Excerpt of full report: Conclusions and recommendations

4th Meeting of the Regional Verification Commission for measles and rubella elimination, 26–29 October 2015

Conclusions 

Based on the 2012-2014 reports and annual status updates (ASUs) submitted by the National Verification Committees (NVCs) of 50 Member States (MS), the Regional Verification Commission for measles and rubella elimination (RVC) concluded that endemic transmission of measles and rubella persisted in the European Region in 2014. Based on this and with comprehensive review of measles and rubella epidemiology in the Region in 2015, the RVC does not believe that the 2015 regional elimination goal for measles and rubella has been achieved. Expecting that 2015 data from NVCs will confirm endemic measles and rubella transmission at the end of 2015 in some countries, the RVC stands committed to continue the verification process throughout the Region and to support national public health authorities with political, technical and advocacy activities. The RVC also calls on the RVC Secretariat and the entire WHO Regional Office for Europe (Regional Office) to continue supporting measles and rubella elimination activities until regional verification has been achieved. The RVC appreciates the support of, and looks forward to further cooperation with, the European Technical Advisory Group of Experts (ETAGE) as well as other global and regional experts and technical groups in working towards measles and rubella elimination.

In 2015, the RVC reviewed documents submitted by NVCs for 2012, 2013 and 2014 to assess the status of endemic measles and rubella transmission for 2014, as well as to determine in which MS measles and rubella can be considered eliminated for the three-year period. The RVC noted that there was significant improvement in the quality of the 2014 ASUs and supporting documents submitted by the NVCs compared to previous years. However, as in previous years, more than one-third of the 2014 ASUs were submitted to the Secretariat after the agreed deadline; several reports contained incomplete or inconsistent information, or self-developed surveillance indicators which were not clearly explained and might be inconsistent with the requirements for verification.

The RVC is concerned with the delay in initiation of the verification process in Albania, Monaco and San Marino. Information provided by national authorities indicates that these three countries have not established an NVC, and consequently have not submitted the required documentation to allow the RVC to assess their measles and rubella elimination status. Additionally, several documents are missing from a few countries with functioning NVCs (Elimination Status Report 2010-2012 from Italy; corrected ASU for 2013 from Serbia and the former Yugoslav Republic of Macedonia; and an official ASU for 2014 from Ukraine). Without complete documentation from all 53 MS, regional verification will not be possible.
Based on the 50 ASUs submitted for 2014, the RVC verified that 32 MS (60%) provided evidence of the interruption of endemic measles transmission in 2014, 18 MS (34%) remain endemic for measles transmission and 3 MS (6%) did not submit any documents. The RVC also verified that 32 MS (60%) provided evidence of the interruption of endemic rubella transmission, 18 MS (34%) remain endemic for rubella transmission and 3 MS (6%) did not submit any documents. Sixteen MS (30%) had endemic transmission of both measles and rubella in 2014. In the absence of an official 2014 ASU, special consideration was given to assessing measles and rubella transmission in Ukraine. Based on surveillance and coverage data for 2014 and the previous documents submitted by the NVC, the RVC concluded that Ukraine still has endemic measles and rubella transmission. The RVC was unable to review the measles and rubella status of the three MS without functioning NVCs. The RVC and Secretariat agreed to abolish the "interrupted, at risk" and "inconclusive" categories for the classification of measles and rubella elimination status, as there was no clear understanding of how to standardize their use in the verification process.

The RVC considers it highly unlikely that the 2015 ASUs will provide evidence to exclude endemic transmission of measles and rubella in all countries of the Region as of 31 December 2015. In this event, the 2015 regional measles and rubella elimination goal will be missed. However, the RVC's 4th meeting was the first opportunity to assess the status of measles and rubella over a three-year period and potentially verify elimination at the country level. Many MS have been able to document the absence of endemic measles and/or rubella transmission within their borders for the period 2012-2014, thereby qualifying them for verification of elimination.

Based on a country-by-country assessment of documents submitted by NVCs for 2012-2014, the RVC verified that 21 MS (39.5%) have provided evidence to demonstrate the interruption of endemic measles transmission for at least 36 months; 11 MS (21%) have provided evidence for interruption for a period of 12 or 24 months; and 18 MS (34%) remain endemic for measles. The RVC verified that 20 MS (38%) have provided evidence to demonstrate the interruption of endemic rubella transmission for at least 36 months; 12 MS (22.5%) have provided evidence for interruption for a period of 12 or 24 months; and 18 MS (34%) remain endemic for rubella. Sixteen MS remain endemic for both measles and rubella.

