by MoH) Denominator 1) Children presenting vaccination documents for school entrance examination (92.6% in 2012) 2) Number of children in a cohort with physician contacts at beginning and end of follow-up period 1) country-wide schoolentrance examinations 2) Cohort generated from analyses of country-wide health insurance claims data; 20

21 2nd dose Description Source of data Comments Numerator 1) Number of children at 4-7 years of age presenting vaccination document and having received at least 2 doses of MCV/ RCV 2) Number of children at 24, 36 and 48 months of age and having received at least 2 doses of MCV/RCV 1) country-wide school-entrance examinations 2) Cohort generated from analyses of country-wide health insurance claims data; 1) update annually 2) update annually as part of vaccination monitoring system (project financed by MoH) Denominator 1) Children presenting vaccination documents for school entrance examination (92.6% in 2012) 2) Number of children in a cohort with physician contacts at beginning and end of follow-up period 1) country-wide school-entrance examinations 2) Cohort generated from analyses of country-wide health insurance claims data; Example: Numerator: Number of children < 24 months of age with one doses of measles/rubella containing vaccine given after 12 months of age Denominator: number of children months of age Source of data: administrative reports from subnational level (annually updated) 21

22 b. Any additional data available for determining immunization coverage in 2013 (e.g. results from rapid coverage monitoring, coverage surveys or seroprevalence studies, when applicable) should be included in the report. For published studies, references may be appended to this report. Serological (S) or coverage (C) studies/surveys 1 Number of children at 24 months of age with 2 doses of MCV or RCV, (C); 2 Number of children at 36 months of age with 2 doses of MCV or RCV, (C); 3 Number of children at 48 months of age with 2 doses of MCV or RCV (C); Targeted territory or subpopulation Cohort generated from analyses of countrywide health insurance claims data; data of 2012 Cohort generated from analyses of countrywide health insurance claims data; data of 2012 Cohort generated from analyses of countrywide health insurance claims data; data of 2012 Results MCV1:95.1% MCV2: 71.0% RCV1: 95.1% RCV2: 71.0% MCV1:97.4% MCV2: 84.1% RCV1: 97.3% RCV2: 84.1% MCV1:97.5% MCV2: 86.4% RCV1: 97.5% RCV2: 86.4% Add row Delete last row c. Administrative territories with M/RCV coverage less than 90% in 2013 Please list all administrative territories at the first subnational administrative level where the coverage (as described under 3.4) with first and/or second doses was less than 90%. Please Include data from smaller administrative territories (e.g. districts), if available: Territories (1 st administrative level) with coverage less than 90% Coverage 1 st dose (%) Coverage 2nd dose (%) 1. Baden-Württemberg (MCV) Saxony (MCV) Baden-Württemberg (RCV) Saxony (RCV) Add row Delete last row 22

23 d. High risk subpopulations (please describe population and distribution) High risk subpopulations Description Coverage (%) Minorities (e.g. religious or ethnic) Roma community (specify generally or in selected areas) Refugees Anthroposophic community Berlin, students of anthroposophic school on a school trip, 2011; n=55 (Gillesberg Lassen S et al., Epidemiol Infect 2014) no data Asylum Seeker Schleswig-Holstein, asylum seekers shelter, 2010; n=300 residents (Takla A et al., Epidemiol Infect 2012) MCV1 or more: 58.2% no data 87.0 seropositive Migrants KIGGS data, , nationwide survey, n=16,460, aged between 0 and 17 years. German-born migrants: n=2773; foreignborn migrants: n=509 (Poethko-Müller C et al.: Vaccine 2009) MCV unvaccinated: no migration background: 6.3% ( ) German-born: 5.0% ( ) foreign-born: 12.9% ( ) Health care workers Frankfurt, Hesse, medical students, 2010; n=324 (Wicker S et al.: BGBL 2011) Brandenburg, Saxony, Saxony- Anhalt, , medical students; nursing students; physicians, n= 1,902 (Voigt K et al.: Gesundheitswesen 2008) Schleswig-Holstein 2003, health care workers, n=4,167 (Bader HM et al.: BGBL 2004) 23 MCV2: 58.0 MCV2: 49.8; 49.6; 18.1 RCV2: 49.5; 51.8; 15.8 MCV2: 39.5 (<20 years), MCV2: 11.8 (20-29

