Pakistan's Progress Toward Measles Elimination, 2000–2018

This report describes Pakistan's measles program through 2018.

In 1997 the 21 countries of the World Health Organization's Eastern Mediterranean Region resolved to eliminate measles, and in 2015 the goal became a priority of the region's Vaccine Action Plan 2016–2020. The WHO regional office set out a four-part strategy:

1. at least 95% coverage with the first dose of measles-containing vaccine (MCV1) in every district, through routine immunization;
2. at least 95% coverage with a second dose (MCV2) in every district, through a routine two-dose schedule or supplementary immunization activities (SIAs), or vaccination campaigns;
3. high-quality, case-based measles surveillance in every country;
4. the best possible clinical care for measles cases, including vitamin A.

Pakistan, with about 200 million people, holds nearly a third of the region's population. Before 2000, measles vaccine coverage there was 57% or lower for two decades, and reported measles cases averaged about 29,000 a year in the 1980s and 3,900 a year in the 1990s.

Routine vaccination

Pakistan added MCV1 to its routine childhood schedule in 1974 and MCV2 in 2009, given at 9 and 15 months of age. According to WHO and UNICEF estimates:

• MCV1 coverage rose from 57% in 2000 to 76% in 2017;
• MCV2 coverage rose from 30% in 2009 to 45% in 2017.

A national Demographic and Health Survey in 2017–2018 estimated 73% coverage for the first dose and 67% for the second, with wide gaps by area:

The same survey found coverage with all basic childhood vaccines ranged from 80% among the richest fifth of children to 38% among the poorest, and from 71% in cities to 63% in rural areas.

Vaccination campaigns

About 232.5 million children received measles vaccine in campaigns through 2018, all using single-antigen measles vaccine:

• 2007–2008: a nationwide catch-up campaign in five phases reached 66.6 million children under 15.
• 2010–2011: after severe flooding in the Indus River Basin across much of Khyber Pakhtunkhwa, Punjab and Sindh, campaigns vaccinated 29.7 million children, those under 13 in flooded areas and under 5 elsewhere.
• 2014–2015: after a 2013 epidemic, a phased nationwide campaign vaccinated 61.4 million children under 10. An independent survey in Sindh estimated 83% coverage.
• 2018: after a 2017–2018 epidemic, a nationwide campaign vaccinated 37.1 million children under 5 (under 7 in Punjab). An independent survey estimated 93.3% coverage overall and 95.7% in Punjab. Gavi, the Vaccine Alliance, helped fund it, and WHO, UNICEF and other partners helped plan and monitor it.

Surveillance and cases

All health facilities report measles case counts through the National Health Management Information System. Case-based measles surveillance began in 2009 and expanded during 2013–2018 to 7,555 reporting units. In 2017–2018 WHO placed technical officers in every province and area to track surveillance quality. Pakistan began reporting measles virus genotypes to WHO's global database in 2007.

Confirmed cases rose and fell with the campaigns:

• 7,641 in 2006, falling to 863 in 2009 after the catch-up campaign;
• 4,321 in 2010, then, after the floods and large population movements, 40,923 in 2013, an incidence of 230.3 per million;
• 4,112 in 2015 after the 2014–2015 campaign, then 33,007 in 2018 (153.6 per million), most of them before the October 2018 campaign.

Average incidence rose from 24.6 cases per million in 2000–2009 to 80.4 in 2010–2018. Part of that rise, especially from 2013 on, reflects better surveillance. Even so, WHO's standard indicators showed underreporting: suspected cases ruled out as not measles after investigation ran at only 2.1 per 100,000 people in 2017 and 1.5 in 2018. Of 201 cases genotyped from 2007 to 2018, 50 were D4, 150 were B3 and one was H1; D4 appeared in 2007–2013, and B3, which spread worldwide in 2010–2018, dominated from 2011.

What is needed

Coverage stayed well below the 95% WHO recommends, and large outbreaks in 2012–2014 and 2016–2018 exposed the gaps. The authors call for:

• reaching all children, especially in rural areas and poor communities, and identifying communities that do not use routine immunization;
• periodic high-quality campaigns following WHO guidelines and readiness checks, with adequate funding;
• expanding case-based surveillance to every health facility, to find groups at risk that need campaigns.

Pakistan was one of only three countries that had never interrupted transmission of wild poliovirus type 1, so polio eradication work there is intense. The authors suggest measles efforts draw on polio's staff, experience and reach: finding missed communities, engaging local leaders so every eligible child is vaccinated, using investigations to target campaigns, and responding faster to outbreaks, while managing any shift of polio resources carefully so polio work is not put at risk. The region's technical advisory group on immunization recommended a multipartner task force to apply polio's lessons, and the introduction of rubella-containing vaccine by 2020, with a measles-rubella campaign for children under 15 to build immunity against both.

Limits

Administrative coverage can be overstated when campaign doses or doses to children outside the target age are counted, or when population or dose figures are wrong. Surveillance likely undercounts measles, because not everyone seeks care and not every case is reported, and improving surveillance over time likely inflated later counts relative to earlier ones.

Sources

• Mere MO, Goodson JL, Chandio AK, et al. Progress Toward Measles Elimination — Pakistan, 2000–2018. MMWR Morb Mortal Wkly Rep 68(22). https://www.cdc.gov/mmwr/volumes/68/wr/mm6822a4.htm
• The report dates its total of 232.5 million campaign vaccinations to both 2000–2018 and 2005–2018, so this page gives no start year. It also calls the rise from 4,321 cases in 2010 to 40,923 in 2013 "approximately eightfold"; this page gives the two counts only.
• The report was written jointly by WHO, CDC and Pakistan's health ministry and national institutes; its figure is not reproduced here.