The RVC noted that the collection and submission of more detailed sub-national data (graphs and maps) would enhance the verification process at the national and regional levels. The RVC also noted that many MS continue to find rubella surveillance challenging, particularly laboratory confirmation of suspected rubella cases, and it is therefore difficult to compile enough cases to establish baseline rubella genotyping data across the Region. Additionally, several countries still cannot provide evidence of sensitive nationwide or effective sentinel surveillance for congenital rubella syndrome (CRS).

As the Region moves towards elimination, it becomes increasingly important to distinguish endemic cases from imported and import-related cases, and to monitor chains of virus transmission through genetic sequencing. Most MS are reporting measles genetic sequence data in a standard format, but the amount of sequence data on rubella remains low. The RVC also recognized that the usefulness of measles and rubella molecular data depends on the quality of the clinical and epidemiologic data of an integrated surveillance system.

The RVC continues to investigate approaches for verification in MS with population sizes considered as too small to maintain endemic transmission of measles and rubella. RVC will work with the Secretariat and use existing WHO initiatives, such as the small countries initiative, as well as the regional polio-free certification experience, to better assess these MS. The RVC also recognized that there are large population movements between MS throughout the Region on a seasonal and/or daily basis, and in the context of the verification process, it is important to share epidemiology and virus transmission data between MS. Developing informal epidemiological blocks might be helpful when considering measles and rubella virus transmission and the risk of importation into the Region.
New approaches could be useful in facilitating the verification process and developing technical guidelines on collecting and analysing information from these countries.

Recommendations

The RVC urges national public health authorities and NVCs of MS with endemic measles and/or rubella transmission to re-confirm their commitment to the Regional goal and to achieve elimination as soon as possible.

The RVC strongly recommends that all NVCs implement country-specific recommendations presented in the annexes of the meeting report. The RVC also invites NVCs and national public health authorities to identify opportunities for the RVC and the WHO Secretariat to provide support towards measles and rubella elimination at the national level. The RVC and WHO Secretariat should take every opportunity to help NVCs to present their evidence for measles and rubella elimination in a manner that is clear and comprehensive. 

The RVC urges Albania, Monaco and San Marino to establish their NVCs and prepare elimination status reports for the period 2010 to 2012 and annual status updates for 2013 and 2014 using the standardized templates as soon as possible. The RVC and WHO Secretariat are prepared to provide any assistance needed to complete the necessary documentation.

The RVC urges the NVCs of Italy, Serbia, the former Yugoslav Republic of Macedonia and Ukraine to submit all missing documentation as soon as possible.

The RVC and WHO Secretariat should continue to participate in global measles and rubella elimination activities, verification commission meetings in other regions, and partners' meetings on measles and rubella elimination to ensure implementation of a consistent global approach to the elimination process in the European Region. 

The WHO Secretariat should:

• keep the RVC informed about developments related to measles and rubella verification activities in the European Region and opportunities for the RVC to advocate and promote measles and rubella elimination activities at the national level;
  o continue to provide guidance to national health authorities and NVCs on completing the ASU;
• continue to facilitate communication with the RVC in-between meetings through regularly scheduled teleconferences;
• explore the possibility of using other WHO initiatives, such as the small countries initiative, to help with the verification process in MS with populations considered too small to maintain endemic transmission of measles and rubella;
• consider informal grouping of countries, particularly small countries sharing land borders with much larger neighbours, into epidemiological blocks for the purpose of assessing virus transmission and evaluating elimination status.

All Member States are urged to:

• support verification activities by providing all needed national and sub-national data, information and documents to NVC, thereby facilitating timely submission of complete and comprehensive annual status reports 
• improve the quality of rubella and CRS surveillance and increase the level of reporting of rubella genetic sequence data;
• support capacity building of the Regional Measles and Rubella Laboratory Network, and improve the capacity to link genetic sequence data to measles and rubella surveillance data;
• ensure that adequate documentation on outbreaks, including supplementary immunization response activities and outcomes, together with adequate outbreak reports are provided to the NVC;
• consider activities to increase population immunity through improving routine immunization coverage and/or targeted supplemental immunization activities.