24 years) Add row Delete last row e. Actions taken to improve the level of immunization coverage in selected territories and/or in high risk subpopulations in the year under review: National information campaign of the German Federal Centre for Health Education (BzGA) In 2013, the Federal Centre for Health Education continued campaign on vaccination against measles using the slogan Germany is searching for the vaccination card. The educational campaign predominantly addresses adolescents and young adults, and supplements the existing information for parents of small children. Besides information provided by leaflets about the clinical picture and vaccination and large format promotional posters in public space as well as a video spot for cinemas, an interactive video vaccination check, an interactive decision support concerning vaccinations against measles and explanation of the international vaccination cards as well as a quiz about measles are also provided at Actions taken on regional level: - Establishment of immunization committees in/for federal states e.g. suggesting measures to improve vaccination coverages e.g. in Bavaria, Berlin, Thuringia. Hamburg and Lower Saxony - Immunization registry and mandatory immunization notification in Saxony-Anhalt, discussion on the implementation of immunization registries in Saxony and Saarland - Regional guidelines for the control of Measles incidents and outbreaks in e.g. Lower Saxony, Bavaria, Thuringia and Hamburg - General agreements of public health services with health insurance organizations to apply costs for immunizations and immunization campaigns - Provision of vaccination rates and supporting documents on local level to promote scientific exchange and measures to improve vaccination rates in Baden-Wurttemberg - Occasional supplemental immunization activities at school level and universities e.g. in Hamburg, Bremen, Schleswig-Holstein and Rhineland-Palatinate - Recurrent checks of vaccination cards including subsequent individual vaccination advice, especially in schools (students of varying age) and other community facilities - Advanced trainings on vaccinations, e.g. for physicians - Efforts to involve the Occupational Medicine to support catch-up immunizations in young adults in Mecklenburg-Western Pomerania, Schleswig-Holstein and Lower Saxony - Partly web-based education projects targeting children and adolescents e.g. in schools to improve vaccination status e.g. in Saxony, Saxony-Anhalt, Mecklenburg-Western Pomerania, Brandenburg and Baden-Wurttemberg - Provision of educational materials for teachers concerning immunology, microbiology and immunization for secondary schools in Baden-Wurttemberg and Thuringia - Competitions especially for adolescents to promote awareness of the benefit of vaccinations and prevention in Baden-Wurttemberg and North Rhine-Westphalia - Media and information campaigns, including campaigns targeting specific population sub- 24

25 groups - Recurrent press releases on regional measles cases and possibilities for prevention at regional level - Support to establish recall systems to assist private physicians in Bavaria, Hesse and Thuringia - Specific events in the context of the European Immunization Week f. Supplemental immunization activities (SIA) Were supplementary immunization activities with measles/rubella containing vaccine conducted in the year under review (please check the appropriate box)? YES NO If supplementary immunization activities were done, please summarize results in the table below and complete the SIA Technical Report form (Annex 2). National or Subnation al SIA Type of SIA ( e.g. catch-up, mop-up) Vaccine (M, MR, MMR) Dates Age (range) of target group Target populatio n size Coverage achieved (%) IM* conducted (Yes/No) na Add row Delete last row ( * Independent monitoring of SIAs is an objective measure of SIA quality. The guidelines developed for polio supplementary immunization activities can be easily adopted for measles/rubella SIAs. These are available at idelines_ pdf) g. Qualitative assessment of SIA. According to administrative coverage and monitoring results (if done), provide qualitative assessment of SIA that was conducted. Indicate whether there were any geographic clusters and/or high risk groups where coverage was less than 90%. not applicable 25

26 Annex 1: Technical report on implementation of supplementary immunization activities 1. Country: 2. Dates of SIAs: 3. Target provinces (if not a nationwide activity): 4. Targets and results for measles / measles-rubella vaccine by first subnational level (state / province / region) Measles / Measles-Rubella /Measles-Mumps-Rubella Vaccine Area Target Age Target Pop No. Reached Admin Coverage Number (and % districts) >95% coverage Survey Coverage (if available) Wastage Rate No. serious AEFI Serious AEFI attributed to SIA Add row Delete last row 5. Targets and results for other interventions by first subnational level (state / province / region) < intervention name >* Area Target Age Target Pop No. Reached Admin Coverage Number (and % districts) >95% coverage Survey Coverage Add row Delete last row *Please fill out the above table for every intervention added to the SIA 6. Number (numerator and denominator) and % of monitored sites with more than 10% un-reached children during end-process monitoring or if LQAS is done, number and % of rejected lots. 26

27 7. Cost of SIA and amount of financial resources mobilized including resources mobilized within the country (in USD) Expenditure Category Budgeted Government Contribution **Donor contribution <specify donor> Donor contribution <specify donor> Total Total Bundled Vaccine Total operational costs Routine system strengthening activities* (if any) Total * this is for routine systems strengthening activities that are linked to the SIA (occur before, during or post the SIA). Example is the cost of an additional day training on non-measles and rubella related issues. ** insert additional columns for donor contribution if more than 2 donors supported a given expenditure category 8. Number of immunization posts actually operational during the SIAs 9. Number of vaccination teams (including number of health workers per team) actually deployed during the SIAs 10. Number of supervisors actually deployed during the SIAs 11. Number of volunteers actually deployed during the SIAs: No Red Cross volunteers No. LDS Volunteers No. Lions volunteers No. Other (please specify) 12. Describe the strategies employed to identify AND to address hard-to reach children, including the descriptions and size of these populations and the experiences in the SIAs? 13. Comments on Vaccine Quality and any serious AEFIs observed or reported (no. AEFIs should be already included in table for question) Q Comments on the experience with injection safety. Questions below are on activities carried out during the planning and preparation of the SIAs and on any activities planned post the SIA to improve routine immunization? 27

28 15. Is there a national /subnational focal point assigned to ensure that SIAs are used to strengthen systems? 16. Is there a budgeted plan for the routine strengthening activities before, during and post the SIA? 17. Did SIA training include training on EPI beyond measles and rubella? State additional elements included in training and number of health workers trained. 18. What cold chain improvements were done in preparation for the SIA (# of refrigerators refurbished, # refrigerators purchased, # vaccine carriers purchased, etc.) 19. What improvements were made in waste management (# of incinerators built, # waste disposal pits, etc.) 20. Did social mobilization include message on routine vaccination? 21. Is there a plan to use the SIA microplans for updating facility-level RI microplans? 22. Were SIAs used to improve measles surveillance? Did SIA training include measles surveillance (and rubella if rubella surveillance is implemented in the country)? Explain 23. Did the SIA training include AEFI surveillance for other VPDs? If so, How many were trained in the above? 24. Were the SIAs used in any other way to strengthen routine immunization? If so, please specify 28

29 Annex 2: Indicators and targets for measuring performance of measles and rubella surveillance Indicator Description Target and Notes Timeliness of reporting (T) Example: Completeness of reporting (C) Example: Percentage of measles or rubella routine reports a submitted to the national level by the deadline b Target: 80% A Number of reports submitted by the deadline T=(A*100)/B (%) B Number of expected reports Percentage of measles or rubella routine reports a submitted to the national level Target: 80% E Number of submitted reports C=(E*100)/B (%) B Number of expected reports Rate of laboratory investigations (L) Example: Rate of discarded cases (D) Example: Percentage of cases suspected for measles or rubella with adequate specimens c collected and tested in a proficient laboratory d Note: Exclude from the denominator any suspected cases not tested by a laboratory and (a) confirmed by epidemiological linkage, or (b) discarded as non-measles/non-rubella by epidemiological linkage to a laboratory-confirmed case of another communicable disease or epidemiological linkage to a measles or rubella IgM-negative case F G Number of suspected measles or rubella cases with adequate specimens collected and tested in a proficient laboratory Number of suspected cases The rate of suspected measles or rubella cases investigated and discarded as non-measles or nonrubella cases using laboratory testing in a proficient laboratory and/or epidemiological linkage to another confirmed disease H J Number of suspected measles or rubella cases investigated and discarded as nonmeasles or non-rubella cases Population Target: 80% L=(F*100)/G (%) Target: At least 2 discarded measles or rubella cases per D=(H* )/J Representativeness of reporting discarded cases (R) Percentage of subnational administrative territories (e.g. at the province level or its administrative equivalent) reporting the rate of discarded cases (D) at least 2 per population per year Example: K Number of subnational administrative territories reporting the rate of discarded cases (D) at least 2 per population per year M Number of subnational administrative territories Target: 80% R=(K*100)/M (%) Viral detection (V) Example: Percentage of laboratory-confirmed chains of transmission of measles or rubella with samples Target: 80% adequate for viral detection collected and tested in an accredited laboratory e P Q Number of chains of transmission of measles or rubella for which adequate samples have been submitted for viral detection / genotyping Number of chains of transmission identified V=(P*100)/Q (%) Origin of infection identified (O) Example: Timeliness of investigation (I) Example: Percentage of measles or rubella cases for which the origin of infection (e.g. imported, importrelated or endemic) has been identified W Number of measles or rubella cases for which the origin of infection (e.g. imported, import-related or endemic) has been identified X The total number of measles or rubella cases Percentage of suspected measles or rubella cases with an adequate investigation f initiated within 48 hours of notification Y Number of measles or rubella cases with an adequate investigation Z Number of suspected measles or rubella cases, respectively Target: 80% O=(W*100)/X (%) Target: 80% I=(Y*100)/Z (%) a Regular monthly or weekly reports, including zero reports to be submitted by each surveillance reporting unit to national level b The deadline to submit data on the previous months or week to be defined by Member State c A single clinical sample obtained at the first contact with the health-care system at any time within 28 days after rash onset is considered adequate for surveillance purposes. d A proficient laboratory is one that is WHO accredited and/or has an established quality assurance programme with oversight by a WHO accredited laboratory. e Measles and rubella viruses can be detected in nasal secretions, urine, serum and whole blood, and dry blood spots up to seven days after onset of the rash and in oral fluid for even longer. f An adequate investigation includes the collection of at least the following essential data elements from each suspected measles/rubella case: case identifier, age (or date of birth), date of rash onset, date of specimen collection and vaccination status. Countries may wish to collect other data that may be important for epidemiologic investigation 29

30 Alternative indicators The following two indicators should be used by countries that are unable to report standard indicators on timeliness of reporting and/or rate of discarded cases as described above. Timeliness of notification (Tn) Example: Rate of cases tested negative for measles or rubella IgM (N) Example: Alternative to Timeliness and Completeness of reporting Percentage of measles or rubella case-based reports to surveillance system submitted within 48 hours of the rash onset A Number of reports submitted within 48 hours B Number of suspected cases Alternative to Rate of discarded cases The rate of cases of measles or rubella-like illnesses (MLI/RLI) whose specimens tested IgM negative in a proficient laboratory A B Number of suspected measles or rubella cases tested negative for measles or rubella IgM Population Target: 80% Tn=(A*100)/B (%) Target: At least 2 MLI/RLI cases tested negative per population (nationwide) N=(A* )/B 30